ChanBeDu/relevant_section_length · Datasets at Hugging Face

43,086

143,354

35122

Discharge summary

report

Admission Date: [**2185-12-21**] Discharge Date: [**2186-4-13**] Date of Birth: [**2148-7-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Acute renal failure Major Surgical or Invasive Procedure: None History of Present Illness: 37 year old female with a past medical history of hepatitis C and etoh cirrhosis on transplant list recently admitted to [**Hospital1 18**] with confusion and ascites now transferred from OSH with acute renal failure and hyperkalemia. Most recent labs were done tuesday and she was called last night with the results and went to [**Hospital 794**] Hospital. She noted 3-4 days ago, she felt nausea (with vomiting while taking lactulose) and LLQ and epigastric abdominal pain and increasing abd girth, fatigue and decreased po intake. No vomiting. Having diarrhea without blood or melena which is at her baseline. Also feels mildly sob secondary to ascites. No fever or cough or wheezing. No recent nsaids. She was taking oxycodone with minimal relief at home for pain. She is not feeling confused at all. No change in taste. Feeling more fatigued. No dizziness, cp, etc. ROS otherwise negative. Past Medical History: hepatitis C (diagnosed 10 years ago, no antiviral treatment) alcoholic cirrhosis cesarean section depression Social History: She contracted her hepatitis C through previous intravenous drug use. She used intravenous drugs including heroin and cocaine for several years and has now been off drugs for 16 years. In addition, she has a history of alcohol excess and previously drank up to a half pint of vodka on a daily basis for a number of years, approximately 10. She gave up drinking 5 years ago but restarted 2 years ago. She is off alcohol now for 6 months. She is enrolled in a relapse prevention program and goes to counseling on several occasions each week. She is single and has 2 children. Her mother does most of the caring for the children. She is currently living alone close to her parents. She smokes a 3- 5 cigarettes per day and has done so for 20 years. Family History: Noncontributory. Physical Exam: Vitals: T 96.6 BP 119/79 P 112 R 18 O2 sat 98% RA General: middle aged female in NAD HEENT: EOMI, sclera anicteric, OP clear, MM mildly dry Neck: Supple, no LAD, JVP at clavicle CV: RR, tacchycardic, 3/6 sem at LUSB does not radiate Lungs: Patient breathing comfortably, CTAB Abd: +BS, very distended and tense, positive fluid wave, no murphys and no tenderness or guarding, dressing RLQ from para last night which was C/D/I Ext: No edema Neuro: AAO X 3, CNII-XII grossly intact, [**5-2**] lower and upper extremity strength, sensation intact, no asterixis Psych: Alert and oriented to person, place and date Skin: No rash or jaundice Pertinent Results: Upon Admission: [**2185-12-21**] WBC-8.6# RBC-3.43* Hgb-11.4* Hct-31.8* MCV-93 MCH-33.1* MCHC-35.7* RDW-17.8* Plt Ct-111* PT-18.6* PTT-37.6* INR(PT)-1.7* Glucose-143* UreaN-91* Creat-4.4*# Na-117* K-4.4 Cl-88* HCO3-15* AnGap-18 ALT-67* AST-127* LD(LDH)-164 AlkPhos-52 TotBili-3.0* Albumin-3.6 Calcium-9.3 Phos-9.4*# Mg-2.7* [**2185-12-27**] TSH-1.9 [**2186-1-9**] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE At Discharge: [**2186-4-13**] WBC-4.9 RBC-3.10* Hgb-8.9* Hct-26.7* MCV-86 MCH-28.7 MCHC-33.3 RDW-16.9* Plt Ct-312 PT-15.8* PTT-28.2 INR(PT)-1.4* Glucose-104 UreaN-39* Creat-1.3* Na-138 K-4.4 Cl-104 HCO3-25 AnGap-13 ALT-24 AST-14 AlkPhos-112 TotBili-0.4 Calcium-9.1 Phos-4.3 Mg-1.6 Brief Hospital Course: 37 year old female admitted with elevated creatinine and worsening ascites. She had previously been discharged post variceal banding about 2 weeks prior. Pre-renal etiology vs HRS were considered. Treatment for HRS was initiated with ocreotide, midodrine and albumin. Nadolol was discontinued. Cr peaked at 5.8 and patient became anuric. Due to this decline, patient was initiated on hemodialysis. Once patient was stabilized on HD. She was evaluated for liver transplant and was accepted on the liver transplant list on [**2186-1-31**]. Throughout hospitalizaion patient was also followed by renal transplant team, who initially felt that her renal impairment was reversible, however after 3 weeks of HD, patient was listed for dual (liver and kidney) for transplantation. . Cirrhosis and worsening liver function due to history ETOH and hep C cirrhosis. MELD calculated on admission labs as 30, peaked at > 40 and on [**2186-1-29**] was 38. Pt had mild cognitive slowing and a trace asterexis on admission. She has varices that were banded during last admission. She has had no previous h/o SBP and has large volume ascites. Paracentesis at OSH showed no SBP. No clear source for exacerbation of liver failure was identified with exception of progressive liver disease. Pt. underwent RUQ u/s showing 9mm and 5mm lesions consistent w HCC, portal hypertension, patent main portal vein with forward flow. She underwent an EGD and had grade III varices banded on [**12-23**]. Patient reported SOB at rest on admission. She underwent several diagnostic and therapeutic paracenteses including 7L on [**1-28**], 3L on [**2-2**], [**1-11**] 5L, therapeutic on [**12-29**] 3L, dx/tx 4L on [**12-24**]. Cx were always negative and ascitic fluid was always high in RBC content: 176K to 1.6M. Patient had a likely HCC seen on CT but still within transplant guidelines. Patient was hyponatremic, ranging 120s - 130s throughout admission, near her baseline (mid 120s). Bilirubin usually elevated after transfusions then nadired at 5-6, similar to previous episodes. Patient had intermittent episodes of encephalopathy that were associated with hypotensive episodes and [**1-31**] day episodes of fevers. Hypotensive episodes were deemed to be due to simultaneous HD sessions and Large volume parecenteses as well as on one occasion GIB requiring temporary MICU admission for monitoring (SBPs < 84mmHg). The source of fever could not be identified and patient was temporarily on IV Vancomycin and Ceftriaxone for empiric SBP and broad spectrum coverage. Patient continued to have abdominal distension on exam which improved significantly w/ therapeutic paracenteses. On admission she was noted to have a LLL consolidation and as treated with 7 day course of Levaquin. Subsequent chest xrays showed persistent lower lobe atelectasis. During [**Month (only) 404**] and [**Month (only) 956**], [**Doctor Last Name 1022**] underwent paracentesis, hemodialysis and stayed hospitalized in anticipation of the need for combined liver kidney transplant. On [**2186-3-13**], the patient underwent combined liver and kidney transplant with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. At the time of surgery she was found to have a large volume of ascites (15 liters of straw-colored clear ascites was removed). She had an enlarged nodular liver and severe portal hypertension. The patient had normal anatomy. The kidney was placed following the liver. She was transferred to the ICU in stable condition. Immediately post op she had excellent kidney function and the liver function progressed nicely with daily downtrending of LFTs. She was transferred to the regular surgical floor on POD4. Over the next few days her urine output was noted to drop significantly to around 100 cc daily. Renal ultrasound showed an increased RI in the renal artery, no evidence of hydronephrosis. On [**3-20**] (POD 7) she had a transplant kidney biopsy with results showing an acute humoral rejection. She had positive C4d staining. Plasmapheresis, IVIg were intitiated on [**3-20**]. She underwent a total of 10 sessions of plasmapheresis ([**3-20**] - [**4-3**]). Each session was followed by IVIG (10 gms each) and she received ATG 100 mg x 6 doses ([**3-21**] - [**3-26**]) as well as a single dose of Rituximab on [**3-22**]. A repeat biopsy was performed on [**3-27**] which was continuing to show some evidence of humoral rejection. She was maintained on hemodialysis following the transplant as recommended by the renal team. Her last day of dialysis was on [**2186-4-1**]. At this time the urine output was noted to increase daily and she was having outputs of greater then one liter and by [**4-5**] her urine output was greater than 2 liters daily. She was managed with daily IV lasix and this continues on discharge. Her creatinine stabilized around 1.3 In the post op period, despite the fact that the liver synthetic function was improving daily, she was still having a large volume of ascites that required paracentesis. The last paracentesis was done on [**2186-4-3**]. Her abdomen remains distended with ascitic fluid. She was also noted to have complaint of chest discomfort and burning. She underwent an EGD on [**3-29**] which showed diffuse circumferential ulceration with focal hemorrhagic areas in the upper and mid esophagus, a large adherent clot was noted in the mid esophagus and some oozing noted from the base of the clot. She also had some scarring from previous banding with no obvious varices noted. The scope was withdrawn to reduce risk of further bleeding. Specimens were not taken at the time of the scope, so she was broadly covered with micafungin (14 days) and gancyclovir which was then converted back to valcyte after symptomatic improvement. She had also been given a short holiday on the antivirals as her white count briefly dipped as low as 1.5, but rebounded once the drug conversions were made. She has returned to fluconazole and the micafungin stopped after 14 days therapy. She is more able to tolerate PO's, but still has some discomfort with swallowing, and advancement of diet should be done slowly to allow for additional healing. On [**2186-4-3**], [**Doctor Last Name 1022**] was noted to have fever to 101. All lines were removed including the triple lumen and the dialysis line. Cultures were sent showing that the triple lumen catheter was positive for staph coag negative. The dialysis catheter did not show any growth, but the blood cultures obtained at that same time were also positive for Staph coag nagative and she was started on Vancomycin which will be complete on [**2186-4-16**]. Post Op, she was nutritionally maintained on TPN. A post pyloric feeding tube was placed on [**4-10**] and tube feeds started and successfully advanced. A Dual lumen Power PICC placed to provide access once the central lines were removed due to fever, and have been used for TPN and antibiotics. Pain management has been an issue for [**Doctor Last Name 1022**] during this hospitalization. She experienced much pain from the esophageal issues as seen on EGD and also significant abdominal pain when ascites fluid volumes were high requiring paracentesis. We have increased her methadone dose on [**4-13**] to 15 mg TID, and switched her to PO dilaudid only with no IV breakthrough recommended. Pain issues were followed by the chronic pain service, and in addition she was followed by the transplant social work team as well for ongoing issues with pain management and coping during a long term hospitalization . . Medications on Admission: 1. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Mirtazapine 45 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Goal 4 bowel movements/day. Hold if >4BM. Disp:*2700 ML(s)* Refills:*2* 7. STOPPED TAKING - Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 10 days. Disp:*40 Tablet(s)* Refills:*0* 8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. STOPPED TAKING - Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold if blood pressure (was not taking for past few days) Discharge Medications: 1. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: Five (5) ml PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluconazole 40 mg/mL Suspension for Reconstitution Sig: Ten (10) ml PO Q24H (every 24 hours). 7. Triamcinolone Acetonide 0.025 % Ointment Sig: One (1) Appl Topical TID (3 times a day). 8. Prednisone 5 mg/mL Concentrate Sig: Three (3) ml PO DAILY (Daily). 9. Hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed. 10. Methadone 10 mg/5 mL Solution Sig: 7.5 ml PO TID (3 times a day): 15 mg TID. 11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) ml Injection Q8H (every 8 hours) as needed for nausea/vomiting. 12. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours): Through [**4-16**]. Via PICC line. 14. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 15. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a day: Check daily Prograf levels until further notice. 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: -Decompensation of liver failure, hepatorenal syndrome, hyperkalemia, anemia, hyponatremia, pneumonia, Cirrhosis, hepatitis C, esophageal varices now s/p combined liver kidney transplant [**2186-3-13**] -Humoral rejection of kidney (treated) Discharge Condition: Stable/fair Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, inabilty to swallow food, fluids or pills. Labwork daily until further notice for trough Prograf level. Chem 10, CBC, AST ALT, Alk Phos, albumin, Tbili twice weekly every Monday and Thursday. Results to be faxed to the transplant clinic at [**Telephone/Fax (1) 697**] [**Month (only) 116**] shower, no tub baths or swimming No heavy lifting Please see pain management recommendations for methadone, PO dilaudid Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2186-4-26**] 10:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2186-4-26**] 11:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2186-5-3**] 11:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2186-4-13**]

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7297

Discharge summary

report

Admission Date: [**2158-6-10**] Discharge Date: [**2158-6-13**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Hypotension, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old male with history of metastatic esophageal adenocarcinoma (recently diagnosed, s/p GEJ stenting [**2158-6-6**]), partial colectomy for transverse colon adenocarcinoma ([**2154**]), restless leg syndrome, GERD who presents with hypotension. The patient had been at home in his usual state of health when he tried to have a bowel movement and was noted by his family to be there for "hours." The patient had generalized weakness and could not come off the commode. EMS was called and enroute, he was noted to be febrile to 101.0 with a low blood pressure ~SBP80s on arrival to the [**Hospital1 18**] ED. The patient denies any subjective fevers/chills, shortness of breath, cough, headache, abdominal pain, dysuria. Has been "spitting up more" since his GEJ stenting and has been taking a soft diet with Ensure at home. In the ED, initial vitals: T101.0, BP100/61, RR 18, 94% on 4L. He was volume resuscitated with 3-4L normal saline. The patient received Vancomycin/Zosyn empirically and Tylenol for his fever. Urinalysis was bland. Lactate initially 2.9 but decreased to 1.0 after fluids. Troponin 0.02. EKG unchanged from priors. CT head unremarkable, CT torso given endorsement of diarrhea and abdominal pain was unremarkable. GI was consulted in the ED and felt there was nothing else to do re: GEJ stent, especially as the CT torso showed no fluid collection. CXR suggestive of possible biateral mid-lung field opacifications so the patient also received Levaquin 750mg IV X1. VS on transfer: HR81, BP101/60, RR22, 100% on 3L NC. The patient does not use oxygen at baseline. On arrival to the MICU, patient resting comfortably in bed with wife, daughter at the bedside. Patient asking when he can go home, wife/daughter would like his toenails to be clipped prior to discharge. ROS: Denies fever, chills, headache, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: * Metastatic esophageal adenocarcinoma * Partial colectomy for transverse colon adenocarcinoma (T3, NO [**2154-6-14**]) * Restless legs syndrome * GERD * Postoperative atrial fibrillation * Cdiff colitis ([**2154-6-14**]) Social History: Lives with wife at home, married for 65-68 years. Daughter lives in area. Prior asbestos exposure. Retired electrician. Denies tobacco, alcohol, illicit drugs. Fought in WWII, in [**Country 2559**]; broke all four extremities, remaining shrapnel in right knee, received Purple Heart. Family History: No family history of sudden cardiac death, son died of lymphoma. Physical Exam: VS: Temp: 97.1 BP: 117/102 HR: 82 RR: 12 O2sat 99% on 2L NC GEN: Pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd RESP: CTA b/l with good air movement throughout, no wheezing/rhonchi/rales CV: Regular rate/rhythm, S1 and S2 wnl, no gallops/rubs, [**3-19**] systolic murmur at [**Doctor Last Name **]/LSB ABD: Nontender, nondistended, +BS, soft, no palpable masses EXT: No cyanosis, ecchymosis, trace bilateral edema. TTP of RLE (chronic since WWII) SKIN: No rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. Strength and sensation intact. Sensorineural hearing loss. Pertinent Results: [**2158-6-10**] 04:25AM GLUCOSE-107* UREA N-15 CREAT-0.8 SODIUM-137 POTASSIUM-3.2* CHLORIDE-107 TOTAL CO2-21* ANION GAP-12 [**2158-6-10**] 04:25AM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.6* MAGNESIUM-1.8 [**2158-6-10**] 04:25AM WBC-13.1* RBC-2.65*# HGB-8.2* HCT-23.3*# MCV-88 MCH-30.7 MCHC-35.0 RDW-14.5 [**2158-6-10**] 12:50AM cTropnT-0.01 [**2158-6-9**] 11:02PM LACTATE-1.0 [**2158-6-9**] 06:18PM LACTATE-2.9* [**2158-6-9**] 06:05PM ALT(SGPT)-20 AST(SGOT)-31 CK(CPK)-175 ALK PHOS-52 TOT BILI-1.0 [**2158-6-9**] 06:05PM LIPASE-18 [**2158-6-9**] 06:05PM cTropnT-0.02* [**2158-6-9**] 06:05PM CK-MB-4 [**2158-6-9**] 06:05PM CALCIUM-9.3 PHOSPHATE-1.7* MAGNESIUM-1.9 EKG: Sinus tachycardia, HR108, left anterior fascicular block, poor R wave progression, no ST elevations/TW inversions. Stable from priors. Imaging: CT head: No actue process. CT torso: CT OF THE CHEST WITHOUT AND WITH CONTRAST: The pulmonary arteries appear patent to the subsegmental levels. Note is again made of aortic and mitral annular calcifications. The heart and great vessels are otherwise unremarkable. There are no pleural or pericardial effusions. Calcified pleural plaques are again seen which likely reflect prior asbestos exposure. Right upper lobe granuloma is stable. There is no lymphadenopathy. There is minimal bilateral dependent atelectasis. Note is made of a bovine aortic arch with common origin of the innominate and left common carotid arteries. The esophagus is dilated with an air-fluid level and wall thickening particularly distally. Narrowing of the stent at the GE junction is likely secondary to known malignancy. CT OF THE ABDOMEN WITH CONTRAST: Liver hypodensities are unchanged. The spleen contains punctate calcifications, which likely represent prior granulomatous disease. The pancreas is atrophic. The adrenal glands and kidneys are grossly unremarkable. The gallbladder contains a few dependent stones. The patient is status post transverse colectomy and surgical clips are seen in the right mid abdomen. Inspissated contrast is seen within multiple diverticula; there is no evidence for diverticulitis. There is no free air or ascites. CT OF THE PELVIS WITH CONTRAST: A Foley catheter is seen within a decompressed bladder. The prostate and seminal vesicles are grossly unremarkable. Severe sigmoid diverticulosis is seen with inspissated contrast within innumerable diverticula without evidence for inflammation. There is no free fluid. There is a large sclerotic lesion in the right iliac bone and there is marked sclerosis of three mid thoracic vertebral bodies, all of which is new compared to prior and concerning for metastatic disease. IMPRESSION: 1. No evidence for pulmonary embolism or other acute process. 2. New sclerotic lesions in the right iliac bone and mid thoracic vertebral bodies, concerning for metastases. 3. Narrowing of the distal esophageal stent compatible with known malignancy, and proximal dilatation of the esophagus filled with fluid. 4. Cholelithiasis. CXR: The heart size is normal. The mediastinal and hilar contours are unremarkable with mild tortuosity of the thoracic aorta identified. There are calcified bilateral pleural plaques which somewhat limit assessment of the underlying pulmonary parenchyma. Compared to the prior radiograph, there may be increased opacification within the mid lung fields bilaterally, and underlying infection cannot be completely excluded. The pulmonary vascularity is not engorged. No pleural effusion or pneumothorax is identified. No acute osseous findings are seen. IMPRESSION: Bilateral calcified pleural plaques limit assessment of underlying pulmonary parenchyma. Given this, there appears to be slight increased opacification within the mid lung fields bilaterally, and an underlying infection cannot be completely excluded. EGD - [**Age over 90 **] y.o. M with recently discovered esophageal adenocarcinoma at distal esopahagus. Pt with severe dysphagia, unable to eat for two weeks. * A fungating, friable mass of malignant appearance was found in the distal esophagus extending from 35cm down to the GEJ at 40cm. The mass caused a partial obstruction. The scope traversed the lesion. Mass infiltration was noted extending from the esophagus into the stomach, circumferentially in the fundus and then unilaterally extending down to the distal body along the lesser curvature. The mucosa appeared congested, suggestive of submucosal tumor infiltration. A 23mm x 120mm [**Company 2267**] Ultraflex Covered Esophageal metal stent was placed across the mass successfully. REF: 1421 LOT: [**Numeric Identifier 26960**] Recommendations: Follow-up with Dr. [**Last Name (STitle) **] Omeprazole 40mg by mouth twice daily Full liquids for 72 hours, then may advance to soft diet CT torso with contrast ([**Hospital1 18**] [**Location (un) 620**], [**2158-5-25**]): FOCAL ESOPHAGEAL/GASTRIC MURAL THICKENING AND STRANDING WITH AT LEAST ONE SMALL PARAESOPHAGEAL LYMPH NODE, AT THE GASTROESOPHAGEAL JUNCTION. THESE FINDINGS COULD INDICATE PRIMARY ESOPHAGEAL OR GASTRIC MALIGNANCY AND FURTHER EVALUATION WITH BIOPSY IS RECOMMENDED; THE POSSIBILITY OF METASTASIS TO THE GASTROESOPHAGEAL JUNCTION CANNOT BE EXCLUDED, HOWEVER. 2. MULTIPLE SCLEROTIC AND LUCENT BONE LESIONS CONCERNING FOR METASTATIC DISEASE NEW SINCE THE STUDY OF [**2154-6-20**]. 3. RETROPERITONEAL LYMPHADENOPATHY. WHILE THIS IS DECREASED IN COMPARISON WITH THE [**2154**] CT, THE APPEARANCE IS CONCERNING MALIGNANCY AND COULD REPRESENT METASTASIS OR ALTERNATIVELY PREVIOUSLY SUGGESTED, LYMPHOMA, IF AN APPROPRIATE HISTORY EXISTS. 4. GALLSTONES AND BILATERAL NONOBSTRUCTING RENAL STONES. TINY HYPODENSE RENAL LESIONS ARE TOO SMALL TO CHARACTERIZE AND IF SOURCE OF MALIGNANCY IS UNKNOWN AND FURTHER CHARACTERIZATION, PARTICULARLY OF THE RIGHT LOWER POLE LESION IS ESSENTIAL, THEN AN ULTRASOUND COULD BE PERFORMED INITIALLY. 5. HYPODENSE HEPATIC LESIONS UNCHANGED IN DISTRIBUTION FROM [**2154**], AT LEAST ONE OF WHICH REPRESENTS A CYST. 6. 3 MM RIGHT MIDDLE LOBE PULMONARY NODULE FOR WHICH FOLLOW-UP WITH CHEST CT IN THREE MONTHS IS RECOMMENDED 7. CALCIFIED PLEURAL PLAQUES CONSISTENT WITH PRIOR ASBESTOS EXPOSURE 8. COLONIC DIVERTICULOSIS. Microbiology: [**2158-6-9**] 6:10 pm BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): 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------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final [**2158-6-10**]): GRAM NEGATIVE ROD(S). Brief Hospital Course: Assessment and Plan: [**Age over 90 **] year old male with history of metastatic esophageal adenocarcinoma (recently diagnosed, s/p GEJ stenting [**2158-6-6**]) called out of the MICU with GNR sepsis. . # E. coli sepsis: Likely due to GI etiology, may be associated with patient's known GE cancer and potential bacterial translocation in the setting of recent stenting in the past week ([**2158-6-6**]). Blood pressures improved with IVF resusucitation and patient did not require pressors. WBC downtrended with addition of IV antibiotics. Pt received 2 days of Zosyn, 2 days of ertapenem, and was discharged with 3 days of oral cefpodoxime (once speciation returned as E. coli sensitive to Ertapenem) for a total of 7 days of treatment for bacteremia/sepsis. A discussion was held with the family and they were told the patient could not go home on hospice with IV antibiotics so the decision was made to pull his midline and send him home on three days of oral antibiotics. # Metastatic esophageal adenocarcinoma: s/p GEJ stenting earlier this week with extensive malignancy noted on EGD and likely has metastases in retroperitoneal lymph nodes and the bones. Recently diagnosed secondary to dysphagia. Patient does not appear to have established care with an oncologist yet. Continued mechanical soft diet. Changed omeprazole to lansoprazole on discharge given dysphagia since he was having difficulty swallowing pills. GI was aware and reports that nothing to do at this time especially given CT scan without abscess or perforation. . # h/o prostate cancer: Metastatic, continue home flutaide and leuprolide q3months. . # Transverse colon adenocarcinoma: Stable since [**2154**] . # Restless leg syndrome: Stable. Continued pramipexole. Added liquid oxycodone for pain control given going home on hospice. . # GERD: Stable. Switched omeprazole to lansoprazole as pt had difficulty with swallowing omeprazole. . # Goals of care: Patient stated multiple times that he wished to go home on hospice. HIs goals of care included returning home, and doing his woodwork for whatever amount of time he had left, and optimizing quality of life. This was discussed in a family meeting with the patient and the family Esophageal cancer appears fairly extensive likely with associated metastases. Goals of care discussed with family and they are aware that swallowing may become progressively difficult as his esophageal cancer progresses and once he is unable to eat this will limit his life span, at which point comfort tastes could be initiated. Patient was discharged home with hospice Choice for family is: Life Choice Hospice: [**Telephone/Fax (1) 26961**] Contact = [**Doctor First Name **]. . #FEN: mechanical soft diet, replete electrolytes prn #PPX: heparin sq #Code: DNR/DNI #Communication: wife [**First Name8 (NamePattern2) **] [**Name (NI) 7356**], HCP [**Telephone/Fax (1) 26962**]), son. #Dispo: Home with IV abx until Friday, then transition to hospice. . [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Last Name (Titles) 4207**]-3 [**Pager number 26963**] Current Clinical Status:afebrile Medications on Admission: * Flutamide 125mg daily * Leuprolide 3.75mg every three months * Omeprazole 40mg twice daily * Pramipexole 0.25mg daily * Docusate 100mg daily * Multivitamin daily Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 2. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) packet PO DAILY (Daily) as needed for constipation: hold for loose stools. Disp:*30 packets* Refills:*0* 3. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 4. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day): hold for loose stools. 5. pramipexole 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily (). 6. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mg PO Q4H (every 4 hours) as needed for pain, anxiety, restless leg. Disp:*150 mg* Refills:*0* 7. flutamide 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 8. ertapenem 1 gram Recon Soln [**Last Name (STitle) **]: One (1) gram Intravenous once a day for 3 days. Disp:*3 grams* Refills:*0* 9. leuprolide 3.75 mg Kit [**Last Name (STitle) **]: One (1) injection Intramuscular q3months. 10. Hospice Please provide Hospice Consult 11. cefpodoxime 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: life choice hospice Discharge Diagnosis: Primary Diagnosis Sepsis Secondary Diagnosis Esophageal Cancer Metastatic Prostate Cancer 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 with an infection in your bloodstream, likely due to bacteria in your GI tract. You required a brief stay in the ICU due to low blood pressures, where you were given fluids and IV antibiotics. Your blood pressure improved and you were discharged on oral antibiotics for three more days to complete one full week to treat your infection. You should go home and be evaluated for hospice. The following changes were made to your medications. 1. Take Cefpodoxime 200 mg by mouth twice a day for three days (start date is [**2158-6-14**], last day is [**2158-6-16**].) 2. Please change your ompeprazole to lansoprazole (this will be easier for you to swallow). 3. We have given you some liquid oxycodone as needed for pain. 4. Please discuss discontinuing your prostate cancer medications with your hospice team and your primary care physician/oncologist. Followup Instructions: Please follow up with your PCP as needed. Completed by:[**2158-6-13**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

15791, 15841

11035, 14149

274, 280

15976, 15976

3682, 4516

17053, 17126

2908, 2976

14364, 15768

15862, 15955

14175, 14341

16159, 17030

2991, 3663

10155, 11012

213, 236

308, 2344

4525, 10111

15991, 16135

2366, 2590

2606, 2892

56,628

149,883

52929

Discharge summary

report

Admission Date: [**2110-5-20**] Discharge Date: [**2110-5-25**] Date of Birth: [**2040-3-22**] Sex: F Service: SURGERY Allergies: Compazine / Sulfa (Sulfonamide Antibiotics) / Penicillins / aspirin / hydrochlorothiazide Attending:[**First Name3 (LF) 695**] Chief Complaint: Hepatocellular carcinoma. Major Surgical or Invasive Procedure: [**2110-5-20**] Segment V liver mass resection, intraoperative ultrasound. History of Present Illness: 70-year-old mathematics professor who recently presented with right upper quadrant abdominal discomfort and an ultrasound demonstrated a 6.6-cm solid smoothly marginated ovoid mass in the inferior anterior right lobe of the liver. CT scan from [**2102**] demonstrated no mass. An ultrasound-guided biopsy on [**2110-4-23**] was interpreted as moderately differentiated hepatocellular carcinoma. CT scan of the abdomen and chest on [**2110-4-30**] demonstrated the hepatocellular carcinoma at the inferior margin of liver measuring 6.6 cm in diameter with a bilobed configuration with a small amount of fat density posteriorly. There is a small amount of mixed density fluid around the mass in the inferior right liver, probably subcapsular hematoma secondary to the core biopsy. No free fluid was demonstrated. CT scan of chest demonstrated biapical lung scarring and punctate calcifications in both apices but no evidence of pulmonary metastases. A CT of the pelvis was unremarkable. A bone scan demonstrated no evidence of metastatic disease. Hepatitis B and C serologies were negative. CA19-9 was 11 and AFP on [**5-1**] was 58.1. She was now brought to the operating room on [**2110-5-20**] for segmental Segment V resection of the liver mass with intraoperative ultrasound. Past Medical History: PMH: hypertrophic obstructive cardiomyopathy, ERCP [**2102**] for elevated lipase and amylase that was normal, colonoscopy [**2100**] normal, HTN, GERD, HLD, RA PSH: appendectomy [**2059-5-7**] Social History: Married with children (many of whom are in medicine). Mathematics professor. Family History: Mother died at age 89 and had a neurological disease of uncertain etiology. Her father died in his 80s of a heart attack. Physical Exam: PE on discharge: VS: T 99, HR 87, BP 118/60, RR 18, 95% RA CV: RRR, no murmurs, rubs or gallops Pulm: CTA bilaterally Abd: Incision clean/dry/intact without erythema or drainage; abdomen soft, nontender, with +Bowel Sounds throughout Ext: Symmetric peripheral 2+ pulses throughout, with minimal edema in lower extremities Pertinent Results: Laboratory: [**2110-5-19**] 08:15AM BLOOD WBC-6.9 RBC-3.97* Hgb-11.8* Hct-35.2* MCV-89 MCH-29.8 MCHC-33.6 RDW-12.6 Plt Ct-376 [**2110-5-20**] 03:53PM BLOOD WBC-15.2*# RBC-2.76*# Hgb-8.3*# Hct-24.2* MCV-88 MCH-30.0 MCHC-34.2 RDW-12.6 Plt Ct-329 [**2110-5-23**] 08:50AM BLOOD WBC-16.7* RBC-3.62* Hgb-10.8* Hct-31.4* MCV-87 MCH-29.9 MCHC-34.5 RDW-13.9 Plt Ct-239 [**2110-5-21**] 09:50AM BLOOD PT-13.6* PTT-31.8 INR(PT)-1.2* [**2110-5-23**] 08:50AM BLOOD Glucose-90 UreaN-8 Creat-0.7 Na-133 K-3.8 Cl-99 HCO3-24 AnGap-14 [**2110-5-19**] 08:15AM BLOOD ALT-17 AST-29 AlkPhos-108* TotBili-0.6 [**2110-5-23**] 08:50AM BLOOD ALT-106* AST-74* AlkPhos-91 TotBili-1.1 [**2110-5-23**] 08:50AM BLOOD Albumin-3.0* Calcium-8.4 Phos-1.9* Mg-2.0 Brief Hospital Course: The patient was admitted to the West 1 Surgical Service for an elective segment V mass resection with intraoperative ultrasound, on [**2110-5-20**]. The surgey was without complication. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids, with a foley catheter, and IV pain control. The patient was hemodynamically stable. . Neuro: The patient received IV analgesiscs with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications, Dilaudid. . CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. She spiked a low grade fever to 100.9 on POD 3 with a non-productive cough and CXR showed evidence of atelectasis; she remained afebrile throughout the rest of her stay, frequently using incenstive spirometry. . GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were initially followed, and repleted when necessary. The fluids were stopped when the patient tolerated diet. . ID: The patient's white blood count and fever curves were closely watched for signs of infection. There were no active issues. The incision remained clean/dry/intact. . Endocrine: No issues . Hematology: The patient's complete blood count remained stable. . Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible, and was cleared by physical therapy to return home. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Diltiazem 360 mg qd, Ethacrynic acid 12.5 mg qd Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 3. ethacrynic acid 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hepatocellular carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any of the following: fever (101 or greater), chills, nausea, vomiting, increased abdominal or incision pain, abdominal bloating, jaundice, incision edness/bleeding/drainage, an increase or decrease in your bowel movements, or any concerns. Please do not lift more than 10 pounds for 4-6 weeks. Followup Instructions: [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator [**Telephone/Fax (1) 673**] will call you with a follow up appointment with Dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2110-5-25**]

[ "530.81", "155.0", "458.29", "424.0", "714.0", "272.4", "518.0", "425.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "50.22" ]

icd9pcs

[ [ [] ] ]

6083, 6089

3329, 5584

374, 451

6158, 6158

2578, 3306

6710, 7064

2096, 2220

5682, 6060

6110, 6137

5610, 5659

6309, 6687

2235, 2238

2252, 2559

309, 336

479, 1768

6173, 6285

1790, 1986

2002, 2080

28,557

178,081

7556

Discharge summary

report

Admission Date: [**2129-5-18**] Discharge Date: [**2129-5-23**] Date of Birth: [**2080-6-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2129-5-18**] - Off Pump CABGx2 (Left internal mammary->Left anterior descending artery, Saphenous vein graft->Posterior descending artery) History of Present Illness: 48 year old man with known CAD s/p PTCA of LAD in [**2119**]. Recently he has developed chest pain and underwent a stress test which was abnormal. A Cardiac catheterization was performed which revealed three vessel disease. Given the severity of his disease, he is now admitted for surgical management. Past Medical History: CAD s/p PTCA [**2119**] HTN Hyperlipidemia ADHD GERD Bipolar disorder Hiatal hernia Social History: Museum worker at [**Location (un) 3320**] Plantation. Never smoked. 1 drink of alcohol weekly. Lives with wife. Family History: Strong for CAD. Mother with MI in her 50's. 2 brothers with [**Name (NI) 5290**] in 40's with one having CABG in early 50's. Other brother died of MI in his 50's. Physical Exam: 55 sb 164/87 (R) 156/83 (L) 70" 217lbs GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: CTA bilaterally. HEART: RRR, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities, no peripheral edema NEURO: No focal deficits. Pertinent Results: [**2129-5-18**] ECHO Pre-CABG: No spontaneous echo contrast is seen in the left atrial appendage. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CABG: The procedure was done off-pump. The patient is in NSR, on low dose Phenylephrine. Preserved biventricular systolic fxn. 1+ MR remains. No AI. Aorta intact. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2129-5-19**] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent off pump coronary artery bypass grafting to two vessels. Please see operative note for further details. Postoperatively he was taken to the cardiac surgical intensive care unit. Within 24 hours, he awoke neurologically intact and was extubated. Plavix, beta blockade, aspirin and a statin were resumed. Later on postoperative day one, he was transferred to the step down unit for further recovery. Mr. [**Known lastname **] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Chest tubes remained in for several days due to small pneumothorax, which was then stable post pull. He was ready for discharge home on POD #5. Medications on Admission: Aspirin 81mg daily Lamictal 150mg twice daily Concerta mg daily Vytorin 10/40mg daily Discharge Medications: 1. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. CONCERTA 27 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 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:*0* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for off pump for 3 months. Disp:*30 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**2-20**] hours as needed. Disp:*50 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*30 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 6136**] Home Care Services Discharge Diagnosis: CAD s/p Off pump CABGx2 Hyperlipidemia HTN ADHD GERD Bipolar disorder Hiatal hernia Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Plavix to be taken for 3 months. 8) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 26191**] in [**11-17**] weeks. Follow-up with Dr. [**First Name (STitle) 27598**] in 2 weeks. [**Telephone/Fax (1) 27599**] Please cal all providers to schedule your appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2129-5-23**]

[ "272.4", "414.01", "E879.9", "314.01", "401.9", "530.81", "296.80", "512.1" ]

icd9cm

[ [ [] ] ]

[ "36.11", "36.15" ]

icd9pcs

[ [ [] ] ]

4620, 4690

2219, 3139

331, 475

4818, 4827

1594, 2196

5606, 6036

1059, 1223

3275, 4597

4711, 4797

3165, 3252

4851, 5583

1238, 1575

281, 293

503, 807

829, 914

930, 1043

15,033

185,664

24553

Discharge summary

report

Admission Date: [**2197-6-21**] Discharge Date: [**2197-7-5**] Date of Birth: [**2118-11-29**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2297**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy Intubation Tracheostomy Placement of PEG tube Placement of central line Placement of arterial line Placement of PICC line History of Present Illness: 78 y/o f with htn, cad s/p mi and pci ([**2178**]), copd (on bipap and 2lnc at home) admitted [**2197-6-1**] to [**Hospital3 **] hospital for a copd exacerbation (started on methylprednisolone 125mg and nebs), felt to be secondary to a rll pna, for which she was placed on levofloxacin, then ticarcillin, then vancomycin for mrsa found in the sputum. She became hypotensive and was briefly on neosynephrine, but weaned off. During her stay, she fell from bed and fractured both her left hip and left humeral neck. The hip has been surgically repaired by ORIF, but not the humerus, with post-op delirium (pain meds) and 19pt hct drop (hematoma to back/thighs [**2-22**] to asa and lovenox use). During course, also briefly intubated for hypercarbic resp failure, then weaned to bipap. Pt was transferred to [**Hospital1 18**] for further management, where she was found to be in respiratory distress and was quickly intubated for ventilatory support. Past Medical History: 1. COPD (2lnc at home) 2. CAD MI/PCI [**2178**] 3. HTN 4. hypothyroidism Social History: Pt is a former smoker. She lives with her son and husband. [**Name (NI) **] son describes her as an indepedent person, able to fully take care of herself prior to this admission. Family History: NC Physical Exam: t 98.2, bp 112/68, hr 98, rr 18, spo2 98% gen- chronically-ill appearing f, sedated/intubated, diffuse ecchymoses primarily on the left heent- anicteric sclera, op clear with dry mucosa neck- trach in place, no jvd cv- rrr, s1s2, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, peg in place, +bs extrm- upper extrm with 2+ pitting edema, right hand with small laceration, weeping; lue with diffuse echymoses; bilat lower extrm with 2+ pitting edema; warm/dry neuro- awake, follows basic commands (will squeeze hand), cn's intact, moves extremities Pertinent Results: ## CT head [**6-21**]: Prominent ventricles, including temporal horns, although not out of proportion to sulci. Probable atrophy. No evidence of intracranial hemorrhage. ## L hip [**6-22**]: Status post bipolar left hip hemiarthroplasty in anatomic alignment. ## L shoulder [**6-22**]: 1) Oblique fracture of the left humeral surgical neck with medial displacement of humeral shaft. Fracture fragments are overlapped, as discussed above. The humeral head is inferiorly subluxed medially rotated. Dislocation cannot be excluded. 2) Lucency at the greater tuberosity, probably a non-displaced fracture. ## CXR [**6-28**]: 1) Persisting right upper lobe opacity, which given the clinical history is likely consistent with a pneumonic infiltrate. Although less likely, without prior films malignancy remains in the differential. 2) Bilateral pleural effusions, which allowing for differences in technique are not significantly changed. ## LABS: [**2197-6-21**] 06:26PM BLOOD WBC-14.9* RBC-3.21* Hgb-9.9* Hct-30.1* MCV-94 MCH-30.8 MCHC-32.9 RDW-15.5 Plt Ct-172 [**2197-6-27**] 03:02AM BLOOD WBC-9.1 RBC-2.91* Hgb-9.2* Hct-28.7* MCV-99* MCH-31.7 MCHC-32.2 RDW-16.4* Plt Ct-208 [**2197-7-4**] 04:15AM BLOOD WBC-9.9 RBC-2.63* Hgb-8.3* Hct-25.5* MCV-97 MCH-31.4 MCHC-32.4 RDW-18.1* Plt Ct-292 [**2197-6-21**] 06:26PM BLOOD Glucose-107* UreaN-73* Creat-0.9 Na-146* K-4.6 Cl-98 HCO3-42* AnGap-11 [**2197-6-23**] 07:35PM BLOOD Glucose-231* UreaN-61* Creat-1.0 Na-145 K-4.5 Cl-104 HCO3-34* AnGap-12 [**2197-7-4**] 04:15AM BLOOD Glucose-169* UreaN-30* Creat-0.7 Na-137 K-4.2 Cl-96 HCO3-36* AnGap-9 [**2197-7-4**] 04:15AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.7 [**2197-6-21**] 06:26PM BLOOD TSH-19* Brief Hospital Course: 78 y/o female with CAD, COPD admitted to osh with copd exacerbation thought [**2-22**] to pna, fell there with resultant left humeral and hip fx (s/p hemiarthroplasty of hip), transferred for furhter management. 1.)Respiratory failure -- Initially hypercarbic respiratory failure secondary to copd, Mrs. [**Known lastname 62033**] had been extubated at the outside hospital. Once admitted, her work of breathing greatly increased, and her pCO2 rose from a baseline in the 60's to around 100, and she was re-intubated. She was slowly weaned on the vent, with decreasing levels of pressure support. The wean was aided by COPD tx (prednisone taper and scheduled albuterol/ipratropium MDI's) and gentle diuresis. However, the patient failed her second extubation attempt despite a bipap bridge; her failure seemed most related to excessive respiratory fatigue, probably from a combination of volume overload and COPD. At this point, in discussion with the family, it was decided the best course would be to perform a tracheostomy and have Mrs. [**Last Name (STitle) 62034**] be discharge to a rehab facility for prolonged rehabilitation and ventilator weaning. At discharge, her baseline venous blood gas was 7.36/67/33. 2.)Altered mental status -- Per her family, she is clear and independent at home. Her AMS was initially due to sedative medications, but was also from ICU psychosis and her general ill-state. She did, at admission, have a CT head that was negative for any acute pathology, such as bleed or mass effect. As her sedation was weaned, she was initially started on haloperidol for agitation on the ventilator, but once she was trached this became unecessary as well. By the time of discharge, she was off of haloperidol and all sedating medicaitons and was clearing. She could communicate basically and follow basic commands. It is anticipated as her health improves, she will become increasingly clearer. 4.)Ortho -- Pt is s/p hemiarthroplasty of left hip at the OSH. Ortho evaluated Mrs. [**Known lastname 62033**] during this admission and said that due to her ill health and poor nutritional reserve, the left humerus should be immobilized in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8688**] brace, and that she was not an operative candidate. Following immobilization, the focus was on pain control, which was achieved with IV fentanyl. This was converted to a fentanyl patch with sc hydromorphone as needed for breakthrough pain. She will follow-up with the orthopedist she saw while an inpatient. 5.)Hematoma -- Slowly resolving during the admission, this finding was from her fall at the outside hospital. Her hct remained stable, and the finding, though still present at discharge, had significantly improved. 6.)Anemia -- Pt had hct drop following procedure, but no other obvious blood loss source; She was transfused one unit given h/o CAD. Baseline anemia mainly related to blood loss into the hematoma and her ill state with its attendant marrow suppression. 7.)Guaiac positive stool -- No melena/hematochezia, this was only a one time finding. Excepting the drop following procdure, her hct otherwise remained stable. She was placed on a [**Hospital1 **] PPI. 9.)FEN -- She was placed on tube-feeds and advanced to goal without residuals. 10.)Hyperglycemia -- Related to her steroid use, she was placed on sliding scale insulin that will need to be titrated down at the rehab as she comes off the taper. Medications on Admission: atenolol 50 [**Hospital1 **] olanzapine lasix 20 [**Hospital1 **] methylprednisolone 60 tid ipratropium asa 81 combivent mdi Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) ml PO BID (2 times a day). 8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO BID (2 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 doses. 12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 13. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Insulin Regular Human 100 unit/mL Solution Sig: As directed by scale Units Injection ASDIR (AS DIRECTED): Sliding scale insulin: 150-200 4units; 201-250 6 units; 251-300 8 units; 301-350 10 units; 351-400 12 units. 15. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours): placed on [**7-4**]. 16. Hydromorphone 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Respiratory failure COPD exacerbation Left humeral fracture S/p left hip hemiarthroplasty MRSA Pneumonia Secondary: COPD (2lnc at home) CAD MI/PCI [**2178**] HTN hypothyroidism Discharge Condition: Fair, stable on vent, improving mental status Discharge Instructions: Call your PCP or return to ED for fevers/chills, uncontrolled pain, or other concerning symptoms. Followup Instructions: Please see your primary care doctor in one to two weeks. Call [**Telephone/Fax (1) 29363**] to make an appointment. Follow-up with Dr. [**First Name (STitle) 4223**] in orthopedics, call [**Telephone/Fax (1) 5499**] to make an appointment.

[ "V09.0", "518.81", "E884.4", "414.01", "280.0", "V46.11", "428.0", "707.07", "293.0", "790.6", "458.9", "V43.64", "412", "E849.7", "401.9", "482.41", "924.00", "244.9", "812.01", "V45.82", "E932.0", "491.21", "V54.81", "424.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "38.93", "31.1", "96.6", "43.11", "96.72", "96.05", "38.91" ]

icd9pcs

[ [ [] ] ]

9224, 9296

4016, 7484

289, 425

9517, 9564

2312, 3993

9710, 9955

1719, 1723

7659, 9201

9317, 9496

7510, 7636

9588, 9687

1738, 2293

230, 251

453, 1409

1431, 1505

1521, 1703

4,592

158,401

4001

Discharge summary

report

Admission Date: [**2114-12-27**] Discharge Date: [**2114-12-31**] Date of Birth: [**2063-10-23**] Sex: F Service: PLASTIC Allergies: Ceftin / Morphine / Vicodin Attending:[**First Name3 (LF) 16920**] Chief Complaint: right breast infection Major Surgical or Invasive Procedure: right breast expander removal and wound drainage History of Present Illness: Mrs. [**Known lastname 17684**] is a 51-year-old Caucasian female who underwent immediate right breast reconstruction in [**2114-11-19**] using a [**Hospital 17686**] medical expander following a right mastectomy for breast cancer. Postoperatively, she had developed some ecchymosis and blistering at the margins of the incision line, and this was treated conservatively with a topical antibiotic regimen. These areas eventually demarcated over a [**2-20**] week period with evidence for full-thickness skin loss. Additionally, the patient had some inflammatory hyperemia and early cellulitis that had been treated with oral antibiotics. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain which had been placed at the time of surgery was draining straw-colored serous fluid, but the patient reported more copious drainage over the past few days, with much of it emerging from the separating wound eschar. Although Mrs. [**Known lastname 17684**] denied any fevers, chills, or other systemic symptoms, the persistent fluid collection with skin cellulitis, in the presence of a prosthetic implant with compromised skin integrity, Dr. [**First Name (STitle) 3228**] decided to take the patient to the operating room for wound debridement, as well as removal of the expander implant. Past Medical History: Airway narrowing from GERD, PSH: Breast bx/reconstruction, tracheostomy '[**06**], cholecsytectomy '[**86**], TAH '[**09**], Bladder sling '[**07**], Fundoplication '[**08**] Social History: non-contributory Family History: non-contributory Physical Exam: HEENT: NC/AT Chest: cellulitis of right breast Cardiac: RRR Pulm: CTAB Abd: S/F/NT Neuro: non-focal Pertinent Results: Brief Hospital Course: 51 y/o female s/p right breast reconstruction in [**2114-11-19**] using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17686**] medical expander who subsequently developed infection of this site. The patient was taken to the OR for debridement of the right mastectomy skin flaps, removal of an intact right breast expander, and lavage washout. After the OR the patient was taken to the floor for IV antibx. On HD 4 the cellulitis had improved and she was discharged home on levo x 7d, JP drain x 1. She will follow up with Dr. [**First Name (STitle) 3228**]. Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-24**] hours as needed for pain for 5 days. Disp:*15 Tablet(s)* Refills:*0* 3. medication please continue taking your other home medications as directed Discharge Disposition: Home Discharge Diagnosis: right breast expander removal and wound drainage Discharge Condition: good Discharge Instructions: Please call Dr. [**Last Name (STitle) **] office or go to the emergency department if you experience fevers, chills, worsening redness around your right breast or for other concerns. Followup Instructions: please follow up with Dr. [**First Name (STitle) 3228**] this coming Thursday or Tuesday. Call for an appointment.

[ "493.90", "458.29", "724.4", "530.81", "611.0", "998.59", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "85.21", "85.96" ]

icd9pcs

[ [ [] ] ]

3096, 3102

2151, 2727

314, 365

3195, 3201

2128, 2128

3432, 3550

1973, 1991

2750, 3073

3123, 3174

3225, 3409

2006, 2108

252, 276

393, 1724

1746, 1923

1939, 1957

4,467

107,451

47759

Discharge summary

report

Admission Date: [**2152-6-11**] Discharge Date: [**2152-7-1**] Date of Birth: [**2079-8-7**] Sex: M Service: MED Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Intubation [**Date range (1) 100821**] History of Present Illness: 72M [**Hospital3 2558**] resident w/ multiple medical problems now admitted for a 1 day h/o acute SOB/hypoxia. He was in his usual state of health until around midnight [**6-11**] when he c/o acute SOB and chest pressure. His O2 sat was noted to be 89% on RA -> 94% 6L, so he was sent to [**Hospital1 18**] ED for further evaluation. In our ED his WBC was noted to be elevated at 16 with 9% bands and CXR with RML consolidation. As a result, he was given 1 dose of levaquin and erythromycin. Around 6am, he developed substernal chest pressure in the ED, was given 2mg morphine, and subsequently became hypoxic to 90% on a NRB resulting in intubation. ROS on admission were otherwise unremarkable. Past Medical History: Recent partial SBO s/p ERCP CBD stent [**2152-5-26**] Diverticulitis Chronic diarrhea Osteoarthritis Left THR '[**43**] HTN CAD s/p MI '[**48**] Opioid/ETOH abuse Multiple bowel surgeries, inc sigmoid resection '[**43**] c/b fistula Lumbar Spinal Stenosis w/ Chronic Back Pain GERD 1st degree AV Block Social History: Lives at [**Hospital3 2558**] Family History: unknown Physical Exam: VS: T 97.0 (Tm 98.0; last fever=103.8 [**6-11**] early am) BP 152/78 (102-150/60s) HR 48(48-71) RR 26(18-32) Sats 98% on 40% face tent I/O: negative 720cc/24hrs; +3.7L for LOS GEN: cachectic, elderly caucasian male, nontoxic, speaking in full sentences, A&O x 3, NAD HEENT: MM sl dry, anicteric, OP clear NECK: supple, no LAD, no TM CV: RRR, no R/M/G LUNGS: [**Month (only) **] at bases bilat, +scatterred ronchi R>L ABD: soft, ND, NABS, no masses, well-healed surgical scar, mild diffuse TTP, no rebound or guarding, no HSM EXT: no edema, no CT, warm, no rashes NEURO: nonfocal and symmetric Pertinent Results: [**2152-6-11**] 03:15PM GLUCOSE-99 UREA N-13 CREAT-0.5 SODIUM-135 POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-22 CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.8 [**2152-6-11**] 03:15PM WBC-9.3 RBC-3.74* HGB-11.5* HCT-34.1* MCV-91 MCH-30.9 MCHC-33.9 PLT COUNT-306 [**2152-6-11**] 12:58PM LACTATE-3.4* [**2152-6-11**] 08:30AM ALT(SGPT)-8 AST(SGOT)-13 LD(LDH)-91* CK(CPK)-16* ALK PHOS-146* AMYLASE-86 TOT BILI-1.3 LIPASE-10 ALBUMIN-2.9* [**2152-6-11**] 02:52AM PT-13.5* PTT-22.8 INR(PT)-1.2 Studies: Dobutamine Echo [**2152-6-28**]: No 2D echocardiographic evidence of inducible ischemia to achieved workload. With exercise, a wide comple tachycardia most likely SVT, developed. MR Hip [**2152-6-23**]: Small right sided hip joint effusion with associated severe degenerative changes, unchanged when compared to [**2152-6-5**]. Limited evaluation of the left hip. Status post left hip replacement. Fluid near the left hip joint and edema of the adjacent muscle groups and posterior lateral soft tissues is unchanged. CT Abdomen [**2152-6-23**]: 1) Biliary ductal dilatation status post stenting. 2) Failure of left hip prosthesis with superolateral distraction. Severe degenerative changes of the right hip. 3) No abscess or diverticulitis identified. EKG [**2152-6-17**]: Sinus rhythm Left atrial abnormality Left axis deviation - consider prior inferior myocardial infarction and left anterior fascicular block but baseline artifact makes assessment difficult Low limb leads voltage - is nonspecific QS configuration in leads V1 and V2 - could be in part - ? positional but consider also prior anteroseptal myocardial infarction Clinical correlation is suggested Since previous tracing of [**2152-6-13**], sinus bradycardia absent and left axis deviation now seen Chest AP Film [**2152-6-11**]: Significant increase in size of bilateral pleural effusions and atelectasis of the lower lobes compared to prior film. Underlying infiltrates cannot be excluded. Brief Hospital Course: 72M [**Hospital3 2558**] resident admitted for 1 day history of acute shortness of breath/hypoxia due to pneumonia requring 24hrs of intubation. Because he was intubated in the ED for airway protection/hypoxic respiratory failure, Mr. [**Known lastname **] was initially admitted to the Medical ICU. His ICU course was notable for transient hypotension immediately after intubation requiring neosynephrine for a few hours, negative cardiac enzymes x 3, successful extubation [**6-12**], a mild transaminitis likely d/t poor perfusion/hypotension, a failed swallow evaluation [**6-13**], and new-onset asymptomatic bradycardia since [**6-13**] AM. His sputum culture came back with moderate MRSA and sparse [**Last Name (LF) **], [**First Name3 (LF) **] as a result, he was started on a 14 day course of IV Vancomycin via PICC and PO Levaquin. So his course by problems: #MRSA Pneumonia - initially intubated x 24hrs for hypoxic respiratory failure and airway protection. The patient was extubated the next day without complication. Transferred to the floor and maintained on a 14 day course of Vancomycin and Levoquin. The patient remained afebrile but had gradual elevation of his WBCC and an accompanying bandemia beginning on [**6-18**]. Further w/u for source had been negative, including blood cx's, cxr, ua, ct abd/pelvis to r/o abscess, and MRI to evaluate for septic joint. However on [**6-23**] a urine culture grew out yeast species. Despite a negative UA, the patient was treated with a 5d course of fluconazole as it was felt that this was a possible of his elevated WBCC. The other most likely etiology is intermittent biliary obstruction, as discussed below. #Cholecystitis- in [**4-28**] pt was admitted with ascending cholangitis (was not manifesting any abdominal pain symptoms) and underwent ERCP stenting of his CBD. Initial plan was for repeat ERCP to remove additional stones but in discussion with Dr. [**Last Name (STitle) 957**] of surgery it was felt that the patient would benefit from open cholecystectomy and subsequent exploration of the biliary tree as an outpatient elecive procedure. During admission the patient's tranasminases and bili have remained normal. #Bradycardia - During the first 48hrs of admission, telemetry revealed intermittent bradycardia to 30s-40s, but patient remained entirely asymptomatic and hemodynamically stable. As a result, his outpatient metoprolol was reduced by half. #Intermittent Chest Pain - has been occurring for past few weeks per patient, but no evidence of EKG changes and was ruled out by CE x 3 initially. A stress MIBI was attempted, but the patient could not lay still enough for the procedure. As a result a dobutamine ECHO was obtained. Mr. [**Known lastname **] developed some NSVT during the dobutamine infusion (not uncommon per cardiology), yet his ECHO failed to reveal any ischemic wall motion abnormalities. Thus, it was thought that he probably does not have active coronary disease. Nevertheless, he was continued on his aspirin, beta-blocker, and ACE. #FEN - despite initial failure, he passed swallow evaluation on [**6-14**], and tolerated regular soft diet/thin liquids during this admission. His electrolytes were checked on a daily basis and repleted as needed. #Chronic Pain Issues ?????? The patient was taking oxycontin 240mg TID (!) as an outpatient. We were able to successfully weane his regimen to 20mg TID at the time of discharge with good control of his pain. #L Hip Dislocation/R Hip DJD - patient has had a long, complicated course with h/o a L septic hip prosthesis that was removed and replaced at the [**Hospital1 756**] [**2-27**] after 6 weeks of IV antibiotics. By report, the organism was [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**]. This was not verified by B&W surgical records. An MRI was obtained of both hips which did not reveal any abscesses or anything suggestive of osteomyelitis. Orthopedics was consulted and feel that the patient would benefit from an outpatient removal of his L hip prosthesis and spacer with an eventual total R hip replacement. He is to remain completely nonweight-bearing on his left lower extremity until after his surgical repair. #Diarrhea - appears to be chronic in nature. Pt was ruled out for C.diff. GI followed in consult for the diarrhea. After an infectious etiology was excluded, the patient was restarted on his outpatient anti-diarrheals (in discussion with his outpt GI doc, Dr. [**Last Name (STitle) 79**] with dramatic improvement. #Proph - the patient was placed on adequate DVT and GI prophylaxis with fall and MRSA precautions #Dispo - PT was consulted, and given all his comorbidities and clinical condition, the patient was deemed most suitable for a skilled nursing facility. He has been discharged with follow-up appointments with Dr. [**Last Name (STitle) 79**] (GI), Dr. [**Last Name (STitle) 49469**] (Ortho), and Dr. [**Last Name (STitle) 957**] (Gen [**Doctor First Name **]). Of note, he will need 3 operations sometime in the near future: a cholecystectomy and bilateral hip replacements. Medications on Admission: metoprolol 25mg [**Hospital1 **] hyoscyamine 0.375mg [**Hospital1 **] cholestyramine 4g qid loperanite 2mg q4hr dicyclone 20mg qid heparin 5000u sq [**Hospital1 **] oxycontin 240mg tid valium 2.5mg q12 artificial tears prn Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 8. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. 9. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12HR Sig: One (1) Capsule, Sust. Release 12HR PO BID (2 times a day). 10. Cholestyramine 4 g Packet Sig: One (1) Packet PO QD (once a day). 11. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral ASDIR (AS DIRECTED). 12. Dicyclomine HCl 10 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 13. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for to peri area. 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Loperamide HCl 2 mg Capsule Sig: Two (2) Capsule PO Q4-6H (every 4 to 6 hours) as needed for Diarrhea: max 16g/day. 17. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for depression and appetite. 18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (once a day). 19. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: Healthbridge Discharge Diagnosis: MRSA Pneumonia Chronic Diarrhea Asymptomatic Bradycardia Depression Displaced L Hip Prosthesis Intermittent Biliary Obstruction [**12-27**] Numerous Gallstones Discharge Condition: stable - tolerating regular diet, afebrile w/ labs stable Discharge Instructions: 1. Take all your prescribed medications 2. Make sure you go to all your follow-up appointments 3. Keep yourself well-hydrated 4. Call your physician or return to ED for any fevers, chills, increased SOB, cough, lightheadedness, dizziness, inability to tolerate food/drink, or anything else that concerns you Followup Instructions: 1.Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2152-7-4**] 1:40 2.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2152-7-7**] 3:00 3.Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 3628**] SURGICAL ASSOC [**Name11 (NameIs) 3628**]-3A Where: LM [**Hospital Unit Name **] SURGICAL ASSOCIATES Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2152-7-14**] 2:00

[ "518.81", "427.89", "996.4", "276.5", "574.91", "427.1", "401.9", "112.2", "482.41" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11283, 11322

4077, 9209

285, 325

11526, 11585

2091, 4054

11941, 12535

1446, 1455

9482, 11260

11343, 11505

9235, 9459

11609, 11918

1470, 2072

226, 247

353, 1058

1080, 1383

1399, 1430

11,272

186,072

27658

Discharge summary

report

Admission Date: [**2185-6-24**] Discharge Date: [**2185-6-29**] Service: MEDICINE Allergies: Codeine / Atorvastatin Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Post-op care following thoracoscopic left ventricular lead placement Major Surgical or Invasive Procedure: Thoracoscopic left ventricular epicardial lead placements (2) for BiVIDC Removal of coronary sinus lead for BiVICD History of Present Illness: HPI: 83M s/p thoracoscopic LV epicardial lead placement x 2, removal of coronary sinus lead [**6-24**]. Patient experienced increasing shortness of breath over past year. States unable to climb one flight of stairs without becoming breathless and "things that took 20 minutes now took one hour" such as showering. Patient also out of breath after walking about 15 yards. States that did not have problems with PND and has always slept with 2 pillows, mostly because of longstanding vertigo when lying flat. Patient had BiVent placement [**5-18**]. He states that after leaving he had couple of days of feeling better and then felt worse. LV lead was found to be pacing the diaphram and device was turned off. Patient went back to baseline functionality. Post surgery, patient has had non-complicated course, with removal of chest tubes and decreased pulmonary edema. His creatinine increased from 2.4 baseline to 2.8. Today he states that he feels dizzy, or lightheaded, when walking. The lightheadedness does not occur immediately on standing but usually starts when walking 10 yards. He also experienced it when getting up and going to the bathroom and straining to have a bowel movement. He states that the sensation is very similar to other times in the past when he has felt lightheadedness on standing, (not the same as his vertigo). ROS: The patient admits to past history of some urinary obstruction during hospitalizations and states that he experienced this again yesterday, but improved with medication. No nausea. No chest pain or history of chest pain. Reports no history of leg edema. Past Medical History: PMH: CAD Ischemic cardiomyopathy: EF 30%, s/p multiple MIs, CHF (Class III), LBBB in setting of chronic a-fib s/p DCPM COPD CRI: Cr 2.5 ALL: codeine (nausea, dizziness) PSH: BiVICD [**2185-5-18**], PPM 3yrs ago, appendectomy, cholecystectomy, thyroidectomy Social History: Social Hx: printer, retired [**2156**], lives alone with family nearby Non-drinker, smoked tobacco several decades ago. Family History: Fam Hx: Parents CAD at older age Sister--pacemaker Physical Exam: Physical Exam: Admission wt. 70kg VSS Gen: comfortable, conversant HEENT: PERRL, EOMI, MMM, anicteric Neck: No LAD CV: RRR, +S3, +S4, no m/r Lungs: CTAB Abd: soft, nondistended, nontender LE: no edema Patient ambulated with resident to nursing station with no dizziness and no shortness of breath. Pertinent Results: Studies: TEE [**6-24**] MEASUREMENTS: Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) * LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -hypo; * RIGHT VENTRICLE: Moderate global RV free wall hypokinesis. * AORTA: Normal aortic root diameter. Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. * MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**12-6**]+) MR. TRICUSPID VALVE: Mild to moderate [[**12-6**]+] TR. * No spontaneous echo contrast is seen in the left atrial appendage. Resting regional wall motion abnormalities include septal, inferior and posterior HK, apical AK. There is moderate global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-6**]+) mitral regurgitation is seen. There is no pericardial effusion. . TTE [**6-28**]: MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.6 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.6 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 35% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aorta - Ascending: *4.3 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 3.33 Mitral Valve - E Wave Deceleration Time: 211 msec TR Gradient (+ RA = PASP): *35 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s) Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Moderate regional LV systolic dysfunction. No resting LVOT gradient. No LV mass/thrombus. LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; inferior apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Moderately dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. 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 thinning and akineis of the inferior and infero-lateral walls. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. At least moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2185-6-27**] CXR PA AND LATERAL CHEST RADIOGRAPH: Comparison is made with the prior chest radiograph dated [**2182-6-26**]. Thoracic aorta is tortuous. Heart is mildly enlarged in size. Cardiac pacemaker leads are unchanged compared to the prior study. New epicardial leads are noted. Previously noted right IJ line has been removed. There are bibasilar opacities, with interstitial markings bilaterally, predominantly in middle and lower lobes. Small pleural effusion is noted, decreased compared to the prior study. Opacity in left lower lobe has decreased compared to the prior study. IMPRESSION: Mild cardiomegaly and interstitial markings bilaterally representing mild CHF. Decrease in pleural effusion and left lower lobe atelectasis compared to the prior study. Brief Hospital Course: Operative report [**2185-6-24**]: PREOPERATIVE DIAGNOSIS: Left ventricular failure. POSTOPERATIVE DIAGNOSIS: Left ventricular failure. FIRST ASSISTANT: [**Name6 (MD) 67548**] [**Name8 (MD) 67549**], M.D. SECOND ASSISTANT: [**First Name8 (NamePattern2) 3230**] [**Last Name (NamePattern1) 7356**], MD (RES) ANESTHESIA: General endotracheal anesthesia. OPERATIONS: 1.Thoracoscopic left ventricular lead placement x2. 1. Removal of coronary sinus lead. 2. Multilevel Intercostal nerve block. OPERATIVE INDICATIONS: The patient is an 83-year-old gentleman who had previously undergone percutaneous lead placement attempt. This was unsuccessful, and as such, the patient presented with the desire for thoracoscopic placement. After discussion with the patient, it was decided to proceed with thoracoscopic placement. The risks and benefits as well as possible benefits were explained to the patient including but not limited to bleeding, infection, MI, CVA, Death, nerve damage, heart damage, and lung damage and possible blood transfusion and he agreed to proceed. All questions were answered to his satisfaction prior to proceeding with the procedure. OPERATIVE COURSE: The patient was brought to the operating room and placed on the operating table. After the induction of general endotracheal anesthesia, a right internal jugular central line was placed. A transesophageal echocardiogram monitor was used during the case. After anesthesia had completed their invasive line, the patient was turned in the right lateral decubitus position with the left side up. The left thorax was prepped and draped in the sterile fashion. A 2 cm incision was made along the fifth intercostal space. A trocar was inserted. About a 10 mm 30 degree scope was inserted. Upon inspection of the thorax, there was no evidence of any abnormalities. The heart was fairly large. Two other trocars were inserted, one in approximately the sixth intercostal space and the other in the posterior position. Two graspers were used to elevate the pericardium. A knife was used to incise the pericardium sharply, taking care not to injure the myocardium. Next, the pericardium was elevated and retracted, allowing access to the myocardium and epicardium. Two epicardial leads were placed, using a device which was able to screw the leads onto the epicardium. Each epicardial lead was tested and was deemed to be working appropriately with acceptable thresholds. Once the lead had been placed, there were no areas of bleeding after placement of the leads. Two chest tubes were placed, both in the left hemithorax. Then, the patient's previous pacemaker/defibrillator pocket was opened. We then tunneled the two leads to the infraclavicular pocket. The coronary sinus lead was evaluated and was removed by simple traction. At this point, the 2 left ventricular leads were attached to a Y connector and were deemed to be working appropriately after attachment. The serial [**Serial Number 67550**]. The Y addapter was then connected to the pacer/defibrillator box and resecured in the pocket after meticulous hemostasis was achieved. All thoracic incisions were closed in layers We then performed a multilevel intercostal nerve block with 1/4% marcaine with epi [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10585**], MD [**MD Number(2) 10586**] Dictated By:[**Name8 (MD) 67551**] Post operative course: SOB: Patient has baseline SOB from heart failure. He stated that on post operative day 3 from procedure, his shortness of breath was improved somewhat from prior to procedure. He underwent daily physical therapy consults, which demonstrated improved functionality, although the patient had some orthostatic hypotension and decreased oxygen saturation on ambulation. He found manual respiratory exercises (percussion with cough) performed by the physical therapist to be very helpful for his shortness of breath. The patient was euvolemic on presentation and appeared not to require his outpatient lasix dose, probably due to improved heart function. By the end of his stay he had developed some mild fluid overload and was discharged on lasix 40 mg every other day with instructions to titrate up or down under the direction of his primary care physician. [**Name10 (NameIs) **] ejection fraction was measured as 35% with TTE postoperatively. . Post-op skin care: The patient had chest tubes postoperatively which were removed without complication and was discharged with instructions on care for the wound sites. Patient had also developed a rash from removal of surgical tape and was given silvadene cream for that. . 3. Kidney function: Patient's creatinine increased from baseline of 2.4 to 2.8 during stay, but was trending downward on discharge. He may benefit from an ACE inhibitor as an outpatient, as determined appropriate by his primary care physician and cardiologist. * 4. Anticoagulation: The patient was maintained on his regular coumadin regimen. * Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet 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. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Except Tuesday. 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every other day. Disp:*30 Tablet(s)* Refills:*2* 8. Silvadene 1 % Cream Sig: One (1) Topical once a day for 5 days: Please apply only to areas of skin irritation. Do NOT allow cream to get on incision sites. . Disp:*1 tube* Refills:*0* 9. [**Male First Name (un) **] Stockings Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: Ischemic cardiomyopathy Congestive heart failure Secondary: COPD Chronic renal insufficiency Discharge Condition: Stable Ambulating Requires further physical therapy Tolerating normal diet Discharge Instructions: 1. Surgery wound sites: Do not put creams, lotions or powders on the incision sites. Keep open to the air. * 2. Do not have tub baths and do not swim for one month. You may have baths and swim once the incisions are fully healed. * 3. You may shower. Wash incision areas gently with mild soap and water, rinse, and then pat dry. * 4. You may apply Silvadene cream (1%) to the areas of skin irritation. DO NOT get silvadene cream on the incision scars. * 5. Please weigh yourself every day. If you gain more than 3 pounds in a day, you may be becoming fluid overloaded. Contact your physician. * 6. Please move from sitting to standing slowly. If you feel yourself getting dizzy or lightheaded, do not walk without assistance. * 7. If you have chest pain or increased shortness of breath, please contact your physician. * 8. You have been discharged on Furosemide 40 mg--take one pill every other day. If you have shortness of breath and weight gain or if you have decreased blood pressure, you may need to adjust the dose of the medication up or down. Please contact your physician. Followup Instructions: 1. You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14966**] on [**7-8**]. at 5:15 pm. Please call his office at ([**Telephone/Fax (1) 64863**] to confirm. * 2. You have an appointment with Dr. [**Last Name (STitle) 914**] scheduled for [**8-3**], 2:00 PM. * 3. You should have your INR level checked within the next two weeks. If your INR (coagulation) level is not in the therapeutic range, you should contact your physician. * 4. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 33129**] Follow-up appointment should be in 2 weeks Completed by:[**2185-7-15**]

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icd9pcs

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27698

Discharge summary

report

Admission Date: [**2163-6-8**] Discharge Date: [**2163-6-10**] Date of Birth: [**2101-12-2**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 2485**] Chief Complaint: shortness of breath and chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 61m with IPF on 2L home o2, HTN, CAD s/p MI and PTCA [**2150**], PTSD who developed increasing dyspnea, hypoxemia, and chest pressure at home. About three weeks prior to admission, he was on a trip to [**State 108**] when he developed increasing dyspnea, cough, and sputum production, no fevers or chills; a prescription for levofloxacin was called in, and he took it for ten days. Upon returning to [**Location (un) 86**], he felt about the same and came to the pulmonary clinic where a chest CT showed worsened [**Last Name (LF) **], [**First Name3 (LF) **] his levofloxacin course as extended another tend days, and azithromycin was added. He said he was beginning to feel better by the end of the course (2d prior to admit), but then one day before admit began to feel worn down and noticed he was requiring more oxygen when he exerted himself. He says his exertional dyspnea was coming on more easily and was taking longer to resolve. At 2:30am on the morning of admission, he awoke with the sudden onset of dyspnea that improved while sitting up in a chair. He routinely checks his home oximetry and noted that he was desaturating to the low 80's on 5L-nc. He's also developed intermittent chest pressure, mainly during desaturations that was relieved temporarily with one sublingual ntg. After a few hours of symptoms, he went to [**Hospital3 24012**] by EMS, where he was given ceftriaxone and asa; he was transferred to [**Hospital1 18**] and given levofloxacin. A CTA at [**Hospital1 18**] showed no pulmonary embolism but significant, diffuse worsening of ground-glass opacities. In the ED he was put onto a 100%-nrb mask and maintained sats in the mid-high 90's at rest, but continued to desat to the 70's-80's with even minimal exertion. At the time of admission, he said he was feeling a bit better than he had that morning. Otherwise, he says his weight has been stable, and he's had no lower extremity edema. He denies fevers or chills, significant cough, sputum, hemoptysis, wheeze, abdominal pain, n/v/d/c, or urinary symptoms. . Past Medical History: -IPF: diagnosed [**8-/2162**] after developing one yr of progressive dyspnea with negative cardiac eval; chest CT with subpleural honeycombing, [**Year (4 digits) **]'s; bx with evidence of UIP; enrolled in Capacity trial (on pirfenidone, anti-tgf-b1 and anti-pdgf); last pft's [**2-/2163**] FVC 58%, FEV1 64%, TLC 58%, DLCO 42%, DL/VA 82%. -HTN -CAD: MI and PTCA to LCX [**2150**] -Prior etoh abuse -PTSD -Bipolar disorder Social History: Pt a retired quality engineer, married, lives with his wife. [**Name (NI) **] smoked [**3-20**] ppd x 30-40yrs, quit in [**2150**]. Family History: No known fhx of lung disease. Mother with [**Name2 (NI) 499**] cancer, sister with breast cancer. Physical Exam: t 100.6, bp 91/70, hr 92, rr 26, spo2 94% on 100%NRB gen- lying nearly flat in bed, nrb mask on, pleasant, interactive, seems in mod resp distress heent- anicteric, op clear with mmm neck- no jvd, lad, or thyromegaly cv- tachy but reg, no m/r/g pul- mod resp distress, intermittenly breathing in midst of sentences, positive accesory muscle use, fair air movement, diffuse dry rales loudest at bases, no wheeze abd- soft, nt, nd, nabs, no hsm back- no cva/vert tendrn extrm- no cyanosis/edema, warm/dry nails- mild clubbing, no pitting/color change/indentn neuro- a&ox3, no focal cn/motor defct Pertinent Results: Labs: [**2163-6-8**] 06:20PM WBC-14.9*# RBC-4.34* HGB-13.3* HCT-37.6* MCV-87 MCH-30.6 MCHC-35.3* RDW-13.7 [**2163-6-8**] 06:20PM PLT SMR-NORMAL PLT COUNT-216 [**2163-6-8**] 06:20PM NEUTS-90.9* BANDS-0 LYMPHS-4.8* MONOS-3.7 EOS-0.3 BASOS-0.3 [**2163-6-8**] 06:20PM GLUCOSE-94 UREA N-12 CREAT-0.8 SODIUM-134 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-14 cTropnT-<0.01 x 3 . Imaging: ECG: nsr, nl axis, nl intervals, probable laa, no lvh, no q's, 0.5-1mm st-depr v2-v5, twi in III and v1; no major change from prior. . Lung biopsy [**8-/2162**]: Features are consistent with usual interstitial pneumonia (UIP) with associated moderate chronic interstitial inflammation and areas of organizing pneumonitis. . [**2163-6-8**] - CTA chest: 1. Study limited by motion with no evidence of pulmonary embolism or thoracic aortic dissection. 2. Continued demonstration of peripheral honeycombing and interlobular septal thickening with marked interval worsening of diffuse ground-glass opacity as well as interstitial thickening. The rapidity of progression would favor an acute process such as infection as opposed to purely an acute exacerbation of chronic lung disease. The absence of pleural effusions and may weigh against pulmonary edema. 3. Stable mediastinal and hilar lymph nodes. Brief Hospital Course: In brief, the patient is a 61 male with IPF, HTN, CAD, PTSD here with sudden onset worsening dyspnea, hypoxemia, and chest pressure occuring about two weeks after a pneumonia treated with levofloxacin. . #Dyspnea and hypoxemia -- Leading diagnoses included infectious > progressive IPF >> CHF. This was felt to unlikely to be CHF given relatively low BNP and no improvement with >1L of diuresis. The patient was treated with broad spectrum antibiotics for possible infectious sources, steroids (per his pulmonologist's recommendations) and pirfenidone for his IPF. Despite the above and being on large amounts of oxygen the patient continued to become more hypoxic and a decision was made to make the patient CMO. These were discussions held with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2168**], the patient's primary pulmonologist, present. The patient was never intubated and never on non-invasive ventilation, based on his preferences. He was placed on a morphine drip and expired of respiratory distress. . #IPF -- It was felt that the patient's hypoxia could have been caused by his IPF that has significantly worsened or is the substrate upon which another process is acting. As above he was treated with prednisone and continued his pirfenidone study assigned medication. . #CAD -- The patient has a history of CAD, so given his dyspnea and chest pressure (relieved by SL nitro) a work-up was pursued. His cardiac enzymes were negative x 2 and ECG was without significant changes. He was continued on his beta-blocker, aspirin, and lipid lowering agents. . #HTN -- No issues continued on atenolol . #Leukocytosis -- The patient had leukocytosis with no fever. Infectious evaluation including urine cultures, blood cultures and legionella were sent. As above the patient was treated with broad spectrum antibiotics and his wbc count followed. . # Agitation -- The patient was agitated though had intact mentation, which did not appear to track with his low O2 sat. His agitation was likely related to bipolar and underlying personality trait, that was exacerbated by profound dyspnea. He was treated for his dyspnea, continued on home mood stabilizers and given standing lorazepam as well. . # Code status -- Given the patient continued to deteriorate he was made DNR/DNI and CMO and expired of respiratory distress. Medications on Admission: Meds: -Pirfenidone -Rosuvastatin 40mg daily -ASA 81mg daily -Atenolol 100mg [**Hospital1 **] -Ezetimibe 10mg daily -Trileptal 300mg 4x/daily -Esomeprazole 40mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: 1. Hypoxemia 2. IPF 3. CAD 4. Leukocytosis Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7653, 7662

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229, 265

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46,208

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40928

Discharge summary

report

Admission Date: [**2177-7-12**] Discharge Date: [**2177-7-22**] Date of Birth: [**2117-2-4**] Sex: F Service: NEUROSURGERY Allergies: Celexa / optiflux dialyzer Attending:[**First Name3 (LF) 1835**] Chief Complaint: s/p fall, found to have a brain mass Major Surgical or Invasive Procedure: [**2177-7-15**]: IVC Filter [**2177-7-15**]: removal of left IJ HD catheter [**2177-7-19**]: Right Craniotomy and resection of mass History of Present Illness: This is a 60-year-old female who fell following dialysis. She had 5 1/2 L taken off of dialysis but otherwise just did not feel "like herself". She states that she has been having intermittent blurry vision for weeks. Prior to the fall she was moving a chair around, near a landing, and she placed it in such a way that the chair has fallen, and she fell after it. She fell forward hitting her head and back. She went into her apartment, but was still feeling unwell so she called EMS, who took her to [**Hospital6 **]. She never lost consciousness. She walked fine with minimal hip pain after her fall and made it to dialysis. She decided to go to the hospital after this and went to [**Hospital3 **]. She had CT scans of her head and torso, and she was found to have a 2.5 by 2.9 parietal/occiptial mass with vasogenic edema. She does have a history of Non-small cell lung cancer and the fact that she prefers to get her care here. Past Medical History: PAST ONCOLOGIC HISTORY: LLL mass discovered in [**2176**] at time of GI bleed. Bx at [**Hospital1 34**] [**6-/2176**] +NSCLC. No apparent mets then, although workup suboptimal due to "other issues" per Onc note. The lesion 7+cm, attached to post peripheral chest wall, and moved <6mm on 4D scan, volume was felt too large to treat quickly. IMRT plan was superior to 3D conformal plan on normal lung sparing parameters. Per Dr. [**Last Name (STitle) 89344**]. = Biopsy demonstrates TTF-1-positive adenocarcinoma back in [**2176**]. This is felt to be at least Stage IIIA, given presence of bulky mediastinal lymphadenopathy, and large 7cm LLL mass. = At that time felt not to be a surgical candidate = Recommended Rad Onc with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - recommended further eval with mediastinoscopy prior to commiting to either CyberKnife or external beam palliative radition. She failed to have this done because she fell and broke her hip and was hospitalized, then discharged to rehab on [**2177-1-11**]. Now s/p radiation for 6 weeks. PAST MEDICAL HISTORY: # CHF (ef 40% on TTE [**8-26**], class III) # [**Month/Year (2) 2091**] - on dialysis # CAD s/p CABG [**75**] years ago c/b sternal wound infection # Extensive PVD # DVT - now on Coumadin indefinitely # Obesity # Hyperparathyroidism # Hypothyroidism # Anxiety # Type 2 DM # COPD # Benign Hypertension # Anemia (Hct baseline high 20s), also had a GI bleed back in [**2177**] requiring 12 units. Social History: She quit smoking 3 weeks ago (1ppd x 20 years). No etoh or IVDA. She is disabled but formerly worked for red cross. She lives with her husband in [**Name (NI) **]. Family History: Sister with [**Name (NI) 2091**] on HD. Father and mother with DM. Father with CAD Physical Exam: On Admission: Vitals 98.9-66-155/69-98%RA Gen: WD/WN, comfortable, NAD. HEENT: OP clear, supple neck, no JVD. Lungs: CTA bilaterally. Chest: Well healed scar CV: RRR. S1/S2. Abd: Soft, NT, BS+, multiple scars in abdomen, well healed. Extrem: Warm and well-perfused. Neuro: CN II-XII intact grossly, other than loss of vision in Upper Outer quadrant in Left Eye. Skin: Multiple hypopigmented macules diffusely throughout the body. Small abrasion on left hand (she tells me from her fall) At Discharge: Her wound was clean and dry. She is AAOr x 3 with a left field cut (hemianopia]. Pertinent Results: On admission: [**2177-7-12**] 03:55AM BLOOD WBC-5.4 RBC-3.66*# Hgb-10.3* Hct-33.3*# MCV-91 MCH-28.3 MCHC-31.0 RDW-16.5* Plt Ct-211 [**2177-7-12**] 03:55AM BLOOD Neuts-83.4* Lymphs-14.3* Monos-1.8* Eos-0.3 Baso-0.3 [**2177-7-12**] 03:55AM BLOOD PT-34.4* PTT-43.8* INR(PT)-3.3* [**2177-7-12**] 03:55AM BLOOD Glucose-211* UreaN-20 Creat-2.2* Na-139 K-4.2 Cl-100 HCO3-27 AnGap-16 Imaging: From [**Hospital6 33**]: - CT head: 2.5 x 2.9 mass centered within subcortical white matter at the junction of the right posterior parietal and occiipital lobes. surrounding vasogenic edema extending into the posterior superior right temporal lobe. mass effect compressing the right occipital [**Doctor Last Name 534**] and < 5 mm midline shift from the right to the left at the level of the septum pellucidum. no fx - CT abd w/ contrast: no acute abdominal process. - CT chest w/ contrast: 3.1 cm diameter partially calcified pleural based mass at the low posterior left lower lobe, at the site of previously dx lung cancer. - renal is aware of patient, no need for urgent dialysis XRAY [**2177-7-11**]: Four Views of lumbar spine: revela diffuse bone demineralization. No evidence of Acute compression fracture, disc space narrowing or spondylolisthesiis. There is mild low lumbar facet osteoparthropathy. Vascular calcifications are noted. [**Hospital1 18**] IMAGING: [**2177-7-12**] CT C-spine without contrast 1. No acute fracture of the cervical spine. Markedly rotated position and mild motion limit assessment of symmetry of structures. No canal or foraminal stenosis. 2. Enlargement of the main pulmonary artery segment consistent with pulmonary hypertension with associated mild cardiac decompensation. 3. T3 (thoracic 3) vertebral body- mild anterior wedging and superior end-plate depression. Correlate clinically for dedicated imaging. CXR PA and Lateral [**2177-7-12**] 1. Airspace opacity in the left lower lobe, consistent with pneumonia in the appropriate clinical setting. 2. Enlargement of the main pulmonary artery, consistent with diagnosis of pulmonary hypertension. 3. Cardiomegaly and interstitial edema consistent with mild congestive heart failure. CT Head w/o contrast [**2177-7-12**] 3.1 x 2.7 cm right parieto-occipital mass with extensive neighboring edema and moderate neighboring mass effect but no evidence for herniation. CT Head with contrast [**2177-7-13**] A 3.1 x 2.8 cm mass centered in the right parieto-occipital region with avid peripheral enhancement and extensive surrounding vasogenic edema compatible with metastatic disease given the history. [**7-15**] ECHO: The left atrium is dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild to moderate regional left ventricular systolic dysfunction with apical septal akinesis, apical anterior akinesis/hypokinesis, distal apical akinesis/dyskinesis and inferoseptal hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**7-18**] CT Head: IMPRESSION: Stable 3.3 cm right parieto-occipital mass compatible with a history of metastatic lung cancer. [**7-19**] CXR: FINDINGS: The right-sided hemodialysis catheter has been removed. The left chest AICD is in place. There continues to be some retrocardiac opacity that could be due to volume loss or infiltrate. Otherwise, the lungs are clear. Overall, the appearance is similar compared to the study from five days ago. [**7-19**] CT Head: IMPRESSION: Expected postoperative parietal craniotomy changes. Brief Hospital Course: ASSESSMENT/PLAN: 60 yo woman with PMHx of [**Month/Day (2) 2091**] (on HD), CABG, HTN, HL, DM2 and NSCLC who presented from an OSH after a CT head showed a new 2.5x2.9cm mass at the parietal-occipital lobe junction. # intracranial brain mass: Ms. [**Location (un) 89345**] presented with new visual symptoms and a new isolated mass at the parietal-occipital junction, with surrounding vasogenic edema. This likely represents a metastasis from her primary NSCLC. She was treated with dexamethasone to suppress inflammation. She was seen by neurosurgery, neuro-oncology, and radiation oncology. It was recommended that the patient should be on seizure prophylaxis with dilantin. Given the solitary nature of the lesion, the decision was made for surgically removal. Although the patient has multiple comorbidities, neurosurgical intervention was thought to be potentially life-saving. The patient was seen by cardiology and cleared for the operation. She had an ECHO done which showed focal wall motion abnormalities c/w prior cardiac event. She was extubated post-op and taken to the ICU. She was given three doses of post-op Ancef. A corrected serum dilantin level was 4.8 on [**7-21**]. The patient was given a 500mg IV bolus of dilantin. She remained neurologically intact with a persistent field cut. On [**7-19**] the patient was transferred to the neurosurgical service and went to the OR for a craniotomy and resection of tumor. Her pacemaker was interrogated by EP pre-op. Surgery was without complication. She was extubated and transferred to the ICU in stable condition. She remained neurologically stable post op and head CT revealed expected post op changes. On [**7-20**] she was again stable and cleared for transfer to the floor. Her Foley was d/c'd and a CT with contrast was ordered to evaluate for residual tumor. She was discharged on a Decadron taper. # [**Month/Day (4) 2091**]: The patient was continued on HD M,W,F. She was also started on Nephrocaps. The patient got dialyzed the day prior to her operation. On [**2177-7-21**], the patient had Hemodialysis and 7 liters were taken off. Physical Therapy saw the patient and when the patient was out of bed she became orthostatic with SBP to 70/38. The patient was placed back in bed and the blood pressure resolved a systolic of 100. # Lung CA: The patient had a CT torso obtained at OSH that showed stable disease in chest, with no disease in the abdomen. As above, head CT showed new solitary brain lesion, likely metastatic. # CAD s/p CABG [**75**] years ago c/b sternal wound infection: EKG unchanged. We obtained a pre-operative Echo which showed focal wall motion abnormalities c/w prior cardiac event. The patient's home medications were continued. She was also seen by Atrius cardiology who cleared her for surgery. # S/P DVT: Ms. [**Location (un) 89345**] is on lifetime Coumadin. Given the fact that her intracranial mass was going to be surgically resected, it was decided that IR placement of IVC filter was indicated, as anticoagulation would have to be avoided for a few weeks postoperatively. This was done on [**2177-7-15**]. # Type 2 DM: As per the patient, has not been taking any medications since starting HD. During the hospitalization, the patient was given Dexamethasone, with associated elevations in blood glucose. The patient was maintained on insulin sliding scale during the hospitalization. However, after her dexamethasone was increased, her sugars remained very elevated, and ultimately she was started on long acting Lantus 30 units daily, in addition to sliding scale while she was an inpatient. Medications on Admission: - ativan 0.5-1mg Q6H PRN - gabapenting 100mg QD - warfarin 5-10mg QD - pantoprazole 40mg [**Hospital1 **] - clonidine 0.4mg QD - torsemide 40mg QD - renal caps 1 tab QD - calcitriol 0.25mcg QD - fluoxetine 20mg QD - lisinopril 10mg QD - atorvastatin 80mg QD - cireg 25mg [**Hospital1 **] - amlodipine 10mg QD - trazodone Discharge Medications: 1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 2. atorvastatin 80 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). Disp:*60 Capsule(s)* Refills:*2* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever: max 4g/24 hrs. 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 12. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 19. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*30 Capsule(s)* Refills:*2* 20. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 21. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: Starting [**7-23**], Take 1 tab po Q12 hrs ongoing. Disp:*30 Tablet(s)* Refills:*0* 22. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Brain metastasis, lung cancer Secondary: DVT 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: Craniotomy for Subdural/Epidural Hematoma Dr. [**Last Name (STitle) 14354**] [**Name (STitle) **] ?????? 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 have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. 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 were on a medication Coumadin (Warfarin), prior to your surgery, you may safely resume taking this on Day #7 after surgery ([**7-27**]). ?????? **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**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions You are schedule to follow up with [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] on [**2177-8-4**] at 1:00pm. Brain tumor clinic is located on the [**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**] building. You need to make a follow up appointment with your PCP. [**Name10 (NameIs) **] were started on long acting insulin (Lantus) for while you are on steroids. Once the steroids are off, you need to be evaluated and may be able to stop the lantus. You were also given an IVC filter which may be removed in the future. Hematology/Oncology Appointment: When:Wednesday, [**8-6**] at 1:30pm With: Dr.[**Last Name (STitle) **] [**Name (STitle) 2405**] Location: [**Location (un) 2274**]-[**Location (un) 2129**], [**Location (un) 86**], MA Phone:[**Telephone/Fax (1) 3468**] Completed by:[**2177-7-22**]

[ "348.5", "V12.51", "285.21", "403.11", "V53.32", "162.5", "V45.81", "250.00", "198.3", "496", "428.0", "585.6", "V58.61", "E885.9", "428.22" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.7", "86.05", "01.59", "88.51" ]

icd9pcs

[ [ [] ] ]

13996, 14047

7833, 11466

328, 462

14145, 14145

3854, 3854

15855, 16778

3152, 3236

11837, 13973

14068, 14124

11492, 11814

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3251, 3251

3753, 3835

251, 290

490, 1429

7743, 7810

3869, 4269

14160, 14304

2559, 2954

2970, 3136

47,127

160,777

19370

Discharge summary

report

Admission Date: [**2164-1-31**] Discharge Date: [**2164-2-12**] Date of Birth: [**2087-11-12**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1481**] Chief Complaint: Gastric Adenocarcinoma Major Surgical or Invasive Procedure: [**2164-1-31**] Subtotal Gastrectomy, Roux-en-Y History of Present Illness: 76-year-old woman who presented with a gastrointestinal bleed. Workup has shown a gastric ulcer. Biopsies originally were negative, then there was some question of dysplasia. She was re-biopsied and found to have invasive cancer. Since her original episode and being placed on proton pump inhibitors, she has had no more bleeding. Work-up for new metastatic disease has been negative. Options include upfront chemotherapy followed by surgery or initial surgery. Patient was discussed at GI tumor conference and the decision was made to go with surgery first. This will help with the general staging and decision making with respect to any further treatment. This was discussed with the patient and her family with an interpreter present. The procedure of subtotal gastrectomy or possible total gastrectomy was outlined with her including the risks and complications. An informed consent form was signed during her office visit. The patient presented for her surgery on [**2164-1-31**]. Past Medical History: -DM -HTN -Diverticulitis -colonic polyps -GERD -Depression -Anxiety . Past Surgical History: -multiple operations for diverticulitis in the past, s/p sigmoid resection [**2151**] -s/p central hernia repair -operations on her elbow and on fingers -TAH and b/l SPO Social History: She does not smoke or drink. She is not working. Retired fashion designer. Divorced with 2 adult children. Family History: Mother with pancreas cancer at age 62 and a father with lung cancer who was a smoker. Physical Exam: VS: GEN: HEENT: CV: PULM: ABD: EXT: Pertinent Results: POST-OP LABS: [**2164-1-31**] 08:10PM BLOOD WBC-10.0 RBC-4.89 Hgb-12.6 Hct-37.4 MCV-76* MCH-25.8* MCHC-33.7 RDW-14.7 Plt Ct-242 [**2164-2-1**] 06:36AM BLOOD WBC-11.9* RBC-4.69 Hgb-11.9* Hct-36.2 MCV-77* MCH-25.4* MCHC-32.9 RDW-14.9 Plt Ct-240 [**2164-1-31**] 08:10PM BLOOD Glucose-179* UreaN-16 Creat-0.8 Na-140 K-4.0 Cl-106 HCO3-24 AnGap-14 [**2164-2-1**] 06:36AM BLOOD Glucose-200* UreaN-19 Creat-0.8 Na-138 K-4.4 Cl-103 HCO3-25 AnGap-14 [**2164-1-31**] 08:10PM BLOOD Calcium-8.7 Phos-4.3 Mg-1.3* [**2164-2-1**] 06:36AM BLOOD Calcium-8.1* Phos-4.9* Mg-2.5 . IMAGING: [**2164-2-1**] CXR: 1. Small bilateral pleural effusions. No overt pulmonary edema or evidence of pneumonia. 2. NGT with sideport at GE junction [**2164-2-6**]: Supine views demonstrate air-filled, dilated loops of ascending colon and a small amount of rectal gas, in a pattern suggestive of colonic ileus. There is no definite free air or pneumatosis on this limited exam. Suture material in the epigastric area, likely related to the prior surgery. Note is made of midline cutaneous staples and left lower lobe pulmonary opacity, possibly atelectatic. [**2164-2-7**] swallow study Large gastric pouch. No evidence of leak of gastrojejunal Preliminary Reportanastomosis or obstruction of the Roux limb. PATHOLOGY: [**2164-1-31**] Tissue from subtotal gastrectomy, Jejunum: Pending at the time of this discharge summary Brief Hospital Course: The patient was admitted to the West 3 surgery service on [**2164-1-31**] and had a subtotal gastrectomy with a Roux-En-Y. The patient tolerated the procedure well. . Neuro: Pre-Operatively a thoracic epidural was placed for pain control. Post-operatively, the patient received Dilaudid/Bupivicaine through the epidural. The patient then had her epidural split, and was placed on a dilaudid PCA with infusiono of bupivicaine through the epidural. Patient was also on scheduled IV tylenol. The epidural was removed on POD3. When tolerating oral intake,the patient was transitioned to oral pain medications. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: Pulmonary toilet including incentive spirometry and earlyambulation were encouraged. On POD0 in the evening patient had sats down to low 70's on RA, she was put on a face mask initially but refused to continue this. She was then put on a nasal cannula and sats increased to low 90's. A CXR was performed POD1 demonstrating bilateral pleural effusions but no signs of infiltrate. On POD2 the patient was triggered for hypoxia in the AM as her room air O2 saturation was 68%. At the time the patient was mentating fine, BP 130's systolic, and she had tachycardia low 100's NSR on tele. She was put on a face mask and was satting 95%. Patient was started on scheduled nebulizers, aggressive chest PT, and continued encouragement with incentive spirometry. Later in the day the patient was weaned down on her O2 back to 3L and was satting 96%, no longer tachycardic. She was continued on supplemental O2 through nasal cannula and was eventually weaned off the oxygen during her stay. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. An NGT was placed intraoperatively, and discontinued on POD2 after there was no output. Her diet was advanced when appropriate, which was tolerated well. Patient passed flatus. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD3. Intake and output were closely monitored. The patient experienced persistent nausea and was given zofran and compazine. KUB was done on [**2164-2-6**] which showed likely ileus. Patient was continuing to pass flatus but had no BMs. A swallow study was done, which was normal, no leak or obstruction. She was made NPO, her emesis decreased, and her diet was advanced again. She was started on reglan & erythromycin and her emesis continued to improve. . ID: Post-operatively, the patient received 1 dose of Ancef. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD___, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating with a walker, voiding without assistance, and pain was well controlled. Patient was seen by Physical Therapy who recommended that the patient be sent to rehab upon discharge. . TRANSITIONAL ISSUES: 1) Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks 2) Follow-up pathology results from gastric/jejunum tissue 3) Discharge to Rehab Medications on Admission: darifenacin 15', diazepam 2qhs, colace, duloxetine 60', glyburide 10", insuline glargine 50 qpm, metoprolol succinate 100', olmesartan-HCTZ 40/25', simvastatin 20', sitagliptin 100', tramadol, pantoprazole 40", metformin 1000" Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain: do not drink alcohol, drive, or operate machinery while taking this medication. Disp:*60 Tablet(s)* Refills:*0* 2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: not to exceed 4000mg in 24 hours. Disp:*100 Tablet(s)* Refills:*0* 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day: to soften stools while taking narcotic pain medications. Disp:*60 Tablet(s)* Refills:*0* 5. darifenacin 15 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. diazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 9. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. 10. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. olmesartan-hydrochlorothiazide 40-25 mg Tablet Sig: One (1) Tablet PO once a day. 12. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 15. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 16. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q8H (every 8 hours) as needed for nausea for 7 days. Disp:*21 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 17. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): while taking erythromycin. Disp:*10 Tablet(s)* Refills:*0* 18. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Gastric Adenocarcinoma Secondary Diagnosis:Post operative ileus, Hypertension, Hyperlipidemia, Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: Please call ([**Telephone/Fax (1) 1483**] upon discharge to schedule an appointment in the office of Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] in 2 weeks, or with any questions/concerns. Clinic is located in the [**Hospital 2577**] Medical Office Building, [**Location (un) **], [**Hospital1 18**]. Please also call your primary care provider to setup [**Name Initial (PRE) **] follow-up appointment in regards to your diabetes, high blood pressure, and high cholesterol. Department: CARDIAC SERVICES When: TUESDAY [**2164-4-10**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: TUESDAY [**2164-4-24**] at 11:00 AM With: [**Name6 (MD) 6821**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2164-2-12**]

[ "151.8", "530.81", "338.18", "560.1", "401.9", "311", "997.49", "511.9", "V12.72", "250.00", "300.00" ]

icd9cm

[ [ [] ] ]

[ "43.7", "03.90" ]

icd9pcs

[ [ [] ] ]

9016, 9082

3404, 6508

327, 377

9258, 9258

1987, 3381

9440, 10585

1828, 1916

6948, 8993

9103, 9103

6696, 6925

1515, 1687

1931, 1968

6529, 6670

265, 289

405, 1400

9165, 9237

9122, 9145

9273, 9417

1422, 1492

1703, 1812

41,550

101,779

10675

Discharge summary

report

Admission Date: [**2116-12-6**] Discharge Date: [**2116-12-10**] Date of Birth: [**2063-1-24**] Sex: M Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 7591**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation/extubation History of Present Illness: HPI: This is a 53 year-old gentleman with HCV cirrhosis and refractory lymphoblastic lymphoma/ALL on rituximab and prednisone who presents with altered mental status. His mother found him this morning with increased lethargy and complaining of diffuse back pain. The back pain was unchanged from his usual back pain, secondary to his ALL, and was not relieved by morphine or methadone. He was recently admitted to the BMT service from [**11-27**] until [**12-1**] for fevers and progressive ALL. Infectious work-up was unremarkable and his fevers were atrributed to a reaction to platelet transfusion. Of note, he had another admission earlier in [**Month (only) **] at which point he developed a strep viridans line infection (from PICC line)-- the PICC line was removed, he was treated with a course of PCN G which was changed to augmentin at his last admission with the last dose due either yesterday or today. After finding him this morning, his mother brought him back to 7 [**Hospital Ward Name 1826**] today for readmission and an ambulance was called from there to bring him to the ED. . In the ED, initial vitals were T 98.3, BP 122/83, HR 100, RR 12, 100% on 4L. He was sleepy but A+O x3. Pt was noted to be very uncomfortable, complaining of back pain. While in the ED, he became more delirious, writhing around in bed, refusing pain medications, and perseverating on wanting to get out of bed to urinate. Pt was intubated for CT head and abdomen. Spiked temp to 101.8 rectally but remained hemodynamically stable. He was given ceftriaxone, vanco, and acyclovir for empiric meningitis coverage. LP was deferred given platelet count of 14. CT head was negative and CT abdomen was notable for slightly worsened ascites, new bibasilar opacities. Attempts to place OGT and foley were unsuccessful and patient was noted to only have 40cc of UOP while in the ED. . ROS: Unable to obtain. Past Medical History: HEMATOLOGIC/ONCOLOGIC HISTORY: Mr. [**Known lastname 2479**] was diagnosed with lymphoblastic lymphoma in [**2116-1-31**]. He presented to [**Hospital1 18**] on [**2115-12-30**] with complaints of diffuse myalgias and arthralgias. A CT scan demonstrated multiple enlarged portahepatis lymph nodes (largest 1.5 x 2.7 cm)and portacaval lymph nodes (largest 1.9 cm x 3.4 ) as well as multiple mildly enlarged paraaortic lymph nodes, the largest measuring 1.2 x 1.9cm. On [**2116-1-6**], he underwent a CT-guided fine-needle aspiration of a portahepatis lymph node which was nondiagnostic. A bone marrow biopsy was obtained on [**2116-2-26**], demonstrating involvement by high-grade B-cell lymphoproliferative disorder. Tumor cells were diffusely positive for pan B cell markers CD20 and PAX-5, with co-expression of CD10 and bcl-2. TdT staining was equivocal, with predominantly cytoplasmic staining and a rare cell with dim nuclear staining. MIB-1 staining showed an overall proliferation index of 50-60%, with focal areas with a higher fraction. The differential diagnosis was felt to include lymphoblastic lymphoma/leukemia (precursor B-cell lymphoma/leukemia) or a blastic transformation/progression of a mature B cell lymphoma. It was noted that a definitive diagnosis would require flow cytometry and molecular studies, which could not be performed because there were no blasts in the peripheral blood and a marrow aspirate could not be obtained (dry tap). However, the peripheral blood sample was sent for immunophenotyping, which demonstrated a new population of CD34 positive cells and a small population of CD19 positive cells in the "blast" gait, without expression of TdT. It was felt that these findings should be interpreted with caution since no blasts were identified on a corresponding peripheral smear. Given his significant liver dysfunction and other medical co-morbidities, the initial treatment regimen chosen for the patient consisted of R-CHOP, which was initiated on [**2116-3-4**]. He received a second cycle of chemotherapy on [**2116-3-24**], consisting of R-CHOP without vincristine, which was held secondary to neuropathy. Modified Hyper-CVAD Course A was given on [**2116-4-10**], with a second course given on [**2116-5-15**] and a third course on [**2116-6-22**]. Course B was not given due to his history of hepatic cirrhosis. Of note, the patient has known retinal involvement by his lymphoma, for which he is followed by Dr. [**Last Name (STitle) **] of ophthalmology. A liver biopsy on [**5-8**] and repeat bone marrow biopsies on [**6-12**] and [**7-19**] have shown no evidence of recurrent lymphoma. The patient presented on [**2116-10-15**] with myalgias, headache, mental status changes, and fevers. A CBC showed a WBC of 7.2 with 14% blasts. A bone marrow biopsy demonstrated marked fibrosis and relapsed acute lymphoblastic leukemia/lymphoma. He was treated with rituximab 500mg, given in three doses of 100mg, 200 mg, and 200mg on [**10-9**] - [**10-11**]. In addition, he was treated with rituximab 375mg/m2, cyclophosphamide 750mg/m2, doxorubicin 20mg/m2, and dexamethasone 20mg from [**10-19**]- [**10-21**]. The patient was noted to have recurrence of peripheral blasts on [**2116-11-9**], with a bone marrow biopsy on [**2116-11-11**] showing residual leukemia in the marrow. After extensive discussion, he opted to continue palliative chemotherapy with rituximab and prednisone. Rituximab was started on [**2116-11-16**] at 100mg, with plans to continue threrapy with 200mg daily on [**11-17**] and [**11-18**]. ADDITIONAL MEDICAL HISTORY: 1. Hepatitis C, not treated. 2. Hepatic cirrhosis. 3. History of intravenous drug use. 4. History of depression. 5. Chronic lower back pain. 6. Status post tonsillectomy and adenoidectomy. 7. Lipomectomy. 8. Steroid-induced diabetes mellitus Social History: The patient is currently living with his mother and his brother, [**Name (NI) 2259**]. [**Name2 (NI) **] has two children and four grandchildren. He is a recovering heroin addict who used IV drugs for over 30 years before becoming clean, but he admits that he intermittently uses illegal drugs, most recently in early [**Month (only) 359**] (cocaine) and did heroin ~5 years ago. He Currently smoke [**2-2**] cigarretes/day and has history of ~20 pack-year. He denies alcohol use. He formerly worked in housing construction as roof constructor. Family History: The patient's father died of lung cancer at 78. His maternal grandmother died of colon cancer 78. His sister died of leukemia. He has 2 brothers and 2 sisters who are healthy as well as 2 children. He is separated Physical Exam: Vitals: T: 101.1 BP: 87/50 HR: 71 RR: 23 O2Sat: 100% Vent settings: AC 600/14 PEEP 5 FiO2 100% GEN: intubated HEENT: PERRL (4-->2mm), sclera anicteric, no epistaxis or rhinorrhea, MMM, ET tube in place NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, diminished breath sounds at the left anteriorly, no W/R/R ABD: Distended, +BS, difficult to assess HSM, +fluid wave EXT: No C/C/E, no palpable cords NEURO: opens eyes to voice, does not consistently follow commands. Moves all 4 extremities spontaneously. Plantar reflex downgoing. SKIN: Scattered ecchymoses on LUE (by PICC line) and abdomen. No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2116-12-6**] 08:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-1+ [**2116-12-6**] 08:25AM NEUTS-25* BANDS-1 LYMPHS-21 MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* NUC RBCS-15* OTHER-48* [**2116-12-6**] 08:25AM GLUCOSE-211* UREA N-26* CREAT-0.6 SODIUM-140 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 [**2116-12-6**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2116-12-6**] 09:00PM GLUCOSE-133* LACTATE-2.3* NA+-137 K+-5.1 CL--115* [**2116-12-6**] 09:00PM TYPE-ART PEEP-5 O2-60 PO2-92 PCO2-31* PH-7.43 TOTAL CO2-21 BASE XS--2 INTUBATED-INTUBATED [**12-8**] DIC labs + Tbili: 5.1 Alb: LDH: [**Numeric Identifier 35002**] Dbili: 0.8 Fibrinogen: 463 Plt: 24 CXR (s/p intubation): Although on the frontal view, the electronic measurement of the distance from the ET tube tip to the carina is less than 6 cm, the tip is above the upper margin of the clavicles, and it is probably 3 cm above optimal placement, with the discrepancy explained by marked patient kyphosis. Aside from mild plate-like atelectasis at the base of the left base, lungs are clear. There is no pleural effusion. Heart size is normal. . CT abd/pelvis: Slightly worsened ascites. No change in splenomegaly, cholelithiasis, portal lymphadenopathy. Bibasal opacities new since [**Month (only) 359**], could be due to atelectasis, pneumonia, aspiration. . CT head: No evidence of acute intracranial abnormalities. MR with gadolinium would be more sensitive for intracranial infections or masses. . KUB: Non-specific bowel gas pattern without free intraperitoneal air. . CXR PA and lat: Interpretation is limited by patient rotation and kyphotic angulation. However, there is no evidence of pleural effusion or focal consolidation. Allowing for change in positioning, the study is overall not significantly changed since [**2116-11-27**]. There is a focus of linear atelectasis at the left lung base. Wedge compression deformities of two low thoracic vertebral bodies are unchanged. Brief Hospital Course: Patient was a 53 year-old male with a history of relapsing refractory ALL on prednisone and rituximab and HCV cirrhosis who presents with fever, altered mental status, and hypotension. Patient was hypotensive, started on pressors, given IVF, worsened in the setting of adrenal insuffiency, and synthetic hepatic dysfunction. Patient was intubated. Once infectious etiology was eliminated, patient's dim prognosis was discussed with family and a determination was made to make the patient CMO. Patient was extubated and started on morphine drip. Patient, due to high drug tolerance, continued to have pain and was responsive on morphine drip. Patient was transferred from the [**Hospital Unit Name 153**] to BMT floor for CMO continuation. Patient continued to show signs of discomfort and sedatation was switched to dilaudid and ativan drip. Patient expired at 7:20 pm on [**2116-12-10**] secondary to respiratory failure from relapsing refractory ALL in the presence of the family. The proxy, [**Name (NI) **] [**Name (NI) 2479**], the patient's son, consented to a full autopsy. Medications on Admission: Amoxicillin-Pot Clavulanate 500-125 mg PO Q8H Lantus 50u daily Humalog ISS Gabapentin 300 mg PO HS Lactulose 30 ML PO QID Lorazepam 0.5 mg Tablet PO Q4H Filgrastim 480 mcg/1.6 mL Q24H Acyclovir 800 mg PO Q8H Methadone 30mg PO QAM , 20mg PO NOON , 30mg PO QPM Mirtazapine 30 mg PO HS Morphine 15 mg PO Q4H prn Nystatin Suspension 5 ML PO QID prn Omeprazole 20 mg PO DAILY Prednisone 20 mg PO daily Spironolactone 100 mg PO DAILY Allopurinol 300 mg PO DAILY Furosemide 40 mg PO DAILY Acetaminophen 650 mg PO Q4H prn Discharge Medications: expired --- none Discharge Disposition: Expired Discharge Diagnosis: lymphoblastic lymphoma / ALL HCV cirrhosis Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2116-12-10**]

[ "785.52", "249.00", "284.1", "789.59", "200.18", "255.41", "V58.67", "038.9", "724.2", "293.0", "571.5", "E947.9", "276.7", "995.92", "788.29", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

11574, 11583

9886, 10968

293, 316

11670, 11680

7695, 9235

11733, 11770

6710, 6927

11533, 11551

11604, 11649

10994, 11510

11704, 11710

6942, 7676

232, 255

344, 2239

9244, 9863

2261, 6126

6142, 6694

5,850

140,865

46605

Discharge summary

report

Admission Date: [**2133-7-7**] Discharge Date: [**2133-7-10**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old man with history of hypertension, coronary artery disease with three vessel disease status post cath, recent syncopal episode, arrhythmia status post pacemaker placement who presented to ER in respiratory distress. The patient was recently admitted to [**Hospital1 69**] for syncopal episode on [**2133-6-17**]. Prior to syncopal event, the patient had unusual feeling in chest with palpitations. Syncopal work-up suggested cardiac etiology. A cath was done on [**2133-6-18**] which revealed three vessel disease, the left main was 20% occluded distally, LAD 80% at bifurcation of diagonal, left circumflex 50% occlusion at proximal, RCA had total occlusion with filling from left to right collaterals. An echo at that time showed an EF greater than 55%, mild regional left ventricular systolic dysfunction, no AR, 1+ MR, mild symmetric LVH and borderline pulmonary hypertension. EKG was suggestive of prior inferior wall infarct at that time showing Q's in 3 and AVF. During the hospital course the patient had a new onset atrial fibrillation and DDD pacemaker was placed and patient was started on Amiodarone. Since discharge over the past two weeks, the patient has been very fatigued, had difficulty sleeping. He went to the cardiologist, Dr. [**Last Name (STitle) 120**] on [**7-3**] where pacemaker was interrogated and one episode of paroxysmal atrial fibrillation was noted on the pacer. The patient was switched from Metoprolol 25 mg [**Hospital1 **] to Toprol 25 mg q d in order to improve his sleeping. Wife says that patient's sleeping did improve over the last couple nights since switching medication. Over the last couple of weeks the patient has also been complaining of neck and shoulder bone pain, chills and spells in which he reportedly looked [**Doctor Last Name 352**], according to the wife. The patient had not had any palpitations, chest pain, shortness of breath, orthopnea, but occasional ankle swelling. He had reportedly been feeling good on day of admission, went to bed and then starting getting short of breath. The shortness of breath progressively worsened and patient was brought to the Emergency Room. The patient denied chest pain at the time. In the Emergency Room his blood pressure was found to be 200/117, pulse 130, respiratory rate 50, O2 saturation 91% on 100% non rebreather. The patient was alert but very agitated on physical exam. He was noted to have bilateral diffuse crackles [**1-25**] of the way up. EKG at the time showed sinus tachy with questionable ST elevations in V1 and V2. The patient was put on C-pap and given Morphine and Ativan for agitation and Lasix and started on Nitro drip. His blood pressure fell and he was taken off the Nitro drip. His respiratory rate fell with the C-pap and his O2 sats improved. PAST MEDICAL HISTORY: Includes hypertension, coronary artery disease, syncopal event, atrial fibrillation, right colon cancer, status post resection in [**2099**], left colon cancer status post resection in [**2115**], benign prostate hyperplasia status post prostatectomy in [**2116**], thalamic bleed secondary to hypertension in [**2125**] and a renal mass, hemorrhagic cyst in [**2129**]. ALLERGIES: ACE inhibitor which causes angioedema. SOCIAL HISTORY: He is an ex-smoker, used to smoke 2-3 packs per day, quit in [**2131**]. He lives with his wife. [**Name (NI) **] had been the chief of pediatrics at [**Hospital3 **] but then was a general pediatrician at [**Hospital3 1810**] and is now retired. FAMILY HISTORY: Noncontributory. MEDICATIONS: Outpatient medications include Amiodarone 200 mg q d, Fluconazole 100 mg q d, Nystatin 100,000 units, [**3-28**] ml qid and Toprol 25 mg q d. In the hospital the patient was given Morphine 4 mg, Lasix 200 mg IV, Ativan 2 mg and the Nitro drip. PHYSICAL EXAMINATION: The patient had a pulse of 79, blood pressure 139/85, respiratory rate 19, pulse ox 100% on C-pap. He was lying in bed, sedated with C-pap mask on with deep breathing and no acute distress. He had positive external jugular but no internal JVP was discernible. No carotid bruit was appreciated. His rate was regular S1 and S2 with questionable S4, no murmurs, rubs or gallops. Lungs had diffuse crackles, expiratory rhonchi and rales ?????? way up. His abdomen was soft, positive bowel sounds, nontender, non distended, trace edema, 2+ radial pulses, DP pulses not palpable. Neuro, patient was sedated, was not responding to commands. LABORATORY DATA: On his admission his labs were white blood count 12.9, up from 7.5 on [**7-1**], hematocrit 34.8, up from 31.3 on [**7-1**] and platelet count 405,000 with MCV of 86. His neutrophils were 70%, lymphs 21%, monocytes 2.9% and eosinophils 4.4%. Sodium 138, potassium 5.8, 106/22, 36/2.0 and 239 for glucose. His creatinine had been baseline at 1.6 to 1.8. His ABG at 2:30 a.m. was 7.3, 44, 229. His PT was 12.4, PTT 25.9. On his prior admission the patient was noted to have iron of 25, TIBC 260, TSH was 1.3 and free T4 1.0. Retic count 1.7, Vitamin B12 327, Folate greater than 20. His hemoglobin A1C was 6.0. His CEA was elevated at 11. On prior admission the patient's peak CPK was 127 and his peak troponin was 11.2. His EKG on admission was heart rate 130, sinus tachy, no axis deviation, ST depressions in V5, V6 and 1 and [**Street Address(2) 4793**] elevations in V1 through V3. Chest x-ray was consistent with CHF. HOSPITAL COURSE: 1. Cardiovascular: The patient has known coronary artery disease, he was started on Aspirin. Heparin was initially held secondary to his history of thalamic bleed and the fact that he had guaiac positive stools on his last admission on [**6-17**]. Beta blockers were also initially held secondary to his CHF. On admission his CPK was 141 and troponin 2.3. The next day his CPK dropped to 129 but the MB was up at 17 with index of 13.2. His troponin peaked at 20. The patient was started on IV Heparin. His cath was reviewed two weeks earlier and showed severe three vessel disease with 90% lesions in the LAD and total occlusion of the RCA and 70% of left circumflex. Possible options were discussed with him including surgical, PCI and medical management. It was agreed upon that the patient would give a trial of medical management for the time being and if he became symptomatic, he would then go for PCI. During the hospital course his EKG returned to [**Location 213**] in terms of ST elevation. He had no longer had shortness of breath or chest pain and IV Heparin was discontinued and patient was started on beta blocker. The patient had no symptoms of angina or chest pain or shortness of breath during the rest of this hospital course. Pump: Since his chest x-ray was consistent with CHF, the patient was started on Lasix and diuresed 2?????? liters over the first 2 days of his hospital course. His respiratory status significantly improved with the diuresis. An echo was done on the first day of admission and it showed an EF of 30-40% LV systolic function moderately depressed, symmetric LVH, severe hypokinesis of anterior septum and anterior free wall, extensive apical HK, AK, no aortic stenosis, no AR, 1+ MR, pulmonary artery systolic pressure was normal and no pericardial effusion was noted. Compared to the echocardiogram done on [**6-17**], his overall LV function was significantly worse secondary to a major anterior septal infarct/injury. Along with beta blocker, patient was started on Isordil, initially 10 mg tid, then 20 mg tid. He was later switched to Imdur 30 mg q d for discharge. Long-term anticoagulation for stroke prophylaxis was determined to be unnecessary and would be too risky due to the patient's history of thalamic bleeding. Rate & Rhythm: The next morning after admission the patient was noted to be in atrial fibrillation. EP was called and interrogated his pacemaker device which showed that the patient was in paroxysmal atrial fibrillation 6% of the time. He was started on 25 mg of Metoprolol [**Hospital1 **], however, during the course of his admission, he was noted to have a sustained run of atrial fibrillation lasting over three hours. For this reason his beta blocker dosage was increased to 50 mg [**Hospital1 **]. The patient was also started on Amiodarone initially 400 mg tid but later decreased to [**Hospital1 **] as per EP consult. The patient will be taking Amiodarone 400 mg [**Hospital1 **] for the next 7 days at which point he will go to a 400 mg q d dose indefinitely. 2. Pulmonary: Patient initially was in respiratory distress requiring C-pap with pressor support with the face mask, however, after diuresis, the patient no longer required face mask and was put on nasal cannula for which he tolerated having good O2 sats. During the hospital course the patient initially was on nasal canaculi 2 liters. He satted well. That was discontinued and patient continued to sat well on regular room air. 3. Renal: His creatinine was slightly higher on admission than baseline which is normally elevated between 1.6 and 1.8. During the course of his admission his BUN and creatinine remained stable. 4. Heme: The patient presented with a hematocrit of 34. The next day his hematocrit was noted to be 27. He was transfused one unit of packed red blood cells. His hematocrit rose to 31 but the following day fell again to 28.9. He was again transfused one unit of packed red blood cells in order to protect his coronary artery disease. On discharge his hematocrit was 34.8. Since on last admission he was noted to be iron deficient, the patient was started on Iron Sulfate 325 mg q d for which he will take after discharge. 5. GI/Onc: The patient has been worked up as an outpatient, reportedly had a negative colonoscopy recently. However, due to his past history of guaiac positive stool on last admission and the fact that he continues to have anemia, the patient should continue to follow-up with his GI doctor as an outpatient. 6. ID: Patient initially had a slightly elevated white blood count, however, this fell during the course of admission and the patient remained afebrile. 7. Neuro: According to his wife and son, patient after initially being agitated and unresponsive, the patient returned to his normal baseline. There were no active neurological issues. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is going home with VNA services. DISCHARGE DIAGNOSIS: 1. Congestive heart failure. 2. Coronary artery disease with ischemic event, positive troponin. 3. Paroxysmal atrial fibrillation. 4. Anemia. DISCHARGE MEDICATIONS: Metoprolol 50 mg po bid, Imdur 30 mg po q d, Amiodarone 400 mg po bid for the first 7 days, then Amiodarone 400 mg po q d indefinitely, Ferrous Sulfate 325 mg po q d, Aspirin 325 mg po q d. FOLLOW-UP: The patient has agreed to follow-up with his primary care physician [**Last Name (NamePattern4) **] [**12-24**] weeks after discharge. He has also agreed to follow-up with his cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**] at [**Hospital1 69**] within the next 4-6 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**] Dictated By:[**Doctor Last Name 43037**] MEDQUIST36 D: [**2133-7-10**] 15:15 T: [**2133-7-14**] 19:23 JOB#: [**Job Number **] cc:[**Last Name (NamePattern4) 98972**]

[ "414.01", "285.9", "428.0", "V10.05", "518.82", "410.71", "427.31", "V45.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3667, 3945

10755, 11578

10584, 10731

5577, 10466

3968, 5560

115, 2936

2959, 3383

3400, 3650

10491, 10563

73,068

193,819

52841

Discharge summary

report

Admission Date: [**2159-1-23**] Discharge Date: [**2159-1-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname 108981**] is a [**Age over 90 **] year old woman with past medical history significant for HTN, HPL, atrial fibrillation on chronic anticoagulation, breast cancer (s/p mastectomy, on chemotherapy with known metastases to sternum), pulmonary hypertension with baseline 2.5L requirement, presenting from home after developing episode of severe RLQ abdominal discomfort that prompted EMS attention. . Patient is accompanied by her daughter, who helps provide most of the medical history. The patient is not well oriented at baseline per patient's daughter. On day of admission, the patient had sudden onset of RLQ abdominal discomfort that was thought to be anginal equivalent. She has h/o angina has been treated with nitrates and recently restarted BB on [**1-9**] by her PCP. [**Name10 (NameIs) **] patient was noted by EMS to be bradycardic to 30s and was given 0.5mg atropine. On presentation to [**Hospital1 18**], she was noted to be bradycardic to 40s and was also hypotensive to 90/40s. The patient was given another 1mg Atropine and was started on peripheral dopamine. She was also noted to have a low oxygen saturation [**Location (un) 1131**] with a normal pleth. She was started on Bipap, but then vomited. Unclear whether she aspirated. ABG was obtained and revealed PO2 of 116 on BiPAP. . Initial labs in the ED revealed K of 7.0, Cr 2.8, and Lactate 6.8. The patient had blood cultures drawn, CXR that was unremarkable. She was noted to be more coherent and reliably answering questions about her abdominal pain in the ED. Her EKG demonstrated regularized wide complex bradycardia @ 43 BPMs, prolonged QTc to 553, with anterolateral deep T wave inversions. The patient was given Insulin and D50 for her hyperkalemia. . . After an extensive discussion with the patient's daughter, the patient's DNR/DNI status was maintained and declined any interventional procedures (including CVL, temp wire placement, etc), but agreed to medical management. . On transfer, patient was on Dopamine @ 10 mcg/kg/min with Ventricular rates in 70s, MAP > 60. Patient had dry mouth and was a bit more disoriented and agitated. . Unable to obtain thorough cardiac review of systems as patient is disoriented. Per daughter, patient walks with walker, has h/o angina, increasing ankle edema. Unable to assess whether patient has had palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: NONE 3. OTHER PAST MEDICAL HISTORY: # Metastatic breast CA -- on femera, s/p bilateral mastectomies; -- metastatic to sternum since [**2150**] -- c/b RUE lymphedema # emphysema # Severe pulmonary hypertension (likely secondary) # AFib on coumadin # HTN # Hyperlipidemia # Hypothyroidism # Pseudogout # History of UTIs # Hiatal hernia - no operations # h/o Cellulitis in arm and legs - hospitalized 2-4 times # TIAs - 8-10 years ago hospitalized at least once # Macular degeneration in L eye # Broken leg - no surgery # Short term memory loss for several years Social History: - no significant smoking history - no alcohol use - no drug use - no known exposure to asbestos - worked as a teacher, now lives in [**Hospital3 **] home with 3 workers 24/7. Daughter is with her almost every day and is very involved with her care. Family History: - Son with DM type II, HTN, high cholesterol - Daughter with pre-DM, allergies, asthma, LCIS age 48 - Son died age 1.5 yo of presumed liver problems - [**Name (NI) **] was an only child, no known family hx of lung dz or other liver dz - Ashkenazi [**Hospital1 **] decent Physical Exam: Admission exam: GENERAL: Oriented x1 (self). Agitated. HEENT: Sclera anicteric. PERRL, EOMI. Dry mucous membranes. No xanthalesma. NECK: JVP 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI LLSB mid systolic murmur. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c. +2 BLE edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: [**2159-1-24**] 04:36AM BLOOD WBC-9.1 RBC-4.12* Hgb-10.9* Hct-35.0* MCV-85 MCH-26.5* MCHC-31.2 RDW-15.9* Plt Ct-502* [**2159-1-24**] 04:36AM BLOOD Glucose-60* UreaN-75* Creat-2.6* Na-137 K-6.0* Cl-106 HCO3-19* AnGap-18 [**2159-1-23**] 04:55PM BLOOD ALT-11 AST-22 CK(CPK)-64 AlkPhos-141* TotBili-0.7 [**2159-1-23**] 04:55PM BLOOD cTropnT-0.10* Brief Hospital Course: [**Age over 90 **] year old woman with multiple medical problems including long standing metastatic breast cancer, severe pulmonary hypertension, emphysema, atrial fibrillation, presenting with worsened hypoxia and abdominal pain (anginal equivalent), found to have bradycardia and hypotension. She was also found to be septic with a UTI. Discussion of goals of care with patient's daughter (HCP) confirmed desire for non-invasive management. The patient became hypotensive, bradycardic and expired during the morning of [**2159-1-24**] # Sinus Node arrest with accelerated ventricular escape: Patient presented bradycardic and had minimal response to initial dose of atropine, requiring second dose. Has a history of AFib with slow ventricular response. The patient's HCP wished for team to be minimally invasive and to medically manage patient. She was started on peripheral dopamine to support her heart rate and blood pressure. #. Sepsis, related to urinary tract infection: Patient presented hypotensive, bradycardic, and hypothermic. UA floridly positive, grossly cloudy. Lactate 6.8-->4.6 The patient was started on zosyn and vancomycin. # HYPOXIA: Multifactorial in setting of pulm hypertension. Patient needed a NRB with PO2 80s. B/l 2.5L oxygen requirement. Patient has no signs on exam to suggest L sided heart failure. Given history of malignancy, PE should be in DDx. Patient also vomited on BiPap in ED which raised the concern for possible aspiration. # Chonic diastolic heart failure: Significant R sided heart failure. 4+ TR, severe PA HTN. EF 70% on echo [**11-22**]. # Hyperkalemia, secondary to ARF: K 7.0 on admission, 6.4 after 10u Regular insulin + D50. # Acute on Chonic Renal Failure: Cr 2.8, b/l 1.0-1.2. Valsartan was held. Medications on Admission: Nitroglycerin 0.3 mg/hr Patch 24 hr Valsartan 80 mg Daily. Furosemide 80 mg PO QAM Furosemide 40 mg PO QPM Warfarin 1.5 mg daily Gabapentin 300 mg Q24H Letrozole 2.5 mg Atorvastatin 20 mg DAILY Levothyroxine 125 mcg DAILY Ranitidine HCl 150 mg DAILY Metoprolol Succinate 25 mg qday Discharge Medications: None, expired. Discharge Disposition: Expired Discharge Diagnosis: Expired. Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired. Completed by:[**2159-1-24**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7113, 7122

4967, 6742

293, 299

7174, 7184

4600, 4944

7241, 7280

3706, 3978

7074, 7090

7143, 7153

6768, 7051

7208, 7218

3993, 4581

2861, 2866

222, 255

327, 2726

2897, 3422

2770, 2841

3438, 3690

17,667

124,466

11423

Discharge summary

report

Admission Date: [**2207-3-10**] Discharge Date: [**2207-3-17**] Date of Birth: [**2150-9-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4765**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: Cardiac Catherization [**2207-3-12**] History of Present Illness: 56 y/oM with PMH of CAD s/p 5 vessel CABG [**2197**], LIMA to LAD, SVG to OM, Radial to PDA, mild chronic LV systolic heart failure (LVEF 45%), diabetes mellitus, CVA in [**2204**], and PAD who presented to [**Location (un) 620**] ED with 4 hours midsternal chest pain and sob. His BNP was 7000. He was given full dose ASA and nitro spray by EMS which improved his chest pain, but not his SOB. At [**Location (un) 620**] where was given lasix 60mg IV x1 (1400cc out), full dose ASA, sublingual nitro, morphine and started on biPAP with improvement in shortness of breath. EKG at [**Location (un) 620**] was nondiagnostic per report, but troponin returned at 0.2 and he was given lovenox 90mg (0600) for NSTEMI and transferred to [**Hospital1 18**] for possible PCI. EKG nondiagnostic. . In [**Hospital1 18**] ED, initial VS: 80 148/80 28 95%. He was initially seen to have resp distress, but was continued on Bipap 8/5, received ativan 2mg, and started on a nitro gtt with improvement in SOB and resolution of chest pain. Troponin returned at 0.18, BNP at 7200. CXR showed moderate alveolar pulmonary edema as well as moderate cardiomegaly with ?small pleural effusions. On transfer, vitals were HR 93, 146/81, 99 on 50%fio2 on [**9-6**] NIMV mask. Access 18 gauge bilaterally. . On review of systems, he denies states he has gotten bleeding at the site of his psoriasis when taking plavix, and so he stopped it without notifying his cardiologist a few years ago. Cardiologist is now aware. He denies any deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CABG: [**2197**], LIMA to LAD, SVG to OM, Radial to PDA - PERCUTANEOUS CORONARY INTERVENTIONS: [**2198**]: Occluded PDA graft. PCI of the LIMA to LAD touchdown site (3.0x18mm S670) and the native ramus (3.0x32mm EXPRESS) [**2198**]: PTCA of the LIMA to LAD (touchdown) in-stent restenosis and PTCA and beta-brachytherapy of the RI [**2205**] ([**Hospital1 2025**]): 2.5x23 mm Xience stent to OM2 [**2205**] ([**Hospital1 18**]): (LIMA-LAD, Lrad-OM-OM -occluded jump, SVG-Diag occluded, SVG-RCA occluded), and PCI x3 ([**3-5**] 4.0x13mm Velocity Hepacoat postdilated to 4.5mm in pLAD, [**5-5**] 3.0x15mm S670 to distal LAD, 2.5 x 23 mm Xience [**2205-2-11**] in OM2) --> no intervention at that time 3. OTHER PAST MEDICAL HISTORY: - PVD s/p left SFA to anterior tibial bypass graft -angiography [**Hospital1 2025**] [**2205-3-13**] showed right below knee popliteal 75%, right AT occlusion; 95% right TPT and peroneal; occluded right PT; underwent Silverhawk atherectomy and balloon angioplasty of the right popliteal, TPT, AT, PT and peroneal - Chronic LV diastolic > systolic heart failure (LVEF 45%-50%) - Cerebellar stroke [**2204**] - Psoriatic arthritis - on Enbrel - severe lymphedema Social History: Previously worked as consultant, currently on disability. Single, lives with sister who is bipolar and reportedly refuses to allow VNA into house. - Tobacco history: former, quit > 10 yrs ago. 40+ pack yr hx - ETOH: occasional - Illicit drugs: denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: HTN, thyroid Ca, cerebrovascular disease - Father: died at 76 from CVA/TIA. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=97 BP=137/84 HR=92 RR=14 O2 sat=94(6L) GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 12 cm. CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles b/l 1/3 up lung fields. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. EXTREMITIES: b/l lymphedema and venous stasis changes, much worse on L than R. . DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: [**2207-3-10**] 04:49PM BLOOD WBC-7.3 RBC-3.03* Hgb-7.9*# Hct-24.9*# MCV-82 MCH-26.0*# MCHC-31.7 RDW-17.5* Plt Ct-332 [**2207-3-10**] 04:49PM BLOOD PT-14.0* PTT-36.3 INR(PT)-1.3* [**2207-3-10**] 07:51AM BLOOD Glucose-152* UreaN-22* Creat-1.3* Na-137 K-4.8 Cl-104 HCO3-23 AnGap-15 [**2207-3-10**] 07:51AM BLOOD CK(CPK)-104 [**2207-3-10**] 07:51AM BLOOD CK-MB-4 proBNP-7592* [**2207-3-10**] 07:51AM BLOOD cTropnT-0.18* [**2207-3-10**] 04:49PM BLOOD Calcium-8.9 Phos-3.1 Mg-1.6 [**2207-3-10**] 04:49PM BLOOD %HbA1c-5.9 eAG-123 Pertinent Studies: [**2207-3-10**] 07:51AM BLOOD CK-MB-4 proBNP-7592* [**2207-3-10**] 07:51AM BLOOD cTropnT-0.18* [**2207-3-10**] 04:49PM BLOOD CK-MB-2 cTropnT-0.21* [**2207-3-10**] 09:00PM BLOOD CK-MB-2 cTropnT-0.22* [**2207-3-11**] 07:55PM BLOOD CK-MB-3 cTropnT-0.19* [**2207-3-10**] 04:49PM BLOOD %HbA1c-5.9 eAG-123 MRSA SCREEN (Final [**2207-3-11**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2207-3-11**] 2:00 pm SWAB Source: a) left dorsal foot b) left heel. GRAM STAIN (Final [**2207-3-11**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. Cardiac Catheterization Report COMMENTS: 1. Selective coronary angiography of this left dominant system demonstrated severe three vessel coronary artery disease. The LMCA was angiographically-free of any flow-limiting stenoses. The LAD had a long segment of subtotal disease extending into the moderate D1 (unchanged). Distal to the LMCA, the mid/distal LAD did appear to fill but it was diffusely and subtotally occluded. The LCx was noted to have a patent stent in the large major OM2 with 50% disease proximal to the stent, as well as moderate disease distally. The LCx also had an 80% lesion distally in the very small PDA. The occluded OM fills via graft with moderate disease. The RCA was known to be occluded and not injected. 2. Selective conduit angiography of the radial-OM1 graft was patent to the OM1. The SVG-RCA graft was known to be occluded and not injected. The LIMA-LAD was patent and not significantly changed from previous catherization in [**2205**]. 3. Limited resting hemodynamics revealed mildly elevated systemic systolic arterial hypertension, with central aortic pressure of 148/85, mean 111 mmHg. 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Severe native three vessel coronary artery disease unchanged since coronary angiography in [**2205**]. 2. Patent radial bypass to OM1. 3. Patent LIMA to LAD. 4. Patent stent in OM2. 5. Mild systemic systolic arterial hypertension. Echo 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. Left ventricular systolic function is grossly preserved (LVEF ?50-55%?). Image quality is suboptimal for assessment of regional wall motion. The right ventricular cavity is mildly dilated The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [**2205-11-23**], mitral regurgitation and tricuspid regurgitation are now more prominent. Cardiac Cath [**2207-3-12**]: COMMENTS: 1. Selective coronary angiography of this left dominant system demonstrated severe three vessel coronary artery disease. The LMCA was angiographically-free of any flow-limiting stenoses. The LAD had a long segment of subtotal disease extending into the moderate D1 (unchanged). Distal to the LMCA, the mid/distal LAD did appear to fill but it was diffusely and subtotally occluded. The LCx was noted to have a patent stent in the large major OM2 with 50% disease proximal to the stent, as well as moderate disease distally. The LCx also had an 80% lesion distally in the very small PDA. The occluded OM fills via graft with moderate disease. The RCA was known to be occluded and not injected. 2. Selective conduit angiography of the radial-OM1 graft was patent to the OM1. The SVG-RCA graft was known to be occluded and not injected. The LIMA-LAD was patent and not significantly changed from previous catherization in [**2205**]. 3. Limited resting hemodynamics revealed mildly elevated systemic systolic arterial hypertension, with central aortic pressure of 148/85, mean 111 mmHg. 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Severe native three vessel coronary artery disease unchanged since coronary angiography in [**2205**]. 2. Patent radial bypass to OM1. 3. Patent LIMA to LAD. 4. Patent stent in OM2. 5. Mild systemic systolic arterial hypertension. Brief Hospital Course: Mr. [**Known lastname 36509**] is a 56 year old with CAD status-post CABG [**2197**], DM, PAD who presented with chest pain and shortness of breath due to flash pulmonary edema secondary to an NSTEMI. Active Diagnoses: # NSTEMI - Mr. [**Known lastname 36509**] [**Last Name (Titles) 20003**] in for an MI with positive troponins (peak of 0.22). Was medically managed with heparin, Aspirin 325mg, Plavix, carvedilol, and nitrates. Initially, he was placed on a nitroglycerin drip but this was transitioned to Imdur 60mg daily. Catheterization showed severe stable disease, and no intervention was performed. Afterload reduction was obtained with amlodipine with improved chest pain. Pharmacy check revealed that pt has not been taking CAD protective medications in the last few months except for celexa. At the time of discharge, patient was taking imdur 60 mg daily, Aspirin 325 daily, Moexipril 30mg daily, Atorvastatin 80mg daily, Plavix 75mg daily, Carvedilol 25mg tid, amlodipine 10mg daily. . # Acute on Chronic Diastolic CHF- EF 50%. SOB resolved but has new crackles on exam and new O2 requirement. Received 60 mg IV lasix with mod urine output. Had not been taking any diuretics at home. Restarted home Lasix 80mg PO daily. Pt euvolemic at time of discharge. . # Lymphedema/Venous stasis changes: Likely related to PVD, has been an ongoing issue. Patient has not had VNA services for a long time to clean the area. Derm consult recommended applying urea 40% cream daily to thick skin areas. Xeroform gauze to suporative areas on dorsal foot and heel, then wrap in kerlex. Pt refused compression. . # Diabetes Mellitus - Glucose was well maintained with a SSI initially, and was transitioned to glipizide. . # CKD - Creatinine remained at baseline 1.3 to 1.4 throughout the admission. . # HTN - Well controlled with amlodipine, imdur, and carvedilol. . # Psoriatic arthritis - Dermatology recommended 0.05% ointment [**Hospital1 **] for a maximum of 2 weeks while in house to be applied to his knees/abdomen/and back. His usual outpatient regimen was to be resumed upon discharge. Medications on Admission: - ASA325mg daily - Carvedilol 25mg [**Hospital1 **] - Clobetasol 0.05% cream [**Hospital1 **] - Crestor 10mg qhs - Difloasone diacetate 1 application 0.05% ointment [**Hospital1 **] to ankle foot and back - Etanercept 50mg sq weekly - Glipizide 10mg [**Hospital1 **] - Lasix 160mg [**Hospital1 **] - Loprox 0.77% cream [**Hospital1 **] prn foot and ankle - Amlodipine 10mg daily - Halobetasol propionate 0.05% [**Hospital1 **] apply to psoriasis on foot and ankle - Moexipril hcl 30mg PO bid - Vicodine 1 tab q6h prn pain Discharge Medications: 1. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*25 Tablet, Sublingual(s)* Refills:*0* 6. furosemide 40 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. moexipril 15 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 10. lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane twice a day: to painful areas of foot. Disp:*1 tube* Refills:*5* 11. Hibiclens 4 % Liquid Sig: One (1) application Topical daily (). Disp:*1 bottle* Refills:*2* 12. dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 13. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 14. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient Lab Work please check Chem-7 on Friday [**2207-3-20**] at Dr.[**Name (NI) 36505**] office. Discharge Disposition: Home Discharge Diagnosis: Acute on Chronic Systolic congestive heart failure Non ST elevation myocardial infarction Lymphedema Hypertension Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had an acute exacerbation of your congestive heart failure and a small heart attack. You continued to have chest pain after the heart attack but a cardiac catheterization revealed blockages that were not amenable to an intervention. We have adjusted your medicines to minimize your chest pain and your outpatient doctors [**Name5 (PTitle) **] continue to adjust these medicines. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. The dermatology team saw you and recommended physical therapy to treat your swollen legs and creams to help your skin heal. Your kidney function and diabetes seem to be stable at this time. . We made the following changes to your medicines: 1. We suggested that you take plavix but you feel this would be detrimental to your skin issues, you can reconsider this in the future 2. change Crestor to atorvastatin 80 mg daily after your heart attack 3. Continue the aspirin 325 mg daily 4. Continue carvedilol twice daily to lower your heart rate and blood pressure 5. Increase the lasix to 80 mg twice daily 6. Continue the dermatology recommended creams of clobetasol, hibiclens scrub and lidocaine gel as needed for pain. 7. Start Dicloxacillin antibiotic to treat the infection in your skin 8. Start Imdur to prevent chest pain 9. Start nitrogycerin tablets under your tongue as needed for the chest pain. . If you are unable to keep any of your appts, please call to reschedule. Followup Instructions: Department: Dermatology When: Wednesday [**2205-3-18**]:00am With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36511**] MD [**Street Address(2) 36512**], [**Location (un) 620**] MA Department: REHABILITATION SERVICES When: TUESDAY [**2207-3-24**] at 1:30 PM With: [**Name (NI) 2801**] [**Name (NI) **], PT OCS [**Telephone/Fax (1) 2484**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 36513**],MD Specialty: Primary Care Location: INTERNIST ASSOCIATED Address: [**Street Address(2) 21374**], [**Apartment Address(1) 36507**], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 6163**] Appt: Friday, [**3-20**] at 11:45am Name: [**Month (only) 4355**] [**Hospital Ward Name 36514**],MD Specialty: Cardiology When: Wednesday [**4-8**] at 1:30pm Address: [**Street Address(2) 25171**], [**Location (un) **],[**Numeric Identifier 3002**] Phone: [**Telephone/Fax (1) 36510**]

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Discharge summary

report+addendum

Admission Date: [**2100-10-22**] Discharge Date: [**2100-10-27**] Date of Birth: [**2038-4-21**] Sex: F Service: CARDIOTHORACIC Allergies: Iodine Attending:[**First Name3 (LF) 1406**] Chief Complaint: Poor wound healing Major Surgical or Invasive Procedure: [**2100-10-25**] Sternal Debridement with Placement of VAC Dressing History of Present Illness: This is a 62 year old female with coronary artery disease s/p coronary artery bypass graft x 4 on [**2100-9-24**]. Post-op course was eventful for atrial fibrillation and was discharged on post-op day 5. She returned on [**10-11**] for post-op visit with superficial sternal wound (per note, 4-5cm in length and 0.5-1cm in depth). Keflex was started and wound was debrided. She has been packing it with wet to dry dressing changes [**Hospital1 **]. Starting 3 days ago she stared using peroxide instead of saline though. She is being admitted today for IV antibiotics and more definitive wound care. Past Medical History: History of NSTEMI [**2090**] (PCI of LAD and RCA) Hypertension Hyperlipidemia Obesity Type II Diabetes mild PVD GERD insomnia History of left parietal CVA [**2091-11-17**] depression moderate arthritis restless leg syndrome s/p cholecystectomy s/p bladder extension Social History: Lives with: husband and son Occupation: retired (worked in quality control of books) Tobacco: none ETOH: none Family History: Non-contributory Physical Exam: General: NAD, overweight female Skin: Dry [x] intact [x] HEENT: PERRLA [X] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] - decreased at bases Inferior pole to mid-incision, about 5 cm area, tract superiorly, 1.0 cm deep with areas deeper while assessing with q-tip, Heart: RRR [x] Irregular [] murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese Extremities: Warm [x], well-perfused [x] LLE wound healed Edema 1+ edema bilateral Varicosities: None [] small spider veins Neuro: Grossly intact [X] Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: NP Left: NP Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: no bruits Pertinent Results: [**2100-10-22**] 06:00PM BLOOD WBC-7.1 RBC-4.32# Hgb-12.3# Hct-36.1# MCV-84 MCH-28.5 MCHC-34.2 RDW-14.6 Plt Ct-296 [**2100-10-25**] 03:51PM BLOOD WBC-7.5 RBC-3.95* Hgb-10.9* Hct-33.1* MCV-84 MCH-27.5 MCHC-32.9 RDW-14.7 Plt Ct-380 [**2100-10-26**] 02:24AM BLOOD WBC-7.2 RBC-3.67* Hgb-10.3* Hct-30.6* MCV-83 MCH-28.2 MCHC-33.9 RDW-14.6 Plt Ct-309 [**2100-10-27**] 04:18AM BLOOD WBC-5.8 RBC-3.64* Hgb-10.2* Hct-30.9* MCV-85 MCH-28.0 MCHC-33.1 RDW-14.6 Plt Ct-249 [**2100-10-22**] 06:00PM BLOOD Glucose-222* UreaN-17 Creat-0.9 Na-135 K-4.6 Cl-97 HCO3-25 AnGap-18 [**2100-10-25**] 08:57AM BLOOD Glucose-107* UreaN-32* Creat-2.0*# Na-136 K-4.6 Cl-98 HCO3-27 AnGap-16 [**2100-10-26**] 02:24AM BLOOD Glucose-57* UreaN-29* Creat-1.8* Na-136 K-4.4 Cl-104 HCO3-25 AnGap-11 [**2100-10-27**] 04:18AM BLOOD Glucose-117* UreaN-28* Creat-1.7* Na-132* K-4.9 Cl-102 HCO3-24 AnGap-11 [**2100-10-22**] 06:00PM BLOOD %HbA1c-7.6* eAG-171* Brief Hospital Course: Mrs. [**Known lastname **] was admitted with superficial sternal wound infection/dehiscence. Cultures were taken and empiric intravenous antibiotics were initiated. Her creatinine increased to 2.0 and her ACE inhibitors, Lasix, and metformin were stopped. On [**10-25**], she was brought to the operating room. Dr. [**Last Name (STitle) **] performed superficial wound debridement and placement of a VAC dressing. She remained on intravenous antibiotics until wound cultures were finalized. Wound cultures showed only sparse growth of Serratia and only rare growth of Klebsiella with sensitivities to Ciprofloxacin. At discharge, she was transitioned to PO Ciprofloxacin and VAC dressing was continued. Her creatinine was trending downward and on the day of discharge, it was 1.7. She be monitored closely by VNA services who will draw weekly CBC and chem 7, in addition to change VAC every three days. She is scheduled to follow up with Dr. [**First Name (STitle) **] on [**11-8**]. Medications on Admission: AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth once a day CEPHALEXIN - (Prescribed by Other Provider) - 500 mg Capsule - 1 Capsule(s) by mouth four times a day FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth twice a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 80 units daily AM LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 (One) Tablet(s) by mouth twice a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth three times a day OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 10 mg Tablet Extended Rel 24 hr - 1 (One) Tablet(s) by mouth once a day PAROXETINE HCL - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth every twelve (12) hours PRAMIPEXOLE - (Prescribed by Other Provider) - 0.25 mg Tablet - 1 (One) Tablet(s) by mouth twice a day PRASUGREL [EFFIENT] - (Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth once day SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth once day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg iron) Tablet - 1 (One) Tablet(s) by mouth once a day GLUCOSAMINE HCL - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Tablet - 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day 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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO bid (). Disp:*60 Tablet(s)* Refills:*2* 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO once a day for 6 weeks. Disp:*84 Tablet(s)* Refills:*0* 10. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Superficial Sternal Wound Dehiscence Coronary artery disease, s/p CABG on [**2100-9-24**] Obesity Type II Diabetes Mellitus Hypertension Peripheral Vascular Disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tramadol Incisions: Sternal - VAC dressing in place Discharge Instructions: **VNA to draw weekly CBC with diff, and chem 7 weekly while on antibiotic therapy - fax results to [**Telephone/Fax (1) 5793**]** Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Surgeon: Dr. [**First Name (STitle) **] [**2100-11-8**] @ 1PM. Please call to schedule appointments with your Cardiologist: Dr. [**Last Name (STitle) 11493**] in [**3-22**] weeks Primary Care Dr. [**Last Name (STitle) 19219**] in [**3-22**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** **VNA to draw weekly CBC with diff, and chem 7 weekly while on antibiotic therapy - fax results to [**Telephone/Fax (1) 5793**]** Completed by:[**2100-10-27**] Name: [**Known lastname 6458**],[**Known firstname **] Unit No: [**Numeric Identifier 6459**] Admission Date: [**2100-10-22**] Discharge Date: [**2100-10-27**] Date of Birth: [**2038-4-21**] Sex: F Service: CARDIOTHORACIC Allergies: Iodine Attending:[**First Name3 (LF) 135**] Addendum: Added to discharge medications: Lantus (glargine) insulin 30 units at bedtime nightly. Discharge Disposition: Home With Service Facility: [**Company **] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2100-10-27**]

[ "998.59", "278.00", "311", "333.94", "412", "998.32", "443.9", "327.23", "530.81", "250.00", "V12.51", "272.4", "V45.81", "E878.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "86.22", "38.97" ]

icd9pcs

[ [ [] ] ]

9685, 9888

3172, 4157

294, 364

7632, 7774

2231, 3149

8657, 9583

1428, 1446

9606, 9662

7444, 7611

4183, 6144

7798, 8634

1461, 2212

236, 256

392, 994

1016, 1284

1300, 1412

28,734

120,387

51892

Discharge summary

report

Admission Date: [**2140-7-21**] Discharge Date: [**2140-7-26**] Service: MEDICINE Allergies: Codeine / Morphine Attending:[**First Name3 (LF) 2234**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: None History of Present Illness: 88yoF with h/o HTN, hyperlipidemia, diet controlled DM2 presents to the ED for further evaluation of hct drop in the setting of black stools. She was recently seen by her PCP for [**Name Initial (PRE) **] yearly physical at which time she c/o "chronic fatigue" and "lack of appetite" over the past year. Labs drawn at that time revealed a hct of 27.6 (down from previously normal baseline last checked in our system one year ago). Repeat hct was performed today as an oupatient and revealed hct of 21.1. She was sent to the ED for further evaluation where her hct was found to be 20.3. . In discussion with the pt's daughter, [**Hospital **] home health aid reported one episode since her [**2140-7-4**] appt. with her PCP doctor of bright red blood on the seat of the patient's home commode. The amount was not quantified. Her daughter [**Name (NI) **] has been paying close attention since to her mother's bowel movements and reports no bright red blood, but perhaps "darker brown/black stools", not maroon colored, over the past week. Pt. denies abdominal pain, but does note "heartburn" occasionally for which she takes TUMS. Her daughter reports that she was previously taking baby aspirin, but is no longer and has not been using other NSAIDs. . In the ED, initial VS revealed T 98.4 HR 88 BP 11/48 RR 16 O2 sat 100% RA. She received 40mg IV protonix and 1L NS. EKG was without evidence of ischemia. . ROS: No fevers/chills, no CP/SOB, daughter reports increased ankle edema over the past week (not previously noted), chronic lightheadedness/dizziness which predates her hct drop per daughter and pt. No abdominal pain/N/V. + intermittent episodes of diarrhea, not currently. No dysuria/hematuria. Past Medical History: Gastritis (no EGD in our system) Diverticulosis ([**2125**] CT abd/pelvis) Type 2 Diabetes mellitus, diet controlled Hypertension Progressive dementia/memory loss Hyperlipidemia Depression Rheumatoid arthritis Osteoarthritis Fibroid uterus Fibroadenoma of the left breast Right eye cataract S/P right hip replacement Social History: She lives alone in [**Hospital3 **] community. Her daughter [**Name (NI) **] [**Name (NI) 110**] lives nearby. She has assistance with ADL by home health aid. She is a lifelong nonsmoker. She reports prior EtOH, none currently. Family History: Noncontributory Physical Exam: Vitals: 96.0 143/57 86 20 100%RA Gen: Pale, well appearing elderly woman in NAD Skin: Pale HEENT: PERRL, MMM, soft tissue protrusion on mucosa of hard pallate. Pale pink conjunctivae Neck: Supple CV: RRR, no mrg apprec. Resp: CTAB, no w/r/r Abd: +BS, soft, NT, ND Ext: + trace edema b/l ankles, 2+ PT and DP pulses b/l although toes cool b/l Neuro: CN 2-12, strength/sensation grossly intact. Patient oriented to self, but not to place nor date (baseline mental status per pt's daughter) Rectal: guaiac + black stool Pertinent Results: Admission labs: [**2140-7-21**] 10:36AM WBC-8.7 RBC-2.71* HGB-6.4*# HCT-21.1* MCV-78* MCH-23.4* MCHC-30.1* RDW-15.8* [**2140-7-21**] 10:36AM calTIBC-373 VIT B12-648 FOLATE-17.5 FERRITIN-4.9* TRF-287 [**2140-7-21**] 10:36AM IRON-7* [**2140-7-21**] 10:36AM RET AUT-2.8 [**2140-7-21**] 09:25PM PT-11.3 PTT-26.2 INR(PT)-0.9 [**2140-7-21**] 09:25PM GLUCOSE-122* UREA N-16 CREAT-0.8 SODIUM-135 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12 [**2140-7-21**] 09:25PM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-2.2 .. .. Daily CBC's: [**2140-7-22**] 07:54AM BLOOD WBC-7.0 RBC-3.37*# Hgb-8.9*# Hct-26.3*# MCV-78* MCH-26.5* MCHC-34.0 RDW-16.0* Plt Ct-521* [**2140-7-23**] 04:24AM BLOOD WBC-6.2 RBC-3.41* Hgb-8.9* Hct-26.7* MCV-78* MCH-26.0* MCHC-33.2 RDW-16.1* Plt Ct-541* [**2140-7-25**] 06:25AM BLOOD WBC-6.7 RBC-3.61* Hgb-9.0* Hct-28.5* MCV-79* MCH-25.0* MCHC-31.7 RDW-16.9* Plt Ct-565* [**2140-7-26**] 06:50AM BLOOD WBC-5.8 RBC-3.59* Hgb-9.2* Hct-28.4* MCV-79* MCH-25.5* MCHC-32.3 RDW-17.2* Plt Ct-559* .. .. [**7-21**] ECG: Sinus rhythm. Normal ECG. No previous tracing available for comparison. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 79 150 82 368/402.42 49 48 40 . [**7-25**] CXR: AP PORTABLE CHEST: There are low lung volumes producing crowding of the pulmonary vascular markings. There are bilateral streaky opacities at both lung bases. There is slight blunting of the left costophrenic angle that may suggest a tiny effusion. No evidence of pneumothorax. Heart size normal. IMPRESSION: Bibasilar streaky opacities may represent atelectasis or early infiltrates Brief Hospital Course: 88yoF with h/o gastritis and diverticulosis presents with falling hematocrit in the setting of black stools. Follow issues were addressed on this admission: . 1. GI bleed, source undetermined: As above, patient with history of gastritis and diverticulosis. Baseline Hct from [**6-/2139**] was 38. She was found to have a HCT of 27.6 at outpatient PCP visit on [**2140-7-4**] and then 21.1 on follow up labs per PCP. [**Name10 (NameIs) **] per patietn's HCP and daughter, [**Name (NI) **] [**Name (NI) 110**], patient had episode of blood in toilet about a week prior to admission but none since. Also with question of black stools recnetly but no frank blood. Here, hemodynamically stable, largely asymptomatic. NG lavage not successful in the ED. She denied any abdominal pain to suggest perf./acute abdomen. Iron studies reveal profound iron deficiency with iron saturation of approximately 2% (iron 7, TIBC 373, ferritin 4.9), suggesting a more chronic process with probable acute exacerbation/bleed. Pt was admitted to the [**Hospital Unit Name 153**] [**7-21**] and transferred 2 units of PRBCs with HCT response from 19 to 26.3. Over [**7-22**] through [**7-26**] crits remained stable around 28. GI evaluated the patient and initially planned for EGD/colonoscopy on [**2140-7-25**]. She developed delirium on [**7-24**] evening and AM of [**7-24**] marked largely by somnolence without altered vital signs or other change in clinical status. Given a)her crit remained stable and no evidence of further bleeding, b)goals of care and desire to minimize procedures and c)high risk for procedure esp with sedation and likely low benefit as unlikely intervenable lesion given bleeding cessation, after discussion with HCP and GI, decision made to defer colonoscopy/EGD unless evidence of re-bleeding. Remained hemodynamically stable with normal BPs and no tachycardia (she is not beta blocked). Hematocrit on discharge 28. Will need repeat CBC on [**7-28**], results to DR. [**Last Name (STitle) **]. Recommend continuing [**Hospital1 **] PPI to minimize risk of upper re-bleed. Holding aspirin, to be re-started at discretion of Dr. [**Last Name (STitle) **]. . 2. Delirium: ON evening of [**7-24**] and AM of [**7-25**] patient with increased somnolence. Had been agitated night of [**7-23**] and received trazadone early AM of [**7-24**]. Did not sleep night of [**7-24**]. By PM [**7-25**], alert and awake. With cessation of sedating meds and return to normal sleep-wake cycle, patient's delirium and lethargy resolved. See UTI below. . 3. Anemia: This is most likely secondary to chronic oozing GI bleed now with acute bleed from either same or new source. B12 and folate studies were normal. Iron studies as above would suggest a chronic process as would her microcytosis. Additionally of note, pt had elevated platelets in the setting of longstanding iron deficiency anemia. See #1. . 4. Hypertension: Pt initially normotensive off any antihypertensive medications, which were initially held due to the GIB. She was re-started on lisinopril [**7-25**] and has remained normotensive throughout . 5. Type 2 DM, diet-controlled: Last hemoglobin A1C was 6.7% on [**2140-7-4**]. Pt was placed on an insulin SS in house.. . 6. Hyperlipidemia: Pt is not on any medications as an outpatient. . 7. Dementia: Per her daughter's history, her mother is at her baseline as of [**8-10**]. She notes progressive worsening of her dementia most notably over the past year, but denies any recent significant changes in her mental status. Baseline status is alert, oriented to herself and generally place but not date. Able to interact, but very poor short term memory . 8. ?of UTI: Patient agitated night of [**7-23**] into [**7-24**] AM. Self d/ced foley catheter and delirious. Given delirium, UA sent but in setting of traumatic d/c, ua difficult to interpret. Started on cipro [**7-23**]. Urine culture ultimately negative and foley out, therefore cipro d/ced. Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Outpatient Lab Work CBC to be drawn on [**7-28**]. REsults to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 9556**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. GI bleeding, undertemined source 2. Acute blood loss anemia 3. delirium Secondary: 1. dementia 2. hypertension 3. depression Discharge Condition: Stable, ambulating with assistance and walker. Tolerating good PO, at baseline mental status Discharge Instructions: Contact your doctor or go to the emergency room if you develop any signs of bleeding including blood in your stool. If you develop any abdominal pain, fevers, or any other new concerning symptoms, contact your doctor immediately. Take all your medications as prescribed. I have recommended you stop taking aspirin because of it increasing your risk of re-bleeding. The only new medications is protonix, which should be taken twice a day to help reduce your risk of re-bleeding. Follow up as below. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **]. You should have your blood count checked (CBC) on [**2140-7-28**]. You have been given a prescription for this. Call tomorrow to set up an appointment with Dr. [**Last Name (STitle) **]. You should be seen either late this week or early next week. I spoke with Dr. [**Last Name (STitle) **] and he has openings. You also have an appointment with him in the future: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2141-1-2**] 9:30

[ "311", "294.8", "401.9", "285.1", "599.0", "578.9", "250.00", "780.09" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9372, 9430

4880, 8884

235, 241

9601, 9696

3170, 3170

10247, 10817

2590, 2607

8907, 9349

9451, 9580

9720, 10224

2622, 3151

187, 197

269, 1985

3186, 4857

2007, 2325

2341, 2574

27,063

139,787

33213

Discharge summary

report

Admission Date: [**2133-1-19**] Discharge Date: [**2133-2-6**] Date of Birth: [**2053-1-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: temp to 105, ERCP Major Surgical or Invasive Procedure: ERCP IR placement of biliary drain History of Present Illness: 80 y/o M w/history of diabetes, gastric cancer, with recent development of painless jaundice, GNR bacteremia, biliary obstruction, and suspected cholangitis, who presents to the hospitalist service s/p ERCP. . In brief, patient admitted to OSH ([**Hospital3 635**]) on [**2133-1-17**] with progressive generalized weakness over the previous one week. Also with increased darkening of urine. No associated fever, chills, nausea/vomiting. Having difficulty walking and getting around secondary to weakness. . ON admission, CXR showed stable cardiomegaly. Electrolytes significant for cr of 3.2, Bicarb of 18. ALT 151, AST 243, alk phos 686, bili 6.3. CBC showed a WBC count of 34.1 with 22% bands, Hct 33. U/A showed evidence of infection with leukocytes greater than 50 WBC.AST was 243, with ALT of 151, alk phos of 778 and bili of 7.7. U/S was performed and showed intrahepatic and extrahepatic biliary duct dilatation without obvious obstruction. WBc trended down to 18 on antibiotics. blood and urine cx both returned positive for E.coli (pan-sensitive). MRCP was subsequently performed which showed hepatobiliary and gb dilatation with eccentric narrowing of the CBD of the head of the pancreas possibly due to occult mass. no ductal or GB stones detected. Also left lower lobe 3cm pulmonary mass of focal consolidation noted. . Given concern for biliary obstruciton, plan made for transfer to [**Hospital1 18**] for ERCP. . Patient underwent ERCP today which demonstrated tumor infiltration of the duodenum, resulting in inability to reach the major papilla. Therefore will need PTC decompression. . The pt was febrile to 105 on the floor. He was tachy to 130s. He was maintenaining pressure to 140s and his satts were OK. He was xferred to [**Hospital Unit Name 153**] to control the hyperthermia Past Medical History: 1. parkinsons disease 2. diabetes 3. h/o gastric adenoCa diagnosed 6 y/ago 4. s/p colostomy 5. htn 6. h/o TIA 7. h/o chronic anemia 8. h/o GI bleed 9. h/o appy 10. h/o CHF- undocumented type 11. h/o large bowel obstruction [**2-14**] sigmoid volvulus in 10'[**31**]. Social History: married, denies tobacco.drinks one alcoholic beverage a night Family History: NC Physical Exam: VS: 101.1 96 108/62 18 97/2l GEN: lethargic HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, firm, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx0. moving all 4 extremities. Pertinent Results: [**2133-2-2**] CT Scan Chest IMPRESSION:1. Small right pneumothorax, predominantly situated anteriorly, but with a small lateral, likely loculated component within a moderate-to-large right pleural effusion. 2. Small left pleural effusion and small pericardial effusion. 3. Left lower lobe posterior basal segment consolidation, with patchy areas of increased airspace opacities throughout both lungs, most consistent with multifocal pneumonia. 4. Ground-glass attenuation and additional biapical centrilobular opacity most likely reflects a component of superimposed pulmonary edema. 5. Right PICC extends through the right heart, with tip situated in the right hepatic vein. [**2133-2-4**] Renal U/S: 1. No evidence of hydronephrosis. 2. Simple cyst in the upper pole of the right kidney [**2133-2-4**] CXR: In comparison with the study of [**2-3**], there is a subclavian PICC line that extends to the lower portion of the SVC. The diffuse areas of bilateral opacification persist. [**2133-2-5**] 04:20AM BLOOD WBC-14.3* RBC-2.59* Hgb-7.6* Hct-26.0* MCV-100* MCH-29.4 MCHC-29.3* RDW-17.2* Plt Ct-518* [**2133-2-5**] 04:20AM BLOOD Neuts-95* Bands-0 Lymphs-3* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2133-2-5**] 09:51AM BLOOD Glucose-157* UreaN-41* Creat-3.9* Na-140 K-4.1 Cl-103 HCO3-25 AnGap-16 [**2133-2-5**] 04:20AM BLOOD ALT-9 AST-52* AlkPhos-157* TotBili-4.6* [**2133-2-5**] 09:51AM BLOOD Calcium-7.1* Phos-4.5 Mg-1.8 [**2133-1-31**] 04:45PM BLOOD TSH-2.0 [**2133-1-30**] 04:55AM BLOOD [**Doctor First Name **]-NEGATIVE [**2133-1-30**] 04:55AM BLOOD C3-113 C4-31 [**2133-2-4**] 08:31AM BLOOD Vanco-28.8* [**2133-2-5**] 11:15AM BLOOD Type-[**Last Name (un) **] Temp-36.2 FiO2-50 pO2-42* pCO2-63* pH-7.24* calTCO2-28 Base XS--1 Intubat-NOT INTUBA [**2133-1-26**] 08:27PM BLOOD Lactate-1.4 [**2133-2-5**] 11:15AM BLOOD freeCa-0.95* Brief Hospital Course: Mr. [**Known lastname 77158**] is an 80 y/o gentleman with PMH significant for diabetes and gastric cancer, transferred from CCH for ERCP given E.coli bacteremia and biliary obstruction. On transfer he was sent to the ICU for fever of 105 and hypotension. He had ERCP which was unable to relieve biliary obstruction [**2-14**] duodenal mass/obstruction. Biopsy of this mass during ERCP showed adenocarcinoma. He then had IR guided common bile duct stent placement. His hospitalization was complicated by worsening renal failure requiring initiation of dialysis. In addition, he developed a right sided pneumothorax and right sided pleural effusion. Given progressively worsening medical conditions, the family decided to make him comfort measures only and stop dialysis on [**2133-2-5**]. . 1)h/o Gastric cancer - Likely recurrant given duodenal mass biopsy showing poorly differentiated adenocarcinoma c/w recurrance of gastric cancer. Oncology consultation deferred during admission given patient's established relationship with oncologist at [**Hospital3 635**] hospital, Dr. [**First Name (STitle) 7049**], and family's wish to pursue further eval and treatment for recurrent gastric cancer closer to home. . 2)Biliary obstruction: most likely due to obstruction from recurrant gastric cancer. Unable to treat obstruction with ERCP due to duodenal obstruction, so he had IR placed common bile duct stent. He required a second IR procedure with extension of the CBD stent due to persistant obstruction from the duodenal mass. Following the second procedure the external drain was removed and his total bilirubin has continued to trend down and he has remained afebrile suggesting that he now has unobstructed internal biliary drainage. He was treated with levofloxacin (start date: [**1-21**]) and fluconazole (start date: [**1-31**]) for GNR bactermia and sparse growth of [**Female First Name (un) **] from his biliary fluid. These were stopped on [**2-5**] once he was made CMO. . 3)Acute renal failure on chronic kidney disease: baseline creatinine 1.5. His course has been complicated by progressive renal failure in the setting of underlying infection and recurrant gastric cancer. He has been followed closely by renal consultation service, who feel that his renal failure is most likely due to progressive ATN, which was difficult to manage due to pulmonary edema/effusions. There was no evidence of obstruction on renal u/s. He had persistant pericardial friction rub concerning for uremic pericarditis. In addition, he also had worsening repiratory status and developing oliguria which led to initiation of dialysis on [**2133-2-4**]. In further discussions with family, goals of care were changed to CMO on [**2133-2-5**] and dialysis was stopped. . 4)Aspiration pneumonia/pneumonitis - course was complicated by likely aspiration event on the floor which resulted in intubation. He was extubated within 48 hours and did well following. CT scan demonstrated multi-focal infiltrates. He was treated with 13 day course of vancomycin and zosyn for aspiration pneumonia. . 5)Pneumothorax, Pleural Effusion - In the setting of worsening respiratory function and increasing O2 requirements a CT scan of his chest was obtained which demonstrated large right sided pleural effusion, right sided pneumothorax and smaller left sided pleural effusion. He had IR guided thoracentesis, pleural fluid with bilirubin level of 4 and sparse [**Female First Name (un) **]. Given these findings, pneumothorax felt most likely to be a complication of CBD stent placement. Chest tube was considered for treatment of his complicated effusion, however no further intervention was pursued as family decided to change to comfort measures only, with no further invasive procedures. . 6)Atrial fibrillation - new onset during this admission of paroxysmal atrial fibrillation. Controlled with diltiazem. He was not started on anticoagulation given multiple procedures. Diltiazem was stopped once made CMO. . 7)Guaiac positive colostomy output - in setting of elevated INR likely due to nutritional deficiency and multiple antibiotics. Felt most likely due to gastritis/trauma from NG tube placement. He was treated with twice daily PPI and bleeding stopped without intervention. . 8)Pericardial friction rub - most likely due to uremic pericarditis. He had two echocardiograms which did not show any significant pericardial effusion. He was initially started on dialysis however this was stopped due to decision for comfort measures only. . 9)Coagulopathy - INR elevated as high as 2.2 during this admission, felt to be due to nutritional deficiencies and antibiotic therapy. Given IR procedures he was treated with IV vitamin K 1mg x1 and transfused 2 units FFP. . 10) Anemia - HCT slowly trended down during his admission and he was transfused total of 2 units of PRBC's. Also has a component of chronic anemia treated with epoetin prior to admission and during admission. . 11) parkinsons: sinemet was stopped once he was made CMO as he was no longer taking PO medications safely. . 12) Code: CMO . 13) communication: with daughter [**Name (NI) 26**] [**Telephone/Fax (1) 77159**] and wife . 14) Dispo: family would like him transferred back to CCH. . Medications on Admission: Meds at home: sinemet 25/250 1 tablet po tid miralax 1mg PO tid glimepiride [**1-14**] tab qam actos 15mg PO daily avapro 150mg PO daily cartia XT 180mg PO daily aspirin 81mg PO daily procrit 2 times a month . Meds on transfer: Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN asa 81mg daily cardizem 180mg daily colace 100mg [**Hospital1 **] zosyn 2.25gm IV q8 zofran prn nausea Vanco 1g daily. Sliding scale insulin sinemet 25/250 TID protonix 40 [**Hospital1 **] davocet prn Morphine Sulfate 2-4 mg IV Q3-4H:PRN Epoetin Alfa 10,000 UNIT SC QMOWEFR miralax 1mg 3 times daily Heparin 5000 UNIT SC TID Ondansetron 4 mg IV Q8H:PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. 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. 3. Morphine Sulfate 1-10 mg IV Q4H:PRN pain titrate to comfort, inform HO if morphine gtt perferred 4. Lorazepam 0.5-2 mg IV Q4H:PRN agitation titrate to comfort Discharge Disposition: Extended Care Discharge Diagnosis: recurrent gastric cancer biliary obstruction acute renal failure aspiration pneumonia right-sided pneumothorax atrial fibrillation Discharge Condition: comfort care. satting well on 4L NC. afebrile. normotensive. Discharge Instructions: You came to the hospital to have a stent placed in your bile duct. Your course here was complicated by fluid in the lung, worsened kidney function, and fevers. Your family has decided to focus the goals of care on making you comfortable. We are transferring you back to [**Hospital3 **] Hospital to be close to your family. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) 4160**] as needed.

[ "576.1", "576.2", "512.1", "584.9", "507.0", "038.42", "995.92", "250.00", "511.9", "V44.3", "585.6", "332.0", "276.7", "V66.7", "428.0", "427.31", "197.4", "420.0", "401.9", "V10.04", "285.29", "286.9", "535.51", "276.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.07", "39.95", "51.10", "96.6", "38.95", "38.93", "99.04", "45.14", "51.98", "96.71", "34.91" ]

icd9pcs

[ [ [] ] ]

11358, 11373

4953, 10226

331, 367

11547, 11612

3080, 4930

11988, 12058

2585, 2589

10901, 11335

11394, 11526

10252, 10462

11636, 11965

2604, 3061

274, 293

395, 2200

2222, 2490

2506, 2569

10480, 10878

9,680

131,543

51902

Discharge summary

report

Admission Date: [**2186-5-26**] Discharge Date: [**2186-6-1**] Date of Birth: [**2132-5-3**] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is a 54 year-old male patient with a history of a myocardial infarction in [**2176**], which has been treated medically. He had a heart catheterization with an angioplasty in the year [**2184**]. He has had recent increasing shortness of breath with exertion. Catheterization on [**2186-5-23**] revealed a left ventricular ejection fraction of 50%, some inferior hypokinesis, some mild anterior hypokinesis, 100% right coronary artery occlusion with collaterals, 100% left anterior descending coronary artery occlusion with collaterals and an 80% left circumflex occlusion. PAST MEDICAL HISTORY: Significant for coronary artery disease as previously described. Hypertension, hypercholesterolemia and gout. PREOPERATIVE MEDICATIONS: Lipitor 20 mg po q.d., Allopurinol 100 mg po q.d., Toprol XL 100 mg po q.d., Altace 5 mg po q.d., aspirin 325 mg q.d. and nitroglycerin prn. ALLERGIES: The patient denies drug allergies. SOCIAL HISTORY: The patient has a remote smoking history. Alcohol intake is approximately one drink per week. He is married and lives with his wife. PHYSICAL EXAMINATION ON ADMISSION: Unremarkable. HOSPITAL COURSE: The patient was admitted to the hospital and taken to the Operating Room on the day of admission [**2186-5-26**] where he underwent coronary artery bypass graft times four, which was done off pump with a left radial artery graft to his obtuse marginal one and obtuse marginal two as well as a left internal mammary coronary artery to the left anterior descending coronary artery and a saphenous vein graft to the posterior descending coronary artery. Postoperatively, the patient was on nitroglycerin and Propofol intravenous drips. He was transported to the Operating Room for the Cardiac Surgery Recovery Unit where he was subsequently extubated on the evening of surgery. the patient remained hemodynamically stable on postoperative day one. His intravenous nitroglycerin was transitioned to po Imdur. The patient remained hemodynamically stable. Physical therapy evaluation was obtained. The patient's chest tubes were removed on postoperative day two and the patient remained in the Intensive Care Unit until postoperative day three due to inability of beds on the telemetry floor. He was moved out to the telemetry floor on [**5-29**], which is postoperative day three and has continued to progress with cardiac rehabilitation, although was slow to ambulate. He remains hemodynamically stable and has had no significant postoperative sequela and is ready to be discharged home today on postoperative day six [**2186-6-1**]. CONDITION ON DISCHARGE: Temperature 97. Pulse 64. Respiratory rate 18. Blood pressure 110/50. Room air oxygen saturation is 96%. His weight today is 105.7 kilograms. Physical examination, the patient's neurological examination is intact. Pulmonary examination his lungs are clear to auscultation bilaterally. Cardiac examination is regular rate and rhythm. His abdomen is benign. His sternal incision is clean and dry with Steri-Strips intact. His radial harvest sites are also clean and dry and his right leg endoscopic vein harvest incision is clean, dry and intact with some ecchymosis noted in that area. DISCHARGE MEDICATIONS: Lasix 20 mg po b.i.d. times seven days, potassium chloride 20 milliequivalents po b.i.d. times seven days, Colace 100 mg po b.i.d., enteric coated aspirin 325 mg po q.d., Plavix 75 mg po q.d. times three months, Imdur 60 mg po q.d., Lipitor 20 mg po q.h.s., Allopurinol 100 mg po q.d., Toprol XL 100 mg po q.d., Percocet 5/325 one to two tablets po q 4 to 6 prn. The patient was given a prescription for 40 Percocets. Ibuprofen 600 mg po q 6 hours prn pain. The patient is to follow up with his cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in two to three weeks. The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] cardiothoracic surgeon in four weeks. The patient is also to follow up with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11139**] in two to three weeks or as needed. DISCHARGE DIAGNOSIS: Coronary artery disease status post coronary artery bypass graft times four. DISCHARGE CONDITION: Stable. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2186-6-1**] 09:55 T: [**2186-6-1**] 10:22 JOB#: [**Job Number 107448**]

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35693

Discharge summary

report

Admission Date: [**2104-6-3**] Discharge Date: [**2104-6-21**] Date of Birth: [**2041-9-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 598**] Chief Complaint: Colovesicular fistula Major Surgical or Invasive Procedure: [**2104-6-12**] Nasal endoscopy, nasopharyngoscopy endoscopically, and laryngoscopy. History of Present Illness: The patient is a 62 year old male with a cardiac history significant for four vessel CABG in [**2092**] at [**Hospital1 2025**] (now with patent LIMA-LAD and SVG-OM1 and occluded SVG-OM2 and SVG-RPDA), POBA of LCx in [**1-/2103**], and DES to proximal LCX in 5/[**2102**]. He had a CT on [**2104-5-21**] showing a perforated sigmoid diverticular abscess with involvement of the bladder wall. He had a cystoscopy on [**2104-5-23**], which showed a likely colovesicular fistular at the bladder dome, as well as a small lesion at the trigone, which was biopsied and found to be nonmalignant, reactive urithelium. He was admitted to [**Hospital6 33**] on [**2104-5-24**] for urinary retention, abdominal pain, and fever. A catheter was placed, finding 1.5 L of retained urine. He was febrile to 101.7 F at that time, and his antibiotic coverage was broadened from a planned week long course of Cipro to Levofloxacin and Flagyl. . His hospital course was complicated by continued fever, perisepsis, and a subsequent NSTEMI due to demand ischemia. On [**2104-5-26**], he spiked a fever up to 104 F and became tachycardic to at least [**Street Address(2) 81205**] changes. The following morning Troponins were 0.63 and CK was 424, peaking at 1.57 on [**2104-5-28**]. He never had any overt chest pain. . He also developed [**Last Name (un) **] without significant oliguria, likely due to ischemic ATN. His Cr was 1.1 on [**2104-5-27**], steadily increasing over the next few days to a peak Cr of 4.3 on [**2104-5-31**]. His antibiotics were changed to Zosyn in the setting of his worsening condition on [**2104-5-28**], and his clinical status slowly improved. He was transferred to [**Hospital1 18**] on [**2104-6-3**] for further cardiac workup and possible fistula repair surgery. . On arrival to the floor he was clear, coherent, and chest pain free with vitals of T 98.5, BP 187/97, HR 74, RR 20, and SpO2 99% on 4L NC. Blood pressures were reportedly as high as 200/100 at the OSH, and he was reportedly on an Esmolol drip for a brief period, but later titrated to Metoprolol 200 mg PO BID. Per report, but not documented, the patient was intermittently too nauseous to tolerate good PO intake. He had an NG tube in place and had been started on TPN for nutrition at the OSH. . On review of systems, he denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denied any exertional buttock or calf pain. He did report diarrhea and foul cloudy brown urine. . Cardiac review of systems was notable for the absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: PAST MEDICAL HISTORY: # CAD: MI in [**2075**] and [**2078**] -- Four vessel CABG at [**Hospital1 2025**] in [**2092**] -- POBA of LCx on [**2103-2-2**] -- DES to LCx on [**2103-3-29**] # Hypertension # Hyperlipidemia # DM-type II (borderline) # Sleep apnea -- on CPAP # Arthritis -- mostly fingers # Hernia repair as an infant # Arthroscopy of the left knee CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension CARDIAC HISTORY: # CABG: Four vessel in [**2092**] at [**Hospital1 2025**] (patent LIMA-LAD and SVG-OM1, subsequently occluded SVG-OM2 and SVG-RPDA) # PERCUTANEOUS CORONARY INTERVENTIONS: -- In [**2103-2-2**], he underwent PCI (POBA only due to difficulty delivering stent) of the origin LCX with 30-40% residual stenosis and stable mild dissection performed after recurrent angina and an abnormal nuclear stress. -- In [**2103-3-29**], he had a repeat cath for progressive repeated angina. He underwent DES to ostial proximal LCx after showing 80-90% disease. He also had diffuse (60-70%) proximal LCX disease and reported 3VD. . . 2D-ECHOCARDIOGRAM AT OSH: EF 50-55%, LVH, septal hypokinesis, trace MR. . OSH IMAGING: Abdominal CT - colovesicular fistula likely secondary to sigmoid divericuli. . ETT ([**2103-1-23**]): He underwent a nuclear stress test on [**2103-1-23**] where he was able to exercise 6 minutes 35 seconds to a maximum heart rate of 113 bpm. Nuclear imaging revealed an inferior wall MI, mild ischemia in the in the mid to basal septum, inferior and septal hypokinesis, LV systolic dysfunction and an EF of 45%. . Echocardiogram ([**2103-1-2**]): Echocardiogram from [**2103-1-2**] revealed a slightly enlarged LA and aortic root, normal systolic function of both ventricles, and LVEF of 75%. . CARDIAC CATH ([**1-/2103**]): PTCA COMMENTS: Initial angiography showed recurrent severe (80-90%) ostial LCX stenosis followed by diffuse (60-70%) proximal LCX disease. We planned to treat this with PTCA and stenting. Bivalirudin was commenced prophylactically. The patient also receieved ASA and Plavix (chronically on 75 mg daily and was reloaded post procedure with additional 600 mg). A 4.0 XB guide provided excellent support and a Choice PT Extra Support wire crossed the lesion without difficulty. We performed serial inflations staring with 1.5x15 Maverick balloon (at 10-12 ATM), 2.5x15 mm Voyager at 8-12 ATM) and 3.0x15 mm Voyager (at 7-14 ATM). We then delivered a 3.0x15 mm Endeavor DES at 18 ATM, post-dilated with 3.0x15 mm Quantum Maverick at 20 ATM and 3.5x8 mm Quantum Maverick at 10 ATM. Final angiography showed 0% residual stenosis with TIMI 3 flow and no dissection or distal emboli. The patient left the cath lab in stable condition and free from angina. COMMENTS: 1- Successful PTCA and stenting of the ostial-proximal LCX with a 3.0x15 mm Endeavor DES, post-dilated to 3.5. Final angiography showed 0% residual stenosis with TIMI 3 flow and no dissection or distal emboli. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA and stening of the ostial-proximal LCX with an Endeavor Drug-Elluting Stent. . Social History: He is married with two grown children. He works as a general salesman for an elevator company. Smoking: Quit ~20 years ago, previously smoked 2 PPD for 15 years Alcohol: Occasional, social Drugs: None Family History: Father died of a MI at age 32. Otherwise noncontributory. Physical Exam: Physical Exam on Admission: VS: T 98.5, BP 187/97, HR 74, RR 20, SpO2 94% on 4L GENERAL: Middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NG tube in place, NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP flat CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR with normal S1, S2. Loud SEM heard throughout precordium. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles at the bases bilaterally. ABDOMEN: Soft, NT, ND. No HSM or tenderness. Abdominal aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No C/C/E. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Some bruising noted around PICC site. PULSES: ...Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ ...Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . . Physical Exam on Transfer: VS: T 97.7(96.3-98.0), BP 142/86(130-153/83-94), HR 78(64-78) ....RR 18(16-18), SpO2 97(94-98) on RA, uses CPAP for sleep apnea ....Wt 100.2 kg today, 101.6 kg yesterday, 107.3 kg at admission Gen: Middle aged male in NAD. Alert and oriented x3. Mood and affect improved from admission. Resting in bed. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP clear. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. No M/R/G appreciated. Chest: Respiration unlabored, no accessory muscle use. Lungs CTAB. Good air movement. No wheezes, rhonchi, or rales. Abd: Active bowel sounds. Soft, obese, NT, ND. No HSM detected. Foley with yellow/brown urine and some sediment. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: PICC line entry site with ecchymosis, no signs of infection. Healing echymosis on right arm. No other rashes, ecchymoses, or lesions noted. . . Pertinent Results: Hematology: [**2104-6-4**] BLOOD WBC-7.3 RBC-2.77* Hgb-8.9* Hct-25.4* MCV-92 MCH-32.0 MCHC-34.9 RDW-14.5 Plt Ct-222# [**2104-6-11**] BLOOD WBC-6.6 RBC-3.40* Hgb-10.6* Hct-30.7* MCV-90 MCH-31.1 MCHC-34.6 RDW-15.2 Plt Ct-180 . Electrolytes: [**2104-6-4**] UreaN-42 Creat-3.2* [**2104-6-11**] UreaN-29 Creat-3.1* [**2104-6-18**] UreaN-34 Creat-4.3* [**2104-6-20**] UreaN-27 Creat-2.7* [**2104-6-21**] UreaN-27 Creat-2.6* . Cardiac Enzymes: [**2104-6-4**] 12:37AM BLOOD CK-MB-2 cTropnT-0.60* [**2104-6-5**] 05:16AM BLOOD CK(CPK)-27* [**2104-6-5**] 05:16AM BLOOD CK-MB-1 cTropnT-0.45* . . Radiology Report CHEST (PORTABLE AP) Study Date of [**2104-6-3**] 10:08 PM INDICATION: Confirmation of PICC line placement. COMPARISON: No comparison available at the time of dictation. FINDINGS: Status post sternotomy and CABG. The PICC line is inserted over the left upper extremity, the tip projects over the cavoatrial junction. Normal course of a nasogastric tube. Low lung volumes, moderate cardiomegaly without signs of pulmonary edema. No pleural effusion. No focal parenchymal opacity suggesting pneumonia. . TTE (Complete) Done [**2104-6-4**] at 4:20:48 PM Left Ventricle - Ejection Fraction: 45% to 50% Conclusions: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional function is difficult to assess but there appears to be inferior and inferoseptal hypokinesis. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Regional function difficult to assess; probable inferior and inferoseptal hypokinesis with mildly depressed left ventricular function. Mild right ventricular dilation with mild hypokinesis. . Radiology Report RENAL U.S. Study Date of [**2104-6-8**] 2:56 PM HISTORY: Colovesicular fistula with acute kidney failure with recent sepsis, evaluate for abscess or obstruction. RENAL ULTRASOUND: The right kidney measures 11.4 cm. The left kidney easures 11.9 cm. There is no evidence of hydronephrosis, solid renal masses or renal calculi. The right kidney contains a simple cyst in the lower pole measuring 2.7 x 3.1 x 3.7 cm. There is no evidence of perinephric fluid collection. IMPRESSION: No evidence of hydronephrosis or solid renal masses. Simple cyst in the right kidney. . [**2104-6-15**] CT Abd : Progression of segmental diverticulitis of the sigmoid colon with regional focal contained perforation. No free air in the upper abdomen or drainable collections. Exophytic sigmoid diverticulum is increasingly decompressed with an air-fluid level and communication with the urinary bladder is less well visualized given urinary bladder decompression with foley catheter. Stable appearance of the kidneys. Inadequately evaluated hypoattenuating lesions, most likely cystic. Cholelithiasis unchanged. . [**2104-6-16**] Video swallow : No gross aspiration or penetration seen. No evidence of obstruction or extravasation. Brief Hospital Course: The patient is a 62 year old male with a cardiac history significant for four vessel CABG in [**2092**] at [**Hospital1 2025**] (now with patent LIMA-LAD and SVG-OM1 and occluded SVG-OM2 and SVG-RPDA), POBA of LCx in [**1-/2103**], and DES to proximal LCX in 5/[**2102**]. He had a CT on [**2104-5-21**] showing a perforated sigmoid diverticular abscess with involvement of the bladder wall. He had a cystoscopy on [**2104-5-23**], which showed a likely colovesicular fistular at the bladder dome, as well as a small lesion at the trigone, which was biopsied and found to be nonmalignant, reactive urithelium. He was admitted to [**Hospital6 33**] on [**2104-5-24**] for urinary retention, abdominal pain, and fever. His hospital course was complicated by continued fever, sepsis, and a subsequent NSTEMI due to demand ischemia with a Troponin of 1.57 at its peak. He also developed [**Last Name (un) **], likely due to ischemic ATN, with a peak Cr 4.3 on [**2104-5-31**]. He was treated with Cipro followed by Levo/Flagyl followed by Zosyn, and his clinical status improved. He was transferred to [**Hospital1 18**] for further cardiac workup and fistula repair surgery. He received cardiac and renal clearance for his surgery, which is planned for [**2104-6-12**]. . # Perisepsis/Colovesicular Fistula: Patient has a known nidus of infection through his fistula. There is communication of stool and gas into the bladder, though reduced since admission. Patient was febrile as high as 104F with tachycardia at OSH, though he has been afebrile on Zosyn since the 14th. The patient will need the fistula repaired, hopefully in the near future, as the patient will continue to have interrmittent UTIs and associated complications until the issue is addressed. CT images and reports from the OSH were obtained and uploaded. Blood and urine cultures showed no growth. His Foley catheter continues to drain somewhat feculent urine, though much improved from the time of admission. He was continued on Zosyn 2.25 g IV Q6H during his hospital stay. Urology and Surgery were consulted and plan for surgery on [**2104-6-12**]. . # Enzyme leak/NSTEMI: This patient has an excellent story and setting for demand ischemia, given his underlying known CAD, high heart rate, and fevers. Echo on [**2104-6-4**] showed probable inferior and inferoseptal hypokinesis with an LVEF of 45-50%. Given his active renal failure and overall more pressing issues, aggressive medical optimization outweighed cardiac cath. He was increased to full dose Aspirin and his other cardiac medications were continued except for his ACE inhibitor, which was held due to his reduced renal function. Heparin was not appropriate as the event was greater than 48 hours ago and was most likely demans rather than thrombotic in origin. He does need aggressive BP and heart rate control to reduce strain on his heart. . # HTN: He had elevated blood pressures up to SBP 200 at OSH. In the setting of recent demand ischemia, he needed agressive but cautious BP control. He should not receive diuretics or ACE inhibitors given his [**Last Name (un) **]. He was started on a Nitro drip on admission, but maintained SBP 126-171 overnight on [**2104-6-4**] without the drip. The Nitro drip was discontinued on [**2104-6-5**] and he was started on a low dose Nitro patch. He continued to have elevated BP, so Hydralazine 25 mg PO Q6H was added with some improvement. His blood pressures stabilized by [**2104-6-7**] on a combination of Metoprolol 200 mg PO BID, Amlodipine 10 mg PO daily, Hydralazine 25 mg PO Q6H, and Nitro Patch 0.2 mg/hr. On [**2104-6-11**], his Nitro Patch was increased to 0.4 mg/hr due to his BP rising somewhat over the prior few days. . # [**Last Name (un) **]: The patient's Cr was 3.2 on admission, significantly improved from a maximum of 4.3 at OSH, but still increased from a baseline Cr of 1.0 on [**2103-3-30**] in our system. OSH records show a Cr 1.0-1.1 on the days immediately prior to his NSTEMI on [**2104-5-28**]. His [**Last Name (un) **] is most likely due to ischemic ATN in the setting of perisepsis, with a possible component of AIN from multiple antibiotics, though this is less likely. Urine and serum lytes showed UNa 75, UCr 63, SNa 146, SCr 3.1 giving FENa 2.53%, which is consistent with ATN. His urine was positive for rare eosinophils. Renal US on [**2104-6-8**] did not show any evidence of obstruction or abscess. Repeat urine lytes on [**2104-6-9**] showed a FENa of 3.04% and FEUrea of 69.72% with urine osmolality 333, urea 390, Cr 51, Na 72, K 15, and Cl 63. These results remained consistent with ATN. His Cr remained fairly stable in the range 3.0-3.3 since admission. Renal consult agreed with the diagnosis of ATN and was following. . # Anemia: His Hct was quite variable early after admission, possibly representing at least one erroneous value. His Hct on [**2104-6-5**] was recorded as 33.1, close to a previous value of 32.1 on [**2103-3-30**]. Anemia labs including iron panel, B12, folate, retic count, and repeat Hct were sent to work up his anemia. The anemia workup was consistent with anemia of chronic inflammation. GI bleeding was a concern given his history of diverticulosis and recent guaiac positive stools. He also had blood on urinalysis, possibly coming from his colovesicular fistula. His hemodynamics did remain stable during his admission. After starting IV fluids on [**2104-6-8**], his Hct dropped to 28.6, likely due to hemodilution. His Hct stayed below 30 on subsequent labs, and he was given 1 unit of blood on [**2104-6-9**], with a smaller Hct increase than expected. His Hct then stabilized at just above 30. It was recommended to consider transfusing again for Hct <30. An active type and screen was kept on file during his stay. . # Diarrhea: There was obvious concern for C.Diff given the multiple broad spectrum antibiotics he had taken recently. Stool C.diff toxin assay was sent and was negative. His agressive bowel regimen may have been playing a role and was reduced. Urine leakage into the colon from his fistula was another possible contributing factor. His diarrhea improved after admission, but worsened again after resuming PO intake of clears and full liquids. It improved after restarting solid food. . # Bladder Spasm: He did not complain of bladder spasm since admission and did not need the Oxybutinin. It was kept as an active order, however, as Oxybutinin 5 mg PO Q8H PRN. . # Sleep Apnea: He was continued on CPAP while in hospital. . # Diabetes: His diabetes was only borderline prior to admission. His oral diabetes medication were held while in the hospital and he was written for an ISS. However, he required only minimal insulin during his stay since his glucose levels usually remained within a normal range. . # FEN/Lytes: On admission, the patient was NPO with an NG tube and was receiving TPN for bowel rest in setting of his fistula. Surgery recommended advancing diet and discontinuing TPN on [**2104-6-6**]. His NG tube was pulled and he was started on clears, which was subsequently advanced to full liquids, and then a cardiac/diabetic diet. He tolerated this diet well. He had some loose stools after starting a liquid diet, but this improved after starting a regular diet. Due to concern for GI losses, he was started on maintenance fluids, NS at 75 ml/hr. . Pt was transferred taken to the OR on [**2104-6-13**] with intention of performing a sigmoid colectomy and repair colovesicular fistula. During preoperative preparation there was concern that the NGT placement attempt had created a false passage. ENT was consulted and the patient was kept intubated and transferred to the ICU without surgery being performed. He was extubated and started on clears two days later, and transferred to the floor on [**2104-6-15**]. . Pt's post-extubation course was largely unremarkable with excellent pain control, nutritional support, continued dvt and pud prophylaxis, and improving physical exam and clinical picture. One outstanding issue was blood pressure control with transient pressures as high as 170/100 which continued to be refractory to home dose metoprolol and amlodipine. Hydralizine was added with resulting pressures in the 130/80 range. Medications on Admission: HOME MEDICATIONS: Ciprofloxacin 500mg [**Hospital1 **] Metoprolol 200mg [**Hospital1 **] Plavix 75mg [**Hospital1 **] Aspirin 325mg Daily Crestor 40mg Daily Prinivil 10mg Daily . MEDICATIONS ON TRANSFER FROM OSH: Aspirin 81 mg PO daily Plavix 75 mg Daily Heparin 5000 units SC TID Metoprolol 200 mg PO BID Crestor 40 mg PO daily Nitro Paste Nitro SL Zosyn 2.25 g PO Q8H RISS Miralax Zantac 150 mg [**Hospital1 **] Zofran 4 mg Q8H PRN Compazine Phenergan Reglan 5 mg Q6H PRN vomiting Senna Belladonna/opium suppository Tylenol 1000 mg Q6H PRN pain Oxybutinin 5 mg PRN for bladder spasm Hyoscyamine PRN spasms Ambien 5 mg Ativan 0.5 mg PRN anxiety Morphine 2 mg Q2H PRN pain 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. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for bladder spasm. Disp:*90 Tablet(s)* Refills:*2* 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 8. Metoprolol Tartrate 100 mg Tablet Sig: Two (2) Tablet PO twice a day. 9. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). Disp:*30 Patch 24 hr(s)* Refills:*2* 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*90 Tablet(s)* Refills:*2* 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): thru [**2104-6-28**]. Disp:*21 Tablet(s)* Refills:*0* 13. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Primary Diagnoses: Colovesicular Fistula Acute Tubular Necrosis Diverticulitis Hypertension Contusion nasopharynx and oropharynx. Secondary Diagnoses: Non ST Elevation Myocardial Infarction Coronary Artery Disease Diabetes Mellitus Type II Hypertension Hyperlipidemia Diverticulosis 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 to be evaluated for possible repair of your colovesicular fistula, an abnormal connection which developed between your colon and bladder. Prior to your admission here, you developed a serious infection which put strain on your heart and caused a type of heart attack called a Non-ST Elevation Myocardial Infarction (NSTEMI). Based on your medical records and evaluation in the hospital, it was determined that a cardiac catheterization would not be helpful, and that from a Cardiology perspective you would be safe for surgery. Your recent illness also put strain on your kidneys, and caused a type of damage called Acute Tubular Necrosis (ATN). Your kidney function is improving, but is not yet back to normal. Some of your medications were stopped because they should not be used unless the kidneys are functioning properly. You also had some kidney dysfunction after you were treated with Meropenum, an antibiotic used to treat diverticulitis. Following discontinuation your kidney function is back at an elevated baseline. Your blood pressure was significantly elevated when you were admitted to the hospital, and several changes were made to your BP medication regimen in order to bring it back down to a normal level. These medication changes are also listed below. General Surgery and Urology were consulted about repairing the colovesicular fistula. The surgery was scheduled for Thursday [**2104-6-12**] but due to issues in the Operating Room inserting a nasogastric tube the surgery was cancelled and the ENT service performed an endoscopic examination to assess your anatomy for any abnormalities or injuries during the attempted nasogastric tube placement. Other than swelling in the area, no abnormalities were found. You developed acute diverticulitis on [**2104-6-15**] and it has taken a few days for your abdominal pain to resolve. You can now be on a low residue diet and you will stay on suppressive antibiotic therapy until your elective operation which will be 3-5 months down the road as long as you remain free of any abdominal pain. Please stop taking the following medications: STOP: Prinivil 10 mg Daily Please continue taking the rest of your medications as prescribed on your discharge medication list. Followup Instructions: Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**12-19**] weeks. Call your Cardiologist for an appointment next week for a blood pressure check and medication adjustments Call your Urologist at [**Hospital6 33**] for a follow up appointment in 1 month [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2104-6-21**]

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Discharge summary

report+addendum

Admission Date: [**2166-3-30**] Discharge Date: [**2166-5-5**] Date of Birth: [**2085-12-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3021**] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: 1. CT-guided aspiration and drainage of para-duodenal fluid collection (abscess) [**2166-3-31**]. 2. Double lumen PICC left arm [**2166-4-1**] (subsequently removed) and right arm [**2166-4-14**] (extant). 3. Thoracentesis (lung fluid drainage) [**2166-4-7**] and [**2166-4-21**]. 4. Bronchoscopy [**2166-4-9**] 5. Pleurex catheter placement [**2166-4-29**] 6. J tube placement [**2166-4-11**] and J tube replacement/repositioning [**2166-4-25**] History of Present Illness: 80 yo F with recent diagnosis of ovarian adenocarcinoma and a recent PE on enoxaparin who is transferred from an OSH for a bowel perforation. She initially presented to [**Hospital1 18**] in [**2-/2166**] with abdominal pain, nausea, and vomiting from an OSH. A CT scan showed a multicystic pelvic adnexal mass. She was diagnosed with ovarian adenocarcinoma during that admission along with a PE and was started on lovenox. Gyn tumor board recommended that patient start neoadjuvant chemotherapy. She started carboplatin/paclitaxel cycle #1 on [**2166-3-26**] with Dr. [**First Name4 (NamePattern1) 19948**] [**Last Name (NamePattern1) **], her primary medical oncologist, but developed worsening abdominal pain, nausea, and vomiting a few days later. She presented to an OSH and was diagnosed with free intraperitoneal air and a retroperitoneal abscess. Transferred to [**Hospital1 18**] ACS service for further evaluation. The option for surgery was discussed with patient and family; opted not to do it at this time and underwent CT guided IR drainage [**2166-3-31**]. Heme-onc also consulted for febrile neutropenia on [**2166-4-1**] and recommended starting G-CSF (Neupogen) and transfer to the Oncology service. Currently being broadly covered by Vancomycin/Zosyn/Fluconazole. . On the floor, patient admits to some RLQ abd pain. Denies any bloody or maroon stools prior to her dx of ovarian cancer. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Oncologic History: Primary ovarian adenocarcinoma, endometrioid type, grade 1. - initially presented in [**2-/2166**] with lower abdominal pain. - CT abd/pelvis revealed an 8.5cm multicystic pelvic mass arising from the adnexa, as well as simple ascites. No retroperitoneal lymphadenopathy or peritoneal implants were identified. - Tumor markers: CA-125 of 2664, CA19-9 of 17,243, CEA of 33. - CTA for persistent tachycardia and new oxygen requirement revealed multiple subsegmental pulmonary emboli. Enoxaparin was started. - Transvaginal ultrasound guided biopsy [**2166-3-5**] confirmed primary ovarian adenocarcinoma, endometrioid type, grade 1. GynOnc tumor board felt she was not a good surgical candidate due to the recent PE and recommended neoadjuvant chemotherapy, followed by debulking surgery, and adjuvant chemotherapy. - [**2166-3-26**]: Cycle 1 of carboplatin/paclitaxel in [**Location (un) **]. . PMH: - Ovarian adenocarcinoma as detailed above - PE diagnosed on [**2-/2166**] on enoxaparin - Hypertension - Hypercholesterolemia - Overactive bladder/incontinence - Knee arthritis - Pneumonia [**1-/2166**] - Colonoscopy ~7 years ago, normal per patient - Annual mammographies normal per patient . PSH: - Knee arthroscopy - Cataracts Social History: Has several supportive children in the area, and an extensive social network. Tobacco history, quit ~30 years ago; no alcohol or drug use. Never worked outside the home. Lives with her husband with Parkinsons and is his primary caretaker. Family History: Denies any history of breast, ovarian or endometrial cancer. Grandfather had [**Name2 (NI) 499**] cancer in his 70s. Physical Exam: ADMISSION EXAM: VS: 97.7 116/48 92 18 96% on RA GA: elderly F, pleasant AOx3, NAD HEENT: PERRLA. MMM. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: distended. +guarding on right side, softer on left. +hyperactive BS. unable to palpate spleen. TTP in RUQ and RLQ. no rebound tenderness. Extremities: wwp, 2+ edema to knees. DPs, PTs 2+. Pertinent Results: ADMISSION LABS: [**2166-3-30**] 10:00PM WBC-4.5 RBC-2.94* HGB-8.9* HCT-25.9* MCV-88 MCH-30.3 MCHC-34.3 RDW-14.5 [**2166-3-30**] 10:00PM PLT COUNT-116*# [**2166-3-30**] 10:00PM PT-13.5* PTT-33.8 INR(PT)-1.2* [**2166-3-30**] 10:00PM GLUCOSE-123* UREA N-40* CREAT-0.8 SODIUM-138 POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-29 ANION GAP-9 [**2166-3-30**] 10:00PM ALT(SGPT)-26 AST(SGOT)-26 LD(LDH)-236 ALK PHOS-63 TOT BILI-0.6 . Abscess culture results ([**2166-3-31**]): GRAM STAIN (Final [**2166-3-31**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. WOUND CULTURE (Final [**2166-4-2**]): [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. ENTEROCOCCUS SP. SPARSE GROWTH. _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- 0.25 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S <=0.5 S ANAEROBIC CULTURE (Final [**2166-4-4**]): NO ANAEROBES ISOLATED. . [**2166-4-21**] 8:03 pm PERITONEAL FLUID GRAM STAIN (Final [**2166-4-22**]): 1+ (<1 per 1000X FIELD):POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD):BUDDING YEAST. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater. ANAEROBIC CULTURE (Final [**2166-4-26**]): NO ANAEROBES ISOLATED. . Blood cultures [**2166-4-1**], [**2166-4-2**], [**2166-4-11**], [**2166-4-16**], [**2166-4-21**]: Negative. Peritoneal Fluid [**2166-3-31**]: POSITIVE (see above) Peritoneal Fluid [**2166-4-21**]: Mixed types (see above) H. pylori titers blood [**2166-3-30**]: POSITIVE. Helicobacter Antigen Detection Stool [**2166-5-3**]: pending C. difficile toxin assay [**2166-4-1**], [**2166-4-12**], [**2166-4-15**], [**2166-4-17**]: Negative. C. difficile toxin PCR [**2166-4-19**]: Negative Urine culture [**2166-4-2**], [**2166-4-21**]: Negative. Pleural fluid Cx [**2166-4-7**], [**2166-4-21**]: NGTD. [**2166-4-7**] was AFB negative. Bronch wash Cx [**2166-4-9**]: NGTD. AFB negative. Induced Sputum [**2166-4-12**]: AFB negative, PCP negative, no bacteria Induced Sputum [**2166-4-13**]: AFB negative PICC tip Cx [**2166-4-9**]: Negative. Adenosine deaminase [**2166-4-7**]: Negative. Aspergillus galactomannan Ag: Negative. Beta glucan: >500 (false positives from pip/tazo). Quantiferon gold: Indeterminate. . Cytology: [**2166-4-7**] Pleural Fluid Cytology: POSITIVE FOR MALIGNANT CELLS. Consistent with adenocarcinoma. . Imaging: [**2166-5-1**] Abd/Pelvic CT:IMPRESSION: 1. Interval significant decrease in size to right retroperitoneal collection likely related to known perforated duodenal ulcer with appropriate positioning of indwelling pigtail catheter. Air remains within the collection indicating persistent communication to the bowel. 2. Persistent moderate right and large left pleural effusion resulting in mild right lower lobe atelectasis but complete collapse of the left lower lobe. 3. Appropriate positioning to GJ tube with tip well past the ligament of Treitz. . [**2166-4-26**] KUB: ONE-VIEW ABDOMEN: A GJ tube appears in unchanged position. T-fasteners are noted in the left upper quadrant. Contrast is seen within several loops of [**Month/Day/Year 499**]. Pigtail catheter is noted within the right mid abdomen. There is a large left-sided pleural effusion. . [**2166-4-21**] Chest CT:IMPRESSION: 1. Decreased size of air fluid collection suggesting functioning drain, however the persistent oral contrast within the collection indicates sustained perforation. 2. Organizing multiloculated fluid collection inferior to the original collection. This will likely respond to conservative treatment and is in a difficult position for percutaneous drainage. 3. Redemonstration of complex multicystic adnexal tumors. 4. Unchanged bilateral pleural effusions, left greater than right, with compressive atelectasis and likely persistent left upper lobe pneumonia. Unchanged small nodules seen in the right lung, assessment is incomplete of the left given large pleural effusion. . [**2166-4-21**] Abd/pelvic CT: IMPRESSION: 1. Decreased size of air fluid collection suggesting functioning drain, however the persistent oral contrast within the collection indicates sustained perforation. 2. Organizing multiloculated fluid collection inferior to the original collection. This will likely respond to conservative treatment and is in a difficult position for percutaneous drainage. 3. Redemonstration of complex multicystic adnexal tumors. 4. Unchanged bilateral pleural effusions, left greater than right, with compressive atelectasis and likely persistent left upper lobe pneumonia. Unchanged small nodules seen in the right lung, assessment is incomplete of the left given large pleural effusion. . [**2166-4-17**]: PCXR & L lat decub: LUL infiltrate smaller (likely due to decreased vascular congestion), L pleural effusion unchanged and layers on decubitus film. Small R pleural effusion. . [**4-13**] R LE Doppler U/S: 1. No evidence of DVT in right common femoral, right superficial femoral and right popliteal vein. The right calf veins could not be evaluated on this study due to calf edema. 2. Edema noted behind the right knee but no focal fluid collections were noted. . [**4-12**]: CXR: 1. Left suprahilar opacity with interstitial thickening is unchanged and may represent pneumonia. However as this has been present since [**2166-3-3**] if this does not radiographically resolve, the possibility of a mass should be considered. 2. Moderately large left-sided effusion has increased in size. . [**2166-4-11**] LE Doppler U/S: Negative. . [**2166-4-11**] CXR: IMPRESSION: 1. Worsening left upper lobe opacity. 2. Worsening superimposed interstitial edema and increasing bilateral pleural effusions. Given that the left upper lobe opacity has persisted over two months, an underlying malignancy cannot be excluded. . [**2166-4-8**] CXR: FINDINGS: Patient's condition required examination in sitting position using AP frontal and left lateral view. The previously identified tiny apical separation of the pleural space in the left hemithorax, a finding related to the preceding successful thoracocentesis, has now disappeared. A left-sided PICC line has changed its position slightly and terminates now overlying the SVC at the level of the carina. The previously described pulmonary findings which include a massive density in the left upper lobe area remain rather unchanged. No significant increase of pleural effusion is identified. . [**2166-4-7**] CXR: IMPRESSION: 1. Decreased left pleural effusion with new small left apical pneumothorax status post thoracentesis. 2. Slightly increased right moderate pleural effusion. 3. Denser more confluent left upper lobe opacity. Differential includes neoplastic or infectious etiologies as described above. . [**2166-4-4**] CT C/A/P: IMPRESSION: 1. Duodenal perforation in the second portion, with contrast leakage into the large collection in the right retroperitoneum despite catheter terminating within the collection. A catheter flush and check is recommended to ensure proper functioning of the drainage catheter. 2. New mild pneumobilia, thought to represent air dissecting cephalad from the duodenum. 3. Likely reactive ascending colonic wall thickening. 4. Redemonstration of complex multicystic adnexal tumors, possibly slightly decreased in size, ovarian cancer. Interval improvement of peritoneal disease, particularly in the left hemi-abdomen. 5. Enlarging bilateral pleural effusions with compressive atelectasis. Persistent left upper lobe pneumonia. 6. Stable scattered sub-4-mm nodules in the right lung. Assessment incomplete due to presence of pleural effusions. 7. Complex exophytic hyperdense cyst in the right kidney, incompletely characterized. Attention on follow up recommended. . [**2166-4-3**] CXR: IMPRESSION: 1. Increased opacification of the left upper lobe, much worse compared to [**2166-3-30**], and only slightly increased compared with [**2166-3-3**]. Probable pneumonia in this immunocompromised patient. 2. New mild interstitial edema. 3. New left PICC, tip at mid SVC. 4. New partial left lower lobe collapse. 5. Stable small left pleural effusion. . [**2166-3-31**] CT AB/PELVIS: IMPRESSION: 1. Large retroperitoneal collection with oral contrast in the cavity likely from second and third portion of the duodenum. Multiple foci of free intraperitoneal air and moderate amount of free retroperitoneal air. 2. Bilateral pleural effusions; left greater than right with bibasilar atelectasis. 3. Complex cystic lesion in the adnexa with multiple irregular thick septa with interval increase in size compared to prior CT. No clear fat plane between the cystic lesion and the urinary bladder. 4. Complex exophytic hyperattenuated cystic lesion in the right kidney, incompletely characterized. Consider renal ultrasound for further evaluation. . [**2166-3-30**] CXR: IMPRESSION: Minimally improved left upper lobe pneumonia, could have malignant component. Unusual organisms, such as actinomycosis, should be considered. . OSH CT: (report in OMR from ob gyn admission note from past [**2-/2166**] admission): Small L pleural effusion, atelectasis vs. scarring in RML/lingula, abnormal adnexal region/uterus, 8.5cm irregularly shaped cystic focus with nodular enhancing margines in the L adnexa. Uterus dieplaced to the R with heterogeneous low level echoes in the central portion. Other cystic foci above the uterus, may represent thick-walled cysts involving the R ovary. Small loculated pockets of pelvic fluid in bilateral adnexae. Mildly dilated small bowel loops, distal small bowel decompressed, suspicious for early or partial SBO. Small to mod amt of diffuse ascites. No peritoneal implants. . DISCHARGE LABS: [**2166-5-5**]: WBC 8.4, Hb 8.2, HCT 25.5, MCV 94, PLT 501. [**2166-4-4**]: Retic 0.4%. [**2166-5-5**]: Na 137, K 4.6, Cl 99, CO2 36, BUN 10, creat 0.4, glu 110. [**2166-5-5**]: Albumin 1.9, Ca 8.3, Phos 3.2, Mg 1.7. [**2166-4-29**]: T bili 0.1, AST/ALT [**12-18**], ALP 85. [**2166-4-24**]: Ferritin 388, iron 16, TIBC 105, TRF 81. [**2166-3-30**]: Folate 10.2, B12 462. [**2166-4-24**]: Chol 85, HDL 21, Trig 74. [**2166-4-21**]: CA-125 224. [**2166-4-27**]: Vancomycin 21.8. Brief Hospital Course: Ms. [**Known lastname **] is an 80 yo woman with ovarian cancer transferred from the surgical service for febrile neutropenia in the setting of bowel perforation secondary to a duodenal ulcer. The perforation occurred one week after starting chemotherapy (carboplatin/paclitaxel) for a new diagnosis of ovarian cancer. She was not a surgical candidate, so a drain was placed into the intra-abdominal abscess adjacent to the duodenal perforation with the initial plan to keep the drain in place x 6wks. She was also started on broad-spectrum antibiotics for peritonitis and TPN while left NPO. Oncology consultation recommended starting G-CSF for developing chemo-induced neutropenia and transfer to the Oncology service. Cultures from the abscess drainage grew coag-negative Staph, Enterococcus, and yeast. ID was consulted and antibiotics eventually narrowed to cipro/metronidazole/vancomycin in addition to fluconazole. Hypoxemia persisted and a CXR showed a persistent LUL infiltrate, unresolved from a pneumonia treated the month before as well as a left pleural effusion. Concern for unusual organisms, resulted in Pulmonary consultaton, repeat CT, thoracentesis (1.3L from the left-sided effusion), bronchoscopy, and transfer to a negative pressure room for rule out of TB. A PPD with Candidal Ag control were placed and a quantiferon gold assay was indeterminate. Bronchoscopy AFB, pleural effusion AFB and deaminase were all negative. Ultimately, the patient ruled out for TB with a negative BAL from bronchoscopy and two negative induced sputums. Pleural effusion cytology was POSTIVE FOR ADENOCARCINOMA. She required a short (two day) stay in the ICU [**Date range (1) 42061**] for worsening hypoxemia despite furosemide the same day after placement of a G-J tube for tube feeding. She was treatd with further diuresis and lower extremity doppler U/S was negative. CXR revealed reaccumlation of her left pleural effusion and mild right pleural effusion. Her hypoxemia improved to her previous baseline - 93-94% on 3L O2. She was transferred back to the hospital floor and remained hemodynamicly stable with a stable oxygen requirement of 3L NC. Her subsequent course was notable for copious, frequent stools in the setting of increasing her tube feeds to their target volume that improved somewhat when the tube feed rate was decreased. Nutrition was consulted and tube feedings were changed. Repeat C. difficile toxin assays and PCR were negative and she was treated supportively with banana flakes in her tube feeds and loperamide. Current regimen is ciprofloxacin PO, metronidazole PO, IV vancomycin, and fluconazole PO per ID. Work up for recurrent fevers ~ [**2166-4-21**] ultimately revealed that her J tube had migrated. It was replaced and repositioned on [**2166-4-25**] with resolution of her fevers. In the last week of her hospitalization, abscess drainage had markedly decreased. Repeat abdominal pelvic CT revealed that the drain was in place and the abscess was resolving and much decreased in size. Interventional radiology was consulted and a pleurex catheter was placed [**2166-4-29**]. . # Febrile neutropenia and infectious disease work up: Fever due to retroperitoneal abscess and extravasation of bowel flora into patient's abdomen. She was not a surgical candidate, so CT-guided drain into abscess was placed [**2166-3-31**]. Blood cultures and C. diff toxin negative. Coag-negative Staph, Enterococcus, and yeast grew in abscess culture. ID was consulted. Antibiotics were narrowed [**2166-4-8**] to cipro, metronidazole, vancomycin, and fluconazole. It is not clear how long abscess drain will need to stay in place and will be dependent on follow-up abdominal/pelvic CT post discharge. She ruled out for TB early in her hospitalization with a negative BAL and 2 negative induced sputums. Pleural fluid culture has been negative, but cytology was POSTIVE FOR ADENOCARCINOMA. The persistent LUL infiltrate on CXR may be a malignant process given that it has not resolved on broad spectrum antibiotics and pulmonary workup has been negative for infection although a tissue diagnosis has not been pursued. Bronchoscopy AFB negative. Aspergillus galactomannan Ag negative. Beta glucan falsely elevated by pip/tazo. Legionella Ag and cryptococcal Ag were negative. Other cultures as noted above. . # Perforated bowel and retroperitoneal abscess: Due to a duodenal ulcer and H. pylori infection. No surgical intervention at this time. Drain into abscess placed [**2166-3-31**]. TPN was converted to tube feeds after G-j tube was placed [**2166-4-11**] for feeding and for perforated ulcer bypass. IV pantoprazole [**Hospital1 **] and abx as above. Pt developed recurrent fevers on [**2166-4-21**]. CT scan showed development of a new organizing fluid collection. After D/W surgery and GYN ONC, fistulogram/sinugram to eval for site of perforation, which showed that J tube tip had migrated to site of perforation. IR advanced the tube [**2166-4-25**] beyond the point of the fluid collection with placement of [**Doctor Last Name **] to minimize risk of tube migarting again. Sinugram also showed that perforation at mid duodenum-resection would require a Whipple's procedure which pt would not tolerate. Conservative management was continued. She will have a repeat CT 10 days after discharge and be seen in surgical follow up with Dr. [**Last Name (STitle) 2028**] (GYN ONC) for consideration of further management. . # H. pylori infection: Continue PPI. Started treatment with metronidazole, amp/sulbactam, and bismuth [**2166-4-27**]. Amp/sulbactam switched back to ciprofloxicin. Stool for H. pylori antigen clearance is pending. . # Hypoxemia: Repeat CXR showed worsening LUL infiltrate. Repeat CT showed persistent LUL infiltrate, new effusions, and pulmonary nodules. Pulmonary consulted. Thoracentesis [**2166-4-7**] drained 1.3L from left side, complicated by small pneumothorax now resolved. Effusion cytology positive for malignancy. Bronchoscopy with BAL was performed on [**2166-4-9**] with negative cultures. The etiology of worsening hypoxemia requiring a brief 2 day [**Hospital Unit Name 153**] admission [**Date range (1) 90111**] was likely multifactorial: LUL infiltrate, recent PEs, atelectasis, splinting from right abdominal pain s/p J tube placement, recurrent malignant pleural effusions. She ruled out for TB with a negative BAL from bronchoscopy and two negative induced sputums on [**4-12**] & [**4-13**]. The LUL infiltrate is not clearly infectious and differential includes lymphangitic pulmonary metastases in light of pulmonary nodules and recurrent malignant pleural effusion. Her baseline oxygenation is stable at ~ 93% on 3 liters O2 nasal cannula. . # Ovarian cancer: s/p cycle 1 carboplatin/paclitaxel [**2166-3-26**], but held on additional chemo until ulcer/perforation was healing. Treatment for malignant effusions would be chemotherapy, but this was on hold due to her bowel perforation. The patient underwent pleurex catheter placement by interventional pulmonary service on [**2166-4-29**] for recurrent malignant pleural effusion. . # Sacral decubitus ulcer: Skin breakdown exacerbated by poor nutritional status. Seen by wound team with incorporation of their recommendations. Wound team reconsulted for further recommendations prior to discharge. . # Lower extremity edema: Lower extremity doppler U/S negative for DVT. Exacerbated by poor nutrition. Treated with elevation and intermittant diuresis. . # Thrush: Nystatin swish and spit temporarily given in addition to the fluconazole. . # Neutropenia: Chemo-induced. Resolved with G-CSF. Leukocytosis, due to both G-CSF and infection, resolved. . # Anemia: Anemia labs reflected anemia of inflammation (chronic disease). Stool guaic was positive as expected with a perforated duodenal ulcer. Transfused 1U RBC [**2166-4-5**], [**2166-4-9**], [**2166-4-10**]. . # HTN: Anti-hypertensives held for BP lower than baseline in setting of infection. . # Hyperlipidemia: Held statin until taking orals. . # PE: Enoxaparin has been held as necessary for procedures and then restarted when procedures are completed. . # FEN: Sips and tube feeds. Repleted hypokalemia, hypophosphatemia, and hypomagnesemia. . # PPX: Bowel regimen. Enoxaparin for PE treatment. . # Pain (abdominal pain): Hydromorphone IV prn for most of hospitalization, switched to oxycodone per J tube prior to discharge. . # Precautions: Fall. . # Lines: Peripheral. PICC placed [**2166-4-1**], but removed [**2166-4-10**] because of mild surrounding erythema. Second double lumen PICC placed on [**2166-4-14**]. . # CODE: DNR/DNI. Medications on Admission: Lisinopril 20mg daily HCTZ 25mg daily Lovenox 70mg [**Hospital1 **] subcutaneous Detrol LA 4mg PO daily Nabumetone 750mg daily Lovastatin 40mg daily Compazine 10mg q 6 hours prn for nausea Carboplatin/paclitaxel q3 weeks s/p 1st cycle Discharge Medications: 1. Roho cushion Roho cushion. 2. enoxaparin 60 mg/0.6 mL Syringe [**Hospital1 **]: One (1) Syringe Subcutaneous Q12H (every 12 hours). 3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. 4. bismuth subsalicylate 262 mg/15 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML PO TID (3 times a day). 5. metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours): Give as suspension through J-tube. Duration will be determined at ID follow-up appt. 6. ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours): Give as suspension through J-tube. Duration will be determined at ID follow-up. 7. vancomycin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO every eight (8) hours: Give through J-tube. Duration will be determined at ID follow-up. 8. vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: 1000 (1000) mg Intravenous once a day: Concentrated, through PICC. Duration will be determined at ID follow-up. 9. fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours): Give suspension per J tube. Duration will be determined at ID follow-up. 10. loperamide 2 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 11. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 5-20 mg PO Q4H (every 4 hours) as needed for pain: Per J-tube. 12. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain, fever. 13. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: [**1-12**] Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed for nausea. 14. sodium chloride 0.9 % 0.9 % Parenteral Solution [**Month/Day (2) **]: Ten (10) ML Intravenous PRN (as needed) as needed for line flush: PICC line non-heparin dependent flushes daily and prn. Discharge Disposition: Extended Care Facility: [**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**] Discharge Diagnosis: Perforated duodenal ulcer. Abdominal abscess. Metastatic Ovarian cancer. Chemotherapy induced neutropenia (low white blood cells). Fever. Pulmonary embolism. Severe protein calorie malnutrition. Stage 3 sacral ulcer. Recurrent malignant pleural effusions. Diarrhea. Left Upper Lobe Infiltrate that has not cleared with antibiotics suspicious for malignancy. H. pylori infection. Lower extremity edema Hypoxemia 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 with abdominal pain and distention due to a perforated duodenal ulcer. An abdominal abscess formed from the perforation and needed a drain placed to help clear the infection along with IV antibiotics and G-CSF (Neupogen), a medication to help produce white blood cells, as your white blood cell count was initially very low due to chemotherapy. While the ulcer was healing, you were fed with high calorie fluids (TPN) through the vein and then through a J-tube placed in your small intestine. The tube feedings caused you to have diarrhea that was treated by changing the type of feedings, adding banana flakes, and occasionally using anti-diarrhea medicine after tests showed the diarrhea was not infectious. The J-tube was also repositioned and secured in place after it had moved. . A CXR and CT scan of the chest both showed that the pneumonia from your last admission had not cleared and you had fluid around the lungs. This fluid (pleural effusion) was drained [**2166-4-7**] and [**2166-4-21**]. Tests of the fluid showed that it has cancer cells in it. You also had a bronchoscopy of your lungs that did not show evidence of infection. Because the fluid came back after drainage, you had a pleurex catheter placed [**2166-4-29**]. . You were continued on your enoxaparin (Lovenox) for blood clots in the lungs (pulmonary emboli), identified on your last admission. The enoxaparin was held when procedures were necessary (bronchoscopy, pleuracentesis, PICC line placement, pleurex catheter placement, J-tube placement, placement of abcsess drain) and then restarted as soon as possible. . You will need to remain on antibiotics until the abscess and ulcer resolve, as determined by future CT scans (ideally with oral gastrograffin to evaluate the ulcer perforation; contrast through the J-tube will not reach this location). These antibiotics will also treat the H. pylori infection, a bacteria that often causes ulcers. While you were in the hospital, you developed thrush and were temporarily treated with nystatin swish and spit. Fluconazole still given for yeast in the abscess also treats thrush. . MEDICATION CHANGES: 1. Your chemotherapy is on hold. Followup Instructions: Department: RADIOLOGY When: WEDNESDAY [**2166-5-14**] at 2:00 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage *** INSTRUCTIONS FOR CT SCAN: PATIENT IS TO BE NPO( NOTHING BY MOUTH OR J-TUBE) FROM 10AM THE MORNING OF THE [**5-14**]. PT NEEDS TO BE ON [**Hospital Ward Name **] 3 AT 1PM TO PREP FOR THE 2PM TEST.*** PLEASE ALERT THE RADIOLOGIST THAT ORAL GASTROGRAFFIN SHOULD BE USED TO EVALUATE THE ULCER PERFORATION. CONTRAST THROUGH THE J-TUBE WILL NOT REACH THIS SITE. . Department: GYN SPECIALTY When: WEDNESDAY [**2166-5-14**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5777**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Oncology Appointment: [**Last Name (LF) 2974**], [**5-30**] at 3pm With:Name: [**First Name11 (Name Pattern1) 19948**] [**Last Name (NamePattern1) 90112**],MD Location: THE MEDICAL GROUP INC Address: [**Last Name (un) 15488**], [**Apartment Address(1) 31103**], [**Hospital1 420**],[**Numeric Identifier 26668**] Phone: [**Telephone/Fax (1) 10508**] . Department: INFECTIOUS DISEASE When: [**Telephone/Fax (1) **] [**2166-5-16**] at 11:00 AM With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14256**] Admission Date: [**2166-3-30**] Discharge Date: [**2166-5-5**] Date of Birth: [**2085-12-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4148**] Addendum: Discharge Medications: Vancomycin IV only, 1000mg daily. NO PO VANCOMYCIN. Discharge Disposition: Extended Care Facility: [**Location (un) 12573**] Nursing & Rehabilitation Center - [**Location (un) 4534**] [**Name6 (MD) **] [**Last Name (NamePattern4) 4150**] MD [**MD Number(2) 4151**] Completed by:[**2166-5-5**]

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icd9cm

[ [ [] ] ]

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25527

Discharge summary

report

Admission Date: [**2199-1-15**] Discharge Date: [**2199-1-25**] Date of Birth: [**2144-10-24**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: cough, shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 54yoF with hx of DM, PVD, COPD presents with fever and productive cough over 5 days. Patient reports that she has had increasing blood-tinged sputum production with association cough over previous 3-5 days, cannot identify a specific time which it started. She denies any sick contacts. Denies diarrhea, nausea, or vomiting. She did receive her flu shot this year, but did not receive pneumovax. Also complains of left sides pleuritic chest pain, below nipple, began 5 days prior to arrival, somewhat associated with breathing. [**Name (NI) **] husband had been noticing elevated glucoses at home and had been communicating with PCP over phone about elevated levels over previous days. Patient had labs drawn the morning before arrival in ED, which showed a glucose of 400 and an anion gap. Of note, patient recently admitted in [**Month (only) 404**] for an above knee, right leg amputation due to an infected ulcer, discharged to [**Hospital3 **], and most recently living at home. She was readmitted to [**Hospital1 18**] in late [**Month (only) 404**] for two days for R-sided chest pain, ?thought [**1-5**] to VATs procedure, started on lidoderm patch. Per report, it appears patient has had difficulty caring for herself. In [**Hospital1 18**] ED, t99, hr 120, sbp 90s, 95%3L nc, ill-appearing female with difficulty clearing secretions. CXR showed LUL pneumonia and labs showed a normal anion gap. Three peripheral IVs were placed and patient given a dose of levaquin, ctx, and flagyl for community acquired vs. aspiration pneumonia. Given vancomycin for unsure reason. She transiently dropped her pressures to the 80s, which responded with fluids, receiving 4L NS while in ED. Past Medical History: 1. s/p AKA [**11-10**] (right) 2. s/p VATS and hypoxemia, biopsy c/w Respiratory Bronchiolitis-interstitial lung disease (RB-ILD) -- now on intermittent supplemental oxygen 3. PVD - s/p rt. ileo-fem bpg [**12-10**] complicated by lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy [**4-10**],rt. ileo-fem graft thrombectomy with bovine patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**], 4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**] 5. ETOH cirrhosis/chronic pancreatitis 6. L breast cyst s/p excision 7. GERD, pud 8. esophagitis with stricture 9. small bowel obstruction 10. PV,SMV thrombosis; h/o DVT/PE 11. asthma/copd on inhalers 12. cervical ca s/p multiple d/c's 13. DM2 insulin dependent 14. entero-colonic fistula 15. cholecystectomy [**06**]. cdiff colitis 17. acute renal failure Social History: recently discharged from [**Hospital3 **] to home. Married and lives at home generally with her husband, no children. Previously worked as a counselor in drug and alcohol programs. She quit smoking approximately [**12/2198**] with an over 80-pack year history of smoking. She quit drinking alcohol 23 years ago. She has no known exposure to tuberculosis. She was cleaning her husband's clothes during the time that he was working with asbestos for a three-month period. She has one dog at home and reports no allergies to animals. Years ago she had a parrot, a dove, and two parakeets. Family History: noncontributory Physical Exam: T 99 BP 107/78 HR 118 RR 20 97% 3L Gen - NAD, A/Ox3, lying in bed, conversant, cooperative. HEENT - no conjunctival pallor, no scleral icterus appreciated, dry mucous membranes NECK - no JVD appreciated CV - tachy, no murmurs appreciated. LUNGS - expiratory rhonchi heard throughout in all fields, more in upper fields. coarse inspiratory sounds in upper, medial fields. Increased area of crackles in left upper lobe, no egophony. ABD - NABS, soft, non-tender, non-distended. No organomegaly appreciated. Significant scarring on abdomen from pancreatic surgeries and feeding tubes. EXT - no lower extremity edema. 1+ palpable pulse on L. R above knee amputation scar intact without ecchymoses or skin breakdown. SKIN: No rashes/lesions, ecchymoses. NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not do fundoscopy. Preserved sensation throughout. MSK 4+/5 bil UEs. Psyche - listens and responds to questions appropriately Pertinent Results: [**2199-1-15**] 01:50AM BLOOD WBC-8.9 RBC-3.63* Hgb-11.5*# Hct-35.3* MCV-97 MCH-31.6 MCHC-32.6 RDW-15.4 Plt Ct-322 [**2199-1-15**] 03:25AM BLOOD WBC-9.5 RBC-3.17* Hgb-9.9* Hct-29.7* MCV-94 MCH-31.2 MCHC-33.3 RDW-15.1 Plt Ct-325 [**2199-1-21**] 06:03AM BLOOD WBC-15.3* RBC-2.65* Hgb-7.9* Hct-25.9* MCV-98 MCH-29.8 MCHC-30.6* RDW-15.2 Plt Ct-447* [**2199-1-22**] 11:53AM BLOOD WBC-14.3* RBC-2.65* Hgb-7.8* Hct-25.5* MCV-96 MCH-29.5 MCHC-30.7* RDW-15.0 Plt Ct-507* [**2199-1-15**] 01:50AM BLOOD Neuts-58 Bands-28* Lymphs-6* Monos-4 Eos-0 Baso-0 Atyps-3* Metas-1* Myelos-0 [**2199-1-22**] 11:53AM BLOOD Neuts-83.9* Lymphs-12.2* Monos-3.0 Eos-0.6 Baso-0.2 [**2199-1-22**] 11:53AM BLOOD PT-17.5* PTT-28.6 INR(PT)-1.6* [**2199-1-21**] 07:24AM BLOOD Glucose-170* UreaN-22* Creat-0.8 Na-139 K-4.4 Cl-107 HCO3-24 AnGap-12 [**2199-1-15**] 03:25AM BLOOD cTropnT-0.03* [**2199-1-15**] 03:25AM BLOOD CK(CPK)-77 DISCHARGE LABS [**1-25**]: WBC 13.6, HCT 24, PLT 605 INR 2.9, PTT 41.6 NA 142, K 4.2, CL 111, BICARB 24, BUN 21, CR 0.6, GLUCOSE 52 [**2199-1-15**] 3:30 am BLOOD CULTURE Site: ARM X2. **FINAL REPORT [**2199-1-21**]** Blood Culture, Routine (Final [**2199-1-21**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. 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 _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final [**2199-1-16**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 0025 ON [**2199-1-16**]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [**2199-1-23**] 8:46 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2199-1-23**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. PANOREX FILMS [**1-21**]: HISTORY: Dental pain. FINDINGS: No previous images. Panorex image shows extensive metallic dental work in the remaining teeth. No convincing evidence of osteomyelitis. CHEST CT WITH CONTRAST: [**2199-1-16**] TECHNIQUE: COPD, interstitial lung disease, left upper lobe pneumonia and evidence of loculated pleural effusion concerning for empyema. TECHNIQUE: MDCT was used to obtain contiguous axial images through the chest after uneventful administration of 70 mL of Optiray IV contrast. Multiplanar reformats were obtained. This study was compared with [**2198-4-27**], [**11-22**]. [**2197**], [**2198-11-28**], [**2198-12-2**], and [**2198-12-24**] chest CT scans. FINDINGS: The left upper lobe consolidation is worse since the [**2198-12-24**] study, with central gas and low density that likely represents a necrotizing component (series 4, image 21). The left lower lobe consolidation is probably similar to the previous study. The right lower lobe consolidation has improved, and the right upper lobe consolidation has also improved. There are sutures along the right lateral chest wall, with a tiny amount of extrapleural air (series 4, image 41). The loculated right pleural effusion is smaller than previous, and is now small. The left pleural effusion is larger than the last examination, and loculated; there is no definite evidence for empyema, though this cannot be excluded at this time. Diffuse smooth intralobular septal thickening is seen, primarily at the lung apices and bases, and can represent superimposed edema on the patient's known emphysema, however, there may be a component of underlying non-emphysematous interstitial lung disease. Lymphadenopathy in the mediastinum has slightly increased, particularly in the left prevascular aorticopulmonary window, now up to a thickness of approximately 13 mm, previously only 11 mm. A subcarinal lymph node conglomerate is similar to the previous study. There is no pericardial effusion. No coronary vascular calcifications are seen. There is no axillary lymphadenopathy. This study is not targeted to the abdomen, however, imaged portion of the liver, adrenals, spleen, kidneys, and stomach are normal. No suspicious sclerotic or lytic lesions. Multiplanar reformats were essential in delineating the findings above, particularly of the left upper lobe findings. IMPRESSION: 1. Increase in consolidation of the left upper lobe with development of central low density, suggesting necrotizing pneumonia with early abscess formation. 2. Overall improved right lobe consolidations. Probably similar left lobe consolidations. 3. Loculated moderately sized left pleural effusion; no definite evidence of empyema at this time. 4. Decrease in right pleural effusion. 5. Mediastinal lymphadenopathy is likely reactive. 6. Smooth intralobular septal thickening may indicate patient's known interstitial lung disease with possible component of superimposed hydrostatic edema. CXR [**1-15**]: AP SEMI-UPRIGHT CHEST: Since the previous study, there has been development of a large area of consolidation in the left mid and upper lung. Pleural effusions have improved. Pulmonary interstitial prominence remains stable. Cardiac and mediastinal contours are unchanged. Lateral view demonstrates the consolidation to be anteriorly situated, thus probably within the left upper lobe. The bones are diffusely demineralized. IMPRESSION: Interval development of large left upper lobe consolidation consistent with pneumonia. Followup imaging after treatment is recommended to ensure resolution. [**1-18**] PICC LINE PLACEMENT: Uncomplicated ultrasound and fluoroscopically guided 5-French PICC line placement via the right brachial venous approach. Final internal length is 38 cm, with the tip positioned in SVC. The line is ready to use. Brief Hospital Course: PNEUMONIA- smoking hx with copd, and on previous admission had persistent hypoxemia with resultant VATS procedure and biopsy that showed respiratory bronchiolitis with underlying interstitial lung disease (RB-ILD), here with a superimposed LUL pneumonia. A chest CT revealed an extensive LUL pneumonia also with a necrotizing component. Her blood cultures grew MSSA. She was started on Ceftriaxone IV, plan to continue this for 4 weeks given fem-[**Doctor Last Name **] bypass graft could be considered hardware, she was afebrile and repeat blood cultures were negative making infected hardware less likely. Patient's symptoms of cough had improved and stabilized upon discharge and she denied any shortness of breath. Last day of antibiotics [**2-12**]. She was continued on her home inhalers. She has PCP and pulmonary follow up as an outpatient. ANEMIA: anemia of chornic disease, patient has needed blood tranfusions in the past, no dramatic drop in hematocrit and no source of bleeding. Baseline hct in mid to low 20s. Plan to transfuse for hct < 21, patient has no active end organ ischemia. Discharge hct: 24.0. Patient should have hct rechecked on Monday [**1-28**] and if < 21 would have patient transfused 1 unit PRBC (if unable at rehab would sent patient to ER for transfusion for anemia of chronic disease). IDDM - patient had not been taking NPH as prescribed since recent discharge from [**Hospital1 **] last week. She had a blood glucose of 400 upon admission. She was discharged on NPH 10 units qam and 4 units qpm in addition to a sliding scale. She should follow up with [**Last Name (un) **] diabetes center. HYPERCOAGULABILITY: history of multiple venous and arterial thrombi in the past without a definitive etiology, has seen hematology, Dr. [**Last Name (STitle) **], in the past and a w/u was negative but patient on anticoagulation at that time. They had determined at that time that she remain on anticoagulation for the long term. On lovenox bridging to a therapeutic INR on coumadin, goal INR [**1-6**]. INR 2.9 upon discharge, on 3mg daily, changed to 2mg on Sat / Sun and 3mg daily on Mon-Fri. PAIN CONTROL: phantom limb pain, pain well controlled on regimen of tylenol, MS contin and MSIR, cymbalta and neurontin. DEPRESSION: clinically depressed with a history of suicidal ideation, no attempts, denies suicidal ideation now. good support from her husband, feels stable, no mania or psychotic features. On cymbalta. Phone number for psychiatry appointment provided to patient upon discharge for outpatient psychiatry follow up. CHRONIC PANCRETITIS: s/p Puestow procedure which anastamosed her pancreastic duct to her small bowel, she is on enzymatic replacement therapy and is stable with this regimen. No active inpatient issues. Medications on Admission: 1. Insulin NPH 16units qam, 7 units qpm 2. Ondansetron 4 mg prn 3. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] 4. Simvastatin 20mg qd 5. Lorazepam 0.5 mg prn 6. Lisinopril 5 mg qd 7. Metoprolol 25mg tid 8. Duloxetine 60mg qd 9. Morphine 30 mg extended release - [**Hospital1 **] 10. Tiotropium Bromide 18 mcg qd 11. Albuterol 90 mcg prn 12. Fexofenadine 60 mg [**Hospital1 **] 13. Hexavitamin qd 14. Folic Acid 1 mg qd 15. Thiamine HCl 100 mg qd 16. Amylase-Lipase-Protease 20,000-4,500- 25,000 tid w/meals 17. Gabapentin 400 mg tid 18. Ranitidine HCl 150 mg [**Hospital1 **] 19. Medium Chain Triglycerides 15cc tid 20. Aspirin 325 mg qd 21. Zinc Sulfate 220 mg qd 22. Warfarin 3mg Tablet qd (but PCP notes state 6mg daily) 23. Docusate Sodium 100 mg [**Hospital1 **] 24. Prochlorperazine Maleate 10 mg prn 25. Amitriptyline 50 mg qhs 26. Lidocaine 5 %(700 mg/patch)patch to chest and leg prn 27. Oxycodone 5 mg q4 prn 28. dalteparin 5k Discharge Medications: 1. hospital bed One hospital bed 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed Subcutaneous as directed: please take 10 units of NPH in the a.m. and 7 units of NPH in the p.m. 4. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection as directed: sliding scale insulin for breakfast, lunch, dinner, and bedtime. 5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q12H (every 12 hours). 13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 19. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 20. Gabapentin 100 mg Capsule Sig: Four (4) Capsule PO Q8H (every 8 hours). 21. Medium Chain Triglycerides Oil Sig: Fifteen (15) ML PO TID (3 times a day). 22. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 24. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16): please take 3mg daily on Monday through Friday and 2mg daily on Saturday and Sunday, please have your INR checked on Monday [**1-28**]. 25. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 26. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 27. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane TID (3 times a day) as needed. 28. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 18 days: until [**2199-2-12**]. 29. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-13**] MLs PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Last Name (LF) **], [**First Name3 (LF) **] Discharge Diagnosis: Primary Diagnosis: Pneumonia Secondary diagnosis: Hypercoagulability s/p R AKA Discharge Condition: stable, sating well on room air Discharge Instructions: You were admitted with pneumonia and treated with antibiotics, you should continue IV antibiotics for a 4 week total course. Start date [**1-15**], last day [**2199-2-12**]. Please call your doctor or return to the emergency room if you have a worsening cough, shortness of breath, fevers or other symptoms that concern you. Followup Instructions: You have the following appointment with a new primary care physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) **] on Tuesday [**2-19**] at 2:30 p.m. (phone [**Telephone/Fax (1) 250**]) You have the following appointment with your pulmonologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**], Wednesday [**2-6**] at 3:30 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 23**] [**Location (un) 436**]. In addition please follow up with the [**Last Name (un) **] Diabetes Center for your diabetes: [**3-11**] at 4:00 p.m. Dr. [**Last Name (STitle) 4379**], [**Last Name (un) **], [**Location (un) **]. ([**Telephone/Fax (1) 4847**] Also, you have the following appointment with psychiatry: ([**Telephone/Fax (1) 33215**] You have the following appointments: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-3-20**] 3:15 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2199-3-27**] 4:10 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2199-3-27**] 4:30 Also, you can call the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Management center at the [**Hospital1 **] to help with your pain. ([**Telephone/Fax (1) 19088**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

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Admission Date: [**2180-5-1**] Discharge Date: [**2180-5-3**] Date of Birth: [**2098-2-16**] Sex: F Service: NEUROLOGY Allergies: Amoxicillin Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: left hand weakness and paresthesias Major Surgical or Invasive Procedure: None History of Present Illness: The pt is an 82 yo F with history of HTN, HL who presented to [**Hospital1 **]-[**Location (un) 620**] 30 minutes after acute onset L hand numbness/weakness, given tPA and transfered to [**Hospital1 **]-[**Location (un) **] for Neuro ICU care. Patient was in her usual state of health until 5:45pm on the day of admission. She states that she fell asleep in a chair for a small nap and then awoke at 6pm with a floppy left hand (could not tell me whether her arm was hanging over side of chair). At first she believed she had slept on it in a funny way and attempted to shake it off however the weakness persisted. At that time she noted that she also had numbness, not pins/needles, over the dorsal aspect of her left hand and the lateral aspect of her proximal L wrist. She had no pain. Given that the deficits persisted for 20-30 minutes, her husband called EMS. She was taken to [**Hospital1 **]-[**Location (un) 620**], CT-head was normal and teleneurology was called and recommended tPA. She was then transfered to [**Hospital1 **]-[**Location (un) 86**] given lack of of ICU. She has never had a stroke beforehand and has never had persistent weakness or numbness anywhere in her body prior to this. Past Medical History: Hypothyroidism - on synthroid Arthritis - HTN HL recurrent UTIs - on trimethoprim Social History: Lives with husband, retired, no illicits, Family History: stroke -sister [**Name (NI) **] brother, son, mother Ca - Father Physical Exam: At admission: Vitals: T: 98 P: 65 R: 16 BP: 146/50 SaO2: 97%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: NIH Stroke Scale score was 2: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 1 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**3-4**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 4+ 5- 5 2 5 2 na 5 5 5 5 5 5 5 R 4+ 5 5 5 4+ 5 na 5 5 5 5 5 5 5 -Sensory: Deficits to light touch, pinprick, cold sensation and vibratory sense but not proprioception over the dorsal aspect of the left hand most prominently over the dorsal wrist and proximal dorsal/lateral forearm. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was mute bilaterally. -Coordination: No intention tremor, some dysdiadochokinesia noted on the left. Dysmetria on FNF on the left (not out of proportion to weakness from wrist/finger extensors). -Gait: defered At tranfer out of NeuroICU: Intact mental status and cranial nerves. Motor exam shows [**2-6**] strength in left wrist and finger extensors, [**4-5**]+/5 in all other intrinsic hand muscles, supinator. Decreased light touch, pin/cold in patchy area over dorsal left hand and forarm. Neurologic exam at discharge: Significant for 2/5 strength in left wrist and finger extensors, 4+/5 in interossei, 3 in thumb abduction. Decreased light touch and pinprick over a small area of dorsolateral left forearm, intact throughout in hand. Pertinent Results: [**2180-5-1**] 12:10AM BLOOD WBC-9.7 RBC-3.81* Hgb-11.4* Hct-36.2 MCV-95 MCH-29.8 MCHC-31.4 RDW-14.6 Plt Ct-202 [**2180-5-1**] 12:10AM BLOOD Neuts-85.1* Lymphs-10.7* Monos-3.6 Eos-0.4 Baso-0.2 [**2180-5-1**] 12:10AM BLOOD PT-12.8* PTT-29.1 INR(PT)-1.2* [**2180-5-1**] 12:10AM BLOOD Glucose-162* UreaN-33* Creat-1.3* Na-139 K-4.6 Cl-107 HCO3-21* AnGap-16 [**2180-5-1**] 12:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2180-5-1**] 01:50AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2180-5-1**] 01:50AM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2180-5-1**] 01:50AM URINE RBC-12* WBC-130* Bacteri-MANY Yeast-NONE Epi-0 [**2180-5-1**] 01:50AM URINE CastHy-7* [**2180-5-1**] 01:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2180-5-1**] 03:06AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2180-5-1**] 03:06AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2180-5-1**] 03:06AM URINE RBC-29* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 [**2180-5-1**] 03:06AM URINE CastGr-2* CastHy-2* [**2180-5-1**] 03:06AM URINE WBC Clm-OCC Mucous-OCC ECG: Normal sinus rhythm with atrial premature beats. Left atrial enlargement. Poor R wave progression in leads V1-V4. Question lead placement. Question clockwise rotation. Cannot rule out prior anteroseptal myocardial infarction. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 67 170 82 398/410 46 1 70 TTE: Conclusions The left atrium is moderately dilated. There is no premature appearance of saline contrast in the left atrium, but subcostal color flow Doppler is strongly suggestive of a secundum type atrial septal defect with left-to-right-flow. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Probable secundum type atrial septal defect. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Increased PCWP. At least mild mitral regurgitation. If clinically indicated, a TEE would be better able to define the interatrial septum. MR brain without contrast: IMPRESSION: 1. Age-appropriate MR of the brain, specifically without evidence of ischemic infarct. 2. Well-circumscribed structure in the retroclival subarachnoid space, which may represent a notochordal remnant although aneurysm of the right V4 segment is not excluded. Further characterization by axial thin section FIESTA and phase contrast cine sequences is recommended. MR head with and without contrast/MRA head (preliminary read): Structure noted above most consistent with notochord remnant. No evidence of aneurysm. Final read pending at time of discharge. Brief Hospital Course: 82 yo F with HTN, HL who presents with acute onset left hand/arm weakness/paresthesia, s/p tPA at [**Hospital1 **]-[**Location (un) 620**] due to concerns for ischemic stroke and subsequently transferred to [**Hospital1 18**] for further care. Initial exam notable for weakness predominantly in extensors of the wrist and fingers but also involving interossei and thumb abduction to a lesser degree. She also endorsed decreased sensation to lt touch/cold/pin over the dorsal hand/arm. NCHCT was unrevealing, and MRI showed no evidence of acute infarct. She was monitored in the ICU overnight for post-tPA care and was subsequently transferred to the neurology floor on [**2180-5-2**]. Currently the most likely etiology of her symptoms appears to be a left radial nerve palsy. . #Neuro: Her examination improved somewhat during her admission, regaining normal sensation in her hand and most of her forearm with the exception of decreased pinprick and light touch over a small area of the dorsolateral forearm. A repeat MRI with contrast and FIESTA sequence along with MRA was performed to better evaluate the possible mass seen on her initial study. This showed a small well-circumscribed structure in the retroclival subarachnoid space anterolateral to the medulla most consistent with a notochord remnant. There was no evidence of aneurysm on MRA. . Stroke risk factors were found to be well-controlled (fasting lipid panel TC 139; TG 92; HDL 58; LDL 71; HBA1c 5.7%). She was continued on her home aspirin 162mg and simvastatin 10mg daily. Home antihypertensives were initially held and were then restarted at her home doses. . She was seen by PT and OT who recommended rehab placement upon discharge. A wrist splint was placed per OT recs. She was advised to have an EMG/NCS in 6 weeks to assess the recovery of her radial nerve. . #CV: Cardiac enzymes were negative x 2. She was maintained on telemetry monitoring during her admission. Home antihypertensives were initially held and were then restarted at her home doses. She was continued on her home aspirin 162mg and simvastatin 10mg daily. A TTE showed probable secundum type atrial septal defect as well as mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. . #ENDO: She was maintained on finger sticks QID and insulin sliding scale with a goal of normoglycemia. . #ID: UA was consistent with UTI, with urine culture positive for klebsiella pneumoniae. She was treated with ciprofloxacin 500mg [**Hospital1 **] x 3 days ([**Date range (1) **]). . #FEN: She was cleared for a cardiac diet on bedside swallow which she tolerated well. . #Prophylaxis: She was maintained on heparin SC and pneumoboots for DVT prophylaxis. She was maintained on a bowel regimen for GI prophylaxis. Fall and aspiration precautions were observed. . # Dispo: She was discharged to [**Hospital 38**] Rehab on [**2180-5-3**] in good condition. She will need continued PT and OT to regain her strength and to learn new techniques to work around her left hand weakness. Medications on Admission: Levothyroxine 50mcg daily Metoprolol Tart 50mg [**Hospital1 **] Quinapril 20mg daily Vitamin B12 Aspirin 162mg daily Trimethoprim 10mg daily Simvastatin 10mg daily Tylenol prn Discharge Medications: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. quinapril 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Halfprin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. trimethoprim 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Left radial neuropathy Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neurologic: 2/5 strength in left wrist and finger extensors, 4+/5 in interossei, 3 in thumb abduction. Decreased light touch and pinprick over a small area of dorsolateral left forearm, intact throughout in hand. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to [**Hospital1 69**] on [**2180-5-1**] with numbness and weakness of your left hand. You were initially seen at [**Hospital1 **] [**Location (un) 620**], where you received tPA treatment due to concern for a stroke and were then transferred to [**Hospital1 18**] [**Location (un) 86**]. You were admitted to the neuro ICU overnight for monitoring and then transferred to the neurology floor. An MRI showed no evidence of stroke. There was a small incidentally noted mass near your brainstem; this most likely represents a developmental variant (notochord remnant) which requires no further intervention and is not related to your symptoms. We believe the most likely cause of your weakness and numbness is compression of your radial nerve, most likely due to sleeping on your arm. Your symptoms should gradually get better on their own. You will receive a wrist splint to wear and will need to work with physical and occupational therapy to regain your strength. We recommend that you have an EMG (test of nerve and muscle function) done in 6 weeks to evaluate the recovery of your nerve. We also treated you for a urinary tract infection with a 3-day course of ciprofloxacin. We made no changes to your home medications. If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay! Followup Instructions: * Neurologist [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD (Phone:[**Pager number **]) on [**2180-6-30**] at 1:00 pm. Please call registration at [**Telephone/Fax (1) **] to update your file in advance of the appointment. Please also obtain a referral from Dr. [**Last Name (STitle) 29111**] for the appointment. *You should also have an EMG (electromyogram) and nerve conduction study performed in 6 weeks. You may call ([**Telephone/Fax (1) 51696**] to set up an appointment at [**Location (un) 620**]. Otherwise if you would like to have the study performed here you may call ([**Telephone/Fax (1) 21904**].

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Discharge summary

report

Admission Date: [**2198-9-16**] Discharge Date: [**2198-9-28**] Date of Birth: [**2143-9-8**] Sex: M Service: MEDICINE Allergies: Ilosone / Dicloxacillin / Ace Inhibitors Attending:[**Last Name (un) 11220**] Chief Complaint: acute kidney injury rhabdomyolysis pulmonary hypertension congestive heart failure Major Surgical or Invasive Procedure: left internal jugular CVC placement History of Present Illness: In the ED, initial VS were:T-97.8 P-103 BP-112/70 R-18 O2%-90% RA 54-year-old man with a history of HIV on HAART, hepatitis C, CAD status post CABG in [**2182**], CHF with an EF of 50%, hypertension, hyperlipidemia, and a severe stroke in [**2184**] with residual dysarthria and left greater than right-sided weakness who presents after falling from his wheelchair and hitting his head. On ground for around an hr. Pt recently d/c'd [**9-14**] with desats to 80s [**1-25**] PNA. Pt denies any CP, SOB, dizziness before the fall or after. IN the ED: PT triggered for hypoxia to 70s. Sat up and did well and came back up to 100% w/ a NRB. hypoT, never tachy . Got labs from art stick. Had no access for peripheral and given L-IJ central line. Pt received 1.5 l NS. Elevated trop with normal CK index. Had negative CT head and neck. On arrival to the MICU: Pt had foley placed with 300CC of tea colored urine produced and received 1.5 L of NS bolus. ABG was drawn. Past Medical History: -HIV: dx [**2176**], likely through IVDU (last CD4 count 438/30% vl 128 on [**2198-4-30**]) -HCV: no therapy, stage I to II fibrosis on liver biopsy in [**2193**], genotype 1A -CAD: CABB x 1 Lima to LAD [**8-/2184**] s/p MI [**2176**] -Diastolic CHF, EF 50-55% -CVA: [**2-/2185**] intercerebral hemorrhage in medial/superior cerebellar peduncle, wheelchair bound w/ residual L paresis -HTN -hypercholesterolemia Social History: He lives alone in an apartment, has assistance from PCAs that come in to help him, not currently working, but formerly worked many jobs including construction and campus police. He is a former smoker, quit many years ago, but smoked actively for 30 years, half to one pack a day. He denies any pets or other environmental exposures. Family History: There is a significant family history of premature coronary artery disease of the father who had an MI at age 56 and uncles who have had heart attacks in the past. Otherwise, there is no other history of unexplained heart failure or sudden death. Physical Exam: Admission physical exam: Vitals: T:afeb BP:113/72 P:82 R:18 O2:96 General: Alert, oriented, HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Wheezing and crackles in all lung fields Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Hypospadias foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Baseline left facial droop with markedlydysarthric speech,LUE and LLE with 4/5 strength, RUE and RLE [**4-28**]. Sensation grossly intact Discharge Physical Exam: VS - 98.7 118/54 70 20 93% on shovel face mask 10L GEN: Awake, alert and oriented. No acute cardiopulmonary distress HEENT: Sclera anicteric, MMM, OP clear NECK: Supple, elevated JVP PULM: Good aeration, CTAB, without w/r/r. CV: RRR normal S1/S2, no mrg/ ABD: Soft, non-tender, obese, nondistended, no rebound or guarding. EXT: WWP. 2+ right radial pulse. left radial pulse not palpable, but left hand is well perfused. DP/PT pulses difficult to palpate [**1-25**] edema. 2+ pitting edema b/l LEs to knee, improved from yesterday. NEURO: awake, A&Ox3, dysarthric. left facial droop. left upper and lower extremities 4/5 strength. Right extremities [**4-28**] strength. SKIN: no ulcers or lesions. venous stasis/chronic edema changes in b/l lower extremities Pertinent Results: Admission labs: [**2198-9-16**] 06:30PM BLOOD WBC-11.8* RBC-4.81 Hgb-15.5 Hct-47.7 MCV-99* MCH-32.2* MCHC-32.4 RDW-16.7* Plt Ct-296 [**2198-9-16**] 06:30PM BLOOD PT-17.7* PTT-33.7 INR(PT)-1.7* [**2198-9-16**] 06:30PM BLOOD Glucose-115* UreaN-42* Creat-3.6*# Na-141 K-3.5 Cl-95* HCO3-32 AnGap-18 [**2198-9-16**] 06:30PM BLOOD CK(CPK)-[**Numeric Identifier 104043**]* [**2198-9-16**] 06:30PM BLOOD CK-MB-34* MB Indx-0.2 cTropnT-1.67* [**2198-9-16**] 06:37PM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-53* pH-7.41 calTCO2-35* Base XS-6 [**2198-9-16**] 06:37PM BLOOD Lactate-2.6* Pertinent labs: [**2198-9-17**] 04:13AM BLOOD CK-MB-26* MB Indx-0.2 cTropnT-1.69* [**2198-9-17**] 04:13AM BLOOD ALT-42* AST-316* CK(CPK)-[**Numeric Identifier 104044**]* AlkPhos-52 [**2198-9-17**] 04:13AM BLOOD Glucose-154* UreaN-41* Creat-2.9* Na-140 K-3.5 Cl-100 HCO3-33* AnGap-11 [**2198-9-21**] 01:14AM BLOOD WBC-11.3* RBC-3.79* Hgb-12.2* Hct-38.7* MCV-102* MCH-32.1* MCHC-31.4 RDW-17.8* Plt Ct-265 [**2198-9-22**] 01:35AM BLOOD WBC-9.0 RBC-4.14* Hgb-13.1* Hct-41.0 MCV-99* MCH-31.8 MCHC-32.0 RDW-17.5* Plt Ct-[**Numeric Identifier **]/02/12 03:43AM BLOOD WBC-7.4 RBC-4.16* Hgb-13.0* Hct-41.7 MCV-100* MCH-31.3 MCHC-31.2 RDW-16.5* Plt Ct-283 [**2198-9-27**] 05:11AM BLOOD WBC-7.1 RBC-3.90* Hgb-12.4* Hct-38.5* MCV-99* MCH-31.8 MCHC-32.2 RDW-16.4* Plt Ct-239 [**2198-9-20**] 04:54AM BLOOD Glucose-90 UreaN-64* Creat-3.0* Na-143 K-3.9 Cl-108 HCO3-23 AnGap-16 [**2198-9-21**] 01:14AM BLOOD Glucose-84 UreaN-67* Creat-2.7* Na-149* K-3.3 Cl-110* HCO3-27 AnGap-15 [**2198-9-22**] 01:30AM BLOOD Glucose-93 UreaN-59* Creat-2.2* Na-150* K-3.3 Cl-109* HCO3-32 AnGap-12 [**2198-9-23**] 04:32AM BLOOD Glucose-110* UreaN-50* Creat-1.7* Na-150* K-3.3 Cl-107 HCO3-39* AnGap-7* [**2198-9-25**] 03:43AM BLOOD Glucose-116* UreaN-37* Creat-1.6* Na-143 K-3.7 Cl-97 HCO3-39* AnGap-11 [**2198-9-27**] 05:11AM BLOOD Glucose-108* UreaN-36* Creat-1.7* Na-140 K-4.0 Cl-94* HCO3-40* AnGap-10 [**2198-9-16**] 06:30PM BLOOD CK(CPK)-[**Numeric Identifier 104043**]* [**2198-9-17**] 04:13AM BLOOD ALT-42* AST-316* CK(CPK)-[**Numeric Identifier 104044**]* AlkPhos-52 [**2198-9-18**] 04:45PM BLOOD CK(CPK)-724* [**2198-9-18**] 05:05AM BLOOD Type-ART Temp-38.6 pO2-89 pCO2-74* pH-7.17* calTCO2-28 Base XS--3 Intubat-NOT INTUBA [**2198-9-22**] 01:34PM BLOOD Type-ART pO2-67* pCO2-59* pH-7.40 calTCO2-38* Base XS-8 [**2198-9-26**] 11:21AM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-71* pH-7.40 calTCO2-46* Base XS-14 [**2198-9-27**] 05:31AM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-72* pH-7.39 calTCO2-45* Base XS-14 [**2198-9-17**] 01:28AM BLOOD Lactate-2.2* [**2198-9-22**] 01:34PM BLOOD Lactate-1.0 Imaging [**9-16**] CXR PORTABLE CHEST: [**2198-9-16**]. HISTORY: 55-year-old man with shortness of breath and acute hypoxia. FINDINGS: Single portable view of the chest is compared to previous exam from [**2198-9-11**]. Compared to prior, there has been interval improvement of aeration at the lung bases. There are some persistent bibasilar opacities, right greater than left. Cardiomediastinal silhouette is stable as are the osseous and soft tissue structures. IMPRESSION: Mild interval improvement in the previously seen bibasilar opacities which persist. These could be due to resolving infiltrates or atelectasis or potentially aspiration. [**9-16**] CT head FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift, or territorial infarct. Right occipital lobe encephalomalacia as well as regions of encephalomalacia centered in the right middle cerebellar peduncle are again seen. Global volume loss of the cerebellum is again noted. Elsewhere, [**Doctor Last Name 352**]-white matter differentiation is preserved. There is partial opacification of the inferior right mastoid air cells. Mucous retention cyst seen in the right maxillary sinus. Other paranasal sinuses and left mastoids are clear. The skull and extracranial soft tissues are unremarkable. IMPRESSION: No acute intracranial process. Encephalomalacia within the right occipital lobe and right middle cerebellar peduncle, unchanged from prior [**2198-9-17**] TTE: Poor image quality.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. No late contrast is seen in the left heart (suggesting absence of intrapulmonary shunting). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is dilated with mild global free wall hypokinesis. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid regurgitation jet is eccentric and may be underestimated. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2197-12-22**], due to poor image quality on prior study, a direct comparison of RV size nad function is not possible. The current study suggests a more dilated/dysfunctional RV though. [**2198-9-17**] lower-extremity venous u/s IMPRESSION: No deep vein thrombosis. [**2198-9-22**] CXR 1. Nasogastric tube is seen coursing below the diaphragm with the tip not identified. Left internal jugular central line has its tip in the proximal SVC. There continues to be diffuse bilateral airspace process with probable associated layering effusions. This may reflect worsening pulmonary edema, although superimposed bilateral pneumonia cannot be entirely excluded. Clinical correlation is advised. No pneumothorax is seen. Overall, cardiac and mediastinal contours are likely stable, but somewhat difficult to assess due to diffuse airspace process. [**2198-9-23**] Head CT IMPRESSION: No acute intracranial process identified to explain patient's neurologic decline. [**2198-9-23**] EEG (from neurology note) EEG was done and showed spikes of 3Hz with right hemispheric predominance. [**2198-9-26**] Video Swallow FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was evidence of intermittent penetration of thin, as well as intermittent aspiration of nectar consistency. For further details, please refer to speech and swallow division note in OMR. Preliminary Report IMPRESSION: Penetration of thin consistency and aspiration of nectar consistency, both intermittently. Brief Hospital Course: Active Problems #rhabdomyolysis- Pt found on the ground for an extended period of time which could be the cause for his rhabdo. PT received aggressive IV fluid to try to maintaine a 200CC urine output while not compromissing his respiratory status. His CK eventually came down but CR was still elevated. Renal was consulted and recommended no HD. PT still producing urine and CR was stable. Creatinine stabilized at 1.6-1.7. This likely represents his new baseline. He continued to have good urine output throughtout rest of admission. #elevated trop- Pt has signigicant elevation of trop. EKG similar to previous. Pt received 325 [**Month/Day/Year **]. His CK-MB index was never elevated and trop was not raising so a cards consult was not obtained. #ATN: Muddy brown cast found in urine [**9-19**]. Most likely [**1-25**] to rhabdo. Improving toward baseline. Most likely CKD at this point. Cr remains stable at 1.7. Good urine output maintained throughout admission. Pt. to follow-up with renal as outpatient #Hypoxemia- Chronic O2 requirment likely multifactorial related to pulmonary HTN, COPD, OSA, OHS. Current increase in O2 requirement likely [**1-25**] PE vs heart failure. Unable to obtain CTA at this time due to pt [**Name (NI) **]. Has been improving with diuresis and thus it is most likely [**1-25**] CHF/pulmonary edema, less likely PE, heparin was switched to subcut. As patient continues to improve with diuresis, did not pursue further PE work-up. Treated with vanco and cefipime after 8 day HCAP coverage. Currently no clinical evidence of pneumonia. Pt. responded well to IV Lasix 40mg [**Hospital1 **]. Upon discharge, pt. likely at his baseline hypoxemia. No evidence of significant pulmonary edema on most recent CXR and only mild bibasilar crackles on exam. Still 5 liters net positive for length of stay [**1-25**] aggressive fulid resuscitation for severe rhabdo upon initial presentation. Would recommend continued diuresis to achieve euvolemia and optimize respiratory status. Renal function slowly improving, so patient likely able to autodiurese soon. Though not confirmed, pt. likely has significant pulmonary HTN based on old TTE, recent chest CT with enlarged PA, and multiple pulmonary HTN risk factors as outlined above. Pt. scheduled to follow in pulmonary clinic with Dr. [**Last Name (STitle) **] for further w/u and treatment of this presumed pulmonary HTN. At time of discharge, pt. saturating in low 90s on nasal canula, which is likely around his baseline oxygenation. No pulmonary symptoms. #new onset seizure activity- PT experienced change in mental status while in the ICU with echolalia, confusion, and leftward gaze deviation with random leftward saccadic eye movements.. A CT head was ordered which showed NAP and EEG which showed epileptiform discharges. Neurology was called and pt was placed on Keppra. His mental status improved significantly back to baseline without any further evidence of seizure activity or changes in mental status. Pt. to be discharged on Keppra 500mg [**Hospital1 **]. Pt. will f/u in epilepsy clinic in [**3-30**] weeks time after discharge for furthur management. #Nutrition - video swallow. Speech therapy recommend ground solids with nectar thickened liquids. Likely chronic aspirator [**1-25**] to prior CVA. Pt. to be discharged on this diet. Chronic Problems #HTN - antihypertensives were held throughout admission, particularly in setting of agressive diuresis following resolution of rhabdo. Metoprolol and triamterene-HCTZ can be restarted once pt. back to euvolemia. #HIV - pt. was maintained on his regimen of Saquinavir and Ritonavir Transitional Issues #Volume overload - upon discharge, pt. net positive 5 liters for length of stay. has been getting IV lasix 40mg [**Hospital1 **]. Would recommend continuing diuresis with goal of euvolemia. Diuresis was associated with significant improvement of pt.'s respiratory status. Discharged on 5L nc, with saturations in low 90s. Probably will only require a couple more days of diuresis, as renal function continues to improve toward his baseline. Would recommend checking daily electrolytes while actively diuresing and while Cr continuing to normalize. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 50 mg PO TID 3. Metoprolol Succinate XL 12.5 mg PO DAILY 4. Rosuvastatin Calcium 40 mg PO DAILY 5. Saquinavir (Invirase) Cap 400 mg PO BID 6. RiTONAvir 400 mg PO BID 7. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY 8. Levofloxacin 750 mg PO DAILY Day 1= [**9-11**], finishes on [**2198-9-15**] 9. Tiotropium Bromide 1 CAP IH DAILY 10. Albuterol Inhaler [**12-25**] PUFF IH Q4H:PRN wheezing, shortness of breath 11. oxygen 416.8 Other chronic pulmonary heart diseases Home oxygen @ 5 LPM continuous via shovel mask, conserving device for portablity Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. RiTONAvir 400 mg PO BID 3. Saquinavir (Invirase) Cap 400 mg PO BID 4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB 5. Furosemide 40 mg IV BID 6. LeVETiracetam 500 mg PO BID 7. Albuterol Inhaler [**12-25**] PUFF IH Q6H:PRN shortness of breath/wheezing 8. Docusate Sodium 50 mg PO BID 9. Metoprolol Succinate XL 12.5 mg PO DAILY (being held for continued diuresis) 10. Tiotropium Bromide 1 CAP IH DAILY 11. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Rhabdomyolysis Acute Kidney Injury Acute on chronic diastolic congestive heart failure Non-convulsive seizure activity Discharge Condition: Mental status: clear, oriented Ambulatory status: requires wheelchair. Full assist for transfers Discharge Instructions: Dear Mr. [**Known lastname 15352**], It was a pleasure taking part in your care here at [**Hospital1 771**]. You were admitted for muscle breakdown known as rhabdomyolysis caused by your fall. This muscle breakdown caused damage to your kidneys, which was treated with IV fluids. Your kidneys and the muscle breakdown improved with IV fluids. You also developed a pneumonia, which was treated with IV antibiotics and your breathing improved. You continued to require more oxygen than normal. This was likely due to some of the fluid that you received backing up into your lungs. We treated this with a medicine called Lasix, which helped to remove fluid, and your breathing improved. You also had a period during which you were very confused. We performed a brain activity test called an EEG which showed some seizure activity. We treated this with an anti-seizure medication called Keppra. Your mental status improved significantly and is now back to normal. You are being transferred to a rehabilitation facility where they will continue to remove fluid to help improve your breathing. They will also work on regaining your strength through physical therapy. It is likely that you have a lung disease known as pulmonary hypertension. This is likely why your oxygen levels are always low. It will be very important that you follow-up with your pulmonologist (lung doctor) Dr. [**Last Name (STitle) **]. Followup Instructions: Department: MEDICAL SPECIALTIES When: THURSDAY [**2198-10-4**] at 2:00 PM With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2198-10-18**] at 2:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

16146, 16212

10776, 14984

382, 420

16375, 16375

3930, 3930

17927, 18577

2224, 2472

15630, 16123

16233, 16354

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4528, 10753

1440, 1855

1871, 2208

3151, 3911

77,245

165,252

54083

Discharge summary

report

Admission Date: [**2193-4-26**] Discharge Date: [**2193-5-3**] Date of Birth: [**2132-2-22**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x1 (Left internal artery grafted to left anterior descending) [**2193-4-29**] History of Present Illness: 61 year old male transferred from [**Hospital6 3105**] with 95% LAD stenosis at 90 degree angle with LM for CABG. Patient has not had a primary care physician for some time but is usually in good health. He presented to LGH with 3 weeks of a severe cough and burning-type chest pain specially on the right chest, worse upon walking or exercising. Had a stress test that suggested some ischemia and a cardiac cath with severe 95% LAD stenosis at 90 degree angle with LM, high risk for PCI, so was transferred to [**Hospital1 18**] for CABG. He has been hemodynamically stable, with some persistent atypical burning sensation mostly on the right chest. Past Medical History: Coronary Artery Disease PMH: Paget disease of the bone, GERD Social History: Lives with: daughter Contact: [**Name (NI) 2147**] Phone # [**Telephone/Fax (1) 110859**] ; [**Telephone/Fax (1) 110860**] Occupation: He worked for 40 years as a construction foreman Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [x] [**2-26**] drinks/week [] >8 drinks/week [] Family History: Father had an MI at age 85, sister has a pacemaker Physical Exam: Pulse: 63 Resp: 18 O2 sat: B/P Right: 134/94 Left: Height: Weight: 104.5 Five Meter Walk Test #1_______ #2 _________ #3_________ General: NAD, AAOx3 Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] 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] Extremities: Warm [x], well-perfused [x] Edema [] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [**Name (NI) 167**]: palp Left: palp Radial Right: palp Left: palp Carotid Bruit Right: none Left: none Pertinent Results: [**2193-4-29**] Intra-op TEE Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricle is not well seen. Esophageal views suggest LVEF 50-55%. The aortic valve leaflets (3) are mildly thickened. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on in the operating room. POST-BYPASS: Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Aorta is intact post decannulation. Rest of the examination is unchanged from prebypass. Very poor transgastric views. [**2193-5-3**] 07:45AM BLOOD Hct-33.6* [**2193-5-2**] 05:12AM BLOOD WBC-7.8 RBC-3.82* Hgb-11.4* Hct-34.4* MCV-90 MCH-29.8 MCHC-33.1 RDW-12.7 Plt Ct-150 [**2193-5-1**] 04:30AM BLOOD WBC-8.8 RBC-3.97* Hgb-11.8* Hct-35.7* MCV-90 MCH-29.8 MCHC-33.1 RDW-12.6 Plt Ct-133* [**2193-5-3**] 07:45AM BLOOD UreaN-16 Creat-1.0 Na-140 K-3.9 Cl-103 [**2193-5-2**] 05:12AM BLOOD Glucose-124* UreaN-14 Creat-0.9 Na-141 K-4.0 Cl-105 HCO3-30 AnGap-10 [**2193-5-1**] 04:30AM BLOOD Glucose-129* UreaN-12 Creat-1.0 Na-137 K-3.9 Cl-104 HCO3-28 AnGap-9 Brief Hospital Course: The patient was brought to the Operating Room on [**2193-4-29**] where the patient underwent CABG x 1 with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. 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 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: Aspirin 81', osteoflex, ibuprofen prn. Discharge Medications: 1. 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* 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 8. potassium chloride 20 mEq Packet Sig: One (1) Packet PO twice a day for 1 weeks. Disp:*14 Packet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease PMH: Paget disease of the bone, GERD Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2193-5-9**], 10:00 Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], [**2193-6-5**], 1:15 Cardiologist Dr. [**Last Name (STitle) 5017**] ([**Telephone/Fax (1) 65679**], Mon [**2193-5-27**], 1:45pm Please call to schedule the following: Primary Care in [**4-25**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2193-5-3**]

[ "413.9", "530.81", "414.01", "731.0" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

5896, 5971

3776, 4847

321, 429

6076, 6241

2345, 3753

7028, 7628

1561, 1614

4937, 5873

5992, 6055

4873, 4914

6265, 7005

1629, 2326

270, 283

457, 1109

1131, 1193

1209, 1545

4,266

193,006

45664

Discharge summary

report

Admission Date: [**2113-8-20**] Discharge Date: [**2113-9-2**] HISTORY OF PRESENT ILLNESS: This is a 76-year-old man with a history of compression fractures, chronic back pain and atrial fibrillation who presents this admission to the Neurology Service on [**2113-8-20**] with new Patient had reported a fall two days ago where legs gave way without warning and he did not injure himself. His wife was there to support him and he had no alternation in consciousness, no vertigo, no lightheadedness, shortness of breath, acute weakness. Then, he had shortly thereafter, had worsening of his back pain, as per his primary care physician, [**Name10 (NameIs) **] his wife. The patient himself denied Yesterday, he was able to use his walker as usual and apart from the back pain felt in his usual state of health. When he awoke the day later (morning of admission) it was found that he was unable to move his legs. No urinary frequency or urgency, incontinence, no bowel movements on the day of admission which patient reported was unusual. Denies weakness in his arms, neck pain, numbness and tingling, no fever, night sweats, headache. Patient and his wife denies any progression of his weakness beyond the a.m. PAST MEDICAL HISTORY: Atrial fibrillation, hypothyroidism, chronic back pain, recent CT of the chest with multiple nodules, inflammatory versus infection, most likely neoplasm, bipolar disorder, chronic obstructive pulmonary disease, left hip replacement, left knee replacement, left femoral plate, shoulder surgery, hernia repair, peripheral vascular disease, organic mania, sleep disorder, basal cell cancer of the back. SOCIAL HISTORY: Drank heavily eight years ago, approximately one pint of Vodka per day, on and off, now drinks one to two Vodka and tonics a day. Smokes approximately a pack per day for many years, retired business man. FAMILY HISTORY: Father with acute leukemia. Mother with rheumatoid arthritis. ALLERGIES: Penicillin. MEDICATIONS ON ADMISSION: Depakote, Coumadin, digoxin, Restoril, Synthroid, hydrocodone, Zantac and OxyContin. PHYSICAL EXAM ON ADMISSION: Blood pressure 130/77. Heart rate 96. Temperature 98. Respiratory rate 16, 02 saturation 98%. Appearance, emaciated elderly lying uncomfortably on his right side, unwilling to cooperate full, disinterested, was fed and irritated. The patient has severe cervical rigidity and kyphosis. Range of motion of the neck is severely decreased. The neck is nontender to palpation. Lungs are clear to auscultation. Cardiac: Normal S1, S2. Abdomen: Soft, tender, no organomegaly, +2 brachial pulses bilaterally. Neurologic exam: He is awake, alert, oriented to all modalities except he believes that it is [**8-27**]. Aware of all the recent current events. Speech fluent, spontaneous, no paraphasic errors. There is no right-left confusion, neglect. Release testing reveals left greater that right palmomental reflex, normal jaw jerk, no rooting, slight grasp bilaterally. On cranial nerve exam: Ocular discs are sharp. Visual fields full, [**1-1**] round and reactive. There is no relative afferent defect. Extraocular movements are full, no nystagmus. Facial sensation intact to light touch. Face is symmetric and movements are intact. Sternocleidomastoid strength of [**4-1**]. Tongue movements are intact and palatal elevation is symmetric. On motor exam, there is generally decreased bulk and tone, decreased symmetrically, there is generalized wasting, especially of the intrinsic muscles of the hands, quads, gastrocnemius bilaterally. No drift. Motor strength testing reveals generally 4+/5 in the upper extremities and anywhere from 0-3 in the lower extremities. He was able to exert some proximal movements, but no distal. Reflexes are brachial 3+ bilaterally and 1+ bilaterally otherwise with downgoing toes bilaterally and no clonus. On sensory exam, light touch is decreased in the feet bilaterally. It is difficult to determine whether or not there is a sensory level. Repeated testing does not show any clear finding. Pinprick and temperature is decreased in the feet symmetrically. Position sense was impaired in the toes, but not impaired in the ankles. Mildly impaired position sense in the fingers bilaterally. Coordination testing, finger to nose is without ataxia. Stance and gait could not be tested. LABORATORY DATA: Electrocardiogram [**2107**]: Atrial fibrillation, nonspecific ST changes. Laboratories from [**8-9**]: CBC: White blood cell count 13.9, hematocrit 34 and CB 115, platelets 110. INR 2.4, CK 171. HOSPITAL COURSE: As noted above, 76-year-old man admitted initially to the Neurology Service on [**2113-8-20**], ultimately transferred to the Medical Service on [**2113-8-30**]. He was admitted with severe paraparesis, status post fall without loss of consciousness or head trauma and worsening back pain. CT of the thoracolumbar spine done on [**8-21**] showed T12, L1, L4-L5 compression fractures with retrolisthesis of L3 and L4 and L4 on L5 and a calcified mass on the tail of the pancreas. CT of abdomen [**8-22**] with contrast showed a 4 x 8 x 5. cm mass in the tail of the pancreas and several tiny nodules in lung bases, left greater with right with patchy linear opacities in right base. Bone scan on [**8-23**] showed increased foci in the lower lumbar spine and right iliac ring suspicious for metastatic disease. MRI of lumbar spine showed mass in the lumbo-sacral region. A myelogram was ordered initially, but could not be done because the patient refused the myelogram on the first day and subsequently had abnormally high INR. On the day that the myelogram was scheduled for, he was transferred to the Medical Intensive Care Unit after a respiratory arrest on [**8-25**] and intubated. Bronchoscopy at that time showed significant aspirated material. Differential diagnoses include: Secondary to his narcotic pain medications versus aspiration pneumonia. His pCO2 at that time was noted to be 89. He was started on levofloxacin and clindamycin and Counseling service while he was in the Medical Intensive Care Unit. He was initially started on dexamethasone for presumed cord compression on [**8-25**] and family ultimately declined transfer to [**Hospital6 1708**] for CT myelogram. It should be noted that the patient was unable to tolerate an MRI secondary to his scoliosis. Transiently on dopamine for hypotension and transfused one unit of packed red blood cells. Ultimately, patient did receive a CT myelogram which showed obstruction to flow of contrast from below at T8 and T9 level. It was an overall limited study. Also a sacral mass at the epidural extension. Question of a T spine epidural mass and ultimately his Decadron was discontinued on [**8-29**], because of no improvement. He received Neurosurgery and Radiation Oncology consults. The patient was extubated on [**2113-8-29**] with a plan for a sacral mass biopsy. CT guided biopsy which was done on [**2113-8-29**]. Patient was transiently transferred to the Medical Service from [**8-29**] through [**8-31**] but had another respiratory arrest while on the floor with gradually worsening hypercapnia and acidosis. He was found unresponsive, without respirations and reintubated and transferred to the Medical Intensive Care Unit. Overall impression at this time on [**8-31**] was that patient likely had metastatic pancreatic disease, left pancreatic cancer. He had a mildly elevated PSA but this was not thought to be related to his current process. Ultimately, his biopsy of his sacral lesions was consistent with malignancy, likely adenocarcinoma. Respiratory support was continued with suspected patient more than likely had a mucus plugging event. In discussion between the family, Dr. [**Last Name (STitle) **], patient's primary care physician, [**Name10 (NameIs) **] the Team, it was felt that the patient clearly had another source of adenocarcinoma. His overall prognosis is extremely grave and the patient's dopamine was weaned. The patient was extubated and accepted by [**Hospital **] Hospice and was transferred there on [**2113-9-2**]. Patient had requested that his body be donated as an anatomic gift to [**Hospital **] Medical School. Family was given the number to contact. CONDITION OF DISCHARGE: Grave. PAST MEDICAL HISTORY: Same as presenting medical history with addition of metastatic adenocarcinoma. MEDICATIONS ON DISCHARGE: Not known to this dictator at this time though medical care was guided as to focused on comfort care and hospice care. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 37298**] MEDQUIST36 D: [**2113-10-4**] 13:13 T: [**2113-10-4**] 13:13 JOB#: [**Job Number 97343**]

[ "427.31", "507.0", "496", "518.81", "198.89", "344.1", "276.8", "198.5", "157.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "87.21", "83.21", "96.72", "03.31" ]

icd9pcs

[ [ [] ] ]

1892, 1980

8454, 8802

2007, 2107

4601, 8324

101, 1227

2122, 2634

2652, 4583

8347, 8427

1669, 1875

9,595

147,805

20081

Discharge summary

report

Admission Date: [**2184-12-1**] Discharge Date: [**2184-12-8**] Date of Birth: [**2184-4-19**] Sex: F Service: Neurology/Medicine HISTORY OF PRESENT ILLNESS: In summary, this is a patient who presents after falling in her bathtub on the morning of [**12-1**]. She then suffered confusion, for which she was transferred to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **]Hospital. A head computed tomography at that time showed a right occipital hemorrhage. She also complained of a posterior headache since the fall. PAST MEDICAL HISTORY: (Her past medical history is significant for) 1. Hypertension. 2. Dementia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Her medications were just Tylenol at the time. SOCIAL HISTORY: She lives at home with her son. FAMILY HISTORY: Her family history was noncontributory for any bleeding disorders or stroke. PHYSICAL EXAMINATION ON PRESENTATION: Examination on presentation revealed the patient was afebrile, her blood pressure was in the 200s/100s, her pulse was regular (in the 80s), and her respiratory rate was 12 to 18. Generally, she was in no acute distress. Normocephalic and atraumatic. No bruises found on the head. The mucous membranes were moist. Her neck was supple. No carotid bruits. Her cardiovascular examination was regular with a 2/6 systolic murmur. Pulmonary examination revealed the lungs were clear to auscultation bilaterally. The abdomen was soft with bowel sounds heard in all four quadrants. The extremities were warm and well perfused with 2+ distal pulses. On mental status examination, she was awake and alert. She was easily distractible and inattentive. She reported that she was at .................... Hospital and that it was [**Holiday **]. She was confused and unable to give much history. Her speech was fluent. She perseverated on several topics. Her naming was normal; however, her repetition was intact. She had no neglect, and she had a glabellar and palmomental sign bilaterally. Cranial nerve examination revealed her disks were flat and sharp. Her visual fields were intact to confrontation. Her pupils were round and reactive to light. Her extraocular movements were intact without nystagmus. She had normal facial sensation with no facial droop. Her strength was [**5-10**]. Her hearing was intact to finger rub bilaterally. She had normal oropharyngeal movement. Her tongue was midline without fasciculations. Her sternocleidomastoid and trapezius muscle movements were normal bilaterally. Her motor examination showed normal bulk and tone without any adventitious movements. She had no pronator drift or slowing of rapid alternating movements. She had motor impersistence and give-way weakness throughout, but there was no asymmetry on her examination. Her sensory examination was intact to light touch. Unable to do full sensory examination due to her inattentiveness. She had extinction to double-simultaneous stimulation. Her reflexes on the left were 3+ in the triceps, biceps, and brachioradialis. On the left, reflexes were 2+ in the right upper arm. Her legs were 2+ bilateral patellar reflexes. The toes were downgoing bilaterally. She did not have any dysmetria. Finger-nose-finger was intact; however, she was not able to follow commands on heel-to-shin. We were not able to walk her at that time. PERTINENT LABORATORY VALUES ON PRESENTATION: On presentation her laboratories revealed an INR of 1.1. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the head showed a right occipital hemorrhage without significant midline shift. She had old right frontal encephalomalacia suggestive of an old lobar bleed likely due to amyloid angiopathy. CONCISE SUMMARY OF HOSPITAL COURSE: Her hospital course was uneventful. She had a repeat head computed tomography which showed no progression in her bleed. She had issues of hypertension during her admission, for which she was given hydralazine as needed times three. Her labetalol was started and increased to 200 mg twice per day; for which her blood pressure was stable in the 140s to 150s systolic. She had a Speech and Swallow evaluation which she passed. She also had Physical Therapy and Occupational Therapy which was recommended on discharge to rehabilitation. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge were) 1. Famotidine 20 mg by mouth twice per day. 2. Insulin sliding-scale; however, her dipsticks were normal. 3. Labetalol 200 mg by mouth twice per day. 4. Dilantin 100 mg by mouth twice per day; her last Dilantin level was 18.5 and therapeutic on [**2184-12-4**]; her liver function tests as a baseline prior to starting Dilantin were also within normal limits. DISCHARGE DISPOSITION/STATUS: She was discharged to [**Hospital 21585**] Rehabilitation in [**Location (un) **]. DISCHARGE DIAGNOSES: Right occipital hemorrhage. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. She was instructed to follow up with her primary care physician in one to two weeks; for which she will set up an appointment. 2. She also had a follow-up appointment with Neurology/Medicine in four to six weeks after discharge; for which she was given the appointment date at the time of discharge. The Neurology/Medicine appointment was here at the [**Hospital1 69**]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**] Dictated By:[**MD Number(1) 54052**] MEDQUIST36 D: [**2184-12-8**] 08:50 T: [**2184-12-8**] 08:54 JOB#: [**Job Number 54053**]

[ "294.8", "401.9", "277.3", "E888.1", "853.01", "599.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

845, 3770

4911, 4940

4365, 4889

729, 777

4973, 5652

3799, 4338

180, 562

585, 702

794, 827

1,267

133,666

20981

Discharge summary

report

Admission Date: [**2186-6-20**] Discharge Date: [**2186-6-30**] Date of Birth: [**2126-9-14**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 59 year old male patient with known aortic stenosis who as discovered to have had a murmur approximately five or six years ago at his primary care physician's office. He continued to have serial echocardiograms. Most recently, this year, the patient underwent an exercise tolerance test which was abnormal and cardiac catheterization was subsequently done. This revealed severe aortic stenosis with preserved left ventricular function and normal coronary arteries. Most recent echocardiogram was in [**2186-4-20**], which showed a left ventricular ejection fraction of 60 to 65 percent, a dilated aortic root and an aortic valve gradient of 98 millimeters of Mercury as the peak gradient. It also reveals an aortic valve area of 0.7 cm squared. The patient was referred for an aortic valve replacement to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. PAST MEDICAL HISTORY: Aortic stenosis as previously described. Left eye cataracts. Questionable benign prostatic hypertrophy. Seasonal allergies. Diverticulosis. History of nephrolithiasis in [**2170**]. PAST SURGICAL HISTORY: Hemorrhoidectomy. Tonsillectomy as a child. MEDICATIONS: The patient takes no medications prior to admission. ALLERGIES: The patient states no known drug allergies. PHYSICAL EXAMINATION: The patient's physical examination preoperatively was unremarkable. LABORATORY DATA: The patient's laboratory values preoperatively were unremarkable. HOSPITAL COURSE: The patient was admitted directly to the preoperative holding area and taken to the Operating Room on [**2186-6-20**], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] where he underwent an ascending aortic graft, supra coronary, as well as an aortic valve replacement, a No. 27 Paramount tissue valve. Postoperatively the patient was transported from the Operating Room to the Cardiac Surgery Recovery Unit on Neo- synephrine, intravenous drip and Propofol. Initially he woke up from anesthesia quite agitated, thrashing and kicking. His Propofol was increased and he was allowed to wake up a second time later on the evening of surgery and was ultimately weaned from mechanical ventilation and successfully extubated at about 09:30 that evening. On postoperative day one, the patient remained hemodynamically stable. He had a cardiac index of six liters per minute. His Swan-Ganz catheter was removed later that day. He was begun on aspirin and was transferred out of the Intensive Care Unit to the Telemetry Unit later that day. On postoperative day two, the patient remained hemodynamically stable and was beginning to progress with cardiac rehabilitation and ambulation. He had a fair amount of chest tube drainage at that time and they were left in due to drainage. Early morning of [**6-23**], postoperative day two going into day three, the patient had worsening agitation, actually began in the evening of [**6-22**] at about 10:30 or 11:00 in the evening. This accelerated to the point that the patient was attempting to pull out his chest tubes, was thrashing, had ripped his intravenous catheters out of his arm and was very difficult to control. His sons were at the bedside and they were helping to restrain him. He received large doses of intravenous Haldol at the time and an emergent Psychiatry consultation was obtained that night. The psychiatrist did see the patient at about 3 o'clock in the morning and it was their recommendation to continue with Haldol as needed for sedation. It was their impression that the patient was delirious at that time of unknown etiology. The following morning on [**6-23**], the patient was calm and cooperative and very lethargic, probably as a result of the sedation that he required the night before. The Psychiatric Service continued to follow him. Their recommendation was to continue with standing Haldol orders as well as p.r.n. if needed for increased agitation. The patient, over the next couple of days, was noted to have an increased [**Month (only) **] as well as increased shortness of breath. He also was noted to have rapid atrial flutter in the late afternoon of [**6-24**]. This lasted approximately two minutes and broke with some Lopressor. The following day, [**6-25**], the patient continued to complain of shortness of breath and a [**Month (only) **] and a chest x-ray was obtained that showed a significantly increased size of his right heart border and as a result of that and his symptoms of shortness of breath and [**Last Name (LF) **], [**First Name3 (LF) **] echocardiogram was obtained. This showed a large pericardial effusion without markers for tamponade, however, it was felt to be in the patient's best interest because his symptoms of shortness of breath and [**First Name3 (LF) **] were progressing, to drain the pericardial effusion; so, on [**2186-6-26**], the patient was taken to the Cardiac Catheterization Lab where he underwent pericardiocentesis using the ECG guided access via subxiphoid approach. Initially 360 cc of dark bloody fluid was removed and a pericardial drain was left in place at that time. Over the next 48 hours, the patient remained in the Cardiac Surgery Recovery Unit / Intensive Care Unit, simply because of the presence of a pericardial drain. Over the next 48 hours while the drain was in place, he drained approximately a liter total of fluid and the drain was ultimately removed. The patient subsequently was transferred to the Telemetry Floor again on [**6-28**]. He was alert and oriented at that time but was complaining of questionable visual field deficits or difficulty with upward gaze. Because of his postoperative agitation and questionable visual difficulties, a Neurology consultation was obtained. The patient also had some rapid atrial flutter noted on the [**6-28**] as well. A CT scan was ultimately performed and was negative. The Neurology Service and the Psychiatry Service continued to follow the patient. The patient continued with significant anxiety, however, was no longer agitated or disoriented. An Ophthalmology consultation was to be obtained on [**6-29**], but early in the morning of [**6-29**], the patient had significant problems with increased anxiety, stating that he felt that he was being caged and needed to get out. He complained of being claustrophobic and wanted to leave, however, the Cardiac Surgery Service felt it important to obtain another echocardiogram to make sure that he was free of arrhythmias prior to safely discharging him home. At that time, the patient did receive 1 mg p.o. dose of Ativan the morning of [**6-29**] due to continued anxiety and his request for something to calm him. As the morning progressed, the patient became increasingly agitated and disoriented quite probably as a result of this Ativan dose. He progressed to significant restlessness and agitation which was treated with doses of intravenous Haldol. Psychiatry staff did come and evaluate the patient and they diagnosed him as having delirium secondary to Ativan as the most likely cause of this deteriorate from a mental status standpoint and they recommended more Haldol to be used as necessary. Later in the day on [**6-29**], the patient received no more benzodiazepines and was treated with Haldol with a total of three doses during the day and by later in the day he was much clearer mentally. It was noted that the patient did have an episode of hypotension while he was sleeping during the dosing of Haldol. This was treated with a 500 cc bolus of normal saline and his blood pressure responded appropriately to that. Ultimately, the patient cleared from a mental status standpoint. Today, [**6-30**], the patient is alert and oriented, asking very specific appropriate questions about his medical course and anxious to go home. Since the patient has had no further episodes of atrial fibrillation and has remained stable from a hemodynamic standpoint, it was felt safe to discharge the patient home. FOLLOW UP: He has been given instructions to follow up with his primary care physician within the next week. He is also to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the Neurology Service here within approximately two to four weeks. He is to followup with his primary Cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], and he is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. CONDITION ON DISCHARGE: The patient's condition upon discharge is good. Temperature is 98.4 F.; pulse of 92 in normal sinus rhythm; blood pressure 119/72. Neurologically, he is intact, alert and oriented. His cardiac examination is regular rate and rhythm. His lungs are clear to auscultation bilaterally. His abdomen is soft, nontender, nondistended. His incision is clean, dry and intact. He has no peripheral edema. His echocardiogram from [**6-29**] revealed very tiny amounts of pericardial fluid with no concern for tamponade and a left ventricular ejection fraction of approximately 60 percent. The patient was also noted yesterday to have a thrombophlebitis of the right antecubital intravenous site and he was placed on oral Levofloxacin as a result of this. DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg p.o. q day. 2. Ibuprofen 400 mg one p.o. q eight hours p.r.n. pain. 3. Lopressor 50 mg p.o. twice a day. 4. Levofloxacin 500 mg p.o. q day for seven days. 5. At the recommendation of Dr. [**First Name (STitle) 2405**], the attending Psychiatrist, the patient was also given a prescription for Haldol, 1 mg tablet, and instructions were given to the patient and his family to take one tablet q eight hours p.r.n. severe agitation or any hallucinations. DISCHARGE INSTRUCTIONS: The patient and his family were instructed for him to be brought to an Emergency Room if he has any episodes of profound agitation that he did exhibit in the hospital. DISCHARGE DIAGNOSES: 1. Aortic stenosis, dilated ascending aorta. 1. Postoperative atrial flutter. 1. Postoperative delirium with agitation. 1. Thrombophlebitis of right antecubital intravenous site. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 5664**] MEDQUIST36 D: [**2186-6-30**] 14:43:25 T: [**2186-6-30**] 19:07:06 Job#: [**Job Number 55753**]

[ "441.2", "292.81", "999.2", "423.9", "424.1", "427.32", "997.1" ]

icd9cm

[ [ [] ] ]

[ "37.0", "39.61", "35.21", "37.21", "99.04", "38.44" ]

icd9pcs

[ [ [] ] ]

10207, 10651

9493, 9992

1659, 8188

10017, 10186

1293, 1464

8200, 8693

1487, 1641

165, 1058

1081, 1269

8718, 9470

24,256

112,694

30738

Discharge summary

report

Admission Date: [**2138-3-20**] Discharge Date: [**2138-3-20**] Service: SURGERY Allergies: No Drug Allergy Information on File Attending:[**Doctor First Name 5188**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laparotomy History of Present Illness: This patient is an 83-year-old female who was transferred to us from the [**Hospital6 8283**] with approximately 28 hours of progressive worsening abdominal pain, nausea and vomiting. She was seen at [**Hospital6 8278**] where she was noted to have significant tenderness on exam of the abdomen and subsequent workup showed based on a CT scan that there was evidence of portal venous air, pneumatosis of the small bowel, the exact length of which was not clear based on the imaging studies that was done there as well as a lactic acidosis, leukocytosis size 26,000 and progressively worsening abdominal pain since the initial presentation to the emergency room. The patient had in the prior 24 hours had had her scheduled hemodialysis as she has multiple comorbidities including end-stage renal disease and significant atherosclerotic disease. She had undergone her scheduled hemodialysis and thereafter had progressive abdominal pain, nausea, and emesis, which subsequently required her to be taken to the hospital. Past Medical History: ESRD, CAD, PVD Social History: unknown Family History: n/c Physical Exam: mentating, alert, following commands but in obvious distress CTAB sinus tachy, no m/r/g abd: extremely tender abdominal exam consistent with rigidity and peritonitis. ext: warm, well perfused Pertinent Results: [**2138-3-20**] 12:00PM WBC-24.3* RBC-4.16* HGB-13.9 HCT-44.0 MCV-106* MCH-33.5* MCHC-31.7 RDW-14.2 [**2138-3-20**] 12:00PM ALT(SGPT)-36 AST(SGOT)-71* CK(CPK)-63 ALK PHOS-102 AMYLASE-443* TOT BILI-1.2 [**2138-3-20**] 12:00PM GLUCOSE-127* UREA N-40* CREAT-4.2* SODIUM-143 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-16* ANION GAP-27* Brief Hospital Course: Patient was seen and a decision was made to proceed to the OR for an exploratory laparotomy to try to salvage any remaining non-necrosed small bowel. During the operation it became aparent that the entire length of the small bowel from the ligament of Treitz to its termination at the ileocecal valve appeared to be completely non-viable and necrotic. At this time, we replaced the intestinal contents within the abdomen and felt that this was a non-survivable insult. We then subsequently closed the fascia and the skin and dressed it appropriately. The patient was then subsequently taken intubated in stable condition up to the intensive care unit. After a lengthy discussion with her husband, it was decided to make the patient CMO and she was started on a morphine drip, extubated and expired shortly thereafter. She was pronounced dead at 2350, and the chief, attending and patient's family were all notified. Medications on Admission: unknown Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: small bowel necrosis Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2138-3-25**]

[ "496", "568.0", "403.91", "V45.81", "585.6", "428.0", "557.0", "567.29" ]

icd9cm

[ [ [] ] ]

[ "54.59" ]

icd9pcs

[ [ [] ] ]

3004, 3013

1996, 2917

258, 283

3078, 3088

1640, 1973

3141, 3283

1408, 1413

2975, 2981

3034, 3057

2943, 2952

3112, 3118

1428, 1621

204, 220

311, 1329

1351, 1367

1383, 1392

82,938

170,239

53910

Discharge summary

report

Admission Date: [**2146-4-15**] Discharge Date: [**2146-4-28**] Date of Birth: [**2075-7-13**] Sex: M Service: NEUROSURGERY Allergies: Dilaudid / trazodone Attending:[**First Name3 (LF) 1835**] Chief Complaint: Thoracic spinal abscess Major Surgical or Invasive Procedure: [**2146-4-16**] Anterior FUSION THORACIC/CORPECTOMY T9 - T10 Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) 363**] [**2146-4-21**] Posterior FUSION LAMINECTOMY T4-T12 History of Present Illness: 70 yr old gentleman who was recently seen inpatient [**Hospital1 18**] for thoracic abscess/discitis. He was in initially followed by ID at [**Hospital3 **] for several m months for MRSA sepsis and a right pleural space infection. On [**12-17**] he fell on the right after shoveling snow sustaining rib fractures with a hemothorax, hypoxemia s/p chest tube placement. He developed high-grade Staph aureus bacteremia and infection of his right pleural space. Pathogen oxacillin -resistant. His hospital course was complicated by cardiac arrhythmia, NSTEMI, prolonged right chest drainage, depression and insomnia. He was on Vancomycin from [**12-25**] through [**1-23**] via a PICC line. One week after stopping antibiotics he developed night sweats and back pain was seen at [**Hospital3 2568**] and transferred to [**Hospital1 18**] for neurosurgery evaluation. [**2146-2-21**]. He was ambulatory and did not have any bowel or bladder dysfunction. MRI [**2-21**] showed T9-T10 diskitis,probable osteomyelitis and small fluid collection, epidural abscess. IR performed a biopsy on [**2146-2-22**] Blood cultures and would culture grew MRSA sensitive to vancomycin. ESR a nd CRP elevated and imaging confirmed osteomyelitis. PICC placed and patient dc'd on antibiotics on [**2146-3-1**]. Admitted for leg swelling, heart failure on [**5-7**]. Currently complains of constant severe left sided pain that is an [**7-7**] on a 0-10 scale. There are no precipitating or ameliorating factors. Of note, he has lost 35 lbs since [**Month (only) 404**]. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - NSTEMI - Right rib hemothorax complicated by MRSA empyema - MRSA bacteremia/sepsis, s/p 4 wks of IV vancomycin - Right rib fractures s/p fall - BPH - Arrhythmia - Depression / insomnia Social History: Married, lives in [**Name (NI) **], wife and 2 attentive sons. [**Name (NI) **] HIV risks. No significant alcohol or tobacco use. Family History: noncontributory Physical Exam: Gen: AF VSS; WD/WN, NAD. HEENT: Pupils: PERRL EOMs intact without nystagmus Neck: Supple. Lungs: no adventitious sounds Cardiac: RRR Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: No abnormal movements, tremors. Strength full power [**4-2**] throughout. No pronator drift Sensation: Intact to light touch; no paresthesias Symmetric reflexes Toes downgoing bilaterally MSK: Thoracic kyphotic deformity On Discharge: Non focal Pertinent Results: [**2146-4-15**] CXR : There is no change in the elevation of the right hemidiaphragm and basilar atelectasis. There is a small right effusion. Pleural effusion has decreased in size. A curvilinear opacity in the right base is unchanged. Exaggerated kyphosis secondary lower thoracic wedge compression deformities and partial vertebral body collapse is unchanged. No Acute cardiopulmonary process. OR T-SPINE [**2146-4-16**]: IMPRESSION: Stabilization construct in lower thoracic spine, in overall anatomic alignment on AP and lateral views. CXR [**2146-4-16**]: IMPRESSION: AP chest compared to [**4-15**]: Left pleural tube impinges on the mediastinum in the midline at the level of the carina. Left hemithorax is hyperinflated and the mediastinum may be shifted slightly to the right, exaggerated by patient rotation, but the interfaces projecting over the left lung laterally are skin folds, not the pleural edges of pneumothorax. On the other hand, this is a supine radiograph and anterior pneumothorax could be missed, particularly since there is subcutaneous emphysema in the left chest wall. When the left pleural tube is repositioned, recommend a right decubitus view of the left hemithorax to look for pleural air. ET tube is in standard placement. Right jugular line ends in the region of the superior cavoatrial junction, nasogastric tube ends in the upper stomach and should be advanced 8 cm to move all the side ports beyond the GE junction. Left PIC line passes at least as far as the upper SVC, where it is partially obscured by the jugular line. ECHO [**2146-4-17**]: Conclusions Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with severe global free wall hypokinesis. Trace aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. Mild to moderate ([**11-29**]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. There is no change in LV or RV function from prior echo. The patient has a overall LVEF of 20-25%, with regional wall motion abnormalities present in the basal, mid, and apical septal and inferior walls as well as the apex. The RV is mildly dilated with severe free wall hypokinesis. Mild to moderate TR, mild-mod MR, and trace AI are unchanged. CXR [**2146-4-17**]: IMPRESSION: AP chest compared to 11:10 p.m. on [**4-16**]: The left pleural tube still impinges on the mediastinum at the level of the carina. Skin folds project over the left lung in the upperexpanded hemithorax. Subcutaneous emphysema is more pronounced. To assess pneumothorax would require right decubitus chest films since the patient presumably cannot tolerate sitting erect. Atelectasis in the infrahilar right lung which preceded surgery is still severe. Mediastinum is unremarkable, although possibly slightly rightward shifted as before. Nasogastric tube passes into the stomach and out of view. Right jugular line and left PIC line are central. CT TORSO [**2146-4-17**]: IMPRESSION: 1. Post operative changes in the form of T9 and T10 corpectomy with interbody spacer and graft material and T8 to T11 fusion. There is no evidence of hardware loosening or fracture. 2. Mild anterior epidural soft tissue at T9-T10 level causing indentation of the thecal sac. Possibility of post operative fluid collection or hematoma cannot be ruled out. Close attention to this area on follow up imaging is advised. 3. Minimal retropulsion of the bony fragments at T9-T10 level with associated ligamentum flavum calcification causing mild narrowing of the thecal sac. This has improved since the prior study. 4. Fractures of superior facets of T10 vertebra bilaterally causing severe bilateral foraminal stenosis. 5. Subacute fractures of posterior ends of right lower ribs. 6. Left sided hydropneumothorax with pleural effusion and basal atelectasis on the right side. 7. Left renal calculi. [**4-18**] ECG: Sinus rhythm with ventricular premature beats and possibly multifocal atrial tachycardia. Since the previous tracing atrial and ventricular arrhythmias are new. Clinical correlation is suggested. [**4-18**] CXR: ET tube tip is 7 cm above the carina. Thoracic hardware is in place. The NG tube tip is in the stomach. Left chest tube is in place. There is minimal if no apical pneumothorax on the left. Right internal jugular line tip is at the level of low SVC. Right rib fractures are unchanged, but there is interval increase in right lower lobe opacity that might reflect aspiration or developing infection, attention to this area on the subsequent studies is recommended. [**4-18**] CXR: Persistent right lower lobe consolidation and parapneumonic effusion. [**4-18**] CXR: Stable right basal consolidation and small effusion [**4-19**] CXR: Stable appearance of small right effusion and right basilar consolidation. [**4-19**] CXR: No large left pneumothorax status post chest tube removal. There may be a small loculated air collection at the chest tube site. [**4-20**] ECHO: IMPRESSION: Moderately depressed left ventricular systolic function with global hypokinesis. The inferior and inferolateral walls are relatively worse and the lateral walls relatively better. Mild mitral and mild aortic regurgitation. Moderate elevation of pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2146-2-24**], overall systolic function (particularly in inferior/inferolateral walls) has improved slightly. The severity of mitral regurgitation has decreased. Estimated pulmonary artery systolic pressure is higher. [**4-20**] CXR: IMPRESSION: 1. Right lower lobe pneumonia and effusion. 2. ETT and NGT removal, with increased left lower lobe atelectasis. 3. Mild pulmonary edema. [**4-20**] unilat rib XRAY: 1. Left anterolateral seventh rib fracture and left eighth posterior rib fracture. 2. Right-sided posterolateral sixth, seventh, and eighth rib fractures. 3. Other intrathoracic findings, unchanged. BILAT LOWER EXT VEINS [**2146-4-25**] No bilateral lower extremity deep venous thrombosis Brief Hospital Course: Mr. [**Known lastname 110582**] was directly admitted to the Neurosurgery service with plan for surgical evacuation of thoracic epidural hematoma, T9-10 corpectomies with anterior and posterior fixation. Cardiology was consulted for preoperative clearance in the setting of significant cardiac history and recent NSTEMI. He went to the OR with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 363**] on [**4-16**] for a FUSION THORACIC/CORPECTOMY T9 - T10. He remained intubated and was scheduled for a posterio fusion on [**4-17**]. He became septic however with temp of 101.7 on this day. Echocardiogram was done at the bedside. This showed an LVEF of 20-25%, with regional wall motion abnormalities present in the basal, mid, and apical septal and inferior walls as well as the apex. His posterior approach surgery was postponed. He remained intubated. On the morning of [**4-18**] he was moving all 4 extremities and following commands, but by the morning of [**4-19**] he was moving his LE's less than the day prior and his L < his R lower extremity. On [**4-20**] he was more awake, was extubated successfully and had [**4-2**] strengths throughout on exam. The patient complained of rib pain and an xray was performed which revealed multiple rib fractures. He was preoped for surgery (Posterior Fusion) for [**4-21**]. On [**4-21**] The patient went to the operating room and underwent Posterior FUSION T4-L1. The patient failed a spontaneous breathing trial in the evening. A epidural catheter was in place for pain management. On Exam, the patient opened eyes spontaneously, had full strength and followed commands.On [**4-22**], The hemovac out put in am 775cc since OR and 230 since midnight at 0800 in the morning decision was to keep the drain in place. Later in teh afternoon when the patient was being fitted for the TLSO brace the hemovac drain was found out of the patient in the bed. The patient failed another spontaneous breathing trial [**4-22**] am and was kept intubated. Physical therapy and occupational therapy consults were placed. The patient had a fever to 102.1 and was pan cultured. On exam, the patient eye opened spontaneously. The patients strength was grossly full [**4-2**] uppers, the lower extremities lifted off bed weakly. The patient was able to follows simple commands but does not participate in proper motor exam. The ICU team gave 20 mg IV lasix for diuresis and CBC revealed a stable Hct at 30. The home dose of spironolactone and lasix were held per the management of the ICU team. Infectious Disease reccomendations were concerning for new ventilator assisted pneumonia and reccomendations were made to discontinue Gentamycin, Cefipime, and was initiated on Tobramycin, and Zosyn. On [**4-23**], The patient was extubated. The [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain was removed. The pain service recommendations included ibcreasing gabapentin. The patient was noted to have increased anxiety. On [**4-24**], The neurological exam was stable. The patient was in the intensive care unit and called out for transfer to the floor but there were no beds available. On [**4-25**] and [**4-26**], he remained stable. He was transferred to the floor. His vanco trough was elevated on [**4-27**] and his dose was decreased to 750mg q12. He was seen by PT/OT and cleared for discharge to rehab facility. He was DC'd to rehab on [**4-28**] in stable condition. Medications on Admission: Aspirin 81mg, metoprolol 100mg TID, lisinopril 20mg daily, metformin 1000mg [**Hospital1 **], spironolactone 12.5mg daily, simvastatin 20mg daily, sertraline 25mg daily, neurontin 200mg TID, oxycodone PRN, Vancomycin 1000mg Q12H, Lasix 40mg Daily, ibuprofen 600mg PRN, omeprazole 20mg DAily, saxagliptin 5mg Daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): HOLD if SBP <100. 4. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO QAM (once a day (in the morning)). 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. 11. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO QPM (once a day (in the evening)). 12. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 16. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: One Hundred (100) ml Intravenous Q6H (every 6 hours) for 1 days: stop after [**4-29**]. 18. vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 12H (Every 12 Hours). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Spinal Abcess Thoracic Kyphosis [**Hospital **] Hospital aquired pneumonia 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: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? 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: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 1 week for a wound check, call [**Telephone/Fax (1) 58980**] for appt Please follow up with Dr. [**Last Name (STitle) **] in 6 weeks. No need for TLSO brace or imaging. Pt will need CBC with diff, ESR/CRP, BUN/Creat, Vanco trough weekly and fax results to [**Telephone/Fax (1) 17715**]. You have an appt with the infectious disease team on [**5-20**] in the [**Hospital **] Medical building at 9 a.m. Completed by:[**2146-4-28**]

[ "995.91", "250.00", "807.09", "E878.8", "737.10", "730.28", "E929.3", "512.1", "V15.51", "709.9", "412", "401.9", "486", "998.12", "733.13", "324.1", "038.11", "041.12", "272.4" ]

icd9cm

[ [ [] ] ]

[ "03.09", "81.05", "34.04", "84.51", "96.71", "81.04", "80.99", "84.52", "03.90", "77.19", "77.70", "81.64", "86.3", "77.79" ]

icd9pcs

[ [ [] ] ]

15466, 15538

10005, 13480

311, 490

15657, 15657

3756, 9982

17603, 18090

2621, 2638

13844, 15443

15559, 15636

13506, 13821

15840, 17580

2653, 2847

2179, 2237

3726, 3737

246, 273

518, 2075

3048, 3712

15672, 15816

2268, 2457

2097, 2159

2473, 2605

73,888

144,271

11296

Discharge summary

report

Admission Date: [**2117-2-9**] Discharge Date: [**2117-3-2**] Service: MEDICINE Allergies: Percodan / Lipitor Attending:[**First Name3 (LF) 1943**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Intubation with mechanical ventilation History of Present Illness: [**Age over 90 **]yo male with history of metastatic prostate cancer, ITP on chronic steroids, and hypercholesterolemia was admitted from the ED with fever and weakness. History was obtained from the chart, patient, and family. He presented with 2-3 days of the following symptoms: fever on the day of admission to 101, cough productive of green sputum, shaking chills, disorientation, fatigue, poor PO intake, and marked weakness. He is typically independent of all ADLs and was noted by his family to be so weak that he could not even stand up. Of note, he underwent kyphoplasty on [**2117-1-29**] for treatment of his bony metastases. Per report from his family, his back pain has completely improved with kyphoplasty. Upon arrival in the ED, temp 96.7, HR 132, BP 84/56, RR 24, and pulse ox 98% on room air. Repeat temperature rectally was elevated to 101.8. Exam was notable for rhonchi throughout and generalized weakness. Labs are notable for creatinine 2.2, WBC 11.2, Hct 35.4, and lactate 2.7. UA was suggestive of UTI, with indwelling foley. CXR was notable for a retrocardiac opacity. ECG demonstrates old RBBB with new TWI in V1-2. He received 3-4L IVF, cefepime, levofloxacin, decadron 10mg IV x 1 (for concern of hypotension in the setting of chronic steroids), and tylenol. Review of systems: (+) Per HPI. weakness, fever, chills, cough, congestions, shortness of breath. (-) Denies pain, night sweats, weight loss, headache, sinus tenderness, rhinorrhea, chest pain or tightness, palpitations, nausea, vomiting, constipation, abdominal pain, change in bladder habits, dysuria, arthralgias, or myalgias. Past Medical History: 1. Metastatic prostate cancer - dx [**2112**], no treatment to date 2. ITP 3. Hypercholesterolemia 4. h/o colon polyps 5. RBBB 6. Chronic Renal Failure - baseine creatinine unknown, was 2.0 early [**1-/2115**] 7. Glaucoma 8. Osteoarthritis 9. s/p surgery for rotator cuff 10. Postural hypotension 11. s/p Kyphoplasty Social History: Home: Per his daughters he is very active, goes to the [**Company 3596**] daily, does all his own ADL's; lives alone Occupation: Former [**Doctor Last Name **], worked in construction EtOH: Denies Drugs: Denies Tobacco: Remote hx of tobacco Family History: Father - died at age 78 - asthma Mother - died at 94 of old age Brother - died of pancreatic cancer at 80 Sister - died of bowel cancer at 46 Brother - died of a CVA in his 60's Sister - died of myocardial infarction in her 80's Physical Exam: T 98.2 / BP 105/58 / HR 70 / RR 22 / Pulse ox 95% on 3L Gen: fatigued, elderly male, no acute distress, speaking clearly HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2117-2-9**] ADMISSION LABS: Na 140 / K 4.3 / Cl 104 / CO2 22 / BUN 38 / Cr 2.2 / BG 164 CK 37 / MB not done / Trop T .03 WBC 11.2 / Hct 35.4 / Plt 525 N 88 / L 7 / M 3 / E 2 / B 0 Lactate 2.7 UA - yellow, clear, 1.016, pH 5, neg urobili, neg bili, tr leuks, mod blood, neg nitr, 25 prot, neg gluc, neg ket, 0-2 RBCs, 6-10 WBCs, mod bacteria, no yeast, 0-2 epis Baseline Cr 2.2-2.4 Baeline Hct 29-32 Baseline WBC [**7-16**] [**2117-2-9**] 06:00PM BLOOD cTropnT-0.03* [**2117-2-10**] 03:30PM BLOOD cTropnT-0.03* [**2117-2-12**] 03:50AM BLOOD CK-MB-3 cTropnT-0.07* proBNP-3322* [**2117-2-13**] 11:56AM BLOOD CK-MB-3 cTropnT-0.05* [**2117-2-14**] 02:17AM BLOOD CK-MB-2 cTropnT-0.06* [**2117-2-14**] 01:04PM BLOOD CK-MB-3 cTropnT-0.04* [**2117-2-9**] 06:00PM BLOOD CK(CPK)-37* [**2117-2-12**] 03:50AM BLOOD CK(CPK)-42* [**2117-2-13**] 11:56AM BLOOD CK(CPK)-43* [**2117-2-14**] 02:17AM BLOOD CK(CPK)-56 [**2117-2-14**] 01:04PM BLOOD CK(CPK)-41* [**2117-2-13**] 11:56AM BLOOD calTIBC-179* VitB12-624 Folate-17.7 Ferritn-332 TRF-138* [**2117-2-13**] 11:56AM BLOOD TSH-2.0 [**2117-2-14**] 02:17AM BLOOD Cortsol-24.8* [**2117-2-12**] 03:50AM BLOOD Cortsol-12.1 [**2117-2-15**] 03:34AM BLOOD Vanco-5.6* [**2117-2-16**] 05:29AM BLOOD Vanco-12.0 [**2117-2-17**] 06:07AM BLOOD Vanco-17.6 [**2117-2-13**] 10:17PM BLOOD Type-ART pO2-97 pCO2-32* pH-7.45 calTCO2-23 Base XS-0 [**2117-2-14**] 12:57AM BLOOD Type-ART pO2-53* pCO2-30* pH-7.46* calTCO2-22 Base XS-0 [**2117-2-9**] 06:00PM BLOOD Lactate-2.7* K-4.3 [**2117-2-13**] 10:06PM BLOOD Lactate-1.5 [**2117-2-13**] 10:17PM BLOOD Lactate-1.2 [**2117-2-14**] 12:57AM BLOOD Lactate-1.4 LABS ON DISCHARGE [**2117-2-23**]: CBC: 29.1/34.2/859 Diff: N 87, Bands 7, L 2, M 2, Metas 1, Promyel 1 Chem: 139/4.6/108/20/81/2.2/160 Ca/P/Mg: 7.9/4.9/2.6 MICROBIOLOGY: [**2117-2-9**] Urine Cx: [**2117-2-9**] 7:15 pm URINE Site: CATHETER **FINAL REPORT [**2117-2-13**]** URINE CULTURE (Final [**2117-2-13**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | ENTEROCOCCUS SP. | | 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-------- 32 S <=16 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S [**2117-2-12**] Urine Cx: [**2117-2-12**] 5:33 am URINE Source: Catheter. **FINAL REPORT [**2117-2-14**]** URINE CULTURE (Final [**2117-2-14**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. PROBABLE ENTEROCOCCUS. 10,000-100,000 ORGANISMS/ML. Urine Legionella Ag: Negative Blood Cx [**2117-2-9**], [**2117-2-12**], [**2117-2-13**], [**2117-2-14**] all negative. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2117-2-22**], [**2117-2-24**]): FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. STUDIES: [**2117-2-9**] Portable CXR - 1. Ill-defined retrocardiac opacity, likely atelectasis but infection cannot be excluded. 2. Unchanged metastatic involvement of the right posterior fifth rib. [**2117-2-9**] ECG - NSR at ~125 bpm, normal axis, RBBB, unchanged from prior. ECHO [**2117-2-16**]: The left atrium and right atrium are normal in cavity size. A patent foramen ovale is present with prominent right-to-left passage of microbubbles at rest and with cough. . Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Patent foramen ovale with right-to-left passage of microbubbles at rest and with cough. Normal biventricular cavity sizes with preserved global biventricular systolic function. Dilated ascending aorta. Mild pulmonary artery systolic hypertension. Mild mitral regurgitation with normal valve morphology. CT CHEST HIGH RES W/O CONTRAST [**2117-2-16**]: IMPRESSION: Findings likely represent hypersensitivity pneumonitis or pulmonary edema. Less likely is an infectious etiology. Interstitial lung disease is very unlikely given the acute onset of findings. CXR AP [**2117-2-16**]: Heart size is normal. Mediastinal position, contour and width are unremarkable. There is slight interval progression of linear interstitial opacities currently with more alveolar component as well as small amount of pleural effusion seen on the right. The findings are most likely representing progression of the pulmonary edema but superimposed infectious process in particular in the right lower lobe cannot be entirely excluded and should be correlated with clinical findings. There is no pneumothorax. BL LE U/S [**2117-2-16**]: IMPRESSION: Slightly limited exam (nonvisualization of the left popliteal vein secondary to patient pain and nonvisualization of the left tibial vein), but otherwise no son[**Name (NI) 493**] evidence for DVT in the bilateral lower extremities. Brief Hospital Course: [**Age over 90 **]yo male with stable metastatic prostate cancer who was admitted from the ED with weakness and fever. Pt was admitted to the ICU in respiratory failure requiring high flow mask with FiO2 of 60%. His respiratory failure was thought to be combination of PNA and acute CHF. After 2 days of successful diuresis and broad spectrum abx, pt did not improve as was still hypoxic to 80s upon movement. CT chest high res revealed diffuse ground glass opacities most c/w hypersensitivity pneumonititis. An echo with bubble study also revealed a patent foramen ovale. It was thought that the patient had a chronic shunt that was unmasked by the acute hypersensitivity pneumonitis. Pt was started on methylpredisolone with improvement in his O2 requirements as he was weaned down to 4LNC. This was changed to prednisone 60mg PO Daily. Still occasionally would get hypoxic with movement however this transient exertional hypoxia was expected to be a chronically resolving process. He stopped taking prednisone after changing his goals of care to comfort measures only. Following transfer to the floor, he became increasingly uncomfortable and voiced consistent desires to go home and die. After discussion with his family, patient was ultimately converted to DNR/DNI and finally CMO. He was admitted to hospice on [**2117-2-25**], and his medication regimen and monitoring were minimized. He was offered morphine gtt for comfort, as well as haloperidol and lorazepam for agitation. Patient expired on [**2117-3-2**] surrounded by family. The time of death was 6:28am. Cause of death was respiratory failure from C. difficile infection, metastatic prostate cancer, and hypersensitivity pneumonitis. DETAILED PROBLEM LIST: # C. difficile colitis: Pt developed profuse watery diarrhea following transfer from ICU, and stool tested positive for C. difficile toxins. Patient was started on PO Flagyl, then switched to PO vancomycin given his severe infection and rising white blood cell count. Patient elected not to take vancomycin following decision to become CMO. # Hypoxemic respiratory failure: Pt was admitted to the ICU in respiratory failure requiring high flow mask with FiO2 of 60%. His respiratory failure was thought to be combination of PNA and acute CHF. After 2 days of successful diuresis and broad spectrum abx, pt did not improve as was still hypoxic to 80s upon movement. CT chest high res revealed diffuse ground glass opacities most c/w hypersensitivity pneumonititis. An echo with bubble study also revealed a patent foramen ovale. It was thought that the patient had a chronic shunt that was unmasked by the acute hypersensitivity pneumonitis. Pt was started on methylpredisolone with improvement in his O2 requirements as he was weaned down to 4LNC. This was changed to prednisone 60mg PO Daily. Still occasionally would get hypoxic with movement however this transient exertional hypoxia was expected to be a chronically resolving process. He stopped taking prednisone after changing his goals of care to comfort measures only. # Hypotension: Patient was hypotensive on presentation to the ED, thought to be initially due to poor PO intake. Was given IVF which likely exacerbated and caused his acute CHF. Adrenal insufficiency was ruled out as normal to high cortisols drawn. Restarted home dose prednisone 5mg daily. Upon further work up the patient was found to mainly be hypotensive during tachycardic episodes. Tele captured possible SVT during these paroxysmal tachycardia, and 12-lead EKG confirmed AVNRT. Pt was started on metoprolol 12.5mg PO Q8H, and AVNRT did not occur on metoprolol. On the floor, patient developed hypotension in the setting of C. difficile colitis that responded to IV fluid boluses. He began refusing his metoprolol, and he had an episode of hypotension down to 70s/50s with AVNRT, which broke with carotid sinus massage. Pt was given one dose of metoprolol 5mg IV following that episode. He was made CMO and continued to refuse metoprolol. # Urinary tract infection: Patient's urine culture grew out pan-sensitive Klebsiella and Enterococcus. He was treated with a 10-day course of Augmentin. # Possible pneumonia: Initially, etiology appeared most consistent with pneumonia in the setting of cough, leukocytosis, fever, and new retrocardiac opacity on CXR. Started levofloxacin for treatment of pneumonia, patient did not improve (likely because the diagnosis was more likely hypersensitivity pneumonitis and unmasked L->R shunt as opposed to PNA), therefore pt was broadened to vancomycin and cefepime. Pt admitted on [**2117-2-10**] and started on Levofloxacin 750mg IV Q48H and discontinued on [**2117-2-15**]. Patient started on vancomycin 1gm IV Q12H on [**2117-2-13**]. Pt started on cefepime 1gm IV Q24H on [**2117-2-14**]. Last doses of vancomycin and cefepime were [**2117-2-17**]. Treatment was completed in house and pt was s/p 8 days of CAP abx. # ITP: Stable, platelet count rose likely reactive to infection. # Hyperlipidemia: Patient continued to take his statin until he was declared CMO. # Metastatic prostate cancer: Patient's disease was stable, with continuation of chronic Foley for urinary retention. # Stage IV Chronic Renal Failure: Patient's renal function remained stable. Medications on Admission: 1. Simvastatin 40mg PO qhs 2. Prednisone 5mg daily, to be discontinued on Friday [**2-12**] 3. Alleve prn Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Metastatic prostate cancer Hypersensitivity pneumonitis Urinary tract infection Atrioventricular nodal reentry tachycardia C. difficile colitis Secondary diagnoses: Immune thrombocytopenia Hyperlipidemia Discharge Condition: Expired on [**2117-3-2**] at 6:28am.

[ "428.0", "V10.46", "041.04", "585.4", "428.33", "E879.6", "287.31", "041.3", "427.69", "584.9", "272.0", "008.45", "518.81", "495.9", "198.5", "599.0", "996.64" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14815, 14824

9381, 11097

230, 270

15091, 15130

3328, 3343

2536, 2766

14845, 15009

14685, 14792

2781, 3309

15030, 15070

1610, 1922

185, 192

298, 1591

3359, 9358

11111, 14659

1944, 2262

2278, 2520

66,015

136,935

34133

Discharge summary

report

Admission Date: [**2163-9-12**] Discharge Date: [**2163-9-16**] Date of Birth: [**2095-10-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Bronchoscopy [**2163-9-12**] Bronchoscopy with Y-stent removal [**2163-9-14**] History of Present Illness: Per MICU admit note, patient is a 67yo male with end stage COPD (3L O2 NC at home), tracheobronchomalacia s/p Y-stent ([**2162**]), squamous cell carcinoma s/p right upper lobe resection with Cyberknife treatment ([**2158**]). Patient's Y-stent was placed [**2163-1-26**] and complicated by cough, copious secretions requiring multiple therapeutic aspirations. Last bronchoscopy was [**5-/2163**] at outside hospital where patient had copious secretions that were removed. Patient states he is compliant with Mucomyst nebs and Mucinex, and he uses oxygen "almost constantly," always at night. He is not, however, compliant with CPAP. Prior to this admission, patient was feeling "full" and unable to expectorate his secretions for 2-3 weeks. Patient also elicits decreased appetite, 50 lb weight loss (X 6 months) and decreased activity tolerance. Of note, he continued to smoke 5 cigarettes a day. A PET scan in [**6-/2163**] revealed FDG avid soft tissue mass adjacent to right upper resection site with some avid nodes concerning for recurrence of lung cancer. Per MICU admit note, patient was scheduled for bronchoscopy on [**9-12**] at [**Hospital1 18**] for his increased secretions and mental status changes. He was difficult to sedate, requiring 8mg versed and 200mcg fentanyl. Bronchoscopy showed no complete opacification, right sided secretions and granulations (non-obstructing). The patient was difficult to arouse after the procedure, with episodic respiratory depression (O2 sat 70%) and required high flow oxygen via non-rebreather mask. After ~5 minutes, patient regained respiratory drive and began saturating in the 90s. Patient was admitted to the MICU for bipap (which he did not tolerate) prior to stent replacement and lung debridement in the OR on [**9-14**]. Interventional pulmonary was found copious purulent secretions around the previous stent which was removed but a new stent could not be placed. Plan is for re-placement of the stent in ~ 4 weeks. On call-out from the MICU, plan was to observe patient's respiratory status, especially with ambulation, taper his steroids over 3-4 weeks and discharge home. ROS: Denies fevers/chills, night sweats, rhinorrhea, congestion, chest pain, abdominal pain, nausea/vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, hematuria, dysuria. Past Medical History: PMHx: * Squamous cell cancer of lung with possible recurrence: s/p RUL lobectomy ([**2158**]), s/p Cyberknife * Coronary Artery Disease s/p cardiac arrest and stent * COPD/emphysema * Tracheobronchomalacia s/p Y-stent * OSA (noncompliant with nocturnal CPAP) * Hypertension * Hypercholesterolemia * Hypothyroidism * Gout Social History: Single, retired from telephone company. Drinks 3-4 beers/night. Was 100+ pack year smoker - 5 cigarettes/day. No known asbestos exposure. He has two daughters, [**Name (NI) 698**] and [**Name (NI) **] who are supportive. Family History: Brother with TB and coronary artery disease Physical Exam: Vitals - T: 96.6 BP: 141/79 HR: 109 RR: 22 02 sat: 86% 3 L NC GENERAL: appears older than stated age, slightly tachpneic HEENT: anicteric, EOMI, cushingoid features, OP - no exudate, no erythema, no cervical LAD CARDIAC: sinus tach, no m/r/g LUNG: wheezes scattered, prominent in RUL, decreased BS throughout lung fields ABDOMEN: NDNT, soft, NABs EXT: no c/c/e NEURO: II-XII grossly intact . On discharge: VSS (O2sat 97% on 3L NC, 92% on 3L with ambulation) GEN: Sitting in chair, no apparent distress, A&O HEENT: EOMI, moist mucus membranes, normal oro/nasopharynx NECK: Soft and supple, no JVD CV: RRR, no murmurs/gallops/rubs, normal S1/S2 Pulm: Thick grey/tan/green sputum per MICU nurse, decreased BS bilaterally, rhonchi bilaterally (Lt>Rt) Abd: Non-tender, non-distended, soft Ext: No cyanosis/ecchymosis/edema Neuro: Sensation and strength grossly intact Pertinent Results: Labs- [**2163-9-12**] 06:26PM BLOOD WBC-20.8* RBC-4.05* Hgb-9.5*# Hct-31.9* MCV-79*# MCH-23.4*# MCHC-29.7*# RDW-14.7 Plt Ct-614* [**2163-9-13**] 03:31AM BLOOD Neuts-97* Bands-1 Lymphs-2* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2163-9-13**] 03:31AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL Target-OCCASIONAL Schisto-1+ Burr-OCCASIONAL [**2163-9-12**] 06:26PM BLOOD Glucose-93 UreaN-6 Creat-0.5 Na-134 K-4.6 Cl-89* HCO3-38* AnGap-12 [**2163-9-12**] 06:26PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2 [**2163-9-12**] 01:10PM BLOOD Type-ART pO2-59* pCO2-80* pH-7.32* calTCO2-43* Base XS-10 [**2163-9-13**] 04:36PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 [**2163-9-13**] 04:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . Sputum [**2163-9-13**] 8:02 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2163-9-13**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. --> pansensitive CEFEPIME-------------- 2 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S . Reports- CXR FINDINGS: As compared to the previous radiograph, there is no major change. Asymmetry of the hemithoraces given the past post-operative history. No newly occurred focal parenchymal opacities suggesting pneumonia. Pre-existing minimal scarring at the left and right lung base are unchanged. No evidence of pleural effusion. No overhydration. No evidence of tumor recurrence. Brief Hospital Course: 67yo male with end stage COPD, tracheobronchomalacia s/p Y-stent, squamous cell carcinoma s/p RUL resection with Cyberknife treatment, s/p flex bronchoscopy admitted for COPD exacerbation. Underwent repeat bronchoscopy today with Y-stent removal, called out of MICU stable for observation on floor. . # Progressive COPD/pseudomonas bronchitis: Given history of worsening somnolence, likely worsening hypercarbia/OSA. At baseline, patient has tracheobronchomalacia. On initial bronchoscopy, patient had copious secretions. He was transfered to the ICU for BIPAP overnight, which he did not tolearate. He was titrated down to his home 3 liters of oxygen with goal sats 88-93%. He was also treated for COPD exacerbation with solumedrol --> prednisone and azithromycin. The plan is for a slow taper, decreasing by 5 mg every 3 days. He went for a exchange of his Y-stent on [**9-14**], however, while the old stent was removed, a new stent was not placed due to purulent secretions. He will need to have a new silicone stent placed, which is planned for [**10-12**]. He was also continued on Mucomyst, Mucinex, and Advair. Sputum and blood cx were sent. Sputum showed moderate growth of pseudomonas that later came back pansensitive. Pt remained afebrile but with an elevated white count so he was started on Zosyn/Cipro ([**2163-9-15**]) for pseudomonas infection. On day of discharge, he was transitioned to just Cipro X7 day course due to its pansensitivity. Patient was given albuterol/ipratropium and advised to resume CPAP at home, avoid smoking while using supplemental oxygen. . # Tracheobronchomalacia: Patient was followed by Interventional Pulmonary. He was restarted on Mucomyst and Mucinex per their recommendations. Patient is scheduled for replacement of Y-stent in 4 weeks as out patient, after resolution of current infection. . # Leukocytosis: Likely secondary to intravenous steroids and ongoing pseudomonas bronchitis. WBC steadily decreased to 13 with antibiotics. Patient did not have any diarrhea concerning for C.difficile. . # Anemia: Patient has been anemic since [**2162-12-30**] (last documented CBC) although his microcytosis is new with this admission. As his anemia is likely due to chronic inflammation/disease, it was not further worked up. Patient's hemoglobin/hematocrit remained stable throughout this admission. . # Chronic respiratory acidosis: Likely chronic, progressive hypercarbia/obstructive sleep apnea in setting of non-compliance with CPAP. On day of discharge, discussed with patient the utility of CPAP and its role in preventing a similar episode of slow recovery from respiratory depressing medications (bronchoscopy on [**9-12**]). Patient was amenable to attempting to use CPAP again while sleeping at home. . # Squamous cell carcinoma of the lung with recurrence: Patient to follow-up as outpatient with Dr. [**First Name (STitle) **] . # Hypertension: Continued Metoprolol tartrate, quinapril and HCTZ with good blood pressure control . # Hyperlipidemia: Continued on Simvastatin . # Hypothyroidism: Continued on levothyroxine . # Pain (chronic lower back): Continued on Naproxen and Fentanyl patch . # Gout: Stable. Continued on Allopurinol . # Code: FULL, confirmed with patient (If patient requires aggressive life saving measures for 3 days of more, would prefer to withdraw care) # Contact: Daughter [**Name (NI) 698**] [**Telephone/Fax (1) 78690**] Medications on Admission: Acetylcysteine 20% solution - 1 neb [**Hospital1 **] Albuterol Allopurinol 100 mg po daily Fentanyl 50 mcg/hour patch q72 hours Fluticasone-Salmeterol 250/50 1 puff INH twice daily HCTZ 12.5 mg po daily Levothyroxine 88 mcg po daily Metoprolol tartrate 50 mg po BID Naprosyn 500 mg po daily Omeprazole 20 mg po daily Oxycodone-Acetaminophen 5/325 1 tablet po q4 hours prn pain Quinapril 20 mg po daily Simvastatin 40 mg po daily Tiotropium Bromide 18 mcg 1 tab po daily ASA 81 mg po daily Mucinex DM 1,200-60 mg po BID MVI 1 tablet po daily Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation every eight (8) hours as needed for shortness of breath or wheezing: Please use with Mucomyst nebulizers. Disp:*42 neb treatments* Refills:*0* 14. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs Miscellaneous Q 8H (Every 8 Hours). Disp:*500 ML(s)* Refills:*2* 15. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 16. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 17. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days: Last day: [**9-21**]. Disp:*11 Tablet(s)* Refills:*0* 18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for PCP [**Name9 (PRE) **] for 41 days: Last Day: [**10-25**] (also last day of prednisone). Disp:*41 Tablet(s)* Refills:*0* 19. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 days: [**9-17**]. Disp:*1 Tablet(s)* Refills:*0* 20. Prednisone 10 mg Tablet Sig: 5.5 Tablets PO once a day for 3 days: [**9-18**]-22. Disp:*17 Tablet(s)* Refills:*0* 21. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day for 3 days: [**9-21**]-25. Disp:*15 Tablet(s)* Refills:*0* 22. Prednisone 10 mg Tablet Sig: 4.5 Tablets PO once a day for 3 days: [**9-24**]-28. Disp:*14 Tablet(s)* Refills:*0* 23. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 3 days: [**9-27**]. Disp:*12 Tablet(s)* Refills:*0* 24. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO once a day for 3 days: [**9-30**]. Disp:*11 Tablet(s)* Refills:*0* 25. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 3 days: [**10-3**]. Disp:*9 Tablet(s)* Refills:*0* 26. Prednisone 10 mg Tablet Sig: 2.5 Tablets PO once a day for 3 days: [**10-6**]. Disp:*8 Tablet(s)* Refills:*0* 27. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: [**10-9**]. Disp:*6 Tablet(s)* Refills:*0* 28. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO once a day for 3 days: [**10-12**]-16. Disp:*5 Tablet(s)* Refills:*0* 29. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: [**10-15**]-19. Disp:*3 Tablet(s)* Refills:*0* 30. Prednisone 5 mg Tablet Sig: One (1) Tablet PO every other day for 3 days: 5 mg on [**2079-10-20**], 27 None on [**2080-10-20**], 28 . Disp:*3 Tablet(s)* Refills:*0* 31. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: [**10-18**]-22. Disp:*3 Tablet(s)* Refills:*0* 32. other Sig: One (1) outpatient once a day: DIAGNOSIS: End stage COPD, tracheobronchomalacia, squamous cell carcinoma of the lung with recurrence (s/p resection, Cyberknife) . PT evaluate and treat . Pulmonary Rehabilitation. Disp:*1 * Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Progressive COPD and tracheobronchomalacia, pseudomonas bronchitis Secondary: Lung Squamous cell carcinoma with recurrence, coronary artery disease s/p cardiac arrest and stent, OSA, hypertension/hypercholesterolemia, hypothyroidism, gout Discharge Condition: Improved. Vital signs are stable. Patient's pulmonary status at baseline and being treated for infection. Patient able to ambulate without issues. Discharge Instructions: -You were admitted with recovering slowly/poor oxygenation after your bronchoscopy on [**2163-9-12**]. Your Y-stent appeared infected so you were taken to the operating room on [**2163-9-14**] and the Y-stent was removed. You are currently being treated with antibiotics for a lung infection (pseudomonas). Your Y-stent will be replaced Ocotber 14 when the infection has resolved. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> CONTINUE all your home medications --> START Ciprofloxacin 750mg twice daily for 5 more days (last dose on [**9-21**]) --> START a taper of Prednisone: 60mg tomorrow, 55mg [**9-18**]-22, 50mg [**9-21**]-25 etc. On [**10-21**], you will take 5mg and none on [**10-22**], alternating until you are completely done with Prednisone on [**10-26**]. --> START Bactrim DS 1 tablet daily while you are on steroids (last day [**10-25**]) --> START Mucinex 1200mg twice daily --> START Mucomyst nebulizers three times daily --> Please try to use your CPAP machine while sleeping as it is high-flow oxygen that can improve your breathing issues . -Contact your doctor or come to the Emergency Room should your symptoms worsen. Also seek medical attention if you develop any new fever/chills, trouble breathing (requiring more than 3L nasal cannula), chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please set-up pulmonary rehabilitation as an outpatient . Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 64744**], your lung doctor within 1-2 weeks. You can call his office at: [**Telephone/Fax (1) 78691**] to set-up an appointment. . You are scheduled to have your Y-stent replaced on [**2163-10-12**] at 11:30am at [**Hospital1 18**]. Please do not have any food or drink (except sips for medication pills) after midnight prior to the procedure.

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icd9cm

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4425

Discharge summary

report

Admission Date: [**2106-8-29**] Discharge Date: [**2106-9-7**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 4760**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 67 yo AAM w PMHx of COPD on 4L home O2 and nightly bipap, HTN, chronic LBP, presented to ED w LLQ abd pain. Pt was given levaquin in ED (has noted allergy to it) and developed rash on his forearms. On floor, he also developed tachypnea and transferred to ICU. Per ICU team, they think it was likely from not using bipap; initially they did not believe had COPD exacerbation or drug reaction. He was continued on prednisone taper. For his diverticulitis he was started on Rocephin and flagyl. He was never intubated. Pt was transferred to the floor the next day. Currently he reports his sob at baseline, denies cp and denies abd pain. He had noted mild hematochezia prior to admission but none since. He denies nausea, vomiting. He thinks the rash is improving ROS: otherwise neg Past Medical History: - COPD on 4l NC at home, FEV1 24%; fev/fvc 35% - h/o VRE UTI - hx of MRSA - CAD s/p NSTEMI ([**1-/2101**]): [**4-10**] cath with minimal disease, TTE with preserved biventricular function in [**2103**] - Hypertension - Hyperlipidemia - Chronic low back pain L1-2 laminectomy from accident at work - Cataracts bilaterally - s/p surgery for both - GERD - BPH s/p TURP Social History: Retired, lives with wife. [**Name (NI) **] son recently had restraining order placed against him by patient [**2-6**] violent behavior. Previous smoker, occasional alcohol, quit marijuana 3 years ago. Originally from [**Country 7936**], moved here to live with grandmother after primary school. Family History: Mother w/ asthma, Alzheimer's disease. Father w/ [**Name2 (NI) 499**] cancer. Physical Exam: Vitals: T 100.9, P 88-110, BP 93-130/50-65, RR 20-26, Sats 95% on 3L GEN NAD EYE Anicteric ENT Moist OP CV RRR RESP CTA w good air entry GI SNT NABS GU no CVAT MSK Warm, no edema Skin - minimal eryhtematous macular rash on forearm ([**Name8 (MD) **] RN this is likely from levaquin he got in ER, improving per pt) NEURO A&Ox3, sensation/motor non-focal PSYCH Calm HEME/[**Last Name (un) **] no LN ACCESS peri Pertinent Results: [**2106-8-29**] 05:41AM WBC-14.0* RBC-3.74* HGB-10.3* HCT-31.8* MCV-85 MCH-27.5 MCHC-32.3 RDW-15.2 [**2106-8-29**] 12:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.039* [**2106-8-29**] 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2106-8-28**] 09:05PM GLUCOSE-120* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-37* ANION GAP-11 [**2106-8-28**] 09:05PM ALT(SGPT)-14 AST(SGOT)-18 ALK PHOS-75 TOT BILI-0.8 [**2106-8-28**] 09:05PM LIPASE-24 CT Abd/Pelv: 1. Very mild stranding adjacent to the diverticula in the proximal sigmoid [**Month/Day/Year 499**], which may reflect presence of mild or early acute uncomplicated diverticulitis. 2. Severe emphysema. 3. Right basal bronchiectasis with associated patchy consolidation. Brief Hospital Course: 67 yo AA male w PMHx of severe COPD on 4l home O2, nightly bipap, HTN, chronic LBP presented w/ diverticulitis. . MICU Course [**Date range (1) 19030**]: The patient was doing well on the floor nearing discharge for home on tapered steroids and a course of antibiotics when he developed acute respiratory distress with tachypnea and shortness of breath. The patient reportedly awoke from sleep needing to go to the bathroom. After removing his overnight BiPAP device and attempting to ambulate to the toilet, he was found yelling for help with severe shortness of breath and tachypnea. Vitals at that time were 97.0 93 115/60 22 98% while receiving a nebulizer treatment. On exam, he was noted to have minimal air movement and ABG revealed a respiratory acidosis 7.28/66/150, but bicarb 32 indicating chronic respiratory acidosis, PCO2 never noted to be below 50. The patient received solumedrol 125mg once and nebulizers. The patient was transferred to the ICU for further respiatory care. On arrival to the ICU the patient appeared comfortable and reported he was back at his baseline. He was given standing nebulizers, and his steroid dose was increased to 40 mg daily and he was given Azithromycin for what now appeared to be a COPD flare. -During his MICU Course, he had 2 more episodes of respiratory distress noted as tachypnea with lots of anxiety. Patient responded well to 1mg of ativan with BiPAP. It is believed that there is a large component of anxiety to his resp distress in addition to his severe COPD. Also patient often refused nebs. We discussed that the patient need scheduled Nebs when he has a flare and can go back to PRN when he is out of the hospital. He was continued on nightly BiPAP and prednisone for presumed COPD flare. . The following is his course on the floor: . # COPD flare: As described above in his MICU course, Mr. [**Known lastname 19017**] has severe COPD with steroid and oxygen dependency. He had 2 episodes of respiratory failure requiring ICU admission. He was treated with IV steroids, as well as ativan for anxiety, and also with azithromycin. He was also treated with prophylactic bactrim given his high steroid requirement. The patient was treated with a prednisone taper. He was tapered down from 60 mg daily, in increments of 5 mg less every 3 days. He had been on prednisone 10 mg daily at home, and should probably increase to 20 mg daily at home. He will be tapered down to 20 mg daily. He was continued on tiotropium, advair, and albuterol/atrovent nebs. He will need outpatient follow up with Dr. [**Last Name (STitle) 575**] of pulmonary. He also remains on 4 L NC and BIPAP at 12/5 at night. #Diverticulitis. He was admitted with abdominal pain, and was found to have mild diverticulitis. He was initially started on IV antibiotics (CTX/flagyl), and subsequently transitioned to PO antibiotics with augmentin to complete a 10 day course. He was tolerating an oral diet, and having normal bowel movements. He likely would not tolerate a colonoscopy to further evaluate his [**Last Name (STitle) 499**], but colonoscopy in [**2105**] showed diverticuli, no malignancy. . #Chronic pain. He has chronic back pain, unchanged from prior, treated with percocet with good effect. He has been seen in the pain clinic in the past with trigger point injections and good relief, so this can be considered in the future. . #Hyperglycemia: Likely [**2-6**] chronic prednisone use. His FS ranged from 80s to low 200s. He required at most 4 U of insulin during the day. His fingersticks should be monitored with his prednisone taper with sliding scale insulin as needed. Consideration can be given to starting low dose lantus if the patient has persistent low dose insulin requirements with his prednisone taper. . # HTN: BP well controlled on verapamil . # CAD: Continued ASA, statin. He was not on BB or ACE. Likely no BB due to many COPD exacerbations. Low dose lisinopril 5 mg daily was restarted. . # Code: He is full cardiac resuscitation but DNI (do not intubate). This was discussed with the patient at the time of discharge. Medications on Admission: 1. Prednisolone 1% drops each eye [**Hospital1 **] 2. Advair 250/50mcg QD 3. Finasteride 5mg qD 4. Sertraline 50mg QD 5. Bactrim one tab Q MWF 6. ASA 81mg QD 7. Pravastatin 40mg QD 8. Omeprazole 40mg [**Hospital1 **] 9. Spiriva one inhaled QD 10. Prednisone 10mg QD until seen by pulmonologist 11. Vitamin D 400 unit QD 12. Alendronate 70mg qD 13. Colace 100mg [**Hospital1 **] 14. Calcium 600mg [**Hospital1 **] 15. Percocet 325/7.5mg 1-2tabs upto 5 times a day as needed 16.Verapamil 120mgSR QD Discharge Medications: 1. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO twice a day. 14. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 15. Calcium 600 + D 600 (1,500)-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO as instructed: On [**9-8**] Take 55 mg (11 tablets); On [**9-5**] take 50 mg (10 tablets); on [**9-8**] take 45 mg (9 tablets); on [**9-11**] take 40 mg (8 tablets); on [**9-14**] take 35 mg (7 tablets); on [**9-17**] take 30 mg (6 tablets); on [**9-20**] take 25 mg (5 tablets); thereafter take 20 mg ongoing (4 tablets). 17. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4 hours) as needed. 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 21. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety,agitation. 22. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 23. Insulin Lispro 100 unit/mL Solution Sig: One (1) units Subcutaneous as directed: For FS of: 150-199 give 2 units; 200-249 give 4 units; 250-299 give 6 units; 300-349 give 8 units; 350-399 give 10 units; above 400 call HO. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Doctor Last Name 1263**] Discharge Diagnosis: Diverticulitis COPD exacerbation Severe COPD Discharge Condition: stable on [**4-10**] L NC Discharge Instructions: You were admitted with abdominal pain. You underwent a CT scan, which showed diverticulitis or inflammation of part of your [**Date Range 499**]. You were treated with antibiotics. You were briefly in the ICU because you felt increasing shortness of breath. This was likely because you did not get bipap at night. In addition, you also were felt to have a flare of your COPD. Your symptoms improved with bipap and steroids. You were continued on your prior medications. . Please return to ED if you notice fevers, chills, worsening abdominal pain, blood in stool, worsening shortness of breath or cough. We have changed your primary care appointment to this friday, please keep that appointment Followup Instructions: ** Please follow up with Dr. [**Last Name (STitle) 8499**] (your primary care doctor) 3PM this Friday [**9-10**] at [**Hospital1 7977**], [**Location (un) 686**], [**Numeric Identifier **]. Call his office at [**Telephone/Fax (1) 7976**] with any questions. . ***You should follow up with your pulmonologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**]. You have an appointment with him on Thursday [**2106-9-16**] at 12:00 noon. He is located at the [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building, [**Location (un) 436**]. You may call his office at [**Telephone/Fax (1) 612**] with any questions. It is very important that you make it to this appointment. . You have an appointment with your ophthalmologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**10-8**] at 9am. Call his office at [**Telephone/Fax (1) 612**] with any questions. . You have an appointment with your ENT doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**9-21**] at 2:45pm. Call his office at [**Telephone/Fax (1) 41**] with any questions.

[ "V15.82", "E930.8", "530.81", "491.21", "275.3", "287.4", "366.8", "250.00", "564.09", "280.9", "412", "724.2", "276.2", "600.00", "518.81", "414.01", "562.11", "327.23", "338.29", "V46.2", "401.9", "693.0", "V58.65" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

10391, 10462

3219, 7312

287, 294

10551, 10579

2346, 3196

11324, 12470

1822, 1901

7859, 10368

10483, 10530

7338, 7836

10603, 11301

1916, 2327

233, 249

322, 1103

1125, 1492

1508, 1806

221

189,243

15781

Discharge summary

report

Admission Date: [**2103-12-9**] Discharge Date: [**2103-12-27**] Date of Birth: [**2070-11-23**] Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: A 34-year-old male status post high speed motor vehicle crash unrestrained driver. There was some loss of consciousness. He was verbal at the scene with altered mental status. He was intubated at the scene and brought to the [**Hospital1 69**]. He was hemodynamically stable upon arrival. PAST MEDICAL HISTORY: Noncontributory. ALLERGIES: No known drug allergies. MEDICATIONS: None. PHYSICAL EXAMINATION: Temperature 98.8, heart rate 88, blood pressure 150/palp, 99% with an endotracheal tube in place. [**Location (un) 2611**] coma score of 3. HEENT: Pupils are equal, round, and reactive to light 3 mm bilaterally. Two cm laceration in the right forehead, tympanic membrane clear. Lungs: Decreased breath sounds on the left side. Cor: Regular, rate, and rhythm. Rectal: Guaiac negative. Pelvis: Stable. Extremities: No deformities. Palpable pulses. LABORATORY DATA: Hematocrit 40, white blood cell count 25, platelets 312, INR 1.1. Electrolytes were within normal limits. Chest x-ray revealed a wide mediastinum and a collapsed right lower lobe and a left pneumothorax. Pelvis x-ray was negative. Head CT scan showed a left frontal subarachnoid hemorrhage. C spine film showed a very slight C4-C5 anterolisthesis with no fractures. Chest CT scan showed a right lower lobe collapse, aorta was okay. Abdominal CT scan was negative. The patient was admitted to the Intensive Care Unit for critical care and had bilateral chest tubes placed. Neurosurgery consult was obtained for the subarachnoid hemorrhage. They repeated a head CT scan in 24 hours which showed no expansion. .................... Cardiology consult was obtained. Echocardiogram was done which revealed no evidence of tamponade. The patient had multiple bronchoscopies performed with significant suctioning of mucus. Neurosurgery had initially placed an intracranial pressure monitor for the subarachnoid hemorrhage. Due to ICPs well controlled, the monitor was removed. The patient was extremely difficult to wean off the ventilator. It was thought that he had an aspiration event. Per Neurosurgery recommendation, subQ Heparin was started on [**12-15**], based on the head CT scan readings. Patient had an evolving ARDS picture which required prolonged intubation. Patient was agitated and difficult to extubate. He was finally extubated on [**12-19**]. He was transferred to the Surgical Floor on [**12-21**]. Nutrition consult was obtained. Tube feedings were started. After the modified barium swallow test was passed, the patient was started on regular diet. Patient was worked with aggressively with occupational and physical therapy services. Patient was stable at the time of discharge. The condition on discharge was stable. DISCHARGE MEDICATIONS: Aspirin 81 mg q day, subQ Heparin 5,000 units [**Hospital1 **]. DISCHARGE STATUS: Rehabilitation facility. FOLLOWUP: The patient is to followup .................... in two weeks. DISCHARGE DIAGNOSES: Status post motor vehicle crash with left subarachnoid hemorrhage found with thoraces, prolonged intubation aspiration. [**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**] Dictated By:[**Name8 (MD) 1308**] MEDQUIST36 D: [**2103-12-27**] 08:26 T: [**2103-12-27**] 08:43 JOB#: [**Job Number 45443**]

[ "870.0", "958.4", "851.42", "482.30", "E812.0", "873.43", "518.5", "507.0", "861.21" ]

icd9cm

[ [ [] ] ]

[ "27.51", "96.04", "34.04", "38.93", "33.24", "96.6", "96.72", "08.81", "01.18", "89.64", "96.33", "88.72" ]

icd9pcs

[ [ [] ] ]

3161, 3526

2955, 3139

595, 2931

178, 472

495, 572

11,590

116,582

2409

Discharge summary

report

Admission Date: [**2157-2-15**] Discharge Date: [**2157-2-17**] Date of Birth: [**2083-8-18**] Sex: F Service: MEDICINE Allergies: Allopurinol / Ethambutol / Colchicine / Efavirenz Attending:[**First Name3 (LF) 9240**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: HPI: 73-yo-woman w/ CAD, CHF, ESRD presents w/ dyspnea x 12 hours. She was feeling well until 1 day prior to admission during dinner, when she developed acute onset dyspnea assoc w/ substernal chest pain. The pain was "achy," moderate severity, non-radiating. There were no assoc palpitations, cough, nausea, vomiting, or diaphoresis. ROS reveals no fever, weight loss, increasing edema, orthopnea, PND, or dietary indiscretion. She has been taking all her meds as prescribed. Her last HD session was the day prior to presentation to the ED. . In the [**Hospital1 18**] ED, she was initially hypertensive w/ BP 210/110, HR 80, O2 sat 100% on BiPAP. She was treated w/ nitro gtt, hydralazine 5mg IV, and enalapril 1.25mg IV x 1, and BP improved to 190/82. Chest pain resolved early during her ED stay. She was dialyzed urgently and admitted to the MICU where she had no further CP or SOB. She was called out to the floor after 1 day. Past Medical History: 1. 3-V CAD; s/p NSTEMI [**6-/2154**], Had Taxus stent placed [**2154-6-7**] in mid-LCx. 2. CHF: Echo [**12-6**] with EF=20%, 1+ AR, [**1-4**]+MR 3. H/o malignant hypertension. 4. Status post intubation for flash pulmonary edema on [**2154-6-3**], complicated by laryngeal edema. 5. History of human immunodeficiency virus, CD4 count 302 on [**2156-12-8**]; viral load less than <50 on [**12-8**], on [**Month/Year (2) 2775**] therapy. 6. End-stage renal disease on hemodialysis secondary to HIV nephropathy. 7. DM II, diet controlled 8. Spinal tuberculosis. 9. Hypercholesterolemia. 10. Hepatitis C viral infection. 11. Gout - has been on prednisone tapers in the past for flares. 12. H/o anemia 13.s/p unknown back surgery, possibly for spinal TB Social History: Pt lives alone and gets around with a walker. She cooks for herself. Her daughter comes over daily to help her take her meds. She denies tobacco, EtOH, IVDA, herbals/vitamins. She has 6 kids. Family History: She has a son with DM and CAD Physical Exam: PE: T 98.8 rectal, BP 143/67, HR 77, RR 14, O2 sat 100% RA Gen: chronically ill appearing elderly woman, lying at 45 degrees in bed, pleasant and conversational, breathing comfortably. [**Month/Year (2) 4459**]: anicteric, EOMI, PERRL, OP clear w/ [**Month/Year (2) 5674**], EJ fills to the mandible at 45 degrees. CV: reg s1/s2, + 2/6 systolic murmur at apex, no s3/s4/r Pulm: CTA anteriorly, no crackles or wheezes. Abd: obese, +BS, soft, NT, ND Ext: warm, 2+ DP b/l, no edema Neuro: a/o x 3, CN 2-12 intact (vision impaired), strength 4/5 throughout, sensation to fine touch intact throughout. Pertinent Results: [**2157-2-15**] 11:08PM CK(CPK)-80 [**2157-2-15**] 11:08PM CK-MB-NotDone cTropnT-0.43* [**2157-2-15**] 04:17PM K+-5.5* [**2157-2-15**] 04:00PM GLUCOSE-235* UREA N-53* CREAT-6.3*# SODIUM-139 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-30 ANION GAP-18 [**2157-2-15**] 04:00PM ALT(SGPT)-29 AST(SGOT)-39 LD(LDH)-259* CK(CPK)-75 ALK PHOS-159* AMYLASE-272* TOT BILI-0.3 [**2157-2-15**] 04:00PM LIPASE-129* [**2157-2-15**] 04:00PM CK-MB-NotDone proBNP-9881* [**2157-2-15**] 04:00PM CALCIUM-10.5* PHOSPHATE-6.7*# MAGNESIUM-2.5 [**2157-2-15**] 04:00PM WBC-6.6 RBC-3.52*# HGB-13.9# HCT-43.4# MCV-123* MCH-39.6* MCHC-32.1 RDW-17.6* [**2157-2-15**] 04:00PM NEUTS-70.2* LYMPHS-23.9 MONOS-3.5 EOS-1.8 BASOS-0.6 [**2157-2-15**] 04:00PM PT-11.8 PTT-27.2 INR(PT)-1.0 [**2157-2-15**] 04:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG . EKG: NSR @ 93 bpm, LAD, LVH, pseudonormalization of T waves in V1-V6 since prior tracing [**5-7**]. . pCXR [**2157-2-15**]: Since most recent comparison film, there appears to be increased interstitial alveolar opacities likely representing [**Month/Day/Year 9140**] pulmonary edema with unchanged appearance to cardiomegaly, and linear calcifications within the ascending and descending thoracic aorta. No focal parenchymal consolidation, pleural effusions, or pneumothorax is identified . pCXR [**2157-2-16**]: A small atelectasis is seen in the left lower lobe retrocardiac area. There has been almost complete resolution of the pulmonary edema. There is no pneumothorax or pleural effusion. Mild cardiomegaly is unchanged. The aorta is unfolded with extensive atheromatous plaques in the ascending, descending, and the arch Brief Hospital Course: 73-yo-woman w/ CAD, CHF, ESRD on HD, HIV, HCV, HTN, and anemia presents w/ dyspnea, thought [**2-4**] pulmonary edema in setting of hypertensive emergency. . # Dyspnea: The patient's shortness of breath was felt most likely secondary to pulmonary edema as evidenced by initial exam and CXR in setting of severe hypertension. Pt with CHF and renal failure, making her prone to this. There is no evidence of PNA, PE, or obstructive disease. The precipitant is unknown, but the patient does have a history of flash pulmonary edema. She denies medication non-compliance or excessive sodium consumption. Her shortness of breath resolved after hemodialysis and better BP control, and she maintained her O2 saturation on room air. Cardiac enzymes revealed flat CKs and elevated troponins (in setting of ESRD) which did not rise. She continued hemodialysis and will continue to be followed by the [**Hospital6 **] in [**Location (un) **]. . # Chest pain: The patient is known to have 3vd, w/ stent in LCX. Her pain was in the setting of hypertensive emergency and resolved with control of her blood pressure, including nitro drip. There were no specific EKG changes on presentation to indicate active ischemia. Her cardiac enzymes were notable for an elevated troponin (in setting of ESRD), with flat CKs. She was monitored on telemetry withoug event. Her chest pain did not recur. She was placed back on her home medications: ASA, metoprolol, ACEI, lipitor, and zetia. She should follow up with her cardiologist. . # ESRD: Her renal failure is secondary to HIV nephropathy. She was urgently dialyzed on the day of admission and then placed back on her usual dialysis schedule(M,W,F). She was followed by the renal service who recommended to switch lisinopril to captopril [**Hospital1 **] (this was done). She was continued on Renagel and Sensipar. The patient will continue to be followed by the [**Hospital6 **] in [**Location (un) **], with dialysis M,W,F. . # Hypertensive Emergency: The patient's blood pressure was initially controlled with volume removal by HD, IV enalapril, IV hydralazine, and nitroglycerin drip. Her BP normalized and she was placed back on her home regimen and monitored. Her pressures remained appropriate. As per renal, her ACEI was changed to Captopril 50mg [**Hospital1 **]. She will continue on Toprol XL and Captopril [**Hospital1 **] as an outpatient. Her HD will resume at [**Hospital6 **] tomorrow. . # Elevated amylase/lipase: This is chronic and likely a chemical pancreatitis from her [**Hospital6 2775**] therapy. There were no signs of clinical pancreatitis. The patient will follow with her ID physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 724**]. . # HIV: The patient's viral load is suppressed with [**Last Name (STitle) 2775**]. She was continued on lamivudine, nevirapine, and zidovudine. She has follow up scheduled with her Infectious disease specialist this month. . # DM type 2: This is controlled with diet as an outpt. Her fingerstick blood glucose was check four times daily. She was covered with an insulin sliding scale. She did not require much insulin and will resume diet control as an outpatient. . # FEN: [**Doctor First Name **], low sodium, cardiac diet. Her electrolytes were repleted prn. . # Proph: She was given heparin SC, but developed a hematoma in her abdomen from these injections. Therefore her heparin injections were stopped. She was ambulatory on the floor. She was given a bowel regimen. . * FULL CODE Medications on Admission: * ASA 325 mg daily * plavix 75 mg daily * lisinopril 20mg daily * Toprol xl 100 mg daily * lipitor 80 mg daily * zetia 10 mg daily * lamivudine 100 mg daily * nevirapine 200 mg [**Hospital1 **] * zidovudine 100 mg tid * renagel 1600 mg tid * sensipar 30 mg daily Discharge Medications: 1. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Captopril 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Zidovudine 100 mg Capsule Sig: One (1) Capsule PO three times a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: 1. Hypertensive emergency 2. Pulmonary edema 3. Congestive Heart failure 4. End Stage Renal Disease Discharge Condition: Stable, symptoms resolved. Discharge Instructions: You were admitted with shortness of breath and chest pain, thought due to severe high blood pressure and fluid building up in the lungs. You were treated with hemodialysis and blood pressure medications. . You should take all medications as prescribed. Please note that your lisinopril was changed to captopril, which is to be taken twice a day. All your other medications are unchanged. . Call your doctor or return to the hospital if you have shortness of breath, chest pain, dizziness, or any other symptom that concerns you. Followup Instructions: * Please follow up with your primary physician [**Last Name (NamePattern4) **] [**1-4**] weeks. * Please continue Dialysis at [**Hospital6 **] in [**Location (un) **] on M,W,F as before. * Please keep your appointments with your infectious disease physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 724**], and your Cardiologist, Dr. [**Last Name (STitle) 8499**], as below: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2157-2-22**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2157-4-5**] 9:00 Completed by:[**2157-2-18**]

[ "250.00", "274.9", "428.0", "428.40", "403.91", "V45.82", "585.6", "518.0", "042", "414.01", "583.9", "070.70" ]

icd9cm

[ [ [] ] ]

[ "39.95", "93.90" ]

icd9pcs

[ [ [] ] ]

9515, 9572

4740, 6155

319, 334

9725, 9754

2985, 4717

10334, 11053

2306, 2337

8581, 9492

9593, 9704

8294, 8558

9778, 10311

2352, 2966

6173, 8268

271, 281

362, 1306

1328, 2078

2094, 2290

5,246

119,872

29297

Discharge summary

report

Admission Date: [**2185-11-14**] Discharge Date: [**2185-12-2**] Date of Birth: [**2111-10-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Unresponsiveness, Hct 14.7 Major Surgical or Invasive Procedure: Right femoral line Intubation/mechanical ventilation Endoscopy Colonscopy History of Present Illness: Pt is 74 yo m w/ COPD, DM, h/o prostate CA, who presented to the ED after having decreased responsiveness at his nursing homee. Pt had FS to 300's, received insulin, and FS decreased to 180's after EMS arrived. Pt reportedly admitted to SOB x several weeks, but denies CP. No N/V/F/C. Denies hematemesis or bloody stools. Pt had increasing edema over past several weeks, and Lasix was recently increased from 40mg qd to 40mg [**Hospital1 **]. . In the [**Name (NI) **], pt was found to have hct of 14.8 and melena on rectal exam. NGL was negative. He had a troponin of 0.12 and EKG changes. He reportedly was alert in the ED, but then on arrival to the [**Hospital Unit Name 153**] became less responsive and had periods of apnea. He was placed on PSV 6/6 and his respiratory status stabiliezed. He became slightly more responsive and did not tolerate BiPAP mask. Past Medical History: - COPD - HTN - DM 2 - dementia - schizoaffective d/o - h/o prostate CA (unclear status and treatment hx) - hypothyroidism - gout - gluaucoma Social History: Lives at [**Hospital6 70405**]. Has a guardian. Sister is HCP. Family History: non-contributory Physical Exam: Vitals: T 96.2 160/70 93 20 95% Gen: obese male in chair in NAD HEENT: PERRLA MM dry. Neck: Thick neck, unable to assess JVP. Cardio: distant heart sounds, S1/S2 RRR Resp: mild EE Wheezes BL Abd: obese, nt, +BS. No rebound/guarding. Ext: 1+ BL LE edema Neuro: A&Ox0. follows commands. ambulating without assistance. Pertinent Results: [**2185-12-1**] 05:41AM BLOOD WBC-8.3 RBC-3.31* Hgb-9.7* Hct-29.0* MCV-88 MCH-29.5 MCHC-33.6 RDW-18.8* Plt Ct-619* [**2185-11-14**] 08:00AM BLOOD WBC-12.5* RBC-1.58* Hgb-4.6* Hct-14.8* MCV-93 MCH-29.1 MCHC-31.3 RDW-24.0* Plt Ct-377 [**2185-12-1**] 05:41AM BLOOD Glucose-82 UreaN-13 Creat-0.8 Na-145 K-3.1* Cl-101 HCO3-35* AnGap-12 [**2185-11-26**] 03:24AM BLOOD CK(CPK)-313* [**2185-11-26**] 03:24AM BLOOD CK-MB-5 cTropnT-0.04* [**2185-12-1**] 05:41AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.8 [**2185-11-14**] 01:44PM BLOOD calTIBC-294 VitB12-602 Folate-8.4 Hapto-212* Ferritn-39 TRF-226 [**2185-11-14**] 07:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2185-11-20**] 04:15PM BLOOD HEPARIN DEPENDENT ANTIBODIES- EGD: Impression: Mucosa suggestive of Barrett's esophagus Erosion in the fundus, stomach body and antrum compatible with NG trauma Otherwise normal EGD to second part of the duodenum Colonscopy: Impression: Diverticulosis of the sigmoid colon, descending colon and ascending colon Otherwise normal colonoscopy to cecum TTE: Conclusions: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF 70-80%). There is no ventricular septal defect. 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. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 0.8 cm2) The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname **] is a 74 year old man with COPD, DM 2, HTN, admitted for unresponsivenes, found to have profound anemia of 14.8, with report of dark tarry stool in ED. He was initially intubated for colonoscopy/EGD, and could not be extubated afterward. His brief ICU course, by problem: . #) Anemia: Baseline hct in high 30's, 14.8 on admission. EGD/colonoscopy unrevealing. Per GI, capsule likely not indicated, patient's behavioral issues may prevent him from cooperating with capsule study requirements. No evidence of active GI bleed or ischemia, thus lower threshold for transfusion. . #) Respiratory failure: Initially failed extubation secondary to presumed VAP. On [**11-18**], he began to have thick green secretions and RR > 30 with fever to 101.8; concern for VAP, placed on vancomycin and cefepime. Chest xray showed evidence of CHF/volume overload. ECHO showed MR, AS, diastolic failure--likely all contributing as well. Currently growing GNR in sputum for Ventilator Associated Pneumonia . #) Acute Blood Loss Anemia: Baseline hct in high 30's, 14.8 on admission. Per GI, capsule likely not indicated, patient's behavioral issues may prevent him from cooperating with capsule study requirements. No evidence of active GI bleed or ischemia, thus lower threshold for transfusion. . #) Thrombocytopenia: Resolved. Multiple possible etiologies considered, including HIT (HIT antibodies negative), drug effect. Platelets 179 on [**11-22**]. . #) NSTEMI: most likely due to demand ischemia in setting of profound anemia. Pt has HTN, and now evidence of moderate AS on TTE. Cardiology aware and recommended transfusing to Hct > 30; will consider BB once hemodynamically stable. - Restart ASA and heparin in setting of GIB - Attempt re-start low-dose beta-blocker today - continue statin . #) Mental status change: Pt currently intubated and sedated. Mental status changes likely multifactorial in setting of anemia, NSTEMI, OSA, hyperglycemia, and hypercarbia in patient with underlying dementia and schizoaffective d/o. Per healthcare proxy, at baseline patient usually more quiet and less agitated/ aggressive, but has periods of agitation/aggression. Resolved over several days post discharge from the ICU. . #) DM 2: pt on insulin 70/30 [**Hospital1 **] at rehab, here was on [**12-27**] dose until [**11-21**] when 2 more units AM and PM were added. Glucose not tightly managed, but given possibility of extubation (and holding tube feeds), will not start long-acting insulin until after extubation - Continue to titrate up by 2 units (18units qAM, 17units qPM) - HISS . #) Comm: with [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 56955**]). Sister [**Name (NI) 382**], [**Name (NI) 56926**] [**Name (NI) **] [**Telephone/Fax (1) 70406**]); guardian ([**Name (NI) **] [**Name (NI) 70407**] [**Telephone/Fax (1) 70408**]) - Per report sister will be in town tomorrow; expect code discussion surrounding extubation #) Access: left subclavian central line. Difficult to gain access. . #) Code: DNR/DNI (per form faxed from NH) Medications on Admission: . Avandia 4mg [**Hospital1 **] glucophage 1000mg [**Hospital1 **] MOM 30cc qhs prn Insulin (Novalin 70/30 32U QAM, 30U QPM) RISS Lisinopril 20mg qd Lasix 40mg [**Hospital1 **] Theophyline 300mg [**Hospital1 **] Trusopt eye drops tid Tylenol 325-1g q6h prn Ultram 50mg q6h prn Zyprexa 2.5mg [**Hospital1 **] Hytrin 1mg qhs Ventolin [**Hospital1 **] Lipitor 20mg qd (per nurse [**First Name (Titles) **] [**Last Name (Titles) **]) . Discharge Medications: 1. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Milk of Magnesia 30cc QHS PRN 6. Insulin Novalin 70/30 32 units QAM and 30 units QPM. Please 1/2 doses when patient not taking PO. Please continue insulin sliding scale as per your outpatient regimen. 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 9. Theophylline 300 mg Tablet Sig: One (1) Tablet PO once a day. 10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 11. Zyprexa 2.5 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Hytrin 1 mg Capsule Sig: One (1) Capsule PO at bedtime. 13. Ventolin 5 mg/mL Solution Sig: 1-2 puffs Inhalation twice a day. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: Acute Blood Loss Anemia Gastritis COPD Obstructive Sleep Apnea Ventilator Associated Pneumonia Hypercarbic Respiratory Failure Hypertension Discharge Condition: Stable Discharge Instructions: Return to the hospital if you have further vomitting of blood, black tarry stools, bleeding, fever/chills Followup Instructions: As Needed

[ "327.23", "285.1", "398.91", "276.2", "396.2", "244.9", "294.8", "278.01", "518.84", "410.71", "578.0", "287.5", "V10.46", "276.0", "530.85", "999.9", "293.0", "562.10", "482.83", "578.1", "401.9", "295.70", "414.8", "274.9", "250.92", "496" ]

icd9cm

[ [ [] ] ]

[ "45.24", "96.72", "93.90", "99.04", "38.91", "96.34", "96.04", "38.93", "45.13", "96.6", "45.23" ]

icd9pcs

[ [ [] ] ]

8654, 8701

3920, 6987

344, 420

8884, 8892

1955, 3897

9046, 9058

1581, 1599

7468, 8631

8722, 8863

7013, 7445

8916, 9023

1614, 1936

278, 306

448, 1319

1341, 1483

1499, 1565

4,900

117,413

12071+56380

Discharge summary

report+addendum

Admission Date: [**2203-6-29**] Discharge Date: [**2203-7-8**] Date of Birth: [**2133-2-23**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3376**] Chief Complaint: Rectal Cancer Major Surgical or Invasive Procedure: s/p Robotic to Open Proctosigmoidectomy with Loop Ileosotomy History of Present Illness: 70 year old male patient diagnosed with rectal cancer and followed in outpatient colorectal surgery clinic with PMH significant for Type 2 Diabetes, chronic pain, myocardial infarction, hyperlipidemia, carotid stenosis, and hypertension presented to [**Hospital1 18**] for elective surgical intervention for rectal cancer with Dr. [**Last Name (STitle) 1120**]. Past Medical History: DMII Chronic Pain Myocardial Infarction Hyperlipidemia Carotid Stenosis Hypertension Rectal Cancer Social History: Married with Son, supportive family. Physical Exam: General: VS: Cardiac: Lungs: Abd: Lower Extremities: Pertinent Results: [**2203-7-8**] 06:30AM BLOOD WBC-11.7* RBC-3.28* Hgb-8.7* Hct-27.9* MCV-85 MCH-26.5* MCHC-31.2 RDW-16.6* Plt Ct-444* [**2203-7-7**] 12:05PM BLOOD WBC-11.0 RBC-3.16* Hgb-8.5* Hct-27.0* MCV-85 MCH-26.8* MCHC-31.4 RDW-15.4 Plt Ct-396 [**2203-7-7**] 04:08AM BLOOD WBC-11.1* RBC-3.25* Hgb-8.6* Hct-28.2* MCV-87 MCH-26.5* MCHC-30.6* RDW-15.4 Plt Ct-429 [**2203-7-6**] 05:52AM BLOOD WBC-11.9* RBC-3.53* Hgb-9.5* Hct-29.6* MCV-84 MCH-27.0 MCHC-32.1 RDW-15.9* Plt Ct-399 [**2203-7-5**] 05:09AM BLOOD WBC-9.8 RBC-3.37* Hgb-9.3* Hct-29.2* MCV-87 MCH-27.5 MCHC-31.8 RDW-15.8* Plt Ct-304 [**2203-7-4**] 02:00AM BLOOD WBC-6.6 RBC-3.32* Hgb-8.9* Hct-28.5* MCV-86 MCH-27.0 MCHC-31.4 RDW-15.4 Plt Ct-265 [**2203-7-3**] 04:05AM BLOOD WBC-5.1 RBC-3.33* Hgb-9.2* Hct-28.6* MCV-86 MCH-27.7 MCHC-32.3 RDW-15.5 Plt Ct-248 [**2203-7-2**] 02:56AM BLOOD WBC-3.5* RBC-3.35* Hgb-9.1* Hct-28.0* MCV-84 MCH-27.2 MCHC-32.6 RDW-16.0* Plt Ct-193 [**2203-7-1**] 06:28PM BLOOD WBC-4.0# RBC-3.42* Hgb-9.3* Hct-29.0* MCV-85 MCH-27.3 MCHC-32.2 RDW-15.8* Plt Ct-227 [**2203-7-1**] 01:12AM BLOOD WBC-13.0* RBC-3.64* Hgb-9.7* Hct-30.1* MCV-83 MCH-26.8* MCHC-32.3 RDW-16.1* Plt Ct-181 [**2203-6-30**] 02:28AM BLOOD WBC-9.6 RBC-4.09* Hgb-11.3* Hct-34.0* MCV-83 MCH-27.5 MCHC-33.1 RDW-16.1* Plt Ct-196 [**2203-6-29**] 05:24PM BLOOD WBC-6.7 RBC-3.93* Hgb-10.7* Hct-32.8* MCV-83 MCH-27.2# MCHC-32.6 RDW-16.0* Plt Ct-188 [**2203-7-8**] 06:30AM BLOOD Plt Ct-444* [**2203-7-7**] 12:05PM BLOOD Plt Ct-396 [**2203-7-7**] 04:08AM BLOOD Plt Ct-429 [**2203-7-6**] 05:52AM BLOOD Plt Ct-399 [**2203-7-2**] 02:56AM BLOOD PT-13.3* PTT-30.8 INR(PT)-1.2* [**2203-7-1**] 01:12AM BLOOD PT-17.2* PTT-32.9 INR(PT)-1.6* [**2203-6-29**] 05:20PM BLOOD PT-15.3* PTT-28.3 INR(PT)-1.4* [**2203-7-8**] 06:30AM BLOOD Glucose-123* UreaN-10 Creat-0.9 Na-140 K-3.6 Cl-104 HCO3-27 AnGap-13 [**2203-7-7**] 04:08AM BLOOD Glucose-125* UreaN-15 Creat-1.2 Na-142 K-4.0 Cl-102 HCO3-28 AnGap-16 [**2203-7-6**] 05:52AM BLOOD Glucose-162* UreaN-10 Creat-0.8 Na-141 K-4.1 Cl-105 HCO3-27 AnGap-13 [**2203-7-5**] 05:09AM BLOOD Glucose-139* UreaN-9 Creat-0.8 Na-138 K-4.3 Cl-101 HCO3-27 AnGap-14 [**2203-7-4**] 02:00AM BLOOD Glucose-163* UreaN-10 Creat-0.7 Na-136 K-4.0 Cl-101 HCO3-29 AnGap-10 [**2203-7-3**] 04:15PM BLOOD Na-138 K-3.9 Cl-101 [**2203-7-3**] 04:05AM BLOOD Glucose-140* UreaN-11 Creat-0.7 Na-137 K-4.0 Cl-100 HCO3-27 AnGap-14 [**2203-7-2**] 02:00PM BLOOD Glucose-160* UreaN-15 Creat-0.7 Na-137 K-4.0 Cl-101 HCO3-27 AnGap-13 [**2203-7-2**] 02:56AM BLOOD Glucose-149* UreaN-19 Creat-0.8 Na-137 K-4.3 Cl-100 HCO3-25 AnGap-16 [**2203-7-1**] 06:28PM BLOOD Glucose-172* UreaN-20 Creat-0.8 Na-134 K-4.3 Cl-100 HCO3-22 AnGap-16 [**2203-7-1**] 01:12AM BLOOD Glucose-166* UreaN-17 Creat-0.9 Na-135 K-4.7 Cl-100 HCO3-25 AnGap-15 [**2203-6-29**] 05:24PM BLOOD Glucose-204* UreaN-11 Creat-0.7 Na-141 K-4.3 Cl-107 HCO3-26 AnGap-12 [**2203-7-7**] 04:08AM BLOOD ALT-12 AST-21 AlkPhos-53 TotBili-0.4 [**2203-6-29**] 05:24PM BLOOD ALT-27 AST-45* AlkPhos-28* TotBili-0.8 [**2203-7-2**] 02:00PM BLOOD CK-MB-4 cTropnT-0.35* [**2203-7-2**] 02:56AM BLOOD CK-MB-6 cTropnT-0.27* [**2203-7-1**] 06:28PM BLOOD CK-MB-9 cTropnT-0.26* [**2203-7-8**] 06:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.6 [**2203-7-7**] 04:08AM BLOOD Albumin-3.0* Calcium-8.3* Phos-4.4 Mg-2.5 Iron-18* Cholest-145 [**2203-7-6**] 05:52AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2 [**2203-7-5**] 05:09AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1 [**2203-7-4**] 02:00AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1 [**2203-7-3**] 04:15PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1 [**2203-7-3**] 04:05AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1 [**2203-7-2**] 02:00PM BLOOD Calcium-8.7 Phos-3.0 Mg-2.4 [**2203-7-2**] 02:56AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3 [**2203-7-1**] 06:28PM BLOOD Calcium-8.8 Phos-2.5* Mg-2.3 [**2203-7-1**] 01:12AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.2 [**2203-6-30**] 02:28AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2 [**2203-6-29**] 05:24PM BLOOD Albumin-3.4* Calcium-8.5 Phos-4.1 Mg-1.8 CT ABD & PELVIS WITH CONTRAST Study Date of [**2203-7-6**] 2:49 PM IMPRESSION: 1. Status post proctosigmoidectomy with dilated small bowel loops and decompressed distal loops. While no definite transition point is seen there is a relative caliber change with angulation of the bowel in the right hemipelvis. These findings could reflect a small bowel obstruction, though post-operative ileus is also possible. Correlation with clinical circumstance and ostomy output is recommended. 2. Small volume free intra-abdominal and pelvic fluid could reflect recent surgery. 3. Bilateral mild hydronephrosis with delayed contrast excretion and distended bladder. 4. Right greater than left small pleural effusions with right basal consolidation could be atelectasis or infection. 5. Ectasia of the left internal iliac artery to 1.8 cm. 6. Prominent paraesophageal node measuring 12mm. Brief Hospital Course: The patient presented to [**Hospital1 18**] for elective surgical treatment of rectal cancer. The planned procedure was laparoscopic however, the patient required open surgery because of bleeding the patient received 4 units of packed red blood cells and the patient's hematocrit stabilized postoperatively and can be seen in the results section of this report. The patient remained on the [**Hospital Ward Name **] of [**Hospital1 18**] as pre-operatively, his cardiac work up revealed he was at risk but cleared for surgery. He was seen by cardiology preoperatively. The patient recovered in the ICU intubated and on [**2203-6-30**] extubated was extubated, he was stable on room air. The patient's pain was managed post-operatively with PCA however this was discontinued related to confusion. The patient's abdomen was noted to be distended. On [**2203-7-1**] the patient had a temperature to 103.2 overnight, he was noted to have mild EKG changes and increase in troponin and cardiology was consulted. [**2203-7-2**] troponin to 0.35, ultimately the patient was started on labetalol IV and metoprolol which stabilized the patient's tachycardia. The patient was transitioned to the floor on metoprolol. While in the intensive care unit the patient continued to have some delirium. The patient high ileostomy output and was repleated with cc/cc repletion. On [**2203-7-3**] spiked to 102.3, cultured and the patient started clonidine patch for agitation. Behavior improving and [**2203-7-4**] he was transferred to the floor. Aspirin and Plavix was restarted and he continued therapy with metoprolol. The patient was started on octreotide and Imodium. On [**2203-7-5**] ostomy output decreased and the octreotide and Imodium was held. Intravenous repletions were discontinued. On [**2203-7-6**] the patient was noted to have increased abdominal pain and abdominal distension A CT scan of the abdomen and pelvis was done which showed likely ileus and small pleural effusion. The patient had been started on vancomycin and Zosyn IV for empiric cover and vancomycin trough values were monitored appropriately and were in appropriate range. A nasogastric tube was placed to decompress the stomach however, overnight the patient removed the NG tube. The ileostomy began to function in appropriate amounts and the ileus was believed to be resolving and the tube was not replaced. Because of the patient's difficult behavior at times and possible sun downing geriatric medicine was consulted for recommendations and attributed much of behavior issues to medications and difficult personality. The patient started a regular diet. The patient was noted to have urinary incontinence however a urinalysis was sent and was negative and he did not have post void residuals. The patient began to use the urinal prior to discharge. [**2203-7-8**] the patient's ileostomy output is stable, the patient has worked with physical therapy, he has been trasitioned to antibiotics by mouth for 7 days. The patient was followed closely by the wound/ostomy nursing team however, has not fully engaged with taking care of the ileostomy and will require continued physical therapy. The patient was stable for discharge. His staples will be removed in outpatient surgical clinic. He should follow-up with cardiology for continued cardiac care. Of note, the patient's stoma is known to have yellow discoloration, slightly necrotic appearing from 3 o'clock to 9 o'clock and the surgical attending is aware of this. Please see the wound/ostomy notes for details. Please see the cardiology note included in this discharge summary. Medications on Admission: gabapentin 400 qid glipizide 10mg [**Hospital1 **] lisinopril 40mg qd metformin 1250mg qd percocet prn Crestor 10mg qd viagra prn Iron 325mg qd Discharge Medications: 1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: hold for increased sedation or RR<12. 6. metformin 500 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 7. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 6-8 hours as needed for pain for 5 days: Do not take more than 4000mg of tylenol in 24 hours. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain: do not take more than 4000mg of tylenol daily. 10. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: Please complete 7 Days of therapy. First day of therapy [**2203-7-8**]. 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] - [**Location (un) 8117**] Discharge Diagnosis: Rectal 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 after a laparoscopic to open proctosigmoidectomy with loop ileostomy for surgical management of rectal cancer. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you [**Name2 (NI) 19605**] these results they will contact you before this time. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may be dicsharged to a rehabilitaion facility to finish your recovery. Please monitor your bowel function closely. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. You must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If you find that your output has become too much or too little, please call the office for advice. The office nurse or nurse [**Name2 (NI) 3639**] can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. You may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to you by the ostomy nurses. Please continue to take the immodium/metamucil wafers/tincture of opium to control the output. As your condition improves you may not need all of this medication, our goal is that you have 500-1200cc from the ostomy every 24 hours. Please call the office to assist you in adjusting your medications. Please keep your Ins and Out's on the provided graft and bring this to any follow-up appointment. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. You have a bridge in place and this will be removed in clinic by the wound/ostomy nurse. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. You have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may gradually increase your activity as tolerated but clear heavy excercise at your follow up appointment. You will be prescribed a small amount of the pain medication oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Call the colorectal surgery office to make an appointment for follow-up two weeks after surgery with the colorectal surgery outpatient nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP. At that appointment you will be set up with an appointment for your second post-operative check. Call [**Telephone/Fax (1) 160**] to make this appointment Please make an appointment with your cardiologist 2-3 weeks after discharge. Completed by:[**2203-7-8**] Name: [**Known lastname 6838**],[**Known firstname 6839**] Unit No: [**Numeric Identifier 6840**] Admission Date: [**2203-6-29**] Discharge Date: [**2203-7-8**] Date of Birth: [**2133-2-23**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1859**] Addendum: Left sided port-a-cath was deaccessed at discharge. Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] - [**Location (un) 7044**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1871**] MD [**MD Number(2) 1872**] Completed by:[**2203-7-8**]

[ "401.9", "458.29", "998.11", "154.1", "250.00", "412", "V64.41", "414.00", "272.4", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "46.01", "99.77", "48.69", "45.95" ]

icd9pcs

[ [ [] ] ]

17005, 17235

5871, 9479

316, 379

10915, 10915

1034, 5848

16035, 16982

9673, 10760

10878, 10894

9505, 9650

11066, 16012

961, 1015

263, 278

407, 770

10930, 11042

792, 892

908, 946

67,149

186,587

42823

Discharge summary

report

Admission Date: [**2173-1-20**] Discharge Date: [**2173-1-25**] Date of Birth: [**2117-1-12**] Sex: M Service: CARDIOTHORACIC Allergies: fish oil / lisinopril / nuts Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [**2173-1-21**] Mitral Valve Repair(28mm Annuloplasty Band) and Closure of Patent Foramen Ovale History of Present Illness: Dr. [**Known lastname **] is a 55 year old gentleman with history of mitral valve disease since mid-90's. And had history of endocarditis in [**Month (only) 205**] [**2162**]. Since that time he has been followed by echocardiograms for mitral regurgitation. His echocardiogram from [**2172-7-16**] showed his mitral regurgitation to be now severe. Dr. [**Known lastname **] does now notes some fatigue/decrease exercise tolerance, and very minimal dyspnea with moderate activity. Given the severity of his disease, he has decided to discuss his surgical options with Dr. [**Last Name (STitle) **]. Past Medical History: - Mitral regurgitation (Flail P2) - Endocarditis [**5-17**] - TIA x 2 ([**2159**]/[**2164**]) - Hypertension Social History: Last Dental Exam: 3-4 weeks ago Lives with: Wife Occupation: MD - Critical care, Pulmonary Cigarettes: Denies ETOH: [**12-22**] drinks/week Illicit drug use: Denies Family History: Denies premature coronary artery disease Physical Exam: Pulse: 60 Resp: 18 O2 sat: 99% B/P Right: 148/73 Left: 131/75 Height: 6'2" Weight: 257 General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] pupils slightly unequal in size d/t eye injury Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade 2/6 systolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema - Varicosities: + Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2173-1-20**] Carotid Ultrasound: There is less than 40% stenosis within the left internal carotid artery. There is no evidence of significant stenosis in the right internal carotid artery. Both vertebral arteries presented antegrade flow. . [**2173-1-20**] Cardiac Catheterization: Right dominant. No angiographically-apparent coronary artery disease. . [**2173-1-21**] Intraop TEE: Pre Bypass: The left atrium is markedly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. A patent foramen ovale is present. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. There are simple atheroma in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. Moderate to severe (3+) mitral regurgitation is seen. Isolated P2 flail. Post Bypass: The patient is s/p Mitral valve repair with a 28 [**Doctor Last Name **] annuloplasty band. The cardiac index is 3.1. The band is well seated with no peri or paravalvular leaks seen. The mean gradient across the valve is 5 mmHg. The EF is preserved at >55%. Aorta is intact post deccannulation. Brief Hospital Course: Dr. [**Known lastname **] was admitted and underwent further preoperative evaluation. Cardiac catheterization showed clean coronary arteries while carotid ultrasound revealed less than 40% stenosis within the left internal carotid artery. Workup was otherwise unremarkable and he was cleared for surgery. The following day, Dr. [**Last Name (STitle) **] performed mitral valve repair along with closure of PFO - for surgical details, please see operative note. Given inpatient stay was less than 24 hours, Cefazolin was given for perioperative antibiotic coverage. Following surgery, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He was started on betablocker, lasix, statin and ASA therapy. He experienced post-operative afib and was treated w/ IV amio with conversion to SR. Amio was d/c'd. CT and pacing wires were removed. He was transferred to the stepdown unit for ongoing post operative care. Had subsequent recurring but self limited bouts of afib and his betablocker was increased. He was started on coumadin therapy. Post-operative pain was well controlled with tylenol and occasional percocet. He was evaluated by physical therpay for strength and conditioning and was cleared for discharge to home on POD#4. Medications on Admission: Amlodipine 5mg daily Benicar 20mg daily Aspirin 325mg daily Crestor 20mg daily Multivitamin daily Vitamin D-3 daily OPC-3 Neutrametrics Antioxidant daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 1 [**11-16**] Tablet PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. Disp:*14 Tablet Extended Release(s)* Refills:*0* 12. 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* 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 14. Coumadin 2.5 mg Tablet Sig: as directed based on INR Tablet PO once a day: Goal INR 2.0-2.5 Indication afib. Disp:*60 Tablet(s)* Refills:*2* 15. Outpatient Lab Work INR draw on [**2173-1-26**] Discharge Disposition: Home With Service Facility: [**Hospital1 11485**] VNA Discharge Diagnosis: Mitral Regurgitation, Patent Foramen Ovale(PFO) s/p Mitral Valve Repair and Closure of PFO complicated by post-op afib History of Endocarditis [**2162**] History of TIA Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol and percocoet Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication post-op Afib Goal INR 2.0-2.5 First draw [**2173-1-26**] Results to phone Dr. [**First Name (STitle) 8711**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 92485**] Followup Instructions: You are scheduled for the following appointments Surgeon: [**Doctor First Name **] [**Doctor Last Name **] [**Telephone/Fax (1) 170**] Date/Time:[**2173-2-24**] 1:15 in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **] WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2173-2-2**] 10:30 in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **] Please call to schedule appointments with your Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- please call for appointment in 2 weeks Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12101**] in [**2-18**] weeks Labs: PT/INR for Coumadin ?????? indication post-op Afib Goal INR 2.0-2.5 First draw [**2173-1-26**] Results to phone Dr. [**First Name (STitle) 8711**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 92485**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2173-1-25**]

[ "427.31", "278.00", "401.9", "997.1", "424.0", "V85.33", "745.5", "429.5" ]

icd9cm

[ [ [] ] ]

[ "35.12", "35.32", "35.71", "88.56", "39.61" ]

icd9pcs

[ [ [] ] ]

6784, 6840

3580, 4893

303, 401

7066, 7317

2160, 3557

8404, 9568

1361, 1403

5098, 6761

6861, 7045

4919, 5075

7341, 8381

1418, 2141

256, 265

429, 1029

1051, 1162

1178, 1345

5,939

110,038

8892

Discharge summary

report

Admission Date: [**2166-5-20**] Discharge Date: [**2166-5-26**] Date of Birth: [**2126-1-20**] Sex: M Service: CSU SERVICE: Cardiothoracic Surgery. HISTORY OF PRESENT ILLNESS: This is a 40-year-old male with 2-3 month history of chest pain and dyspnea on exertion. He had a positive stress test and underwent a cardiac catheterization which revealed three-vessel coronary artery disease with an ejection fraction of approximately 35 percent. He was referred to Dr. [**Last Name (STitle) 70**] for evaluation of coronary artery bypass graft. PAST MEDICAL HISTORY: Diabetes mellitus, status post cadaveric renal transplant, hypertension, high cholesterol, hepatitis C. SOCIAL HISTORY: Positive for smoking and positive alcohol abuse. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Captopril 50 mg p.o. b.i.d. 2. Imdur 60 mg p.o. q d. 3. Aspirin 81 mg p.o. q d. 4. Zantac 150 mg p.o. q d. 5. Prograf 2 mg p.o. b.i.d. 6. Folate 1 mg p.o. q d. 7. CellCept 1,000 mg p.o. b.i.d. 8. Lipitor 10 mg p.o. q d. 9. Atenolol 100 mg p.o. q a.m. and 50 mg p.o. q p.m. 10. Protonix 40 mg p.o. q d. 11. Humalog insulin sliding scale. 12. Bactrim one tablet p.o. Monday, Wednesday and Friday. 13. Prednisone 5 mg p.o. q d. 14. Lantus insulin. PHYSICAL EXAMINATION: He was afebrile with stable vital signs. His lungs were clear. Heart was regular. Abdomen was soft, nontender, nondistended with bowel sounds present. He had a well healed renal transplant scar. LABORATORY DATA: His labs are all within normal limits. HOSPITAL COURSE: The patient was seen in consultation and it was decided that the patient would undergo a coronary artery bypass graft. The patient was taken to the Operating Room on [**2166-5-21**] for a coronary artery bypass graft times three. Please see the Operative Report for further details. The patient was transferred to the Cardiac Surgery Recovery Unit postoperatively and was slowly weaned from his ventilator and extubated. He was put on multiple agents to enhance his blood pressure. These were slowly weaned over the next couple of days. The Transplant Renal service was consulted for management of his renal transplant medications and they followed him throughout his hospital course. The patient was weaned from the ventilator and weaned from his cardiac medications over the next couple of days. He had chest tubes placed intraoperatively and those were ultimately removed prior to discharge. Also, the [**Hospital6 30927**] was consulted for management of his insulin during this hospital stay. They followed him throughout and managed his insulin accordingly. The patient continued to do well. His blood pressure medications were slowly titrated up as he was able to be weaned from his pressors. His chest tubes were removed. Psychiatry was consulted on [**2166-5-23**] because the patient was combative and there was a question of whether or not he was withdrawing. They felt that this patient was delirious likely due to postoperative and postanesthesia effects, as well as nicotine and questionable alcohol withdrawal. His delirium slowly resolved and the patient was normal without any signs of agitation prior to discharge. The patient continued to do well and Physical Therapy was consulted. He was ambulating significantly on his own and continued to improve. He was able to do stairs and actually ultimately was going outside on his own to smoke and was active. The patient was discharged to home on [**2166-5-26**] and he was doing well. The patient was discharged to home in stable condition on [**2166-5-26**]. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft times three. 2. Diabetes mellitus. 3. Renal insufficiency, status post cadaveric renal transplant. 4. Hypertension. 5. High cholesterol. 6. Hepatitis C. 7. Positive for smoking. 8. Positive for alcohol use. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q d. 2. Percocet 1-2 tablets p.o. q four hours p.r.n. 3. Atenolol 100 mg p.o. q a.m. and 50 mg p.o q p.m. 4. Imdur 60 mg p.o. q d. 5. Plavix 75 mg p.o. q d. 6. CellCept 1,000 mg p.o. b.i.d. 7. Prednisone 5 mg p.o. q d. 8. Lipitor 10 mg p.o. q d. 9. Folic acid 1 mg p.o. q d. 10. Protonix 40 mg p.o. q d. 11. Prograf 2 mg p.o. b.i.d. 12. Lantus. 13. Bactrim one tablet p.o. Monday, Wednesday and Friday. 14. Reglan 10 mg p.o. q.i.d. with meals. 15. Vitamin C 500 mg p.o. b.i.d. 16. Captopril 50 mg p.o. t.i.d. CONDITION ON DISCHARGE: Stable condition. FOLLOW UP: The patient is to follow-up with his primary care physician [**Last Name (NamePattern4) **] [**1-10**] weeks and with his renal doctor as well, as well as with his cardiologist and follow-up with Dr. [**Last Name (STitle) 70**] in [**4-15**] weeks. DISPOSITION: The patient is discharged to home in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], MD 2358 Dictated By:[**Doctor Last Name 11225**] MEDQUIST36 D: [**2166-5-26**] 14:21:40 T: [**2166-5-26**] 15:00:30 Job#: [**Job Number 18897**]

[ "305.1", "V42.0", "272.0", "070.54", "414.01", "303.91", "250.01", "401.9", "293.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3649, 3933

3956, 4528

825, 1303

1598, 3628

4584, 5153

1326, 1580

200, 566

589, 694

711, 799

4553, 4572

60,737

185,545

51809

Discharge summary

report

Admission Date: [**2171-8-12**] Discharge Date: [**2171-8-15**] Date of Birth: [**2104-10-2**] Sex: M Service: MEDICINE Allergies: fish / Spiriva with HandiHaler / Lithium Attending:[**First Name3 (LF) 2782**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 91849**] is a 66M [**Location (un) **] home resident with h/o eosinophilic lung disease on chronic steroids/azathioprine, COPD, recurrent aspiration s/p g tube placement, and PE s/p IVC filter placement who initially presented [**2171-8-12**] in the setting of a fall and respiratory distress. Per report, patient was transferring from his motorized scooter to a chair and suffered a mechanical fall, landing on his L side. At that time, he was noted by staff to be hypoxic to 75% on RA (versus his baseline of 93-94% on RA, with occasional use of 1-2L supplemental oxygen following exertion), prompting transfer to [**Hospital1 18**], where he was admitted to the TSICU. CT head/neck/torso were unremarkable, apart from a possible L seventh rib fracture. Chest CT was concerning for a possible infection versus aspiration versus acute-on-chronic pulmonary process, though patient denies any apparentaspiration events, noting that he is strictly NPO, with the exception of swish/suction of coffee and sublingual morphine for pain control. He received vancomycin/cefepime/levofloxacin x1 and Medrol x1 in the ED, but these were not continued in the TSICU. He also was noted to have an elevated Tn to 0.49, without change in EKG or CK-MB and subsequently downtrending Tn. Past Medical History: suspected Churg [**Doctor Last Name 3532**] recurrent aspiration pneumonia h/o PE s/p IVC filter MS chronic back pain s/p spinal fusion depression bipolar disorder hypothyroidism s/p henia repair multiple spinal compression fractures presumably [**2-14**] prednisone use COPD with occasional 1-2L NC at home OSA with CPAP at home Social History: 75 pack year h/o smoking; quit several years ago. H/o heavy alcohol use, also quit several years ago. Family History: Not discussed this admission. Physical Exam: Physical Exam at Discharge: VS: 98 77 105/55 16 94% on 2L Gen: NAD HEENT: PERRL, EOMI, OP clear Neck: Supple, no JVD Lungs: CTA bilaterally w/o wheezes/rales/ronchi Heart: RRR, no mrg Abd: Tenderness over L ribs, abd soft and nontender, naBS, no CVA tenderness, Gtube c/d/i Ext: 2+ DP pulses equal bilaterally, no c/c/e Neuro: AOx3, CNII-XII intact, moving all extremities Pertinent Results: Admission Labs: [**2171-8-12**] 06:45PM BLOOD WBC-7.4 RBC-4.16*# Hgb-12.6*# Hct-38.7*# MCV-93 MCH-30.2 MCHC-32.4 RDW-16.6* Plt Ct-190 [**2171-8-12**] 06:45PM BLOOD Neuts-79.1* Lymphs-10.2* Monos-4.3 Eos-5.8* Baso-0.5 [**2171-8-12**] 06:45PM BLOOD PT-10.6 PTT-30.5 INR(PT)-1.0 [**2171-8-12**] 06:45PM BLOOD Glucose-91 UreaN-12 Creat-0.5 Na-137 K-3.8 Cl-100 HCO3-30 AnGap-11 [**2171-8-12**] 06:45PM BLOOD ALT-21 AST-26 AlkPhos-71 TotBili-0.3 [**2171-8-13**] 12:27AM BLOOD CK(CPK)-101 [**2171-8-13**] 08:04AM BLOOD CK(CPK)-81 [**2171-8-12**] 06:45PM BLOOD Lipase-13 [**2171-8-12**] 06:45PM BLOOD cTropnT-0.04* [**2171-8-13**] 12:27AM BLOOD CK-MB-8 cTropnT-0.49* [**2171-8-13**] 08:04AM BLOOD CK-MB-7 cTropnT-0.18* [**2171-8-12**] 07:30PM BLOOD Type-ART O2 Flow-6 pO2-60* pCO2-51* pH-7.42 calTCO2-34* Base XS-6 Intubat-NOT INTUBA [**2171-8-12**] 06:52PM BLOOD Lactate-1.0 K-3.7 Discharge Labs: [**2171-8-15**] 09:10AM BLOOD WBC-7.6 RBC-4.60 Hgb-13.9* Hct-43.7 MCV-95 MCH-30.2 MCHC-31.8 RDW-16.5* Plt Ct-234 [**2171-8-15**] 09:10AM BLOOD Neuts-70.8* Lymphs-18.5 Monos-5.4 Eos-4.9* Baso-0.4 [**2171-8-15**] 09:10AM BLOOD Glucose-71 UreaN-24* Creat-0.6 Na-145 K-3.8 Cl-103 HCO3-34* AnGap-12 EKG ([**2171-8-12**]): Sinus rhythm. Left anterior fascicular block. Compared to the previous tracing of [**2171-6-23**] no significant change. EKG ([**2171-8-13**]): Sinus rhythm. Left anterior fascicular block. Compared to the previous tracing no significant change. EKG ([**2171-8-14**]): Sinus rhythm. Left anterior fascicular block. Poor R wave progression, likely a normal variant. Cannot exclude a prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2171-8-13**] no diagnostic interim change. Portable CXR ([**2171-8-12**]): Bibasilar opacities are concerning for an infectious process superimposed on a background of chronic scarring and atelectasis. Upper lung fields appear relatively clear. There is no mediastinal widening. The cardiac silhouette is unremarkable. Pulmonary vascularity is normal. Noncontrast head CT ([**2171-8-12**]): No evidence of acute intracranial pathology. Noncontrast spine CT ([**2171-8-12**]): No evidence of fracture or dislocation. Emphysema at the lung apices. CT chest/abdomen/pelvis with contrast ([**2171-8-12**]): 1. Acute on chronic process within the lungs with extensive ground glass opacities, particularly in the right middle and lower lobes, suggesting an infectious process; inflammatory lung disease and aspiration are other possibilities which could be considered in the appropriate setting. 2. Stable hepatic and renal cysts. 3. Stable gallbladder adenomyomatosis. 4. Equivocal nondisplaced hairline fracture of the left seventh rib (2:48) cannot be completely excluded. Old rib deformities bilaterally. Compression deformities within T10-L2 vertebral bodies. Stable loss of vertebral height noted within mid portion of L1 vertebral body and anterior wedging defect at T11 vertebral body, similar to the prior examination. Brief Hospital Course: Mr. [**Known lastname 91849**] is a 66M [**Location (un) **] home resident with h/o eosinophilic lung disease on chronic prednisone/azathioprine, recurrent aspiration, PE s/p IVC filter placement p/w fall and respiratory distress c/w with an apiration event and splinting in the setting of a rib fracture. . # Hypoxia: Given acuity of presentation, new hypoxia was felt to represent possible aspiration/microaspiration event despite presence of g tube. Pneumonia was felt to be less likely in the absence of fever or leukocytosis while exacerbation of his underlying pulmonary disease was felt to be similarly unlikely, given acuity of presentation despite CT findings possibly consistent with pneumonia versus acute-on-chronic lung disease. Splinting due to pain likely also contributed to his supplemental oxygen requirement, with pain relief from PCA and subsequently morphine. He remained afebrile/HD stable without leukocytosis throughout admission, and supplemental oxygen requirement was weaned from 3L to his home requirement of 2L. He continued to receive prednisone and azathioprine for his chronic lung disease, with taper of prednisone to 7.5mg and azathioprine to 100mg planned at discharge as per his outpatient pulmonologist's intention. . #L-sided pain: Pain on palpation was consistent with radiographic evidence of rib fracture and was controlled with PCA and subsequently morphine sublingual. At the time of discharge he was on his home pain regimen. . #Troponin elevation: Initial elevation to 0.49, with flat CK-MB, subsequently downtrending troponins, and unchanged EKGs was felt to represent strain and not acute coronary syndrome requiring intervention. . # Hypothyroidism: The patient was continued on his home levothyroxine. . # Chronic Pain: Home fentanyl patch and gabapentin were continued. Patient was given morphine as above. . # GERD: Home lansoprazole and metoclopramide were continued. . # HL: Home ASA and atorvastatin were continued. . # Mental health: Home citalopram and quetiapine were continued. . # H/o multiple fractures: Patient was continued on his home calcium and vitamin D. Patient likely would benefit from a DEXA scan as an outpatient. . Transitional issues - Patient will continue to follow up with his outpatient pulmonologist for further titration of prednisone and azathioprine. - Given history of extensive steroid use and fractures, patient likely would benefit from a DEXA scan and consideration of bisphosphinate therapy. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Nursing home records. 1. Docusate Sodium 100 mg PO BID 2. Senna 1 TAB PO HS 3. PredniSONE 10 mg PO DAILY 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath 6. Levothyroxine Sodium 25 mcg PO DAILY 7. Pravastatin 40 mg PO DAILY 8. gabapentin *NF* 750 mg Oral q8 9. Calcium Carbonate 500 mg PO TID 10. Metoclopramide 5 mg PO QIDACHS 11. Quetiapine Fumarate 100 mg PO HS 12. traZODONE 25 mg PO HS 13. Bisacodyl 10 mg PO HS:PRN constipation 14. Risperidone 1 mg PO Q6H:PRN agitation 15. Aspirin EC 81 mg PO DAILY 16. Citalopram 30 mg PO DAILY 17. Azathioprine 100 mg PO DAILY 18. Fentanyl Patch 50 mcg/hr TP Q72H 19. Sulfameth/Trimethoprim SS 1 TAB PO QOD 20. Chlorhexidine Gluconate 0.12% Oral Rinse 5 mL ORAL Q6H 21. Morphine Sulfate (Concentrated Oral Soln) 20 mg PO Q4H 22. Lorazepam 0.5 mg PO Q6H:PRN Agitation Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Azathioprine 100 mg PO DAILY 3. Bisacodyl 10 mg PO HS:PRN constipation 4. Calcium Carbonate 500 mg PO TID 5. Citalopram 30 mg PO DAILY 6. Fentanyl Patch 50 mcg/hr TP Q72H 7. gabapentin *NF* 750 mg Oral q8 8. Levothyroxine Sodium 25 mcg PO DAILY 9. Metoclopramide 5 mg PO QIDACHS 10. Morphine Sulfate (Concentrated Oral Soln) 20 mg PO Q4H 11. PredniSONE 7.5 mg PO DAILY 12. Quetiapine Fumarate 100 mg PO HS 13. Senna 1 TAB PO HS 14. Acetaminophen 1000 mg PO TID:PRN pain 15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 16. Chlorhexidine Gluconate 0.12% Oral Rinse 5 mL ORAL Q6H 17. Docusate Sodium 100 mg PO BID 18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath 19. Lorazepam 0.5 mg PO Q6H:PRN Agitation 20. Pravastatin 40 mg PO DAILY 21. Risperidone 1 mg PO Q6H:PRN agitation 22. Sulfameth/Trimethoprim SS 1 TAB PO QOD 23. traZODONE 25 mg PO HS 24. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Rib fracture Aspiration pneumonitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr [**Known lastname 91849**], It was a pleasure participating in your in care while you were admitted to [**Hospital1 69**]. As you know you were admitted because you fell at [**Hospital3 2558**] and fractured your ribs. You also had worsening shortness of breath with low oxygen saturations. This was likely due pain limiting your ability to take deep breaths. You had a chest CT that was concerning for a possible infection; however, you did not have a fever or elevated white blood cell count, and it was felt that an infection was unlikely. You might have had a small aspiration event contributing to your symptoms. You oxygen saturation improved, though you continued to need a small amount of oxygen. Followup Instructions: Department: PAIN MANAGEMENT CENTER When: MONDAY [**2171-9-2**] at 10:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Department: RADIOLOGY CARE UNIT When: THURSDAY [**2171-10-17**] at 8:00 AM [**Telephone/Fax (1) 446**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: RADIOLOGY When: THURSDAY [**2171-10-17**] at 9:30 AM With: XSP WEST [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

10095, 10165

5610, 8092

309, 315

10245, 10245

2569, 2569

11162, 11991

2125, 2156

9124, 10072

10186, 10224

8118, 9101

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3460, 5587

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2199, 2550

262, 271

343, 1636

2585, 3444

10260, 10404

1658, 1989

2005, 2109

8,432

179,403

43510

Discharge summary

report

Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-27**] Date of Birth: [**2075-8-31**] Sex: F Service: MEDICINE Allergies: Lisinopril / Adhesive Tape / Vancomycin Attending:[**First Name3 (LF) 45**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: Upper Endoscopy History of Present Illness: 74 yo F with h/o GI AVMs but none on scope 1 year ago, on warfarin for mechanical mitral valve. Showed up at [**Hospital 191**] clinic and had an episode of coffee ground emesis there. Denies fever, chills, chest pain. . In the ED, initial vs were: 97.4 70 130/35 100. Patient reported as having pallor and appearing fatigued at presentation. NG lavage initially with scant coffee grounds and cleared on second 500 mL lavage. HCT at 23.4 in ED down from 33 on [**2150-6-15**]. Patient was crossmatched for six units. No vitamin K or FFP given in the ED. Receiving first unit of PRBC at time of signout to floor. Vitals at time of signout to ICU were T afebrile, HR 76, BP 136/76, RR 16, O2Sat 100% RA. GI reportedly aware of patient and planning to scope in AM unless becomes unstable. . Upon arrival, patient appears fatigued, pale. Her husband describes that she was recently admitted for acute decompensated right sided heart failure and was aggressively diuresed. She was discharged to home and about 24 hours later began to have worsening nausea and began to vomit. She vomited for several days without evidence of coffee grounds or hematemesis, and reduced PO intake. She eventually came in to [**Company 191**] for further evaluation where she vomited and was found to have coffee grounds in her emesis and was sent to the ED. The only recent medication changes were that her spironolactone was increased from 25mg to 100mg, and that she was told to stop taking her diovan. She has had no sick contacts or travel. She admits to chills but no fevers. No diarrhea or abdominal pain, no dysuria or shortness of breath. . Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Rheumatic mitral valve disease s/p valvuloplasty in 01/90, s/p St-Judes MVR in 03/[**2144**]. s/p multiple cardiac catheterizations with clean coronaries. 2. H/o LGIB thought to be secondary to AVM's 3. Atrial fibrillation. 4. S/P VVI placement for symptomatic bradycardia in [**2120**], now s/p two replacements with last replacement in [**2143**] 5. DM type 2 6. History of CHF 7. Hypercholesterolemia 8. History of hepatic congestion of unclear etiology with multiple abdominal ultrasounds over last few years, as well as history of hemangiomas improved after MVR 9. Depression 10. Breast mass with negative work-up. 11. Vitamin B12 deficiency anemia. Social History: - Tobacco: none - Alcohol:none - Illicits:none She is married with 3 children, lives with her husband in [**Name (NI) 4047**]. No history of EtOH or tobacco use. Originally from [**Country 5881**]. Worked running a pizza shop on mass ave but now not able to work due to CHF. Family History: Mother with diabetes, lived to 92 Physical Exam: Vitals: T: BP: 139/38 P: 70 R: 18 O2: 99% 2L General: Fatigued, somewhat somnolent but arousable HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bibasilar crackles. CV: Regular rate and rhythm, III/VI holosystolic murmur heard best at LLSB with mechanical S1. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. Significant hepatomegaly with liver edge palpated to 4 finger-breadths below the costal margin. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Cardiology Report ECG Study Date of [**2150-6-19**] 2:09:36 PM Ventricular paced rhythm. Compared to the previous tracing of [**2150-6-18**] there is no change. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 0 176 462/477 0 -74 109 Radiology Report CHEST (PRE-OP AP ONLY) PORT Study Date of [**2150-6-22**] 12:25 AM SINGLE PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: Severe multichamber cardiomegaly, pulmonary vascular engorgement and right basal septal thickening persist. The patient is status post mitral valve replacement. There are multiple median sternotomy wires in unchanged position. The left chest wall pacemaker is in unchanged position. There is no large pleural effusion, consolidation or pneumothorax. IMPRESSION: Persistent severe cardiomegaly. Probably no acute decompensation. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2150-6-23**] 2:30 PM FINDINGS: The hepatic veins and their confluence are markedly distended, consistent with provided history of heart failure. The hepatic echotexture is normal, without evidence of a focal lesion. The main portal vein is patent with hepatopetal flow, with pulsatility again reflective of right heart failure. Small gallstones are present within the gallbladder, without secondary findings for cholecystitis. There is no intra- or extra-hepatic biliary ductal dilatation with the CBD measuring 2 mm. The spleen is normal in size measuring 11 cm. No ascites is evident. The pancreas is normal in echotexture, without evidence for peripancreatic or fluid collection. No pancreatic ductal dilatation or calcifications are evident. IMPRESSION: 1. No peripancreatic fluid identified. 2. Markedly distended hepatic veins and pulsatility of the portal vein, compatible with provided history of tricuspid regurgitation. 3. Cholelithiasis. CT ABD W&W/O C Study Date of [**2150-6-25**] 11:09 AM FINDINGS: In the liver, segment IV hypodense lesion measuring less than 1 cm is again identified, too small to characterize, but unchanged from prior study. IMPRESSION: 1. No CT evidence of acute pancreatitis or complications thereof, including no peripancreatic stranding, peripancreatic fluid collections, vascular compromise, or evidence of pancreatic necrosis. 2. Findings reflecting known congestive failure, including marked dilation of the IVC and hepatic veins, contrast reflux into the venous system on arterial phase imaging, heterogeneous hepatic parenchymal perfusion, and periportal edema/gallbladder wall edema secondary to third spacing. 3. Multiple bilateral low-attenuation renal lesions, previously characterized as cysts by ultrasound. [**2150-6-19**] 02:00PM BLOOD WBC-10.8 RBC-3.10*# Hgb-7.8*# Hct-23.4*# MCV-76* MCH-25.3* MCHC-33.5 RDW-16.4* Plt Ct-306 [**2150-6-27**] 05:55AM BLOOD WBC-9.9 RBC-3.36* Hgb-9.1* Hct-28.4* MCV-85 MCH-27.2 MCHC-32.2 RDW-17.1* Plt Ct-220 [**2150-6-19**] 02:00PM BLOOD Neuts-90.7* Lymphs-5.5* Monos-3.2 Eos-0.2 Baso-0.4 [**2150-6-19**] 02:00PM BLOOD PT-51.9* PTT-30.0 INR(PT)-5.7* [**2150-6-22**] 12:40PM BLOOD PT-29.6* INR(PT)-2.9* [**2150-6-25**] 05:45AM BLOOD PT-20.3* PTT-33.6 INR(PT)-1.9* [**2150-6-27**] 05:55AM BLOOD PT-22.3* INR(PT)-2.1* [**2150-6-19**] 02:00PM BLOOD Glucose-282* UreaN-174* Creat-1.7* Na-125* K-3.8 Cl-77* HCO3-28 AnGap-24* [**2150-6-20**] 09:33AM BLOOD UreaN-130* Creat-1.3* Na-139 K-3.2* Cl-93* HCO3-36* AnGap-13 [**2150-6-21**] 03:45AM BLOOD Glucose-129* UreaN-70* Creat-1.0 Na-140 K-3.4 Cl-101 HCO3-34* AnGap-8 [**2150-6-27**] 05:55AM BLOOD Glucose-180* UreaN-20 Creat-0.9 Na-136 K-4.3 Cl-98 HCO3-32 AnGap-10 [**2150-6-19**] 02:00PM BLOOD ALT-13 AST-22 CK(CPK)-23* AlkPhos-119* TotBili-0.6 [**2150-6-22**] 06:00AM BLOOD ALT-18 AST-29 LD(LDH)-220 CK(CPK)-20* AlkPhos-89 TotBili-0.8 [**2150-6-27**] 05:55AM BLOOD ALT-14 AST-20 AlkPhos-110* [**2150-6-19**] 02:00PM BLOOD Lipase-138* [**2150-6-22**] 06:00AM BLOOD Lipase-146* [**2150-6-19**] 02:00PM BLOOD cTropnT-0.03* [**2150-6-22**] 06:00AM BLOOD CK-MB-2 cTropnT-0.03* [**2150-6-27**] 05:55AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.3 [**2150-6-24**] 05:40AM BLOOD calTIBC-391 VitB12-442 Ferritn-76 TRF-301 [**2150-6-23**] 05:40AM BLOOD Triglyc-85 [**2150-6-21**] 03:45AM BLOOD Digoxin-1.6 Brief Hospital Course: 74 yo F with history of right sided CHF admitted with UGIB found to have acute renal failure in the setting of aggressive diuresis, presenting with GI bleed. #. Upper GI Bleed- The patient was admitted to the MICU after having coffee ground emesis at [**Company 191**]. She was placed on a protonix drip and received 2 units of pRBCs and 2 units of FFP while in the ED prior to admission to the MICU. Due to her mechanical valve, her supratherapeutic INR was not reversed with vitamin K. She underwent an EGD on MICU day 2 which showed evidence of erosive gastritis. She had no further bleeding after the EGD and was called out to the floor, with her diet being advanced to clears. She has a known history of AVMs in her small bowel and colon, which could have contributed to GI bleed, but bleeding was felt to be secondary to gastritis. Patient's Hct trended downwards slowly on floor, and she was transfused 1u pRBCs, after which her Hct was stable for several days. Aspirin was held and may be restarted by primary care physician in the future if felt to be safe. # Anticoagulation s/p Mechanical Mitral Valve and Paroxysmal Afib Upon discharge, INR was subtherapeutic for mechanical mitral valve, felt to be secondary to poor absorption of warfarin when taken with sucralfate, which was discontinued upon discharge. She was initially on enoxaparin bridge until noted to have slow Hct drop on floor; enoxaparin bridge was stopped because of GI bleed risk -- risk for stroke in a few days felt to be less than risk of GI bleed. INR should be rechecked on Monday at followup appointment. #. Acute Renal Failure - Her creatinine was rising upon discharge from her last admission after aggressive diuresis and symptoms of nausea and vomiting very likely related to marked uremia with BUN of 174 on admission. BUN/creatinine ratio and urine electrolytes were in keeping with a pre-renal cause. Patient was noted to be auto-diuresing in MICU, which may have been post-ATN diuresis. Patient did take low dose valsartan for 1-2days post discharge when creatinine was elevated after aggressive diuresis; this may have exacerbated an ATN. Patient has also had poor po intake for several days, likely worsening prerenal state at home prior to presentation, worsening uremia. On the floor, kidney function was stable at baseline 0.9, and patient was re-started on po diuretic regimen. #. Right sided heart failure - Managed by Dr. [**First Name (STitle) 2031**] at [**Hospital2 **] [**Hospital3 **]'s with recent admission for decompensation. She was intravascularly volume deplete from aggressive diuresis and UGIB. Diuresis was held during her ICU stay and she was given gentle IV fluids. Upon transfer to floor, a po diuretic regimen was started after a few of days of monitoring GI bleed and question pancreatitis. She was discharged on spironolactone 25mg and furosemide 120mg daily. She was restarted on low dose valsartan, which she was on previous to the last hospitalization, for cardioprotection. #. Pancreatitis - Patient was noted to have epigastric pain radiating to the back with eating, initially attributed to her gastritis, though she likely had some component of pancreatitis. Her lipase was elevated to 140s, and she complained of pain and nausea. She tolerated a diet of clears for a few days, and diuresis was held initially. Abdominal ultrasound and pancreatic protocol CT did not show any signs of gallstone pancreatitis, peripancreatic fluid or pseudocyst. #. Cholelithiasis - Patient was noted to have gallstones on abdominal ultrasound. She intermittently complained of right sided scapular pain which may be secondary to her cholelithiasis. She did complain of some right side abdominal discomfort radiating to the back with eating fatty foods. Ultrasound showed no evidence of cholecystitis. Patient may benefit from general surgery evaluation as an outpatient. #. Iron Deficiency Anemia - Patient has chronic iron deficiency anemia, for which she takes iron supplements. She does have known AVMs and newly discovered erosive gastritis with no signs of ulcers on EGD. B12 and folate are not low. Medications on Admission: Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY Calcium Carbonate Ferrous Sulfate 325 mg [**Hospital1 **] Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H Omeprazole 20 mg Capsule daily Warfarin 5 mg Tablet Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Spironolactone 100 mg Tablet daily Furosemide 80mg [**Hospital1 **] Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Calcium Carbonate-Vitamin D3 600 mg(1,500mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Disp:*60 Tablet, Chewable(s)* Refills:*2* 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID: PRN. Disp:*60 Capsule(s)* Refills:*2* 14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Upper GI Bleed Secondary Diagnoses: Iron Deficiency Anemia Chronic Diastolic Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 93554**], You were admitted to the hospital because you had vomited up some dark blood which was concerning. Your blood counts dropped, so you were given blood transfusions. You had an upper endoscopy while in the ICU; with the small camera, they were able to look inside your stomach and the beginning part of your small intestine and saw that you have bad gastritis, which means that your stomach lining is very inflamed. They did not see any ulcers. While you were here, you kidney function appeared to become normal. You have a little bit of extra fluid but it is stable. Please weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. Please remember to avoid as much sodium/salt in your food and drink as possible. While you were in the hospital, we also found that your pancreas was a little inflamed for a little while, but it improved. Your gall bladder has some stones, but it is not clear whether this is causing your right sided back pain or not. When you see Dr. [**Last Name (STitle) **] in [**Month (only) 205**], you may discuss this issue with him and whether or not you should go to General Surgery clinic to be evaluated or not. The following changes have been made to your medications: - Please INCREASE your furosemide back to your old dose of 120mg daily - Please DECREASE your spironolactone dose back to your old dose of 25mg daily - Please RESTART your valsartan (Diovan) 40mg daily - Please START pantoprazole 40mg TWICE daily to reduce your stomach acid - Please STOP your aspirin 81mg for now because it can irritate your stomach further - Please start calcium carbonate with Vitamin D3 TWICE daily - you may take Tylenol Extra Strength (500mg) for pain at home-- Please do not take more than 4 of these pills per day (2 grams total) - You may take Docusate (Colace) stool softeners TWICE daily to help soften your stool and make it easier for you to pass bowel movements Your visiting nurse should check your blood pressure when she visits your home to make sure it is not too low and to make sure you are not having symptoms of lightheadedness or dizziness. You will also need to have your INR (coumadin level) checked on Monday at your primary care appointment at [**Hospital **]. Please also remember to check your blood sugars every morning and two hours after finishing lunch. Please do not drink juice as this will raise your blood sugar. Followup Instructions: Please be sure to keep all of your followup appointments as listed below. Department: [**Hospital3 249**] When: MONDAY [**2150-6-29**] at 11:30 AM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage --> At this first visit, please have your INR (coumadin level) checked. Department: GASTROENTEROLOGY When: MONDAY [**2150-7-6**] at 8:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2150-7-8**] at 3:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], 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 Department: [**Hospital3 249**] When: TUESDAY [**2150-7-28**] at 1:40 PM With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2150-8-11**] at 2:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]

[ "427.31", "428.32", "427.89", "790.92", "250.00", "584.5", "428.0", "577.0", "280.9", "535.41", "V43.3", "574.20", "V45.01", "V58.61", "272.0", "E934.2" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

14364, 14439

8303, 12444

320, 338

14594, 14594

4085, 8280

17210, 19035

3443, 3478

13018, 14341

14460, 14460

12470, 12995

14745, 17187

3493, 4066

14516, 14573

2010, 2450

259, 282

366, 1991

14479, 14495

14609, 14721

2472, 3132

3148, 3427

21,691

112,283

29925

Discharge summary

report

Admission Date: [**2178-1-26**] Discharge Date: [**2178-1-31**] Date of Birth: [**2111-7-14**] Sex: F Service: UROLOGY Allergies: Sulfa (Sulfonamides) / Zocor Attending:[**First Name3 (LF) 1232**] Chief Complaint: Metastatic renal cancer with primary on left side Major Surgical or Invasive Procedure: Radical nephrectomy with adrenalectomy and multiple nodes. History of Present Illness: This is a 66-year-old female who was detected to have a large renal mass during work up for abdominal pain. She has imaging to confirm that she has a large left renal mass with apparent adrenal metastatic involvement and a small thrombus extending into the left renal vein to the position of the medial aortic side. She presented to the [**Hospital1 18**] for elective resection of the mass. Past Medical History: PMH: anemia (gammaglobulinopathy), OA, hyperlipidemia, chr back spasm PSH: tonsillectomy, appy, TAH-BSO, deviated septum repair Physical Exam: NAD, AAOx3 RRR, S1S2 CTAB, mildly decreased BS on R base Abd: soft, ND, aprop. tender incision c/d/i Ext: no c/c/e Pertinent Results: [**2178-1-30**] 05:55AM BLOOD WBC-6.0 RBC-4.38 Hgb-11.5* Hct-36.0 MCV-82 MCH-26.2* MCHC-31.9 RDW-17.5* Plt Ct-354 [**2178-1-29**] 05:55AM BLOOD WBC-8.6 RBC-4.39 Hgb-11.4* Hct-34.6* MCV-79* MCH-25.9* MCHC-32.8 RDW-17.3* Plt Ct-362 [**2178-1-28**] 04:04AM BLOOD WBC-11.1* RBC-4.35 Hgb-11.4* Hct-35.1* MCV-81* MCH-26.2* MCHC-32.5 RDW-16.9* Plt Ct-351 [**2178-1-27**] 06:44PM BLOOD WBC-10.6 RBC-3.87* Hgb-9.9* Hct-30.0* MCV-78* MCH-25.6* MCHC-33.1 RDW-17.4* Plt Ct-352 [**2178-1-27**] 12:50AM BLOOD WBC-7.7 RBC-4.13* Hgb-10.2* Hct-33.1* MCV-80* MCH-24.8* MCHC-31.0 RDW-17.8* Plt Ct-402 [**2178-1-27**] 06:44PM BLOOD Neuts-79* Bands-2 Lymphs-12* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2178-1-27**] 06:44PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL Burr-1+ [**2178-1-30**] 05:55AM BLOOD Plt Ct-354 [**2178-1-29**] 05:55AM BLOOD Plt Ct-362 [**2178-1-29**] 05:55AM BLOOD PT-13.1 PTT-34.0 INR(PT)-1.1 [**2178-1-28**] 04:04AM BLOOD Plt Ct-351 [**2178-1-28**] 04:04AM BLOOD PT-13.4* PTT-29.1 INR(PT)-1.2* [**2178-1-27**] 06:44PM BLOOD Plt Ct-352 [**2178-1-27**] 06:44PM BLOOD PT-14.0* INR(PT)-1.2* [**2178-1-27**] 12:50AM BLOOD Plt Ct-402 [**2178-1-30**] 06:15PM BLOOD Glucose-128* UreaN-14 Creat-0.9 Na-138 K-4.2 Cl-104 HCO3-26 AnGap-12 [**2178-1-30**] 05:55AM BLOOD Glucose-72 UreaN-13 Creat-0.8 Na-140 K-4.0 Cl-106 HCO3-23 AnGap-15 [**2178-1-29**] 04:00PM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-138 K-4.2 Cl-103 HCO3-23 AnGap-16 [**2178-1-29**] 05:55AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-136 K-4.0 Cl-102 HCO3-24 AnGap-14 [**2178-1-28**] 04:04AM BLOOD Glucose-121* UreaN-12 Creat-0.9 Na-138 K-4.3 Cl-107 HCO3-23 AnGap-12 [**2178-1-27**] 06:44PM BLOOD Glucose-142* UreaN-14 Creat-0.7 Na-140 K-4.3 Cl-111* HCO3-20* AnGap-13 [**2178-1-27**] 12:50AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-140 K-4.2 Cl-104 HCO3-18* AnGap-22* [**2178-1-30**] 06:15PM BLOOD Calcium-8.6 Phos-1.4* Mg-2.1 [**2178-1-30**] 05:55AM BLOOD Calcium-7.9* Phos-2.0* Mg-2.1 [**2178-1-29**] 05:55AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.3 [**2178-1-28**] 04:04AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2 [**2178-1-27**] 12:50AM BLOOD Calcium-10.2 Phos-2.9 Mg-2.2 [**2178-1-27**] 06:44PM BLOOD RedHold-HOLD [**2178-1-28**] 04:32AM BLOOD Type-ART pO2-99 pCO2-43 pH-7.37 calTCO2-26 Base XS-0 [**2178-1-28**] 01:01AM BLOOD Type-ART pO2-106* pCO2-43 pH-7.33* calTCO2-24 Base XS--3 [**2178-1-27**] 10:31PM BLOOD Type-ART pO2-115* pCO2-48* pH-7.29* calTCO2-24 Base XS--3 [**2178-1-27**] 06:44PM BLOOD Type-ART pO2-107* pCO2-50* pH-7.26* calTCO2-23 Base XS--4 [**2178-1-27**] 04:26PM BLOOD Type-ART pO2-218* pCO2-38 pH-7.31* calTCO2-20* Base XS--6 Intubat-INTUBATED [**2178-1-27**] 02:29PM BLOOD Type-ART pO2-224* pCO2-35 pH-7.38 calTCO2-22 Base XS--3 Intubat-INTUBATED Vent-CONTROLLED [**2178-1-28**] 04:32AM BLOOD Lactate-0.7 [**2178-1-28**] 01:01AM BLOOD Glucose-140* Lactate-0.6 Na-137 K-4.2 Cl-110 [**2178-1-27**] 10:31PM BLOOD Lactate-0.5 [**2178-1-27**] 04:26PM BLOOD Glucose-143* Lactate-0.5 K-3.9 [**2178-1-27**] 02:29PM BLOOD Glucose-111* Lactate-0.4* Na-138 K-3.7 Cl-112 [**2178-1-27**] 04:26PM BLOOD Hgb-9.9* calcHCT-30 [**2178-1-27**] 02:29PM BLOOD Hgb-9.7* calcHCT-29 [**2178-1-28**] 04:32AM BLOOD freeCa-1.16 [**2178-1-28**] 01:01AM BLOOD freeCa-1.17 [**2178-1-27**] 10:31PM BLOOD freeCa-1.15 [**2178-1-27**] 04:26PM BLOOD freeCa-1.25 [**2178-1-27**] 02:29PM BLOOD freeCa-1.30 Brief Hospital Course: This is a 66-year-old female who was detected to have a large renal mass during work up for abdominal pain. She has imaging to confirm that she has a large left renal mass with apparent adrenal metastatic involvement and a small thrombus extending into the left renal vein to the position of the medial aortic side. She presented to the [**Hospital1 18**] for elective resection of the mass. On [**2178-1-27**] the patient underwent a radical nephrectomy with adrenalectomy and multiple nodes. She tolerated the proceudre well and was transferred to the ICU to monitor here respiratory status for the night. Her chest tube was placed to suction and a CXR obtained overnight revealed no PTX and she had no air leak. She remained stable and her post-op acidosis resolved with pain control and fluid resuscitation. On POD #1 she was transferred to the floor. Her CXR remained stable so her chest tube was D/C'd. Her pain was controlled with IV meds and she was kept NPO/NGT/IVF. Her calcium levels, which were very high pre-op, came down into normal range. Her HCT and other labs remained stable. On POD #2 her NGT was d/c'd. On POD #3 the patient passed gas and her diet was advanced. She was changed to PO pain meds and her calcium values were borderline low so she was started on Ca and Vit D. She was able to ambulate and her foley was d/c'd after which she had not trouble voiding. She was kept in house to further monitor her changing calcium levels. On POD #4 she continued to do well without any issues and was discharged to home in good condition. Medications on Admission: Tussionex prn, FeS 150 mg, Procrit injections, lovastatin 20 mg, Extra Strength Tylenol Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Metastatic renal cancer with primary on left side Discharge Condition: Good Discharge Instructions: [**Name8 (MD) **] M.D. if fever > 101.5, nausea, vomiting, shortness of breath, chest pain, redness or drainage from incision, inability to urinate or any other concerns. You may shower, but do not take a tub bath for 10 days. Do not drive while taking narcotics. Followup Instructions: Please call Dr.[**Doctor Last Name **] office to schedule a followup in 2 weeks. [**Telephone/Fax (1) 25444**]. Completed by:[**2178-2-5**]

[ "189.0", "198.7", "197.0", "272.4", "197.1" ]

icd9cm

[ [ [] ] ]

[ "07.22", "40.3", "55.51" ]

icd9pcs

[ [ [] ] ]

6773, 6779

4557, 6112

338, 399

6873, 6880

1121, 4534

7192, 7334

6250, 6750

6800, 6852

6138, 6227

6904, 7169

986, 1102

249, 300

427, 820

842, 971

24,102

122,906

53430

Discharge summary

report

Admission Date: [**2157-8-12**] Discharge Date: [**2157-9-2**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 15344**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laporotomy, lysis of adheasions, small bowel resection History of Present Illness: 88F with h/o DM, CHF, afib, recent pneumonia (Zosyn) and C diff (course of Flagyl), among other med issues, presents with one day of abdominal pain. Pain began at epigastrium and migrated by presentation to ED to hypogastrium, and finally localized to RLQ at time of admission. No N/V/BRBPR. Diarrhea per recent c diff, but normal BM yesterday was her last BM. Dark stools secondary to iron supplementation, but guiaic neg in ED. Pt denies nausea per se, but had one episode of emesis yesterday brought on by coughing spell. Additional issues for this admission developed as patient was in rapid afib in ED, tachypneic, and had B diffuse crackles on lung exam. O2 sats stable on 100%, but patients normal requirement is only 2L. CPAP was attempted in ED, but patient refused and became agitated. After multiple doses of Diltiazem IV brought pulse rate to 90's, O2 was pulled back to 4L and O2 sat was 98%. Patient has had multiple admissions recently for pulmonary edema, at [**Hospital1 112**] and [**Hospital1 18**], treated effectively with diuresis and diltiazem drip when patient in rapid afib. Past Medical History: CHF--> (last echo [**5-19**] showed good LVF with EF=60%, mild symmetric .... LVH, and mildly increased pulm artery pressures) Afib DM Type 2 Polycythemia [**Doctor First Name **] CRI (Cr 1.6 to 2.6) Hypothyroidism Pneumonia DVT few months ago; off coumadin based on risk of falls Social History: Since falling about a year ago the patient has been in and out of [**Hospital1 112**]. She is now living at [**Hospital3 95406**]. She was widowed 2 years ago.No alcohol and no smoking. Her son is a urologist at [**Hospital6 **]. She has three grandchildren. Family History: No h/o clotting disorders. Physical Exam: T:99r P:126 BP:181/90 R:36 O2:98% on 5L Gen: elderly female, breathing rapidly and shallowly, otherwise in NAD HEENT: NCAT, PERRLA, EOMI, +proptosis, +exotropia, MMM Neck: no bruit, JVP to level of superior thyroid cartilage CV: tachy, irreg rhythm, no m/g/r Pulm: crackles B from bases to 1/2 up, diffuse rhonchi Abd: distended with hypoactive bowel sounds; tender only to deep palpation at LLQ Ext: 1+ pitting edema BLE to knees, but not grossly edematous Neuro:A&O to self, place, year; however, did not recognize examiner on return to exam room after 5 minute absence. Guiaic: neg Pertinent Results: [**2157-8-12**] 05:38PM LACTATE-1.3 [**2157-8-12**] 05:37PM CK(CPK)-85 [**2157-8-12**] 05:37PM CK-MB-2 cTropnT-0.01 [**2157-8-12**] 01:56PM TYPE-ART PO2-199* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--3 [**2157-8-12**] 12:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2157-8-12**] 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2157-8-12**] 12:20PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 RENAL EPI-<1 [**2157-8-12**] 12:20PM URINE AMORPH-OCC [**2157-8-12**] 11:46AM LACTATE-1.49 [**2157-8-12**] 11:40AM GLUCOSE-140* UREA N-48* CREAT-1.8* SODIUM-142 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-15 [**2157-8-12**] 11:40AM CK(CPK)-26 [**2157-8-12**] 11:40AM CK-MB-NotDone cTropnT-0.03* [**2157-8-12**] 11:40AM WBC-19.2*# RBC-3.56* HGB-12.0 HCT-39.2 MCV-110* MCH-33.8* MCHC-30.7* RDW-22.1* [**2157-8-12**] 11:40AM NEUTS-87 BANDS-3 LYMPHS-8 MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2157-8-12**] 11:40AM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-1+ TEARDROP-1+ [**2157-8-12**] 11:40AM PLT SMR-VERY HIGH PLT COUNT-1026*# Brief Hospital Course: Pt was admitted for obervation and control of her rapid a-fib. It was hoped that controling the a-fib would help resolve her CHF. She was started on a diltiazem drip and on HD 1 her HR began to normalize. On HD 2 pt's abdominal pain worsened and she was taken to the OR where she was found to have a possible right ovarian mass and necrotic small bowel. She underwent an exploratory laporotomy, lysis of adheasions, repair of enterotomy, resection of small bowel, and right oopherectomy. Postoperatively she was noted to have a significantly decreased urine output, and a nephrology consult was obtained. By HD3 (POD1) the pt's creatinine had increased to 3.1 from 2.1. Nephrology confirmed the diagnosis of post IV-contrast nephropathy. Pt was monitored in the SICU for the following 4 days to monitor closely her volume and renal status. It was during this time that she developed one episode of hemoptosis after her swan was wedged. The swan was removed and a CT surgery consult was obtained when a chest x-ray was read as having a possibly widened mediastienem. CT showed no abnormality and CT surgery signed off. Mrs.[**Known lastname 109877**] urine output was at this time minimally responsive to lasix, and her creatinine ultimately peaked at a value of 4.1. Mrs. [**Known lastname **] slowly improved and was moved to the floor. Her creatinine slowly dropped to a new baseline of 2.2. On POD 11 she developed diarrhea and the suspicion of repeat c.diff enterocolitis was confirmed. Pt was started on flagyl, but her white counts remained persistently elevated and a UTI of a poly resistant klebsiella grew. ID was consulted and an antibiotic regimen of vanco PO and ceftriaxone IV was initiated. On several occations, pt's PO2 dropped from the mid 90s to the high 80s, and her O2 requirement grew. These episodes occured on several nights, but seemed to be related to aspiration of thin liquids at night. A swallow study during the day demonstrated no impairment, but aspiration precautions were initiated, especially at night. Pt's WBC continued to increase and Heme-Onc was consulted to rule out transformation of her [**Last Name (NamePattern4) **] to lukemia. They confirmed that the WBCs were all mature forms, and a combination of hydroyurea and epo was started to help resolve the pt's anemia and high WBC count. The pt's wbc peaked at 57'000. It then has declined to a value of 12'200 on [**9-1**]. Heme-onc has reccommended that we continue the hydroxyurea and epo and follow cbcs with diff every four days or so. Pt ultimately was dced to rehab after her coumadin was theraputic (INR=2.9), her SaO2 was stable, her diarrhea is tapering, her CHF is much improved (now minimal crackles in b/l bases, her UTI is being adequately treated, her anemia is resolving (hct 33.9), her WBC count is normalizing (last 12.2), her heart rate is controled (80s and 90s), and her creatinine is much improved (now 2.2). She still needs to improve her caloric intake and begin physical rehab. Medications on Admission: Aranesp 200mg PO q14d Cardizem CD 240 PO qday Trazodone 25mg PO qhs Atrovent INH 2.5mLq6h PRN SOB Levoxyl 100mcg PO qam Hydrea 500mg PO qday Heparin 5000units SQ qday ASA EC 81mg PO qday Lasix 40mg PO qday Oscal 250+D 500mg po TID Allopurinol 100mg PO Qday Zocor 20mg PO qhs Thiamine 50mg PO qday Fosamax 70mg PO qday Lido 5% patch qam to lower back Bisacodyl 10mg PR PRN constipation FeSO4 325mg PO BID Lactinex 2 tabs PO BID MVI Vitamin C 500mg PO BID Insulin NPH 12 units qam, 8units qhs + sliding scale Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation q6 hrs prn as needed. Disp:*15 neb* Refills:*2* 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*2* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Tablet Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Epoetin Alfa 10,000 unit/mL Solution Sig: Four (4) ml Injection once a week. Disp:*20 ml* Refills:*2* 9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO once a day for 2 weeks. Disp:*14 Capsule(s)* Refills:*0* 10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 11. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 12. Ceftriaxone Sodium 1 g Recon Soln Sig: One (1) g Intravenous once a day for 7 days: if no IV than can give as IM shot. to give IM, recon the ceftriaxone with 2.1 mL of strerile water or lidocaine. . Disp:*7 g* Refills:*0* 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*5 Suppository(s)* Refills:*0* 14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Currently being held. Last INR 2.9 on [**9-1**]. Target INR 1.8 to 2.0 as per Dr. [**Last Name (STitle) 1365**] (Heme-Onc) . Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient [**Name (NI) **] Work Pt will need to have her INR checked to maintain a target INR of 1.8-2.0 16. Outpatient [**Name (NI) **] Work Please monitor the pt's CBC as her hydroxyuria dose was just decreased. 17. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day: We have been maintaining her on an insulin sliding scale QID for glycemic control. Disp:*5 mL* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary: small bowel necrosis, treated with lysis of adheasions and small bowel resection, c.diff colitis, UTI, post IV-contrast nephropathy, malnutrution Secondary: A-fib, CHF, DM, polycythemia [**Doctor First Name **], HTN, hypothyroidism, chronic renal insuff. incontinence Discharge Condition: stable Discharge Instructions: You may retrun to [**Hospital 100**] Rehab. You need to have two more weeks of vancomycin and one more week of ceftriaxone. You may eat a regular diet and may resume your regular activities. If you develop worsening diarrhea, fevers, chills, or pain please call the office or return to the hospital. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **]. Her phone number is [**Telephone/Fax (1) 73613**]. Please call to make an appointment. Please also follow up with Dr. [**Last Name (STitle) 2036**] at [**Hospital Ward Name **] CENTER HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2157-9-5**] 10:00 Please also follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**]. His number is: [**Telephone/Fax (1) 1300**] Completed by:[**2157-9-2**]

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icd9cm

[ [ [] ] ]

[ "46.73", "48.23", "54.59", "45.91", "89.64", "45.62", "38.93", "00.17", "65.39" ]

icd9pcs

[ [ [] ] ]

9798, 9863

3984, 7005

284, 353

10184, 10193

2740, 3961

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Discharge summary

report+addendum+addendum

Admission Date: [**2140-6-8**] Discharge Date: [**2140-6-13**] Date of Birth: [**2102-8-24**] Sex: M Service: [**Company 191**] HISTORY OF PRESENT ILLNESS: This is a 39-year-old C6-C7 quadriplegic with decubitus ulcers that are chronic, multiple urinary tract infections, who presented with fevers for three days to 102 degrees Fahrenheit, decreased p.o. intake and nausea and vomiting. He felt lightheaded and had dark urine. He wears a condom catheter. He reported a dry cough that was chronic and denied diarrhea, chest pain, shortness of breath, or palpitations. He had a visiting nurse for the decubitus ulcers until he was kicked out of his sister's house Sunday. He was febrile to 103.5 in the Emergency Department and became hypotensive to 70/35. He was given intravenous fluids and transferred to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] the patient received levofloxacin and clindamycin to cover empirically. The patient's urine did not show an acute infection and his chest x-ray was clear. Without a clear source, the antibiotics were discontinued. The patient's hypotension resolved with intravenous fluids and he was advanced on a p.o. diet. His nausea and vomiting also resolved, and he was transferred to the floor. Upon transfer to the floor the patient had no complaints, denied pain, nausea, vomiting or chills. PAST MEDICAL HISTORY: 1. Quadriplegia status post motor vehicle accident, C6-C7. 2. History of urinary tract infections. 3. Sacral decubitus ulcer since [**2135**] status post multiple debridements. 4. History of positive PPD treated with INH. 5. Neurogenic bladder and bowel. 6. History of duodenal ulcer. 7. History of substance abuse. 8. History of asthma. 9. History of impulse control disorder. MEDICATIONS: 1. Baclofen 10 mg p.o. q.i.d. 2. Valium 5 mg q. 6 hours p.r.n. 3. Dilaudid 1 mg p.o. q. 4-6 hours. 4. Combivent metered dose inhaler 2 puffs q. 4-6 hours p.r.n. 5. Tylenol 325 to 650 mg p.o. q. 4-6 hours p.r.n. ALLERGIES: Penicillin causes angioedema. Vancomycin causes a rash. Gentamicin causes hives. SOCIAL HISTORY: The patient is homeless or semihomeless, sometimes lives with his sister. [**Name (NI) **] drinks a six-pack of beer every day. He smokes half a pack of cigarettes per day for the last 25 years. He has a history of smoking cocaine and actively smokes marijuana. PHYSICAL EXAMINATION: Vital signs were temperature 101.7, heart rate 90, respiratory rate 18, blood pressure 155/84 and oxygen saturation of 96% on room air. In general he was sitting in a wheelchair in no apparent distress. His HEENT examination was normocephalic, atraumatic, extraocular movements were intact, pupils were equal, round, and reactive to light, moist mucous membranes and his oropharynx was clear. He had very poor dentition but no obvious sources of infection or pus. Neck was supple, no lymphadenopathy, neck veins were flat. Chest was clear to auscultation bilaterally. His cardiovascular examination showed a regular rate and rhythm, normal S1 and S2 without murmurs, rubs or gallops. Abdomen was distended, tympanic. He had positive bowel sounds, was nontender with no masses and no hepatosplenomegaly. His extremities showed no muscle tone, decreased bulk, scars bilaterally on his lower extremities, no edema. Neurological examination showed paralysis of bilateral lower extremities, semiparalysis of his upper extremities. He was able to move them but did not have fine motor control of his fingers. He had decreased muscle tone and bulk. On skin examination, he had bilateral scars on his lower extremities which were hypopigmented. He had a gluteal decubitus ulcer 3 cm x 3 cm x 3 cm deep with pink granulation tissue present on the outside and no pus. LABORATORY DATA: The patient's white count was 15.3, hematocrit 32.5 and platelet count 314. His ESR was 80. The patient has had multiple cultures drawn and at this point have all had no growth to date. HOSPITAL COURSE: This is a 37-year-old man with C6-7 quadriplegia and chronic right decubitus ulcers here for fever and hypotension. 1. Fever: Chest x-ray was negative. Source unknown at this time, cultures pending, suspect osteomyelitis versus a wound source from the sacral decubitus ulcers versus a GI source. Plane films were obtained of the lumbosacral spine and pelvis which did not show any obvious sources of osteomyelitis. The patient also received an MRI which was concerning for soft tissue and bony infection, but did not show any osteomyelitis, just a question of early osteomyelitis. The patient also received a triple-phase bone scan, the results of which are pending. In the hospital the patient was started on levofloxacin 500 mg p.o. q.d. to cover for an osteomyelitis or pneumonia. At the time of dictation the triple-phase bone scan results are pending. If the bone scan corroborates a source of osteomyelitis, the plan is to discontinue antibiotics and perform a CT-guided biopsy of the affected area in order to guide antibiotic therapy. If the triple-phase bone scan is negative, the patient will continue on levofloxacin for a two-week course. The patient had a consultation by infectious disease during his hospital stay, who recommended the bone scan. 2. Decubitus ulcers: The patient was seen by plastic surgery who examined and debrided his ulcer. The patient used an air mattress while in the hospital and was under the care of the wound care team. Plastic surgery recommended wet-to-dry dressings three times a day. 3. Alcohol use: The patient was placed on a CIWA scale while in the hospital. DISPOSITION: To either the [**Doctor Last Name **] House or a skilled nursing facility after the source of his fever is identified. FOLLOW-UP PLANS: The patient will follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**], after discharge. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Last Name (NamePattern1) 2706**] MEDQUIST36 D: [**2140-6-13**] 09:25 T: [**2140-6-13**] 09:42 JOB#: [**Job Number 107408**] Name: [**Known lastname 15689**], [**Known firstname **] Unit No: [**Numeric Identifier 17403**] Admission Date: [**2140-6-7**] Discharge Date: [**2140-6-17**] Date of Birth: [**2102-8-24**] Sex: M Service: ADDENDUM: This is an addendum to the previous dictation up until [**2140-6-13**]. HOSPITAL COURSE FROM [**2140-6-13**] UNTIL [**2140-6-17**]: 1. FEVER: The patient remained afebrile during this period. The Infectious Disease Service was consulted. It was recommended that the patient undergo a triple phase bone scan which was completed on [**2140-6-14**], the results of which were consistent with chronic osteomyelitis at the right ischial tuberosity. At the recommendation of the Infectious Disease Service, the Levofloxacin was discontinued pending CT guided bone biopsy which was conducted on [**2140-6-16**]. The cultures from the bone biopsy were negative at the time of this dictation. The Gram stain showed no organisms. 2. PERIPHERAL ACCESS / HYPOTENSIVE EPISODE: At 16:00 hours on [**2140-6-14**], the patient's systolic blood pressure dropped to 78/40. He was asymptomatic during this event and quickly regained his blood pressure to 100/70. Of note, the patient does have a history of labile blood pressures, however, the episode was concerning because the patient lacked peripheral access at this time; thus, a peripheral intravenous line was placed on the evening of [**2140-6-14**], and a PICC line was placed in the right antecubital fossa on [**2140-6-15**]. This PICC line was intended to be used for fluid boluses as well as eventual antibiotic treatment. 3. DECUBITUS ULCER: The CT scan guided bone biopsy of the right ischial tuberosity was performed without traversing the decubitus ulcer site. Plastic Surgery continued to follow and recommend wet-to-dry dressings three times a day. The planned skin graft for the sacral decubitus ulcer would have to be postponed until after the completion of antibiotic treatment for the chronic osteomyelitis. Meclofen 10 mg qid. 4. PAIN: The patient's pain was adequately controlled on Dilaudid 2 mg q. six. Neurontin 100 mg three times a day and Baclofen 10 mg four times a day. 5. ASTHMA: The patient was placed on Albuterol and Combivent and was breathing at 97% on room air without any wheezes. 6. THROMBOCYTOSIS: The patient's thrombocytosis was thought to be secondary to acute phase reactant versus alcohol withdrawal. 7. ACCESS: The patient had a PICC line placed on [**2140-6-15**]. 8. ANEMIA: The patient's anemia was felt to be chronic and should be worked up as an outpatient. DISPOSITION: At this time, the patient will most likely be discharged to Star of [**Doctor Last Name **] Skilled Nursing Facility. Antibiotics are being held at this point until the cultures grow out specific organisms for which we can target treatment. An additional dictation summary will follow. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 872**] Dictated By:[**Last Name (NamePattern1) 3139**] MEDQUIST36 D: [**2140-6-17**] 16:13 T: [**2140-6-17**] 18:29 JOB#: [**Job Number 17538**] Name: [**Known lastname 15689**], [**Known firstname **] Unit No: [**Numeric Identifier 17403**] Admission Date: [**2140-6-7**] Discharge Date: [**2140-6-20**] Date of Birth: [**2102-8-24**] Sex: M Service: This addendum will cover the hospital course from [**2140-6-18**] to [**2140-6-20**]. 1. Labile blood pressure: The patient was hypotensive to systolic blood pressure in the 80s x1. He was bolused with 500 cc of normal saline and quickly returned to a systolic blood pressure over 100. He had a history of labile blood pressure secondary to paraplegia, and has never been symptomatic from these brief episodes. The patient had not had any other hypotensive episodes since this time. 2. Chronic osteomyelitis: Infectious Disease consult recommended levofloxacin 500 mg IV q day and metronidazole 500 mg IV tid for a [**3-6**] week course. He has a PICC line, which was replaced on [**2140-6-19**]. Patient will follow up with [**Hospital **] Clinic (Dr. [**Last Name (STitle) 17539**] on [**2140-7-17**], [**Telephone/Fax (1) 496**]. Laboratories: Gram stain as of [**2140-6-16**] tissue, bone fragments, no microorganisms seen, 2+ PMNs. Tissue showed no growth. Anaerobic cultures showed no growth. The acid-fast culture was negative. The AFB smear was negative. Blood cultures showed no growth and a Gram stain was negative. 3. Decubitus ulcer: [**Hospital1 **] wet-to-dry dressings were continued. Plastic Surgery had the patient scheduled for a skin flap graft on [**2140-6-30**] by Dr. [**Last Name (STitle) 2023**]. His phone number is [**Telephone/Fax (1) 7811**]. The patient is advised to call ahead 1-2 days in advance. 4. Pain: Dilaudid 1 mg subQ with dressing changes. Dilaudid 2 mg qid prn, Neurontin 100 mg tid for neuropathic pain, Baclofen 10 mg qid prn. 5. Asthma: This has been stable on albuterol, Combivent. 6. Smoking: The patient was counseled regarding smoking cessation. DISCHARGE MEDICATIONS: 1. Baclofen 10 mg one tablet po tid for muscle spasms as needed. 2. Diazepam 5 mg one tablet po q6h prn. 3. Wellbutrin 150 mg tablet one po bid. 4. Ferrous sulfate 325 mg tablet one po q day. 5. Albuterol 0.83 mg/mL solution one puff q6h prn. 6. Albuterol sulfate/ipratropium 103-18 mcg aerosol with adapter 1-2 puffs q6h prn. 7. Hydromorphone 2 mg/mL dispensed syringe one injection q6h prn with dressing changes. 8. Heparin 500 units subcutaneous q12h for DVT prophylaxis. 9. Famotidine 20 mg tablet one po bid. 10. Gabapentin 100 mg capsule one po tid prn. 11. Nicotine patch/nicotine gum one buccal q1h prn. 12. Metronidazole 500 mg IV q8h through PICC line, duration six weeks. 13. Levofloxacin 500 mg IV q day, duration six weeks. 14. Hydromorphone 2 mg tablet po q6h. FOLLOWUP: 1. The patient is advised to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 6696**] within one week of leaving the hospital. 2. The patient is advised to followup with his plastic surgeon, Dr. [**Last Name (STitle) 2023**] and advance to a skin flap operation on [**2140-6-30**], [**Telephone/Fax (1) 7811**]. 3. Patient has an appointment with Dr. [**First Name4 (NamePattern1) 2368**] [**Last Name (NamePattern1) 15813**] on [**2140-7-15**] at 11 am in the Riseman Building at [**Telephone/Fax (1) 496**]. DISCHARGE INSTRUCTIONS: The patient is advised to call 911 or go to the nearest Emergency Room if chest discomfort, shortness of breath, palpitations, night sweats, or fevers, signs of infection would be redness, swelling, pus, or pain at the PICC line or over the sacral decubitus ulcer. These should be reported to Dr. [**Last Name (STitle) **] immediately. Patient is advised to take all medications as prescribed. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 872**] Dictated By:[**Last Name (NamePattern1) 3139**] MEDQUIST36 D: [**2140-7-27**] 09:46 T: [**2140-7-27**] 09:46 JOB#: [**Job Number 17540**]

[ "344.04", "730.15", "493.90", "707.0", "276.5", "285.9" ]

icd9cm

[ [ [] ] ]

[ "86.28", "38.93", "77.49" ]

icd9pcs

[ [ [] ] ]

11420, 12776

4030, 5788

12801, 13468

2432, 4012

5806, 11397

177, 1391

1414, 2126

2143, 2409

14,522

118,577

31025

Discharge summary

report

Admission Date: [**2200-6-1**] Discharge Date: [**2200-6-10**] Date of Birth: [**2137-5-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Shortness of breath w/ Resp. failure and PEA arrest Major Surgical or Invasive Procedure: [**2200-6-3**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to OM, SVG to Diag, SVG to PDA) [**2200-6-1**] Cardiac Catherization History of Present Illness: 63M with hx of CAD (no stents), PVD, DM, HTN who presents with resp failure and PEA arrest. Per pt's wife, he complained of acute onset of shortness of breath at home. He did not complain of any chest pain or palpitations. She gave him inhalers which did not help him and so she called EMS. When EMS arrived, pt became unresponsive and pulseless. On rhythm strip, he was in PEA. He was intubated in the field and his pulse returned. Pt was initially taken to [**Hospital6 3105**] where he was noted to have 1mm ST depressions in II, III and aVF and 2mm ST depressions in V4-V6. He was given lopressor, lasix and started on nitro and heparin drips. He was then transferred to the [**Hospital1 18**] ER. He was taken initially to the CCU and then to the cath lab where he was found to have 3-vessel disease. Past Medical History: Coronary Artery Disease, Respiratory failure and PEA arrest (prior to admission), Hypertension, Diabetes Mellitus, Hypercholesterolemia, Stroke [**2-22**] yrs ago, Peripheral Vascular Disease, Psoriasis, s/p Left CEA Social History: Social history is significant for the absence of current tobacco use but pt smoked 1ppd x 50 years, quit in [**2199**] after stroke. There is history of heavy alcohol abuse, quit 20 years ago. Family History: Pt has strong family history of CAD. He has 16 brothers and sister, all of whom have CAD and DM. His mother died suddenly of heart attack while dancing at age of 59. Two of his brothers died in their early 60s of heart disease. Pertinent Results: [**2200-6-10**] 06:25AM BLOOD WBC-6.8 RBC-2.55* Hgb-8.2* Hct-24.0* MCV-94 MCH-32.2* MCHC-34.2 RDW-15.0 Plt Ct-341 [**2200-6-8**] 01:50PM BLOOD WBC-5.0 RBC-2.48* Hgb-8.0* Hct-23.4* MCV-94 MCH-32.2* MCHC-34.2 RDW-14.8 Plt Ct-254 [**2200-6-1**] 04:10AM BLOOD WBC-12.8* RBC-4.42* Hgb-14.5 Hct-42.4 MCV-96 MCH-32.9* MCHC-34.3 RDW-14.8 Plt Ct-184 [**2200-6-10**] 06:25AM BLOOD Plt Ct-341 [**2200-6-4**] 03:45AM BLOOD PT-13.1 PTT-30.4 INR(PT)-1.1 [**2200-6-1**] 04:10AM BLOOD Plt Ct-184 [**2200-6-1**] 04:10AM BLOOD PT-14.1* PTT-118.6* INR(PT)-1.2* [**2200-6-1**] 04:10AM BLOOD Fibrino-230 [**2200-6-9**] 06:40AM BLOOD UreaN-29* Creat-1.4* K-4.8 [**2200-6-10**] 06:25AM BLOOD Glucose-159* UreaN-28* Creat-1.5* Na-137 K-5.3* Cl-102 HCO3-22 AnGap-18 [**2200-6-1**] 11:04PM BLOOD Glucose-201* UreaN-27* Creat-1.4* Na-142 K-3.6 Cl-104 HCO3-25 AnGap-17 [**2200-6-2**] 06:25AM BLOOD ALT-25 AST-20 AlkPhos-33* Amylase-84 TotBili-0.5 [**2200-6-1**] 12:30PM BLOOD CK(CPK)-317* [**2200-6-2**] 06:25AM BLOOD Lipase-25 [**2200-6-2**] 06:25AM BLOOD CK-MB-7 cTropnT-0.02* [**2200-6-1**] 12:30PM BLOOD Triglyc-100 HDL-60 CHOL/HD-3.5 LDLcalc-127 [**2200-6-1**] 04:10AM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG RADIOLOGY Final Report CHEST (PA & LAT) [**2200-6-9**] 8:28 AM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 63 year old man s/p CABG REASON FOR THIS EXAMINATION: evaluate effusion HISTORY: 63-year-old man status post CABG. COMPARISON: [**2200-6-7**]. CHEST, PA AND LATERAL: Cardiac, mediastinal and hilar contours are stable status post median sternotomy and CABG. Pulmonary vasculature is unremarkable. Bilateral mid and lower lung linear atelectasis is unchanged. The small left pleural effusion is stable. No right effusion is identified. Osseous and soft tissue structures are unchanged. IMPRESSION: Stable appearance of the chest with linear atelectasis and small left pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 5004**] THAM DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: MON [**2200-6-9**] 4:37 PM RADIOLOGY Final Report BILAT LOWER EXT VEINS [**2200-6-8**] 3:55 PM BILAT LOWER EXT VEINS Reason: PAIN AND SWELLING [**Hospital 93**] MEDICAL CONDITION: 63 year old man with possilble DVT REASON FOR THIS EXAMINATION: r/o DVT INDICATION: Possible DVT. COMPARISON: None. FINDINGS: Grayscale and color Doppler images of the common femoral, superficial femoral, and popliteal veins were performed bilaterally. Normal compressibility, augmentation, flow, waveforms are demonstrated. No intraluminal thrombus is identified. Approximately 2.5 x 1.1 cm superficial hypoechoic collection in the left calf traverses the entire length of the inner calf and likely represents a postsurgical hematoma. IMPRESSION: 1. No evidence of DVT. 2. Left calf hematoma. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] Approved: MON [**2200-6-9**] 12:56 PM Cardiology Report ECG Study Date of [**2200-6-3**] 12:44:44 PM Sinus rhythm Left ventricular hypertrophy Diffuse nonspecific ST-T wave abnormalities with prolonged Q-Tc interval - may be due in part to left ventricular hypertrophy but clinical correlation is suggested Since previous tracing of [**2200-6-2**], QT-c interval appears prolonged Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 90 130 88 [**Telephone/Fax (2) 73288**] 59 0 Cardiology Report ECHO Study Date of [**2200-6-3**] PATIENT/TEST INFORMATION: Indication: Intra-op TEE for CABG Height: (in) 62 Weight (lb): 140 BSA (m2): 1.64 m2 Status: Inpatient Date/Time: [**2200-6-3**] at 08:52 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW01-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.3 cm (nl <= 4.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *5.9 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.9 cm Left Ventricle - Fractional Shortening: *0.17 (nl >= 0.29) Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 2.8 cm (nl <= 3.4 cm) Aorta - Arch: 2.5 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Moderate (2+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally post-bypass data Conclusions: PRE-BYPASS: 1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid inferior, infero septal walls, lateral apical walls. Overall left ventricular systolic function is mildly depressed. 3. Right ventricular chamber size and free wall motion are normal. 4. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly thickened. High mild to moderate/borderline Moderate ([**1-21**]+) mitral regurgitation is seen. The jet is central with a 2-4 mm vena contracta. Pulmonary vein flow Pattern is normal. POST-BYPASS: 1. Perserved biventricular function with slight improvement in inferior wall function. LVEF 40-45% 2. Mitral regurgitation is now moderate (2+) 3. There is now mild tricuspid regurgitation. 4. Aortic Contours are intact. 5. Remaining exam is unchanged. 6. All findings discussed with surgeons at the time of the exam. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2200-6-5**] 18:30. [**Location (un) **] PHYSICIAN: RADIOLOGY Final Report CAROTID SERIES COMPLETE [**2200-6-2**] 4:15 PM CAROTID SERIES COMPLETE Reason: degree of stenosis [**Hospital 93**] MEDICAL CONDITION: 63 year old man with known carotid stenosis w/ Left CEA, now with 3VD to go to CABG REASON FOR THIS EXAMINATION: degree of stenosis CAROTID SERIES COMPLETE REASON: Carotid stenosis. FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaques identified. On the right, peak systolic velocities are 90, 78, 78 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.1. This is consistent with less than 40% stenosis. On the left, peak systolic velocities are 110, 106, 73 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This is consistent with less than 40% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: [**Doctor First Name **] [**2200-6-5**] 1:35 PM Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was admitted from OSH and underwent a cardiac cath on day of admission which revealed severe three vessel disease. He underwent usual pre-operative work-up and on [**6-3**] was brought to the operating room where he underwent a coronary artery bypass graft x 4. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. He required blood transfusion initially for low HCT. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. His chest tubes were removed on post-op day two and he was started on beta blockers and diuretics. He was gently diuresed towards his pre-op weight throughout his hospital course. Later on post-op day two he was transferred to the telemetry floor for further care. His epicardial pacing wires were removed on post-op day three. He continued to improve and worked with physical therapy for strength and mobility. On post-op day seven he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Plavix 75mg qd, Zocor 80mg qd, Soriatane 25mg qd (anti-psoriatic), Avandia 4mg [**Hospital1 **], Metformin 1000mg [**Hospital1 **], Toprol XL 100mg qd, Enalapril 20mg [**Last Name (LF) **], [**First Name3 (LF) **] 81mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 4. 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* 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Soriatane 25 mg Capsule Sig: One (1) Capsule PO once a day. 8. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 14. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day for 5 days. Disp:*5 Tablet Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Respiratory failure and PEA arrest (prior to admission) PMH: Hypertension, Diabetes Mellitus, Hypercholesterolemia, Stroke [**2-22**] yrs ago, Peripheral Vascular Disease, Psoriasis, s/p Left CEA 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 101.5. 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. 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 [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] please call to schedule Dr. [**First Name (STitle) 13469**] in [**1-21**] weeks [**Telephone/Fax (1) 73289**] please call to schedule Cardiologist in [**2-22**] weeks please call to schedule Wound check [**Hospital Ward Name 121**] 2 please schedule with RN Completed by:[**2200-6-11**]

[ "518.81", "401.9", "414.01", "V15.82", "428.0", "443.9", "410.71", "250.00", "V17.3", "998.89", "780.6", "424.0" ]

icd9cm

[ [ [] ] ]

[ "36.15", "99.04", "36.13", "96.71", "89.60", "37.23", "88.56", "39.61" ]

icd9pcs

[ [ [] ] ]

13636, 13711

10664, 11731

372, 508

14011, 14017

2057, 3411

14759, 15117

1809, 2038

12003, 13613

9722, 9806

13732, 13990

11757, 11980

14041, 14736

5882, 9522

281, 334

9835, 10641

536, 1343

9558, 9685

1365, 1583

1599, 1793

28,292

147,132

2466

Discharge summary

report

Admission Date: [**2152-7-28**] Discharge Date: [**2152-8-10**] Date of Birth: [**2089-11-17**] 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: [**2152-7-31**] Cardiac catheterization [**2152-8-4**] Aortic valve replacement with a 23 mm [**Doctor Last Name **]-Magna bioprosthetic valve, Coronary bypass grafting x 4 (LIMA to LAD, SVG to Diag1, SVG to OM1 to OM3) History of Present Illness: Mr. [**Known lastname 12638**] is a 62 year old male with remote history of MI (in setting of cocaine abuse), HTN, hyperlipidemia, ESRD on HD, Hep C with Stage IV liver fibrosis, s/p L exostectomy, ulcer excision and bone stimulator removal ([**2152-7-18**]) presented from rehab due to chest pain and worsening shortness of breath. He was transferred from the [**Location (un) 931**] House to [**Location (un) **] ED where he was found to have a BNP of 1594, but no ST segment changes on EKG. His 1st troponin was 0.26 and the 2nd was 4.16 so he was started on IV heparin. He was then transferred directly to the cath lab at [**Hospital1 18**]. Past Medical History: Type 2 DM: + Nephropathy leading to ESRD on HD (M,W,F) -S/P L forearm AV fistula, [**6-12**] CAD, s/p MI in his mid40's secondary to cocaine use Hypertension Hypercholesterolemia Hepatitis C with stage IV liver fibrosis Diabetic Neuropathy (bilateral symmetric polyneuropathy) Charcot arthropathy - S/P left Charcot debridement - S/P right Charcot arthrodesis S/P bilateral fourth toe amputation S/P multiple foot ulcers Social History: Currently residing in [**Location (un) 931**] House rehab facility secondary to foot surgeries. Denies tob/drugs currently; he smoked previously but quit 15 years ago. He occasionally drinks ETOH every 2-3 weeks and previously drank heavily Family History: Brother with MI, unclear age of onset heart disease Physical Exam: VS: T 100.1, BP 126/77, HR 87, RR 32, O2 98% on NRB, 88% on room air Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8 cm. CV: RR, normal S1, S2. Loud, harsh systolic murmur at RUSB. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Breath sounds were decreased throughout anteriorly. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: fistula in left forearm. No c/c/e. No femoral bruits. Has left foot covered in bandage. Skin: decreased hair pattern on lower extremities Pulses: Right: Carotid 2+ without bruit; Femoral 1+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 1+ without bruit Pertinent Results: [**7-31**] Cath: 1. Selective coronary angiography of this right dominant system demonstrated 3 vessel coronary artery disease. The LMCA had 60-70% distal stenosis. The LAD had 80% mid and diffuse distal disease. The ostia of the LCx had 80% stenosis. The RCA had mild disease. 2. Resting hemodynamic measurement demonstrated an elevated systemic arterial pressure of 176/67 mmHg. The left sided filling pressure was mildly elevated with an LVEDP of 23 mmHG. Simultaneous measurement of the systemic arterial pressure and the LVESP revealed a 16 mmHg pressure gradient across the aortic valve. [**7-31**] Carotid U/S: There is a 1-39% right ICA stenosis and a 1-39% left ICA stenosis with antegrade flow in both vertebral arteries [**8-4**] Echo: Pre bypass: A small secundum atrial septal defect is present. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). There is mild global right ventricular free all hypokinesis. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild to moderate ([**1-11**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Post bypass: Patient is being AV paced and receiving an infusion of epinephrine and phenylephrine. Biventricular systolic function is improved- EF 45%. Bioprosthetic valve seen in the aortic position. The leaflets move well and the valve appears well seated. There is no aortic insufficiency and the peak gradient across the valve is 99 mm Hg. Mild mitral regurgitation present. Aorta intact post decannulation. [**2152-8-10**] 05:52AM BLOOD WBC-6.4 RBC-2.72* Hgb-8.0* Hct-23.8* MCV-88 MCH-29.6 MCHC-33.8 RDW-16.2* Plt Ct-183 [**2152-8-9**] 06:56AM BLOOD WBC-6.9 RBC-2.81* Hgb-8.4* Hct-24.5* MCV-87 MCH-29.8 MCHC-34.2 RDW-16.4* Plt Ct-173 [**2152-8-10**] 05:52AM BLOOD Plt Ct-183 [**2152-8-8**] 02:39AM BLOOD PT-13.6* PTT-27.5 INR(PT)-1.2* [**2152-8-10**] 05:52AM BLOOD Glucose-84 UreaN-37* Creat-5.9*# Na-139 K-4.4 Cl-100 HCO3-29 AnGap-14 [**2152-8-7**] 02:13AM BLOOD ALT-14 AST-29 AlkPhos-78 TotBili-0.5 Brief Hospital Course: Mr. [**Known lastname 12638**] was admitted to the [**Hospital1 18**] on [**2152-7-28**] for further management of his myocardial infarction. He continued on heparin, plavix, apirin, beta blockade and nitroglycerin which kept him free of chest pain. He underwent a cardiac catheterization on [**2152-7-31**] which revealed left main and severe two vessel disease. Given the severity of his disease, the cardiac surgical service was consulted for surgical management. Mr. [**Known lastname 12638**] was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed a 1-39% bilateral internal carotid artery stenosis. The hepatology service was consulted for risk assessment given his current hepatitis C cirrhosis and his surgical risk was deemed low. A dental consult was obtained for oral clearance for surgery. The renal service was consulted given his renal failure. Hemodialysis was continued. After completing an exam and obtaining a panorex film, Mr. [**Known lastname 12638**] was cleared from an oral standpoint for surgery. Heparin and plavix were discontinued in preparation for surgery however on [**2152-8-2**], Mr. [**Known lastname 12638**] developed chest pain with with EKG changes. He was returned to the catheterization lab for the possibility of placement of an IABP. As his discomfort resolved and his pressures were stable, a ballon pump was not utilized. Heparin and nitroglycerin were resumed. The podiatry service was consulted given his left foot exostectomy with ulcer excision and bone stimulator removal. Unasyn was recommended after dialysis to complete three weeks. On [**2152-8-4**], Mr. [**Known lastname 12638**] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels and an aortic valve replacement using a 23mm [**Doctor Last Name **]-Magna bioprosthetic valve. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. Hemodialysis was resumed by the renal service as it was preoperatively, however was unable to remove fluid secondary to hypotension. He was transfused 2 units. He was extubated on POD #2. His hemodynamics improved, his vasoactive drips were weaned and HD was continued.He was transferred to the floor on POD #3. He progressed well and was ready for discharge to rehab on POD #5. Medications on Admission: MEDS ON TRANSFER: heparin gtt, nitrostat SL prn, procardia XL 90 mg daily, cinacalcet 30 mg daily, sevelamer 800 mg TID, nexium 40 mg daily, lisinopril 5 mg daily, ativan 1 mg Q8H prn, flexeril 5 mg TID prn, compazine 10 mg Q6H prn, ambien 5 mg QHS prn, indocin 50 mg Q8H prn, percocet 5/325 mg q4h prn, aspirin 325 mg daily, Nitropaste, insulin sliding scale . CURRENT HOME MEDICATIONS: procardia 90 mg daily, ativan 1 mg q8h prn, cinacalcet 30 mg daily, lisinopril 5 mg daily, colace/senna, trazadone 25 mg QHS, protonix 40 mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Units Injection ASDIR (AS DIRECTED). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Myocardial Infarction, End stage renal disease on HD (s/p left forearm AV fistula), Hepatitis C with Stage IV hepatic fibrosis, Hypertension, Hyperlipidemia, Diabetes Mellitus, Peripheral Neuropathy, Charcot arthropathy s/p left charcot debridement and right charcot athrodesis, s/p bilaterl fourth toe amputation, s/p multiple foot ulcers 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. 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) Continue hemodialysis as instructed. 8) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with cardiologist Dr. [**Last Name (STitle) 6174**] in [**1-11**] weeks. [**Telephone/Fax (1) 12639**] Dr. [**First Name (STitle) **] (pcp) in [**2-12**] weeks at [**Telephone/Fax (1) 250**] Call all providers for appointments. Completed by:[**2152-8-10**]

[ "410.71", "412", "V17.3", "250.60", "571.5", "585.6", "272.4", "276.7", "070.54", "424.1", "V49.72", "414.01", "403.91", "285.21", "250.40", "428.30", "428.0", "357.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "37.21", "88.56", "37.22", "35.21", "36.15", "36.13", "38.93", "89.60", "39.61" ]

icd9pcs

[ [ [] ] ]

9232, 9346

5322, 7664

332, 553

9836, 9842

2930, 5299

10596, 10947

1948, 2001

8249, 9209

9367, 9815

7690, 7690

9866, 10573

2016, 2911

8078, 8226

282, 294

581, 1229

1251, 1674

1690, 1932

7708, 8060

20,201

142,678

16252

Discharge summary

report

Admission Date: [**2111-1-28**] Discharge Date: [**2111-2-27**] Date of Birth: [**2039-7-9**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is a 71-year-old gentleman who was admitted to the [**Hospital6 649**] as a transfer from the [**Hospital6 46354**]. Prior to admission, he had a long and complicated hospital course at the outside hospital. His hospital course began on [**2111-1-8**] when he underwent a right carotid endarterectomy for 95% stenosis of the carotid artery. His postoperative course was complicated by nonspecific T wave changes consistent with myocardial infarction postoperatively as well as hematoma formation. The hematoma formation was rapidly expanding and he received an emergent surgical airway in the Intensive Care Unit. This emergent cricothyroidotomy was converted then to a formal tracheostomy. During his subsequent hospital course, he had an additional CHF exacerbation. He was medically managed and eventually his tracheostomy was decannulated. However, just prior to admission to [**Hospital6 256**] he had another acute decompensation with CHF exacerbation. This necessitated emergent intubation. With EKG changes consistent with myocardial infarction, he was transferred to the [**Hospital6 256**] for further management. PAST MEDICAL HISTORY: 1. Diabetes type 2 treated with oral medication. 2. Cerebrovascular disease, status post left carotid endarterectomy in [**2105**]. 3. Status post right cerebrovascular accident in [**2106**] with residual left-sided weakness. 4. Status post right carotid endarterectomy on [**2111-1-8**]. 5. Fall from standing on [**2110-12-24**] with resultant displaced radial fracture which was reduced, closed, and casted. 6. Hypertension. 7. Coronary artery disease. No history of catheterization prior to admission to the [**Hospital6 2018**]. 8. Chronic renal insufficiency with a baseline creatinine of 2.0 to 2.7. MEDICATIONS ON TRANSFER THE [**Hospital1 18**]: 1. Lovenox 1 mg per kilogram subcutaneously b.i.d. 2. Aspirin 81 mg p.o. q.d. 3. Lopressor 50 mg p.o. b.i.d. 4. Lansoprazole 30 mg p.o. q.d. 5. Regular insulin sliding scale. 6. Captopril 6.25 mg q.i.d. 7. Lasix drip at 2 per hour. 8. Versed drip. 9. TPN. PHYSICAL EXAMINATION ON ADMISSION: This is a gentleman who is intubated, comfortable, with minimal sedation. He was afebrile with a temperature of 99.1. His pulse was in the 70s, blood pressure 119/58. He was breathing 12 per minute and saturating 98%. His CVP is ranging from [**6-21**]. He was intubated and has a nasogastric tube. His neck has a well-healed right carotid endarterectomy scar. There is also a well-healing tracheostomy scar. The lungs were clear to auscultation bilaterally. The heart was regular with an S1 and S2. The abdomen was soft, nontender, nondistended with normoactive bowel sounds. The extremities were without edema. The left arm was in a cast. HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the CCU at the [**Hospital6 256**]. Upon admission, he was treated for his pneumonia. He was medically managed for CHF and underwent a cardiac catheterization on [**2111-1-29**]. His catheterization revealed 70% stenosis of the distal left main coronary artery, 90% stenosis of the LAD, 80% stenosis of the circumflex, 90% stenosis of OM2 and a proximally occluded right coronary artery. After reviewing cardiac catheterization data, a consultation was made with Cardiothoracic Surgery who deemed that he was a good candidate for coronary artery bypass grafting. Over the ensuing days, Mr. [**Known lastname **] CHF was managed by the CCU Team and he received treatment for what was now determined to be a Klebsiella pneumonia. He was treated with a full course of Zosyn. On [**2111-2-3**], Mr. [**Known lastname **] went to the Operating Room with Dr. [**Last Name (STitle) 1537**]. He underwent a coronary artery bypass graft of four vessels. He had a saphenous vein graft to his LAD and diagonal in a sequential fashion, saphenous vein graft to his PDA and a saphenous vein graft to his OM. The procedure was performed by Dr. [**Last Name (STitle) 1537**] and assisted by Dr. ..................... The patient tolerated the procedure well without complication and was transferred to the Cardiac Surgery Recovery Unit without complication. Please see the previously dictated operative note for more details. Mr. [**Known lastname **] had a long postoperative course. His postoperative course was complicated by hypertension which was managed medically. During his postoperative course, he did not suffer from any arrhythmias nor did he have any episode of hypotension. At the time of discharge, he was on a stable antihypertensive regimen appropriate for someone with a decreased ejection fraction. Mr. [**Known lastname **] had had a long protracted period of intubation prior to the operation. The status of Mr. [**Known lastname **] pulmonary system necessitated a prolonged postoperative intubation. After a very slow wean from ventilatory support, Mr. [**Known lastname **] was successfully extubated on postoperative day number nine. He continued to be very tenuous from a pulmonary point of view and required frequent chest PT. For this reason, Mr. [**Known lastname **] was kept in the Intensive Care Unit where very close monitoring could be performed. In addition, he had chest PT performed at very regular intervals by the ICU staff. His pulmonary status was so tenuous that we were unable to transfer him to the regular patient care floor during his hospitalization. Mr. [**Known lastname **] had an emergent cricothyroidotomy followed by a formal tracheostomy at the outside hospital. There is much scarring surrounding his larynx. Such a situation frequently makes it very difficult to swallow without aspirating. As is expected, Mr. [**Known lastname **] failed a swallowing study early on in his [**Hospital 46355**] hospital course. The study was repeated and yet again Mr. [**Known lastname **] was unable to swallow without evidence of aspiration. After a prolonged period of being fed via nasogastric tube, Mr. [**Known lastname **] finally had a formal percutaneous endoscopic gastrostomy tube placed in the Intensive Care Unit. This was performed on [**2111-2-24**], postoperative day number 21. This procedure was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 954**] and assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The procedure was performed under endoscopic guidance in the Intensive Care Unit without complication. Please see the previously dictated operative note for more details. Mr. [**Known lastname **] [**Last Name (Titles) 18095**] a distal radius fracture prior to arriving to the hospital. This injury had been reduced and casted at the outside institution. Postoperatively, there was much edema associated in the postoperative course from coronary artery bypass grafting. His cast was removed by the Orthopedic Service in anticipation of this edema and to avoid compartment syndrome. The cast was replaced by a plaster splint. Mr. [**Known lastname **] should follow-up with his orthopedic surgeon in the [**Hospital1 **] for reassessment of his injury and possible removal of the splint. By postoperative day number 23, Mr. [**Known lastname **] pulmonary status was deemed sufficiently stable. His hypertension was well controlled and he was tolerating tube feeds. At this point, he was ready to be discharged to rehabilitation. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post coronary artery bypass graft, four vessels. 2. Congestive heart failure. 3. Klebsiella pneumonia. 4. Failed swallow study status post percutaneous endoscopic gastrostomy tube placement. 5. Central line culture positive for coagulase-negative Staphylococcus aureus, status post a 14 day treatment with vancomycin and removal of the line. MEDICATIONS ON DISCHARGE: 1. Methylphenidate 5 mg p.o. q.d. 2. Lasix 40 mg p.o. b.i.d. 3. Captopril 50 mg p.o. t.i.d. 4. Glyburide 10 mg p.o. b.i.d. 5. Miconazole powder 2%, apply q.i.d. p.r.n. 6. Paxil 20 mg p.o. q.d. 7. Albuterol nebulizer solution one nebulizer q. four hours. 8. Metoprolol 100 mg p.o. t.i.d. 9. Heparin 5,000 units subcutaneously q. 12 hours. 10. Amlodipine 5 mg p.o. b.i.d. 11. Percocet one to two tablets p.o. q. four hours p.r.n. pain. 12. Colace 100 mg p.o. b.i.d. 13. Aspirin 325 mg p.o. q.d. 14. Tube feedings; Mr. [**Known lastname **] is to be discharged on tube feeds, Promote, with fiber full-strength at 80 cc per hour around the clock. His PEG tube should be flushed with 30 cc of water after every use. ACTIVITY: Mr. [**Known lastname **] activity is ad lib. He is also to be strict n.p.o. He should be n.p.o. until he has a repeat swallow evaluation which demonstrates his ability to swallow without aspiration. FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1537**] in his office in four to six weeks. The patient should follow-up with his primary care physician within one week. The patient should follow-up with his orthopedic surgeon at the next convenient time to determine the length of duration of his casting. CONDITION ON DISCHARGE: Stable. PHYSICAL EXAMINATION ON DISCHARGE: Mr. [**Known lastname **] is afebrile with a temperature of 97.1, pulse 77, sinus rhythm. His blood pressure was 142/68, breathing 21 breaths per minute, 94% on 2 liters nasal cannula. His pupils were equal, round, and reactive. Extraocular muscles intact. His head was normocephalic, atraumatic. The lungs were clear to auscultation bilaterally. The heart revealed a regular rate and rhythm. The abdomen was soft, nontender, nondistended. He had a PEG tube in his left upper quadrant. The site was clean and dry. There was no evidence of necrosis, erythema or exudate at the site. The extremities were warm and well perfuse. There was trace edema in both lower extremities. His right lower extremity has ecchymosis related to a saphenectomy site. This ecchymosis is much improved from previous examinations. There was no increased warmth over this area nor is there any exudate from his wounds. All of his wounds including sternotomy wound were clean, dry, and intact. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 6355**] MEDQUIST36 D: [**2111-2-27**] 02:23 T: [**2111-2-27**] 15:35 JOB#: [**Job Number 46356**]

[ "996.62", "250.00", "414.01", "428.0", "997.3", "511.9", "410.71", "482.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.14", "39.61", "37.23", "38.93", "88.56", "34.04", "96.04", "96.72", "43.11", "45.13", "96.6" ]

icd9pcs

[ [ [] ] ]

7635, 8018

8044, 9312

2989, 7614

9381, 10648

2317, 2971

1349, 2302

9336, 9366

17,008

161,167

4441

Discharge summary

report

Admission Date: [**2107-11-16**] Discharge Date: [**2107-11-18**] Date of Birth: [**2063-8-24**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Ceclor Attending:[**First Name3 (LF) 1148**] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: EGD on [**2107-11-17**]. History of Present Illness: Patient is a 44 year old female with history of duodenal bulb strictures (peptic) status post multiple dilations every few months since [**2106-12-7**]. She had a dilatation on [**11-15**] via endoscopic balloon to 18mm. At home, the same day, while recovering patient felt nauseous and went to sleep. She awoke at 11pm with liquid bowel movement that was dark red with frank blood. Had a similar episode at 3am on [**11-16**]. She had four more episodes of diarrhea and felt slightly dizzy. She finally called her GI doctor on afternoon of [**11-16**] and told to come to ED. Hematocrit was 34.4 in ED (baseline 37-38). She related increased abdominal discomfort, that was out of proportion to her usual abdominal discomfort following previous dilations. CT abdomen on [**11-16**] did not reveal any free air in diaphragm. She denied fever and endorsed minimal PO intake. She was transferred to the MICU. Although hemodynamically stable, her abdomen was diffusely tender and she had guiaic positive dark stool. Her hematocrit continued to trend down to 30. EGD on [**11-17**] revealed a mucosal tear in the duodenal bulb. [**Hospital1 **]-CAP electrocautery applied and hemostasis successful. Patient transferred to medicine on night of [**11-17**]. Past Medical History: - Status post cholecystectomy in [**2087**]: post cholecystectomy syndrome with biliary type pain requiring multiple ERCPs and stenting in the past. - Status post appendectomy in [**2089**] - Back surgeries on two occasions:[**2091**] and [**2092**] - Benign parotid gland tumor - Laparoscopies: diagnosis of endometriosis. - Hypertension Social History: Married with four children. Smokes a half a pack of cigarettes a day. Denies any alcohol or IVDU. Works part-time for a nursing agency. Family History: - Mother is alive and has hypertension, hypercholesterolemia and osteoporosis. - Father has a history of hypertension. - She has two female siblings, one of whom has hypothyroidism and two, healthy male siblings. Physical Exam: On acceptance to Medical Floor: Vitals: T 99.2 BP:144/80 HR:72 RR:18 O2sat: 97% room air General: Pleasant. Cooperative. Alert and oriented to person, place, date. HEENT: MMM. No conjunctival pallor. No scleral icterus. PERRLA. EOMI. Neck: No cervical lymphadenopathy. Well healed surgical incision on right side. No thyroid nodules appreciated. CV: RRR. Normal S1 and S2. No M/R/G. Chest: Clear to auscultation, bilaterally. No crackles or wheezes. Abdomen: Multiple well healed surgical incisions. Tender to deep palpation in upper right quadrant. Soft and active bowel sounds throughout. No guarding. No rebound tenderness. Ext: Warm and well perfused. No clubbing. No edema. 2+ bilateral radial pulses, bilaterally. Pertinent Results: [**2107-11-18**] 01:55PM BLOOD WBC-10.6 RBC-3.60* Hgb-11.4* Hct-31.3* MCV-87 MCH-31.7 MCHC-36.4* RDW-14.7 Plt Ct-242 [**2107-11-18**] 06:05AM BLOOD WBC-9.7 RBC-3.53* Hgb-10.6* Hct-31.6* MCV-90 MCH-30.1 MCHC-33.7 RDW-14.7 Plt Ct-223 [**2107-11-17**] 02:45AM BLOOD WBC-9.9 RBC-3.41* Hgb-10.5* Hct-30.6* MCV-90 MCH-30.9 MCHC-34.4 RDW-14.6 Plt Ct-232 [**2107-11-17**] 02:45AM BLOOD Neuts-43.7* Bands-0 Lymphs-49.0* Monos-3.9 Eos-2.2 Baso-1.2 [**2107-11-18**] 06:05AM BLOOD Glucose-87 UreaN-8 Creat-0.7 Na-141 K-3.8 Cl-105 HCO3-27 AnGap-13 [**2107-11-18**] 06:05AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.2 [**2107-11-16**] 11:10PM HGB-11.6* HCT-32.0* [**2107-11-16**] 08:50PM GLUCOSE-91 UREA N-19 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16 [**2107-11-16**] 08:50PM WBC-11.6* RBC-3.96* HGB-12.3 HCT-34.4* MCV-87 MCH-31.2 MCHC-35.8* RDW-14.6 [**2107-11-16**] 08:50PM NEUTS-54.5 LYMPHS-39.4 MONOS-3.6 EOS-1.9 BASOS-0.6 [**2107-11-16**] 08:50PM PLT COUNT-258 [**2107-11-16**] 08:50PM PT-12.0 PTT-22.6 INR(PT)-1.0 . KUB ([**2107-11-16**]): Three views of the abdomen were reviewed. There is no evidence for free air. No dilated bowel loops are identified. Few nonspecific air-fluid levels are present. Patient is status post cholecystectomy. . EGD ([**2107-11-16**]): Retained fluids in stomach. A small point of oozing of blood was seen in the duodenal bulb, most likely a small mucosal tear at the site of recent dilation. There was no active bleeding. No old or clotted blood was seen. (thermal therapy) The duodenal bulb stricture was wide open and the scope easily passed through it. Otherwise normal EGD to second part of the duodenum . CT Abdomen ([**2107-11-16**]): No free intraperitoneal air or other evidence for perforation. Pneumobilia is likely related to history of ERCP. Brief Hospital Course: Assessment and Plan: 44 year old woman with history of duodenal strictures that are dilated regulalry, who presents with bright red blood per rectum and hematocrit decrease following duodenal dilation on [**11-15**]. EGD revealed mucosal tear on [**11-17**]. Hematocrit stable since revision. . 1) GI bleed: Patient has history of duodenal stricture. Received regular endoscopic-balloon dilation to 18mm. Following procedure, developed several episodes of bright red blood per rectum. Hematocrit fell from a baseline of 37-39 to 30. EGD on [**11-17**] revealed mucosal tear at duodenal bulb. Cauterized and GI bleed stable. Continued to follow hematocrit: 31-30-32. Will continue proton pump inhibitor. Patient will need to follow up with GI physician and PCP in the next week. . 2) HTN: Patient normotensive, so will restart univasc 7.5 mg qd. . 3) Neuropathy: Will maintain patient on trileptal 150 [**Hospital1 **]. She takes medication for her neck pain that resulted from parotid gland tumor resection. . 4) FEN: Patient denies nausea. Will advance diet to clears, as tolerated. . 5) Prophylaxis: Continue PPI. . 6) CODE: FULL . Medications on Admission: - Univasc 7.5 mg a day - Ativan 1 mg b.i.d. - nexium 20 mg b.i.d. - Trileptal 150 mg b.i.d. - calcium - Vitamin D supplements. Discharge Medications: 1. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Continue calcium and vitamin D supplements. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Upper GI bleed 2. Peptic stricture in duodenal bulb Secondary Diagnosis: 1. Neuropathy Discharge Condition: Afebrile. Hemodynamically stable. Tolerating PO. Ambulating. Discharge Instructions: **You were admitted with bright red blood per rectum following your duodenal dilation. Subsequent EGD revealed a small mucosal tear that was cauterized. Since then, you have been hemodynamically stable. **Please call your primary doctor or return to the ED if you develop fever, chills, chest pain, shortness of breath, bright red blood per rectum, bloody vomiting or any other concerning symptoms. **Please take all your medications as directed. **Please keep you follow up appointments as below. Followup Instructions: **Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 3183**]) in [**2-7**] weeks from now. **You should follow up with your GI doctor, as planned.

[ "401.9", "E849.7", "355.9", "578.1", "998.2", "E870.4" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

6710, 6716

4999, 6156

313, 339

6873, 6936

3157, 4976

7486, 7703

2166, 2380

6333, 6687

6737, 6737

6182, 6310

6960, 7463

2395, 3138

245, 275

367, 1633

6836, 6852

6756, 6814

1655, 1995

2011, 2150

23,036

137,033

23720

Discharge summary

report

Admission Date: [**2133-4-17**] Discharge Date: [**2133-5-7**] Date of Birth: [**2063-8-24**] Sex: F Service: MEDICINE Allergies: Amoxicillin / Sulfa (Sulfonamides) / Codeine / Iodine; Iodine Containing / Ambisome / Furosemide / Heparin Agents / Vancomycin / Linezolid / Gluten Attending:[**First Name3 (LF) 1377**] Chief Complaint: Nausea, dry heaves, diarrhea. Major Surgical or Invasive Procedure: Left Shoulder Washout and Vancomycin Bead Placement History of Present Illness: The patient is a 69 year old woman with autoimmune hepatitis causing cirrhosis, on chronic prednisone, celiac sprue, CODP, and multiple infections (see below) who presents with nausea, dry heaves and diarrhea. Patient states this is d/t linezolid, and has been occuring for 10-12 days, worsening as the week has progressed. Relates poor PO intake and 4 pound weight loss in one week (although ate chicken salad and french fries for lunch). No fevers, chills, or abdominal pain. No melena or hematochezia. Patient has not noticed increasing abdominal girth, although her daughter thinks that her belly might be slightly larger. No abdnormal foods, eating out at restaurants, sick contacts, camping. + salty and dry mouth. No dysuria, SOB, chest pain. Last dry heave this a.m. . In regards to the infections, her most recent one included MRSA septic arthritis ([**1-15**]) with MRSA bactermia ([**1-13**]) treated with IV vanc x 4 weeks, followed by repeat admission on [**2-13**] for fevers, found to have shoulder abscess demonstrating MRSA on [**2133-2-19**] (PICC had been pulled on [**2133-2-12**] in [**Hospital **] clinic). The abscess was treated again with IV vancomycin, but stopped on [**3-10**] d/t rash. She was then started on linezolid, which she is currently taking. All surveillance blood cultures since then have been negative. Was again admitted on [**3-24**] for fevers and workup inhouse found a UTI and possible continued infection of left shoulder joint, continued on linezolid. Past Medical History: # Septic left shoulder joint with MRSA abscess formation and osteomyelitis # MRSA bacteremia # Klebsiella and citrobacter UTI on [**2133-3-19**] # Autoimmune hepatitis x 5 years. # Cirrhosis; on the transplant list. # Chronic abdominal abscess [**1-1**] diverticular microperforations controlled with a long course of antibiotics which included daptomycin - resultant sepsis # Perforated duodenal ulcer # Celiac sprue. # Osteoporosis. # COPD. # Status post hysterectomy. # Status post laryngeal tumor removal which was benign # Eczema # ex lap for duodenal ulcer [**9-3**] # s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] patch for perfed DU [**10-4**] # diverticular abscess [**11-3**] rx'd with Levo Social History: The patient lives with her daughter who is her healthcare proxy. . She has a history of tobacco use but quit 6 years ago (prior to that 1ppd). In addition, she also drank quite heavily but quit 6 years. She used to work as a bartender Family History: Her father died of cirrhosis. Her mother also had hepatitis. Physical Exam: Vitals: 97.7, 90/46 (baseline SBP 90's), 86, 16, 95% RA [**Month/Year (2) 4459**]: Head atraumatic, PERRL, EOMI, MM dry, OP clear Neck: Supple, no LAD, thyroid not enlarged Cardiac: RRR, NL S1 and S2, no MRGs Lungs: CTAB, no W/R/C Abdomen: Soft, not distended, ?small amount of fluid, dullness to percussion in dependent areas bilaterally, not tender to palpation, +BS, no rebound or guarding Ext: no C/C/E, 2+DP pulses Neuro: A&O x 3, CN III-XII intact, MAE Pertinent Results: ADMISSION LABS: [**2133-4-17**] 04:50PM WBC-4.1 RBC-2.03* HGB-6.6* HCT-19.0*# MCV-94 MCH-32.3* MCHC-34.5 RDW-15.1 [**2133-4-17**] 04:50PM NEUTS-69.3 LYMPHS-29.2 MONOS-1.1* EOS-0.3 BASOS-0.1 [**2133-4-17**] 04:50PM PLT SMR-VERY LOW PLT COUNT-31*# LPLT-1+ [**2133-4-17**] 04:50PM PT-15.1* PTT-33.4 INR(PT)-1.4* [**2133-4-17**] 04:50PM HAPTOGLOB-135 [**2133-4-17**] 04:50PM GLUCOSE-194* UREA N-31* CREAT-1.6* SODIUM-134 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-13* ANION GAP-28* [**2133-4-17**] 04:50PM ALT(SGPT)-43* AST(SGOT)-38 LD(LDH)-150 ALK PHOS-117 TOT BILI-0.4 [**2133-4-17**] 04:50PM ALBUMIN-3.4 CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-2.0 [**2133-4-17**] 06:16PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2133-4-17**] 06:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . [**4-18**] CT abdomen and pelvis: IMPRESSION: 1. New moderate intraabdominal ascites, most prominent surrounding the liver and spleen. 2. Gas filled collection in left lower pelvis is again see consistent with patient's known diverticular abscess. However, there is new wall thickening and intraluminla debris concerning for superinfection. 3. Unchanged lobular liver contour consistent with patient's known aurtoimmune hepatitis. . [**4-21**] EKG: Sinus rhythm with atrial premature complexes Probable left anterior fascicular block Diffuse ST-T changes are nonspecific Since previous tracing of [**2133-2-19**], axis less leftward . [**4-24**] Shoulder films: FINDINGS: There has been interval placement of radiopaque material in the left humeral head in the regions of previously described lucencies. There is still one area of lucency without the radiopaque material filling it and staples are present. There is a small amount of soft tissue air. A drain is in place. . Micro: [**4-24**] UCX no growth [**4-22**] UCX Klebsiella [**4-24**] Tissue from shoulder debridement - gram stain negative, 2+ PMN's, no growth to date Daily blood cultures negative Stool cultures negative for C. diff x 3, O&P negative, fecal cultures negative . [**2133-3-25**] TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES POSITIVE . Rads: [**2133-4-12**] IMPRESSION: 1. Persistent abscess cavity within the humeral head and proximal humeral diaphysis with resolution of the previously noted edema in the mid and distal humeral diaphysis. 2. Worsening avascular necrosis of the humeral head which now involves 2 cm of the overlying articular surface (previously 1 cm), without evidence of focal collapse of the cortex. 3. Chronic rupture of the long head of the biceps tendon, unchanged. . [**2133-2-19**] Tissue from L shoulder GRAM STAIN (Final [**2133-2-19**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2133-2-22**]): STAPH AUREUS COAG +. RARE GROWTH. OXACILLIN RESISTANT . CHEST (PORTABLE AP) [**2133-5-5**] 7:36 PM AP CHEST RADIOGRAPH: There has been interval removal of the right-sided subclavian line. New right-sided PICC line is seen with tip overlying the distal SVC. There is no evidence of pneumothorax. Cardiomediastinal and hilar contours appear unchanged. Pulmonary vascularity appears within normal limits and no focal consolidation seen within the lungs. Surgical staples noted in the left shoulder with postoperative changes again seen. IMPRESSION: Interval removal of right subclavian line with placement of right PICC with tip overlying the distal SVC. No evidence of pneumothorax. Brief Hospital Course: 69 year old female with autoimmune hepatitis, celiac sprue, and recurrent infections who presents with nausea, dry heaves, diarrhea, and poor PO intake. . # Nausea/Dry Heaves/Diarrhea - Nausea, diarrhea, pancytopenia, and lactic acidosis all consistent with linezolid toxicity. Linezolid was stopped and nausea/dry heaves, and diarrhea all improved. Pancytopenia continued, but the patient was supported with blood products as needed, and this stabalized. Lactic acidosis resolved (high of 15, low of 2). Stool was sent for evaluation and was negative for C. diff x 3, fecal cultures and O&P also negative. LFT's normal. Initially there was concern for failure to thrive d/t poor PO intake, but once the nausea resolved, the patient was able to maintain adequate caloric intake and did not require an NGT. . # Septic Arthritis/Osteomyelitis - MRI on [**4-13**] showed evidence of worsening [**Month/Year (2) 1083**] process. [**Month/Year (2) 5498**] was consulted and initially stated that it would be very difficult to debride or intervene without causing impairment to limb. The patient was initially treated with linezolid but this was stopped when she was found to be linezolid toxic. ID was consulted and recommended daptomycin, recognizing that this was an inferior choice to both vancomycin and linezolid. The patient continued to spike fevers and it was decided to perform vancomycin desensitization. This was done on [**4-23**] in the ICU, and the patient had no anaphylaxis or rash during the process. She was continued on vancomycin [**Hospital1 **] without incidence. However, it was clear that the patient would not clear the infection with antibiotics alone, so the patient was taken to the OR on [**4-24**] for incision and drainage, and antibiotic beads were placed. She tolerated the procedure well without any complications. The shoulder has remained nonpainful. The patient will need to return for removal of the beads per ortho in [**5-7**] weeks. The tissue was sent for gram stain, culture, and sensitivities, and the gram stain was negative. She was discharged on Vanco 750mg IV BID for one more month (total of 6 weeks course) after discharge with f/u with Dr. [**Last Name (STitle) 4334**] of ID on [**2133-6-3**]. Needs weekly vanco trough levels. . # Autoimmune hepatitis/Cirrhosis - Patient had new evidence of intraabdominal ascites on CT, never been tapped. Started on PO lasix and this improved. Maintained on prednisone 7.5 mg PO QD(decreased in beginning of [**Month (only) 116**] by Dr. [**Last Name (STitle) 497**]. Patient is awaiting transplant (but currently complicated by right shoulder osteomyelitis and AVN). She got Vit K elevated INR d/t liver disease. She was discarged on lasix 40 mg PO QD. . # Enterococcal Bacteremia - Treated with IV daptomycin and will need two more weeks of QD IV Daptomycin to finish [**2133-5-14**] and f/u with Dr. [**Last Name (STitle) 4334**] of ID. . # Sigmoid Diverticular Abscess - Has had chronic sigmoid diverticular abscess which she decided not to have operated on at this time. She was evluated by Dr. [**First Name (STitle) **] of Transplant surgery. . # Bacteruria - Patient was felt to be colonized as UA did not show any WBC's or nitrates, but in setting of recurrent fevers, she was treated with a course of levofloxacin which has finished. . # Anemia - Baseline (high 20's, low 30's) anemia thought to be d/t anemia of chronic disease. However, decrease on admission was d/t linezolid, and later fall was likely from surgery and continued linezolid toxicity. She was transfused to keep HCT >21. She was discharged with a HCT of 26. . # Thrombocytopenia - Likely combination of linezolid and possible ITP, as patient with autoimmune disorders (hepatitis and celiac). Also with known HIT. All heparin products were avoided. She was transfused for plts <50 prior to surgery. Her platelet count recovered before discharge. . # Code - Full . IV Access- She has a right arm PICC which was placed on [**2133-5-4**] by Interventional radiology with confirmed position overlying the distal SVC most recently by CXR on [**2133-5-6**]. Medications on Admission: Multivitamin Acetaminophen 325 mg as needed Pantoprazole 40 mg QD Linezolid 600 mg [**Hospital1 **] Prednisone 7.5 mg PO QD Calcium 500 mg PO QD Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 3. 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* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Vancomycin 500 mg Recon Soln Sig: 750mg Recon Solns Intravenous Q 12H (Every 12 Hours) for 1 months. Disp:*QS Recon Soln(s)* Refills:*0* 7. Daptomycin 500 mg Recon Soln Sig: 500 mg Recon Solns Intravenous Q24H (every 24 hours) for 2 weeks. Disp:*QS Recon Soln(s)* Refills:*0* 8. Outpatient Lab Work Check CBC, LFT's, Creatinine, ESR, CRP, CK, and vancomycin trough weekly and fax results to Dr. [**Last Name (STitle) 4334**] at [**Telephone/Fax (1) 1353**]. 9. PICC Care PICC care per protocol, with the exception that patient can not have heparin flushes because of her history of Heparin Induced Thrombocytopenia. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Enterococcal Bacteremia Left Shoulder Osteomyelitis MRSA Sigmoidal Diverticular Abscess Autoimmune Cirrhosis Celiac Sprue Discharge Condition: Stable, ambulatory. Discharge Instructions: Please call Dr. [**Last Name (STitle) 47403**] [**Telephone/Fax (1) 52051**] or Dr. [**Last Name (STitle) 497**] if you have any problems, including fevers or abdominal pain. Please follow up with Dr. [**Last Name (STitle) 4334**] of [**Last Name (STitle) **] Disease [**Telephone/Fax (1) 457**] for your antibiotic adjustment. You will need to have your blood drawn each week and the results faxed to Dr. [**Last Name (STitle) 4334**]. This information will be given to the VNA so it can be done. Please take all medications as prescribed. You will need daily antibiotics for four more weeks until you see Dr. [**Last Name (STitle) 4334**]. Please follow up with Dr. [**Last Name (STitle) 7376**] [**Telephone/Fax (1) 1228**] of the [**Telephone/Fax (1) **] department to have your shouldr evaluated and the vancomycin beads removed. Followup Instructions: PCP [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 52051**] [**Telephone/Fax (1) **] Disease Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2133-6-3**] 11:00 Hepatology [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] [**Last Name (NamePattern1) 5498**] Dr. [**Last Name (STitle) 7376**] [**Telephone/Fax (1) 1228**] For Vanco bead Removal in 4 wks [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2133-5-31**]

[ "571.49", "276.51", "496", "571.5", "790.7", "579.0", "567.22", "791.9", "730.02", "E930.8", "276.2", "733.00", "284.8", "041.04", "V09.0", "787.91", "562.10", "789.5", "V58.65", "733.41", "730.12", "041.11", "455.8", "263.9", "E934.2" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.04", "77.02", "38.93", "99.05", "00.14", "99.21" ]

icd9pcs

[ [ [] ] ]

12834, 12885

7230, 11364

437, 491

13051, 13073

3593, 3593

13960, 14599

3035, 3098

11560, 12811

12906, 13030

11390, 11537

13097, 13937

3113, 3574

368, 399

519, 2021

3609, 7207

2043, 2765

2781, 3019

26,135

159,741

16171

Discharge summary

report

Admission Date: [**2190-1-30**] Discharge Date: [**2190-2-4**] Service: ACOVE HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old man with a history of atrial fibrillation on Coumadin and hypertension who initially presented with right upper quadrant pain in early [**2190-1-6**]. At that time an abdominal ultrasound demonstrated cholelithiasis without gallbladder thickening or common bile duct dilatation. On the day of admission the patient presented to an outside hospital with severe right upper quadrant pain, fever to 105 and jaundice. He was found to have a total bilirubin of 9.7, and a white blood cell count of 4.9 with 22 bands. He was given Unasyn 3 grams intravenous, Gentamycin 400 mg intravenous, and was then transferred to the [**Hospital1 346**] for an endoscopic retrograde cholangiopancreatography. This endoscopic retrograde cholangiopancreatography demonstrated bulging of the major papilla (possible impacted stone), successful stent placement in the lower third of the common bile duct with subsequent drainage of pus and bile, sphincterotomy was not performed due to INR of 2.2. No obvious stones were seen and the pancreatic duct was not visualized. Following the procedure while still in the endoscopic retrograde cholangiopancreatography suite, the patient became hypotensive with a systolic blood pressure in the 70s. He was given 4 liters of normal saline with stabilization of his blood pressure into the 100s. The patient was mentating well throughout his hypotensive episode. He was subsequently admitted to the Intensive Care Unit for further monitoring. On initial physical examination post endoscopic retrograde cholangiopancreatography, temperature 98.4, heart rate 88, blood pressure 102/80, respiratory rate 20, oxygen saturation 99% on 4 liters nasal cannula. The patient was asleep, but arousable to voice. Mucous membranes are moist. Conjunctiva were slightly icteric. There was no JVD. Regular rate and rhythm with normal S1 and S2 heart sounds. His lungs were clear to auscultation bilaterally. His abdomen was soft and without bowel sounds. There was mild right upper quadrant tenderness without rebound or guarding. The patient had 2+ dorsalis pedis pulses bilaterally. On initial laboratory evaluation pre endoscopic retrograde cholangiopancreatography, serum sodium 136, potassium 3.9, chloride 99, bicarbonate 28, BUN 24, creatinine 1.4, and glucose 159. Total protein 6.6, albumin 3.2, amylase 89, alkaline phosphatase 261, AST 63, ALT 86, total bilirubin 9.7, direct bilirubin 6.2 and indirect bilirubin 3.5. Post endoscopic retrograde cholangiopancreatography, the patient's white blood cell count was 15.2, hematocrit 38.6, and platelets 113. PT 20.3, INR 2.7, and PTT 35. His initial electrocardiogram here demonstrated heart rate of 81, left axis deviation, Q waves in leads 2, 3, and AVF and normal sinus rhythm. HOSPITAL COURSE: Post procedure, the patient improved clinically and on hospital day two he was transferred to the general medicine floor. 1. Gastrointestinal: Following his endoscopic retrograde cholangiopancreatography, the patient had no further right upper quadrant pain. He was changed to Augmentin from Unasyn on hospital day three. His alkaline phosphatase and total bilirubin slowly trended down throughout his hospitalization. At the time of discharge his alkaline phosphatase was 337 and his total bilirubin 3.3. On hospital day four, the general surgery team was consulted regarding the appropriate timing of cholecystectomy in this patient. The general surgery service felt that the patient should have an outpatient cholecystectomy at a later date. He was therefore instructed to follow up with Dr. [**Last Name (STitle) **] as noted below. At the time of discharge the patient was tolerating a regular diet without difficulty. Also, of note, on hospital day four, the patient had a repeat abdominal ultrasound that demonstrated multiple gallstones in the gallbladder and a thickened gallbladder wall with gallbladder edema. 2. Cardiovascular: As noted above, the patient's blood pressure responded appropriately to intravenous fluid resuscitation and he had no subsequent episodes of hypotension throughout this hospitalization. However, prior to his transfer from the Intensive Care Unit the patient had an eight beat run of nonsustained ventricular tachycardia and he was therefore ruled out for myocardial infarction by cardiac enzymes following his transfer to the medicine floor. His repeat electrocardiogram showed no changes from the electrocardiogram noted above. On hospital day four the patient had a TTE that demonstrated mild left atrial dilatation, mild symmetric left ventricular hypertrophy, mild to moderate left ventricular global hypokinesis, mild aortic root and ascending aortic dilation, 1+ aortic regurgitation, 3+ mitral regurgitation and no pericardial effusion. His ejection fraction was estimated at 40 to 45%. Given these findings, the patient was started on Captopril at a low dose and was titrated up throughout the remainder of his hospitalization. On the morning prior to discharge the patient went into atrial fibrillation with rapid ventricular response. He converted back into normal sinus rhythm after the administration of Metoprolol 5 mg intravenous times three and Diltiazem 10 mg intravenous times one. The patient was therefore restarted on Warfarin following his discharge from the hospital. In addition he was started on Metoprolol 25 mg b.i.d. for additional blood pressure control and rate control as well as for his findings consistent with congestive heart failure on his echocardiogram. The patient had a cholesterol panel that demonstrated serum cholesterol 148, triglycerides 181, HDL 15 and LDL of 97. 3. Endocrine: In the setting of his acute cholangitis, the patient had marked hyperglycemia. He was therefore started on a regular insulin sliding scale with finger stick blood glucose checks every four hours. These values were largely within the range of 90 to 150. A hemoglobin A1C was checked prior to discharge and this value came back at 6.6%. The patient was counseled regarding dietary and exercise modifications with the plan to follow up on his glucose measurements as an outpatient in the future. DISCHARGE CONDITION: Stable. DISCHARGE PLACEMENT: Home. DISCHARGE DIAGNOSES: 1. Cholangitis status post common bile duct stenting via endoscopic retrograde cholangiopancreatography. 2. Congestive heart failure (stage one). 3. Atrial fibrillation. 4. Diabetes mellitus type 2. 5. Cholecystitis. 6. Chololithiasis. DISCHARGE MEDICATIONS: 1. Augmentin 875 mg po b.i.d. through [**2190-2-19**]. 2. Metoprolol 25 mg po b.i.d. 3. Lisinopril 5 mg po q day. 4. Warfarin 5 mg po q Monday, Wednesday and Friday. 5. Warfarin 2.5 mg po q Tuesday, Thursday, Saturday and Sunday. 6. Furosemide 40 mg po q day. 7. Potassium 20 milliequivalents po q day. The patient was instructed to follow up as follows: 1. The patient was instructed to call his primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 46195**] on the Monday following discharge to arrange a follow up appointment with him on the week following discharge. 2. An appointment was scheduled for the patient with Dr. [**Last Name (STitle) 957**] in the Department of General Surgery on [**2190-2-10**] at 11:45. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) **] Dictated By:[**Doctor Last Name 25381**] MEDQUIST36 D: [**2190-2-17**] 10:21 T: [**2190-2-18**] 10:26 JOB#: [**Job Number **]

[ "038.3", "458.2", "997.1", "398.91", "574.91", "401.9", "427.1", "427.31", "276.1" ]

icd9cm

[ [ [] ] ]

[ "51.88", "51.87" ]

icd9pcs

[ [ [] ] ]

6340, 6378

6399, 6642

6666, 7742

2931, 6318

117, 2913

2,689

187,799

13205

Discharge summary

report

Admission Date: [**2147-9-11**] Discharge Date: [**2147-9-18**] Date of Birth: [**2086-6-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2074**] Chief Complaint: back pain, nausea, SOB Major Surgical or Invasive Procedure: cardiac catheterization with stent placement [**2147-9-11**] History of Present Illness: Pt is a 61 y/o man with a PMH of hypercholesterolemia who was playing raquetball yesterday when he experienced severe pain in the upper back, between the scapulae L>R, associated with SOB, nausea, dizziness and generalized "achiness". He had never experienced a pain like this before. He says that the pain was alleviated with some advil, then returned when he awoke the next morning. No palpitations, but he did have lightheadedness for several hours when the pain originally occurred. He does not admit to PND or orthopnea. He went to his PCP, [**Name10 (NameIs) 1023**] performed an EKG, and sent him to the ER. In the ER, he was found to have T 98.9, BP: 128/83 P: 78 satting 96% on RA, on EKG was found to be in NSR, with RAD, [**Apartment Address(1) **]-2mm in V2-V6, and ST segment depression in lead III. He was started on ASA, BB, heparin gtt, plavix, integrillin gtt. Cardiology saw him, took him for emergent cath. . ROS otherwise negative: No more N/V. No constipation, has regular BMs. No urinary symptoms. No abd pain. Notes that he feels feverish, but no chills. Able to walk several flights of stairs a day without difficulty. Plays racquetball twice a week. Past Medical History: Hypercholesterolemia Social History: Never smoked. Drinks 1-2 beers or hard liquor per night (bourbon) for "forever." No IVDA. Family History: Brother died of MI at age 63 (3 years ago). Father died of emphysema, but had multiple MIs, starting before the age of 50. Physical Exam: Temp: BP: 119/80 P: 86 RR: 12 Oxygen sat: 100% on 4L NC General: 61 y/o man in NAD. Breathing comfortably in bed. AOX3. HEENT: PERRL, MMM, oropharynx clear without lesions. Neck: Difficult to assess JVD given lying flat, but not elevated. No LAD. Lungs: CTAB CV: RRR, S1 and S2 audible, distant HS Abd: Obese, soft, NT, ND, NABS, no masses Peripheral vasc: cool extremities, 2+ peripheral DP and PT pulses. No edema bilateral lower extremities Neuro: Grossly intact. No focal deficits. Pertinent Results: [**2147-9-11**] WBC-10.1 RBC-4.80 Hgb-13.9* Hct-39.6* MCV-82 MCH-29.0 MCHC-35.2* RDW-13.3 Plt Ct-151, Neuts-73.7* Lymphs-19.4 Monos-6.3 Eos-0.4 Baso-0.2, Plt Ct-151 [**2147-9-11**] Glucose-103 UreaN-13 Creat-1.1 Na-138 K-4.8 Cl-101 HCO3-24 AnGap-18 [**2147-9-11**] 04:57PM BLOOD CK(CPK)-3770*, CK-MB-361 (PEAK) * MB Indx-9.6* cTropnT-5.89* [**2147-9-11**] 10:06PM CK(CPK)-3827* PEAK, CK-MB-242* MB Indx-6.3* cTropnT-12.87 (PEAK)* [**2147-9-12**] 04:35AM BLOOD CK(CPK)-3085*, CK-MB-135* MB Indx-4.4 cTropnT-7.04* [**2147-9-12**] 12:16PM BLOOD CK(CPK)-2343*, CK-MB-67* MB Indx-2.9 [**2147-9-13**] 03:09AM BLOOD CK(CPK)-1185*, CK-MB-21* MB Indx-1.8 cTropnT-5.51* . CARDIAC CATH [**2147-9-11**] COMMENTS: 1. Selective coronary angiography in this right dominant system revealed an occluded proximal LAD without angiographically significant disease in the other vessels. The LMCA was without significant flow limiting stenosis. The LAD was completely occluded after a small D1. The LCX fed a large OM1 and both vessels were patent with only mild disease. The continuation of the LCX was small. The RCA had mild diffuse disease. 2. Hemodynamics revealed severely elevated filling pressures with mean PCWP of 31 and LVEDP of 32mmHg. The RA mean was also elevated at 20mmHG and there was moderate pulmonary htn 49/29/37. There was no evidence of aortic stenosis. The cardiac output was severely depressed at 3.14/1.5 3. Successful PTCA/stenting of the proximal LAD with a 3.5x18mm Cypher DES with excellent results (see PTCA comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction with depressed cardiac output by Fick 3. Acute anterior myocardial infarction, managed by acute ptca. PTCA of vessel. Cath: CO/CI 3.14/1.5 Ao (S/D/M) 119/84/99 PCW (M/A/V) 35/36/31 RA (M/A/V) 25/34/20 PA (S/D/M) 49/29/37 RV (S/D) 54/20 LVEF unrec Cor: R dominant system LMCA: normal LAD: 100% prox LAD lesion, normal mid- and distal LCX: normal RCA: normal prox, with diffuse diseased mid and distal Stents: Cypher DES to LAD . ECHO [**2147-9-12**] EF 25-30% Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with akinesis of the mid to distal septum and anterior wall including the apex. The basal LV systolic function is hyperdynamic. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Impression: 61 y/o man with h/o hypercholesterolemia presents with STEMI s/p cath with DES to LAD. 1. [**Name (NI) 40268**] Pt did well status post Cypher stent to the left anterior descending artery. Of note, per report, there was macroscopic embolization to the distal and apical LAD noted after apical inflations, with flow was restored to apical LAD. His cardiac enzymes peaked on [**2147-9-11**] with Troponin 12.87, with CKs peaked on [**2147-9-11**] 3827. The patient was placed on aspirin, plavix, a statin, and integrillin gtt post-cath. Integrillin was discontinued 18 hours post cath. We started a beta blocker, Carvedilol, and titrated up on the dosage. He received 20mg IV lasix in the cath lab, and diuresed appropriately. Two days prior to discharge, an ACEI was added to his meds. A post cath echo demonstrated severe regional left ventricular systolic dysfunction with akinesis of the mid to distal septum and anterior wall including the apex. We started a heparin gtt post-cath for prevention of thrombus formation, given his akinetic septum and apex, and coumadin was added for outpatient anticoagulation. He will be discharged on 5mg coumadin po qd. He was instructed to follow up in [**Hospital 197**] Clinic to have INR checked, and Dr. [**First Name8 (NamePattern2) 233**] [**Last Name (NamePattern1) 5444**], who is covering for Dr. [**Last Name (STitle) **], the pt's PCP, [**Name10 (NameIs) **] notified to follow up with result, as there was difficulty in obtaining a coumadin clinic appt. The pt's appt with Dr. [**Last Name (STitle) **] was set for [**Month (only) 359**] (first avail). His INR at discharge was 1.9. He was instructed to follow up with Dr. [**Last Name (STitle) **] in clinic in [**Month (only) **]. He will have an echocardiogram 1 month from now. 2. Low grade fever- The pt had a fever to 101.6 on [**9-14**]. He was pan-cultured: blood cx X2 pending at discharge, urine cx with mixed bacterial flora ( >= 3 COLONY TYPES) consistent with fecal contamination, with negative UA, sputum cx: upper resp flora/contaminant. His CXR [**9-14**] showing a small left pleural effusion, LLL atelectasis, no PNA. He remained afebrile after this temp, without leukocytosis. He did not have any infectious symptomatology. 2. Hypercholesterolemia We continued a statin. 3. FULL CODE Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. ST-segment elevation myocardial infarction status post cardiac catheterization with stent placement to the left anterior descending artery 2. Hypercholesterolemia Discharge Condition: Stable Discharge Instructions: If you experience any chest pain, shortness of breath, or sweating, please report to the emergency room immediately. Please take all of your medicines. Please follow up with your physicians (see information below). Followup Instructions: Please follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]. Your appointment is for [**2147-10-25**] at 3:00 pm. His office number is: [**Telephone/Fax (1) 4022**]. You need to have your labs drawn on Wed, [**9-20**] to have your INR checked. Goal INR is [**3-2**]. Report to the [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 5074**], [**Hospital1 **]. You will need to call Akil or [**Doctor First Name **] for an Echocardiogram appointment at [**Telephone/Fax (1) 128**]. Call this number ASAP to schedule an appointment in 1 MONTH. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Your appointment is for [**11-3**] at 9:50am. His office number is [**Telephone/Fax (1) 250**]. His office is in the [**Hospital Ward Name 23**] building, [**Location (un) **]. If you would like an earlier appointment, please call his office for any cancellations. Completed by:[**2147-9-18**]

[ "780.6", "272.0", "410.11", "518.0", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8526, 8532

5467, 7806

338, 401

8744, 8753

2446, 3988

9017, 10076

1790, 1917

7829, 8503

8553, 8723

4005, 5444

8777, 8994

1932, 2427

276, 300

429, 1620

1642, 1664

1680, 1774

530

149,648

9577

Discharge summary

report

Admission Date: [**2119-4-7**] Discharge Date: [**2119-4-27**] Date of Birth: [**2039-10-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Location (un) 1279**] Chief Complaint: Fevers, rigors, respiratory distress Major Surgical or Invasive Procedure: intubation and mechanical ventilation transfusions History of Present Illness: 79 yo male discharged from [**Hospital1 18**] on [**4-4**] after undergoing apical-aortic conduit surgery through a left thoracotomy for a heavily calcified aortic valve that could not be repaired conventially. His post-op course was c/b atrial fibrillation and brachial plexopathy. He was discharged to [**Hospital 38**] rehab. He presented to [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital with SOB, shaking chills, and respiratory distress. He was initially alert and able to reponded to BIPAP. Per the ICU attending, he acutely desaturated to ~70% with a blood pressure of ~60 systolically. He was initially on BIPAP, then intubated. His pressure responded to Levophed and IV fluids. A Foley was placed drained cloudy urine, per report. He was given Lasix for crackles on exam, precipitating further hypotension. An Echo was done there showing an EF of ~10%, patent conduit, and heavily calcified aortic valve. Blood and urine cultures were drawn before pt transferred to [**Hospital1 18**] for further management. Of note, pt's incision wound appeared erythematous. ROS positive for recent diarrhea better on Flagyl despite C. Dif negative. Past Medical History: 1. apical-aorta conduit surgery [**3-18**] 2. aortic stenosis, valve area 0.5 cm2 3. aortic valvuloplasty [**1-14**] 4. CAD s/p CABG [**2107**] with LIMA to dLAD, SVG to ramus, SVG to diag, SVG to dRCA with last cath [**5-15**] at [**Hospital3 **] with occluded SVG-dRCA s/p stent, otherwise open grafts and occluded natives 5. paroxysmal atrial fibrillation 6. supraventricular tachycardias 7. prostate cancer s/p radiation 8. radiation cystitis- with significant hematuria over past year with hx of cauterization and 3way foley irrigations and no hematuria off asprin. Social History: - Retired engineer- Lives in [**Location 620**] with wife- [**Name (NI) **] tobacco, rare EtOH Family History: Unremarkable. Physical Exam: VS: 100.9, 107/42, 71 Gen: Intubated and sedated Cor: III/VI systolic murmur at 6th intercostal space left midclavicular line, II/VI diastolic murmur at LLSB Chest: CTA anteriorly, no wheezes Abd: +BS, S, NT, ND Ext: 2+/2+ pitting edema Brief Hospital Course: Mr. [**Known lastname 11182**] is a 79 year old male with severely calcified aortic valve s/p recent unconventional correction by apical-aortic conduit (Apex of heart to descending aorta), transferred from an outside hospital intubated with sepsis, found to have an aortic thrombus. He was intubated and started on pressors. From the standpoint of infection, Mr. [**Known lastname 11182**] was initially thought to be septic since he had a positive UA at the OSH. His blood cultures revealed MRSA and he was started on vanco. The infectious disease team was consulted and felt that his conduit was seeded, so the patient would now need lifelong suppressive treatment. He was also given gentamycin for synergy and once a 7 day course had elapsed and his blood cultures were negative, rifampin was initiated. With his supertherapeutic INR, haptoglobin, LD, and fibrin split products were obtained and were not consistent with disseminated intravascular coagulation. It was thought that the high INR was secondary to malnutrition and Vitamin K deficiency. His initial transthoracic echocardiograms revealed an aortic thrombus. This was thought likely due to forward flow from stenotic aorta in setting of retrograde flow from conduit, despite supratherapeutic INR. Surgery was not thought to be an option given operative risk and thrombus will reform given etiology the dual flow state. Mr. [**Known lastname 11182**] was hypotensive with upper extremity BP is about 15 points lower than lower extremity. He required Levophed for about 2 weeks and it was eventually weaned. His cortisol stimulation test was not consistent with adrenal insufficiency. His blood pressure responded well when he was given blood products, which seemed to indicate that he was intravascularly depleted but that he was total body overloaded. Of note, Mr. [**Known lastname 11182**] developed hematuria, requiring placement of a three way foley for irrigation. The urology service provided advice on treatment of his radiation cystitis. He had several clots were drawn out each day from the foley. He also was transfused on several occassions. Mr. [**Known lastname 11182**] arrived with a history of atrial fibrillation and was initially in h/o AF, then NSR following DC cardioversion. He then intermittenly went back into atrial fibrillation. After a long course aspiration pneumonia requiring reintubation, Mr. [**Name13 (STitle) 32485**] developed worsening multiorgan failure. His renal failure and respiratory failure progress and not only did he require ventilation but increasing amounts of 2 pressors. Mr. [**Name (NI) 32486**] son and wife were present for a family meeting. They determined that aggressive, heroic efforts were not his wishes. The wanted to stop these measures since they seemed unlikely to improve his outcome. Shortly thereafter, the patient was extubated. He expired the same evening. Medications on Admission: NA Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA

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icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "96.72", "96.48", "99.62", "96.04", "34.09", "99.04", "88.72", "00.17", "38.93" ]

icd9pcs

[ [ [] ] ]

5618, 5627

2640, 5536

349, 401

5673, 5677

5728, 5733

2349, 2364

5589, 5595

5648, 5652

5562, 5566

5701, 5705

2379, 2617

273, 311

429, 1626

1648, 2221

2237, 2333

76,695

134,419

49477

Discharge summary

report

Admission Date: [**2135-1-17**] Discharge Date: [**2135-2-17**] Date of Birth: [**2050-3-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Lower GI Bleeding Major Surgical or Invasive Procedure: Bronchoscopy with lavages Percutaneous endoscopic gastrotomy tube placement Percutaenous tracheostomy Transesophageal echocardiogram central venous line access arterial line access Flexible sigmoidoscopy Chest tube History of Present Illness: 84F admitted to [**Hospital3 **] on [**2134-12-26**] with lower abdominal pain and hypotension found to have diverticulitis on CT scan and was admitted to the ICU. Pt was also found to be in acure renal failure with a Cr of 2.7 (baseline 0.8). Pt was hyponatremic with a Na of 121 at time of admission. On [**1-5**] pt underwent exploratory laparotomy with sigmoid resection, [**Doctor Last Name 3379**] and end colostomy. Intraoperatively she had a 1cm hole in her sigmoid colon and feculent peritonitis. Pt extubated on [**2135-1-8**], was reintubated the same day and has remained intubated since. Since reintubation, pt has been minimally responsive with minimal improvement - occasionally moving her arms and and legs and rarely opening her eyes. She was alert and oriented at the time of admission to OSH. Upon transfer the pt has a pressor requirement on Levophed. Pt is approximately 15 kilos positive since her admission on [**12-26**]. She has had multiple brinchoscopies for persistent partial left lung collapse at the OSH. Pt has had rectal bleeding since [**2135-1-16**], continuously draining small amounts of blood. Pt recieved one unit of PRBC overnight [**Date range (1) 48570**] with her last HCT 31.5. Pt transferred to [**Hospital1 18**] on [**1-17**] for further managemnet of LGIB. Past Medical History: PMH: Presyncopal episodes, Hypertension, Hyperlipidemia, h/o electrolyte disorders, Hypothyroidism, Asthma/COPD PSH: sigmoid colectomy, hartmanns Social History: Social History: No Tobacco, No EtOH, no ilicit drug use. Retired food service worker. Lives in [**Hospital1 **] with her son. Family History: NC Physical Exam: Exam: Temp 99.6, HR 99, BP 86/43 (52), PS 0.5/10/5 500x20, 97% Levophed 0.2 Gen: Intubated, Unresponsive Neuro: Pupils 3-2mm bilaterally, symmetrical but sluggish, grimaces to abdominal palpation, extremities flacid x4 with no withdrawing or localizing to pain, Babinski reflex absent CV: RRR, No R/G/M RESP: Slightly decreased on left, otherwise CTAB ABD: Soft, Non-distended, winces to palpation, midline laparotomy incision with retention sutures in place, incision C/D/I, LLQ colostomy with appliance in place and brown stool in bag Rectal: Small ammount of gross blood. One small non-thrombosed external hemorrhoid, no active bleeding GU: Foley to gravity Ext: Trace-1+ BLE Edema, 3+ BUE edema Pertinent Results: [**2135-1-17**] 03:42PM BLOOD WBC-16.7* RBC-3.43* Hgb-10.5* Hct-32.5* MCV-95 MCH-30.6 MCHC-32.3 RDW-17.7* Plt Ct-235 [**2135-2-8**] 01:58AM BLOOD WBC-1.2* RBC-3.45* Hgb-10.4* Hct-31.1* MCV-90 MCH-30.0 MCHC-33.4 RDW-17.3* Plt Ct-115* [**2135-2-8**] 01:58AM BLOOD Neuts-0 Bands-0 Lymphs-78* Monos-7 Eos-0 Baso-0 Atyps-15* Metas-0 Myelos-0 [**2135-2-7**] 02:06AM BLOOD Neuts-0* Bands-0 Lymphs-74* Monos-4 Eos-0 Baso-0 Atyps-22* Metas-0 Myelos-0 [**2135-2-6**] 04:25PM BLOOD Neuts-0 Bands-0 Lymphs-78* Monos-9 Eos-0 Baso-0 Atyps-12* Metas-0 Myelos-0 NRBC-1* Other-1* [**2135-2-6**] 02:17AM BLOOD Neuts-0* Bands-0 Lymphs-90* Monos-6 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 NRBC-2* [**2135-2-8**] 01:58AM BLOOD Plt Ct-115* [**2135-2-8**] 01:58AM BLOOD PT-19.8* PTT-48.2* INR(PT)-1.8* [**2135-2-8**] 01:58AM BLOOD Glucose-82 UreaN-50* Creat-0.8 Na-137 K-3.8 Cl-105 HCO3-26 AnGap-10 [**2135-1-17**] 03:42PM BLOOD Glucose-217* UreaN-80* Creat-1.4* Na-149* K-4.3 Cl-112* HCO3-30 AnGap-11 [**2135-2-8**] 01:58AM BLOOD ALT-14 AST-8 AlkPhos-208* TotBili-1.5 [**2135-1-17**] 03:42PM BLOOD ALT-31 AST-23 LD(LDH)-255* AlkPhos-429* Amylase-80 TotBili-0.4 [**2135-1-17**] 03:42PM BLOOD Lipase-105* [**2135-1-25**] 06:59AM BLOOD Lipase-75* [**2135-1-31**] 03:00AM BLOOD calTIBC-138* TRF-106* [**2135-2-1**] 02:54AM BLOOD calTIBC-142* Ferritn-358* TRF-109* [**2135-2-6**] 04:25PM BLOOD D-Dimer-[**2121**]* [**2135-1-17**] 03:42PM BLOOD Triglyc-90 [**2135-1-17**] 03:42PM BLOOD TSH-5.9* [**2135-1-30**] 03:11AM BLOOD TSH-7.4* [**2135-2-7**] 02:06AM BLOOD TSH-1.5 [**2135-1-17**] 03:42PM BLOOD T4-3.2* T3-39* Free T4-0.67* [**2135-2-7**] 02:06AM BLOOD Free T4-1.1 [**2135-2-8**] 09:59AM BLOOD Glucose-95 Lactate-1.8 K-3.7 CT head: 1. Interval near-complete opacification of the mastoid air cells bilaterally, with scattered air-fluid levels. Fluid in the nasopharynx, likely related to intubation. 2. No intracranial hemorrhage or mass effect. CT abd: 1. Multicystic area in the mid-to-upper left hemothorax, poorly evaluated on this technically limited study, demonstrates multiple air-fluid levels within cystic spaces. This may represent loculated hydropneumothorax such as due to hemopneumothorax or empyema, or alternatively infection or hemorrhage within bullae (although no bullae were noted in this region on the prior study, there is evidence of severe emphysema). Repeat CT scanning with a dedicated Chest CT protocol would likely be helpful for further clarification. 2. New since the prior exam are multiple peribronchovascular nodules and ground-glass opacities in the left upper lung, consistent with infectious or inflammatory process. 3. 2.3 x 6.5 cm new hemorrhagic fluid collection in the anterior peritoneal cavity, adjacent to the surgical incision along the anterior abdominal wall. Density in deep pelvis may represent free hemoperitoneum or possibly a loop of bowel. Limited evaluation of the pelvis and the surgical bed due to technical problems encountered with the scan. Additionally, oral contrast does not reach the distal bowel. Recommend rescanning the patient after contrast has passed more distally, for better visualization of deep pelvic contents. 4. Borderline enlarged loops of proximal small bowel, without other evidence of obstruction. 5. Cholelithiasis. 6. Atherosclerotic disease. MRI head: Extensive small vessel ischemic change. Tiny acute infarction in the right parietal lobe in a periventricular location, without associated mass effect or edema. Brief Hospital Course: 84F tx from [**Hospital3 **] on [**2135-1-17**] with h/o perf diverticulitis s/p ex lap, sigmoid colectomy with [**Doctor Last Name 3379**] ([**1-5**]). Post-op course c/b hypoxia in setting of LUL collapse requiring re-intubation [**1-11**], somnolence, renal failure. Head CT demonstrated small vessel disease. Multiple bronchoscopies for persistent partial left upper lobe collapse at [**Hospital3 **] as well as thoracentesis. On [**1-16**], she developed small amounts of rectal bleeding, and received 1 U PRBCs overnight. Hematocrit stable. On transfer, she was on a Levophed gtt, minimally responsive, withdrawing to pain, massive generalized edema and had gained ~33 pounds since admission to OSH. After admission to the intensive care unit, Dr.[**Name (NI) 11471**] surgical service, respiratory status was a concern. Chest CT c/w pulmonary abscesses and she was placed of Vancomycin, Cipro, and Zosyn. Her hemodynamics improved while her mental status was very slow to recover. She was placed on escalating doses of levothyroxine as she had persistently elevated TSH values. Over the days of [**12-14**], her white blood cell counts fell dramatically, requiring neutropenia precautions. Hematology performed a bone marrow biopsy and viral and fungal studies were sent. ID recommended adjusting her antibiotic regimen and to treat empirically for C. difficile. Her remaining hospital course can be summarized by the following review of systems: Neuro: Patient's mental status continue to wax and wane. She will respond and move all extremities on command. Initially, due to initial hypotensive phase, requiring pressors, concerns were for hypoxic-ischemic encephalopathy. MRI and CT of her head did not show any acute processes but small vessel disease and a small focus acute infarct rt parietal lobe w/o mass effect. Ventricles & sulci prominent but appropriate for age. No abscess noted. Narcotics and analgesics were minimized. Her mental status continues to fluctuate. Cardio: Pt arrived on vasopressors and as eventually weaned off. However, continued to be hypotensive and tachycardic. Over stay, she had two transthoracic echocardiograms to evaluate cardiac function and possible infectious source. They both have been negative for any vegetations or abscesses. No intracardiac source of embolus identified; however, complex atheroma were noted in the aortic arch and descending aorta. Her EF is > 55%. Small left ventricular cavity suggestive of low preload/intravascular volume depletion; EF . She was switched to phenylephrine and midodrine added. She was eventually weaned off as her volume status was carefully repleted. Lopressor was added for heart rate control but has been discontinued. She is currently hemodynamically stable and making sufficient urine. Pulm: On arrival, patient clinically had a tenuous respiratory status. She remained intubated. Several bronchoscopies and lavages performed to wash out mucus plugging performed by interventional pulmonology. To monitor her fluid status closely, a central venous line was placed, which unfortunately caused a moderate L-sided pneumothorax which was demonstrated on chest x-ray upon admission. A chest-tube was placed and the pneumothorax has since resolved; however, the multi-cystic area was noted on follow-up CT scan obtained today. Thoracic surgery did not feel she was a suitable candidate for any invasive procedures. She responded to antibiotics and pulmonary toilet. She failed to wean successfully from the ventilator and was entirely dependent on mechanical breathing. ICU team performed a tracheostomy with placement of a feeding gastrostomy tube for enteral feeds. She is currently doing well on trach mask. Aside from occasional sleep apneic periods, requiring pressure support, she is stable on trach collar. Speech and swallow evaluated and placed a Passy-Muir valve. She is currently using her Passy-Muir valve without issues. GI: She was transferred to [**Hospital1 18**] for treatment and management of peritonitis and sepsis. Ostomy care involved in wound care. With her GI bleeding, Hct were trended. She received a colonoscopy through her Hartmann which were negative for any active bleeding. We continued to trend her liver panel enzymes. There was an elevation with alkaline phosphatase. Obtained a RUQ US showing scattered hepatic cysts, unchanged from the comparison CT and no concerning hepatic masses. Cholelithiasis and gallbladder mural edema in a non-distended gallbladder. Given the presence of ascites, the mural edema is nonspecific and may be related to third-spacing of fluid. Ascites with complex internal echoes and septations, raising concern for possible infectious or inflammatory process. Gastrotomy tube placed for enteral feeds. Her tube feeds were advanced. Started on reglan for motility. An upper endoscopy performed by gastroenterology for maroon colored ostomy output associated with decrease in Hct. Study showed ulcers near tube site but no active bleed. Bleeding and Hct stabilized with transfusions, reversal INR with Vit K, and NG lavage washed. She was maintained on higher dose PPI. H.pylori returned negative. Ostomy continued to work without any concerns. FEN: She is tolerating tube feeds (Fibersource) at full strength (goal 40 mL/hour - (23 kcal/kg)). Her electrolytes were repleted daily with intravenous and oral supplements as needed. She received 26 vials of albumin to effectively wean pressors and provide more intravascular volume. Renal: With initial septic event, urine status was critical and carefully monitored. As she clinically improved, she is no longer oliguric and is making 20-30 ml/hr. Lasix was used for diuresis to attempt ventilator wean given positive net fluid status. She is auto-diuresing. Foley catheter is placed due to poor mobility. Urine output carefully monitored with urinalysis for any colonization and changed if needed. ID: Pt was placed on IV vanco/zosyn/cipro at admission on [**1-17**]. WBC was elevated at 16.7 on [**1-17**]. Surveillance BC remained neg. Underwent chest Ct imaging which demonstrated loculated collection in LUL; technically difficult to drain and broad spectrum antibiotic therapy continued; underwent BAL on [**1-19**]; culture no growth; had Trach and g tube placement on [**1-21**]. Pt??????s WBC was noted to have declined to 2.0 on [**2-2**]; diff: 42 segs, 37 lymphs, 16 monos, 5 atypical. ANC of 840. The WBC continued to decline over the next few days with WBC of 700 on [**2-3**]; diff 18 segs, 64 lymphs; 14 monos; 4 atypicals. BC on [**2-3**] were no growth to date. With febrile neutropenia, she was placed on neupogen and infectious disease consult requested for further management. With fevers, she continued to be pan-cultured which all yielded negative results. With neutropenic state, she was started on empiric flagyl with anti-fungals since history indicated perforated intra-abdominal contents. Zosyn discontinued due to concerns of causing neutropenia. Viral serologies were sent and have been all negative. All antibiotics were discontinued on [**2135-2-15**] as fevers resolved. Heme: Please refer to hematology consult notes for more information. Essentially, patient was neutropenic and thrombocytopenic secondary to zosyn. Bone marrow biopsies taken and were otherwise inconclusive. Her leukocyte numbers normalized as she was taken off antibiotics. Patient was also coagulopathic likely from vitamin K deficiency in setting prolonged antibiotic use. She was given vitamin K with good effect. Labs were cycled for concerns of DIC given presumed sepsis. In review, BM results suggest a possibility of involvement by a T-cell lymphoproliferative disorder. But this Clonal T cell proliferation can also be due to infectious / inflammatory stage. Patient needs Hem /Onc follow up after her acute issues are resolved (follow up in 1 month). With low platelets, heparin discontinued for concerns of HIT. During stay, she was transfused 9u pRBC and one pack of platelets. She is not on heparin due to concerns of HIT. She is receiving boots and lab values do suggest that she is coagulopathic. Endo: Patient maintained on her thyroid medication while in patient. Thyroid function checked to assess levels as medication resumed and adjusted to her metabolic needs. She was provided with an insulin sliding scale for coverage. Due to presumed initial hemodynamically unstable state, she was given stress steroid dosing which were effectively weaned off. Consults involved: infectious disease, gastroenterology, heme/onc, general surgery, SICU, thoracic surgery, nutrition, speech/swallow, PT, neurology Lines/Tubes/Drains: Tracheostomy,Gtube, foley, PICC, colostomy Wounds: Midline laparotomy incision, Tracheostomy She is still full code. Medications on Admission: Vancomycin 1000mg IV Daily Zosyn, 3.375g IV Q6h Levophed gtt Levothyroxine 150mcg PO Qday Novolin Insulin SS Digoxin 0.125mg PO Q48h Heparin 5000 Units SC TID Lopressor 25mg PO Qday Hydrocortisone 50mg IV Qday Tylenol PRN Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution [**Date Range **]: per sliding scale sliding scale Injection ASDIR (AS DIRECTED). 2. Miconazole Nitrate 2 % Powder [**Date Range **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for thrush. 3. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y (650) mg PO Q4H (every 4 hours) as needed for pain/fever. 4. Metoclopramide 10 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a day). 5. Levothyroxine 100 mcg Tablet [**Age over 90 **]: Two (2) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 7. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. Discharge Disposition: Extended Care Facility: NE [**Hospital1 **] Discharge Diagnosis: perforated diverticulitis s/p sigmoid colectomy acute respiratory distress syndrome prolonged intubation requiring tracheostomy encephalopathy, slowly resolving pulmonary abscess neutropenia lower gastrointestinal bleed anemia requiring transfusion Discharge Condition: Mental Status:Confused - always Level of Consciousness:Lethargic but arousable Activity Status:Bedbound Discharge Instructions: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. PICC Line: *Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is significantly soiled for further instructions. Monitoring Ostomy output/Prevention of Dehydration:\ *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: Please follow up with your surgeon who did your operation at the outside hospital. You will have follow up with Dr. [**Last Name (STitle) 2036**] or one of his associates. Please call his office at ([**Telephone/Fax (1) 13344**], if they have not contact[**Name (NI) **] you with an appointment date in one week. Your follow up with hematology/oncology is recommended for 1 month.

[ "348.39", "518.0", "348.1", "567.21", "440.0", "272.4", "038.9", "493.20", "276.50", "513.0", "E930.0", "584.9", "286.7", "531.90", "512.1", "785.52", "401.9", "V44.3", "288.03", "562.11", "998.11", "995.92", "780.61", "008.45", "244.9", "934.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "45.24", "33.24", "38.91", "43.11", "34.04", "31.1", "38.93", "96.72", "45.13", "88.72" ]

icd9pcs

[ [ [] ] ]

16358, 16404

6450, 7887

333, 549

16697, 16697

2952, 4652

19411, 19796

2213, 2217

15497, 16335

16425, 16676

15251, 15474

16827, 17729

18022, 19388

2232, 2933

7907, 15225

17762, 18006

275, 295

577, 1883

4661, 6427

16711, 16803

1905, 2053

2085, 2197

41,744

137,167

41093

Discharge summary

report

Admission Date: [**2190-2-17**] Discharge Date: [**2190-2-18**] Date of Birth: [**2135-9-12**] Sex: M Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 1271**] Chief Complaint: Intraventricular hemorrhage Major Surgical or Invasive Procedure: . History of Present Illness: Mr. [**Known lastname **] is a 54 yo M recently diagnosed with metastatic cancer, who developed respiratory distress and altered mental status today. The patient was found to have widely metastatic cancer with unknown primary about 3 weeks ago (mets include brain, lung, liver, pancreas). He is following with [**Hospital1 2025**] oncology. The patient developed worsening lethargy and difficulty breathing today at home. His family describes that he "passed out" but his eyes remained open, though he was less responsive. He was brought to [**Hospital3 **], where he was dyspneic and hypoxic. He failed BiPAP and required intubation for respiratory fatigue and hypoxia. He then became hypotensive and tachycardic, started on neo, and transferred to [**Hospital1 18**]. At [**Hospital1 18**] ED, patient was switched to Levophed and given vanco/levaquin. CXR was clear. FAST scan showed some peritoneal fluid, which surgery determined was not a significant hematoma. INR was 12, and he was given vitamin K, FFP and profiline. Head CT showed hemorrhage in the 3rd ventricle, suspicious for pituitary hemorrhage focus with intraventricular extension. Past Medical History: metastatic cancer with unknown primary (dx 3 wks ago) mechanical AVR on coumadin Social History: married, has 2 sons. Family History: NC Physical Exam: Admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 1.5mm nonreactive EOMs +dolls eyes Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: intubated, sedated. Not opening eyes to noxious stimuli, not following any commands. Pupils equally round but nonreactive to light, 1.5 mm bilaterally. + dolls eyes + corneal reflexes Not moving spontaneously, not withdrawing to noxious Reflexes 1+ symmetric throughout, normal tone. Toes mute bilaterally Pertinent Results: C/A/P CT scan [**2190-2-17**] Small volume high density fluid in pelvis, [**Last Name (un) **] hemoperitoneum. RLL infrahilar mass like structure, concerning for malignant involvement. Noncontrast tech limits eval of full extent of metastatic dz Head Ct [**2-17**] Acute intraventricular hemorrhage centered within the third ventricle, of unclear etiology, though possibly due to bleeding hypervascular metastasis. No obstructive hydrocephalus. Recommend correlation with prior imaging once available and consider CTA and MRI for further evaluation. [**2190-2-17**] 08:50PM GLUCOSE-88 UREA N-43* CREAT-2.1* SODIUM-149* POTASSIUM-5.1 CHLORIDE-120* TOTAL CO2-20* ANION GAP-14 [**2190-2-17**] 08:50PM estGFR-Using this [**2190-2-17**] 08:50PM ALT(SGPT)-594* AST(SGOT)-895* ALK PHOS-361* TOT BILI-2.5* [**2190-2-17**] 08:50PM LIPASE-913* [**2190-2-17**] 08:50PM ALBUMIN-2.8* CALCIUM-8.3* PHOSPHATE-5.5* MAGNESIUM-2.6 [**2190-2-17**] 08:50PM PH-7.26* [**2190-2-17**] 08:50PM GLUCOSE-90 LACTATE-2.9* NA+-148 K+-5.3 CL--120* TCO2-18* [**2190-2-17**] 08:50PM HGB-12.6* calcHCT-38 O2 SAT-98 [**2190-2-17**] 08:50PM freeCa-1.12 [**2190-2-17**] 08:50PM WBC-18.2* RBC-3.61* HGB-12.5* HCT-36.4* MCV-101* MCH-34.5* MCHC-34.3 RDW-15.2 [**2190-2-17**] 08:50PM NEUTS-74* BANDS-1 LYMPHS-15* MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2190-2-17**] 08:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2190-2-17**] 08:50PM PLT SMR-NORMAL PLT COUNT-250 [**2190-2-17**] 08:50PM PT-102.7* PTT-82.2* INR(PT)-12.9* Brief Hospital Course: This is a 54 year old man who was admitted to the NSICU, Dr. [**Last Name (STitle) 739**] for management of IVH in the setting of metastatic lung cancer. His INR was 12 on admission due to Coumadin use for AVR. This was corrected by the ICU to 1.8. His oncologist at [**Hospital3 2576**] was contact[**Name (NI) **] and he felt that his prognosis prior to this admission and IVH was less then 3 months. He and Dr. [**Last Name (STitle) 739**] agreed that no surgical intervention would improve his grave prognosis. Family meetings were held on [**2-17**] and [**2-18**] and the family ultimately decided to make him CMO. He expired in the afternoon on [**2190-2-18**]. Medications on Admission: Coumadin and a cholesterol medication Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Intraventricular Hemorrhage Metastatic Lung Cancer Discharge Condition: . Discharge Instructions: . Followup Instructions: . [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2190-2-18**]

[ "199.1", "518.81", "V58.61", "197.8", "790.92", "785.50", "E934.2", "V49.86", "198.3", "197.7", "197.0", "V43.3", "431" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.97" ]

icd9pcs

[ [ [] ] ]

4632, 4641

3844, 4515

318, 322

4736, 4740

2239, 3821

4790, 4918

1661, 1665

4603, 4609

4662, 4715

4541, 4580

4764, 4767

1680, 1895

251, 280

350, 1501

1910, 2220

1523, 1606

1622, 1645

63,672

128,131

40964

Discharge summary

report

Admission Date: [**2122-8-5**] Discharge Date: [**2122-8-22**] Date of Birth: [**2036-10-16**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2122-8-17**] coronary artery bypass grafting x4 (Left Internal Mammary Artery to left Anterior descending artery, reverse Saphenous Vein Graft to Obtuse Marginal, reverse Saphenous Vein Graft to Diagonal artery, reverse Saphenous Vein Graft to Posterior Diagonal Artery) History of Present Illness: 85 year year old male with progressive shortness of breath for past 4 days prior to presenting to outside hospital emergency room. Treated for pneumonia, heart failure and NSTEMI. Ruled in for NSTEMI with elevated CK and troponin see was worked up for cardiac disease which included cardiac catheterization. This revealed coronary artery disease and he is referred for surgical evaluation. In relation to question of pneumonia as per pulmonary consult at outside hospital no evidence of community aquired pneumonia, however completed course of azithromycin for potential of bronchitis. He also was continued on steroids for potential COPD exacerbation however no previous history of COPD but current tobacco use. Past Medical History: CKD stage 3, DVT, PAD, HTN, Diastolic HF, Anemia, Left fem-popiteal bypass, s/p cataract bilateral [**2121**] and [**2120**], s/p AAA 10 years ago Social History: Race: Caucasian Last Dental Exam: 2 teeth - last exam > 1 year Lives with: wife Contact: [**Name (NI) 89387**] Phone # [**Telephone/Fax (1) 89388**] Occupation: retired iron worker Cigarettes: Smoked no [] yes [x] last cigarette [**7-31**] Hx: 60 pack year history ETOH: < 1 drink/week [] [**3-16**] drinks/week [] >8 drinks/week [x] Shinley rye - 3 shots a night Illicit drug use - denies Family History: Family History:Premature coronary artery disease Physical Exam: Pulse: 70 Resp: 18 O2 sat: 96 RA B/P 149/78 General: Pleasant, HOH, no acute distress Skin: Dry [x] intact [x] left leg and groin surgical scar Left flank surgical scar HEENT: PERRLA [x]- sluggish 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] +BS [x] Extremities: Warm [x], perfused [x] Edema None Varicosities: bilateral spider at ankles and upper legs Neuro: Grossly intact [x] Pulses: Femoral Right: cath site +2 Left: +2 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: + bruit Left: no bruit Pertinent Results: ECHO [**2122-8-17**] PRE-CPB:1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the aortic root. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. The aortic arch is mildly dilated. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (mobile) atheroma in the descending aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-8**]+) mitral regurgitation is seen. 7. There is a very small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. A pacing with PAC's. Preserved biventricular systolic function with LVEF now 50%. Improved anterior and inferior hypokinesis. MR is now 1+. The aortic contour is normal post decannulation. The mobile atheroma in the discending aorta is not seen post cpb. Pre-op labs: [**2122-8-5**] 06:30PM PT-11.8 PTT-24.9 INR(PT)-1.0 [**2122-8-5**] 06:30PM PLT COUNT-224 [**2122-8-5**] 06:30PM WBC-9.4 RBC-3.70* HGB-11.7* HCT-33.8* MCV-92 MCH-31.6 MCHC-34.5 RDW-15.0 [**2122-8-5**] 06:30PM %HbA1c-5.8 eAG-120 [**2122-8-5**] 06:30PM ALBUMIN-3.5 MAGNESIUM-2.1 [**2122-8-5**] 06:30PM CK-MB-4 [**2122-8-5**] 06:30PM LIPASE-67* [**2122-8-5**] 06:30PM ALT(SGPT)-45* AST(SGOT)-48* LD(LDH)-283* CK(CPK)-370* ALK PHOS-49 AMYLASE-49 TOT BILI-0.4 [**2122-8-5**] 06:30PM GLUCOSE-208* UREA N-40* CREAT-1.5* SODIUM-140 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14 Discharge labs: Bun22/creat 1.5 Hct 26.5/ WBC 4.8 INR 1.7 (coumadin 2.5mg) Brief Hospital Course: Mr [**Known lastname 17204**] was admitted post NSTEMI and underwent an extensive pre-operative work up during which an incidental lung nodule was found for which he will have a follow up appointment with thoracic surgeon Dr. [**Last Name (STitle) **] post cardiac revascularization. His surgery was further delayed when he developed herpes simplex for which he was treated with antivirals. Once his lesions were crusted he was taken to the operating room on 7//[**12-18**] where he underwent coronary bypass grafting, please see operative report for details. In summary he had: coronary artery bypass grafting x4 with Left Internal Mammary Artery to left Anterior descending artery, reverse Saphenous Vein Graft to Obtuse Marginal, reverse Saphenous Vein Graft to Diagonal artery, reverse Saphenous Vein Graft to Posterior Diagonal Artery. His bypass time was 90 minutes with a crossclamp time of 70 minutes. He tolerated the operation well and post-operatively was transferred to the cardiac surgery ICU. He did well in the immediate post-operative period. Weaned off Neo and transitioned to Lopressor. He woke neurologically intact and was extubated on the morning of POD1. He remained in the ICU that day to monitor his pulmonary status. Anticoagulation was resumed for his history of DVT. He was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. Postoperatively he has been intermittently confused but is improving and today answers all questions appropriately. he is very hard of hearing. His foley was replaced evening of POD#3 for failure to void and drained 600cc. He was cleared for discharge to [**Hospital 13040**] Nursing and Rehab rehab today on POD# 5 with foley in place. Plan voiding trial within a few days at rehab. All follow up appointments were advised. He has scant serosang drainage from the midportion of his sternal incision. He must shower daily and will require the incision to be painted daily with betadine and covered with a DSD daily. He also has a follow up appointment to be seen on [**8-27**] at 11am for a sternal wound evaluation. Medications on Admission: Nifedipine 90', ASA 81', Dyazide 25/37.5', Klor Con 20', Coumadin Medications on transfer Solumedrol 20 mg IV q8h x2 doses 6/29 on taper [**Hospital1 **], Mucinex 600 mg [**Hospital1 **], Azithromycin 500 mg IV BID, Lipitor 80 mg daily, Atrovent nebs q6h, Albuterol nebs q6h, Triamterene 1 daily, Potassium Chloride 20 mEq daily, Nifedipine XL 90 mg daily, Lopressor 12.5 mg [**Hospital1 **], Aspirin 325 mg daily, Coumadin 2.5 mg stopped [**8-1**] Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for leg pain. 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. warfarin 2.5 mg Tablet Sig: dose per INR Tablet PO once a day: Dose Based on INR Indication hx DVT Goal INR 2.0-2.5 No lovenox bridge. 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: until edema resolves then maintenance as needed. 13. wound care Paint sternal incision with betadine daily and cover with DSD. Discharge Disposition: Extended Care Facility: [**Location (un) 13040**] Nursing & Rehabilitation Center Discharge Diagnosis: coronary artery disease CKD stage 3, DVT, PAD, HTN, Diastolic HF, Anemia, Left fem-popiteal bypass, s/p cataract bilateral [**2121**] and [**2120**], s/p AAA 10 years ago Discharge Condition: Alert and oriented x3 nonfocal - very hard of hearing Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing, no erythema or scant serosang drainage from mid portion of the incision Leg Right/Left - healing well, no erythema or drainage. Edema trace to 1+ Discharge Instructions: **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** 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 - Please paint the sternal incision with betadine daily and cover with DSD daily. Call the cardiac surgery sugery office [**Telephone/Fax (1) 170**] if the drainage changes and becomes purulent or increases in amount. 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 one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] [**9-10**] at 1:15 pm [**Telephone/Fax (1) 170**] [**Hospital **] Medical Building [**Hospital Unit Name **] Wound check on thursday [**2122-8-27**] in the [**Hospital **] medical office building [**Hospital Unit Name **] per Dr. [**Last Name (STitle) **] due to scant serosang sternal drainage. Cardiologist: Dr. [**Last Name (STitle) 8051**] [**Telephone/Fax (1) 8058**] on [**9-21**] at 10:15 am PFT,INTERPRET W/LAB NO CHECK-IN PFT INTEPRETATION BILLING Date/Time:[**2122-9-15**] 11:00 PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2122-9-15**] 11:00 RADIOLOGY MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-9-15**] 12:20 Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) **],AUROBINDO [**Telephone/Fax (1) 8058**] in [**5-12**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication :hx DVT Goal INR 2.0-2.5 First INR draw tomorrow [**2122-8-23**] then mon/wed/fri for 2 wweks until INR stable Please arrange couamdin follow up upon discharge from rehab. Followup with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] regarding your lung nodule on [**2122-9-15**] at 1:30pm on [**Hospital Ward Name **], [**Hospital Ward Name 23**] [**Location (un) **]. Prior to this appointment you will have: PFT is at 11:00am on [**2122-9-15**] [**Hospital Ward Name 2104**] [**Location (un) **] ([**Location (un) 3387**]) Brain MRI at 12:00pm [**Hospital Ward Name 23**] 4 [**Hospital Ward Name **] If questions call [**Telephone/Fax (1) 2348**]. Completed by:[**2122-8-22**]

[ "285.9", "054.19", "428.32", "433.30", "305.1", "998.12", "729.5", "443.9", "585.3", "403.90", "518.89", "E879.0", "433.10", "V12.51", "410.71", "414.01", "428.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8917, 9001

4926, 7079

330, 607

9216, 9520

2765, 4827

10707, 12507

1967, 2003

7579, 8894

9022, 9195

7105, 7556

9544, 10684

4843, 4903

2018, 2746

271, 292

635, 1352

1374, 1522

1538, 1936

11,723

127,726

28439

Discharge summary

report

Admission Date: [**2177-12-23**] Discharge Date: [**2178-1-7**] Date of Birth: [**2145-7-4**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 5755**] Chief Complaint: pancytopenia Major Surgical or Invasive Procedure: bone marrow biopsy History of Present Illness: 32 year old female with history of SLE (with proteinuria and pleurissy) who presented with pancytopenia. Patient has recently been complaining of fatigue, dyspnea on exertion, epistaxis, petechiae over her shins, and then developed zoster over her abdomen on [**2177-12-6**]. She also complained of a blind spot in her vision over the past 2 days without associated pain. On further review of systems, she denied any fevers, chills, headache, confusion, loss of hearing, neck stiffness, abdominal pain, n, v, diarrhea, numbness, tingling, or focal weakness. In the ED she was found to be profoundly pancytopenic. She was seen by heme. Smear without schistocytes and bone marrow bx was done. She was admitted to the [**Hospital Unit Name 153**] for continued care. Past Medical History: # SLE: dx '[**68**], membranous nephropathy by bx, + facial rash # Sjogrens syndrome # Rayndaud's # gastritis Social History: No tob, etoh, drugs. Recently married. Works as a computer programmer. Family History: adopted Physical Exam: (per ICU admit note): T 98.7 bp 117/77 hr 73 rr 16 O2 100% RA genrl: in nad heent: op clear, perrla, eomi neck: supple, no jvd cv: rrr, no m/r/g pulm: cta bilaterally abd: nabs, soft, tender to palpation over zoster in LLQ extr: no c/c/e neuro: a,ox3, cn 2-12 intact, normal strength/sensation in limbs x 4 skin: petechiae over bilateral shins, scabbed zoster overlying LLQ and left flank Pertinent Results: [**2177-12-23**] 12:45PM WBC-0.5*# RBC-1.30*# HGB-4.0*# HCT-11.1*# MCV-86 MCH-30.8 MCHC-35.9* RDW-20.7* [**2177-12-23**] 12:45PM NEUTS-75* BANDS-0 LYMPHS-18 MONOS-5 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2177-12-23**] 12:45PM PLT SMR-VERY LOW PLT COUNT-8*# [**2177-12-23**] 12:45PM GRAN CT-420* . [**2177-12-23**] 12:45PM PT-12.6 PTT-26.9 INR(PT)-1.1 [**2177-12-23**] 12:45PM FIBRINOGE-378 . [**2177-12-23**] 12:45PM HAPTOGLOB-193 [**2177-12-23**] 07:07PM LD(LDH)-101 [**2177-12-23**] 07:07PM RET AUT-0.5* [**2177-12-23**] 07:07PM IRON-138 [**2177-12-23**] 07:07PM calTIBC-207* VIT B12-258 FOLATE-12.4 HAPTOGLOB-159 FERRITIN-390* TRF-159* FOLATE 12.4, B12 258 . [**2177-12-23**] 12:45PM GLUCOSE-121* UREA N-13 CREAT-0.9 SODIUM-132* POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-14 [**2177-12-23**] 12:45PM ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-130 ALK PHOS-86 AMYLASE-102* TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 [**2177-12-23**] 12:45PM LIPASE-24 [**2177-12-23**] 12:45PM ALBUMIN-3.5 . [**2177-12-23**] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2177-12-23**] 04:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2177-12-23**] 04:30PM URINE RBC-1 WBC-3 BACTERIA-RARE YEAST-NONE EPI-[**1-19**] . URINE PROTEIN/CREATININE 1.0 . SPEP: POLYCLONAL HYPERGAMMAGLOBULINEMIA, NO MONOCLONAL IMMUNOGLOBULIN SEEN INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD [**Last Name (Titles) 66046**]: NEGATIVE . C3 48, C4 12 HIV AB: NEGATIVE EBV: NOT DETECTABLE PARVOVIRUS IGM: NEGATIVE 6MP/AZATHIOPRINE METABOLITES: LOW TO WITHIN NORMAL LIMITS CMV VL: UNDETECTABLE MONOSPOT: NEGATIVE EBV IGG AND IGM: POSITIVE . FUNGAL BLOOD CX: NO GROWTH TO DATE BLOOD CX: NO GROWTH URINE CX: NO GROWTH . [**2177-12-23**] 6:30 pm BONE MARROW RECD. IN YELLOW ACD SOLUTION A TUBE. FLUID CULTURE (Final [**2177-12-26**]): NO GROWTH. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . EKG: Sinus rhythm. Low precordial voltage. Delayed precordial R wave progression. No previous tracing available for comparison. . BONE MARROW BX FLOW CYTOMETRY IMMUNOPHENOTYPING: The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 3, 5, 10, 13, 19, 20, 23, 34 and 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Cell marker analysis demonstrates that the cells isolated from this bone marrow consists of a mixture of polyclonal B and T cells. T cells express mature lineage antigens. CD34-positive blasts comprise of ~2% of total events. INTERPRETATION Non-specific reactive lymphoid profile; no phenotypic evidence of lymphoma in specimen. CD34-expressing blasts are approximately 2% of all events. Correlation with clinical findings and morphology (see separate report S07-5329C) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. . BONE MARROW, ASPIRATE AND CORE BIOPSY: HYPOCELLULAR MARROW WITH TRILINEAGE MYELOSUPPRESSION (SEE NOTE) NON-PARATRABECULAR LYMPHOID INFILTRATE, FAVOR BENIGN Note: The marrow appears hypocellular with suppression of all three hematopoietic cell lines. Blasts are enumerated at 2% of marrow cellularity by morphology. The residual myeloid and erythroid cells are left shifted. CD138 highlights plasma cells which account for almost 30-40% of marrow cellularity. They are polytypic for immunoglobulin light chains kappa and lambda; CD68 highlights numerous interspersed macrophages. Overt hemophagocytosis is not present. No intranuclear inclusions or viral cytopathic effects are seen. Special stains including AFB, GMS, and PAS are negative for stainable organisms. While the overall findings may be the result of myelo-suppressive therapy or of infectious etiology, close clinical follow-up with a repeat biopsy is recommended if clinically indicated. Please correlate with cytogenetics, other clinical and laboratory findings. MICROSCOPIC DESCRIPTION. Peripheral Blood Smears: The smear is from [**2177-12-23**], and is a buffy coat preparation, due to low WBC. Erythrocytes show aniso-poikilocytosis, microcytic and hypochromic. There also appear to be two populations of erythrocytes. Rare nucleated red cells are present. The white blood cell count appears markedly decreased. Neutrophils contain toxic granules and rare left shifted myeloids are present. Platelet count appears markedly decreased. Giant forms are present. Differential count (300 cells) shows 72 % neutrophils, 7 % monocytes, 18 % lymphocytes, 3 % eosinophils. Aspirate Smears: The aspirate material is adequate for evaluation and contains several hypocellular spicules. There are focal small clusters of mature-appearing plasma cells. The M:E ratio is 0.5:1. Erythroid precursors are present. Rare erythroids have mild megaloblastic changes and irregular nuclear membrane. Myeloid precursors appear decreased in number and show left shifted maturation. Megakaryocytes are decreased in numbers; abnormal forms are not seen. While rare histiocytes with intra-cytoplasmic cellular debris is seen, evidence of overt hemophagocytosis is not seen. Differential shows: 2 % Blasts, 1 % Promyelocytes , 3 % Myelocytes, 6 % Metamyelocytes, 5 % Bands/Neutrophils, 39 % Plasma cells, 14 % Lymphocytes, 30 % Erythroid. Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation. Cellularity is variable. Overall cellularity is estimated at 10-30%. The M:E ratio is decreased with a relative erythroid dominance. Erythroid precursors are overall (absolute) decreased in number and show left shifted maturation. Occasional irregular nuclear membrane are noted within erythroids noted. Myeloid elements are markedly decreased in number. Megakaryocytes are present in overall normal number and occur focally in loose and tight clusters. Small, hypolobated forms are also seen. Occasional, small non-paratrabecular lymphoid infiltrates are seen. There are many focal clusters of plasma cells, estimated at 30-40% of marrow cellularity. Increased interstitial hemosiderin-laden macrophages are noted. Immunoperoxidase stains reveal the following: CD138 highlights plasma cells, which are estimated at 30-40% of marrow cellularity. Some plasma cells are in small aggregates and clusters. Kappa and lambda immunostains reveal that these were polytypic. CD68 highlights many histiocytes/macrophages. No overt hemophagocytosis is detected by CD68 immunostains. [**Last Name (un) **] (EBV encoded RNA) by in-situ hybridization studies were negative. Further immunostains for CD20, CD3 and CD34 are pending and will be reported in an addendum. Special Stains: Iron stain is adequate for evaluation. Storage iron is markedly increased. Rare sideroblasts are present. Ringed sideroblasts are absent. GMS, AFB and PAS stains do not reveal any stainable micro-organisms. ADDENDUM: This addendum is to incorporate the results of additional immunoperoxidase stains. CD20-immunostain was equivocal with very dim to absent staining of scattered B-lymphocytes (reactive external control). CD3-immunostain highlights scattered T-lymphocytes. CD34 immunostain highlights blasts comprising of ~1-2% of marrow cellularity. The overall diagnosis remains unchanged. . BONE MARROW - CYTOGENETICS: KARYOTYPE: 46,XX INTERPRETATION: No cytogenetic aberrations were identified in metaphases analyzed from this unstimulated specimen. This normal result does not exclude a neoplastic proliferation. Mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. . PA AND LATERAL CHEST RADIOGRAPH The lungs are clear without evidence of parenchymal consolidation bilaterally. There is a small left-sided pleural effusion with a slightly larger right- sided pleural effusion as well as right pleural thickening, best appreciated on the lateral view which appears similar to [**8-21**] examination. Overall increased interstitial markings on the lateral view is likely related to low inspiratory effort. Cardiomediastinal silhouette and hilar contours are unremarkable. No evidence of pneumothorax. IMPRESSION: 1. No acute cardiopulmonary process identified. 2. Bilateral pleural effusions (right greater than left) with right pleural thickening. . CT OF THE CHEST: The heart, pericardium, and great vessels appear normal, apart from a trace pericardial effusion. No pathologic axillary, mediastinal, or hilar lymphadenopathy is appreciated. There is a 5-mm prevascular lymph node, a 7 mm precarinal lymph node, and an 8 mm subcarinal lymph node. There is also borderline lymphadenopathy in the right hilar region. The central airways are patent. In the lungs, there is an oval nodule measuring 3 mm in the right upper lobe (3:22). There is atelectasis in the right lower lobe and small bilateral pleural effusions, right greater than left. Small bullae are seen in the right lung. A 1.4-cm hypodensity with peripheral enhancement is seen in the right lobe of the liver inferiorly. There is both intra- and extrahepatic pneumobilia. There is prominence of the common bile duct measuring up to 10 mm. There is very mild central intrahepatic ductal dilation as well. The gallbladder is not distended, does not have gallbladder wall edema and there is no pericholecystic fluid. There is, however, nondependent gas within the gallbladder lumen, as well as gas in the cystic duct. The adrenal glands and pancreas appear normal. A small region of hypoattenuation in the pancreatic head (3:66) is only seen on the axial view and is likely related to partial volume averaging. The pancreatic duct is not dilated. The spleen measures 12 cm in diameter, at the upper limits of normal in size, but has a slightly bulky appearance subjectively. The kidneys enhance and excrete contrast normally without hydronephrosis. The loops of bowel are normal in caliber without evidence of wall thickening or surrounding inflammation. There is a small amount of fluid in the abdomen surrounding the liver anteriorly. The major vascular structures are patent and are of normal caliber. CT OF THE PELVIS: The bladder and rectum appear unremarkable. There are multiple heterogenous lobulations of the uterus consistent with fibroids. Multiple borderline and slightly enlarged lymph nodes are seen in the retroperitoneal region. There is also prominent lymph nodes in the inguinal regions, measuring up to 12 mm in short axis. There is a small amount of free fluid in the pelvis. Marked skin thickening in the anterior pelvis, predominantly on the left, consistent with patient's skin involvement by herpes zoster. OSSEOUS/SOFT TISSUE STRUCTURES: There are no concerning lytic or sclerotic lesions. There is skin thickening seen in the left abdominal and pelvic regions. Discussion with the clinical team reveals that the patient has zoster in these regions. IMPRESSION: 1. Gas within the intra- and extrahepatic biliary ducts, the cystic duct, and the gallbladder lumen. These findings are most suggestive of prior sphincterotomy. Discussion with the clinical team reveal that the patient has had two ERCPs with sphincterotomies in the past. 2. Mildly dilated common bile duct, which is visualized to the level of the ampulla. This is suggestive of ampullary stenosis, although an ampullary lesion cannot be totally excluded. Please correlate with ERCP findings. 3. Mildly enlarged retroperitoneal lymph nodes and prominent inguinal lymph nodes. This is likely related to the patient's autoimmune disease or may be reactive given the patient's zoster, however lymphoma cannot be excluded based on the imaging findings. 4. Likely hemangioma in the right lobe of the liver, which is not fully evaluated on this study. 5. Fibroid uterus. Brief Hospital Course: # Pancytopenia: Fatigue likely secondary to anemia. Petechiae and epistaxis likely secondary to low plt. In the ED, she received 2 U PRBC and 2 bags of platelets. No sign of acute infection (no fevers) on presentation. Most likely aplastic anemia from drug (imuran, NSAID). Of note, imuran drug levels/metabolites within the normal range. Less likely myelophythsic process such as lymphoma - bone marrow biopsy not supportive. No schistosytes on smear and hemolysis labs neg. Heme was consulted and followed along. Counts steadily improved on neupogen and epogen. Parvo, HIV, CMV, EBV, and monospot all unrevealing. B12 and folate were normal and spep showed no monocolonal gammopathy. She received prophylactic antibiotics while neutropenic given immunosuppressed with prednisone. She was discharge home on epogen, thiamine, and folate until her counts recover. She is scheduled for outpatient hematology follow-up. . # Zoster: Her zoster had not changed over the time course that her WBC decreased. The patient reported that it was not spreading. Neuro exam normal and no signs of encephalopathy. LFTs normal. Lesions were crusted over. No treatment was indicated on admission; however, while in the ICU, new lesions were noted. Patient was on droplet precautions given risk of asymptomatic disseminated infection. She was treated with a total of 10 days of acyclovir with good response. She is receiving gabapentin with good relief for postherpetic neuralgia. . # Visual Changes: Ophtho was consulted. They diagnosed patient with diffuse hemorrhages and cotton wool spots bilaterally and recommended outpatient follow-up with Dr. [**Last Name (STitle) **]. . # SLE: Patient followed by rheum here(Dr. [**Last Name (STitle) 6426**]. Her creatinine is stable. She reports that her chronic cough (from pleuritis) is unchanged. CXR also unchanged. Her nabumetone and imuran were discontinued. She was continued on her prednisone and had no worsening of symptoms. Rheumatology followed along during her admission. She was instructed to follow-up with her renal doctor for her persistent proteinuria. . # Transient fever: Onset with start of neupogen. Cultures negative. Resolved once neupogen d/c. Covered empirically with antibiotics while neutropenic. . # Gastritis - cont PPI . # PPX: PPI/calcium/vitamin D (on steroids), Medications on Admission: imuran 50mg TID ([**Hospital1 **] since [**2178-10-3**], increased to TID on [**11-7**]) ultram 100mg [**Hospital1 **] (since [**2177-12-12**]) prednisone 10mg QD (since [**2177-12-12**]) protonix 40mg QD Nabumetone 1 gram daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 1 months. Disp:*180 Capsule(s)* Refills:*0* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Disp:*60 Tablet, Chewable(s)* Refills:*2* 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Epogen 20,000 unit/2 mL Solution Sig: One (1) injection Injection qFriday. Disp:*4 prefilled syringes* Refills:*0* 10. Outpatient Lab Work Please draw CBC with differential on [**2178-1-9**] and fax to [**Telephone/Fax (1) 34802**], attention Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 877**] Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: primary: pancytopenia herpes zoster retinal hemorrhages secondary: systemic lupus erythematosis with proteinuria Discharge Condition: good: counts steadily improving, no fever Discharge Instructions: Please call your doctor or go to the emergency room if you experience temperature > 101, sore throat, rash, bleeding (bloody nose, heavy menstrual bleeding, etc), if you fall and hit your head, dizziness, shortness of breath, lightheadedness, or other concerning symptoms. Please be extra careful to avoid falls or trauma: no contact sports, avoid climbing ladders etc. Please don't take your imuran or nabumetone anymore. Followup Instructions: Please follow-up as follows with rheumatology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Date/Time:[**2178-1-20**] 12:45 Location: [**Last Name (NamePattern1) 439**], [**Hospital Unit Name **], [**Location (un) **], [**Hospital Unit Name **] Phone: ([**Telephone/Fax (1) 1668**] Please follow-up as follows with the hematologist: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2178-1-14**] 3:30 Location: [**Hospital1 18**], [**Hospital Ward Name **], [**Hospital Ward Name 23**] Building, [**Location (un) **] Phone: ([**Telephone/Fax (1) 14703**] Please follow-up with the kidney doctors as follows: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3271**], Wednesday, [**1-21**] 3:30pm Location: [**Hospital1 18**], [**Hospital Ward Name **], [**Hospital Ward Name **] building, [**Location (un) 436**] Phone: ([**Telephone/Fax (1) 68978**] Please follow-up with your primary care doctor as follows: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5700**], Thursday, [**1-22**] at 2:45pm Phone: [**Telephone/Fax (1) 31923**] Please follow-up with the eye doctor as follows: Dr. [**Last Name (STitle) **], Monday [**2-2**] at 1:30 PM Location: [**Hospital1 18**], [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) 442**] ** THIS WILL BE A 2-3 hour APPOINTMENT **

[ "E933.1", "053.9", "710.0", "362.81", "284.8", "710.2" ]

icd9cm

[ [ [] ] ]

[ "99.05", "41.31", "99.04" ]

icd9pcs

[ [ [] ] ]

17678, 17727

13828, 16184

282, 303

17885, 17929

1778, 3766

18402, 19832

1341, 1350

16464, 17655

17748, 17864

16210, 16441

17953, 18379

1365, 1759

3802, 3833

3866, 13805

230, 244

331, 1103

1125, 1236

1252, 1325

10,237

128,509

54061

Discharge summary

report

Admission Date: [**2135-10-28**] Discharge Date: [**2135-11-9**] Service: General Surgery Purple Team HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old gentleman re-presenting to the Emergency Room with a distended and tender abdomen. He was recently diagnosed with a descending colon mass and an abscess. He was percutaneosly drained and was awaiting an outpatient colonoscopy for diagnosis. He was readmitted for constipation and a repeat CT scan was performed. There was no evidence of a leak and the drain was therefore removed. He presents today c/o left lower quadrant pain and obstipation. He denies fever or chills. He has been anorectic and nauseous. He vomited several times today. A KUB perfomed in the ED revealed a large bowel obstruction. He is admitted for fluid resuscitation and an emergent bowel resection with temporary colostomy. Past medical history is significant for chronic atrial fibrillation requiring a pacer, status post myocardial infarction in [**2129**], ? perforated colon cancer first noted in [**2135-7-25**], dementia, hypertension, and hypercholesterolemia. HOSPITAL COURSE: The patient was taken to the operating room on [**2135-10-28**] for an exploratory laparotomy, left hemicolectomy, Hartmann's pouch and end colostomy. Please see operative note per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for details of this operation. The patient's postoperative course was complicated by hypovolemia requiring admission to the Intensive Care Unit for monitoring of his fluid status by central line. The patient was aggressively rehydrated in the unit, and was ultimately discharged to the floor. On the floor, the patient's stay was also complicated by postoperative fever. Blood cultures were obtained indicating methicillin-resistant Staphylococcus aureus. The patient was then placed on Vancomycin. Subsequent cultures have remained negative. The patient's course was also complicated by infection of his abdominal wound requiring opening of the upper and lower parts of his abdominal incision. The patient was started on a clear diet. Upon transfer to the floor, he advanced in his diet as tolerated. The patient required one-to-one encouragement of feeding to maintain adequate intake. On the day of discharge to the rehabilitation facility, the patient was taking in adequate oral intake. His ostomy was productive and he was voiding normally. His abdominal wound was without erythema or evidence of infection. Of note, the pathology revealed a T3N1 colon cancer. He was seen by oncology and will f/u with that service after discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehab facility. DISCHARGE DIAGNOSES: Perforated colon cancer status post exploratory laparotomy, left hemicolectomy, Hartmann's and end colostomy. Discharge medications included Vancomycin 1250 mg IV bid for an additional nine days, milk of magnesia 30 cc po bid, aspirin 81 mg po q day, lisinopril 5 mg po q day, oxycodone acetaminophen elixir 5-10 cc po q4-6 hours prn, amiodarone 400 mg po bid until [**11-12**] at which point it will be switched to 200 mg po bid and metoprolol 50 mg po bid. FOLLOW-UP PLANS: Following with Dr. [**Last Name (STitle) **] in the next 1-2 weeks as well as follow up with the oncologist as the family decides on whether to pursue chemotherapy. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13186**], M.D. [**MD Number(1) 13187**] Dictated By:[**Last Name (NamePattern1) 1752**] MEDQUIST36 D: [**2135-11-9**] 09:03 T: [**2135-11-9**] 09:18 JOB#: [**Job Number **]

[ "153.8", "560.89", "997.1", "486", "584.9", "998.59", "427.31", "997.5", "997.3" ]

icd9cm

[ [ [] ] ]

[ "45.75", "38.93", "38.91", "45.95", "46.11", "48.23", "99.15" ]

icd9pcs

[ [ [] ] ]

2728, 3189

1128, 2633

3207, 3651

142, 1110

2658, 2706

2,973

195,519

8158

Discharge summary

report

Admission Date: [**2146-4-23**] Discharge Date: [**2146-4-30**] Date of Birth: [**2094-5-1**] Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male transfer from [**Hospital3 10310**] Hospital. He was admitted there with wide variety of medical problems, most arising from longstanding insulin-dependent diabetes mellitus. His functional status was mediocre, but he managed independently with some help from his mother. [**Name (NI) **] is status post a renal transplant for diabetes-induced nephropathy. He had an attempted pancreatic transplant in [**2143**] for treatment of diabetes which was complicated by early acute rejection, with septic shock, with necrosis with the transplanted pancreas, a large abdominal would which took more than one year to heal, peripheral ischemia, and gangrene of his feet (ultimately requiring amputation). He had done well in terms of recovery from those problems with a baseline creatinine which ran into the vicinity of 2.5 to 2.8. He was followed by the [**Hospital 1326**] Clinic here at [**Hospital1 346**]. He was doing reasonably well until about three weeks prior to admission when he became nauseated daily. About two weeks prior, he started having bouts of vomiting every other day which became more frequent and more severe. There did not seem to be any precipitating factors. The vomiting seemed to be consistent with what he had just eaten. No bile. No blood. He would have considerable retching. Along with this, he had some loose stool, but no overt diarrhea. This persisted and he had eaten rather little in the past few days prior to admission. He had not been vomiting up his pills. He came to the Emergency Room when he became overtly dehydrated. He had not had significant headaches, confusion, loss of consciousness, shortness of breath, cough, sputum production, significant abdominal pain, dysuria, hematuria, skin rashes, fevers, or sweats. He had had some mild chills in the evening. PAST MEDICAL HISTORY: Extensive - including longstanding insulin-dependent diabetes mellitus, diabetic nephropathy, with renal failure, renal transplant, hypertension, diabetic retinopathy, and attempted pancreatic transplant (as above). MEDICATIONS ON ADMISSION: Insulin, metoprolol, Kayexalate, prednisone, Bactrim, Protonix, Imuran, zinc, aspirin, Percocet, Rapamune, Lipitor, Paxil, and Epogen. SOCIAL HISTORY: He lives at home with his mother who helps him out. He has ongoing visiting nurse services. His functional status is mediocre. He is a former smoker. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: The patient appeared debilitated and chronically ill, but no different from baseline, in no distress. He was sitting comfortably in bed, breathing room air. Mental status was completely normal. His baseline temperature was 97.2, his pulse was 80, his respirations were 20, his blood pressure was 205/94, and his oxygen saturation was 100 percent. His skin showed no rashes. Head, eyes, ears, nose, and throat examination revealed pupils were reactive to light without icterus or photophobia. The oropharynx was dry and without lesions. The neck was supple and without lymphadenopathy. The lungs had some minimal bibasilar crackles. Cardiac examination revealed a normal rate and rhythm without murmur, rub or gallop. The abdomen revealed a large midline wound which was healed completely but left a large defect. No tenderness over the transplanted kidney in the left lower quadrant. The abdomen was completely nontender. Extremities showed below- the-knee amputation of the right leg and transmetatarsal amputation of the left foot; all of which had healed completely. No edema or cellulitis. PERTINENT RADIOLOGY-IMAGING: An electrocardiogram showed a sinus rhythm at a rate of 74 and a right bundle branch block. No other significant abnormalities. A chest x-ray showed no acute cardiopulmonary pathology. PERTINENT LABORATORY VALUES ON PRESENTATION: Sodium was 134, potassium was 5.2, blood urea nitrogen was increased from baseline at 55, creatinine was 3, and blood glucose was 143. White blood cell count was 6300 (with 76 polys and 12 bands), his hematocrit was 48 percent, and his platelets were normal. Urinalysis was quite unremarkable with trace protein, no cells. Liver function tests and lipase were completely normal. SUMMARY OF HOSPITAL COURSE: The patient was transferred to [**Hospital1 69**] for further workup with a presumed small-bowel obstruction and was taken to the operating room on [**2146-4-24**] for a small-bowel resection with closed loop obstruction. Postoperatively, the patient was afebrile and did very well. On postoperative day two, a peritoneal swab showed 2 plus polymorphonuclear neutrophils with no microorganisms. The patient-controlled analgesia was discontinued, and the patient was put on oral pain medications with diet furthered. On postoperative day three, the patient's levofloxacin and Flagyl was continued. Physical Therapy continued to see the patient. The patient was slightly hypertensive on postoperative day four, and hydralazine was increased with the addition of clonidine to his regimen of cardiac drugs. The patient's diet was advanced on postoperative day four, and the patient was discharged home on postoperative day six without event and in no acute distress. DISCHARGE DIAGNOSES: Closed loop small-bowel obstruction, status post small-bowel resection, primary anastomosis. MEDICATIONS ON DISCHARGE: 1. Epogen 4000 units injected two times per week. 2. Prednisone 5 mg one by mouth every day. 3. Clonidine 0.2 mg one by mouth three times per day. 4. Percocet 5/325-mg tablets one to two tablets by mouth q.4- 6h. 5. Lopressor 50-mg tablets one tablet by mouth every day. 6. Rapamycin 1-mg tablets three tablets by mouth once per day. 7. Hydralazine 50-mg tablets one tablet by mouth q.6h. 8. Protonix 40-mg tablets one tablet by mouth every day. 9. Ativan 0.5-mg tablets one tablet by mouth q.4-6h. 10. Flagyl 500-mg tablets one tablet by mouth three times per day. 11. Levofloxacin 250-mg tablets one tablet by mouth every day. 12. Imuran 50-mg tablets 1.5 tablets by mouth every day. DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed to call with any concerns, and a follow-up appointment was made with the [**Hospital 1326**] Clinic for followup. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2919 Dictated By:[**Doctor Last Name 9174**] MEDQUIST36 D: [**2146-5-2**] 13:07:18 T: [**2146-5-3**] 18:43:34 Job#: [**Job Number 15343**]

[ "557.0", "250.00", "285.9", "401.9", "V42.0", "560.2", "567.9" ]

icd9cm

[ [ [] ] ]

[ "45.62", "46.81", "45.91" ]

icd9pcs

[ [ [] ] ]

2625, 4434

5453, 5547

5573, 6705

2301, 2437

4463, 5431

182, 2034

2057, 2274

2454, 2608

32,678

148,332

19888

Discharge summary

report

Admission Date: [**2194-2-15**] Discharge Date: [**2194-2-21**] Service: NEUROSURGERY Allergies: Codeine / Percocet / Lisinopril / Lidocaine/Transparent Dressing Attending:[**First Name3 (LF) 1835**] Chief Complaint: Neck pain Major Surgical or Invasive Procedure: [**2-19**]: C1,C2 Laminectomy and lesion biopsy History of Present Illness: 85 year old female who presents with a week and a half of worsening neck pain that has affected her ability to ambulate and chew food comfortably. She was ambulating with a walker but because of the pain she has been unable. She also reports some numbness/tingling to her R fingertips but reports a history of carpal tunnel. A C-spine CT was done four days prior which showed a cervical mass but pain had intensified over the last few days and was brought to ER for pain management. Past Medical History: 1. CAD RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - Mitral valve regurgitation S/P post mitral valve repair with annuloplasty ring on [**2192-5-23**]. - Atrial fibrillation, off Coumadin - Mild hypertension. -CABG: Never -PERCUTANEOUS CORONARY INTERVENTIONS: Cath in [**2191**], no interventions. -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Osteoarthritis - Osteopenia - Gastroesophageal Reflux Disease - Rectal polyp s/p partial resection [**3-16**] - Diverticulosis - CHF with preserved EF on ECHO [**4-5**] - cervical and lumbar spondylosis SURGICAL HISTORY: - s/p right total knee replacement [**2188**]. [**Doctor Last Name 15568**]-NWH - s/p cholecystectomy in [**2145**] - s/p appendectomy in [**2145**] - s/p cataract removal - s/p bilateral carpal tunnel release Social History: She has 3 daughters. Widowed. Retired executive secretary who was also a sales representative for Nestle. -Tobacco history: Denies -ETOH: Occasional Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAM on Admission: O: T: 97.6 BP: 138/66 HR: 72 R 16 O2Sats 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic Neck: Supple. Extrem: Warm and well-perfused. Arthritic. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, proprioception intact bilaterally Reflexes: B T Br Pa Ac Right 2 2 1 2 0 Left 2 2 0 2 0 Proprioception intact Toes up-going bilaterally [**2194-2-21**]: Awake alert and oriented x3. Neuro: exam bilat upper and lower extremities full strength without decreased sensation. Left shoulder strength mildly decreased at baseline secondary to old rotator cuff injury. Tolerating Aspen collar. Dressing at posterior cervical site removed. Sutures intact, wound open to air, no drainage. Pertinent Results: ADMISSION LABS: [**2194-2-14**] 11:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2194-2-15**] 01:00AM WBC-7.8 RBC-4.68 HGB-13.4 HCT-39.3 MCV-84 MCH-28.7 MCHC-34.2 RDW-13.9 [**2194-2-15**] 01:00AM GLUCOSE-108* UREA N-21* CREAT-0.7 SODIUM-141 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-32 ANION GAP-15 [**2194-2-15**] 05:30PM WBC-9.7 RBC-4.67 HGB-13.6 HCT-39.3 MCV-84 MCH-29.0 MCHC-34.5 RDW-13.8 Discharge Labs: [**2194-2-21**] 06:00AM BLOOD WBC-10.7 RBC-4.24 Hgb-12.9 Hct-35.9* MCV-85 MCH-30.3 MCHC-35.9* RDW-13.7 Plt Ct-261 [**2194-2-21**] 06:00AM BLOOD Plt Ct-261 [**2194-2-21**] 06:00AM BLOOD Glucose-99 UreaN-16 Creat-0.6 Na-133 K-3.1* Cl-94* HCO3-31 AnGap-11 [**2194-2-21**] 06:00AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.8 IMAGING: C-spine MRI [**2-15**]: Thickening of the ligaments at the atlanto-odontoid joint with isointense and slightly enhancing mass on the right side of the spinal canal at C1 level and extending posteriorly and merging with the thickened ligaments. The combination of changes most likely suggests extensive degenerative change with degenerative pseudotumor with moderate compression of the spinal cord and moderate-to-severe spinal stenosis at C1 level. Multilevel degenerative changes are also noted at other levels as described above. CTA Neck [**2-15**]: No evidence of vascular occlusion or stenosis identified. In particular, no vertebral artery occlusion or displacement identified. Degenerative changes at the craniocervical junction with thickening ligaments as noted on the previous MRI. MR [**Name13 (STitle) 2853**] [**2-20**]: Status post posterior decompression and resection of the soft tissue present at the C2 level. The spinal canal has been decompressed, and the spinal cord appears normal. No definite residual tissue is detected although small amounts may be obscured by the expected postoperative changes. Brief Hospital Course: The patient was admitted to the NSurg service for pain control and for further evaluation of this cervical lesion. She was placed on Decadron 4mg Q8, and was given a soft collar for comfort. It was decided that she have an open biopsy of this cervical lesion to yeild diagnosis. Prior to the OR, she was seen by her cardiologist Dr.[**Name (NI) 53712**], who, from a cardiac standpoint, cleared her for surgery. He ordered an ECHO, which was acceptable, and requested the patient be on telemetry. The patient went to the operating room on [**2194-2-19**] for a C1,2 Laminectomy and lesion biopsy with Dr. [**Last Name (STitle) **]. Pathology revealed hematoma and not malignancy therefore steroid was discontinued. She was in an Aspen collar while awake. Speech and Swallow service saw her on [**2-20**]. They recommended an altered diet and this was initiated. MR W/WO Contrasat [**2194-2-20**]: Status post posterior decompression and resection of the soft tissue present at the C2 level. The spinal canal has been decompressed, and the spinal cord appears normal. No definite residual tissue is detected although small amounts may be obscured by the expected postoperative changes. On POD#2, her surgical dressing was removed showing a small amount of erythema, however no obvious drainage or foul odor. She was seen by PT and OT, who recommended rehabilitation. She was discharged to an appropriate facility on [**2-21**]. Medications on Admission: 1. Atenolol 50 mg once a day. 2. Atorvastatin 80 mg once a day. 3. Aspirin 81 mg once a day. 4. Famotidine 20 mg once a day. 5. Levothyroxine 75 mcg once a day everyday with a skip at one day a week. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Known firstname 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**] Discharge Diagnosis: C1- C2 Cervical Lesion **found to be hematoma(path not finalized) Discharge Condition: Neurologically stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. -Please wear your Cervical collar while awake, you may take it off while sleeping, or briefly when you shower. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? 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: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office in [**6-7**] days for removal of your sutures. Please call the office at ([**Telephone/Fax (1) 88**] for an appointment for suture removal. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.[**Last Name (STitle) **] to be seen in 6 weeks. Completed by:[**2194-2-21**]

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icd9cm

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5748

Discharge summary

report

Admission Date: [**2118-10-3**] Discharge Date: [**2118-10-8**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: [**10-5**] CT Guided stereotactic aspiration of Right Cerebellar hemorrhage History of Present Illness: This is an 89 year old male with a history significant for metastaic melanoma, on coumadin (INR 4.9), 81 mg aspirin, with recent lumbar laminectomy doing rehab at home. The night prior to presentation, he was feeling dizzy. In the middle of the night he was grasping at the door frame, and kept waking every half hour to vomit. He woke and felt nauseous and vomited. That morning, he had a fall at home and hit the right side of the head, no LOC. He was taken to [**Hospital1 18**] by ambulance. Past Medical History: Primary melanoma in [**2105**] with right axillary dissection and radiation - discontinued due to R arm swelling. L-sided axillary mass w/ excision of chest wall tumor and L-axillary dissection and s/p 10 treatments XRT recently. S/p a lumbar spinal laminectomy in [**2118-7-31**], has been unsteady and using walker at home. prostate cancer diabetes Social History: He lives in [**Hospital1 **]. He used to work as an attorney. He is currently in rehabilitation. He lives with his wife. [**Name (NI) **] has four children and five grandchildren. Family History: NC Physical Exam: On Admission: T 97.2 BP 126/66 P 80s R 16 SpO2 97% GEN: elderly male lying on bed in c-collar, NAD HEENT: non-icteric, atraumatic CV: RRR, no murmurs Pulm: CTABL Abd: soft, NT, ND Ext: RUE swelling significantly larger then L MS: alert, oriented to [**Hospital1 **], date, and name. Speech was slurred, slight dysarthria, but was fluent, no paraphasic errors, no anomia, no evidence of neglect, apraxia. CN: pupils [**3-1**] b/l to light, VFF to confrontation, EOMI w/ significant R-beating nystagmus on lateral gaze, facial sensation intact, smile symmetric, hearing intact b/l, palate symmetric, tongue midline. Motor: increased tone b/l at LE, significant swelling of the R arm, strength full throughout Reflexes: normal throughout, toes flexion b/l Coordination: significant dysmetria w/ b/l arms and legs on FNF testing and on HTS testing Sensation: intact to light touch and pinprick throughout Gait: not tested On Discharge: Expired Pertinent Results: [**2118-10-3**] 08:33AM PT-46.0* PTT-33.0 INR(PT)-4.9* [**2118-10-3**] 08:33AM PLT COUNT-156 [**2118-10-3**] 08:33AM NEUTS-89.7* LYMPHS-6.3* MONOS-3.7 EOS-0.1 BASOS-0.1 [**2118-10-3**] 08:33AM WBC-5.8 RBC-3.99* HGB-11.0* HCT-33.4* MCV-84 MCH-27.7 MCHC-33.1 RDW-15.0 [**2118-10-3**] 08:33AM cTropnT-0.02* [**2118-10-3**] 08:33AM estGFR-Using this [**2118-10-3**] 08:33AM GLUCOSE-321* UREA N-32* CREAT-1.3* SODIUM-131* POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-23 ANION GAP-16 CTA Head and Neck [**2118-10-3**] 1. Right cerebellar hemisphere hemorrhagic lesion, better seen on the recent non-contrast head CT. No evidence of underlying AVM or aneurysm. This could represent a parenchymal hematoma in the setting of the patient's anticoagulated status or a metastasis from his melanoma. 2. No cervical spine fracture. Extensive degenerative changes. 3. Post-radiation/post-surgical changes in the right lung apex and right axilla partially visualized. CT head [**2118-10-3**]: Large (~ 6.0 x 4.8 cm) Ill-defined hyperdense collection in the right cerebellar hemisphere with hematocrit levels, consistent with hemorrhage, likely subacute. Local mass effect as described, with leftward shift of the right cerebellar hemisphere and concern for early tonsillar herniation. Differential diagnosis includes traumatic injury, hemorrhagic metastatic disease given history of melanoma or vascular abnormality. MRI/MRA or CTA should be considered for further evaluation. CXR [**2118-10-3**]: AP supine portable view of the chest is obtained. Low lung volumes somewhat limit evaluation as well as slight patient rotation to the right. Clips in the right axilla are noted. The lungs appear clear bilaterally, aside from area of known scarring in the right lung apex. The cardiomediastinal silhouette appears unremarkable. Old healed right lower rib fractures are again noted. No acute fractures are seen. IMPRESSION: No acute traumatic injuries evident. MRI Brain [**2118-10-4**]: 1. Nodular area of enhancement along the lateral margin of the large infratentorial hemorrhage is suggestive of an underlying mass, compatible with metastatic disease. 2. New small focus of hemorrhage in the left anterior inferior cerebellar hemisphere. New supratentorial subarachnoid hemorrhage in the sylvian fissures and the occipital sulci. 3. Intraventricular hemorrhage. Stable partial effacement of the fourth ventricle with stable enlargement of the lateral and third ventricles. 4. The cerebellar tonsils efface the CSF space in the foramen magnum but do not herniate below the foramen magnum. CT head [**2118-10-4**] Compared to [**10-3**] head CT, increased size and distribution of right cerebellar hemorrhage with increased surrounding edema and mass effect; however, lesion is stable compared to more recent MRI. Increased hydrocephalus, particularly evident in the left lateral occipital [**Doctor Last Name 534**]. Doppler US [**2118-10-4**]: No new acute deep vein thrombosis identified. Chronic, occlusive subclavian clot is seen, the appearance of which is stable since the torso CT of [**2118-5-9**]. A single tiny venous structure identified in the region of the subclavian represents either collateral flow or is extremely diminutive vessel lumen. [**10-5**] Head CT: IMPRESSION: Decreased size of right cerebellar hemorrhage with decreased associated mass effect and reestablished patency of the fourth ventricle. Stable hydrocephalus. New post-operative extra-axial pneumocephalus and air within pre-existent clot cavity. [**10-6**] Head CT: IMPRESSION: No significant interval change. 1. Similar size of right cerebellar hemorrhage. 2. Stable hydrocephalus. 3. Bilateral frontoparietal and occipital subarachnoid hemorrhage which appears similar. 4. Interval decrease in size of extra-axial pneumocephalus, and stable air within preexisting clot cavity. [**10-7**] Head CT: 1. Interval worsening in the obstructive hydrocephalus. 2. Stable bilateral frontal, parietal, and occipital subarachnoid hemorrhage. 3. Stable right cerebellar hemorrhage with slight redistribution of blood due to positioning. Brief Hospital Course: Mr. [**Known lastname 953**] was admitted to SICU under the care of Dr. [**Last Name (STitle) 739**] on [**2118-10-3**] for evaluation of Right cerebellar hemorrhage. He had an MRI on the evening on [**10-4**] which revealed tumor, presumed to be metastatic melanoma. He required Zyprexa for this study bu was still lethargic and disoriented many hours later. CT revealed extension of the hemorrhage. He was slowly becoming for alert. A family meeting was held with Dr. [**Last Name (STitle) 739**] and his wife and four children. Surgical nd conservative treatments were discusses. Dr. [**Last Name (STitle) 724**] of the Neuro oncology group reviewed the images and was in favor of surgery. Dr. [**Last Name (STitle) **] also met with the family to discuss the potential for a CT guided stereotactic biopsy and spiration. They agreed to procede. On [**10-5**], he was more lethargic and confused and he was taken to the OR. Surgical frame was placed on pre-op and he had a CT scan. Biopsy and aspiration was performed without complication. Approximately 40ml was aspirated. The patient remained intubated and in the PACU overnight. Post op head CT revealed residual hematoma but significant evacuation and decompression of 4th ventricle. On POD#1 a repeat Head CT was performed and stable. He was weaned from the neosynephrine and extubated. Pt's exam was stable but he remained lethargic. He was transferred to ICU for close neurological observation. The family was updated and plan was to place EVD if hydrocephalus were to worsen vs. no intervention if hemorrhage were to worsen. The patient's code status was changed back to DNR/DNI. On POD#2 the patient became less verbal. A Head CT was performed revealing extension of the hemorrhage. The family was updated and decided that no further intervention would be performed. Upon their arrival to the ICU, the patient was made CMO. On [**10-8**], patient passed away with family at bedside. Medications on Admission: Uroxatral 10 mg daily Glyburide 5 mg daily Lisinopril 5 daily Metoprolol Tartrate 25 mg daily Omeprazole 20 mg daily Simvistatin 40 mg daily Warfarin 2.5 daily Aspirin 81 mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cerebellar tumor Cerebellar hemorrhage Hydrocephalus Intraventricular Hemorrhage Brain Compression Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2118-10-8**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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282, 360

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153,566

42311

Discharge summary

report

Admission Date: [**2117-3-2**] Discharge Date: [**2117-3-16**] Date of Birth: [**2047-9-10**] Sex: M Service: SURGERY Allergies: XIBROM Attending:[**First Name3 (LF) 2836**] Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: [**2117-3-3**]: Technically successful CT-guided drain upsizing with a 10-French biliary drain inserted into the right-sided peritoneal collection. [**2117-3-5**]: IVC filter placement [**2117-3-11**]: Successful upsizing x 2 two and placement of a third percutaneous drainage. History of Present Illness: 69M hx necrotizing hemorrhagic pancreatitis c/b abd compartment syndrome requiring decompressive laparotomy, MOSF, cardiac arrest, intraabdominal abscesses and hemorrhage requiring re-exploration, multiple washouts, and ultimately drain placement, prolonged intubation and tracheostomy at [**Hospital1 498**] and subsequent IR drainage at [**Hospital1 18**] presents from [**Hospital 100**] Rehab with sudden onset sustained tachycardia and pleuritic chest pain x24hrs. Per rehab records and patient's son, the patient has been doing well at rehab with the exception of persistent watery stool until today when, per report, pt noted to have new onset tachycardia to 120-130 with intermittent chest discomfort without radiation. No antecedent or precipitating factors reported. Per conversation with [**Hospital 100**] Rehab Staff ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] RN) and their review of facility [**Month (only) 16**], it seems pt was refusing SCD/ambulation, but confirms receiving HSQ 5000unit TID. Denies associated dyspnea, SOB, orthopnea, hemoptysis, cough, fevers, or chills. Pt is tolerating PO intake which is supplemented by cycled Vivonex tube feeds via GJT. His bilateral flank drains continue to drain light tan purulent appearing fluid. Persistent diarrhea with 5-7 loose watery stools overnight while on tube feeds and [**2-12**] watery stools during the day. Per rehab records, pt was empirically started on PO Vancomycin [**2-24**] for empiric coverage for C.Diff. No culture data available at time of consultation. Last seen in clinic [**2-26**] where note is made of persistent diarrhea and initiation of empiric antibiotics for concern of C.Diff with ID follow-up. At that time, HR recorded as 105 with SaO2 100% rm air. At time of consultation, pt is afebrile with sustained sinus tachycardia 120-130, otherwise hemodynamically appropriate with SaO2 97% rm air. Lung fields clear to auscultation with clear and equal breath sounds at bilateral bases. Abdomen is soft without rebound or guarding, GJT in place, bilateral flank drains secured. Pt comfortable and conversant, and otherwise nontoxic appearing. Past Medical History: PMH: 1. Gastroesophageal reflux disease 2. Vitamin deficiency 3. Hypertension 4. B12 deficiency anemia 5. Gastritis 6. Benign prostatic hypertrophy 7. Hyperlipidemia 8. Calculus of the kidney 9. Macular degeneration of the retina 10. Cataracts, status post cataract removal with lens prosthesis . PSH: remote: Cataract removal with lens prosthesis [**2116-10-2**]: Bedside decompressive laparotomy for abdominal compartment syndrome [**2116-10-21**]: Re-exploration, [**Last Name (un) **] gastrostomy, debridement of suprapubic subcutaneous tissue, muscle, and fascia. [**2116-12-2**] ([**Hospital1 498**]): exploratory laparotomy, drainage of infected hemorrhagic collections with placement of sump drains x3 [**12-5**] & [**12-8**] ([**Hospital1 498**]): wash out and partial closure of abdominal wound [**2116-12-10**] ([**Hospital1 498**]): closure of abdominal wound [**2116-12-24**] ([**Hospital1 498**]): Open tracheostomy [**2116-12-25**] ([**Hospital1 498**]): Tracheostomy exchange [**2117-1-17**]: Uncomplicated placement of a 16 French pigtail catheter into right collection Social History: Currently resident at [**Hospital 100**] Rehab. Accompanied by son who corroborates history. Denies tobacco and alcohol use. Denies IVDY/Illicits. Family History: No family history of pancreatitis or pancreatic malignancy Physical Exam: Physical Exam on Admission: VS: T 98.7, HR 123, BP 124/77, RR 17, SaO2 99% rm air GEN: NAD, A/Ox3 HEENT: MMM, EOMI, no scleral icterus CV: sinus tachycardia, no M/R/G PULM: CTAB, clear bases bilaterally, equal excursion BACK: bilateral flank drains secured to skin, nonerythematous. R drain with dark brown effluent, no blood/clots. L drain with tan yellow effluent, no blood/clots. ABD: soft, well healed midline laparotomy incision, GJ in place, no surrounding erythema/fluctuance/drainage. PELVIS: deferred EXT: WWP, no edema, distal pulses intact . Physical Exam on Discharge: VS: 98.4, 110, 100/64, 16, 97% RA GEN: NAD, Comfortably lying in bed CV: Sinus tachycardia CTAB: Diminished on bases b/l ABD: Right flank/Left flank/Right Presacral Drains to bulb suctions and secured to the patient with sutures and butterfly dressing. Left drain with minimal yellowish output, right drains with [**Last Name (un) 17993**] purulent output. GJ tube in place and patent. PELVIS: Flexiseal in place with EXTR: No edema, + distal pulses Pertinent Results: [**2117-3-2**] 01:15PM BLOOD WBC-6.8 RBC-3.30* Hgb-9.8* Hct-28.4* MCV-86 MCH-29.8 MCHC-34.5 RDW-16.3* Plt Ct-194 [**2117-3-15**] 08:40AM BLOOD WBC-8.0 RBC-3.52* Hgb-10.4* Hct-30.7* MCV-87 MCH-29.5 MCHC-33.8 RDW-16.5* Plt Ct-335 [**2117-3-2**] 01:15PM BLOOD Neuts-76.9* Lymphs-17.2* Monos-4.1 Eos-1.4 Baso-0.4 [**2117-3-2**] 01:15PM BLOOD PT-13.0* PTT-26.7 INR(PT)-1.2* [**2117-3-13**] 06:15AM BLOOD PT-18.2* INR(PT)-1.7* [**2117-3-13**] 06:15AM BLOOD Plt Ct-340 [**2117-3-15**] 08:40AM BLOOD Glucose-106* UreaN-21* Creat-0.6 Na-141 K-3.4 Cl-115* HCO3-16* AnGap-13 [**2117-3-2**] 01:15PM BLOOD ALT-43* AST-35 AlkPhos-216* TotBili-0.4 [**2117-3-2**] 01:15PM BLOOD cTropnT-0.09* [**2117-3-2**] 09:20PM BLOOD CK-MB-4 cTropnT-0.17* [**2117-3-3**] 03:23AM BLOOD CK-MB-4 cTropnT-0.14* [**2117-3-3**] 06:50AM BLOOD Albumin-2.5* Calcium-8.7 Phos-2.7 Mg-2.0 [**2117-3-15**] 08:40AM BLOOD Calcium-7.8* Phos-2.3* Mg-2.0 . [**2117-3-2**] CTA torso: IMPRESSION: 1. Large bilateral pulmonary emboli without CT evidence of right heart strain. Right base opacity grossly stable compared to prior, most likely atelectasis, however early underlying infarct is difficult to exclude. Apparent filling defects in the bilateral common femoral veins which could reflect thrombus. Ultrasound could be considered for further characterization if clinically indicated. 2. Unchanged moderate nonhemorrhagic pleural effusion and bibasilar atelectasis. 3. Slight decrease in the size of the left posterior intra-abdominal fluid collection. All other collections appear grossly unchanged compared to prior and continue to be concerning for abscesses. Percutaneous pigtail drains appear in standard position. 4. Stable enhancement of the pancreatic parenchyma without new areas of necrosis. Patent splenic artery and vein centrally. 5. Moderate mesenteric and subcutaneous edema. 6. Unchanged mild right hydroureteronephrosis with gradual tapering at the level of the mid ureter secondary to extrinsic compression from adjacent fluid collections. . [**2117-3-4**]: BLE US - Significant nonocclusive deep vein thrombosis seen bilaterally in the femoral veins. Clot at the left common femoral vein is large and is soft, appearing to be partially mobile. . [**2117-3-5**] ECHO: Conclusions The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size is normal with normal free wall contractility. There is abnormal septal motion/position possibly consistent with increased right ventricular pressure. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2117-3-9**] EGD normal. Colonoscopy: Diverticulosis of the colon. Areas of likely necrotic tissue with some overlying clot was seen in the transverse colon. With washing, white fluid was repeatedly flowing out of the area raising the possibility of a Otherwise normal colonoscopy to cecum [**2117-3-15**] CXR: Moderate left lower lobe atelectasis and small left pleural effusion are unchanged. New azygos distention suggests elevated central venous pressure or volume, but not reflected in pulmonary vascular congestion or any edema. No pneumothorax. Brief Hospital Course: 69M history necrotizing hemorrhagic pancreatitis c/b abdominal compartment syndrome/hemorrhage/cardiac arrest/MOSF requiring multiple exploratory laparotomies and intraabdominal fluid collection drainage presented with tachycardia. He was found to have bilateral pulmonary emboli and significant nonocclusive deep vein thromboses in bilateral femoral veins. He was begun on empiric anticoagulation with a heparin drip, transitioned to Coumadin. A leak was noted around his right flank drain, and he underwent technically successful CT-guided drain upsizing on [**2117-3-3**] with a 10-French biliary drain inserted into the right-sided peritoneal collection. 130 mL of purulent fluid was drained along with a significant amount of fluid which drained along the drain tract prior to insertion of the 10-French drain. On HD3 his hematocrit was noted to drop from a baseline of 30 to 25, and he was transfused 2u. He passed 1L of BRBPR with clots on HD3, his heparin drip was held, and the GI service was consulted (PTT at the time was 40). EGD was normal and colonoscopy showed likely pancreatico-colic fistula (likely the source of his bleeding). In the setting of a lower GI bleed and bilateral PE's the decision was made to stop Coumadin, and the patient was taken to the OR for IVC filter placement on HD4 by the vascular surgery service. On [**2117-3-11**], given persistent intra-abdominal collections, his bilateral IR drains were upsized to 14Fr and a presacral drain was placed. The infectious disease service followed the patient throughout his hospitalization, and antibiotic coverage was adjusted appropriately. Abscess cultures returned GPC/GNR/pseudomonas sensitive to meropenem, and he was found to have Cdiff + stool. He was discharged with a PICC (placed [**2117-3-15**]), on an antibiotics. Outpatient ID follow up was arranged. He was continued on tube feeds while in patient, which he tolerated well. Neuro: Patient alert and oriented x 3. Minimal requirement for pain medication during hospitalization. CV: Patient remained sinus tachy 100-120s during his hospitalization, his PO dose of Metoprolol was increased to 100 mg TID from 100 mg [**Hospital1 **]. Cardiac Echo revealed LVEF > 55% and moderate pulmonary artery hypertension. The patient's HR was monitored with telemetry device. PULM: The patient with bilateral pulmonary emboli remained stable with O2 sats within normal limits on room air during hospitalization. GU: Patient known to have right kidney hydronephrosis caused by pre sacral fluid collection. Renal function test remained stable and patient denied flank pain. Urology was consulted and treatment was not indicated at this time. Medications on Admission: PO Vanco 500'' ([**2-24**]-), Occuflex R eye'''', Timoptic 0.5% L eye'', Heparin 5000''', Lispro SSI, Creon 24 2cap''', Lactobacillus 1''', Megace 400'', Prilosec 40'', NaCl 325'', Tobramycin oint R eyeqHS, Lopressor 100'', MVT, Lisinopril 2.5, APAP 650:prn Discharge Medications: 1. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)). 2. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day: Please hold if SBP < 100 or HR < 60. 3. ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic QID (4 times a day). 4. Creon 3,000-9,500- 15,000 unit Capsule, Delayed Release(E.C.) Sig: Four (4) Cap PO twice a day. 5. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). 6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks: was satred on [**2117-3-15**]. 7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. Meropenem 500 mg IV Q6H 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Necrotizing hemorrhagic pancreatitis 2. Pancreatico-colic fistula 3. Infected intra abdominal fluid collections 4. Bilateral pulmonary emboli 5. Bilateral lower extremities DVT 6. Right-sided hydronephrosis 7. Sepsis 8. Stool positive for Clostridium Difficile 9. Persistent tachycardia 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: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. . Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please follow up with the infectious disease physicians as recommended. . Right flank/Left flank/Right Presacral Drains: To bulb suction. Flush drains with 5-10 cc of NS TID. Change dressing QD and prn. Please note color, consistency, and amount of fluid in the drain. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Clean the skin around drains with commercial wound cleanser spray and patted dry. Then apply Critic Aid Clear ointment to the peri-drain skin to protect from the drainage and promote healing. Apply Allevyn Trach foam around the drain to help absorb the drainage. . PICC Line: *Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is significantly soiled for further instructions. Followup Instructions: Department: SURGICAL SPECIALTIES When: FRIDAY [**2117-3-26**] at 11:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: INFECTIOUS DISEASE When: MONDAY [**2117-3-29**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: INFECTIOUS DISEASE When: MONDAY [**2117-4-12**] at 11:30 AM With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2117-3-16**]

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icd9cm

[ [ [] ] ]

[ "54.91", "45.23", "96.6", "38.7", "45.13" ]

icd9pcs

[ [ [] ] ]

12972, 13038

8737, 11412

277, 557

13372, 13372

5172, 8714

15113, 16074

4043, 4103

11721, 12949

13059, 13351

11438, 11698

13548, 15090

4118, 4132

4700, 5153

226, 239

585, 2751

4146, 4672

13387, 13524

2773, 3861

3877, 4027

51,165

162,075

53259

Discharge summary

report

Admission Date: [**2119-4-27**] Discharge Date: [**2119-5-9**] Date of Birth: [**2038-10-23**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: s/p seizure Major Surgical or Invasive Procedure: Left-sided craniotomy for resection of left frontal tumor on [**2119-5-5**] by Dr [**Last Name (STitle) **] History of Present Illness: This is an 80 year old man on coumadin for a-fib who presented to OSH after a seizure. He has had rare generalized seizures for the past 13 years. Overall he reports four events with loss of consciousness, incontinence, and postictal confusion, usually associated with a medical illness or intervention. Last [**Month (only) **], after two seizures, neuroimaging revealed a left convexity meningioma. No antiepileptic was started. The most recent event occured at his dentis's office. He was evaluated in the ED where he had an another seizure. He reports passing out and taking hours to recover afterwards. He does not remember his deficits, but medical records indicated right face weakness and aphasia. He was given levetiracetam and fosphenytoin. [**Last Name (un) **] s/p new onset of seizure at dentist office. Patient has known L frontal lesion that was found in [**2118-8-10**], but has since then had no follow up. He was seen to have a R facial droop and aphasia. While in MRI, patient was seen to have another seizure and given fosphenytoin and keppra and transferred to [**Hospital1 18**]. Patient denies any headache, n/v, dizziness, blurred vision, or dysarthria. Past Medical History: atrial fibrillation, hyperlipidemia, Hodgkin's lymphoma Social History: The patient is widowed and lives alone. He is retired. He has two healthy children. He had seven siblings, three of them died at ages 73,75, and 79. He never smoked Family History: non contributory Physical Exam: On Admission: O: T:97.7 BP:130/81 HR:90 R:18 O2Sats:96%RA Gen: WD/WN, comfortable, NAD. HEENT: R facial droop, R eye ptosis, atraumatic, normocephalic Pupils:3-2mm bilaterally EOMs: intact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-9**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: R facial droop and R eye ptosis. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-13**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger On Discharge [**2119-5-9**]: awakens to voice, oriented x0, expressively aphasic PERRL readily following commands x 4 extremities MAE's with good strengths Pertinent Results: CHEST (PORTABLE AP) Study Date of [**2119-4-27**] 7:54 PM Minimal bilateral lower lobe atelectasis. CTA HEAD W&W/O C & RECONS Study Date of [**2119-4-28**] 3:24 PM Left frontal extra-axial mass with surrounding vasogenic edema and calcification. CT angiography demonstrates some enhancement of the pial vessels in the region which could indicate supply from the pial vasculature. No significantly enlarged external carotid branches are identified although evaluation is limited on the CTA. The mass does appear to cause mild mass effect without midline shift ECG Study Date of [**2119-5-4**] 8:43:14 AM Atrial fibrillation with a mean ventricular rate of 86. Diffuse non-diagnostic repolarization abnormalities. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Intervals Axes Rate PR QRS QT/QTc P QRS T 86 0 90 356/401 0 -19 19 Tissue: LEFT FRONTAL MASS, left Study Date of [**2119-5-5**] Report not finalized ******************** Assigned Pathologist [**Doctor Last Name **],HASINI MR HEAD W/ CONTRAST Study Date of [**2119-5-5**] 5:53 AM IMPRESSION: Stable left frontal extra-axial enhancing mass is most consistent with a meningioma. No other intracranial lesions identified. CT HEAD W/O CONTRAST Study Date of [**2119-5-5**] 2:59 PM IMPRESSION: 1. Left frontal lobe intraparenchymal hemorrhage adjacent to the resection site is larger than expected in the postoperative setting. 2. Extra-axial fluid collection overlying the left frontal lobe measures up to 2.2 cm in thickness. 3. Unchanged mild rightward shift of normally midline structures without evidence of central herniation. 4. Moderate pneumocephalus is not unexpected postprocedurally. Post-operative MRI brain with and without contrast [**2119-5-7**] IMPRESSION: Slight increase in hematoma in the left frontal lobe, recommend evaluation with unenhanced head CT. Small foci of acute ischemia/artifact from blood products as detailed above. Brief Hospital Course: Mr. [**Known lastname 37430**] presented to [**Hospital1 18**] on [**4-27**] after a seizure while at the dentist. MRI at an OSH redemonstrated the known frontal lesion consistent with a meningioma. He was admitted to the floor for management and to devise a treatment plan. He was seen by Dr. [**First Name (STitle) 13014**] of radiation oncology and Dr. [**Last Name (STitle) 60181**] of neuro-oncology. They were in favor of surgical resection. His coumadin was being held. He was not actively reversed. He was placed on Dilantin as well as dexamethasone. A transition to Keppra was initiated on [**4-10**] at the advisement of Dr. [**Last Name (STitle) 6570**]. Keppra has less interaction with oral anticoagulation. He remained stable on the floor. He was discussed in Brain [**Hospital 341**] Clinic on [**5-1**]. Surgical intervention was recommended and possible XRT if pathology was atypical His hospital course was otherwise uneventful. Surgical intervention was discussed with patient and family for a Left frontal craniotomy for removal of left frontal mass. On [**5-4**], he was pre-oped for the OR and was made NPO after midnight. The patient was [**First Name9 (NamePattern2) 109617**] [**Last Name (un) 2677**]. Her was alert and oriented to person place and time. The patients strength was full. The patient was ehibiting some unihibited behavior at times that was attributed to the location of the brain mass. On [**5-5**], the patient underwent a Left-sided craniotomy for resection of left frontal tumor by Dr [**Last Name (STitle) **]. The patient was recovered in the neurosurgical intensive care environment and his post operative stay in the ICU was uneventful. The post-operative head CT was performed consistent with expected post operative changes. On [**5-6**], On exam, he was oriented to name answering "[**Last Name (un) 46536**]" to questions, opening his eyes to voice. expressive aphasia was noted. his pupils were 3-2 mm bilaterally. There was no pronator drift noted. an old R ptosis was noted. He was sitting out of bed to the chair. The patient was transferred to the Step down unit to continue on telemetry for atrial fibrillation and expressive aphasia. the blood pressure paremeters were libralized to allow SBP 100-160. The foley catheter was discontinued. subcutaneous heparin was initiated. after transfer to the Step down Unit,the patient was periodically confused and became aggitated at night pulling at dressings and attempting to get out of bed. On [**5-7**], the patient opened eyes to stimulus. the pupils were equal and reactive. His neuro exam continued to wax and wane. A Decadron taper was initiated and pain medications were weaned in an attempt to decrease possible causes of delerium. a standing order for tylenol was wriiten and LFTs were ordered for the morning which were unremarkable. The patient was Triggered for heart rate in 120s. The patient had refused his am Lopressor. The patient's serum BUN elevated at 29 from the day prior at 24. Due to intermittent confusion the patient had poor nutrition and IV fluid was initiated Normal Saline at 75cc/hr. A Nutrition consult was placed and calorie count ordered. Consults for physical and occupational therapy were placed. A post operative MRI of the Brain was performed which was consistent with a small foci of acute ischemia versus artifact along the medial and posterior portions of the left frontal lobe. On [**5-8**] he was still abulic but brighter and his Right ptsosis had resolved. On [**5-9**] he was neurologically stable and cleared for discharge to rehab. Medications on Admission: crestor 5mg QD, coumadin 5mg QD Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. insulin regular human 100 unit/mL Solution Sig: per SS Injection ASDIR (AS DIRECTED). 5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. phenytoin 125 mg/5 mL Suspension Sig: Four (4) mL PO Q8H (every 8 hours). 9. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for post operative pain. 13. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q 6h () for 2 days: cont on [**5-9**] & [**5-10**]. 14. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8h () for 2 days: start on [**5-11**]. 15. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q12h () for 2 days: start [**5-13**]. 16. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q24h () for 2 days: start on [**5-15**]. discontinue medication after 2 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Left Frontal Meningioma Delerium Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You were on a medication such as Coumadin (Warfarin),prior to your surgery, you may safely resume taking this 10 days after surgery. You were seen in house by the medicine service and it was determined that you did not need to restart it at this time. We recommend that you follow up with your PCP. ?????? 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 have been discharged on Keppra (Levetiracetam)as well, but this will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ?????? Your staples need to be removed on [**2119-5-15**]. This can be done at the rehabilitation facility. If there are any problems or questions please call [**Telephone/Fax (1) 1669**]. ?????? 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 with contrast. Completed by:[**2119-5-9**]

[ "201.90", "345.91", "427.31", "348.5", "225.2", "272.4", "585.2", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

10538, 10585

5352, 8959

320, 430

10662, 10662

3306, 5329

13058, 13469

1917, 1935

9042, 10515

10606, 10641

8985, 9019

10838, 13035

1950, 1950

269, 282

458, 1640

2453, 3287

1964, 2161

10677, 10814

1662, 1719

1735, 1901

353

159,476

9276

Discharge summary

report

Admission Date: [**2153-6-27**] Discharge Date: [**2153-7-7**] Date of Birth: [**2089-7-23**] Sex: M Service: MEDICINE Allergies: Ativan / Tetracycline Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: back pain/ positive blood cultures Major Surgical or Invasive Procedure: central venous line, attepmted IR guided [**Last Name (NamePattern4) 2286**] cathether x 2 (second successful), intubation History of Present Illness: 63 year old male with ESRD on HD, DM, history of multiple line infections had blood cultures drawn from line on [**6-25**] growing 2/4 bottles Gram positive cocci. His blood cultures were drawn as a result of back pain he had been having for 3 weeks as a concern for possible epidural abscess. He states that 3 weeks ago, he was taken by ambulance to OSH for low blood sugar and felt he "wrenched his back." He states that the discomfort is bilateral low back without radiation down the backs of his legs. It is worse with lying flat and better sitting up in his wheelchair. It has improved in the past week, although he was recently prescribed tramadol. He is able to ambulate some with prosthetics (b/l BKAs). He denies fevers, chills, nausea, vomiting, diarrhea. He has had some constipation but takes stool softeners. He makes little urine. He denies bowel incontinence. He denies headaches, changes in vision, numbness, weakness, tingling. No chest pain, shortness of breath or cough. He received vancomycin at HD prior to being sent to ED. . ED: rectal exam with normal rectal tone. His bp in ED was 80's systolic but improved after 1 L NS. MRI ordered, but patient declined at that time. Past Medical History: - Several previous line infections, last one [**2152-6-18**] tx with 27 d of vanco IV renally dosed - ESRD on HD MWF for 5 yrs - Placement of new hemodialysis catheter [**2151-11-23**] R subclavian (L arm av --> L subclavian --> R arm av --> R subclavian - DM 1 or 2 c/b PVD, CAD, ESRD - DM for 20 yrs since age 44 - bilateral BKAs - CAD s/p CABG - s/p MSSA bacteremia [**12-1**] - h/o VRE, MRSA 5 yrs ago in wound infection in L stump and UTI - HTN - Afib on coumadin - Bilateral contractures on hands - Cataracts bilaterally Family History: Significant for both of his grandmothers, his mother, and father with diabetes. Father with peripheral vascular disease. Mother is still alive. Father died at 90. No hx of cancer or heart disease. Physical Exam: V: 100.3F HR 80 BP 80/dop 20 94 RA Gen: awake, alert and oriented, pleasant, talkative, NAD HEENT: PERRL, EOMI, anicteric sclera, OP clear without lesions, MM slightly dry Neck: obese CV: RRR, S1, S2. right subclavian line dressed, intact and non-tender PUlm: faint crackles right base Abd: Normoactive bowel sounds, soft, obese, nontender Ext: bilateral BKAs. Neuro: CN II-XII intact. [**3-31**] in prox/distal upper extremities and prox lower extremities bilaterally. sensation intact to light touch bilaterally. Back: mild TTP left paraspinal muscles in lumbar region. No spinal TTP. Pertinent Results: [**2153-6-27**] 06:50PM BLOOD WBC-6.8 RBC-3.02* Hgb-11.1* Hct-33.4* MCV-111*# MCH-36.8* MCHC-33.2 RDW-17.0* Plt Ct-154 [**2153-7-6**] 03:07AM BLOOD WBC-7.9 RBC-2.54* Hgb-9.5* Hct-27.4* MCV-108* MCH-37.3* MCHC-34.6 RDW-18.2* Plt Ct-230 [**2153-6-27**] 06:50PM BLOOD Neuts-78.2* Lymphs-14.3* Monos-6.0 Eos-1.2 Baso-0.3 [**2153-6-27**] 06:50PM BLOOD PT-31.3* PTT-39.6* INR(PT)-3.3* [**2153-7-6**] 03:07AM BLOOD Glucose-127* UreaN-80* Creat-7.0* Na-138 K-5.2* Cl-98 HCO3-23 AnGap-22* [**2153-6-27**] 06:50PM BLOOD Glucose-132* UreaN-17 Creat-3.1*# Na-144 K-4.4 Cl-100 HCO3-35* AnGap-13 [**2153-6-28**] 06:35AM BLOOD ALT-14 AST-24 LD(LDH)-238 AlkPhos-128* Amylase-105* TotBili-0.5 [**2153-7-4**] 07:58PM BLOOD ALT-107* AST-181* LD(LDH)-532* CK(CPK)-312* AlkPhos-131* Amylase-60 TotBili-0.7 [**2153-7-5**] 03:16AM BLOOD ALT-140* AST-209* LD(LDH)-338* AlkPhos-118* TotBili-0.8 [**2153-7-6**] 03:07AM BLOOD ALT-86* AST-65* AlkPhos-98 Amylase-83 TotBili-0.7 [**2153-7-4**] 07:58PM BLOOD CK-MB-6 cTropnT-0.08* [**2153-6-28**] 06:35AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.6# Mg-2.2 [**2153-7-4**] 07:58PM BLOOD Albumin-4.0 Calcium-13.2* Phos-6.1*# Mg-3.2* VBG at time of code: [**2153-7-4**] 08:15PM BLOOD Type-ART pO2-87 pCO2-96* pH-7.04* calTCO2-28 Base XS--7 Comment-GREEN TOP [**2153-7-4**] 09:17PM BLOOD Type-ART FiO2-100 pO2-316* pCO2-53* pH-7.23* calTCO2-23 Base XS--5 AADO2-343 REQ O2-62 -ASSIST/CON Intubat-INTUBATED [**2153-7-4**] 11:57PM BLOOD Type-ART Rates-/28 Tidal V-500 PEEP-5 FiO2-50 pO2-72* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 -ASSIST/CON Intubat-INTUBATED . IR PROCEDURES: Femoral line HD: RADIOLOGISTS: The procedure was performed by Drs. [**Last Name (STitle) 9441**] and [**Name5 (PTitle) 380**]. Dr. [**Last Name (STitle) 380**], the attending radiologist, was present and supervising throughout the procedure. PROCEDURE AND FINDINGS: After informed consent was obtained from the patient explaining the risks and benefits of the procedure, the patient was placed supine on the angiographic table, and the right groin was prepped and draped in the standard sterile fashion. Using ultrasonographic guidance and local anesthesia with 1% lidocaine, a 21-gauge needle was advanced into the right common femoral vein and a 0.018 guide wire was advanced through the needle up to the distal part of the IVC under fluoroscopic guidance. Hard copy ultrasound images were obtained before and after venous access was obtained documenting vessel patency. The needle was then exchanged for a 4.5 French micropuncture sheath. The wire was exchanged for a 0.035 [**Doctor Last Name **] wire that was placed with the tip in the IVC. The groin incision was progressively dilated with 12 and 14 French dilators. A double lumen 14.5 French hemodialysis catheter was placed over the wire, and the wire and the inner dilator were removed. The patient's final fluoroscopic image of the line demonstrates the tip in the IVC. The patient tolerated the procedure well, and there were no immediate complications. IMPRESSION: Successful placement of temporary hemodialysis line via the right common femoral vein. The line is ready for use. . MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: eval for cerebral edema or stroke [**Hospital 93**] MEDICAL CONDITION: 63 year old man admitted with fevers, now s/p PEA arrest and unresponsive, although patient was responsive briefly after arrest REASON FOR THIS EXAMINATION: eval for cerebral edema or stroke MRI SCAN OF THE BRAIN WITH MR ANGIOGRAPHY. HISTORY: Admitted with fevers, status post pulmonary embolism with arrest. Unresponsive. Assess for cerebral edema or stroke. TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was obtained. COMPARISON STUDIES: None. FINDINGS: There is mildly restricted diffusion within the thalami bilaterally, as well as increased FLAIR signal in this locale. A similar pattern of restricted diffusion and elevated FLAIR signal is also seen in a ribbon-like distribution involving both parietal lobe cortices. The symmetric distribution of the findings is in [**Location (un) **] with the suspected anoxic episodes sustained by the patient. There is no evidence for abnormal blood products intracranially. There is no hydrocephalus or shift of normally midline structures. The principal vascular flow patterns are identified. There are extensive air-fluid levels distributed throughout the paranasal sinuses as well as probable secretions within the [**Last Name (un) **]- and oropharynx. These findings presumably represent the effects of intubation. There is low T1 signal within the odontoid process. The etiology of this finding is uncertain. If there is concern for malignancy elsewhere that could spread to bone, a correlative radionuclide bone scan would be of assistance in comprehensively evaluating the skeleton, when the patient's clinical state would permit such an investigation to be conducted. It is possible, however, that this finding may merely be a somewhat unusual expression of degenerative disease. CONCLUSION: Findings of concern for anoxic brain damage as noted above. MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **] AND ITS TRIBUTARIES. TECHNIQUE: Three-dimensional time-of-flight imaging with multiplanar reconstructions. FINDINGS: The major vascular tributaries of the circle of [**Location (un) 431**] are patent, without sign for the presence of hemodynamically significant stenosis. Within the limits of this study technique, no definite sign of an aneurysm is apparent, either. There may be very slight irregularity of caliber of the occipital branch of the left posterior cerebral artery, which if real, could represent a minimal degree of atherosclerotic change. Echo: Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. LV systolic function appears depressed. Right ventricular systolic function is normal. There are simple atheroma in the descending thoracic aorta. 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. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations identified. [**2153-7-6**] Chest x-ray: SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Followup pulmonary edema Comparison is made with prior study performed a day earlier. ET-tube is in standard position. Left IJ line tip is in the artery level of the cavoatrial junction. NG tube tip is out of view below the diaphragm. Mild-to-moderate right pleural effusion has mildly increased in amount. Mild- to-moderate pulmonary edema got worse. Right lower lobe opacity is increasing consistent with atelectasis. [**2153-7-6**] EEG: IMPRESSION: This is a markedly abnormal brain death protocol EEG. The majority of the tracing demonstrates a flat and non-reactive background even at high sensitivity gains. This is consistent with a severe encephalopathy with dysfunction of the deep midline structures. Lack of reacitivity suggests a poor prognosis. The tracing cannot meet the criteria for brain death however given that several brief bursts of sharp and wave discharges were captured from the bifrontal regions. While it is possible that these discharges were purely artifactual we cannot say this definitively. Note that clinical correlation of brain death is required by hospital protocol. Brief Hospital Course: Hospital course prior to CODE: Patient is a 63 yo M with ESRD on HD, with Diabetes and multiple line infections admitted initially for bacteremia and back pain found to have osteomyelitis secondary to a line infection. Since admission, the patient has been treated with vancomycin but had persistent bacteremia thought due to persistent infected line. Line was removed on [**7-2**] and this was the last time of [**Month/Day (4) 2286**]. Events prior to code: [**6-30**] diagnosed with osteomyelitis/discitis. Events: [**6-30**] hypoxia after 12 mg morphine +tramadol [**7-2**] HD line removal [**7-3**] Hypotensive prior to TEE [**12-29**] ?16mg morphine (TEE without signs of endocarditis) [**7-4**] IR procedure done- prolonged and unsuccessful placement of HD line (100 mg fentanyl, versed). Day of CODE BLUE: Per team today patient was doing well but had prolonged IR procedure without HD catheter placement due to difficulty cannulating vessels (Left IJ was placed). Per team, the patient returned to the floor and was initially stable. He was more somnolent than usual, but given his recent sedation, this was thought to be expected. At approximately 8PM, the patient was found to be unresponsive. Patient was found to be pulseless and CPR was initiated. CODE BLUE was called. The patient was intubated and given epinephrine 1mg. Found to be in bradycardia and given atropine. Labs were sent. Calcium and bicarb were given. Rhythm changed to VT and patient was shocked. 1 Amp bicarb given and again shcoked. Compressions resumed. Blood sugar was 111 and insulin+D50 were given In the ICU Patient was then stabilized on the ventilator without significant acid base disturbances. Though the patient initially had mild signs of neuro function, it did not persist and with complete withdrawal of sedation, the patient was still without recovery. Per neurology: minimal activity on EEG and no response to sternal rub. Neuro exam is significant for sluggishly reactive pupils otherwise no other obtainable reflexes or response to noxious stimulation indicating gross dysfunction of bilateral hemispheres and brainstem. Prognosis is poor based on initial exam but will need to be followed serially. Care was withdrawn after extensive discussions with his HCP (brother). The patient quickly expired after this. By problem list prior to expiration: 1) PEA arrest/Neuro status: Patient had arrest likely secondary to respiratory depression given that the patient was found to have shallow breathing and decreased rr prior to code and found to have profound acidosis during the arrest. Other potential causes including hypercalemia were ruled out. Given patient's previous history of hypotension, somnolence to versed and fentanyl, it seems likely that the patient arrested as a result of respiratory acidosis. After transfer to the ICU and correction of acidosis, patient was monitored after this and was found to have no residual neurologic function. Per neurology consult minimal activity on EEG and no reaction to noxious stimuli (see eeg report). Insult likely secondary to hypoxic brain injury as a result of hypotension in the setting of PEA arrest. These findings were communicated to the [**Hospital 228**] healthcare proxy (brother) who felt that given the poor overall prognosis, his brother's wishes would be to withdraw care. 2) ID: Patient was initially admitted with line infection/bacteremia later found to have osteomyelitis: Line was removed with, IJ replaced. No signs endocarditis on TEE. Surveillance cultures were negative. Also treated with vancomycin. Was given one dose of gentamycin for synergy. - osteomyelitis: T7-8, not able to get sample, but presuming infected secondary to persistent bacteremia, treated with vancomycin IV - sacral decubitus ulcers: chronic and stage 2 3) ESRD: patient with [**Hospital 2286**] need and difficulty placing access and had failed IR attempts to place [**Hospital 2286**] catheter, was not dialyzed for several days. Able to obtain access eventually on [**7-5**], right common femoral venous line was placed, but patient was not dialyzed after this given overall decline in clinical status. # Transaminitis: Occurred in the setting of the code/ hypotension likely due to hypoperfusion. # Atrial fibrillation: rate controlled and supratherapeutic INR while in the ICU. Holding anticoagulation for now. # Diabetes: sliding scale # Contractures: appear to be chronic # Sternum- concerning for sternal fracture in the setting of aggressive CPR. Medications on Admission: GLIPIZIDE 5mg po bid LISINOPRIL 2.5 mg daily ASPRIN 81MG daily LOPRESSOR 12.5mg daily sl NTG prn COUMADIN 4 mg qday ZOCOR 40 mg qhs NEPHROCAPS 1 mg daily PHOSLO 667 mg--take 3 tabs po tid Renagel 800 mg - TID w/ each meal Colace - [**Hospital1 **] Discharge Disposition: Expired Discharge Diagnosis: ESRD Hypoxic brain injury Osteomyelitis Atrial fibrillation Discharge Condition: deceased [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V49.75", "427.1", "458.29", "348.1", "428.0", "428.20", "427.5", "997.1", "511.9", "790.7", "722.92", "V45.1", "996.62", "V45.81", "427.31", "707.03", "403.91", "E878.8", "414.01", "585.6", "041.19", "250.00", "V58.61", "730.28" ]

icd9cm

[ [ [] ] ]

[ "38.95", "96.04", "39.95", "99.62", "88.72", "96.71" ]

icd9pcs

[ [ [] ] ]

15611, 15620

10793, 15312

323, 447

15724, 15871

3061, 6281

2239, 2438

6318, 6446

15641, 15703

15338, 15588

2453, 3042

249, 285

6475, 10770

475, 1672

1694, 2223

50,629

183,318

14878

Discharge summary

report

Admission Date: [**2124-12-15**] Discharge Date: [**2124-12-27**] Date of Birth: [**2061-12-2**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 5790**] Chief Complaint: Right lower lobe lung cancer Major Surgical or Invasive Procedure: [**2124-12-15**]: Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and right lower lobectomy with sleeve bronchoplasty (tubular bronchoplasty of the right middle lobe for reanastomosis), mediastinal lymph node dissection, intercostal muscle flap buttress, and pericardial flap buttress. History of Present Illness: Mr. [**Known lastname 7168**] is a 63-year-old gentleman with a right lower lobe squamous cell carcinoma with endobronchial invasion at the level of the superior segment and distal bronchus intermedius. He had undergone previous cervical mediastinoscopy which was negative for any mediastinal nodal disease. He then underwent 8 weeks of pulmonary rehab. He symptomatically felt much better though his post rehab pulmonary function tests were still severely impaired with an FEV1 of 47% of predicted and a DLCO 50% of predicted. His cardiopulmonary exercise testing, however, revealed a VO2 max of 21.8 mL/kg per minute. He was admitted for lobectomy or possible bilobectomy with the help that we could simply do a right lower lobectomy; but in order to get an adequate bronchial margin, this would likely require a tubular bronchoplasty or reanastomosis of the right middle lobe onto the bronchus intermedius. Past Medical History: 1. COPD, currently undergoing pulmonary rehab to pursue surgical resection of the right lower lobe squamous cell carcinoma. 2. History of pneumonia treated with antibiotics as described above. 3. Abdominal hernia 4. Hypertension. 5. Cervical spine surgery. The details are not available to us at this time. 6. Basal cell carcinoma. 7. History of polypectomy in [**6-/2118**] on colonoscopy. 3-cm as well as a 1 cm inflammatory polyp. Social History: The patient is married and accompanied by his wife. [**Name (NI) **] has two children. 80-pack-year history of tobacco. He quit approximately three months ago. Prior heavy alcohol consumption; he quit at the time of his diagnosis. He worked in a nuclear power plant in [**Location (un) 3320**], [**State 350**] for approximately 24 years. The patient describes having significant radiation exposure during that period of time. Family History: There is no family history of any carcinomas. Physical Exam: VS: Wt. 135 lbs P 93 BP 123/72 RR 16 T 98 %O2 Sat 95 GENERAL: Well-appearing gentleman, alert and oriented x3, no apparent distress. HEENT: Normocephalic, atraumatic, anicteric sclerae. EOMI. Oropharynx with moist mucous membranes without thrush or other lesions. NECK: Supple without any cervical, supraclavicular, or infraclavicular lymphadenopathy. CARDIAC: Regular rate, S1, S2, no murmurs, rubs, or gallops. LUNGS: Clear to auscultation with prolonged expiratory phase, consistent with COPD, however, there are no wheezes. ABDOMEN: Soft, nontender, nondistended, no organomegaly. EXTREMITIES: Without any clubbing, cyanosis, or edema. BACK: Without point spinal tenderness. SKIN: Without any apparent rashes. NEUROLOGIC: Grossly intact. Pertinent Results: [**2124-12-15**] 07:41PM BLOOD WBC-9.9 RBC-4.07* Hgb-13.2* Hct-37.8* MCV-93 MCH-32.5* MCHC-35.0 RDW-14.2 Plt Ct-271 [**2124-12-16**] 02:55AM BLOOD WBC-6.8 RBC-3.88* Hgb-12.3* Hct-36.1* MCV-93 MCH-31.7 MCHC-34.1 RDW-14.0 Plt Ct-223 [**2124-12-17**] 03:09AM BLOOD WBC-5.8 RBC-3.74* Hgb-11.8* Hct-34.8* MCV-93 MCH-31.6 MCHC-33.9 RDW-14.1 Plt Ct-183 [**2124-12-18**] 03:02AM BLOOD WBC-4.8 RBC-3.39* Hgb-11.2* Hct-31.7* MCV-94 MCH-32.9* MCHC-35.2* RDW-14.0 Plt Ct-191 [**2124-12-19**] 06:15AM BLOOD WBC-5.2 RBC-3.90* Hgb-12.6* Hct-35.8* MCV-92 MCH-32.3* MCHC-35.3* RDW-14.0 Plt Ct-245 [**2124-12-19**] 04:09PM BLOOD WBC-6.1 RBC-4.09* Hgb-13.1* Hct-37.6* MCV-92 MCH-32.0 MCHC-34.7 RDW-13.7 Plt Ct-283 [**2124-12-21**] 12:35AM BLOOD WBC-7.7 RBC-3.68* Hgb-11.5* Hct-33.0* MCV-90 MCH-31.2 MCHC-34.8 RDW-13.9 Plt Ct-364 [**2124-12-22**] 04:00AM BLOOD WBC-6.2 RBC-3.74* Hgb-12.1* Hct-34.7* MCV-93 MCH-32.4* MCHC-34.9 RDW-13.9 Plt Ct-296 [**2124-12-23**] 03:12AM BLOOD WBC-8.8 RBC-3.50* Hgb-11.4* Hct-31.8* MCV-91 MCH-32.7* MCHC-36.0* RDW-13.7 Plt Ct-356 [**2124-12-24**] 06:50AM BLOOD WBC-9.2 RBC-3.50* Hgb-11.1* Hct-31.6* MCV-91 MCH-31.6 MCHC-35.0 RDW-13.5 Plt Ct-397 [**2124-12-19**] 04:09PM BLOOD PT-16.9* PTT-36.0* INR(PT)-1.5* [**2124-12-21**] 01:00AM BLOOD PT-17.1* PTT-33.7 INR(PT)-1.5* [**2124-12-22**] 11:23AM BLOOD PT-17.9* PTT-42.9* INR(PT)-1.6* [**2124-12-15**] 07:41PM BLOOD Glucose-103 UreaN-20 Creat-0.8 Na-144 K-4.8 Cl-108 HCO3-24 AnGap-17 [**2124-12-16**] 02:55AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-144 K-4.8 Cl-105 HCO3-24 AnGap-20 [**2124-12-17**] 03:09AM BLOOD Glucose-126* UreaN-15 Creat-0.8 Na-141 K-4.4 Cl-103 HCO3-31 AnGap-11 [**2124-12-17**] 08:37AM BLOOD Glucose-124* UreaN-15 Creat-0.8 Na-140 K-4.5 Cl-103 HCO3-31 AnGap-11 [**2124-12-18**] 03:02AM BLOOD Glucose-96 UreaN-14 Creat-0.7 Na-140 K-4.3 Cl-104 HCO3-29 AnGap-11 [**2124-12-19**] 06:15AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-138 K-4.3 Cl-101 HCO3-29 AnGap-12 [**2124-12-19**] 04:09PM BLOOD Glucose-120* UreaN-13 Creat-0.7 Na-139 K-3.5 Cl-99 HCO3-29 AnGap-15 [**2124-12-20**] 06:05AM BLOOD Glucose-114* UreaN-15 Creat-0.7 Na-138 K-3.9 Cl-101 HCO3-29 AnGap-12 [**2124-12-21**] 12:35AM BLOOD Glucose-115* UreaN-17 Creat-0.7 Na-139 K-3.7 Cl-105 HCO3-25 AnGap-13 [**2124-12-21**] 12:05PM BLOOD Glucose-118* UreaN-12 Creat-0.6 Na-140 K-3.9 Cl-108 HCO3-25 AnGap-11 [**2124-12-22**] 04:00AM BLOOD Glucose-104 UreaN-8 Creat-0.6 Na-138 K-4.8 Cl-103 HCO3-25 AnGap-15 [**2124-12-23**] 03:12AM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-137 K-3.8 Cl-102 HCO3-25 AnGap-14 [**2124-12-24**] 06:50AM BLOOD Glucose-94 UreaN-7 Creat-0.5 Na-134 K-3.9 Cl-100 HCO3-26 AnGap-12 [**2124-12-25**] 06:00AM BLOOD Glucose-95 UreaN-7 Creat-0.6 Na-135 K-5.1 Cl-99 HCO3-30 AnGap-11 [**2124-12-19**] 04:09PM BLOOD ALT-20 AST-25 CK(CPK)-153 [**2124-12-19**] 04:09PM BLOOD CK-MB-2 [**2124-12-15**] 07:41PM BLOOD Calcium-9.0 Phos-4.3 Mg-1.8 [**2124-12-16**] 02:55AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.8 [**2124-12-17**] 03:09AM BLOOD Calcium-9.2 Phos-1.9*# Mg-2.2 [**2124-12-17**] 08:37AM BLOOD Calcium-9.3 Phos-2.3* Mg-2.1 [**2124-12-18**] 03:02AM BLOOD Calcium-8.9 Phos-2.0* Mg-1.9 [**2124-12-19**] 06:15AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.8 [**2124-12-19**] 04:09PM BLOOD Calcium-9.4 Phos-2.4* Mg-2.4 [**2124-12-20**] 06:05AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.9 [**2124-12-21**] 12:35AM BLOOD Calcium-8.7 Phos-3.7# Mg-1.7 [**2124-12-21**] 12:05PM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8 [**2124-12-22**] 04:00AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.7 [**2124-12-23**] 03:12AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8 [**2124-12-24**] 06:50AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7 [**2124-12-25**] 06:00AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.7 Brief Hospital Course: Pt was admitted on [**2124-12-15**] and taken to the OR for flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and right lower lobectomy with sleeve bronchoplasty (tubular bronchoplasty of the right middle lobe for reanastomosis), mediastinal lymph node dissection, intercostal muscle flap buttress, and pericardial flap buttress. A paravertebral catheter was placed for pain control w/ PCA w/ excellent effect. 2 chest tubes were placed at the time of surgery for drainage and to assist w/ lung re-expansion. [**Name (NI) **], pt was admitted to the ICU for invasive respiratory and hemodynamic monitoring. POD#2 Went into rapid afib; he was placed on IV lopressor, then IV amiodarone was added for conversion and better rate control w/ good effect. Chest tubes w/ moderate serosang output. Continued to require aggressive pulmonary tiolet. POD#4 Transferred to floor from the ICU. Removed one chest tube. Eval by PT. POD#5 Mucous plug w/ desats. Transferred back to ICU. Attempted flex bronch but secretions too thick. Intubated and re-bronched w/ thick secretions of right and left bronchial tree. Started on vanco/zosyn empirically. Anastomotic site intact. POD#6 Bronched with BAL, then extubated. BAL eventually grew out normal oropharyngeal flora. POD#7 Remained in ICU for secretion management. One episode of desaturation. Paravertebral catheter removed. Chest tubes put to waterseal. Zosyn d/c'd. POD#8 Apical chest tube removed. Transferred from ICU to floor. Vanco d/c'd and started on PO Levo until [**12-27**]. POD#9 Advanced to regular diet. POD#10 Remaining chest tube removed. POD#11 Oxygen desats once with ambulation; CXR revealed improving pneumothorax, but presence of hydrothorax. Kept on oxygen while ambulating. POD#12 Repeat CXR stable. Patient discharged with home O2 of 2L. Medications on Admission: Norvasc 10 mg daily, Combivent 2 puff q6h, Albuterol 2 puffs q6h, Prilosec 20 mg daily, Ativan 0.5 q8h prn, folic acid 1 mg daily, magnesium oxide 400 mg daily, vitamin B-12 100 mcg daily, MVI, calcium and vitamin D 600 mg daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*2* 2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-29**] Puffs Inhalation Q6H (every 6 hours). 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. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*120 Tablet(s)* Refills:*0* 13. Oxygen Home oxygen at 2 liters via nasal cannula when ambulating and during sleep at night. Increase to 4 liters prn shortness of breath as necessary. Conserving Device For Portability 14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times a day. Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Left lower lobe nodule COPD History of pneumonia treated with antibiotics Abdominal hernia Hypertension Cervical spine surgery Basal cell carcinoma History of polypectomy in [**6-/2118**] on colonoscopy. 3-cm as well as a 1 cm inflammatory polyp. Post-op pneumonia Discharge Condition: Stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience. -Fever > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage *** -You may shower on Thursday, [**12-28**]. After showering, remove chest-tube remove dressing and cover with a bandaid. Should site begin to drain cover with a clean dressing and change as needed to keep site clean and dry. -No tube bathing or swimming for 6 weeks. -No driving while taking narcotics. Take stool softeners with narcotics. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on the [**Hospital Ward Name 517**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **] on [**1-9**] at 11am. Please arrive 45 minutes prior to your appointment and report to the [**Location (un) **] radiology for a chest XRAY. Completed by:[**2124-12-27**]

[ "486", "V10.83", "492.8", "997.1", "401.9", "934.1", "E915", "162.5", "997.39", "518.5", "427.31", "V12.72", "276.2", "518.0" ]

icd9cm

[ [ [] ] ]

[ "40.3", "33.24", "33.48", "96.71", "32.49", "33.23" ]

icd9pcs

[ [ [] ] ]

10552, 10613

7006, 8828

309, 617

10922, 10931

3322, 6983

11504, 11822

2485, 2533

9107, 10529

10634, 10901

8854, 9084

10955, 11481

2548, 3303

240, 271

645, 1558

1580, 2024

2040, 2469

10,653

117,279

29655

Discharge summary

report

Admission Date: [**2116-1-28**] Discharge Date: [**2116-2-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: temporary pacing wire placed permanent pacemaker placed History of Present Illness: Ms. [**Known lastname 71073**] is an 86 yo woman with a h/o CAD s/p CABG, AS s/p [**Known lastname 1291**], HTN, DM2, CHF, and dementia who p/w syncope and was found to have complete heart block. On [**1-28**], she awoke with nausea, walked to the bathroom, became lightheaded and fell. Per the family, she has had several syncopal episodes over the last 6 months and had been feeling general fatigue over the last 2 weeks. Denied fevers, wt loss, n/v/d. Following this episode and fall, she presented to OSH with c/o MSK pain, but was found to be becoming less responsive with HR in 30s. EKG showed complete heart block with ventricular escape of 38. She received atropine x1 with transient improvement, then had transcutaneous pacing pads placed. She was transferred to [**Hospital1 18**] for further evaluation and pacemaker. Past Medical History: CAD s/p 2-vessel CABG [**2104**] RBBB and L posterior fascicular block on EKG in [**2115**] [**Month (only) **] s/p [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] in [**2104**] for AS CHF HTN Diabetes on glyburide Hypothyroid, non-compliant Dementia, mild-moderate Social History: A widow, she lives alone and has a home health aide who visits daily; she is unable to complete most IADLs. She walks with a walker. Supportive daughter. [**Name (NI) **] EtOH, no smoking Family History: n/c Physical Exam: T97.8 BP149/58 P65 R18 100%2L Gen: Well-appearing woman in NAD, appearing her stated age. HEENT: NC/AT. MMM no erythema/exudate. JVP normal. Neck supple w/o LAD. Edentulous. Pulm: Clear to auscultation bilaterally. PM site without erythema/exudate CV: Regular Rate and Rhythm, with 3/6 HSM RUSB, mechanical S2. Abd: Soft, non-tender and non-distended. Bowel sounds are normoactive. Ext: 2+ dorsalis pedis pulses; no edema, clubbing, or cyanosis. Neuro: AAOx2 (thought it was [**Month (only) **]). Speech fluent with intact comprehension, naming; impaired repetition. Recall [**1-22**]. Serial 7s [**1-24**]. CNII-XII grossly intact. Pertinent Results: Notable Labs (Also see below): Chem 7: 135 99 15. 121 3.8 28 0.7 Ca: 8.4 Mg: 2.0 P: 2.5 WBC: 10.6; Hct: 29.6; Plt: 188; MCV 80. PT: 15.8 PTT: 123.0 INR: 1.4 . Studies: - EKG: Sinus rhythm at 64, R axis, 1st degree AV block, RBBB, TWI III and aVF. - Tele: Paced at 68 - CXR: The patient has had median sternotomy. Cardiac silhouette is moderately enlarged with particular left atrial and pulmonary artery enlargement. Mild interstitial edema is present. There is no pleural effusion or pneumothorax. A right transjugular right ventricular temporary pacer lead follows the expected course to the floor of the right ventricle. There is no mediastinal widening. - CT HEAD: No intracranial hemorrhage or mass effect. - CT C-Spine: No cervical spinal fractures. Mild degenerative anterolisthesis at C3/4 and C5/6 as well as mild posterior degenerative spondylolisthesis at C6/7. Prominence of the pulmonary vessels and thickening of the inter- and intra-lobular septa consistent with pulmonary edema. - CT Angio Chest: 1. No evidence of aortic dissection. 2. Dense atherosclerosis involving the coronary arteries, mitral valve, thoracic and abdominal aorta, and proximal mesenteric branches. Severe stenosis of the celiac artery at its origin. Moderate stenosis of the SMA at its origin. 3. Loss of height of L1 and T9 - age indeterminate. 4. 5-mm nodule in the left upper lobe. Followup in six months' time is recommended to document stability. - ECHO: Mild symmetric left ventricular hypertrophy with hyperdynamic systolic function. Bileaflet aortic valve prosthesis with high transvalvular gradients and mild aortic regurgitation. Moderate mitral stenosis, likely secondary to extensive mitral annular calcification. Mild-to-moderate mitral regurgitation. Moderate pulmonary hypertension. Moderate tricuspid regurgitation. Brief Hospital Course: A/P: This is an 86 y/o F w/ h/o HTN, CAD, [**Month/Day (1) 1291**], p/w syncope, found to have complete heart block. She had a pacemaker placed, complicated by a post-placement hematoma which was evacuated. . # Cardiac: a) Rhythm: Ms [**Known lastname 71073**] presented with complete heart block, likely [**2-21**] worsening of long-documented conduction disease (RBBB and L post-hemiblock). She had reverted to sinus rhythm with prolonged AV conduction by [**Hospital1 18**] presentation; a temporary pacing wire was placed and she was eventually taken to the EP lab for permanent pacemaker. This procedure was complicated by a large hematoma (requiring 9 U pRBCs) which was also associated with hypotension requiring dopamine. She was sent to the CCU for monitoring; her anticoagulation was not reversed secondary to her mechanical AV valve. She was intubated and taken to the EP lab on [**2-7**] for hematoma evacuation. She improved and was taken to the floor on [**2-11**] for further cares. . b) Ischemia: Ms. [**Name14 (STitle) 71074**] is s/p old IMI. She is currently on statin therapy. Her aspirin was held throughout her hospital stay given her persistent risk of bleeding. It may need to be restarted as an outpatient, after documentation of stable hct. c) Pump: She has a [**Hospital3 9642**] [**Hospital3 1291**] and Diastolic CHF with pulmonary edema s/p intra-op fluid recussiation. EF 75%. She was maintained on amlodipine and metoprolol. Her INR goal of [**2-22**] was maintained with coumadin after heparin bridging. d) St Jude's valve: Goal INR [**2-22**]. Maintained on coumadin. #) Fever. Ms. [**Known lastname 71073**] had intermittent fever during her stay. She was given a course of vancomycin to cover concern for hematoma abscess. She was also treated with cipro for a UTI. Her fevers resolved prior to discharge. #) Hematoma. A large hematoma post-operatively required 9 Units pRBCs and operative evacuation on [**2-7**] with resulting hct stabilization. Retention sutures were placed. She received a six day course of antibiotics and her arm was kept in a sling for one week. Her wound was followed by the surgery wound care RN. #) Anemia. GI was consulted for anemia on admission. They have recommended iron supplementation and colonoscopy as an outpatient. #) HTN. She has chronic HTN and was maintained on lisinopril as discussed above. #) DM2. Ms. [**Known lastname 71075**] blood sugars remained in control on standing lantus and sliding scale insulin. She will be returned to her oral medications on discharge. #) Hypothyroid. Maintained on levothyroxine. #) Dementia/Social: Pt is moderately demented, and we continued lexapro and risperdal. Her baseline status does not suggest capability for safe functioning at home at this time and a rehab screen was initiated with the help of occupational and physical therapy. #) Dispo: She was screened for rehab and discharged to Medications on Admission: synthroid 25 metoprolol 12.5 daily norvasc 5 diovan 80mg dialy lasix 20mg daily lipitor 80mg daily glyburide 7.5 [**Hospital1 **] lexapro 5mg daily risperdal 0.25 daily prn inhaler "qvar" tylenol #3 coumadin: 2.5 q sun, mon, tues, wed, fri; 5mg thurs and sat Discharge Disposition: Extended Care Facility: [**Hospital 26478**] Care Center Discharge Diagnosis: Complete heart block. Congestive heart failure. Pacemaker placement. Wound hematoma. Urinary tract infection. Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital for a cardiac condition known as complete heart block. This condition necessitated the placement of a device called a pacemaker to regulate your heartbeat. You were also treated for an exacerbation of congestive heart failure (CHF) and had a wound hematoma evacuation that will continue to require daily dressing changes. You should maintain a low sodium, heart healthy diet. If your daily weight fluctuates by more than 3 pounds you should consult your doctor. Call your doctor or return to the emergency department if you experience chest pain, worsening shortness of breath, fever > 101.5, discharge or bleeding from your wound, any lightheadedness or dizziness, or any new or concerning symptom. You should keep all of your follow up appointments. You were discharged home on an antibiotic to treat a urinary tract infection. You should take the entire course of this medication. Do not stop early, even if you begin to feel better. Wound Care: -Commercial wound cleanser to cleanse left breast and left pacemaker site ulcers. -Pat the tissue dry. -Apply No Sting Barrier wipe to the periwound tissue left breast and pacemaker site. Air dry. -Apply wound gel to open sites, cover with Allevyn Foam Adhesive dressing, change every 3 days. Followup Instructions: Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 71076**], [**3-11**] at 11:45 am. You have an appointment to follow up with the Device Clinic on Thursday, [**2-27**] at 11:30 am. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "294.8", "998.59", "V45.81", "518.0", "998.11", "428.0", "401.9", "428.30", "244.9", "599.0", "280.0", "427.32", "369.4", "V58.67", "427.31", "424.2", "V43.3", "V58.61", "414.01", "426.0", "424.0", "611.0", "998.12", "250.92", "110.3", "110.5", "997.3", "707.8" ]

icd9cm

[ [ [] ] ]

[ "37.83", "99.07", "37.79", "38.93", "37.72", "37.78", "99.04", "99.21" ]

icd9pcs

[ [ [] ] ]

7535, 7594

4298, 7225

271, 328

7748, 7758

2430, 3104

9091, 9500

1755, 1760

7615, 7727

7251, 7512

7782, 8760

1775, 2411

223, 233

8772, 9068

356, 1187

3113, 4275

1209, 1534

1550, 1739

24,056

107,668

24946

Discharge summary

report

Admission Date: [**2188-2-19**] Discharge Date: [**2188-2-28**] Date of Birth: [**2122-11-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Esophageal cancer Major Surgical or Invasive Procedure: s/p transhiatal esophagectomy for adenocarcinoma of esophogas [**2-19**] History of Present Illness: This is a 65 year old gentleman who has a history of known Barrett's esophagus who has developed invasive carcinoma. He has had reflux symptoms for years and surveillance biopsies in [**2186**] revealed high-grade dysplasia. Endoscopic mucosal resection but there was persistant invasive cancer. Endoscopic ultrasound showed no dominant tumor mass, staging him at TxNoMo. He had a PET scan demonstrating hypermetobolic uptake at the tumor site but not elsewhere. Past Medical History: Diabetes Mellitus Hypertension Hyperlipidemia CAD s/p CABG x 5 '[**84**] Gangrenous omentum s/p ex-lap GERD Social History: He smoked a pack and a half a day for 25 years, but quit 15 years ago. He is a recovering alcoholic with no recent binges. Family History: non-contributory Physical Exam: on admission: Afebrile, vital signs stable, weight 217 pounds Gen: well-developed middle-aged male HEENT: moist mucous membranes, no scleral icterus Neck:no lymphadenopathy in the neck CV: RRR, no murmurs Pulm: clear to auscultation bilaterally Abd: soft, NT/ND, normoactive bowel sounds Extr: warm, well-perfused Neuro: grossly intact Pertinent Results: [**2188-2-19**] 03:26PM BLOOD WBC-10.3 RBC-3.89* Hgb-11.7* Hct-32.3* MCV-83 MCH-30.2 MCHC-36.4* RDW-14.2 Plt Ct-256 [**2188-2-20**] 02:20AM BLOOD WBC-12.2* RBC-3.82* Hgb-11.3* Hct-32.4* MCV-85 MCH-29.6 MCHC-34.9 RDW-14.4 Plt Ct-238 [**2188-2-21**] 01:55AM BLOOD WBC-15.3* RBC-3.63* Hgb-10.7* Hct-30.4* MCV-84 MCH-29.3 MCHC-35.0 RDW-14.4 Plt Ct-193 [**2188-2-22**] 03:08AM BLOOD WBC-14.7* RBC-3.48* Hgb-10.2* Hct-29.6* MCV-85 MCH-29.4 MCHC-34.5 RDW-14.3 Plt Ct-214 [**2188-2-23**] 05:37AM BLOOD WBC-13.0* RBC-3.64* Hgb-10.9* Hct-31.4* MCV-86 MCH-29.9 MCHC-34.7 RDW-14.6 Plt Ct-255 [**2188-2-24**] 05:30AM BLOOD WBC-11.1* RBC-3.77* Hgb-11.2* Hct-32.6* MCV-86 MCH-29.7 MCHC-34.3 RDW-14.4 Plt Ct-271 [**2188-2-25**] 09:47AM BLOOD WBC-13.2* RBC-3.83* Hgb-11.3* Hct-32.9* MCV-86 MCH-29.4 MCHC-34.2 RDW-14.7 Plt Ct-300 [**2188-2-27**] 08:30AM BLOOD WBC-11.1* RBC-3.77* Hgb-11.1* Hct-32.7* MCV-87 MCH-29.6 MCHC-34.0 RDW-15.0 Plt Ct-346 [**2188-2-19**] 03:26PM BLOOD PT-14.5* PTT-24.4 INR(PT)-1.3* [**2188-2-21**] 01:55AM BLOOD Glucose-148* UreaN-13 Creat-1.0 Na-137 K-3.6 Cl-102 HCO3-26 AnGap-13 [**2188-2-22**] 03:08AM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-141 K-4.0 Cl-104 HCO3-28 AnGap-13 [**2188-2-24**] 05:30AM BLOOD Glucose-144* UreaN-19 Creat-0.7 Na-142 K-4.1 Cl-108 HCO3-25 AnGap-13 [**2188-2-26**] 08:04AM BLOOD Glucose-185* UreaN-19 Creat-0.8 Na-141 K-4.2 Cl-104 HCO3-27 AnGap-14 [**2188-2-27**] 08:30AM BLOOD Glucose-180* UreaN-17 Creat-0.8 Na-139 K-4.8 Cl-104 HCO3-27 AnGap-13 [**2188-2-19**] 03:26PM BLOOD Albumin-3.3* Calcium-8.5 Phos-6.2* Mg-1.0* Iron-105 [**2188-2-26**] 08:04AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.5* [**2188-2-27**] 08:30AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7 RADIOLOGY: [**2-19**] post-op CXR: The patient is status post transhiatal esophagectomy. The tip of the endotracheal tube is identified 2 cm above the carina. The right jugular Swan-Ganz catheter terminates in the right main PA. A nasogastric tube terminates in the intrathoracic stomach. There is mild congestive heart failure with cardiomegaly. Patchy atelectasis is seen at the lung bases. There is no evidence of pneumothorax. [**2-21**] CXR: Cardiac and mediastinal contours are stable. There has been removal of a nasogastric tube. Surgical drains remain in place in the upper mediastinum. There is an air collection present adjacent to the drain which may relate to air within the proximal neoesophagus or postoperative extraluminal air collection. There is mild perihilar haziness suggestive of mild perihilar edema, and note is made of small bilateral pleural effusions, slightly improved in the interval. [**2-26**] Barrium Swallow eval: Barium passes freely through the esophagus. An end-to-side anastomosis is noted within the upper mediastinum. There is no evidence of anastomotic leak. A drain is seen within the superior mediastinum. IMPRESSION: No evidence of anastomotic leak. PATHOLOGY: I. Esophagogastrectomy (A-AH,CA-CK ): 1. Barrett's esophagus with extensive low grade and foci of high grade glandular dysplasia (see note). 2. Hiatal hernia. 3. Gastric segment and regional lymph nodes, within normal limits. 4. Esophageal squamous epithelium at proximal margin and gastric corpus mucosa at distal margin. 5. There is no carcinoma. II. Left gastric lymph nodes (BA-BK): 1. Hyperplasia of lymph nodes. 2. No tumor. Note: The glandular dysplasia is low grade in the more proximal part of the esophageal segment, and high grade in the lower part. The entire columnar-lined esophagus is sampled, and there is no residual carcinoma. Brief Hospital Course: This is a 65 year old gentleman with high-grade Barrett's esophagus with adenocarcinoma who presented for esophagectomy. He underwent transhiatal esophagectomy without complication on [**2188-2-19**] (please see the operative note of Dr. [**First Name (STitle) **] [**Doctor Last Name **] for full details). He had an uncomplicated post-operative course. He was extubated on post-operative day 1 and diuresed gently. He received perioperative antibiotics. Tube feeds were started on post-op day 2. His pain was well controlled with an epidural catheter. The patient accidentally removed his nasogastric tube on post-op day 2. He had flatus on post-op day 5 and tube feeds were advanced to goal. He underwent a swallow eval on post-op day 7 which he passed and a diet was started; he was tolerating a regular diet by post-op day 8 and had good pain control on oral pain medications. His JP drain and staples were removed on post-op day 8. He was discharged to home on post-op day 9 with planned visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with tube feeding. Allq uestions were answered to his satisfaction upon discharge. Medications on Admission: Aspirin 325 mg po qdaily Lopressor 150 mg po qdaily Protonix 40 mg po qdaily lipitor 80 mg po qdaily lisinopril 40 mg po qdaily Glipizide 10 mg PO BID Metformin 1000 mg po BID Norvasc 5 mg po Qdaily Prozac 20 mg po qdaily Discharge Medications: 1. tube feeding probalance 80cc/hr x24hours, cycle as per tolerance [**5-28**] cans/day 2. tube feeding supplies kangaroo pump iv pole feeding bags 60cc catheter tip syringes tube feeding extension tubing 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): crush and take by mouth. Disp:*120 Tablet(s)* Refills:*1* 5. Fluoxetine 20 mg/5 mL Solution Sig: Five (5) cc PO DAILY (Daily). Disp:*100 cc* Refills:*2* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*120 ML(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Diabetes Mellitus, Hypertension, Hyperlipidemia, Coronary artery disease, s/p Coronary artert bypass graft x 5 '[**84**], gangrenous omentum s/p exploratory-laparoscopy, Gastric esophogeal reflux disease, [**1-28**]- cardiac ejection fraction 37%, adenocarcinoma of esophogas Discharge Condition: good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**]/Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for:fever, shortness of breath, chest pain, difficulty swallowing, excessive nausea, vommitting, J- tube clogging and inability to unclog w/ cola, meat tenderizer, redness, drainage and new pain at j-tube site or incision site. REsume regular medications as listed in discharge instructions. You may shower when you return home. Change j-tube dressing every day-keep dressing dry, change if wet. TUBE FEEDING-ProBalance formula- cycle schedule 110cc/hr for 18 hours/day; 120cc/hr for 16 hours/day; 140cc/hr for 14 hours/day; 160cc/hr for 12 hours/day. VNA Services-[**Last Name (un) 2646**] VNA- [**Telephone/Fax (2) 62697**] Tube feeding support with-[**Telephone/Fax (1) 43291**] Followup Instructions: Call Dr.[**Doctor Last Name 4738**]/Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for appointment in [**10-4**] days. Completed by:[**2188-2-28**]

[ "V45.81", "428.0", "151.0", "530.81", "530.85", "414.01", "401.9", "250.00", "272.4" ]

icd9cm

[ [ [] ] ]

[ "42.41", "46.39", "43.5" ]

icd9pcs

[ [ [] ] ]

7904, 7953

5156, 6302

340, 415

8272, 8279

1587, 5133

9100, 9257

1196, 1214

6574, 7881

7974, 8251

6328, 6551

8303, 9077

1229, 1229

283, 302

443, 908

1244, 1568

930, 1040

1056, 1180

3,214

181,901

47375

Discharge summary

report

Admission Date: [**2164-8-13**] Discharge Date: [**2164-8-23**] Date of Birth: [**2104-4-2**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 60-year-old white female with a history of CAD, status post inferior MI in [**2161-11-18**], status post complex RCA stent x3, status post catheterization in PTCA of RCA with 30% residual stenosis, status post CABG x3 in [**2164-7-25**] with SVG to the LAD, SVG to the OM, SVG to the PDA, who was recently discharged from [**Hospital1 69**] on [**2164-8-2**] status post CABG, who represented to the Emergency Room on [**2164-8-13**]. She reported doing well until [**Month (only) 404**] of '[**64**] when she developed dyspnea on exertion, was unable to climb a flight of stairs, or walk up an incline without dyspnea. The patient was evaluated and had a positive exercise ETT MIBI, went for catheterization on [**2164-5-30**] with left main 50% ostial lesion, left circumflex 60-70% lesion, RCA with fractured stenosis 80%, 80% ostial lesion, 1+ MR, EF 46%. Subsequently, the patient underwent three vessel CABG on [**2164-7-25**]. She denies symptoms preoperatively. She had no orthopnea or PND. Preoperative she had complained of episodes of palpitations which have resolved spontaneously in less than one hour. She reported an uneventful operative course except for difficulty with hallucinations after anesthesia and she had left arm and shoulder tingling. The patient was discharged home with one week course of Lasix. Since discharge post-CABG, the patient reports increasing dyspnea, and inability to lay flat secondary to the dyspnea. She had two-three pillow orthopnea. The last time she had taken Lasix was [**2164-8-9**]. Since that time, her weight had increased by 10 pounds. She had increasing lower extremity edema, increasing dyspnea with exertion, and chronic nonproductive cough. She had palpitations and increasing fatigue with minimal exertion. She presented to the Emergency Room on the 28th with the complaints of dyspnea and palpitations. She was felt to be in CHF. She was started on oxygen and Lasix with some improvement, and EKG at that time showed new onset AFib. She was rate controlled with Cardizem and Lopressor. She was admitted for rule out MI. Her enzymes were negative. The Cardizem and Lopressor were titrated up and the patient converted to normal sinus rhythm on the [**8-14**]. An echocardiogram on the 29th showed no focal wall motion abnormalities, moderate pericardial effusion, no tamponade. The patient had been stable hemodynamically without pulsus paradoxus on the floor. Due to the echocardiogram findings of a pericardial effusion, Heparin drip which had been started on admission was discontinued, and diuresis was held. The patient was still quite short of breath. A repeat echocardiogram on [**8-16**] showed an increasing effusion at this time, it was felt now to be moderate to large size. In addition, the patient had become hypoxic on the floor. A CTA was ordered to rule out pulmonary embolus, however, the CT was held in light of the patient's enlarging effusion. She was transferred to the CCU for close observation and pericardial drain placement. PHYSICAL EXAMINATION: Her vitals on admission to the CCU, her temperature was 98.4, her blood pressure was 108/60, heart rate was 88, respiratory rate 20, and her O2 sats were 98% on 4 liters. In general, she was a thin white female sitting upright in a chair on O2 nasal cannula breathing was labored at time. HEENT: PERRLA. Sclerae are anicteric. Oropharynx clear. Mucous membranes are moist. Neck is supple. Her jugular venous pressure was about 15 cm. There were no carotid bruits. Cardiovascular: Regular, rate, and rhythm, normal S1, S2, no murmurs, rubs, or gallops. Respiratory: She had decreased breath sounds at the bases bilaterally to [**1-20**] of the way up her lung fields. There was no egophony. Abdomen is soft, obese, nontender, and nondistended. Bowel sounds are present. Extremities: She had 2+ pitting edema just to up below the knees. She had 2+ DP and PT pulses bilaterally. LABORATORIES: Unremarkable. Thyroid function tests were sent and were pending. An ABG showed a pH of 7.45, pCO2 of 40, pO2 of 82 on 4 liters O2 nasal cannula. A chest x-ray on the 30th showed that the heart was within normal limits. Slight interval increase of the bilateral pleural effusions, her left hemidiaphragm was not well visualized which is consistent with effusion or left lower lobe collapse or consolidation. The echocardiogram results were as previously noted. PAST MEDICAL HISTORY: 1. Hodgkin's disease status post mantel radiation. 2. Small basal cell carcinoma. 3. Breast cancer status post right mastectomy and lymph node resection. 4. CAD with a history of IMI as noted in the history of present illness. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Lopressor 50 mg p.o. q.d. 3. Imdur 30 mg p.o. q.d. 4. Zestril 10 mg p.o. q.d. 5. Albuterol prn. 6. Levothyroxine 112 mcg p.o. q.d. 7. Triamcinolone. 8. Lasix 40 mg p.o. q.d., which was discontinued on the 24th. ALLERGIES: 1. Iodine. 2. Dye. 3. Bruises with Plavix. MEDICATIONS AT TIME OF ADMISSION TO THE CCU: 1. Indomethacin 25 mg p.o. t.i.d. 2. Mucomyst 600 mg p.o. b.i.d. x2 days. 3. Heparin subQ. 4. Metoprolol 50 mg p.o. t.i.d. 5. Diltiazem 60 mg p.o. q.i.d. 6. Lisinopril 2.5 mg p.o. q.d. 7. Colace. 8. Protonix. 9. Tylenol. 10. Albuterol 1-2 puffs q.6h. 11. Levothyroxine 112 mcg q.d. CCU COURSE: A pericardial drain was placed 250 cc of blood were drained initially. The pericardial pressure was 20 mm Hg upon entering and three after the drain was placed. After the drain was placed, shortness of breath and cough resolved, and the patient was given 30 mg of IV Lasix and she could lay flat at 30 degrees and rest without shortness of breath. Her O2 requirement at this point fell. The drain was placed on [**8-17**]. Prior to the pericardial drainage, the patient was anxious and went into rapid AFib with rates of 140-160, 5 mg of IV Lopressor were given x2. Her rate fell to 100 to 110, but her heart rate then increased again. Diltiazem drip was started at 5 mg and her heart rate came down to 100, however, her systolic blood pressure fell to 80, so the diltiazem drip was held, a 250 cc bolus was given, and the patient's systolic blood pressure increased appropriately, and the diltiazem drip was restarted. Endocrine wise, the patient's thyroid function tests: Her TSH was 26, which was low. Her T3 was 72 which is low and her T4 was 8.1, which was normal. Her Synthroid was increased, this was felt to be consistent with hypothyroidism and her Synthroid was increased to 125 mcg a day. On the 3rd, the patient was started on a Heparin drip. She was dig loaded. Her diltiazem drip was changed to Cardizem p.o. as she had spontaneously converted to normal sinus rhythm and her pericardial output from the drain had started to decrease. On the 4th, a bedside echocardiogram was done, which showed a very small pericardial effusion. The pericardial drain was pulled without complications. She denied chest pain or palpitations, no shortness of breath. The patient could now lie more comfortably, and her medicine regimen was continued. As her dyspnea was improving, her oxygen was gradually weaned off. Physical Therapy was consulted. Patient was felt to be medically stable, so she was transferred to the floor on the 4th. It was decided that the patient would benefit from amiodarone therapy, so pulmonary function tests were ordered, which the results were FVC was 54% of predicted, her FEV1 was 60% of predicted. Her FEV1:FVC ratio was 49%. It was felt at this time, that the FVC was likely underestimated due to patient had a strong gag reflux during spirometry maneuver with otherwise good test quality. Her total lung capacity was 71% of predicted. Her FRC was 75% of predicted. Despite the pulmonary function tests findings, it was felt that it would worthwhile to start the patient on amiodarone and have her follow up one month later to do repeat pulmonary function tests when she would likely be able to get better effort. On the 5th, the patient had an episode of 6 beat V-tach. Her blood pressure remained stable. For the V-tach, the patient was to receive a Holter monitor and [**Doctor Last Name **] of Hearts monitor. On the 7th, metoprolol was increased to 75 mg b.i.d. for better rate control. EP was consulted, and they felt that the amiodarone load should be continued and the beta blocker should be increased to a goal resting heart rate of 60 as tolerated by her blood pressure and bradycardia. Laboratories were ordered, which were within normal limits, but they resolved spontaneously. The primary team was notified. On the 6th, the patient was started on Coumadin. Urinalysis suggested a possible UTI. The patient was discharged home in stable condition on the 7th. DISCHARGE INSTRUCTIONS: She was to have [**Hospital1 1474**] VNA follow her as an outpatient. She was to continue taking all medications as instructed. DISCHARGE DIAGNOSES: 1. Pericardial effusion. 2. Coronary artery disease status post inferior myocardial infarction. 3. Status post coronary artery bypass graft on [**2164-7-25**]. 4. Hypothyroidism. 5. Breast cancer status post mastectomy. 6. Basal cell carcinoma. MAJOR SURGICAL OR INVASIVE PROCEDURES: She had a pericardial drain placed and cardiac catheterization. DISCHARGE MEDICATIONS: 1. Albuterol 1-2 puffs q.6h. prn. 2. Protonix 40 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Vitamin D one tablet p.o. q.d. 5. ............ 2.5 mg p.o. q.d. 6. Fluvastatin four capsules p.o. q.h.s. 7. Colace 100 mg p.o. b.i.d. 8. Senna one tablet p.o. q.h.s. 9. Calcitonin 200 units spray q week. 10. Calcium carbonate 500 mg tablet chew t.i.d. 11. Levothyroxine 125 mg p.o. q.d. 12. Furosemide 40 mg p.o. q.d. 13. Acetaminophen 325 mg p.o. q.4-6h. prn pain. 14. Maalox 30 cc p.o. q.6h. prn. 15. Metoprolol 75 mg p.o. b.i.d. 16. Amiodarone 600 mg p.o. q.d. for a two week course, which would end on [**2164-9-6**] and she should start taking amiodarone 200 mg p.o. q.d. 17. Coumadin one 5 mg tablet p.o. q.h.s. APPOINTMENTS AND FOLLOWUPS: She was to followup with her primary care physician [**Last Name (NamePattern4) **] [**1-19**] weeks. She should have her INR checked on [**8-23**] by the VNA Services. She is to followup with her primary cardiologist in [**1-19**] weeks. She is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2164-8-29**]. She was to followup with Dr. [**Last Name (STitle) 70**] on [**2164-9-5**]. TREATMENTS: Cardiac was cardiac heart healthy diet. Post discharge services was Physical Therapy. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 910**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2164-10-12**] 16:50 T: [**2164-10-15**] 09:00 JOB#: [**Job Number 100262**]

[ "511.9", "458.9", "411.0", "423.0", "427.31", "428.0", "518.0", "201.90", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "37.21", "37.0" ]

icd9pcs

[ [ [] ] ]

9125, 9476

9499, 11007

4875, 8949

8974, 9104

3224, 4599

155, 3201

4621, 4849

79,938

196,808

49999

Discharge summary

report

Admission Date: [**2144-4-21**] Discharge Date: [**2144-4-24**] Date of Birth: [**2081-10-24**] Sex: F Service: MEDICINE Allergies: Morphine / Prochlorperazine Attending:[**First Name3 (LF) 5119**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 62 yo F with h/o COPD(on 3L O2 at baseline), obesity, [**Hospital **] transferred from rehab to OSH Ed with hypoxia satting 85% on 5 L. Patient had been complaining of increased coughing and mild shortness of breath x 1 day. She has been at rehab for approximately 2 weeks after fall and right humerous, radius, ulnar and metatarsal fractures. At the OSH he received zithromax 500mg and ceftaz 1gm IV and solumedrol 125mg IV and lovenox 60mg SQ before being transferred to the [**Hospital1 18**] ED. . In ED, vitals were T 98.1 HR 80 BP 132/58 RR 20 POx 85% - 73% on RA. Noted positive D-dimer at OSH. CXR demonstrated R basilar PNA and a CTA was negative for PE. Lactate was 3.1, K 5.6, HCT 27.7 Patient given 1L NS. Vital signs before transfer 114/38 89% on nebs, RR 24. No stool guiac'd, but did receive kayxalate. . on arrival to the [**Hospital Unit Name 153**], patient was comfortable on 100% shovel mask. Patient admitted to shoulder pain, but stated that her shortness of breath is improved. All other ROS negative. Past Medical History: COPD 3L home O2 DM2 paroxysmal a.fib Obesity hypothyroidism depression insomnia recent R clavicular fx s/p TAH s/p C-section hx of bladder suspension Social History: Has 2 daughters, lives alone in [**Name (NI) **]. Recently admitted to rehab after fall and right shoulder and foot fracture. Extensive smoking hx, 50 pack years. No significant EtOH, no illicits. Family History: NC Physical Exam: GENERAL - comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, unable to appreciate JVD LUNGS - Bilateral LL crackles, expiratory wheezes HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - RLE in splint. 2+ BLE edema. NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: [**2144-4-21**] 06:00PM WBC-4.6 RBC-2.98* HGB-8.6* HCT-27.7* MCV-93 MCH-28.8 MCHC-31.0 RDW-14.6 [**2144-4-21**] 06:00PM NEUTS-93.1* LYMPHS-5.5* MONOS-1.3* EOS-0.1 BASOS-0.1 [**2144-4-21**] 06:00PM PLT COUNT-134* [**2144-4-21**] 06:00PM PT-13.0 PTT-26.1 INR(PT)-1.1 [**2144-4-21**] 06:00PM GLUCOSE-226* UREA N-23* CREAT-0.8 SODIUM-137 POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-31 ANION GAP-17 [**2144-4-21**] 06:27PM LACTATE-3.1* . CXR: IMPRESSION: Left lower lobe ill-defined opacity which is nonspecific, and may represent an area of atelectasis or infection. There is an adjacent small left pleural effusion. . EKG Sinus rhythm @ 96bpm. Low precordial lead voltage. Technically limited study. Baseline artifact. ST-T wave flatteing inferiorly. No previous tracing available for comparison. Clinical correlation is suggested. . CT chest: IMPRESSION: 1. No central or segmental pulmonary embolism or secondary signs of embolism. 2. In the absence of history of malignancy, a 4-mm pulmonary nodule warrants no further follow- up unless there are risk factors for malignancy, in which case follow- up in one year is recommended. 3. Impacted proximal right humeral fracture, partially imaged. . 2D echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Mild symmetric LVH. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. No pathologic valvular abnormality seen. Moderate pulmonary artery systolic hypertension. . LLE duplex: IMPRESSION: Negative for left lower extremity DVT. Brief Hospital Course: 62 yo F with COPD exacerbation and PNA admitted to the [**Hospital Unit Name 153**] for hypoxia. . #. Hypoxemic Respiratory Failure - Etiologies included COPD exacerbation and PNA with left lingular infiltrate on CTA, with CTA negative for PE. Patient denies any cardiac history, but may also have a small component of volume overload on exam. Has BLE edema, bilateral crackles, unable to assess JVP based upon body habitus. Patient has history of hypercapnea and has required intubation in past. Patient's current ABG is 7.30/78/64/40. Patient was on BIPAP over the first night for 5 hours, quickly weaned to face mask, then nasal cannula by 2nd day in ICU. Initially given IV solumedrol, CTX, azithromycin for CAP, and lasix 40mg IV, and standing nebs. The patient clinically imprved and was transitioned to the inpatient floor. There was a question of whether or not acute systolic or diastolic CHF was contributing to her symptoms. A 2D echo was limited because of her body habitus but showed preserved systolic function. She was continued on her home dose of Lasix which she takes for LE edema. Her steroids were transitioned to PO and she will complete a slow taper. Antibiotics were transitioned to PO Levaquin. She remained stable on her home O2 requirements of 2-3L. . #. Anemia, acute vs. chronic, normocytic - Unknown baseline. Hct remained stable during this hospitalization. . #. Type 2 DM: Patient was monitored on HISS while inpatient. Her metofromin was initially held but restarted at discharge. . #. Hypothyroidism: Continue levothyroxine . #. s/p RUE fx and R 4th and 5th MT fracture - Continued LE splint. pain control was obtained with oxycodone 5mg q4hrs prn . #. Hypertension: Patient on Diltiazem, lisinopril at home. Patient also reports a possible abnomal heart rhythm in the past. Currently in NSR. Home medications were initially held due to low BPO but were reintroduced as she clinically improved. . # Conjunctivitis: The patient developed some irritaiton and redness in her left eye the day of discharge. There were no signs of pustular discharge and the patient denied any red flag symptoms. Patient was afebrile. EOMI. Antibiotics not indicated. Gave supportive care. . # Dispo- d/c back to rehab for further care. Medications on Admission: Effexor XR 300mg daily aspart SC TID QHS Glucophage 500mg po BID Advair 500/50 1 inhalation [**Hospital1 **] trazadone 300mg po QHS colace 100mg po BID levothyroxine 150mcg daily prilosec 20mg po daily diltiazem ER 120mg po daily lisinopril 5mg po daily lasix 20mg po daily spiriva 18mcg one inhalation daily lovenox 40mg SC daily Oxycodone 5mg po Q2H prn Albuterol neb prn Atrovent neb prn Ativan 0.5mg prn Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO once a day. 4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**1-10**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. 13. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. 14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 15. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Taper to 50mg on [**2144-4-26**] then taper by 10mg q3days until off. 16. Trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 18. Insulin Regular Human 100 unit/mL Solution Sig: AS DIR Injection QAC AND QHS: AS PER SLIDING SCALE. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: COPD exacerbation Discharge Condition: Good. Discharge Instructions: You were admitted for an exacerbation of your COPD. Continue all your medications as prescribed and use your O2. . RecommendationS: -Participate in rehab care -Take all meds as prescribed. -Complete a slow prednisone taper as prescribed. -have your dcotor notified if you start having fevers/chills, worsening shortness of breath, nausea/vomiting, worsening pain, worsening vision, purulent discharge from your eye or any other worrisome signs/symptoms. Followup Instructions: Follow up with your PCP after you are discharged from rehab [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2144-4-26**]

[ "486", "311", "276.7", "278.00", "780.52", "427.31", "372.30", "518.81", "V88.01", "491.21", "285.9", "V46.2", "401.1", "250.02", "244.9", "V15.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8785, 8865

4328, 6599

297, 303

8927, 8935

2163, 4305

9438, 9671

1767, 1771

7057, 8762

8886, 8906

6625, 7034

8959, 9415

1786, 2144

250, 259

331, 1364

1386, 1537

1553, 1751

52,207

119,211

42780

Discharge summary

report

Admission Date: [**2130-5-26**] Discharge Date: [**2130-6-2**] Date of Birth: [**2090-4-15**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5790**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2130-5-26**] Cervical tracheal resection and reconstruction, and flexible bronchoscopy with bronchoalveolar lavage [**2130-6-1**] Bronchoscopy [**2130-6-2**] Bronchoscopy History of Present Illness: Ms [**Known lastname 30890**] is a 40 year old female with dyspnea for 2 months and found to have complex subglottic/proximal tracheal stenosis. She is s/p bronchoscopy x 2 with electrocautery knife tissue ablation, balloon dilation, and mitomycin application now with recurrent dyspnea, mildly labored breathing and cough. She also underwent pH testing that ruled out gastric cause of stenosis. She now presents for eval for surgical management. Pt denies fever, chills, productive cough. She presents now for resection Past Medical History: Ovarian cysts removed at age 15 - was intubated for this procedure Social History: Works as Oncology nurse [**First Name (Titles) **] [**Last Name (Titles) **]. Vincents. Lives with husband, 2 children. Denies tobacco, occ EtOH. Denies illicits. Family History: Denies FamHx of CAD, early cardiac death. GF with lung CA, GM with possible colon CA. Physical Exam: BP: 132/75. Heart Rate: 61. Weight: 146.2. BMI: 25.1. Temperature: 98.6. O2 Saturation%: 100. Gen: healthy appearing female, NAD Neck: no [**Doctor First Name **] Chest: clear ausc. dry barking cough noted Cor: RRR no murmur Ext: no CCE Pertinent Results: [**2130-5-29**] CXR: Clear lungs. No evidence of aspiration or pneumonia or atelectasis. . [**6-1**] and [**6-2**] Bronchoscopy: first bronch w/ clot on anastamosis, removed w/ cryo, patient breathing much better Brief Hospital Course: Mrs. [**Known lastname 30890**] was admitted to the hospital and taken to the Operating Room where she underwent a cervical tracheal resection. She tolerated the procedure well and returned to the SICU extubated and in stable condition. She maintained good oxygen saturations with a cool aerosol mask. She was able to keep her head in gentle flexion with the help of a chin/chest guardian stitch. Following transfer to the Surgical floor she continued to make good progress. She was able to cough up her secretions and her voice was getting stronger daily. She had a few episodes of early morning coughing and an dry throat with some stridor. Racemic epinephrine nebulizer helped immediately but due to recurrent episodes the Otolaryngology service was consulted for a bedside fiberoptic scope which was done on [**2130-5-29**]. The exam was essentially normal with normal cord function. She complained of increased DOE on [**2130-6-1**] and on bronchoscopy had a large blood clot sitting over the area of resection which was removed. Following bronchoscopy she felt 100% better. She was able to ambulate without dyspnea and had no further "noisy" breathing. She had a repeat bronchoscopy on [**2130-6-2**] to reassess and the exam was within the normal limits, she was discharged with follow-up to home. She was eating, drinking, urinating, ambulating, breathing, and reporting good pain control at the time of discharge. Medications on Admission: none Discharge Medications: 1. acetaminophen 650 mg/20.3 mL Solution Sig: Thirty (30) mls PO Q6H (every 6 hours) as needed for pain. Disp:*250 mls* Refills:*2* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Cervical tracheal stenosis. 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 airway and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol 650 mg every 6 hours in between your narcotic. If your doctor allows you may also take Ibuprofen to help relieve the pain. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk 4-5 times a day and gradually increase your activity as you can tolerate. Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, change in your voice, chest pain or any other symptoms that concern you. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2130-6-13**] at 8:30 AM With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [**Location (un) 470**] of the Wesy Clinical Center for a chest xray. Call Dr.[**Name (NI) 81497**] office (OTL)at [**Telephone/Fax (1) 85782**] for a follow up appointmeny in 2 weeks Completed by:[**2130-6-2**]

[ "519.19", "786.09", "E878.8", "934.0", "285.9" ]

icd9cm

[ [ [] ] ]

[ "33.24", "33.22", "31.79", "98.15", "31.42" ]

icd9pcs

[ [ [] ] ]

3761, 3767

1945, 3380

329, 507

3839, 3839

1708, 1922

5339, 5987

1347, 1434

3435, 3738

3788, 3818

3406, 3412

3990, 5316

1449, 1689

270, 291

535, 1060

3854, 3966

1082, 1150

1166, 1331

45,612

126,294

36463

Discharge summary

report

Admission Date: [**2161-4-19**] Discharge Date: [**2161-4-29**] Date of Birth: [**2108-8-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: [**Hospital 82594**] transfer from [**Hospital2 **] [**Hospital3 6783**] Hospital Major Surgical or Invasive Procedure: Intubation Arterial line placement Thoracentesis SVC stent placement History of Present Illness: 52 F with 30 pack year smoking history who presented [**2161-4-8**] with 5 day history of dyspnea and chest tightness, mild productive cough found to have a RUL mass on CXR in the ER. Underwent workup during initial admit from [**Date range (1) 35607**] including CT torso, CT head, bronchoscopy and liver biopsy all consistent with diagnosis of metastatic small cell lung cancer. On [**4-15**] patient went to oncologist's office with increasing dyspnea and left sided face and arm swelling as well as stridor. Patient was intubated for airway protection and chemotherapy was given on [**4-21**] with carboplatin (1 day) and etoposide (3 days). Repeat CT scan showed minimal improvement in diameter of trachea from 4mm to 8mm and right mainstem bronchus from 5mm to 8mm. She was initiated on low dose heparin gtt for SVC syndrome. Vent settings on transfer were AC 450/15 PEEP 7.5 and FiO2 0.4 with saturations 96-100%. Past Medical History: Hyperlipidemia Tobacco abuse- 30 pack year history Surgery: TAH BSO for fibroids s/p breast lumpectomy- benign Social History: Married, lives with husband. 2 daughters, son. Had quit smoking 12 days prior to initial presentation. Smoked 1 PPD for 30 years. No ETOH use. Unemployed. Family History: Breast cancer and heart disease in the family. Physical Exam: On Discharge: Vitals - T:98.1 BP:100/60 HR:75 RR:22 02 sat: 97RA GENERAL: NAD, comfortable, audible upper respiratory wheeze SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, L pupil 4mm, R pupil 2mm, anicteric sclera, pink conjunctiva, patent nares, MMM, poor dentition, nontender supple neck, no LAD, no JVD. CARDIAC: RRR, S1/S2, no mrg LUNG: increased breath sounds on left side, scatter rhonchi throughout. ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, [**5-12**] UE/LE strength, sensation intact Pertinent Results: [**2161-4-8**] CT chest- RUL mass [**2161-4-9**] Bronchoscopy- no malignant cells, bx deferred due to risk bleeding. No endobroncheal lesion. [**2161-4-9**] CT abd/pel- nultiple large hepatic lesions CT head- no brain lesions [**2161-4-13**] Liver biopsy- small blue cells + AE1/AE3, synaptophysin, chromogranin consistent with diagnosis of metastatic small cell carcinoma consistent with lung primary [**2161-4-17**] TTE: small pericardial effusion, echodensity seen anteriorly, hyperdynamic left ventricle [**2161-4-18**] CT chest with contrast- Large RUL paramediastinal mass, bulky mediastinal, supraclavicular and hilar adenopathy, encasement of brachiocephalic and SVC which is significantly narrowed but patent, large right pleural effusion. Narrowing of trachea below tip ETT, right mainstem bronchus narrowed. Hepatic hypodense lesions, largest 4.5 by 4.8cm c/w metastases. No PE. DISCHARGE LABS: [**2161-4-29**] 05:50AM BLOOD WBC-1.1*# RBC-2.63* Hgb-8.4* Hct-24.7* MCV-94 MCH-31.8 MCHC-33.9 RDW-13.6 Plt Ct-82* [**2161-4-29**] 05:50AM BLOOD Neuts-5* Bands-0 Lymphs-84* Monos-7 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2161-4-29**] 05:50AM BLOOD Gran Ct-55* [**2161-4-29**] 05:50AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-136 K-4.0 Cl-101 HCO3-23 AnGap-16 [**2161-4-29**] 05:50AM BLOOD ALT-29 AST-38 LD(LDH)-1131* AlkPhos-110 TotBili-0.6 [**2161-4-29**] 05:50AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.6 [**2161-4-22**] 12:16PM PLEURAL WBC-145* RBC-725* Polys-36* Lymphs-29* Monos-2* Meso-27* Macro-6* [**2161-4-22**] 12:16PM PLEURAL TotProt-3.5 Glucose-108 LD(LDH)-1071 Brief Hospital Course: 52 yo F transferred here on [**4-19**] intubated from OSH for possible tracheal stent placement given tracheal compression [**2-9**] to large left sided small cell lung tumor, metastatic to liver. Had received chemotherapy at the OSH on [**4-21**] (carboplatin and etoposide). She was admitted initially to the ICU and underwent bronchoscopy found to have 80% stenosis of RUL bronchus. No intervention undertaken. SVC found to be completely occluded and stent was placed with excellent effect. Additionally, patient found to have R subclavian thrombus. She was initially treated with heparin and transitioned to and discharged on lovenox. Echo on [**4-21**] revealed severely depressed EF of 20% presumed to be from myocarditis - viral vs. chemotherapy induced. Repeat echo one week on [**4-28**] showed slight improvement to 20-25%. She was treated with ACEi and BB for non-decompensated heart failure. Patient also underwent 160cc thoracentsis of R pleural effusion and received empiric treatment for pneumonia which was completed prior to transfer to floor. She was successfully extubated and transferred to the floor. On the floor patient became pancytopenic as expected 10 days post-chemotherapy administration. Her respiratory status improved and she was successfully weaned off of oxygen though she remained short of breath (though not hypoxic) with ambulation more than 10 yards. She was monitored for several days to ensure increase in counts which started to trend back up towards normal and she was discharged in stable condition on room air home with services on lovenox. Per patient preference, she will follow up with oncology at [**First Name8 (NamePattern2) 1495**] [**Hospital3 6783**] Hospital. Medications on Admission: TRANSFER MEDICATIONS: Combivent Q4H Protonix 40mg daily Decadron 4mg IV Q6H Fentanyl prn Dilaudid 2-4mg IV Q4H: PRN Propfol gtt Heparin 700 units/hr Ativan PRN SSI given steroids Discharge Medications: 1. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 4. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day). Disp:*1000 ml* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*15 Tablet(s)* Refills:*2* 8. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). Disp:*14 Syringes* Refills:*2* 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed. Disp:*1 inhaler* Refills:*2* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Primary: Metastatic Small Cell Lung Cancer Hyperlipidemia Tobacco abuse- 30 pack year history, quit [**3-/2161**] Surgery: TAH BSO for fibroids s/p breast lumpectomy- benign Discharge Condition: Vitals stable, breathing comfortably on room air. Ambulating without difficulty or pain. Discharge Instructions: You were admitted from an outside hospital where you had been intubated as you were found to have a large tumor compressing your airway and much of your left lung. You were brought here to [**Hospital1 18**] and had a stent placed in your superior vena cava (SVC) as it had a large clot in it which was preventing blood flow out of your head. You initially were admitted here to the ICU but were extubated and did well. The chemotherapy that you received at the outside hospital has decreased the size of your tumor and your breathing has become much better. While you were here, our oncology team saw you and talked with you about further chemo to help shrink the tumor further. You stated you preferred to go to [**First Name8 (NamePattern2) 1495**] [**Hospital3 6783**] as it is closer to you. You will have a follow up appointment with Dr. [**Last Name (STitle) 35902**] . You can also follow up here at [**Hospital1 18**] if you choose. You can reach the oncology out patient office at ([**Telephone/Fax (1) 21188**]. You white blood cell count was dropped very low because of the chemotherapy but it was rising before your discharge. You should avoid large crowds and people who are actively sick until your counts fully recover. If you have ANY shortness of breath, chest pain, fever or chills, blood in your sputum, nausea or vomiting, dizziness or lightheadedness or any other concerning symptom, please seek medical care immediately. It was a pleasure meeting you and participating in your care. Followup Instructions: Dr. [**Last Name (STitle) 35902**] on Wed. [**5-6**] at 4:30pm. Please follow up with your primary care doctor soon after you see Dr. [**Last Name (STitle) 35902**].

[ "284.1", "519.19", "518.81", "425.4", "785.51", "276.8", "288.00", "428.21", "197.7", "453.2", "459.2", "305.1", "530.3", "780.61", "162.3", "E933.1", "519.8", "997.31", "272.4", "428.0", "785.6", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "39.50", "96.71", "00.40", "33.23", "39.90", "00.45", "88.51", "38.91" ]

icd9pcs

[ [ [] ] ]

7403, 7448

4168, 5895

394, 464

7667, 7758

2564, 3461

9322, 9492

1740, 1788

6124, 7380

7469, 7646

5921, 5921

7782, 9299

3477, 4145

1803, 1803

1818, 2545

273, 356

5943, 6101

492, 1417

1439, 1552

1568, 1724

58,679

169,560

35087

Discharge summary

report

Admission Date: [**2160-10-11**] Discharge Date: [**2160-10-16**] Date of Birth: [**2128-8-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: The patient presented as a trauma from a motor vehicle accident Major Surgical or Invasive Procedure: None History of Present Illness: 38M who was involved in a rollover MVA early this morning. Ejected from vehicle, found on pavement about 50 feet from automobile. GCS at the scene reportedly 12. Multiple abrasions noted. Taken to OSH where NCHCT reportedly demonstrated right temporal epidural hematoma. Transferred to [**Hospital1 18**] ED for further care. En route, decompensated in terms of mental status, GCS went from 12 to 6. Intubated for airway protection. On arrival to [**Name (NI) **], pt seen to be moving all extremities prior to sedation. Pt unable to offer complaints at the time of my encounter. Past Medical History: unknown Social History: unknown Family History: unknown Physical Exam: On day of admission: O: T: AF BP: 149/84 HR: 115 R 14 O2Sats 100% Gen: Lying in bed, eyes closed. HEENT: Multiple abrasions, including large right frontal abrasion. Neck: In hard collar. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Pertinent Results: CT head [**10-11**] IMPRESSION: 1. 14-mm right anterior temporal epidural hematoma. No mass effect or shift of normally midline structures. 2. Right parietal/temporal fracture extending through the greater [**Doctor First Name 362**] into the right posterior orbit and right sphenoid sinus. 3. Right orbital emphysema and preseptal subcutaneous emphysema. 4. Partial opacification of the left mastoid air cells, without definite fracture identified. CT C spine [**10-11**] IMPRESSION: 1. No fracture or malalignment of the cervical spine. 2. Increased denstiy dependently at the lung apices, concerning for aspiration. XRay Wrists RIGHT WRIST: No fracture or dislocation is identified. LEFT WRIST, THREE VIEWS: No fracture or dislocation is present. IMPRESSION: No fracture. Chest x ray [**10-11**] Comminuted right mid clavicular fracture. Brief Hospital Course: The patient was admitted to the trauma service. He was intubated and sedated for airway protection. His ventilatory support was weaned as tolerated and he was extubated on [**10-12**]. [**10-12**] following extubation, his diet was advanced, he was started on antibiotics by the facial trauma service for fractures and transferred to the surgical floor for continued monitoring. [**10-13**] Physical therapy and occupational therapy worked with the patient towards a goal of being discharged home. He was started on Keppra per neurosurgery. His pain was well controlled on oral medication. Physical and occupational therapy continued working with the patient and he was cleared for home on [**10-16**] Medications on Admission: none Discharge Medications: 1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Comminuted right mid clavicular fracture. 2. Right anterior temporal epidural hematoma without shift 3. Right parietal/temporal fracture extending into Right posterior orbit & Right sphenoid sinus 4. Right lateral rectus paralysis Discharge Condition: Stable 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. * 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. Head of bed elevated >30 degrees Sneeze with an open mouth Do not use a straw Continue antibiotics for 5 days Followup Instructions: Please call the office of Plastic Surgery to arrange a follow up appointment in [**11-21**] weeks at ([**Telephone/Fax (1) 2868**] Orthopedics - please call ([**Telephone/Fax (1) 2007**] to arrange a follow up appointment in [**12-23**] weeks. Please call the office of Opthalmology to arrange a follow up in 2 weeks at ([**Telephone/Fax (1) 5120**] Please call the office of Dr. [**First Name (STitle) **] of neurosurgery to arrange a follow up appointment in 1 month. You will need a head CT on day of follow up. ([**Telephone/Fax (1) 88**]

[ "801.01", "958.7", "810.00", "852.41", "E816.0", "800.01", "378.55" ]

icd9cm

[ [ [] ] ]

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icd9pcs

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3822, 3831

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5,909

128,027

49707

Discharge summary

report

Admission Date: [**2181-9-5**] Discharge Date: [**2181-9-18**] Date of Birth: [**2125-9-30**] Sex: M Service: MED Allergies: Codeine / Gentamicin Attending:[**First Name3 (LF) 689**] Chief Complaint: CHF exacerbation Major Surgical or Invasive Procedure: Placement of LIJ tunneled dialysis catheter Ultrafiltration History of Present Illness: 55 year old male with a PMH of DM, pancreas/[**First Name3 (LF) **] transplants, CAD s/p multiple stents, CHF with EF: 50-55%, Hep B/C admitted [**9-5**] c/o abdominal pain and increased SOB for one week. The pain was described as being sharp and increasing with movement. + chills, +low grad fevers. HE stated he was in his usual state of health until 3-4 days prior to admission when he began to get more SOB with increasing orthopnea and four pound weight gain. He denies any recent medicine changes, follwed by [**Doctor Last Name 2031**] as outpatient. During hospitalizations here, given Lasix IV causing his CR to increase and urine output only -400 net. CHF service consulted as only one kidney now and cr was rising with Lasix. Dr. [**Last Name (STitle) **] recommended enrolling in Nesiritide/ CHF filtration trial. Patient's abd pain w/u includd negative KUB and thought likely secondary to CHF. ID/ transplant following during the admission. Past Medical History: Diabetes type 1, coronary artery disease, status post MI, status post PTCA, multiple coronary artery stents, congestive heart failure with an ejection fraction of 50 to 55 percent, cardiomyopathy, hepatitis B virus, hepatitis C virus, hypothyroidism, hypercholesterolemia, benign prostatic hypertrophy, peripheral vascular disease, cerebrovascular accident in [**2174**] with residual left-sided weakness. Social History: Married, no smoking, no alcohol, no drugs Family History: nc Physical Exam: T: 97.5 HR; 56 RR: 20 BP: 127/58 Weight- 146.4-- 143 yesterday 98% on RA I/O:[**Telephone/Fax (3) 103947**]/300 since MN GEN: AEO x3 HEENT: PERRLA, EOMI, +JVD to earlobe, JVP approx 16, no carotid bruits CV: nl s1, s2, RRR, no M/R/G LUNGS: Bibasilar crackles with decreased BS ABD: Midline wound with wet to dry dressing, +pain to palpation in all quadrants, no rebound, voluntary guarding EXT: superficial wound on anterior left foot + dryness and erthema, cannot palpate DP and TP pulses, but warm extremities with <2 seconds cap refill, 1+ edema blt lower extremities Pertinent Results: [**2181-9-5**] 10:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM [**2181-9-5**] 10:45PM URINE RBC-[**2-2**]* WBC-[**10-20**]* BACTERIA-OCC YEAST-NONE EPI-<1 [**2181-9-5**] 09:15PM GLUCOSE-178* UREA N-45* CREAT-2.8* SODIUM-137 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 [**2181-9-5**] 09:15PM CK(CPK)-32* [**2181-9-5**] 09:15PM CK-MB-NotDone cTropnT-0.09* [**2181-9-5**] 09:15PM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-1.9 [**2181-9-5**] 09:15PM WBC-4.0 RBC-3.67* HGB-10.4* HCT-32.5* MCV-89 MCH-28.4 MCHC-32.1 RDW-18.6* [**2181-9-5**] 09:15PM PLT COUNT-204 [**2181-9-5**] 06:10AM URINE HOURS-RANDOM [**2181-9-5**] 06:10AM URINE GR HOLD-HOLD [**2181-9-5**] 06:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2181-9-5**] 06:10AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [**2181-9-5**] 06:10AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2181-9-4**] 11:25PM GLUCOSE-91 UREA N-44* CREAT-2.8* SODIUM-137 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13 [**2181-9-4**] 11:25PM ALT(SGPT)-16 AST(SGOT)-35 CK(CPK)-38 ALK PHOS-598* AMYLASE-24 TOT BILI-0.6 [**2181-9-4**] 11:25PM LIPASE-16 GGT-238* [**2181-9-4**] 11:25PM CK-MB-3 cTropnT-0.12* [**2181-9-4**] 11:25PM TOT PROT-5.9* ALBUMIN-2.9* GLOBULIN-3.0 CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-1.9 [**2181-9-4**] 11:25PM TSH-6.3* [**2181-9-4**] 11:25PM WBC-4.1 RBC-3.92* HGB-10.8* HCT-34.6* MCV-88 MCH-27.7 MCHC-31.4 RDW-18.7* [**2181-9-4**] 11:25PM NEUTS-66.9 LYMPHS-18.5 MONOS-12.0* EOS-1.4 BASOS-1.2 [**2181-9-4**] 11:25PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MICROCYT-1+ [**2181-9-4**] 11:25PM PLT COUNT-210 EKG: sinus brady, LAD/ LAFB, QTC prolonged at 516 Echo: [**2181-9-24**] The left atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears mildly to moderately depressed. Resting regional wall motion abnormalities include inferior/inferolateral akinesis/hypokinesis. The mitral valve leaflets are structurally normal. There is moderate thickening of the mitral valve chordae. 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. Cardiac cath: [**10-2**]- s/p Lcx stent in [**2174**], s/p lcx/om3 stent [**75**] s/p lcx stent in [**2178**] (left dominant, LMCA/LAD normal, left circumflex stent patent) Urine culture from [**8-30**] showed Pseudomonas Aeroginosa 10-100,000 sensitive to Zosyn Abd x-ray on [**9-5**]- no SBO evidence Abd US on [**9-5**] - nl transplant kidney, nonspecific findings, elevated resistive indices CXR- R basilar infiltrates, Bilteral pleaural effusion R>L Brief Hospital Course: A/P: 55 year old male with extensive PMH of DMI, s/p pancreas and [**Month/Day (4) **] transplant (CRT x 2), CAD s/p multiple percutaneous interventions, CHF, and recent takedown of Hartmann's pouch admitted with CHF exacerbation and abdominal pain. 1. CHF- The patient's increasing dyspnea was felt to be due to a CHF exacerbation. The patient was originally to undergo ultrafiltration however a tunneled line could not be placed at the bedside. He was admitted to the CCU for niseritide with modest response and then transferred to the floor on a lasix infusion. His weight did not drop on the lasix drip at which and he was felt to be persistently volume overloaded. The patient subsequently underwent a tunneled line placement in the left IJ by IR and was started on ultrafiltration. He underent several sessions of UF while in house with removal of [**1-2**] liters with each session. The patient tolerated this procedure well although his creatinine did bump from his basline to approximately 3.0. He will be discharged on lasix 50 mg po bid and will receive 3 sessions of UF per week as an outpatient. In addition, he will remain on his beta blocker and low dose hydralazine was added. 2. Abdominal pain- The patient initially had abdmominal pain of unclear etiology. Significantly, the patient had abdominal cellulitis last month but the incisional area does not appear infected on exam. No fluid collection in that area was seen on ultrasound. LFTs were within normal limits except for an elevated alkaline phosphatase and elevated GGT. The patient's abdominal US was nonrevealing except for mildly elevated flow pressures in the transplanted kidney but these were stable compared to a prior exam. Plan films of the abdomen were negative for SBO. We discussed CT of the abdomen with the patient however he was unwilling to drink contrast and this was not pursued. The most probable cause of abdominal pain was felt to be hepatic congestion from fluid overload and mesenteric edema. Transplant surgery was consulted and did not find the patient to have any acute surgical issues. The patient also complained of diarrhea. C. diff was negative x 3. A CMV viral load was negative. The patient admitted to eating many sugar free, sorbitol containing hard candies. When these were discontinued, his diarrhea resolved. 3. ESRD s/p [**Date Range **] transplant- The patient's creatinine was at baseline on admission and his transplanted kidney was unchanged on US from previous studies. His creatinine did bump with diuresis and initiation of ultrafiltration; however, this did not represent a significant loss of GFR. He was continued on prednisone and imuran for immunosuppression. A PTH was also checked and was elevated. He was started on calcitriol for this. 4. Type 1 DM- The patient had elevated blood sugars intermittently though this admission. His lantus was increased to 13 units HS and he was maintained on a RISS. He will follow up with his [**Last Name (un) **] diabetologist as an outpatient. 5. CAD- ECG unchanged from baseline and patient denied chest pain. He was ruled out for MI on admission and was continued on his home CAD meds including beta blocker and statin. Pt reports he is not on ASA because he has bled on this in the past. 6. Proxysmal atrial fib- Pt with good rate conrol. He was continued on his beta blocker and amiodarone. There was some concern for amiodarone toxicity given his unusually high dose and his dose was decreased on [**2181-9-6**]. The patient is not on anticoagulation due to bleeding on aspirin and coumadin in the past. 7. HTN- The patient's blood pressue was well controlled on beta blocker, nitrates and hyralazine. 8. Hypothyroidism- The patient has had severe hypothyroidism in the past with TSH in the 70s-100s. This was felt to be a precipitant to CHF exacerbations in the past. His dose of levoxyl was maintained at 150 mcg though the majority of his hospital course. A TSH was checked prior to discharge and was elevated at 14. A free T4 returned normal. Endocrine was consulted and recommended increasing his levoxyl to 200 mcg and repeating his thyroid function tests in [**3-6**] weeks. 9. UTI- The patien had a multidrug resistant pseudomonas UTI and was trated with 10 days of piperacillin. A follow up UA/UCx was positive for yeast (>100K colonies). He is being discharged on a 7 day course of fluconazole. 10. GERD- He was treated with a PPI with good effect. 11. FEN- The paient was given a low sodium, [**Date Range **], [**Doctor First Name **] diet. He was maintained on a 1.5 liter fluid restriction. He was also informed to avoid all sorbitol containing foods. 12. Proph- Bowel regimen; PPI; SC heparin. 13. Dispo- The patient is being discharged to home with PCP, [**Name10 (NameIs) **], and [**Last Name (un) **] follow up. He will initiate oupatient ultrafiltration 3 days after discharge. Medications on Admission: 1. Prednisone 5 mg daily 2. Protonix 40 mg daily 3. Bactrim SS 1 tab Mon, Wed, Fri 4. Lipitor 10 mg daily 5. Amiodarone 400 mg [**Hospital1 **] 6. Lantus insulin 10 units QHS 7. Levothyroxine 100 mcg daily 8. Hydralazine 10 mg TID 9. Imdur 30 mg daily 10. Lasix 80 mg daily 11. Toprol XL 25 mg daily 12. Imuran 50 mg daily 13. Colace 100 mg [**Hospital1 **] 14. Percocet PRN 15. Rapimine 1 mg daily 16. Flagyl 500 mg TID 17. Lactulose PRN Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WK (MWF) (). 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). 8. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical QD (once a day). 9. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Topical Q6H (every 6 hours) as needed. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QD (once a day). Disp:*30 Capsule(s)* Refills:*2* 12. Insulin Glargine 100 unit/mL Solution Sig: Thirteen (13) units Subcutaneous at bedtime. 13. Regranex 0.01 % Gel Sig: One (1) application Topical once a day. Disp:*100 grams* Refills:*0* 14. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO once a day for 6 months. Disp:*180 Tablet(s)* Refills:*0* 15. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 16. Lasix 40 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*2* 17. Hydralazine HCl 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 18. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 19. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 20. Insulin Regular Human Subcutaneous 21. Insulin Regular Human 300 unit/3 mL Syringe Sig: per sliding scale units Subcutaneous four times a day: BS < 150 : 0 units BS 151-200: 2 units BS 201-220: 4 units BS 221-260: 6 units BS 261-300: 8 units BS >301: 10 units . Discharge Disposition: Home With Service Facility: [**Last Name (un) 2646**] Discharge Diagnosis: Primary diagnosis: CHF exacerbation Secondary diagnosis: Abdominal pain Type 1 diabetes mellitus CAD S/P MI and multiple PTCA. Pt ruled out for MI on admission. Hypothyroidism PVD CVA in [**2174**] BPH s/p TURP Hypercholesterolemia GERD Discharge Condition: Weight decreased. Abdominal pain improved. Diarrhea resolved. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters 1. Please keep all follow up appointments. --Call your nephrologist Dr. [**Last Name (STitle) **] [**Last Name (STitle) 1391**] for an appointment [**Telephone/Fax (1) 88465**] --Go to DCI dialysis center [**9-21**] and Mon/Wed/Fri, call with questions [**Telephone/Fax (1) 17126**]. 2. Please take all medications as prescribed. 3. Seek medical attention for chest pain, shortness of breath, abdominal pain, nausea, vomiting, or other concerning symptoms. 4. You will need to have your thyroid function tests repeated in [**3-6**] weeks. Followup Instructions: 1. Call your nephrologist Dr. [**Last Name (STitle) 103948**] for an appointment [**Telephone/Fax (1) 88465**]. You should also follow up with Dr. [**Last Name (STitle) 2204**] within 1 week of discharge. 2. Call the DCI dialysis center if you have questions about your appointment on [**9-21**] [**Telephone/Fax (1) 17126**] 3. Call the [**Hospital **] Clinic and schedule an appointment with Dr. [**Last Name (STitle) 10088**] within 1 month of discharge 4. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2181-10-19**] 9:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2181-11-2**] 9:30 5. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2181-9-27**] 2:40 Completed by:[**0-0-0**]

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38835

Discharge summary

report

Admission Date: [**2181-3-11**] Discharge Date: [**2181-3-28**] Date of Birth: [**2099-10-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: fever, confusion Major Surgical or Invasive Procedure: Central line placement Arterial line placement History of Present Illness: Mr. [**Known firstname **] [**Known lastname 86198**] is a 81 year old man with a history of CHF, Afib, COPD and DM2 presented to an OSH after several days of nausea, vomiting, and diarrhea with new onset altered mental status. His family reports several family members with similar recent GI symptoms. At the OSH he was found to be febrile 102.8, hypotensive (77/44), confused, and hypoglycemic (fsbs 45). He underwent chest x-ray and was started on vancomycin and zosyn for presumed hospital acquired pneumonia. He was also given 2 L IVF and started on stress dose steroids for history of COPD with frequent steroid use. His INR was found to be 11 and he was given Vitamin K 10 mg IV. His blood pressure was documented as 77/44 and he was started on peripheral levophed. Due to bed availablity patient was transferred to [**Hospital1 18**] ED. . In the ED, initial VS: T 100.1 HR 110 BP 94/55 RR 26 SpO2 100% 4L NC. WBC was elevated at 12 with 22% bands. He underwent CXR which did not show clear evidence of pneumonia. Urinalysis was negative for infection. RUQ U/S was suggestive of possible acute cholecystitis. Surgery was consulted. They did not recommend urgent surgery given his hemodynamic instability and supratherapeutic INR. They recommended perc cholecystectomy in the morning pending correction of his INR and stable blood pressures. CVL was placed and levophed was titrated to MAP > 65. He received 4 g IV prior to transfer to the ICU. . On arrival to the ICU, patient is alert and oriented. He admits to poor appetite and RUQ pain with deep inspiration or palpation. He reports several days of increased fevers and chills. He admits to increased loose stools and nausea. He denies any hematuria, dysuria, productive cough, chest pain, black or tarry stools, BRBPR, history of blood clots. . Of note, patient had multiple recent hospital admission in [**State 108**] for CHF exacerbations and pneumonia. Past Medical History: Coronary Artery Disease: s/p c.cath [**2174**] that showed 3vd (per outpt cardiologist Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]) DM2 Gout Hyperlipidemia HTN Severe aortic stenosis Systolic CHF EF 20-25% BPH Anemia COPD/Asthma s/p appendectomy s/p hernia repair s/p carpal tunnel release s/p tonsillectomy Social History: Retired. Was in boat sales for 50 yrs. Lives with wife of 59 years. Denies any tobacco or etoh use in over 30 years. Independent of ADLs at baseline Family History: Non-contributory Physical Exam: Vitals - T: BP: 104/61 HR:104 RR: 25 02 sat: 96% on 4 L GENERAL: NAD, pleasant HEENT: watery eyes, anicteric sclera, dry mm CARDIAC: distant heart sounds, tachycardic, no MRG LUNG: CTA bilaterally, decreased bs at bases, loud rhonchorus upper airway sounds that improved with cough. Mildly labored breathing with talking, able to finish full sentences. ABDOMEN: + bs, soft, RUQ tenderness, no rebound, no guarding EXT: warm, dry NEURO: a+o x 3, no focal deficits. DERM: No rashes, small scattered ecchymoses, warm, dry Pertinent Results: Admission Labs: [**2181-3-11**] 10:50PM BLOOD WBC-12.0* RBC-3.91* Hgb-10.8* Hct-34.0* MCV-87 MCH-27.5 MCHC-31.7 RDW-17.0* Plt Ct-148* [**2181-3-11**] 10:50PM BLOOD Neuts-70 Bands-22* Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2181-3-11**] 10:50PM BLOOD PT-57.4* PTT-42.4* INR(PT)-6.5* [**2181-3-11**] 10:50PM BLOOD Glucose-103* UreaN-36* Creat-1.3* Na-138 K-4.0 Cl-107 HCO3-18* AnGap-17 [**2181-3-11**] 10:50PM BLOOD ALT-16 AST-28 LD(LDH)-231 CK(CPK)-75 AlkPhos-58 TotBili-0.5 [**2181-3-11**] 10:50PM BLOOD cTropnT-0.10* [**2181-3-12**] 12:17AM BLOOD Lactate-1.9 ======== . ECHO [**3-12**]: moderately dilated left ventricle with severe global LV hypokinesis. Dilated and hypokinetic RV. The mid lateral wall has relatively preserved function. Calcific aortic stenosis that is probably severe/critical - low flow state makes calculation of valve area difficult. Mild mitral regurgitation. . CT Torso [**3-12**]: 1. Bibasilar consolidations and smaller bilateral pulmonary opacities compatible with multifocal infection. Small right and trace left pleural effusions. 2. Similar appearance of moderately dilated and edematous gallbladder with a small calculus. 3. Findings compatible with pulmonary arterial hypertension. 4. Cardiomegaly, coronary artery calcifications and significant atherosclerotic involvement of the thoracic and abdominal aorta and branches. 5. Multilevel severe degenerative changes in the thoracolumbar spine. Brief Hospital Course: . MRSA/Pseudomonas Pneumonia: Mr. [**Known lastname 86198**] was empirically started Vancomycin and Zosyn on presentation due to sepsis and suspicion for hospital acquired pneumonia. Sputum cultures grew MRSA and Pseudomonas aeruginosa. Chest CT was consistent with multilobar pneumonia. . MRSA Bacteremia: Blood cultures from OSH yielded two out of four bottles positive for MRSA. He was started on Vancomycin empirically on arrival to the ED. With positive cultures, ID team was consulted who recommended completing a three week course of Vancomycin. This will be complete on [**4-8**]. . Acute on Chronic Systolic Heart Failure: Medical records from OSH suggested systolic heart failure and aortic stenosis. Transthoracic echo was performed during this admission which showed no evidence of vegetations. Aortic valve area was measured at 0.8 cm2 and EF was 10%. After resuscitation for sepsis, he was significantly volume overloaded but with borderline low BP (low 90s systolic). The cardiac consulting team was involved. Standing IV lasix 80 mg TID was started but intermittently held for hypotension. On this regimen he improved significantly, although significant lower extremity edema persisted. He was changed to oral lasix 80 mg [**Hospital1 **]. On discharge, he was changed to 100 mg [**Hospital1 **] lasix and metolazone was added. Clinical status was notable for [**1-17**]+ lower extremity edema with clear lungs, mild orthopnea, and O2 Sats in the mid daily and consider increasing lasix or continuing metolazone beyond the 1 week in order to achieve euvolemia. . Coronary artery disease: Patient with elevated troponin on presentation. Concurrent chest heaviness, shortness of breath and elevated cardiac enzymes was concerning for ACS. Patient was continued on daily aspirin, home dose statin was increased. He was placed on a heparin gtt for 48 hours as empiric medical management of ACS. His enzymes trended down. Beta blocker was initially held due to significant hypotension. Patient's outpatient cardiologist (Dr. [**Last Name (STitle) 86199**] was contact[**Name (NI) **] who revealed that the patient has known three vessel disease diagnosed on cardiac catheterization in [**2174**]. He was uncertain as to why patient did not undergo any interventions at that time. The cardiac consulting team was involved and thought that this was likely demand ischemia and did not think any intervention was appropriate. Troponin trended down. Chest heaviness recurred intermittently in the absence of EKG changes or troponin elevation. It is possible that this represents angina. He had previously been on a long-acting nitrate. This was restarted at a lower dose on discharge and should be titrated to comfort as BP tolerates. Follow up was arranged with his cardiologist, and discharge summary will be faxed. . Atrial fibrillation: Beta blocker was initially held given hypotension. This was restarted at a lower dose when he was hemodynamically stable. Rate control was adequate. He was anticoagulated with a supratherapeutic INR on admission, having received Vitamin K 10 mg IV at OSH prior to arrival. Coumadin was held initially. INR was closely monitored while on antibiotics. Coumadin was restarted when INR fell in order to maintain therapeutic anticoagulation. This was restarted at a lower dose and titrated up. In the days prior to discharge, he received 2.5 mg daily through [**3-25**], on [**3-26**] INR supratherapeutic so dose held and restarted at 2 mg daily on [**3-27**]. INR was 3.5 on [**3-27**]. Coumadin was changed to 1 mg. INR should be rechecked [**3-29**] and coumadin titrated appropriately. . Left wrist inflammation: Patient with known history of gout. With painful swelling of left wrist on [**2181-3-16**] colchicine and allopurinol were restarted and rheumatology consulted. Joint swelling was also concerning for possible septic joint given recent bacteremia. Because of patient's elevated INR arthrocentesis was not performed. His symptoms improved with allopurinol and a prednisone taper. He completed the taper in house. . GOALS OF CARE: The patient and his family expressed that he was to be DNR/DNI. Prior to discharge, the patient and his family expressed that they wanted to continue all medical measures but not pursue any further invasive measures. Medications on Admission: MEDICATIONS: .Coreg 6.25 mg Tab Oral Twice Daily .Allopurinol 100 mg Tab Oral Daily .Aspirin 81 mg Tab Oral Daily .Lipitor 10 mg Tab Oral Daily .Colchicine 0.6 mg Tab Daily .Digoxin 125 mcg Daily .Advair Diskus 250 mcg-50 mcg Twice Daily .Lasix 20 mg Daily .Glyburide 2.5 mg Twice Daily .Isosorbide Dinitrate 30 mg Daily .Mobic 7.5 mg Twice Daily .Metformin 500 mg Daily .Niaspan 500 mg Once Daily .Protonix 40 mg Daily .Aldactone 25 mg Daily .Flomax 0.4 mg Daily .Diovan 80 mg Daily .Coumadin 5 mg Daily (Odd days) .Coumadin 2.5 mg Daily (Even days) .Albuterol Sulfate Neb Solution Every 4-6 hrs, as needed .Atrovent HFA 17 mcg/Actuation Aerosol Every 4-6 hrs, as needed Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: primary: sepsis secondary to pneumonia, acute on chronic systolic congestive heart failure, gout secondary: type 2 diabetes mellitus, 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 came to the hospital because of a bad pneumonia. You were in the intensive care unit on antibiotics. You improved on this regimen. However, because of your congestive heart failure you had a lot of extra fluid in your body. You were on a general medicine service where you were given IV lasix to improve this. You also had a flair of your gout which improved with a course of prednisone. The following medications were changed: Coreg was decreased to 3.125 mg twice daily Lipitor was increased to 80 mg daily Lasix was increased to 100 mg twice daily Glyburide was changed to glipizide Isosorbide Dinitrate was changed to isosorbide mononitrate daily Mobic was stopped Niaspan was stopped Aldactone was stopped Diovan was decreased to 40 mg daily Coumadin was changed to 2 mg daily, but the doctors at the rehab will be adjusting this as needed Vancomycin was added, to continue until [**4-8**] Cefepime was added, to continue until [**4-8**] Tylenol was added as needed for pain Docusate was added Senna was added as needed for constipation Metolazone was added Followup Instructions: We arranged the following appointments for you: Name: EMMET [**Last Name (NamePattern4) 86200**] MD SPECIALTY: PRIMARY CARE Address: [**Apartment Address(1) 86201**], [**Location (un) 10068**],[**Numeric Identifier 39453**] Phone: [**Telephone/Fax (1) 86202**] WHEN: WEDNESDAY [**4-4**] 2pm Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD SPECIALTY: CARDIOLOGY ADDRESS: [**Street Address(2) 86203**], [**Location (un) 10068**], MA PHONE: [**Telephone/Fax (1) 9674**] WHEN: THURSDAY [**4-5**] 3:15pm Completed by:[**2181-3-29**]

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Discharge summary

report

Admission Date: [**2116-4-2**] Discharge Date: [**2116-4-15**] Date of Birth: [**2066-10-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4219**] Chief Complaint: SOB and abdominal distention Major Surgical or Invasive Procedure: Paracentesis Thoracentesis History of Present Illness: Pt well known to me from my [**Hospital 3782**] clinic. Mr.[**Known lastname **] is a 49 YOM with new diagnosis of cirrhosis likely from Hep B and C after Hx of IVDA. I saw him a few weeks ago in the [**Hospital 3782**] clinic after hospitalization for ascities. He was doing well and losing weight on his diuretics. He phoned me 2 days PTA stating he was become SOB. I asked him at that time to go the the ED to be evaluated. He declined but made an appointment to be seen in the [**Hospital 191**] clinic today. He was seen and felt to have singnificant hypoxia with ambulation down to 86% on RA and extensive LE edema and tense ascities. Upon arrival to ED he was afebrile and still hypoxic on RA. He states he has been getting progressively more short of breath over past few days. He attributes this to laying on his right side and thinks the fluid from his belly has "rolled into my chest". No fevers or chills at home. Abdominal pain is unchanged. He states he is taking his medications as directed. . ROS Positive for nausea, "watery vomitting", no blood in emesis. Have [**1-3**] bowel movements a day. Past Medical History: Includes a motor vehicle accident and back pain, hepatitis B and C recently diagnosed as well as IV drug use x30 years. Social History: The patient began smoking after his recent discharge. No alcohol use. He is unemployed. Last worked a few years ago in a factory. He spends most of his day, he says, sleeping. Family History: Mother is living, 86 years old, with hypertension. He has a sister and a brother in good health. Physical Exam: T 98.3 BP 114/64 HR 88 RR 24 89% RA 96% on 2L GENERAL: temporal wasting, and appears chronically ill. HEENT: Pupils equal, round, reactive to light. Extraocular movements intact. There is no scleral icterus. Some slight erythema in the throat. Otherwise, oropharynx is clear. He also has on his right forehead a raised erythematous lesion approximately 1 cm in diameter that he states is an ingrown hair that has been present for a number of weeks. SKIN: He has multiple telangiectasias upon his chest as well as obvious collateral veins dilated across his chest and abdomen. There is no pallor and there is no sign of jaundice. NECK: There is no lymphadenopathy. JVP appears to be elevated at approximately 12 cm. LUNGS: Markedly decreased BS on right with dullness to percusion. Also, on chest exam, the patient has bilateral gynecomastia. CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. ABDOMEN: Distended, tense, tympanitic throughout. He has a significant ventral hernia when sitting up. Bowel sounds present. I am unable to palpate his spleen or liver. EXTREMITIES: He has 3+ pitting edema that rises approximately 3 inches past his knees. Neuro: AOX3 non-focal. no asterixis. Pertinent Results: [**2116-4-2**] 12:15PM GLUCOSE-78 UREA N-19 CREAT-1.1 SODIUM-132* POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-14 [**2116-4-2**] 12:15PM ALT(SGPT)-31 AST(SGOT)-48* ALK PHOS-108 AMYLASE-99 TOT BILI-2.1* [**2116-4-2**] 12:15PM LIPASE-59 [**2116-4-2**] 12:15PM ALBUMIN-2.7* CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.7 [**2116-4-2**] 12:15PM WBC-4.5 RBC-4.21* HGB-13.5* HCT-39.3* MCV-93 MCH-32.1* MCHC-34.5 RDW-16.4* [**2116-4-2**] 12:15PM NEUTS-70.7* LYMPHS-19.3 MONOS-8.0 EOS-1.5 BASOS-0.5 [**2116-4-2**] 12:15PM ANISOCYT-1+ MACROCYT-1+ [**2116-4-2**] 12:15PM PLT COUNT-132*# [**2116-4-2**] 12:15PM PT-17.1* PTT-32.6 INR(PT)-1.6* _ _ _ _ _ _ _ _ _ ________________________________________________________________ RADIOLOGY Final Report CHEST (PA & LAT) [**2116-4-2**] 3:18 PM CHEST (PA & LAT) Reason: rule out infiltrate, CHF [**Hospital 93**] MEDICAL CONDITION: 49 year old man with ascites and SOB REASON FOR THIS EXAMINATION: rule out infiltrate, CHF INDICATION: Ascites, shortness of breath, evaluate for infiltrate versus CHF. COMPARISON: None. PA AND LATERAL CHEST RADIOGRAPHS There is complete opacification of the right hemithorax. There is slight leftward shift of the trachea and heart suggesting that this is largely due to effusion, and most likely collapse. Underlying left lung appears clear. RADIOLOGY Final Report CHEST (PA & LAT) [**2116-4-5**] 9:34 AM CHEST (PA & LAT) Reason: Please evaluate for interval change [**Hospital 93**] MEDICAL CONDITION: 49 year old man with ascites and SOB with righ side pleural effusion s/p paracentesis REASON FOR THIS EXAMINATION: Please evaluate for interval change CHEST TWO VIEWS, PA AND LATERAL History of ascites with shortness of breath and pleural effusion, status post paracentesis. There is total opacity of the right hemithorax with possible slight shift of heart to the left consistent with persistent massive right pleural effusion, unchanged since prior film of [**2116-4-2**]. Minimal atelectasis is present at the left lung base. IMPRESSION: Complete opacification of the right hemithorax, likely secondary to effusion. Underlying infection cannot be excluded. Discussed with Dr. [**First Name4 (NamePattern1) 14392**] [**Last Name (NamePattern1) 14393**] at 4:15 p.m., [**2116-4-2**]. CHEST (PORTABLE AP) [**2116-4-7**] 3:01 AM CHEST (PORTABLE AP) Reason: please eval for interval change [**Hospital 93**] MEDICAL CONDITION: 49 year old man with esld and effusion, now hypoxic to 80's on face mask. REASON FOR THIS EXAMINATION: please eval for interval change REASON FOR EXAMINATION: Evaluation of known pleural effusion in patient with end-stage liver disease. Portable AP chest radiograph compared to [**2116-4-5**]. The right hemithorax is almost completely opacified by large amount of pleural fluid with prominent mediastinal shifting. There is some small improvement of aeration of the right lung in the right upper lobe. The left lung is clear with no pleural effusion. IMPRESSION: Large amount of right pleural effusion, which is slightly less with small improvement in the aeration of the right upper lobe. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2116-4-15**] 11:20 AM CHEST (PORTABLE AP) Reason: interval change in pleural effusion/PTX [**Hospital 93**] MEDICAL CONDITION: 49 year old man with esld and pleural effusion, PTX after thoracentesis REASON FOR THIS EXAMINATION: interval change in pleural effusion/PTX INDICATION: End-stage liver disease and pleural effusion, post thoracentesis. COMPARISON: [**2116-4-13**]. The large right pleural effusion has substantially increased in size in two days. Left lower lobe linear atelectasis is unchanged. There is equivocal contralateral shift of the mediastinum. Left lung is clear and no left pleural effusions are present. Unilaterality of effusion without a significant mass effect (mediastinal shift) suggests a possible etiology beyond known end-stage liver disease. IMPRESSION: Worsening large pleural effusion. _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ RADIOLOGY Final Report CT CHEST W/CONTRAST [**2116-4-8**] 3:58 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: injury to thoracic duct, mediastinal mass or lymphadenopathy Field of view: 39 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 49 year old man with chylothorax, liver failure REASON FOR THIS EXAMINATION: injury to thoracic duct, mediastinal mass or lymphadenopathy. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 49-year-old male with chylothorax, liver failure, injury to thoracic duct. Assess for mediastinal mass or lymphadenopathy. No comparison studies. TECHNIQUE: MDCT-acquired axial images of the chest, abdomen, and pelvis were performed with IV contrast. CT CHEST WITH IV CONTRAST: There is an extremely large right-sided pleural effusion taking up nearly the entire right hemithorax causing right middle and right lower lobe entire collapse and partial collapse of the right upper lobe. This expansive right effusion is causing further mediastinal shift compared to one-day prior chest x-ray. There is compression upon the entire left lung. There are multiple patchy areas of ground-glass within the left upper and lower lobes, which could represent early development of pneumonia or atelectasis given compression. Recommend clinical correlation. Within the mediastinum, there is one area of soft tissue density likely representing a lymph node in the pretracheal region, however, recommend followup study post-drainage of effusion for better assessment of additional nodes within the mediastinum given that study is limited secondary to shift and image quality. CT ABDOMEN WITH IV CONTRAST: Liver is small and nodular consistent with cirrhosis. There is a marked amount of ascites. Gallbladder contains a small stone. Pancreas is grossly unremarkable. Spleen is enlarged. Adrenal glands are not clearly visualized, however, no large masses are identified. The kidneys are unremarkable. The small bowel and large bowel are of normal caliber with no evidence of obstruction. There is soft tissue density seen within the retroperitoneum, seen surrounding the aorta at the level of the SMA, however, difficult to assess whether or not soft tissue density represents normal or abnormal tissue given poor image quality. Again recommend followup study after resolution of effusion and/or possibly ascites. CT PELVIS WITH IV CONTRAST: Ascites extends down into the pelvis. Urinary bladder is unremarkable. The prostate and rectum are within normal limits. Few diverticuli within the sigmoid colon with no evidence of diverticulitis. BONE WINDOWS: No suspicious lytic or blastic osseous lesions. IMPRESSION: 1. Extremely large right pleural effusion, increased in size compared to one-day prior, causing significant mediastinal shift, collapse of right middle and lower lobes, and compression of left lung. 2. Borderline enlarged lymph node in the right pretracheal station. Recommend followup CT scan for better assessment of both this as well as other possible nodes within the mediastinum following resolution of pleural effusion. 3. Multiple patchy ground-glass opacities within the left upper and lower lobes, which could represent pneumonia in the appropriate clinical setting. Also could represent atelectasis given compression from right pleural effusion. Recommend clinical correlation. 4. Marked ascites as seen on prior ultrasound. 5. Cirrhotic liver and splenomegaly. 6. Cholelithiasis. 7. Questionable retroperitoneal soft tissue surrounding aorta at level of SMA. Recommend followup scan for better delineation of this lesion given poor quality of current examination. _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ RADIOLOGY Final Report US ABD LIMIT, SINGLE ORGAN [**2116-4-2**] 3:40 PM US ABD LIMIT, SINGLE ORGAN Reason: please scan all 4 quadrants and mark for paracentesis [**Hospital 93**] MEDICAL CONDITION: 49 year old man with abd distension, Hep B/C cirrhosis, here with ascites. REASON FOR THIS EXAMINATION: please scan all 4 quadrants and mark for paracentesis LIMITED ULTRASOUND SCAN OF THE ABDOMEN. CLINICAL DETAILS: Chronic liver disease, evaluate for ascites. FINDINGS: Large amount of intra-abdominal ascites, which appears simple on ultrasound. This is present throughout the four quadrants. Cutaneous ink mark was placed overlying the largest depth of ascites in the right lower quadrant. At that point, the abdominal wall measures 1 cm in thickness with the ascites measuring over 5 cm in depth deep to the anterior abdominal wall at that level. CONCLUSION: Large amount of intra-abdominal ascites. _ _ _ _ _ _ _ ________________________________________________________________ Cardiology Report ECHO Study Date of [**2116-4-6**] PATIENT/TEST INFORMATION: Indication: Shortness of breath. Height: (in) 72 Weight (lb): 198 BSA (m2): 2.12 m2 BP (mm Hg): 110/60 HR (bpm): 100 Status: Inpatient Date/Time: [**2116-4-6**] at 14:28 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W019-1:00 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) 14394**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 3.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 3.0 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 0.7 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.0 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 1.8 cm Left Ventricle - Fractional Shortening: 0.55 (nl >= 0.29) Left Ventricle - Ejection Fraction: 75% to 85% (nl >=55%) Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.29 Mitral Valve - E Wave Deceleration Time: 262 msec TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: Large left pleural effusion. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal regional LV systolic function. Hyperdynamic LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve. No AS. MITRAL VALVE: Normal mitral valve leaflets. No MVP. No mass or vegetation on mitral valve. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2116-4-6**] 14:57. _ _ _ _ _ _ _ _ _ ________________________________________________________________ Cytology Report PLEURAL FLUID Procedure Date of [**2116-4-6**] REPORT APPROVED DATE: [**2116-4-8**] SPECIMEN RECEIVED: [**2116-4-7**] 06-[**Numeric Identifier 14395**] PLEURAL FLUID SPECIMEN DESCRIPTION: Received 1500ml bloody fluid. Prepared 1 ThinPrep slide. CLINICAL DATA: Patient with ESLD and effusion on the right. PREVIOUS BIOPSIES: [**2116-2-17**] 06-[**Numeric Identifier 14396**] PERITONEAL FLUID REPORT TO: DR. [**First Name (STitle) **] [**Name (STitle) **] DIAGNOSIS: Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Abundant reactive mesothelial cells, lymphocytes, histiocytes and red blood cells. DIAGNOSED BY: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8846**], CT(ASCP) [**First Name11 (Name Pattern1) 2127**] [**Last Name (NamePattern1) **], M.D. _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ [**2116-4-3**] 4:21 pm PERITONEAL FLUID **FINAL REPORT [**2116-4-9**]** GRAM STAIN (Final [**2116-4-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2116-4-6**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2116-4-9**]): NO GROWTH. _ _ _ _ _ _ _ _ _ ________________________________________________________________ [**2116-4-6**] 4:08 pm PLEURAL FLUID DAS,ACU ADDED 1741. GRAM STAIN (Final [**2116-4-6**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2116-4-9**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2116-4-12**]): NO GROWTH. ACID FAST SMEAR (Final [**2116-4-7**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): Brief Hospital Course: 49 yo man with an extensive h/o IVDA, hepatitis C, admitted with SOB and abdominal distention. . #SOB/Ascities - Likely related to cirrohsis. Has been compliant with medications. But not eating a low salt diet. Large right pleural effusion related to ascities. No fever, elevated WBC, or change in abdominal pain to suggest SBO. Diagnostic and therapeutic paracentesis done on [**2116-4-3**] about 7 liters of chylous transudative fluid removed that was culture and cytology negative. His diuretics were increased to lasix 80 [**Hospital1 **] and spironolactone 200 mg [**Hospital1 **]. On Monday [**2116-4-6**] 2.5 liters of chylous transudative fluid was removed from his right chest wiht interval improvement of his CXR. he recieved 4 mg of ativan peri-procedure. That evening he had an acute oxygen desaturation to the 80s on 4L. This was thought to be [**1-2**] sedation from meds, no PTX but the fluid had already reaccumulated. He was put on a NRB with sats returning to the mid 90s. He spent one night in the ICU for continuous O2 monitoring with out incident. He remained on the floor getting [**Hospital1 **] diuretics. A CT scan was done to look for cause of chylous nature of fluids (mediastinal adenopathy) but there was too much compression of structures [**1-2**] to fluid to look and thoracic duct and near by structures. A second large therapeutic tap was done on [**2116-4-11**] and 5L of similarly colored fluid was removed (none sent to the lab). Over the next few days O2 sats improved with more fluid taken off. he refused further thoracentesis. On Monday [**2116-4-13**] his O2 sats were improved. However at this point his Na began to drop and Cr began to rise. It seemed he was developing hepatorenal syndrome. His diuretics wre stopped. His Na continued to drop and CR rise. On Wednesday [**2116-4-15**], it was decided to treat his hepatrenal syndrome with octreatide and midodrine. He however became angry after a negative interaction with the hepatology team and decided to leave the hospital AMA. #Heroin addiction - pt stable on methadone 60 mg po qd. Medications on Admission: Lasix 40 mg once a day, spironolactone 200 mg once a day, lactulose 15 mL t.i.d., Protonix 40 mg once a day, and methadone 60 mg once a day provided by the [**Location (un) **] methadone clinic. Discharge Medications: 1. 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* 2. Methadone 10 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily): provided by [**Hospital **] clinic. 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO BID (2 times a day). Disp:*2700 ML(s)* Refills:*2* 5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). Disp:*1 tube* Refills:*2* 6. Medical equipment Please provide patient with hospital bed Discharge Disposition: Home Discharge Diagnosis: Cirrohsis Pleural effusion Ascities Acute Renal Failure Hyponatremia Discharge Condition: Good Discharge Instructions: Please return to emergency department if you have fevers, abdominal pain, or trouble breathing. . Please restrict the amount of fluid you drink each day to 1L(that is equal to about 4 cans of soda) and restrict the amount of salt and sodium you take in. Followup Instructions: Please come to [**Hospital 191**] clinic on Thursday [**2116-4-16**] to have labs drawn at 1pm. Please wait to speak with me after the labs come back. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2116-4-23**] 1:30 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2116-5-20**] 1:40 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**] Completed by:[**2116-4-21**]

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icd9cm

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32802

Discharge summary

report

Admission Date: [**2162-10-14**] Discharge Date: [**2162-11-12**] Date of Birth: [**2106-11-25**] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 12131**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Fixation of right femoral neck/intertrochanteric fracture with intramedullary device and prophylactic fixation of several distal femur metastatic lesions prophylactically with intramedullary device on [**2162-10-22**] Open reduction internal fixation left radius fracture, curettage left radius bone lesions on [**2162-11-3**] History of Present Illness: 55-year-old male with DMII, CAD status post inferior MI, hypertension, hyperlipidemia, and depression who presented to the ED with altered mental status and was found to be in DKA and with head imaging concerning for new metastatic lesions. Today, neighbors called EMS as patient was lying on his floor naked and screaming. Wife was at work at the time. At ED, initial vital signs were 98.4 106 180/77 20 100% 6L. Labs showed glucose 544, anion gap 33, K 6.0, Cr 1.5 (baseline 1.1), WBC 16.2. Pt states that he did not take his insulin this morning. He was given 10units insulin and started on an insulin gtt at 8units/hr. He received a total of 3liters of IVFs while in ED. He was also given calcium gluconate for his hyperkalemia. U/A showed few bacteria; cxr was largely unremarkable Patient endorsed headache and neck pain and stated that he fell at home. CT head was done which showed vasogenic edema most likely [**2-25**] underlying mass or multiple metastases. CT C-spine showed destruction of the left C2/C3 pedicle associated with a soft tissue lesion extending into adjacent epidural space, concerning for metastatic lesion. Of note, he has been seen at [**Company 191**] and at ED for lower back pain. Wife states that he has been debilitated from back pain for the last two weeks. Initially, back pain was felt to be musculoskeletal and he was referred to PT who noted decreased reflexes and pt complained of urinary incontinence. On [**2162-10-12**] he presented to ED where MRI L-spine was performed showing acute/subacute compression fracture at L2; no cord compression or cauda equina. Final read MRI also noted large heterogeneous mass involving the interpolar region of the left kidney. Attempt was made to contact PCP with the final results but this was never communicated to PCP or to patient. He was discharged from ED with valium and oxycodone. Wife reports that he has not taken valium, may have taken oxycodone. On arrival to the MICU, pt is A & O x 3, complaining of back pain. Review of systems: Unable to obtain from patient; per wife, no fevers/chills, diarrhea, abdominal pain, cough, URI-like systems. Past Medical History: 1. Coronary artery disease, status post inferior STEMI in [**2158**]. 2. Hypertension. 3. Hyperlipidemia. 4. Mitral regurg, mild on stress echo. 5. Diabetes. 6. Depression. Social History: Lives with his wife and 8-year-old daughter. [**Name (NI) **] drinks two glasses of wine at night, not recently. Smokes roughly three cigarettes a day. No drug use. Family History: Mother with brain tumor. No other malignancies. Physical Exam: T afebrile HR 78 BP 159/96 Spo2 95% on RA General: Alert, oriented x 3, complaining of pain HEENT: Sclera anicteric, dry MM, oropharynx clear, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: uncooperative with neuro exam, moving all extremities, following commands, intact rectal tone, pain on LE strength exam DISCHARGE PHYSICAL EXAM: Gen: Alert, oriented to person and place but not time, NAD HEENT: unchanged CV: unchanged Pulm: unchanged Abd: unchanged GU: condom catheter MSK: R arm flexed against chest, able to passively extend with some mild discomfort; L forearm in splint; healing surgical wound at R upper lateral thigh Neuro: CNII-XII intact, uncooperative with neuro exam, moving left lower leg to try to sit up in bed, movement of right lower extremity limited secondary to pain, movement of right upper extremity limited Pertinent Results: ADMISSION LABS [**2162-10-14**] 11:40AM BLOOD WBC-16.2*# RBC-4.21* Hgb-14.1 Hct-43.3 MCV-103* MCH-33.5* MCHC-32.6 RDW-12.1 Plt Ct-487* [**2162-10-14**] 11:40AM BLOOD Neuts-90.0* Lymphs-7.3* Monos-2.4 Eos-0.1 Baso-0.3 [**2162-10-14**] 11:40AM BLOOD Plt Ct-487* [**2162-10-14**] 06:45PM BLOOD PT-10.9 INR(PT)-1.0 [**2162-10-14**] 11:40AM BLOOD Glucose-544* UreaN-24* Creat-1.5* Na-135 K-6.0* Cl-91* HCO3-11* AnGap-39* [**2162-10-14**] 06:45PM BLOOD ALT-13 AST-18 [**2162-10-14**] 02:23PM BLOOD Calcium-10.2 Phos-4.0 Mg-2.1 [**2162-10-14**] 07:11PM BLOOD Type-ART pO2-106* pCO2-25* pH-7.31* calTCO2-13* Base XS--11 [**2162-10-14**] 11:59AM BLOOD Lactate-3.8* [**2162-10-14**] 01:00PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2162-10-14**] 01:00PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0 [**2162-10-15**] 05:20PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0 Lymphs-26 Monos-0 Macroph-74 [**2162-10-15**] 05:20PM CEREBROSPINAL FLUID (CSF) TotProt-86* Glucose-135 __________________________________________________________ [**2162-10-15**] 5:20 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final [**2162-10-15**]): 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 (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): VIRAL CULTURE (Preliminary): __________________________________________________________ [**2162-10-15**] 5:20 pm CSF;SPINAL FLUID Source: LP. **FINAL REPORT [**2162-10-15**]** CRYPTOCOCCAL ANTIGEN (Final [**2162-10-15**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. __________________________________________________________ [**2162-10-14**] 4:21 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): __________________________________________________________ [**2162-10-14**] 1:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ [**2162-10-14**] 1:00 pm URINE **FINAL REPORT [**2162-10-15**]** URINE CULTURE (Final [**2162-10-15**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2162-10-12**] MRI L SPINE 1. Acute/subacute compression fracture or Schmorl's node in the superior endplate of L2 with less than 50% vertebral body height loss and no retropulsion. 2. Mild degenerative changes of the lumbar spine with grade 1 anterolisthesis of L5 over S1 and bilateral pars defects at this level. No evidence of compression of the distal spinal cord or of cauda equina syndrome. 3. Large heterogeneous mass involving the interpolar region of the left kidney is partially visualized. Further evaluation with dedicated renal ultrasound is recommended. As the patient had been discharged, attempts were made to contact the patient's primary care physican (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4026**]) both at the office number provided in the paging system and at the pager number subsequently provided by the office, but this was unsuccessful. Results were therefore posted to the critical communications dashboard at 11:50 am, approximately 3 hours after discovery of the findings. [**2162-10-15**] CT HEAD Multiple hyperdense metastatic lesions with surrounding vasogenic edema within the cerebrum. An MRI with contrast is recommended for further evaluation. [**2162-10-15**] CT C SPINE 1. Metastatic lesion resulting in osseous destruction of the left C2 and C3 lamina and facet joint as well as the C3 pedicle, with adjacent epidural soft tissue mass extending into the neural and transverse foramina. MRI of the cervical spine with contrast is recommended for further evaluation. 2. Lytic metastases involving the second ribs bilaterally. 3. Moderate cervical spondylosis. [**2162-10-15**] MRI C SPINE 1. Abnormal enhancing mass involving the left C2-C3 facet joint extending into the posterior epidural space and left C2-C3 neural foramen without abnormal signal of the cord most likely representing metastatic disease in this patient with widespread metastases. 2. Multilevel degenerative changes of the cervical spine. 3. Bilateral atelectasis. [**2162-10-15**] MRI BRAIN 1. Multiple supratentorial peripherally enhancing masses with associated edema and mild mass effect, consistent with widespread metastases. No evidence of midline shift or herniation. 2. Extensive sinus disease. [**2162-10-15**] MRI C AND T SPINE 1. Abnormal enhancing mass involving the left C2-C3 facet joint extending into the posterior epidural space and left C2-C3 neural foramen without abnormal signal of the cord most likely representing metastatic disease in this patient with widespread metastases. 2. Multilevel degenerative changes of the cervical spine. 3. Bilateral atelectasis. FEMUR [**2162-10-15**] There is a mildly angulated subcapital fracture of the proximal femur. There are multiple lytic lesions seen in the mid and distal femur. [**2162-10-15**] CT CHEST AND ABDOMEN 1. Large left renal interpolar ill-defined heterogeneous mass measuring 7.7 x 5.0 x 7.1 cm compatible with renal cell carcinoma. 2. Widespread distribution of pathologically enlarged lymph nodes in the mediastinum, hila and left paraaortic space along with a lytic lesion in the left iliac [**Doctor First Name 362**] and left femoral neck. These findings are consistent with metastatic sites of disease. 3. Right femoral neck fracture. 4. Large fat density lesion within the left gluteus medius muscle with focal high-density nodules which could represent a liposarcoma or lipoma. Presence of internal nodules favor liposarcoma. 5. Left upper pole renal cysts. 6. Gallstone. 7. L2 vertebral Schmorl's node. [**2162-10-18**] RENAL BIOPSY PATHOLOGY Kidney, core needle biopsy: Renal cell carcinoma, suggestive of clear cell type [**2162-10-20**] BONE SCAN RADIOPHARMACEUTICAL DATA: 26.0 mCi Tc-[**Age over 90 **]m MDP ([**2162-10-20**]); The patient was injected with radiotracer but was no images were obtained due to patient agitation and refusal of the study. [**2162-10-22**] RIGHT FEMORAL REAMINGS PATHOLOGY DIAGNOSIS: Femoral neck reamings, Metastatic renal cell carcinoma [**2162-11-3**] RIGHT ELBOW PLAIN FILMS IMPRESSION: Lucent area in the distal humerus which could represent a metastatic lesion. [**2162-10-30**] EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of diffuse background slowing with mixed theta and delta activity suggesting moderate diffuse encephalopathy. There is no focal slowing or epileptiform features recorded. Compared with the recording yesterday, the delta slowing is more prominent suggesting worsening encephalopathy. [**2162-11-5**] CT HEAD WITHOUT CONTRAST IMPRESSION: Similar size and distribution of bilateral vasogenic edema without evidence of increased herniation. Minimal effacement of the bilateral sulci and left lateral ventricle is similar to prior. No new intracranial hemorrhage. [**2162-11-5**] RIGHT ELBOW PLAIN FILM IMPRESSION: Lucent area in the distal humerus which could represent a metastatic lesion. [**2162-11-5**] TISSUE, RIGHT RADIUS LESION PATHOLOGY DIAGNOSIS: Radius, left, lesion: Metastatic renal cell carcinoma URINE CULTURE (Final [**2162-11-9**]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S Blood Culture, Routine (Final [**2162-11-11**]): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S Brief Hospital Course: 55-year-old male with DM-I, CAD status post inferior MI, hypertension, hyperlipidemia, and depression who presented to the ED with altered mental status and was found to be in DKA and with head imaging concerning for new metastatic lesions. Had stay in ICU for management of DKA, was unfortunately found to have metastatic renal cell carcinoma, and was transferred to oncology service for management. ICU COURSE: Upon admission, the patient was admitted to the ICU for management of his DKA. ICU course is as follows, by problem: - DKA: Likely precipitated by insulin noncompliance (does not recall taking insulin prior to admission). Infectious etiology unlikely as U/A and CXR are reassuring, was afebrile. Any stress can precipitate DKA; neoplastic process may trigger hyperglycemia. This improved with fluids and insulin drip and he was transitioned to subcutaneous insulin and oral food. - Metastatic lesions: CT head and C-spine concerning for metastatic lesions. Previous MRI L-spine also showed renal mass. Suspicion for neoplastic process was high. At that time, tissue diagnosis was unclear. Suspected to have primary renal carcinoma. He was treated wtih steroids and keppra for cerebral edema. He had a biopsy on [**2162-10-18**] prior to transfer from the ICU. This eventually revealed renal cell carcinoma, suggestive of clear cell type. - Prerenal Acute kidney Injury: Cr increased to 1.5 from baseline 1.1, improved with IVF. HOSPITALIZATION SUMMARY: The remainder of his acute and chronic issues throughout his hospitalization are discussed below. Mr. [**Known lastname **] was hospitalized for an extended period of time (approximately one month). His course by problem is summarized as follows: 1) Diabetic ketoacidosis - As discussed in the ICU course above, Mr. [**Known lastname **] presented with DKA. This was successfully controlled in the ICU, after which he was transferred to the floor. 2) Renal cell carcinoma, suggestive of clear cell type - Mr. [**Known lastname **] underwent biopsy on [**2162-10-18**] demonstrating renal cell carcinoma. He unfortunately has widely metastatic disease to bone and brain. Prior to presentation, he fell to his right side and suffered pathologic fracture. An attempt for bone scan resulted in an acute delirious state with severe agitation - the scan was aborted (discussed below). MRI revealed diffuse metastatic cerebral disease as well, as above. He received 5 fractions of whole-brain radiation for suppression of CNS involvement. He underwent orthopedic repair of his pathologic fracture on [**2162-10-22**], after which he received 5 fractions to his right femur as well. Biopsy during this procedure revealed metastatic renal cell carcinoma. He received one dose of radiation to a lesion in his distal right humerus as well. Upon discharge, Mr. [**Known lastname **] had developed a contracture of his right arm, likely secondary to pain from this lesion and cerebral disease. Mr. [**Known lastname **] suffered a pathologic fracture of his left radius during his hospitalization. This was caused by a wrist restraint. The indications for this restraint is discussed below. He had ORIF on [**2162-11-3**]. Biopsies of this site demonstrated metastatic RCC. He did not undergo nephrectomy. Systemic therapy, including [**Last Name (LF) 76383**], [**First Name3 (LF) **] to be discussed at an outpatient appointment with Dr. [**Last Name (STitle) **]. 3) Altered mental status - He continued to exhibit altered mental status throughout his hospitalization. While his mental status waxed and waned throughout his stay, he generally was oriented to place and person, but not time. His altered mental status is likely multifactorial. Initially upon transfer to the floor, he had a large component of ICU delirium and resolving DKA. Equally significantly, Mr. [**Known lastname **] has a significant amount of CNS metastatic disease burden, including frontal lobe mets - these undoubtedly play a large role in his poor cognition/executive functioning. Electrolyte abnormalities also contributed to his AMS - hypercalcemia specifically, discussed further below. Finally, iatrogenic causes of his poor mental status included significant opioid and steroid requirements. To treat his CNS metastases, he completed 5 fractions of whole-brain radiation during his stay. Cerebral edema was controlled with dexamethasone prior to and following WBXRT. Unfortunately, his mental status did not improve significantly following WBXRT. A series of head CT scans without contrast demonstrated stable cerebral edema. Steroids were slowly tapered while hospitalized; repeat CT scans did not demonstrate rebound edema either to XRT or to steroid taper. He was discharged on a regimen of dexamethasone 2 mg PO daily. Plans for continued taper and steroid discontinuance were to be addressed at a follow-up appointment with Dr. [**Last Name (STitle) 6570**] of neuro-oncology (he will have an MRI on [**2162-11-29**] prior to this appointment). On [**2162-10-20**], bone scan was attempted to determine sites of bony involvement. This procedure was unfortunately halted due to patient's extreme agitation and aggressive behavior during the procedure. This pattern of sudden-onset/waxing-and-[**Doctor Last Name 688**] agitation persisted for several days, often triggered by radiation or radiaographic procedures. Etiology is unclear. This was very obviously demonstrative of hyperactive delirium. Initial attempts to correct his delirium using frequent redirection, normal sleep-wake cycles when possible, and minimizing benzodiazepines (thought to be disinhibiting frontal lobe behavior). Unfortunately, he did not respond to these measures, and required periodic intravenous haloperidol. The psychiatry service was consulted for management recommendations. Initially, standing and escalating doses of haloperidol were attempted to correct his agitation. While this did indeed minimize his agitation, it resulted in over-sedation and constant somnolence. Haloperidol was exchanged for standing quetiapine at bedtime, which seemed to encourage normal sleep-wake cycle and did not create excessive sedation. (As patient's mental status started to improve and agitation subsided, this medication was changed from standing to PRN - he infrequently required it by discharge). Mr. [**Known lastname **] experienced an unfortunate and significant complication from his agitation. He required restraints overnight due to acute agitation. During this episode, he was actively removing his clothes, intravenous lines, therapeutic devices (ankle contracture-prevention boots and pneuamtic compression devices), and surgical dressings. He did not respond to low dose sedating agents, and required soft mitts to prevent further harm to himself and interference with his care. He managed to remove these mitts and continued with his agitation as above, necessitating wrist restraints. These restraints were removed as soon as possible. Follow-up physical examination identified soft tissue swelling and tenderness to palpation of his left wrist. A plain film x-ray identified fracture. This was repaired in the OR, and a metastatic lesion was diagnosed at the site of fracture - which corresponded with the site of restraint. Electrolyte abnormalities were a component of his poor mentation. Mr. [**Known lastname **] was hypercalcemic - likely secondary to a combination of bony metastases (major contributing factor) and paraneoplastic PTHrP (minor factor). This was though to perhaps play a role in his agitation as discussed above. Hypercalcemia was corrected via a combination of continuous IV fluids and single doses of calcitonin and pamidronate. This did not yield significant improvement in his mentation, though it did return his calcium levels to normal ranges. IV fluids were discontinued prior to discharge. An EEG approximately one week prior to discharge was suggestive of diffuse metabolic encephalopathy. Ultimately, his altered mental status was attributed to a combination of CNS disease, prolonged hospital stay, and opioids/steroids. Upon discharge, Mr. [**Known lastname **] mental status had improved from his admission to the oncology floor. He remained oriented to person and place, and demonstrated increased insight into his condition. He exhibited word finding difficulties, but was generally appropriate in his communication. He was able to participate in a discussion regarding his goals of care and transition to rehab, stating "Let's go for it". 4) Pseudomonas urosepsis - On [**2162-11-5**] he spiked a fever to 103. He was somnolent during this period (attributed to fentanyl patch sedation). The fentanyl patch was removed; his mentation improved considerably over the next 12 hours. Initial empiric antibiotics included vancomycin and meropenem. Urine and blood cultures grew pan-sensitive Pseudomonas. His antibiotic regimen was tailored to ciprofloxacin 500mg PO BID. He did not spike more fevers, and follow-up blood cultures were negative for bacterial growth. 5) Glucose control - Throughout his stay, he demonstrated a wide range of blood glucose levels. Per his wife, his type I diabetes was very difficult to control prior to this hospitalization, with periods of both hypo- and hyperglycemia at home. 6) Pain control - Mr. [**Known lastname **] pain control requirement changed throughout his hospitalization. Upon admission, he required analgesia for control of bony metastasis pain. He underwent 2 surgical procedures for fracture repair. He received radiation to right femur and distal right humerus which improved pain control. He required a combination of oral hydrmorphone, intravenous morphine, transdermal fentanyl, and acetaminophen during his stay. Upon discharge, his pain was adequately controlled with hydromorphone 2-4 mg PO Q4H:PRN. 7) Hypertension: Systolic BP initially elevated after extubation in the ICU. His blood pressure was then well-controlled while on the oncology floor. Home doses of metoprolol were continued. 8) Coronary artery disease - Stable throughout his hospitalization. He was continued on his home rosuvastatin and metoprolol. =========================================== TRANSITIONAL ISSUES: - CODE STATUS: Mr. [**Known lastname **] was full code throughout his stay. - EMERGENCY CONTACT: [**Name (NI) 2808**] [**Name (NI) **], wife, [**Telephone/Fax (1) 76384**] - STEROID TAPER: Discharged on dexamethasone 2mg PO daily. Further tapering/discontinuance to be addressed by Dr. [**Last Name (STitle) 6570**] and medical-oncology team. Appointment pending with Dr. [**Last Name (STitle) 6570**], [**Telephone/Fax (1) 1844**]. - ANTIBIOTIC REGIMEN: Receiving ciprofloxacin 500mg PO q12hr to complete course of anti-pseudomonal treament for urosepsis. Final day of antibiotics = [**2162-11-18**]. - HEMATOLOGY-ONCOLOGY: Follow-up appointment to be created with Dr. [**Last Name (STitle) **] for consideration of systemic therapy after discharge. Office number [**Telephone/Fax (1) 13016**]. - GLYCEMIC CONTROL: Needs gentle titration of sliding scale and long acting insulin for goal glucose 100-200 throughout the day. Medications on Admission: BUPROPION HCL - bupropion HCl XL 300 mg 24 hr tablet, extended release 1 Tablet(s) by mouth daily No Substitution CHLORTHALIDONE - chlorthalidone 25 mg tablet 1 Tablet(s) by mouth daily No Substitution FLUOXETINE [PROZAC] - Prozac 20 mg capsule 3 Capsule(s) by mouth DAILY FLUTICASONE - (Not Taking as Prescribed) - fluticasone 50 mcg/actuation Nasal Spray, Susp 2 spays(s) nasal q day INSULIN ASPART [NOVOLOG FLEXPEN] - Novolog Flexpen 100 unit/mL Sub-Q 20 units before each meal (three times a day). INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL Sub-Q 45 units at bedtime No Substitution LORAZEPAM - lorazepam 0.5 mg tablet 1 Tablet(s) by mouth at night as needed for anxiety Do not take while drinking alcohol or operating machinery as medication can cause sedation METFORMIN - metformin ER 1,000 mg tablet,extended release 24hr 1 Tablet(s) by mouth daily No Substitution METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg tablet,extended release 24 hr 2 Tablet(s) by mouth DAILY (Daily) MODAFINIL [PROVIGIL] - Provigil 200 mg tablet 1 Tablet(s) by mouth q a.m. and q 3 hrs later take 1st tab upon awakening and 2nd 3 hrs later NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet 1 Tablet(s) sublingually every 5 minutes up to 3 tablets total as needed for chest pain ROSUVASTATIN [CRESTOR] - Crestor 40 mg tablet 1 (One) Tablet(s) by mouth daily SILDENAFIL [VIAGRA] - Viagra 100 mg tablet [**1-27**] Tablet(s) by mouth daily several times a month. Use one hour prior to activity. TIZANIDINE - tizanidine 4 mg tablet 1 tablet(s) by mouth twice a day as needed for back pain ZOLPIDEM - zolpidem 5 mg tablet 1 Tablet(s) by mouth at bedtime for use with CPAP only ASPIRIN - (OTC; Dose adjustment - no new Rx) - aspirin 81 mg tablet,delayed release One Tablet by mouth once a day BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - One Touch Ultra Test Strips use to monitor blood suagr four times a day or as directed INSULIN NEEDLES (DISPOSABLE) [BD INSULIN PEN NEEDLE UF ORIG] - BD Insulin Pen Needle UF Orig 29 x [**1-25**]" to be used with insulin pen three times a day Discharge Disposition: Extended Care Facility: [**Hospital6 85**] Discharge Diagnosis: PRIMARY: - metastatic renal cell carcinoma SECONDARY: - diabetic ketoacidosis - acute confusional state - metabolic encephalopathy - right femur fracture - left radius fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to [**Hospital1 18**] for complications related to your new diagnosis of renal cell carcinoma (kidney cancer). We are very sorry to learn of your cancer diagnosis. You had an extended hospital stay, including time spent in the ICU, for management of a variety of complications and challenges presented by your disease. You are being discharged to an extended-care facility to receive further rehabilitation as you recover from your hospitalization. You will be evaluated as an outpatient for consideration of systemic therapy for your renal cell carcinoma (including agents similar to chemotherapy). You should keep all your scheduled appointments with your doctors. Please tell the staff at the rehab facility if you experience any of the following: headache, loss of conciousness, seizures, increasing pain, chest pain, trouble breathing, difficulty urinating, or any other symptoms that concern you. The office number of Dr. [**Last Name (STitle) **] is listed below. Followup Instructions: Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Specialty: Hematology/Oncology Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 13016**] We are working on a follow up appointment for you to be seen by Dr. [**Last Name (STitle) **] in oncology. You will be called at rehab with the appointment. If you have not heard within 2 business days or have questions, please call the number listed above. Department: RADIOLOGY When: MONDAY [**2162-11-29**] at 11:15 AM With: RADIOLOGY MRI [**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: NEUROLOGY/NEURO-ONCOLOGY When: MONDAY [**2162-11-29**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please discuss with the staff at the facility a follow up appointment with a primary care provider when you are ready for discharge.

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icd9cm

[ [ [] ] ]

[ "77.63", "92.29", "03.31", "96.71", "79.15", "55.23", "79.32" ]

icd9pcs

[ [ [] ] ]

26761, 26806

13452, 23657

297, 626

27027, 27027

4436, 5848

28251, 29568

3208, 3259

26827, 27006

24630, 26738

27202, 28228

3274, 3891

5929, 6655

6689, 13429

23678, 24604

2693, 2804

236, 259

654, 2674

27042, 27178

2826, 3007

3023, 3192

5880, 5895

3916, 4417

2,592

199,163

3511+55478

Discharge summary

report+addendum

Admission Date: [**2187-7-13**] Discharge Date: [**2187-7-30**] Date of Birth: [**2112-9-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Colonoscopy Central line placement PICC placement History of Present Illness: 74 yo M with history of CHF, AF, TIA admitted to MICU from OSH with GIB. Pt was admitted to [**Hospital 1263**] Hospital on [**2187-7-12**] with two episodes of red blood clots in his stool that morning. He complained of lower quadrant cramping at that time, without nausea, vomiting, weight loss or any recent change in stool color, caliber or frequency. On initial presentation, pt's BP was 98/49 with HR 97, O2 sat 93%. Hct was 26.2, down from 42.4 ([**2187-3-17**]). INR on admission 2.7. The patient was hemodynamically stable throughout admission to OSH. He was given 2U FFP, 1mg IV Vit K, and 4U of PRBC with hct of 27.7. Had colonoscopy to terminal ileum with preliminary report suggesting significant blood throughout entire colon, (L>R). There were multiple diverticula, without a source of bleeding identified. There was a 3cm polyp. Pt had a tagged RBC scan which showed active bleeding in left midabdomen at the level of the descending colon. The pt was transferred to [**Hospital1 18**] for possible exploratory laparotomy vs. IR-guided angio procedure. On presentation, the pt has no complaints. Denies abdominal pain/cramping, chest pain, shortness of breath. No further bleeding per rectum. Past Medical History: CHF, EF 30-40% Atrial fibrillation Cardiac arrest [**5-30**] with v-fib s/p AICD placement HTN Colon polyps s/p polypectomy 3 yrs ago Radiation proctitis Left frozen shoulder Subdural bleed after fall [**2184**] -> keppra PPX S/P TIA Depression Prostate CA Basal cell CA C5-7 fracture s/p decompression laminectomy and cervical spine fusion [**2137**] at [**Hospital1 2177**] Polio Social History: Social Hx: Pt lives in [**Location 1475**] with his wife. [**Name (NI) **] is a retired pharmacist (previously Chief Pharmacist at [**Hospital1 **]). He does not smoke or drink, though previously drank [**6-6**] drinks/day. No drug use. Family History: Mother died of PE with HTN. Father died of renal disease. Physical Exam: Vitals: T 96.5 HR 88 BP 140/58 RR 14 97% RA Gen: alert and oriented, well-appearing, NAD HEENT: PERRL, EOMI, mmm, OP clear Neck: supple, no carotid bruits Lungs: CTA bilaterally with mild bibasilar crackles Cor: irregularly irreg, nml S1S2, no murmurs appreciated Abd: NABS, soft NTND Ext: no c/c/e, 2+ right DP, trace left DP Pertinent Results: ADMISSION LABS: [**2187-7-13**] 10:33PM GLUCOSE-100 UREA N-16 CREAT-0.7 SODIUM-150* POTASSIUM-3.0* CHLORIDE-111* TOTAL CO2-28 ANION GAP-14 [**2187-7-13**] 10:33PM WBC-7.6 RBC-2.94*# HGB-9.0* HCT-25.2*# MCV-86 MCH-30.8 MCHC-35.8*# RDW-16.7* [**2187-7-13**] 10:33PM PLT COUNT-217 [**2187-7-13**] 10:33PM PT-13.5* PTT-23.4 INR(PT)-1.2 PORTABLE AP CHEST AT [**2187-7-25**]: 13:12: Comparison is made to [**2187-7-22**]. The newly inserted right PICC tip is in the SVC. Right IJ line tip is in the SVC more proximally. Dual chamber pacemaker leads are unchanged. There is a new external object overlying the right lower abdomen, as the control box for the pacemaker appears to be on the left on the prior study. There is stable moderate cardiomegaly and marked pulmonary arterial enlargement. There is worsening opacity in the right lower lobe, and possibly in the left lower lobe, suspicious for pneumonia. CT l-spine [**7-27**]: 1. L1 vertebral body compression fracture. Please see lumbar spine CT scan of the same day for further details. 2. Bilateral pleural effusions and associated compressive atelectasis. 3. Degenerative changes of the thoracic spine. No fractures identified. ECHO [**2187-7-23**]: The left and right atrium are markedly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis. The aortic root and ascending aorta are mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. An eccentric jet of at least mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. EKG [**2187-7-20**]: Atrial fibrillation with a somewhat rapid ventricular response.Other than a somewhat more rapid rate, no significant change from the tracing of [**2187-7-15**]. DISCHARGE LABS: [**2187-7-30**] 05:39AM BLOOD WBC-7.9 RBC-3.18* Hgb-9.2* Hct-27.7* MCV-87 MCH-28.8 MCHC-33.0 RDW-15.8* Plt Ct-448* [**2187-7-30**] 05:39AM BLOOD Plt Ct-448* [**2187-7-25**] 08:20AM BLOOD PT-13.4* PTT-25.0 INR(PT)-1.2 [**2187-7-30**] 05:39AM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-138 K-3.6 Cl-104 HCO3-28 AnGap-10 [**2187-7-28**] 05:55AM BLOOD ALT-14 AST-26 AlkPhos-203* TotBili-0.6 [**2187-7-28**] 05:55AM BLOOD Albumin-2.4* Calcium-8.6 Phos-3.9 Mg-1.6 [**2187-7-25**] 08:20AM BLOOD Triglyc-87 [**2187-7-27**] 05:26AM BLOOD PSA-3.0 Brief Hospital Course: 1. GIB: Data from colonoscopy and tagged RBC scan at OSH shows lower GI bleed, specifically in descending colon. Diverticulosis, polyp, ischemic bowel. Pt was monitored closely in MICU, but bleeding scan and colonoscopy showed blood on left-side of colon with oozing from diverticuli, no specific source of bleeding. Pt was called out from MICU and hct was monitored on the floor. Hct was stable. Pt was started on TPN which he received for about four days until he tolerated PO's. Pt has had multiple brow bowel movement, none with frank blood, only guiac positive. 2. CV/Rhythm: rate controlled on toprol. Coumadin was held then reversed with vitamin K/FFP. ASA not restarted given that pt was still guiac positive. Anticoagulation can be restarted as an outpatient. 3. CV/CHF: mild CHF exacerbation due to holding diuretics. Pt was re-started on toprol an lasix but at a lower dose than he was on at home (80mg qd). Pt put out well to 40 and 20mg, so he was continued on 20mg po. If his weight increases, pt instructed to double dose of lasix. Prior to discharge, pt was re-started on lisinopril and aldactone. These will be titrated back up as an outpatient. 4. Line sepsis: pt had fevers, blood cultures positive for MSSA. Central line tip culture also grew out MSSA. Transthoracic echo showed mild AS but no other major abnormalities. Pt was treated with Vanco [**Date range (1) 16125**], and then changed to Oxacillin [**7-22**] which should be continued through [**8-1**]. Pt remained afebrile on abx and follow up blood cultures were w/ NGTD. Once antibiotics are completed, patient should have surveillance blood cultures checked. 5. "infiltrate" on CXR: pt was afebrile but splinting due to back pain. Pt given incentive spirometer and remained afebrile without leukocytosis. 6. FEN: Pt was NPO during much of MICU stay so TPN was initiated. Pt was HD stable, therefore once he tolerated PO diet, this was discontinued. 7. PPX: Pneumoboots. PPI. Pt had history of SDH so he was treeated with Keppra for two years. Pt had no seziures, after discussion with Neurology, this was discontinued. 8. Full code Medications on Admission: Coumadin 2mg daily Prednisone 4mg daily Zoloft 50mg daily Lisinopril 40mg [**Hospital1 **] Toprol XL 50mg daily Allopurinol 100mg daily Lasix 80mg daily Spirinolactone 25mg daily Pepcid 20mg daily Keppra 250mg daily Celebrex 100mg daily K-lyte 25mEq prn Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (): 12hrs on/12hrs off; appl to back. 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (): apply to shoulder; 12hrs on, 12hrs off. 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 12. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) gm Recon Soln Injection Q6H (every 6 hours) for 3 days: Abx started [**7-19**], last dose [**2187-8-1**]. 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 15. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily): Hold for SBP<100,HR<60 . 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Lower GI bleed L1 compression fracture congestive heart failure atrial fibrillation prostate cancer Discharge Condition: Stable, afebrile, stable hct. Discharge Instructions: Please seek medical attention for fevers>101, lightheadedness/dizzness, significant amounts of blood in stool. Please take your medications as directed. Stop taking your coumadin. Followup Instructions: Please see Dr. [**Last Name (STitle) 58**] [**Telephone/Fax (1) 3329**] within 1 week of discharge from rehab. 1) Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2187-12-6**] 1:00 2) Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2187-12-6**] 1:30 Name: [**Known lastname 2534**],[**Known firstname 133**] Unit No: [**Numeric Identifier 2535**] Admission Date: [**2187-7-13**] Discharge Date: [**2187-7-30**] Date of Birth: [**2112-9-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 211**] Addendum: ASA was restarted prior to discharge after discussion with Dr. [**Last Name (STitle) **]. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] TCU - [**Location (un) 50**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**] Completed by:[**2187-7-30**]

[ "733.13", "455.0", "038.10", "041.4", "427.31", "562.12", "996.62", "428.0", "280.0", "599.0", "995.91" ]

icd9cm

[ [ [] ] ]

[ "45.23", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

10999, 11228

5283, 7426

323, 375

9791, 9822

2718, 2718

10052, 10976

2296, 2355

7730, 9548

9668, 9770

7452, 7707

9846, 10029

4726, 5260

2370, 2699

275, 285

403, 1620

2734, 4710

1642, 2026

2042, 2280

8,236

134,446

30922+57726

Discharge summary

report+addendum

Admission Date: [**2138-4-17**] Discharge Date: [**2138-5-5**] Date of Birth: [**2071-7-24**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: transferred for carotid stenting Major Surgical or Invasive Procedure: Right carotid extracranial angioplasty and intracranial stent placement [**2138-4-19**] s/p CABGx6(LIMA->LAD, SVG->Diag, OM1, OM2, RCA, PDA) [**2138-4-24**] History of Present Illness: Pt. is a 66 y/o Hindi-speaking female with a hx of HTN, hyperlipidemia, DM2, recent TIA ([**3-18**]) with w/u that revealed RCA stenosis, followed by an episode of chest pain ([**4-1**]), NSTEMI, found to have 3VD on cardiac catheterization, who is transferred here for carotid stenting. Pt's history starts on [**3-18**], when she was admitted to [**Hospital 8**] hospital for work up of a TIA. Per Dr.[**Name (NI) 20920**] initial stroke consult note, she had awoken to use the bathroom and felt like she was falling to the right. She then stood up and her left leg gave out. Her family had to pick her up from the floor, and noticed that she had left sided weakness with facial droop and dysarthria. The symptoms lasted approximately 6 hours. Examination by neurology was reportedly normal. An MRA revealed severe stenosis of the right ICA cavernous segment and additional proximal right common carotid artery stenosis of 67-75%. She was noted to also have elevated troponins, LVH with ST depressions in V2-6 on EKG, and an ECHO showing diastolic dysfunction. She was discharged on aggrenox and ASA. On follow up in interventional neuroradiology, she was not taking the ASA, but had no further symptoms. The plan was for an outpatient angiogram. Before this could be performed she presented again to [**Hospital 8**] Hospital on [**4-1**] with chest pain. She had elevated troponins with peak Tn-I of 0.7 and was diagnosed with a NSTEMI. She was started on heparin and loaded with plavix. Catheterization showed three vessel disease (99% RCA, 70% pLAD, 75% Lcx) and was transferred to [**Hospital1 18**] for possible CABG. Per her [**4-11**] d/c summary, as part of the work up prior to CABG, she underwent cerebral angiogram on [**4-8**] by Dr. [**Last Name (STitle) **] which revealed 30 to 40% stenosis of the right internal carotid artery at the bifurcation, 55% stenosis at the junction of the petrous and cavernous portions of the right internal carotid artery, 40 to 45% stenosis of the petrous portion of the left internal carotid artery. On the evening of [**4-9**], the patient was noted to be orthostatic with SBP 90s and developed slurred speech and left leg weakness. She was bolused with IV fluids and her anti-hypertensive held to maintain a goal SBP>120. Her symptoms completely resolved with these measures, and were felt to represent TIA. It was felt that her peri-CABG stroke risk outweighed the risk of carotid stenting and that the risk of the stroke during CABG was greater than the risk of MI in the next few days and based on the location of her lesions, they recommended transfer to [**Hospital1 112**] for Wingspan stenting of her right carotid lesion. She was re-loaded with 600mg plavix, followed by 75mg daily, and continued on aspirin 325mg daily. Her aggrenox continued to be held. She was transferred to the Neurology Service at [**Hospital1 112**] on [**4-11**], with a plan for Wingspan stenting by Dr. [**Last Name (STitle) 73121**]. It was planned that she return to [**Hospital1 18**] for CABG with Dr. [**Last Name (STitle) 914**] from Cardiothoracic Surgery after carotid stenting. At [**Hospital1 112**] MRI was performed and showed acute R frontal infarcts, predominantly affecting the ACA territory, possibly minimally affecting the right MCA territory, and hypertensive microvascular disease. Cerebral angiogram was repeated and showed 60% stenosis of the left ICA at C3 and C4 vertebral body levels, diffuse intracranial atherosclerosis, R ICA cavernous segment with 40% stenosis at the posterior genu. Angiographically the R A1 segment demonstrated no filling and the L A1 segment was hypoplastic. Dr. [**Last Name (STitle) 73120**] was consulted and felt that since the ICA lesions did not appear to be flow limiting she didn't meet criteria for wingspan. She was therefore transferred back to [**Hospital1 18**] for traditional carotid stenting. Her daughter (who translates for her) reports that she has not had any further episodes of L sided weakness, facial droop, or slurred speech, or any symptoms concerning for stroke. Past Medical History: 1. Diabetes type 2. 2. Hypertension. 3. Hyperlipidemia. 4. h/o TIAs in [**2131**] and [**3-/2137**] with known carotid stenosis 5. Iron deficiency anemia. 6. Hyperthyroidism with h/o multinodular goiter 7. Sciatica 8. Coronary artery disease Social History: The patient is from [**Country 11150**] and speaks Hindi, lives with her daughter's family. Activities of daily living: She is able to cook, clean, and ambulate without difficulty. She denies any alcohol, tobacco, or occasional drug use. Family History: No family history of stroke or cardiovascular disease. Physical Exam: T- 98.7 BP- 145/64 HR- 66 RR- 18 O2Sat- 100% on RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Speech is fluent with normal comprehension per daughter. [**Name (NI) **] dysarthria per daughter. [**Name (NI) **] right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1- V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally Coordination: finger-nose-finger normal, RAMs normal. Gait: Narrow based, steady. Romberg: Negative Pertinent Results: [**2138-4-28**] 07:20AM BLOOD WBC-9.6 RBC-3.75* Hgb-11.3* Hct-33.6* MCV-90 MCH-30.1 MCHC-33.6 RDW-14.9 Plt Ct-289 [**2138-4-26**] 12:45AM BLOOD PT-12.9 PTT-30.0 INR(PT)-1.1 [**2138-4-28**] 07:20AM BLOOD Glucose-130* UreaN-9 Creat-0.5 Na-143 K-3.9 Cl-105 HCO3-29 AnGap-13 RADIOLOGY Final Report CHEST (PA & LAT) [**2138-4-28**] 8:50 AM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 66 year old woman s/p CABG REASON FOR THIS EXAMINATION: evaluate effusion TWO VIEW CHEST Of [**2138-4-28**]. COMPARISON: [**2138-4-25**]. INDICATION: Status post coronary artery bypass surgery. Left internal jugular catheter has been removed with no evidence of pneumothorax. Cardiac and mediastinal contours are stable in the postoperative period. Minor bibasilar atelectasis is present adjacent to small bilateral pleural effusions. On the lateral view, a small air-fluid level is present in the retrosternal region. Trachea is deviated towards the left above the thoracic inlet level with mild coronal narrowing without change from the preoperative radiograph of [**2138-3-18**], corresponding to enlargement of the right lobe of the thyroid gland on interval CT. IMPRESSION: 1. Small pleural effusions and minor basilar atelectasis. 2. Retrosternal air-fluid level, which can be a normal postoperative finding in the early postoperative period in the absence of clinical signs of infection. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: MON [**2138-4-28**] 11:07 AM Cardiology Report ECHO Study Date of [**2138-4-24**] PATIENT/TEST INFORMATION: Indication: Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Right ventricular function. Status: Inpatient Date/Time: [**2138-4-24**] at 14:53 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW5-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: 40% to 55% (nl >=55%) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function. Overall normal LVEF (>55%). LV WALL MOTION: remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**11-19**]+) MR. Eccentric MR jet. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: PREBYPASS 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The remaining left ventricular segments contract normally. 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There is prolapse of the A2 segment of the anterior leaflet (demonstarted on 3D reconstruction) with resultant mild to moderate ([**11-19**]+) eccentric mitral regurgitation is seen.There is a posteriorly-directed jet of MR. 7. An epiaortic scan was performed which demostrated no significant atheromatous disease in the portion of the ascending aorta scanned. POSTBYPASS: On infusion of phenylephrine. Preserved LV systolic function post cpb. MR is now 1+. AI is 1+. Normal aortic contour post decannulation. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2138-4-24**] 18:06. Brief Hospital Course: The patient was transferred back to from [**Hospital6 **] and had an intracranial stent angioplasty for tandem [**Country **] stenosis. She was transferred to the neuro ICU and remained stable. On [**2138-4-24**] she underwent CABGx6(LIMA->LAD< SVG-.Diag, OM1, OM2, RCA, PDA). The cross clamp time was 100 mins., and total bypass time was 121 mins. She tolerated the procedure well and was transferred to the CSRU in stable condition. She was extubated on the post op day 1 and had her chest tubes d/c'd and was transferred to the floor on POD#2. Her epicardial pacing wires were d/c'd on POD#3. She continued to progress and was discharged to home in stable condition. Medications on Admission: Tylenol 650 Q4H PRN Headache ASA 325 QD Lipitor 80 mg QD Plavix 75 mg QD Colace 100 [**Hospital1 **] Lovenox 30 mg SC QD NPH 18 U QAM, 6 U QPM RISS Maalox PRN MOM PRN Methimazole 15 mg QAM Metoprolol 12.5 mg TID NTG PRN chest pain Omeprazole 20 mg QD 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. 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* 4. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO Q 24H (Every 24 Hours). Disp:*90 Tablet(s)* Refills:*2* 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eighteen (18) Subcutaneous q AM: 6 units q PM. Disp:*8 vials* Refills:*2* 11. Lancets & Blood Glucose Strips Combo Pack Sig: One (1) Miscellaneous four times a day. Disp:*1 pack* Refills:*2* 12. syringe 3cc insulin syringe 1 [**Hospital1 **] dispense 60 2 refills Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Right carotid extracranial and intracranial stenosis status post extracranial angioplasty and intracranial stenting. 2. History of transient ischemic attacks and bilateral watershed strokes 3. Coronary artery disease with three vessel disease with recent NSTEMI 4. Diabetes #2 5. Hypertension 6. Hyperlipidemia 7. Iron deficiency anemia 8. Hyperthyroidism with history of multinodular goiter 9. Sciatica Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Do not use creams, lotions, or powders on wounds. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for sternal drainage, temp>101.5. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2138-6-4**] 1:30 Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks. Make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Telephone/Fax (1) 73124**] Completed by:[**2138-4-29**] Name: [**Known lastname **],[**Known firstname 12161**] Unit No: [**Numeric Identifier 12162**] Admission Date: [**2138-4-17**] Discharge Date: [**2138-5-5**] Date of Birth: [**2071-7-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1546**] Addendum: Patient developed LT sided weakness/TIA on [**2138-4-29**]. patient remained in hospital until [**2138-5-5**]. See discharge summary from [**Date range (1) 12163**] and [**Date range (1) 12164**]. Chief Complaint: Left sided weakness on day of discharge (see previous summary for events [**Date range (1) 12163**]) Major Surgical or Invasive Procedure: Right carotid extracranial angioplasty and intracranial stent placement [**2138-4-19**] s/p CABGx6(LIMA->LAD, SVG->Diag, OM1, OM2, RCA, PDA) [**2138-4-24**] Right carotid endarterectomy and Dacron patch angioplasty [**2138-5-2**] History of Present Illness: Patient was being readied for D/C today after being asymptomatic and tolerating walking up and down stairs with no problems over last few days. Her dose of Lisinopril was increased this am. At 1:10 pm she had difficulty with raising the left hand while sitting in bed eating lunch. She also noted L leg weakness associated. No headache or other symptoms. Stroke team was called and was at bedside within 5 minutes of being called. At that time exam notable for L arm drift (strength in L arm 3-4/5, weaker distally) and L leg drift (grade [**2-20**]). No other focal findings on exam. BS normal. Bp was slightly lower at 110s/50s. Started on IVF and head of bed kept down and taken to MRI. MRI revealed scattered DWI lesions but most looked old with no clear change on MRA. Upon coming out of MRI, pt had improved considerably with very slight L arm drift only. Over the course of the next 30 minutes patient had almost completely recovered with no notable drift of arm or leg. Taken for CTA head and neck to rule out thrombus around stent. Dr [**Last Name (STitle) 12165**] looked at these images and thought that there was no clear vessel cutoff but that there was significant narrowing of the R ICA at the bifurcation. Scheduled for Right carotid endarterectomy and Dacron patch angioplasty with Dr. [**Last Name (STitle) **] Past Medical History: 1. Diabetes type 2. 2. Hypertension. 3. Hyperlipidemia. 4. h/o TIAs in [**2131**] and [**3-/2137**] with known carotid stenosis 5. Iron deficiency anemia. 6. Hyperthyroidism with h/o multinodular goiter 7. Sciatica 8. Coronary artery disease 9. NSTEMI MI ([**Hospital 15**] hospital) Social History: The patient is from [**Country 11955**] and speaks Hindi, lives with her daughter's family. Activities of daily living: She is able to cook, clean, and ambulate without difficulty. She denies any alcohol, tobacco, or occasional drug use Family History: No family history of stroke or cardiovascular disease. Physical Exam: 98, 89, 120/50 97%RA GEN: NAD, RT neck incision-C/D/I, staples removed CV: RRR, sternum incision stable Lungs: CTA Abd: soft, NT Ext: warm, no edema, palpable pulses. Lt groin/thigh hematoma stable Pertinent Results: [**2138-5-4**] 04:55AM BLOOD WBC-8.3 RBC-3.32* Hgb-9.9* Hct-30.1* MCV-91 MCH-29.7 MCHC-32.8 RDW-15.3 Plt Ct-486* [**2138-5-4**] 04:55AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-137 K-4.5 Cl-102 HCO3-31 AnGap-9 [**2138-5-4**] 04:55AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1 [**2138-4-29**] CT ANGIOGRAPHY OF THE NECK AND HEAD HISTORY: Rule out thrombus in region of intracranial stent. TECHNIQUE: Preliminary noncontrast head CT scan. COMPARISON STUDY: [**2138-4-29**] study, interpreted by Drs. [**Last Name (STitle) 12166**] and [**Name5 (PTitle) 12167**] as revealing "resolution of previously identified hypoattenuating lesions likely reflective of contrast blush immediately post-procedure. Unchanged old watershed infarct at left anterior cerebral and middle cerebral artery border zone". FINDINGS: The present study has a number of scans degraded by patient motion. Some of these were repeated. Within these limitations, there is no definite sign for the presence of interval appearance of an intracranial hemorrhage or new area of brain infarction. No new osseous pathology is identified. The radiopaque stent in the region of the cavernous portion of the right internal carotid artery is demonstrated. CT angiography of the neck and head was obtained. COMPARISON STUDY: Conventional angiography from [**2138-4-19**]. FINDINGS: Comparison with the prior study, perhaps due to modality differences, suggests that there is a high-grade (90+ percent) stenosis at the exact origin of the right internal carotid artery. The lumen does rapidly expand to an area of minor stenosis distal to this point, with adjacent heavy atherosclerotic calcification along the posterior wall of the right internal carotid artery seen. On the left side, there is only minor stenosis of the origin of the left internal carotid artery, but again there is heavy atherosclerotic calcification along the posterior wall of this vessel. No other definite vascular stenoses involving the cervical carotid systems are appreciated. Intracranially, there is clear contrast enhancement on either side of the stent, but it is somewhat difficult to be certain of the exact status of the lumen within the stent itself. Certainly, there is contrast material seen within the intracranial vasculature elsewhere, but it is to be acknowledged that it is difficult to be certain as to the contribution of collateral flow into the anterior circulation tributaries of the right cavernous carotid artery. Certainly, transcranial Doppler measurements might be useful in this regard. Intracranially, there does appear to be a moderate stenosis of the proximal M1 segment of the right middle cerebral artery that was not as clearly appreciated on the prior angiogram, but of course the present study allows for multiplanar reconstructions. The axial projection, particularly shows this stenosis to maximal extent. The right callosalmarginal artery appears quite diminutive, which was probably present on the prior angiographic study, as well. The left vertebral artery distal to the origin of the left posterior inferior cerebellar artery has an area of moderate stenosis and there is a more severe stenosis involving the distal right vertebral artery just proximal to its junction with the basilar artery. CONCLUSION: Studies raise the question of a high-grade stenosis now seen at the origin of the right internal carotid artery with additional multiple intracranial stenoses as noted above. It is quite difficult to ascertain the stent patency, even with the sub-mm sections employed for this CT angiogram. These findings were discussed with the requesting stroke neurologist, Dr. [**Last Name (STitle) 12168**], and the issue of a proximal internal carotid stenosis was raised with the interventional neurosurgeon, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 8374**] on [**4-29**], shortly after the conclusion of the examination. [**2138-5-1**] CAROTID SERIES COMPLETE REASON: Stroke. FINDINGS: Duplex evaluation was performed of both carotid arteries. Significant plaque was identified on the right. On the right, the internal carotid artery peak systolic/diastolic velocity is 260/114. In the remainder of the vessels, the peak systolic velocities are 81, 70 in the CCA, ECA respectively. The ICA to CCA ratio is 3.3. This is consistent with an 80-99% stenosis. On the left, peak systolic velocities are 83, 85, and 103 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This is consistent with a less than 40% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: Significant right-sided plaque with an 80-99% carotid stenosis. On the left, there is a less than 40% carotid stenosis. [**2138-4-29**] EMERGENCY MR SCAN OF THE BRAIN: HISTORY: Right intracranial carotid stenosis and stent. Now presents with acute left arm weakness. Rule out acute stroke. TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging, including the use of diffusion-weighted scans. COMPARISON MR STUDY: None. FINDINGS: The diffusion-weighted images disclose a 1-cm wedge-shaped area of restricted diffusion that likely represents a relatively acute area of brain ischemia superimposed on much more extensive chronic small vessel infarction involving the white matter of both cerebral hemispheres. There is no new major vascular territorial infarction identified. There are no areas of abnormal susceptibility in the brain seen to suggest an area of hemorrhage. CONCLUSION: 1-cm focus of restricted diffusion in the right occipital lobe suspicious for an area of acute brain ischemia. MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) 243**] AND ITS TRIBUTARIES TECHNIQUE: Three-dimensional time-of-flight imaging with multiplanar reconstruction. PREVIOUS STUDY FOR COMPARISON: Standard angiography of [**2138-4-19**]. FINDINGS: Since the previous angiogram, there has apparently been placement of an intravascular carotid stent within the cavernous portion of this vessel on the right side. Flows signal through the stent appears to be somewhat reduced in caliber but it is possible that some of this apparent reduction could reflect susceptibility effects from the stent metallic content. There does appear to be symmetric flow signal within both middle cerebral arteries. As was noted on the standard angiogram, both anterior cerebral arteries appear to derive flow from the left carotid system. Brief Hospital Course: This 66-year-old woman, status post coronary bypass and intracranial internal carotid artery stenting, scheduled for discharge on [**2138-4-29**] and developed left sided weakness, transient ischemic attack. Evaluated by stroke team and carotid ultrasound and a CT angiogram showed progression of her previous 40% internal carotid artery stenosis to 80%-99%. Scheduled for right carotid endarterectomy on [**2138-5-2**]. Continued on Neo for BP support and Heparin. Neurology closely following. [**2138-5-2**]: weakness of LLE resolved. Underwent uneventful right carotid endarterectomy. Extubated. Pain controlled. [**Date range (3) 12169**] No overnight events, VSS. IV fluid HL, diet advanced, foley d'ced. Neurologically intact. Lt thigh pain post CABG/left greater saphenous vein harvesting is unchanged. [**2138-5-5**] No overnight events, VSS. Tolerating regular diet. Physical therapy evaluated and cleared patient for home. RT CEA Staples discontinued. Will discharge to home with services. Home diabetic medications resumed. CT surgery evaluated Lt groin/thigh hematoma prior to discharge. Hematoma is stable. recommendations include warm compress and elevation. Patient understands all discharge instructions (reviewed with her RN who speaks Hindi). Follow up appointment scheduled with primary care next week. She will follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] in [**12-22**] weeks. Medications on Admission: Metformin 1000mg [**Hospital1 **], Glipizide 5mg TID, Lisinopril 10mg', Lipitor 20mg', Methimazole 10mg', Aggrenox 25/200', Atenolol 12.5mg', Baby ASA Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Call primary care for [**Hospital1 **]. Disp:*60 Capsule(s)* [**Hospital1 **]:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* [**Hospital1 **]:*0* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* [**Hospital1 **]:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO Q 24H (Every 24 Hours): Call primary care MD [**First Name (Titles) **] [**Last Name (Titles) 3906**]. Disp:*90 Tablet(s)* [**Last Name (Titles) **]:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Call primary care MD [**First Name (Titles) **] [**Last Name (Titles) **]. Disp:*60 Tablet(s)* [**Last Name (Titles) **]:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): Call primary care for [**Last Name (Titles) **]. Disp:*30 Tablet, Delayed Release (E.C.)(s)* [**Last Name (Titles) **]:*0* 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Lancets & Blood Glucose Strips Combo Pack Sig: Check Blood sugar 4x per day Miscellaneous four times a day: Call primary care for [**Last Name (Titles) **]. Disp:*120 1* [**Last Name (Titles) **]:*2* 12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare Discharge Diagnosis: 1. Right carotid extracranial and intracranial stenosis status post extracranial angioplasty and intracranial stenting and carotid endarterectomy. 2. History of transient ischemic attacks and bilateral watershed strokes 3. Coronary artery disease with three vessel disease with recent NSTEMI 4. Diabetes #2 5. Hypertension 6. Hyperlipidemia 7. Iron deficiency anemia 8. Hyperthyroidism with history of multinodular goiter 9. Sciatica Discharge Condition: Good. Cr 0.6 HCT 30.1 Warm compress to left groin/thigh hematoma. Elevate LE when not ambulating Discharge Instructions: Discharge instructions from CT surgery (S/P CABG) Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Do not use creams, lotions, or powders on wounds. Shower daily, let water flow over wounds, pat dry with a towel. Call our office/Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1477**] for sternal drainage, temp>101.5. Division of Vascular and Endovascular Surgery Carotid Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? You should not have an MRI scan within the first 4 weeks after carotid stenting ?????? Call and schedule an appointment to be seen in [**1-19**] weeks for post procedure check and ultrasound What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office/[**Doctor Last Name **] at [**Telephone/Fax (1) 4749**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Division of Vascular and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions What to expect when you go home: 1. Surgical Incision: ?????? It is normal to have some swelling and feel a firm ridge along the incision ?????? Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness ?????? Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery ?????? Try ibuprofen, acetaminophen, or your discharge pain medication ?????? If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon??????s office 4. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: F/U scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (primary care MD) on [**5-12**] at 910am. Office phone [**Telephone/Fax (1) 12170**]. Copy of discharge summary faxed to office. Call Dr.[**Name (NI) 12171**] office at [**Telephone/Fax (1) 5643**] to schedule post op visit in [**12-22**] weeks. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1887**], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 12172**] Date/Time:[**2138-6-4**] 1:30 Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks [**Telephone/Fax (1) 1477**] . Make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Telephone/Fax (1) 12173**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**] Completed by:[**2138-5-5**]

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Discharge summary

report

Admission Date: [**2159-7-4**] Discharge Date: [**2159-7-12**] Date of Birth: [**2078-9-9**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4277**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: s/p intramedullary nailing for impending femoral stress fracture History of Present Illness: This is an 80 y/o M with a history of metastatic renal Carcinoma diagnosed after he fell from a tree, had several broken ribs and had a CT scan which showed a right kidney mass s/p resection. He had serial CTs, and in [**2151**] he was found to have a large right chest wall soft tissue mass that was also resected and also underwent radiation therapy. Follow up CT showed solitary right upper lung nodule enlarging, 3.3mm by CT in [**2158**] had VATS with RU lobectomy. He continues to follow with his oncologist. Has lung, pancreatic involvment, slow growing, no role for systemic treatment. Started having left upper leg pain, found to have left femur met on XR, saw Dr [**First Name (STitle) 4223**] in consultation, recommended resection and reconstruction of his femur. Before [**Hospital Unit Name 153**] transfer, the patienth had left femoral rodding procedure (pathologic fracture from mets). Intraop, bled 800cc. Was given about 4 liters of fluid during the procedure and post op, and also recieved 1 unit PRBCs. Upon intubation, he was tachypneic to 40-50, desating, improved on CPAP, gas showed he was hyperventilating, alkalosis. Still in 30-40s, O2 sats 93 on face mask. moonlighter-[**Pager number 82289**] On arrival to the MICU, patient's VS were T: 98.3 BP: 116/67 HR: 80 rr: 28 sp02: 99% on BIPAP 5/5. Pt desaturated to 80s when mask removed to deliver nebulizer and cpap reinstituted. Pt alert and oriented. Does c/o pain at incision site. Lung sound rhonchi and wheezes throughout. Sp02 97% on BIPAP. RR in high 20??????s to low 30??????s at times. The patient became hypotensive with SBP high 80s, so was given 1 L NS. Past Medical History: -Renal Cell Ca: Diagnosed and resected his R kidney mass in [**2141**] after the mass was found incidentally on CT scan. A 14.5 cm soft tissue mass was found on follow up CT scan in [**2151**], which was resected. He also had a VATS RU lobectomy in [**2158-7-7**]. In [**2156**] CT scan showed RUL lung mass, which was resected. He also had pancreatic involvement. Recently, he experienced leg pain and was found to have a L femer met. His cancer has been overall growing slowly, and prior to surgery he experienced great quality of life and was very active. -s/p tumor removal from the eye -s/p skin cancer removed from the cheek -HTN -BPH -s/p appendectomy -s/p inguinal hernia repair x3 -s/p carotid endarterectomy Social History: Not currently working, used to work in manufacturing. Hi lives with his wife and has daughters living nearby and in [**Name (NI) 108**]. Former smoker, quit > 1 year ago. No alochol. Married and lives with his family. 20 pack-year history ex-smoker who quit 20 years ago. No alcohol. Family History: Diabetes, No Family history of Cancer. non-contributory Physical Exam: General: Alert and oriented, no acute distress, on CPAP. HEENT: MMM, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Lungs: Diffuse wheezes and crackles throughout b/l lung fields. No breath sounds in RUL distribution s/p VATS. (Scar visible on chest wall). 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. Left femur surgical site, mild tenderness to palpation. Stage 1 coccyx ulcer. Pertinent Results: Blood gas: 4:56 pm: pH 7.28, pCO2 55, pO2 380, HCO3 27 p8:35 pm: H 7.37, pCO2 49, pO2 58, HCO3 29 (not intubated) Na 135, K 4.4, Cl 98, Glu 178, Ca 1.23, Lactate 1.2 WBC 15.2, H/H 13.0/40.1, Glu 241 . Images: CXR Portable: Pending Femur A/P/lateral X ray: Pending Lower Extremity Fluoro: Pending Micro: Tissue Path: Pending EKG:unchanged from prior [**2159-7-12**] 08:50AM BLOOD WBC-8.0 RBC-3.34* Hgb-10.1* Hct-30.5* MCV-91 MCH-30.3 MCHC-33.2 RDW-15.0 Plt Ct-298 [**2159-7-10**] 09:10PM BLOOD WBC-9.8 RBC-3.47* Hgb-10.5* Hct-31.3* MCV-90 MCH-30.2 MCHC-33.5 RDW-14.8 Plt Ct-273 [**2159-7-12**] 08:50AM BLOOD Plt Ct-298 [**2159-7-12**] 08:50AM BLOOD PT-20.7* PTT-35.6 INR(PT)-2.0* Brief Hospital Course: 80 yo M w/ HTN and metastatic renal Ca (to lung, chest wall, pancreas, femur) was transfered to the [**Hospital Unit Name 153**] after left femur rodding procedure for tachpnea and hypoxemia. # Post-surgical hypoxemia and tachypnea - Differential diagnosis included pulmonary edema, tranfusion relation blood injury, negative pressure pulmonary edema. Patient improved with diuresis. CT chest revealed infiltrates in lower lung bases, but with the absence of clinical symptoms including cough, fever, leukocytosis, he was not treated for pneumonia. CTA performed and b/l LE dopplers were negative. Initially on BIPAP, transitioned to nasal canal. # A. fib/tachycardia: Rated controlled on diltiazem gtt, transitioned to diltiazem XR 120mg po. Given conversion back to NSR, not need to anti-coagulation. Post operative has been doing well however has failed 3 voiding trials and has required an extended duration foley (5-7 days) as well as a lingering oxygen requirement with exhertion - Home or Rehab O2 PRN. After trying to arrange for Home care he has elected to go to a rehab facility Cardiology re anticoagulation after new onset afib and patient was bridged to coumadin with Lovenox . current INR 2.0 Medications on Admission: TAMSULOSIN 0.4 mg Capsule,Ext Release 24 hr - 1 Capsule(s) by mouth once a day VALSARTAN [DIOVAN] -320 mg tablet once a day VERAPAMIL -120 mg Tablet - three times a day Fish oil Fiber suppliment Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:*100 Tablet(s)* Refills:*0* 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous twice a day for 2 weeks. Disp:*28 * Refills:*0* 5. Home oxygen 2L nasal cannula, continuous titrate to O2 sat >92% 6. diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: Langdon Place of [**Location (un) **], NH Discharge Diagnosis: Renal Cell CA s/p femoral IMN Discharge Condition: stable, unsteady however and likely [**Hospital **] rehab Discharge Instructions: Ambulate with walker - Weight bearing as tolerated may shower soap/water and blot dry dressing only Physical Therapy: Physical therapy onn outpatient basis. Pt is willing to drive to therapy to supplement home visits WBAT ROM ad lib PT for strength and abmulation Treatments Frequency: Will need to continue foley catheter after DC but can Discontinue 5-7 days after DC ([**Date range (1) 82290**]). Please DC in early am and check for voiding later that day. Lovenox can be DC'd with latest INR 2.0 - will need reg check of INR. Primary care will check INR at home and ultimately at Cardiologist where his spouse follows hers Continue diltiazem Followup Instructions: [**Location (un) 4223**] - 2 weeks as scheduled

[ "428.33", "401.9", "V10.52", "198.89", "198.5", "600.00", "V15.82", "707.03", "427.31", "428.0", "707.21", "V10.83", "518.51", "197.8", "197.0", "997.1", "285.9" ]

icd9cm

[ [ [] ] ]

[ "93.90", "78.55" ]

icd9pcs

[ [ [] ] ]

6640, 6708

4536, 5750

326, 393

6782, 6842

3829, 4513

7536, 7587

3128, 3186

5996, 6617

6729, 6761

5776, 5973

6866, 6966

3201, 3810

6984, 7130

7152, 7513

267, 288

421, 2067

2089, 2809

2825, 3112

16,077

169,143

21112

Discharge summary

report

Admission Date: [**2172-6-30**] Discharge Date: [**2172-7-1**] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2074**] Chief Complaint: Shortness of breath, dizziness Major Surgical or Invasive Procedure: none History of Present Illness: 86 yo male with CAD s/p CABG, CHF, s/p PM who p/w SOB/dizziness. Pt reports getting home from the store this afternoon ~3:30 pm, then went to sit outside when he started to feel dizzy, lightheaded. Tried to stand up, felt like he was going to pass out, went inside to rest. Dizziness persisted, felt like room was spinning. Then felt SOB and anxious. Also noted lower sternal CP - sharp, radiating to toes. No N/V or diaphoresis. Called EMS who brought to [**Hospital1 18**]. . Of note, his medications were changed 2 days ago - amlodipine d/c'd and started on flomax 0.4 mg Qhs which he has now had x 2 days. He denies any dietary indiscretions in the past few days, but he had had increased fluid intake. He was outside alot over the past weekend and has been drinking copious amounts of fluid over the past few days to stay hydrated. He is able to walk about 1 block w/o difficulty, his baseline, and denies any DOE, CP, PND, palpitations, LE edema or other new sx in the past few weeks. Stable 1 pillow orthopnea. . In the ED, he was noted to be htn at 181/99 and mildly hypoxic, put on 2 liters O2. He was given Asa 325 mg po, nitro 0.4mg SL x 1, lasix 80 mg IV, and MSO4 4 mg IV with improvement of symptoms. Chest pain resolved with nitro gttp. Several attempts made to wean nitro gttp but he did not tolerate [**3-5**] recurrent CP. He put out 2500 cc urine in response to lasix in ED. . At time of eval, he denies any chest pain. SOB now back to baseline. No other c/o. Past Medical History: CAD s/p CABG (3VD) - [**2166**] biV PM/ICD - placed [**2170**] (original PM in [**2166**]) CHF DM - on OHA htn hyperlipidemia BPH colon ca s/o resection - [**2136**] depression/anxiety h/o vertigo h/o malaria h/o dengue fever Social History: Family History: Physical Exam: VS- T= 96.4 P= 65 BP= 181/59 R=22 P2sat 100% on 2 liters Gen- anxious appearing male, speaking in full sentences w/o difficulty, in NAD HEENT- EOMI, o/p clear with MMM Neck- soft and supple, JVP 14 cm CV- RR, no m/r/g Pulm- bibasilar crackles Abd- S/NT/ND Ext- W&D, no edema Neuro- A&Ox4, non-focal Pertinent Results: CHEST (PORTABLE AP) [**2172-6-30**] 5:47 PM . COMPARISON: None. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There is a left-sided pacemaker with leads in standard position. The patient is status post median sternotomy. There is cardiomegaly. Thoracic aorta is unfolded. There is prominence of the pulmonary vasculature. There is an ill-defined opacity at the right base. No pleural effusions are clearly identified. IMPRESSION: 1. Cardiomegaly with slightly prominent pulmonary vasculature consistent with mild congestive heart failure. 2. Opacity in the right lower lobe could represent vascular crowding or atelectasis, early pneumonia is a possibility. Correlate clinically. ............................................................... CHEST (PORTABLE AP) [**2172-7-1**] 7:06 AM . IMPRESSION: AP chest compared to [**6-30**]: Moderate cardiomegaly and pulmonary vascular congestion have improved and right lower lobe abnormality has cleared, indicating as was asymmetric edema, not pneumonia. Transvenous right atrial and right ventricular pacer leads are unchanged in their standard placements. Transvenous right ventricular lead and a transvenous right ventricular pacer defibrillator lead are also unchanged in their positions. The proximal electrode on the defibrillator lead ends in the right atrium. Clinical assessment is advised. ................................................................ [**2172-6-30**] 05:50PM WBC-6.9 RBC-3.95* HGB-12.3* HCT-35.4* MCV-90 MCH-31.1 MCHC-34.7 RDW-14.3 PLT COUNT-152 . NEUTS-67.1 LYMPHS-25.2 MONOS-5.6 EOS-1.7 BASOS-0.4 . PT-20.1* PTT-29.6 INR(PT)-1.9* . GLUCOSE-175* UREA N-43* CREAT-1.8* SODIUM-136 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-23 ANION GAP-19 . CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-2.2 . ALT(SGPT)-28 AST(SGOT)-32 CK(CPK)-208* ALK PHOS-54 AMYLASE-89 TOT BILI-0.7 LIPASE-87* . CK-MB-7 proBNP-7335* cTropnT-0.01 . TSH-3.6 . DIGOXIN-0.3* . URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: This is an 86 yo male with CAD s/p CABG, CHF, s/p PM who presented with worsened dyspnea/dizziness. On presentation, the patient was hypertensive, tachypneic saturating 90-92 on RA and 96-98 on 4L. He complained of R sided chest pain and was placed on nitroglycerin drip. Exam notable for elevated JVP and crackles on lung exam. EKG revealed no ischemic changes and cardiac enzymes were within normal limits. He was aggressively diuresed in ED (2.5 L diuresed over 3 hrs, but was unable to be weaned off of the nitroglycerin. He was then admitted to the coronary care unit for CHF management and further evaluation/treatment. The patient was successfully weaned off the nitroglycerin drip. Further diurese overnight was withheld given the aggressive diuresis in EDHis oxygen saturation improved with resolution of his tachypnea He ruled out for MI by enzymes and lack of EKG changes. His chest pain seemed, in part, related to anxiety and to abdominal pain (RUQ pain may have been secondary to liver engorgement from CHF). His pain was controlled with morphine and ativan. He was given IV lasix the following morning. It was believed the patient would be best served by transferring him to the [**Hospital1 2025**] where had been getting all his previous cardiology care. . In summary, this is an 86 year old gentleman with CAD status post CABG, CHF, s/p BiV pacemaker admitted with CHF exacerbation. He responded well to diuresis with lasix and ruled out for myocardial infarctionl. His respiratory status improved and the patient remained hemodynamically stable. He was subsequently transferred to [**Hospital1 2025**] where his primary cardiologist is located. Issues and plan from this hospitalization. . Cardiac: Primary cardiologist is Dr. [**Last Name (STitle) 56024**], affiliated with [**Hospital1 2025**]. 1. CHF - Pt with CHF, unknown EF, presented with CHF exacerbation. This is most likely due to excess fluid intake - reports drinking copious fluids over the weekend while outside in the heat. This combined with recent med change may have led to decompensation in his CHF. Now s/p 2500 cc fluid diuresis in ED, appears grossly euvolemic. Given 2500 cc diuresis in the span of 2 hours in the ED, was not further diuresesd overnight. Initially on nitro drip overnight, weaned off on day of transfer. Continued on beta blocker and ace inhibitor. Digoxin initially held and then restarted after level returned. Cardiac enzymes cylced to r/o ischemic etiology and have been negative thus far. TSH was within normal limits. Patient's fluid status was monitored and he was fluid restricted. No ECHO data in the system as patient recieves most of his care at [**Hospital1 2025**]. Records had not been received at time of transfer. . 2. CAD - Pt with known CAD s/p CABG in [**2166**]. Apparently had cath since then (? [**2170**]), but records still unavailable (gets care at [**Hospital1 2025**]). He does describe chest pain here, assoc w/ SOB and relieved by nitro, however, it is not his typical anginal pain. He is also extemely anxious with his pain. Cardiac enzymes negative x 2, and EKG shows paced rhythm (no prior for comparison). He was continued on asa, statin, beta blocker and an ace inhibitor. Patient had an episode of sharp [**11-10**] burning substernal/epigastric pain on [**7-1**] which developed after lunch and lasted several minutes. Patient was also feeling short of breath at the time, however, was maintaining his O2 sats at 100% on 2 L NC. He received one SL nitro but by the time he received the pain had already started to subside. The pain seemed to resolved with belching. The patient was given Maalox. . 3. Rhythm --> History of atrial fibrillation, on coumadin for anticoagulation. Coumadin continued, however, patient gives history of multiple falls in the last 1-2 months. Would consider discussing discontinuation of anticoagulation with patient and family given his fall risk. . 4. Dizziness - could be related to fluid shifts/CHF, especially over the holiday weekend. Could also be med related - recently started on flomax which could precipitate orthostatic symptoms. Patient is also very anxious and so a component of anxiety associated with SOB may also be contributing to symptoms. Patient's flomax was held. . 5. DM - on OHA at home. These were held and patient was covered with a sliding scale. Hgb A1C 6.9 on [**2172-7-1**]. . 6. CRI - At baseline creatinine of 1.8. . 7. BPH - Held flomax given above symptoms. Might benefit from proscar instead. . 8. Depression/anixety - Continued on Prozac and trazadone. Patient has a considerable amount of anxiety related to his physical symptoms and might benefit from counseling. Code status is DNR/DNI. Disp: transferred to [**Hospital1 2025**]. Medications on Admission: ASA 81 mg QD lipitor 40 mg QD isorsorbide 40 mg QID digoxin 250 mcg QD fosinopril 20 mg QD toprol XL 50 mg QD lasix 80 mg QD coumadin 5 mg Q [**Doctor First Name **]/T/T/Sa; 7.5 mg Q M/W/F prozac 20 mg QD avapro 300 mg QD trazodone 50 mg QD MVI QD colace 100 mg [**Hospital1 **] levoxyl 150 mcg QD . All: NKDA Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for prn constipation. 2. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Fosinopril 20 mg Tablet Sig: One (1) Tablet PO daily (). 6. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily (). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Isosorbide Dinitrate 10 mg Tablet Sig: Four (4) Tablet PO QID (4 times a day). 11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 14. Digoxin 125 mcg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding scale Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Discharge Diagnosis: CHF exacerbation Discharge Condition: stable Discharge Instructions: Please take all of your medications as prescribed. * Please call your doctor or return to the emergency room if you develop shortness of breath, chest pain, you cannot eat, drink or take your medications or you develop any other symptoms that are concerning to you. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **] [**2-3**] weeks.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11185, 11200

4446, 9211

273, 280

11261, 11270

2411, 4423

11584, 11667

2076, 2076

9572, 11162

11221, 11240

9237, 9549

11294, 11561

2091, 2392

203, 235

309, 1790

1812, 2040

2058, 2058

13,648

112,926

6697

Discharge summary

report

Admission Date: [**2164-12-23**] Discharge Date: [**2164-12-29**] Date of Birth: [**2118-1-6**] Sex: F Service: [**Hospital1 212**] CHIEF COMPLAINT: New myocardial infarction. HISTORY OF PRESENT ILLNESS: This is a 46 year old Caucasian female with a past medical history of coronary artery disease, three vessel disease with a recent myocardial infarction in [**2164-10-16**], and an echocardiogram revealing questionable mural thrombus who presented to [**Hospital6 3426**] on [**2164-12-22**], with left sided chest pain and dizziness. She was found by her mother the morning of presentation and brought to [**Hospital6 33**] for further evaluation. At [**Hospital6 33**], the patient was noted to have a blood sugar of 1200 and laboratories consistent with diabetic ketoacidosis, acute renal failure with creatinine of 2.4, baseline creatinine of 1.5. Her electrocardiogram was notable for new right bundle branch block, inferior ST depression, anterior T wave changes, new as compared to recent electrocardiogram. She was admitted to the Intensive Care Unit there where she was treated for diabetic ketoacidosis with intravenous fluids and insulin drips. She was treated for the new non ST elevation myocardial infarction with Aspirin but no beta blocker secondary to her low blood pressure. At that point, the hospital course was complicated for new altered mental status. She has chronic anticoagulation with Coumadin and CT of the head was conducted to rule out intracerebral hemorrhage. The first CT had questionable changes along the tentorium cerebelli and thus the Heparin was held until [**2164-12-23**], when repeat head CT was negative. Lumbar puncture and electroencephalogram were not done. Neurology was consulted and they suggested that the altered mental status was secondary to toxic metabolic causes. Of note, the patient's peak CK was 498, MB 86 and troponin 3.16 at the outside hospital and repeat electrocardiogram showed resolution of the inferior depressions. Of note also at the outside hospital, she was on intravenous Vancomycin and Tequin for questionable infection of her outer ear as a cause of her diabetic ketoacidosis. PAST MEDICAL HISTORY: 1. Coronary artery disease, three vessel, myocardial infarction in [**2163-11-17**], and [**2164-10-16**]. Echocardiogram in [**2164**], showed a questionable mural thrombus. 2. Congestive heart failure with an ejection fraction of 15 to 25% and 1+ mitral regurgitation. 3. Diabetes mellitus type 1, times thirty-six years, brittle, complicated by retinopathy and nephropathy and neuropathy. 4. Asthma. 5. Osteoporosis, multiple tibial fibular fractures, the last one and one half years prior to admission which has failed to heal. 6. Chronic skin infections. 7. Iron deficiency anemia. 8. Glaucoma. 9. Irritable bowel syndrome. 10. Gastroparesis. 11. Dermatitis herpetiformis. 12. Chronic hyponatremia. ALLERGIES: Amoxicillin and injected cortisone. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: No alcohol, tobacco or drug use. MEDICATIONS ON TRANSFER: 1. Aspirin. 2. Heparin. 3. Tequin 200 mg once daily. 4. Clarinex 5 mg once daily. 5. Neurontin 600 mg four times a day. 6. Doxepin 200 mg once daily. 7. Celexa 20 mg once daily. 8. Niacin 500 mg p.o. three times a day. 9. Digoxin 0.125 mg p.o. once daily. 10. Synthroid 137 mcg once daily. 11. Prednisone drops, Trusopt drops. 12. Protonix. 13. Serevent. 14. Flovent. 15. Xalatan. 16. Atropine. 17. Vancomycin. LABORATORY DATA: On admission, the patient had a chest x-ray that showed poor inspiration, small bilateral effusions. She had a head CT at the outside hospital which showed bilateral symmetric postthalamic calcifications but no hemorrhage. She had the following laboratories apparently on admission to [**Hospital1 69**]: Sodium 124, potassium 4.7, chloride 93, bicarbonate 21, blood urea nitrogen 47, creatinine 1.7, glucose 193, calcium 8.4, phosphorus 4.6. She had an AST of 26, ALT 22, alkaline phosphatase 165, total bilirubin 0.2. CK on admission was 381, MB 57, albumin 3.1, troponin 3.16. Prothrombin time was 31.3, partial thromboplastin time 45.4 and INR 4.4. Her white blood cell count was 12.1, hematocrit 33.7, platelet count 310,000. She had an echocardiogram in [**2164-9-16**], which showed severe regional wall left ventricular dysfunction with an akinetic distal one half septum, distal one third of anterior inferior wall. The apex is akinetic. There was question for small mural thrombus, 1+ mitral regurgitation, and ejection fraction of 25%. Electrocardiogram on [**2164-12-22**], which showed normal sinus rhythm at 76 beats per minute, normal PR interval, QRS greater than 120, right bundle branch block, right axis deviation, T wave inversion V1 through V3, questionable ST depressions in V4 through V6. Compared with [**2164-10-6**], she had new right bundle branch block, T wave inversions and ST depressions and new right axis deviation. The patient had other studies of significance including the following: Repeat echocardiogram on [**2164-12-26**], showed no mural thrombus. The echocardiogram also demonstrated left ventricular ejection fraction of 20 to 25%, basically unchanged from [**2164-10-16**], and without further akinesis or hypokinesis. In addition, the patient underwent an x-ray of her left lower leg which demonstrated a continuous nonhealing fracture of the tibia and fibula. Two days prior to discharge, the patient had the following laboratory values: White blood cell count 8.6, hematocrit 32.9. Chem7 revealed sodium 132, potassium 4.7, chloride 95, bicarbonate 23, blood urea nitrogen 24, creatinine 1.0, glucose 236, calcium 9.0, magnesium 2.1, phosphorus 5.7 and the day of discharge she had an INR of 1.5. HOSPITAL COURSE: 1. Cardiovascular - The patient was treated conservatively with beta blockers, ace inhibitors, Heparin and Aspirin and remained chest pain free the majority of her remaining hospital stay. As mentioned previously, her repeat echocardiogram showed no change in her cardiac function and demonstrated no mural thrombus. She gradually became volume overloaded through the course of her hospital course and required diuresis for the last three hospital days. 2. Endocrine - The patient presented to the outside hospital with blood sugar in the 1200 range. She was treated conservatively with intravenous fluids and insulin drip and her blood sugar gradually came into the 200 to 300 range the remainder of her hospital stay. Her blood sugar is extremely brittle and very difficult to control but she had no further complications from the diabetes through the hospital stay. 3. Hematology - The patient had previously been anticoagulated for akinesis related to her previous myocardial infarction and she remained stable through the course of her hospital stay. Per cardiology, she had a target INR of 1.8 for three months following discharge and then a goal of 1.5 following those three months. In addition, she has a chronic anemia likely secondary to iron deficiency and chronic renal insufficiency. She is to be treated with Ironist 2.5 mg injections once a week. 4. Dermatology - The patient has a history of dermatitis herpetiformis recently controlled with Niacinamide and Minocycline and Ultravate cream. She was treated with these medications during her hospital stay and the rash remained stable. The patient also had a lesion on her right anthelix which was biopsied and showed subcellular atypia and needs to be rescheduled for biopsy by dermatology as an outpatient. 5. Renal - The patient has a baseline renal insufficiency with a creatinine of roughly 1.5. She was hydrated through the course of her hospital stay and her creatinine was at baseline the day of discharge. She had intermittent rise in her creatinine during the hospital stay presumed due to a prerenal state as it corrected with volume repletion. She also has chronic hyponatremia and her sodium remained around 130s through her hospital stay. 6. Gastroenterology - The patient has a history of gastroparesis and irritable bowel syndrome. She tolerated p.o. through her full stay in the hospital. 7. Psychiatric - The patient has a history of depression. She was seen by psychiatry who recommended continuing her Celexa at 40 mg p.o. once daily and adding Trazodone for sleep. They also mentioned they would consider additional low dose benzodiazepine for short term treatment of anxiety or Buspirone. They also recommended adding Tox therapy for the patient. 8. Orthopedic - The orthopedic service saw the patient for persistent right leg pain related to her cast bowing. They reshot films and noted continued failure of her tibia/fibula fracture on the right to heal and changed the cast and recommended follow-up with orthopedics in one to two weeks following discharge. CONDITION ON DISCHARGE: The patient was in fair condition at discharge. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSES: 1. Status post myocardial infarction. 2. Diabetes mellitus, status post diabetic ketoacidosis. 3. Dermatitis herpetiformis. 4. Sacral decubitus. 5. Right eye hemorrhage. 6. Neuropathy. 7. Congestive heart failure. 8. Tibia/fibula fracture of right. 9. Depression. 10. Hypercholesterolemia. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg p.o. once daily. 2. Insulin NPH 12 units q.a.m. and 11 units q.p.m. 3. Humalog sliding scale. The patient has her scale and should resume upon rehospitalization. 4. Atropine Ophthalmic Solution 1% one drop both eyes twice a day. 5. Latanoprost 0.005% Ophthalmic Solution one drop both eyes q.h.s. 6. Flovent 110 mcg two puffs inhaled twice a day. 7. Serevent two puffs inhaled twice a day. 8. Protonix 40 mg p.o. twice a day. 9. Prezolimide 2% Ophthalmic Solution one drop right eye four times a day. 10. Prednisolone Acetate 1% Ophthalmic Solution one drop to the right eye four times a day. 11. Synthroid 137 mcg p.o. once daily. 12. Digoxin 0.125 mg p.o. once daily. 13. Niacin 500 mg p.o. three times a day. 14. Celexa 40 mg p.o. once daily. 15. Ferrous Sulfate 325 mg p.o. three times a day. 16. Neurontin 600 mg p.o. four times a day. 17. Colace 100 mg p.o. twice a day. 18. Albuterol one to two puffs MDI p.r.n. shortness of breath. 19. Zestril 10 mg p.o. once daily. 20. Fentanyl patch 25 mcg per hour q72hours. 21. Coumadin 3 mg p.o. q.h.s. to be adjusted twice a week to a goal INR of 1.8 for three months and thereafter a goal of 1.5. 22. Bactroban 2% cream twice a day to skin ulcers. 23. Ultravate cream to skin twice a day. 24. Lasix 120 mg p.o. twice a day. 25. Trazodone 50 mg p.o. q.h.s. 26. Minocycline 100 mg p.o. once daily. 27. Claritin 10 mg p.o. once daily. 28. Plavix 75 mg p.o. once daily. 29. Livostin eyedrops one drop O.D. four times a day times two weeks. 30. Ironist 2.5 mg intramuscular q.week. FOLLOW-UP PLANS: The patient is to follow-up with Dr. [**First Name (STitle) **] of orthopedics. The patient is to follow-up with ophthalmology at the [**Hospital **] Clinic. She is to follow-up with dermatology and also with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. The patient has all the numbers for these follow-up appointments and indicated that she would call and do so. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15868**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2165-1-7**] 16:05 T: [**2165-1-14**] 19:59 JOB#: [**Job Number 25526**]

[ "733.16", "428.40", "276.1", "707.0", "584.9", "424.0", "410.71", "250.11", "276.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2986, 3004

9017, 9317

9343, 10897

5799, 8879

10915, 11599

167, 195

224, 2184

3080, 5782

2206, 2969

3021, 3055

8904, 8996

5,658

160,101

47848

Discharge summary

report

Admission Date: [**2194-12-29**] Discharge Date: [**2195-1-5**] Service: ADMISSION DIAGNOSIS: Colon cancer hepatic flexure. DISCHARGE DIAGNOSIS: Colon cancer hepatic flexure. PROCEDURES DURING ADMISSION: Right colectomy. HISTORY OF PRESENT ILLNESS: The patient is a 79 year-old man with a past medical history significant for coronary artery disease status post coronary artery bypass graft in [**2188**] as well as at and insulin dependent diabetes mellitus found to have hepatic flexure tumor positive for dysplasia. The patient presented with blood in his stool and on colonoscopy the lesion was noted in the hepatic flexure of the colon. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Insulin dependent diabetes mellitus. 3. Atrial fibrillation. PAST SURGICAL HISTORY: 1. Coronary artery bypass graft in [**2188**]. ALLERGIES: Procainamide and amiodarone. FAMILY HISTORY: No significant for family history. SOCIAL HISTORY: Married and retired. HOSPITAL COURSE: The patient was admitted on [**2194-12-29**] and taken to the Operating Room for a right colectomy. The patient tolerated the procedure well and was transferred to the PACU and then to the floor in stable condition. His postoperative course was essentially uneventful. He was seen by cardiology as well as [**Last Name (un) **] for monitoring of his cardiac medications as well as his insulin. Due to low blood pressure postoperative the patient's Lisinopril was discontinued and his Carvedilol dose was halved to 12.5 po b.i.d. The patient's diet was advanced and on postop day number six the patient was ready for discharge when he fell getting out of the bathroom. He did not hit his head. He had no loss of consciousness. Vital signs were stable. Given this event the patient was seen by physical therapy for clearance and on postoperative day seven [**2195-1-5**] the patient was discharged home in stable condition. DISCHARGE MEDICATIONS: 1. Coumadin 5 mg po q.d. Sunday and Thursday, Coumadin 2.5 mg po q.d. Monday, Tuesday, Wednesday, Friday and Saturday. 2. Digoxin 0.125 po q day. 3. Amitriptyline 25 mg po q.d. 4. Labetalol 20 mg po q day. 5. Potassium chloride 20 milliequivalents b.i.d. 6. Hydrochlorothiazide 50 mg po q.d. 7. Mevacor 20 mg po with evening meals. 8. Colace 100 mg po b.i.d. 9. Nitrostat prn. 10. Carvedilol 12.5 mg po b.i.d. 11. NPH insulin 12 units b.i.d. The patient was told to call his cardiologist for follow up regarding his change in medication dose. He was also told to call the [**Last Name (un) **] for follow up of his finger sticks as his NPH dose is adjusted. He was told to call Dr.[**Name (NI) 10946**] office for a follow up appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**] Dictated By:[**Last Name (NamePattern1) 4985**] MEDQUIST36 D: [**2195-1-5**] 08:13 T: [**2195-1-5**] 08:56 JOB#: [**Job Number **]

[ "458.2", "427.31", "250.01", "275.41", "414.8", "V45.81", "998.89", "414.01", "153.6" ]

icd9cm

[ [ [] ] ]

[ "45.73", "45.93" ]

icd9pcs

[ [ [] ] ]

911, 947

1959, 2990

157, 235

1004, 1935

803, 894

105, 136

264, 659

682, 779

964, 986

51,798

112,271

32806

Discharge summary

report

Admission Date: [**2143-6-29**] Discharge Date: [**2143-7-31**] Date of Birth: [**2061-12-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2009**] Chief Complaint: Chest and Abdominal pain Major Surgical or Invasive Procedure: ERCP x2 NJ Tube placement PICC line placement right side, replaced onto left side History of Present Illness: 81M p/w cp/abd pain x 2d. Pt reports nausea with emesis x 3 yesterday. Reports that the pain is over the L side of his chest and abdomen, radiating to his back. In the ED, initial VS were: 10:01 96 102 134/88 20 97%. Given morphine and pressures dropped to the 100s, switched to fentanyl for pain control. A stat CTA was performed which demonstrated no evidence of dissection/ aortic rupture. Lipase 3200 and CT abdomen consistent with pancreatitis. Lactate 3.8, troponin <0.1, BNP 1451. 88 155/84, 16, 100% NC On arrival to the MICU, patient is febrile and rigoring, but comfortable, getting fluids, in no acute distress. Not struggling to breathe, no leg pain. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, states that he has gained weight due to a good appetite. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. No orthopnea, PND, claudication. Denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PMH per admission note - DM2 - Aortic stenosis (mild per [**9-1**] echo) - HTN - Peripheral artery disease - Myelodysplasia/leukopenia/thrombocytopenia PSH per admission note - [**2141-3-2**] - Open AAA repair with aortobifemoral bypass using Dacro 18x9 bifurcated graft - [**2141-3-9**] - bilateral femoral exploration and iliofemoral embolectomy - [**2141-3-22**] - RP percutaneous drain - [**2141-3-27**] - RLQ perc drain - [**2141-3-28**] - anterior abd drain Social History: The patient immigrated from [**Country 532**] in [**2119**] having previously been a chemist. Lives in [**Location **] with wife who has metastatic cancer, he is the sole caretaker. [**Name (NI) **] is active and walks around. Son is [**Name (NI) **]. The patient reports a remote history of tobacco use. He quit in [**2124**] following many years at one to two packs per day. The patient denies alcohol or illicit drug use. Family History: Family History: 1. CVA - father. 2. Diabetes mellitus - brother. 3. Coronary artery disease - brother. Physical Exam: Admission exam: Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, but difficult to tell. No LAD CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur, radiating to carotids, no rubs, gallops Lungs: Trace crackles at bases Abdomen: soft, tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: positive cap refill, but somewhat cool, no pain, only doplerable at right DP, no clubbing or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge exam: O: Physical Exam: 98.6 121/63 99 22 96%RA General: Alert, oriented, appears comfortable HEENT: oropharynx clear Neck: supple, JVP not elevated Lungs: CTA CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: mildly distended, nontender to palpation throughout including over drain site, bowel sounds present. Drain with dark brown/green fluid. Ext: PICC site on the Left demonstrates no tenderness to palpation. No streaking or cellulitis present. Temperature in each hand is symmetric. temperature in right foot is cooler then left foot to touch. PT pulses are dopplerable B/L. Lower extremeties demonstrated diffuse extreme pitting edema. Pertinent Results: Admission labs: [**2143-6-29**] 10:30AM GLUCOSE-268* UREA N-26* CREAT-1.3* SODIUM-135 POTASSIUM-8.2* CHLORIDE-102 TOTAL CO2-19* ANION GAP-22* [**2143-6-29**] 10:30AM ALT(SGPT)-65* AST(SGOT)-81* ALK PHOS-78 TOT BILI-1.4 [**2143-6-29**] 10:30AM LIPASE-3200* [**2143-6-29**] 10:30AM cTropnT-<0.01 [**2143-6-29**] 10:30AM proBNP-1451* [**2143-6-29**] 10:30AM ALBUMIN-4.5 [**2143-6-29**] 10:30AM WBC-14.4*# RBC-6.37*# HGB-18.7*# HCT-57.9*# MCV-91 MCH-29.4 MCHC-32.3 RDW-14.0 [**2143-6-29**] 10:30AM TRIGLYCER-124 [**2143-6-29**] 10:30AM NEUTS-79.1* LYMPHS-17.2* MONOS-3.4 EOS-0.1 BASOS-0.3 [**2143-6-29**] 10:30AM PLT COUNT-105* [**2143-6-29**] 10:30AM PT-35.7* PTT-52.3* INR(PT)-3.5* [**2143-6-29**] 05:54PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.050* [**2143-6-29**] 05:54PM CALCIUM-8.5 PHOSPHATE-1.7* MAGNESIUM-1.8 [**2143-6-29**] 05:54PM URINE RBC-15* WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 Discharge labs: [**2143-7-31**] 04:42AM BLOOD WBC-6.5 RBC-2.62* Hgb-7.6* Hct-23.9* MCV-91 MCH-29.1 MCHC-32.0 RDW-20.1* Plt Ct-195 [**2143-7-30**] 06:32AM BLOOD Neuts-58.9 Lymphs-34.8 Monos-5.0 Eos-0.8 Baso-0.6 [**2143-7-31**] 04:42AM BLOOD PT-14.6* PTT-65.3* INR(PT)-1.4* [**2143-7-31**] 04:42AM BLOOD Glucose-139* UreaN-18 Creat-0.7 Na-128* K-4.3 Cl-95* HCO3-27 AnGap-10 [**2143-7-31**] 04:42AM BLOOD ALT-22 AST-28 AlkPhos-89 TotBili-1.3 [**2143-7-31**] 04:42AM BLOOD Lipase-63* [**2143-7-31**] 04:42AM BLOOD Calcium-7.5* Phos-3.6 Mg-2.1 All Blood, urine and wound cultures were negative [**2143-6-29**] 10:08:50 AM Cardiovascular Report ECG Sinus tachycardia. Non-specific ST segment changes in the precordial leads and in the inferior leads. Compared to the previous tracing of [**2141-6-9**] the rate has increased and the non-specific ST segment changes are new. [**2143-6-29**] CHEST (PORTABLE AP)IMPRESSION: No evidence of acute cardiopulmonary process. [**2143-6-29**] 11:00 AM # [**Telephone/Fax (1) 76388**] CTA ABD & PELVIS and CHEST 1. No evidence of acute aortic syndrome, no aortic dissection. 2. Focal area of hypoenhancement and edema centered in the pacreatic head and neck, consistent with acute pancreatitis. Moderate amount of simple free fluid in the abdomen and pelvis is new since [**2142-1-15**] exam and likely relates to underlying panreatitis. No pseudcyst formation or vascular complications at this time. 3. Coarse hepatic calcification is longstanding and likely represents sequela of prior infection or trauma. 4. Emphysema. 5. Severe coronary artery calcifications. 6. Post-surgical changes related to left axillary-bifemoral graft. Femoral arteries appear patent. Persistent thrombosis of the infrarenal aorta. [**2143-6-30**] 9:02 AM # [**Telephone/Fax (1) 76389**] LIVER OR GALLBLADDER US-IMPRESSION: Sludge ball in the gallbladder neck, but no evidence of acute cholecystitis on US. Normal 5-mm CBD without evidence of obstruction. [**2143-6-30**] 3:40 PM # [**Telephone/Fax (1) 76390**] MRCP (MR ABD W&W/OC) MRCP (MR ABD W&W/OC)-IMPRESSION: 1. Diffuse signal abnormality involving the pancreas with hypointensity on the T1 sequences and hyperintensity on the T2 sequences most consistent with diffuse pancreatitis. A more focal region of hypoenhancement involving the pancreatic neck is suspicious for early necrosis. If the clinical situation of the patient worsens over the next few days/weeks, then a followup MRCP examination may be obtained. 2. 1.2 cm pancreatic cyst. A followup MRI may be obtained in six months to ensure stability. 3. Gallstones. 4. No evidence of intra- or extra-hepatic biliary ductal dilatation. [**2143-7-8**] Cardiovascular ECG Sinus rhythm. Borderline prolonged Q-T interval. Compared to the previous tracing of [**2143-6-29**] the T waves in leads V2-V6 are taller. This may represent acute ischemia or, more likely, an electrolyte abnormality. [**2143-7-8**] CT ABD W&W/O C IMPRESSION: 1. New focus of gas within paripancreatic fluid anterior to the pancreatic head is highly concerning for infection. This collection is not yet organized. No drainable collections are present. 2. Markedly increased stranding and neighboring fluid throughout the pancreas, with two evolving foci of necrosis within the pancreatic head. 3. New moderate narrowing of the SMV/portal vein confluence; the vessels remain patent. 4. New moderate right pleural effusion with adjacent compressive atelectasis is new since [**2143-6-29**]. 5. Moderate amount of fluid surrounding the inferior aspect of the liver and along the right paracolic gutter. 6. Chronic occlusion of the infrarenal abdominal aorta. A left axillary-extremity bypass appears patent. [**2143-7-13**] Radiology PORTABLE ABDOMEN There is no interval development of substantial bowel dilatation, neither small nor large. Calcification projecting over the liver is redemonstrated, known. If clinically warranted, correlation with cross-sectional imaging might be considered. [**2143-7-13**] Radiology MRCP (MR ABD W&W/OC) IMPRESSION: 1. Interval increase in size of hemorrhagic peripancreatic collections and increased size of right subhepatic collection. 2. Extrinsic compression of the distal CBD by the enlarged peripancreatic collection at the pancreatic head. The CBD now measures 0.9 cm versus 0.3 cm on the previous MRCP. 3. Severely attenuated portal vein, splenic vein, SMV and splenic artery, again secondary to compression by the peripancreatic collections. No definite evidence of thrombus or pseudoaneurysm formation; focal contour deformity of the main portal vein is unchanged and probably secondary to mass effect from adjacent inflammatory change and collections; nonocclusive thrombus is felt less likely. 4. Decreased amount of free fluid within the peritoneal cavity. 5. Occluded infrarenal abdominal aorta with patent axillary [**Hospital1 **]-fem bypass graft. 6. 3.2 cm calcified lesion within segment [**Doctor First Name 690**]/VIII of the liver - this is unchanged since [**2140**] and could be secondary to previous infection or trauma or calcification of a nonaggressive lesion. [**2143-7-15**] 11:01 AM # [**Telephone/Fax (1) 76391**] CHEST (PORTABLE AP) CHEST (PORTABLE AP) FINDINGS: In comparison with the study of [**7-9**], there is increasing prominence of interstitial markings consistent with elevation of pulmonary venous pressure. Bibasilar opacifications are consistent with pleural effusion and compressive atelectasis. [**2143-7-16**] Radiology CHEST PORT. LINE PLACEM FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. A right-sided PICC line has been placed, seen to terminate overlying the right atrial contours. The tip is located 8 cm below the level of the carina and it is recommended to withdraw the line by 5 cm so to have optimal position in the mid portion of the SVC. In comparison with the next preceding chest examination of [**2139-7-15**], no new pulmonary or cardiovascular abnormalities identified. No pneumothorax is seen. [**Doctor First Name 8513**] was paged at 3:28 p.m. [**2143-7-17**] Radiology GB DRAINAGE,INTRO PERC CONCLUSION: 1. Could not drain the intrahepatic bile ducts directly. While the ducts could be opacified and appeared normal in caliber, they could not be securely accessed for further intervention. 2. Uncomplicated ultrasound-guided placement of a cholecystostomy tube. 3. Unsuccesful attempt to advance dobhoff tube into the duodenum with fluoroscopy. [**2143-7-25**] Radiology UNILAT UP EXT VEINS US IMPRESSION: No evidence of deep vein thrombosis. [**2143-7-26**] Radiology CHEST PORT. LINE PLACEM CONCLUSION: New left-sided PICC line is somewhere in the neck in left jugular vein. IV nurse has been contact[**Name (NI) **] for the results. [**2143-7-26**] Radiology [**Numeric Identifier 76392**] EXCH PERPHERAL W/ IMPRESSION: 1. Successful exchange of a left-sided PICC with tip in the distal SVC. Line is ready for use. Brief Hospital Course: 81M with history of AAA s/p repair presenting with chest/abd pain x 2d with labs and imaging consistent with pancreatitis. Active Diagnoses # Necrotizing Pancreatitis: Patient diagnosed with pancreatitis given classic pain radiating to the back, elevated lipase, and findings on CT c/w pancreatitis. In terms of etiology, gallstone pancreatitis is most likely, given evidence of gallstones on MRCP and mild transaminitis, despite no evidence of ductal dilitation (likely stone passed). Ischemic pancreatitis initially considered due to significant vascular history; however, improved with fluid resuscitatation. Autoimmune pancreatitis ruled out given normal IgG panel. No clear medication or viral cause. BISAP initially 2 but elevated Hct and Cr raised concern for severe pancreatitis. His lactate was initially elevated, but trended down. He was fluid resuscitated in the ICU and by [**2143-7-1**], he was tolerating clears PO. By [**2143-7-2**], he was tolerating a full diet and his pain had resolved. On [**7-8**] he developed fever and CT scanning noted air with an area of pancreatic necrosis concerning for infection; he was started on meropenem/flagyl for infected necrotizing pancreatitis and continued for a full 14 day course. After discontinuation of antibiotics he was never febrile or developed a WBC count. On [**7-13**] he was noted with increasing LFTs and lipase; MRCP was performed which showed worsening pancreatic necrosis and edema as well as worsening hemorrhagic collections around the pancreas (at this time he was coagulopathic with an INR of ~6). The edema was felt to be extrinsically compressing the ductal system causing biliary obstruction. ERCP was performed for stent placement but was unable to access the ampulla due to extensive duodenal edema. Therefore IR was consulted for percutaneous biliary drain placement; they were unable to place this drain and so defaulted to a percutaneous cholecystostomy tube. After tube placement his bili (which peaked at ~12) and LFTs/lipase downtrended back to normal and remained normal after starting oral feeds. The drain initially had ~1L per day output which tapered off to ~100-200cc daily, suggesting (per GI) that his duodenal edema had resolved and the ampulla was no longer extrinsically compressed or obstructed. The drain needs to remain in place until he is evaluated by pancreaticobiliary surgery as an outpatient, who will determine drain removal and cholecystectomy timing. He had a dobhoff tube placed which was advanced endoscopically into the proximal jejunum; tube feeds were started ATC and continued to discharge. His diet was advanced to full liquids and tolerated well; when attempting to advance to a bland solid diet, he experienced GI upset with some abdominal discomfort and a small elevation in his lipase, suggesting that he would require a prolonged course of gradual dietary advancement prior to being able to eat normally. # Volume overload: due to volume resuscitation for severe pancreatitis, patient has developed extensive third spacing of fluid including ascites, pleural effusions (initially had O2 requirement, no longer) and extensive anasarca with pitting edema throughout. He was placed on daily lasix 20mg IV for goal diuresis 1L net negative daily; IV was utilized throughout due to concern of bowel edema and poor PO absorption. He should receive standing lasix IV daily with daily chemistry panels until his edema has improved. # Peripheral vascular disease: noted with complicated history from AAA repair that clotted off requiring conversion to an axillobifemoral bypass graft that is high risk for clot. He was on coumadin which was allowed to downtrend as he remained coagulopathic. As above, when he was noted to have hemorrhagic conversion of his pancreatitis his INR was reversed with IV vitamin K and his anticoagulation was managed with a heparin drip up until the day of discharge. He was given coumadin 2 days prior to discharge (home dose 6mg) and will need to continue heparin bridge with goal PTT 60-90 until his INR is [**1-25**] for 48 hours, at which point he can be maintained on coumadin only. He remained with dopplerable PT/DP pulses bilaterally (PT>DP) and [**1-25**] second capillary refill throughout. # Thrombocytopenia: patient developed in the past in [**2140**]. Negative HIT antibodies and negative serotonin release assay. Perhaps related to his history of MDS compounded by critical illness and marrow suppression. # Elevated INR to 4.7: Possibly due to nutritional changes versus illness. No recent antibiotics. Warfarin was initially held. By [**2143-7-1**], the INR was 2.8, and warfarin was restarted; once again became supratherapeutic and warfarin was held prior to surgery, transition to heparin drip on [**2143-7-7**] when INR was 2.3. This was then turned off when he became coagulopathic again; he was finally reversed with IV vitamin K after hemorrhagic pancreatitis was noted on MRCP on [**7-13**]. # DM: at home on GlipiZIDE 5 mg PO QHS and GlipiZIDE 2.5 mg PO QAM. This was initially held, and paitent was placed on insulin sliding scale. Due to his worsening pancreatic function, he required escalating doses of insulin eventually stabilizing on 34u lantus daily with an aggresive sliding scale. Chronic Diagnoses # HTN: at home, on home Lisinopril 20 mg PO DAILY and Metoprolol Tartrate 12.5 mg PO BID. These were held upon discharge due to him having no issues with blood pressure while in hospital. They should be restarted upon discharge or by his PCP when he is more stable. Metoprolol was restarted prior to discharge. # HL: at home, on Atorvastatin 10 mg PO DAILY. # Constipation: Bowel regimen. Transitional Issues # Communication: Patient, son [**Name (NI) **] [**Telephone/Fax (1) 76393**] # [**Name2 (NI) 7092**]: Full (confirmed) - percutaneous cholecystostomy tube to remain in place and course dictated by pancreaticobiliary surgery - cholecystectomy at some point to be determined by surgery - ongoing heparin bridge to coumadin, goal INR [**1-25**] for bypass graft - ongoing gradual diet advancement with continuation of tube feeds till regular low fat diet is acheived without abdominal symptoms or LFT/lipase elevation - ongoing evaluation for insulin requirement - restarting home blood pressure medications when more medically stable and required - daily diuresis with IV lasix for goal of -1L net negative - pancreatic cyst noted on initial MRCP - will need repeat in 6 months. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR PCP. 1. Lisinopril 20 mg PO DAILY 2. Metoprolol Tartrate 12.5 mg PO BID 3. Senna 5 TAB PO HS 4. Warfarin 10 mg PO DAILY16 5. Atorvastatin 10 mg PO DAILY 6. GlipiZIDE 5 mg PO QHS 7. GlipiZIDE 2.5 mg PO QAM Discharge Medications: 1. Atorvastatin 10 mg PO DAILY 2. Warfarin 6 mg PO DAILY16 3. Acetaminophen 1000 mg PO Q6H:PRN pain, fever 4. Bisacodyl 10 mg PR HS:PRN constipation Patient may refuse. Hold for loose stools. 5. Docusate Sodium 100 mg PO BID 6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 7. Glargine 32 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 8. Pantoprazole 40 mg PO Q24H 9. Polyethylene Glycol 17 g PO DAILY 10. 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. 11. Heparin IV per Weight-Based Dosing Guidelines 12. Furosemide 20 mg IV DAILY hold for sbp<100 Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Acute gallstone pancreatitis Pancreatic necrosis with superinfection Hemorrhagic pancreatitis Coagulopathy Peripheral vascular disease with axillobifemoral graft Type 2 Diabetes Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 76385**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted for abdominal pain due to acute pancreatitis. You had a very protracted course with multiple complications from your pancreatitis, including necrosis and hemorrhage. You were treated with IV fluids, antibiotics, anticoagulants and with a feeding tube. You will have this tube removed when you are tolerating a full diet. You will also have your PICC line removed when you do not need heparin any longer. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2143-8-14**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], 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 Department: SURGICAL SPECIALTIES When: FRIDAY [**2143-8-30**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please discuss with the staff at the facility a follow up appointment with your PCP below when you are ready for discharge. With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 28089**], MD Location:[**Hospital **]/[**Hospital1 18**] [**Location (un) **]., [**Location (un) 86**], MA [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Phone:[**Telephone/Fax (1) 2010**]

[ "E879.8", "999.33", "995.94", "276.1", "424.1", "789.59", "286.7", "575.8", "576.2", "275.41", "401.9", "V58.67", "428.33", "428.0", "250.00", "238.75", "577.2", "287.5", "577.0", "574.50", "443.9", "532.90" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.97", "51.01", "87.51", "96.6", "45.13" ]

icd9pcs

[ [ [] ] ]

19760, 19826

12116, 18618

330, 414

20061, 20061

4081, 4081

20767, 21892

2592, 2684

18969, 19737

19847, 20040

18644, 18946

20212, 20744

5037, 12093

3409, 4062

3391, 3394

1130, 1624

266, 292

442, 1111

4098, 5020

20076, 20188

1646, 2112

2128, 2560

30,299

167,583

49262

Discharge summary

report

Admission Date: [**2122-1-14**] Discharge Date: [**2122-1-23**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2108**] Chief Complaint: Shortness of breath and altered mental status. Major Surgical or Invasive Procedure: PICC line placement. History of Present Illness: Mr. [**Known firstname 32277**] [**Known lastname **] is a [**Age over 90 **]-year-old man with history of dementia, atrial fibrillation on aspirin, hypertension, and hyperlipidemia who presented to the ED from [**Hospital1 599**] Senior Center, where he lives, with altered mental status and increased respiratory rate. His initial vitals in the ED were T 99, HR 113, BP 87/72, RR 35, oxygen saturation 97% on NRB. Patient was nonverbal, although this is not far from his baseline, per ED report. His lungs sounded "okay," per report, and he was noted to be guiaic negative. He has decubitus ulcers, stage II, on his right buttocks. In the ED, labs were notable for hematocrit of 54, up from baseline in the mid to high 20s. White count was 27, with 85% polys and 1% bands. Notably, since [**2119**] he does appear to have a chronically elevated white count (mid to high teens) with neutrophilic predominance. Other labs showed a creatinine of 3.7, up from baseline 1.5-1.7, BUN of 105, and sodium of 174. Troponin was 0.48. He had an electrocardiogram that showed non-specific st-changes in V2-V6. A urinalysis showed many bacteria, negative leuk esterase and negative nitrite. A chest x-ray showed multiple areas of patchy opacities consistent with possible aspiration pneumonia. The patient was treated empirically for aspiration pnuemonia with vancomycin and Zosyn. He was given 2+ liters of IVF for volume resuscitation and admitted to the ICU given his oxygen requirement (non-rebreather). Vitals at time of admission were HR 83, BP 124/46, RR 24, satting 97% on non-rebreather. Per ED report, the patient's son [**Name (NI) **] was contact[**Name (NI) **] and confirmed that patient's code status is DNR/DNI. While in the [**Hospital Unit Name 153**] a PICC line was placed, his sodium slowly trended down to 166 and his IVF was slowed to 100 cc/hour. Vanc level 13.7 thus gave another dose tonight with the plan to check an AM trough. He was continued on cefepime and vancomycin. His O2 sat improved to 92% on 2L thus his presentation was thought to be most consistent with an aspiration pneumonitis. On ROS, patient minimally interactive and not following simple commands. Thus ROS was unobtainable. Past Medical History: - Per prior cardiology note, had an echo with trivial to mild TR, enlarged RV and possibly a PFO. - Longstanding exertional dyspnea - has pulmonologist who reportedly has done "multiple tests with no abnormalities" - Polymyalgia rheumatica (ESR initially 100, now 6) - HTN - TIAs - per wife, 10yrs ago he had a few minutes of unsteadiness - Hyperlipidemia - h/o prostate cancer, s/p resection [**2096**] - Recent admission for rapid heart rate (wife does not know why) - R postsurgical pupil - MGUS - Baseline Cr 1.4-1.7 in [**10-21**] (no earlier levels known) - PALPITATIONS - shown to be ventricular premature beats in multiple Holter monitors - MITRAL VALVE DISORDER - ATRIAL FIBRILLATION - LUMBOSACRAL SPONDYLOSIS - ATRIAL PREMATURE BEATS - GERD - Degenerative disk disease in the thoracic spine. Social History: He lives at [**Hospital1 599**] Senior Center. Per NH report, bathing, grooming, dressing: totally dependent. Eating: continual supervision. Does not ambulate. Family History: Non-contributory. Physical Exam: Vital signs: satting mid 90s on 3L by nasal cannula; hr 74, sbp 90s General: agitated, confused, non-cooperative; no respiratory distress HEENT: dry mucus membranes, poor dentition, foul-smelling breath Respiratory: limited exam due to poor respiratory effort Cardiovascular: regular rate and rhythm Abdomen: soft, non-tender Extremities: non-edematous, cold distally Neurological: withdraws extremites to pain, pupils equal and reactive; does not respond to simple commands Pertinent Results: Admission Labs: [**2122-1-14**] 06:00PM BLOOD WBC-27.1*# RBC-5.66# Hgb-17.3# Hct-53.6*# MCV-95 MCH-30.5 MCHC-32.2 RDW-14.3 Plt Ct-630*# [**2122-1-14**] 06:00PM BLOOD Neuts-85* Bands-1 Lymphs-5* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2122-1-14**] 06:00PM BLOOD PT-16.3* PTT-25.8 INR(PT)-1.4* [**2122-1-14**] 06:00PM BLOOD Glucose-153* UreaN-105* Creat-3.9*# Na-174* K-4.5 Cl-128* HCO3-24 AnGap-27* [**2122-1-15**] 01:05AM BLOOD ALT-18 AST-33 LD(LDH)-385* AlkPhos-72 TotBili-0.5 [**2122-1-14**] 06:00PM BLOOD cTropnT-0.48* [**2122-1-15**] 06:44AM BLOOD CK-MB-9 cTropnT-0.33* [**2122-1-14**] 06:00PM BLOOD Calcium-10.2 Phos-5.3* Mg-3.8* [**2122-1-14**] 08:35PM BLOOD Glucose-149* Lactate-4.9* K-4.9 Labs prior to discharge: [**2122-1-21**] 05:39AM BLOOD WBC-10.9 RBC-3.53* Hgb-10.7* Hct-30.9* MCV-88 MCH-30.4 MCHC-34.6 RDW-13.7 Plt Ct-275 [**2122-1-23**] 06:05AM BLOOD Glucose-99 UreaN-12 Creat-1.2 Na-138 K-4.0 Cl-108 HCO3-22 AnGap-12 [**2122-1-23**] 06:05AM BLOOD Mg-2.3 [**2122-1-15**] 06:44AM BLOOD Vanco-13.7 [**2122-1-18**] 06:47PM BLOOD Vanco-21.3* [**2122-1-19**] 06:18AM BLOOD Vanco-18.1 [**2122-1-19**] 11:27AM BLOOD Type-ART pO2-93 pCO2-29* pH-7.49* calTCO2-23 Base XS-0 CXR [**2122-1-14**]: Patchy bibasilar opacities. Findings could represent aspiration, pneumonia, or atelectasis. [**2122-1-14**]: [**2122-1-14**] 8:44 pm URINE Site: NOT SPECIFIED **FINAL REPORT [**2122-1-17**]** URINE CULTURE (Final [**2122-1-17**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [**2122-1-14**] 6:00 pm BLOOD CULTURE x 2 **FINAL REPORT [**2122-1-20**]** Blood Culture, Routine (Final [**2122-1-20**]): NO GROWTH. CXR [**2122-1-19**]: In comparison with study of [**1-15**], the patient has taken a poor inspiration. This may account for the appearance of decreased aeration at the left base in the region of pneumonia that involves the mid and lower lung zones on this side. Mild basilar atelectasis is seen on the right and the central catheter remains in place. CXR [**2122-1-15**]: The tip of the right subclavian PICC line extends to the mid portion of the SVC. It is difficult to determine whether there may still be slight coiling distally HEAD CT WITHOUT CONTRAST [**2122-1-16**]: No evidence for acute intracranial process. Changes consistent with chronic small vessel ischemic disease and age-related cortical atrophy. Brief Hospital Course: Altered mental status: likely was multifactorial due to aspiration pneumonia, hypoxemia, acute renal failure, hypernatremia, all in the setting of baseline dementia. His mental status improved with treatment of these problems however given his severe underlying dementia he did not improve to the point at which he was able to cooperate to take POs. He was dependent on 1 liter of IVF per day to help prevent dehydration. His end stage dementia is severe, and the irreversibility and severity was discussed at legnth with the patient's son [**Name (NI) **]. Palliative care was involved and a plan was made to give the patient some time from his acute illness to evaluate for any recovery. [**Doctor Last Name **] have chosen the end of [**2122-1-14**] as an end date of IVF if the patient does not improve at all with time, and at that point the patient would be transitioned to comfort measures. He was able to state that he felt fine, spoke in [**2-17**] word sentances only when asked, otherwise would be sleeping with his mouth open and appeared comfortable. He would answer "no" to pain, nausea or shortness of breath. He was AOx1, occasionally he would not answer the question "what is your name." PNEUMONIA: Treated with 10 days of vancomycin and cefepime. ASPIRATION: the patient was seen by speech and swallow and was not able to cooperate to initiate a swallow close his lips and make an effort to swallow with his mouth. If he improves this should be readdressed. Atrial fibrillation: Aspirin continued PR, amiodarone and metoprolol could not be given as he was unable to take POs. Medications on Admission: --acetaminophen prn, not to exceed 4 gm in 24 hours --amiodarone 200 mg daily --Tums prn for heartburn --aspirin 325 mg daily --docusate 200 mg qhs --lovastatin 20 mg daily --metoprolol 25 mg twice daily --mirtazepine 15 mg daily at night --multivitamin daily --memantine 10 mg twice daily --senna 2 tabs at bedtime --trazodone 12.5 mg daily at night --trazodone 12.5 mg every six hours as needed for agitation --vitamin D 800u daily --bisacodyl 10 mg pr daily prn --MOM/fleet enema prn constipation Discharge Medications: 1. aspirin 300 mg Suppository [**Date Range **]: One (1) Suppository Rectal DAILY (Daily). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 3. amiodarone 200 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 4. lovastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO daily (). 5. metoprolol tartrate 25 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Priamry Diagnosis: Severe dementia Metabolic encephalopathy Aspiration Pneumonia Hypernatremia Acute renal failure Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital with a high sodium, pneumonia and kidney injury. These have resolved. Please take your medications as prescribed. Followup Instructions: Please follow up with your rehab doctor when you return to rehab: [**Last Name (LF) **],[**First Name3 (LF) **] K. [**Telephone/Fax (1) 719**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9907, 9997

7239, 7247

298, 320

10156, 10156

4113, 4113

10466, 10612

3582, 3601

9391, 9884

10018, 10135

8867, 9368

10292, 10443

3616, 4094

212, 260

348, 2563

4129, 7216

10171, 10268

2585, 3389

3405, 3566

2,079

126,184

18618

Discharge summary

report

Admission Date: [**2131-6-7**] Discharge Date: [**2131-6-14**] Date of Birth: [**2085-11-19**] Sex: F Service: [**Company 191**]-MED DISCHARGE DIAGNOSES: 1. Pancreatitis. 2. Cholecystitis. 3. Biliary leak. CONDITION AT DISCHARGE: Stable. CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is a 45-year-old woman status post laparoscopic cholecystectomy at [**Hospital 1263**] Hospital on the [**2131-5-27**] but returned to [**Hospital 1263**] Hospital on the [**5-4**] with right upper quadrant pain. She had a right upper quadrant ultrasound, abdominal CT and a HIDA scan at [**Hospital 1263**] Hospital which revealed perihepatic fluid suggestive of bile leak thought secondary to pressure from the stone. Patient was started on antibiotics at [**Hospital 1263**] Hospital and an attempt at ERCP which was ultimately unsuccessful occurred. The patient was transferred here on the [**5-8**] and a second attempt at ERCP was performed but this was also unsuccessful. On third successful ERCP was performed on the [**5-9**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with a stent being placed in the common bile duct but, again, the occluding stone could not be removed, however, free flow was observed. The patient had percutaneous tube left in place and was put on nasogastric tube to suction. The patient was initially admitted to the Intensive Care Unit on initial admission and then later transferred to the Medical floor on the [**2131-6-10**]. PAST MEDICAL HISTORY: Notable also for hypertension. OUTPATIENT MEDICATIONS: Included: Cardizem 240 mg q. day. The patient was transferred over on a combination of levofloxacin and cefoxitin of which she had been on a three day course. She was also on pain medications, Percocet and Demerol p.r.n. as well as Diflucan for some oral thrush. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: She has a son and a mother involved in her care. PHYSICAL EXAMINATION: She was a well-developed middle-aged woman in no apparent distress. Temperature was 98.6 on admission, blood pressure 136/95 with heart rate of 110 and she was satting 100% on room air. HOSPITAL COURSE: The patient was intubated during the procedure therefore initiating the Intensive Care Unit stay initially. The patient did receive two units of packed red blood cells while she was in the ICU as well as boluses of normal saline. The patient was extubated on the [**6-10**]. Post extubation she had stable oxygen saturations. Nasogastric tube was maintained for transfer to the floor. On the floor she complained of some pain from a PICC that was placed in her right upper extremity. There was some erythema initially noticed near the site of insertion of the PICC on the [**6-10**] and so hot packs were applied to the site. Decision was then made to discontinue the PICC once access was established with peripheral IV's. A right upper extremity ultrasound was ordered to rule out thrombosis. No thrombosis was seen. The patient was kept NPO for several days during hospital course and then gradually transitioned back to low fat clears and then eventually to house diet prior to discharge. Of note, a repeat CT was ordered at the recommendation of surgery. Repeat abdominal CT revealed the presence of at three walled off fluid collections suggestive of persistent bile as well as suggestion also that her current biliary drain was not optimally placed. Interventional Radiology as well as the CT scan service were consulted as well as Surgery regarding the repositioning of her current drain plus/minus the placement of additional drains, however, given the localization of these walled off areas of fluid, procedures were deemed to be too high risk given that the patient was clinically improving with decreased abdominal discomfort and tolerating p.o.'s and remained afebrile and also had defervesced and had white blood cells that were trending downward. Her cultures also remained negative throughout this period and she was maintained on antibiotics including ampicillin and metronidazole and gentamicin. Also during the patient's hospitalization she had complaints of subjective swelling of the left lower extremity so a lower extremity ultrasound was ordered which was negative for a deep venous thrombosis. Since the patient was net volume positive several liters over the course of hospitalization, suspicion was the edema was possible secondary to some possible fluid overload. The patient was found to have some bronchial breath sounds initially during this admission and was found on chest x-ray to have a right pleural effusion which was found to be stable with a repeat CT and we believe may be secondary to perhaps a reactive process secondary to her pancreatitis. In addition, her platelet count had increased upward. We believe this secondary to reactive thrombocytosis. These values also were seen to have peaked, plateaued with a gradual decline seen on the [**6-10**]. FOLLOW-UP PLANS: In consultation with the ERCP Service as well as the Surgery Service, the plan is to discharge the patient on the [**6-10**], today, with the following follow up. First, the patient will have a repeat abdominal CT at the end of [**Month (only) 205**] to reevaluate the fluid collections, the drain now having been discontinued under fluoroscopic guidance and her current drain being discontinued by fluoroscopic guidance by Radiology on the [**6-10**]. Further she will have a follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Surgery to reassess her after the CT is done. Her appointment has been set with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on the [**6-1**] at 2:00 p.m. in his office at [**Last Name (NamePattern1) 439**], [**Last Name (un) **] Building, [**Location (un) 436**], at [**Telephone/Fax (1) 673**]. Also patient has a follow-up ERCP scheduled with Dr.[**Name (NI) 12202**] office on the [**6-12**] at 6:30 a.m. Office number [**Telephone/Fax (1) 21143**]. In addition, patient has been instructed to follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], for a follow-up appointment this week. DISCHARGE MEDICATIONS: Patient will be discharged on a combination of levofloxacin and metronidazole for an additional two weeks. The levofloxacin at a dose of 500 mg daily during this period and metronidazole at a dose of 500 mg t.i.d. for two weeks. Patient will also be instructed to continue her Protonix at 40 mg daily. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 8442**] MEDQUIST36 D: [**2131-6-14**] 14:33 T: [**2131-6-14**] 16:33 JOB#: [**Job Number 51116**]

[ "112.0", "567.8", "560.1", "577.0", "511.9", "998.11", "518.81", "574.51", "285.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "99.15", "96.07", "51.87", "45.13", "96.71", "97.55" ]

icd9pcs

[ [ [] ] ]

175, 241

6359, 6931

2229, 5037

1613, 1933

2023, 2211

256, 265

5055, 6335

283, 300

329, 1533

1556, 1588

1950, 2000

1,463

172,960

8564

Discharge summary

report

Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-9**] Date of Birth: [**2162-3-13**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 21 year old, otherwise healthy female who was in her usual state of health up until [**2184-2-20**] when she was in a high speed motor vehicle crash and was actually admitted to an outside hospital. Work-up there included negative abdominal imaging despite complaints of left upper quadrant abdominal pain. She was actually ultimately discharged at home after 24 hours. She was doing quite fine and tolerating a diet with minimal pain complaints until the afternoon of [**2184-3-3**]. She was actually at a Mall and noticed the acute onset of bilateral upper quadrant abdominal pain with radiation to her shoulders, followed by a syncopal episode that was witnessed by her mother. The patient had presented to the Emergency Department here at [**Hospital1 69**] and was initially hemodynamically stable with a blood pressure of 120. She was persistently tachycardiac with heart rates between 110 and 120. Admission hematocrit was 33. She was given Morphine for pain control for her abdominal pain and ultimately, her blood pressure dropped into the 80's and 90's. An abdominal CT scan that was obtained on her initial trauma survey work-up revealed extensive amount of bilateral upper quadrant fluid and blood, consistent with likely delayed splenic bleed from a presumed missed splenic lack. The patient was admitted to the Intensive Care Unit and given serial hematocrits under the direction of Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**], the covering trauma attending. Ultimately, the patient's hematocrit after fluid resuscitation, as well as presumed bleeding, dropped to as low as 23.7. The patient ultimately was transfused two units of packed cells and under the direction of Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) **], the patient was taken to the operating room where Dr. [**Last Name (STitle) 519**] performed a splenorrhaphy on [**2184-3-4**]. The intraoperative course was relatively uneventful. The patient's blood loss was minimal. She tolerated the procedure well and was discharged to the Intensive Care Unit postoperatively on [**2184-3-4**]. Serial hematocrits postoperatively never dropped below 29. She did not require any further transfusion. By [**2184-3-5**], she was transferred to the floor. Diet was advanced. She was kept on a PCA for pain control with Demerol. Her home medications were started back and ultimately, her diet was advanced to full by postoperative day number two and three. She was chronically requiring an extensive bowel regimen. This was resumed as she had prior history of constipation. She was given her normal bowel regimen with good effect. Ultimately, by postoperative day number five, the patient was afebrile, tolerating a diet. She was hemodynamically stable with a heart rate under 100; blood pressure 110 to 120 and taking adequate p.o. Examination was benign. Incision was clean, dry and intact. Her discharge hematocrit was 31. At this point, she was transitioned to oral pain medications including Vicodin, no ANSAID. She was continued on her home medications of Lamictal, birth control pills, Klonopin and Effexor. MEDICATIONS ON DISCHARGE: Klonopin. Effexor. Lamictal. Vicodin. Colace 100 mg p.o. twice a day. Dulcolax 10 mg tablets one to two tablets p.r. or p.o. twice a day prn. Milk of Magnesia 30 cc p.o. q. six hours prn. DISPOSITION: The patient's discharge disposition is to home without any services. FOLLOW-UP PLAN: See Dr. [**Last Name (STitle) 519**] in his clinic in approximately two weeks from the time of discharge. There are no staples required for removal as she did have a subcuticular closure to her wound. The patient is allowed to shower and pat the wound dry. She will not bathe for approximately two to three weeks from the time of operation. She was instructed not to undergo any heavy lifting greater than 10 to 20 pounds for the next two to three weeks either. The patient may resume all other home medications as instructed previously. Please note that in the patient's past medical history, this is significant for depression and anxiety. ALLERGIES: None. MEDICATIONS AT HOME: Lamictal. OCP's. Klonopin. Effexor. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Noncontributory. SOCIAL HISTORY: Significant for being single, no children. No intravenous drug abuse. No tobacco history. DISCHARGE DIAGNOSES: Status post motor vehicle crash on [**2184-2-20**], representing with a delayed splenic bleed, secondary to a grade I splenic laceration. She is also status post exploratory laparotomy with splenorrhaphy on [**2184-3-4**]. Depression. Anxiety. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2184-3-8**] 08:26 T: [**2184-3-8**] 20:38 JOB#: [**Job Number 30082**]

[ "780.2", "285.9", "E812.0", "865.09" ]

icd9cm

[ [ [] ] ]

[ "41.2", "41.95" ]

icd9pcs

[ [ [] ] ]

4409, 4427

4595, 5120

3378, 4334

4355, 4392

4447, 4465

154, 3352

4482, 4574

13,786

190,267

11805+11806

Discharge summary

report+report

Admission Date: [**2162-2-9**] Discharge Date: [**2162-3-11**] Date of Birth: Sex: B Service: Neonatology NOTE: This is an interim dictation from [**2162-2-9**] through [**2162-3-11**]. HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: The patient was received on [**2-9**] on ventilator settings of 19/6 with a rate of 18 and FIO2 of 30% to 45%. He had bilateral chest tubes in place; the right one being to water seal. This was for pleural effusions that had been present antenatally on day of life 12. On [**2-12**], the right chest tube was also placed to water seal. On [**2-15**], the left chest tube was taken out with only the right chest tube remaining in place. Due to reaccumulation of fluid on [**2-16**], the patient was re-tapped on the left side. The pleural fluid was sent for analysis and it showed a white blood cell count of 2944, a red blood cell count of 889; the differential was 0 polys, 93 lymphocytes, 6 monocytes, and 1 atypical lymphocytes, with total protein of 2.1, glucose of 78, albumin was 1.3, triglycerides were 396 which supported the diagnosis of chylous effusions. The rate accumulation of fluid was thought to be due to refeeding him with breast milk (see the fluids/electrolytes/nutrition section). Due to reaccumulation, the left chest tube was replaced; and due to increased work of breathing his ventilator settings were increased to 25/6 with a rate of 30. By the following day the right chest tube had been putting out 94 cc, and the left chest tube had put out 14 cc. On [**2-23**] the patient was found to have a pneumothorax on the right side. This was thought to be due to frequency manipulations of the chest tube. Attempts were made to aspirate the pneumothorax that day but were unsuccessful. In an effort to decrease the positive pressure that could be contributing to the pneumothorax, the patient was electively weaned to extubation and then extubated on [**2-25**]. However, his increased work of breathing escalated and he required reintubation the following day. After reintubation, the pneumothorax was again aspirated successfully and confirmed by chest x-ray. His ventilator settings were weaned down over the course of the next couple of days, and the patient was extubated to room air on approximately [**2-28**]. He has remained on room air since then. He does have a baseline work of breathing. Since reinitiation of [**Known lastname 37300**] feeds on [**3-5**] he has had no further reaccumulation of the pleural fluid and no increase work of breathing over his baseline. A chest x-ray was done three days ago which showed no pleural fluid. Our plan is to obtain an ultrasound on Monday to evaluate for the presence of pleural fluid. 2. CARDIOVASCULAR: The patient has had no cardiovascular issues during this month. 3. FLUIDS/ELECTROLYTES/NUTRITION: At the beginning of the month the patient was at total fluids of 140 cc/kg per day. N.p.o. with PM and Intralipid. He was started on feeds on [**2-11**]. He reached full feeds on [**2-16**] and was then changed to breast milk. Shortly thereafter the pleural fluid reaccumulated to the point of requiring chest tube placement, and he was again made n.p.o. He continued on a n.p.o. course of 14 days in an attempt to decrease his pleural effusions. Feeds were restarted again on [**3-5**] with [**Known lastname 37300**] and he has tolerated this without reaccumulation of his pleural fluid. Initially after starting feeds, he had some episodes of feeding intolerance with spitting and vomiting. Therefore, feeds were advanced more slowly. Since then he has had no feeding intolerance issues. He is currently p.o. ad lib [**Known lastname 37300**], taking at least 120 cc/kg per day. Yesterday he took 160 cc/kg per day. Due to the fact that he is on [**Known lastname 37300**], the Pulmonary team has recommended supplementation with vitamins A, D, E, and K, fat-soluble vitamins at 1 cc q.d. 4. INFECTIOUS DISEASE: At the beginning of the month, the patient was on a rule out sepsis with vancomycin and gentamicin secondary to a temperature to 101.7 on [**2-8**]. These antibiotics were discontinued after 48 hours. On [**2-13**] it was noted that his peripherally inserted central catheter line site was erythematous. He was started on a 5-day course of vancomycin and gentamicin. His blood cultures remained negative during that time. On [**2-24**] the patient spiked a temperature to 101.4. A rule out sepsis workup was again done. Gram-positive cocci, likely coagulase-negative Staphylococcus grew out of his blood culture bottle, and he was continued on a course of vancomycin and gentamicin for seven days. Subsequent blood cultures have been negative. 5. HEMATOLOGY: The patient had a blood transfusion on approximately [**2-15**] secondary to a low hematocrit and pallor. Because it was felt that he would be losing immunoglobulins through his chylous effusions, serum quantitative immunoglobulins were drawn on [**2-18**] which showed a low IgG of 238; IVIG 500 mg/kg was given at that time. We are in the process of checking a new set of serum quantitative immunoglobulins and may be giving him another dose of IVIG. His most recent complete blood count was on [**2-24**] which showed a white blood cell count of 46. He was in the middle of his rule out sepsis at this time. His hematocrit was 33.7, and his platelet count was 505. 6. NEUROLOGY: The patient was initially on a Fentanyl drip at the beginning of the month at 3 mcg/kg per minute. This was weaned down slowly. He was then switched over to p.o. neonatal morphine. He was slowly weaned off of this and has been off all sedation since approximately [**2162-3-4**]. He has had no signs of withdrawal. 7. ACCESS: The patient went for Broviac placement approximately two weeks ago. He underwent this procedure without any complications at [**Hospital3 1810**]. The surgery was done by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7860**]. 8. SENSORY: The patient still needs a hearing screen. CURRENT CONDITION: He is in good condition on room air with full p.o. feeds of [**Known lastname 37300**]. PRIMARY PEDIATRICIAN: Name of primary pediatrician is unknown at this time. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**] Dictated By:[**Name8 (MD) 36241**] MEDQUIST36 D: [**2162-3-11**] 16:46 T: [**2162-3-11**] 15:53 JOB#: [**Job Number 37301**] Admission Date: [**2162-1-28**] Discharge Date: [**2162-3-16**] Date of Birth: [**2162-1-28**] Sex: M HISTORY: Baby [**Name (NI) **] [**Known lastname 37302**] is a 46 day old former 38 weeker who was admitted to the Neonatal Intensive Care Unit on his day of birth on [**2162-1-28**]. He was admitted for management of his hydrops fetalis. MATERNAL HISTORY: Mother is a 36 year old G2, Para 0-1, with significant maternal labs for blood type A positive, antibody negative, Hepatitis B negative, RPR nonreactive, rubella immune and Group B Strep negative. The prenatal course was noted for: 1. Level II ultrasound done at 20 weeks gestation which was structurally normal. and there was noted pleural effusions bilaterally in the fetus. This scan was done at Mouth [**Hospital1 **] and on the scan it was noted to have minimal ascites and no pericardial effusion. HOSPITAL COURSE: At delivery, the patient had a weak cry and had increased work of breathing and for those reasons was intubated in the delivery room with a 3.5 ET tube and had initial Apgars of 5 and 7. The admission weight was 4.2 kilograms and the summary of the hospital course by systems is as follows: 1. Respiratory: The patient was on the ventilator with initial settings of 19/6 with a rate of 18 and FIO2 of 30 to 45 percent. He had bilateral chest tubes in place and by the beginning of [**Month (only) 404**], the right chest tube was to water seal. These chest tubes were for pleural effusions that had been present antenatally. On [**2-12**], the right chest tube was also placed in water seal and on [**2-15**], the left chest tube was taken out with only the right chest tube remaining in place. Due to reaccumulation of fluid, on [**2-16**], the patient was retapped on the left side. The pleural fluid was sent for analysis and it showed a white blood cell count of 2,944, a red blood cell count of 889, the differential was zero polys, 93 lymphocytes, 6 monocytes and one atypical lymphocyte with a total protein of 2.1 and a glucose of 78. Albumin was 1.3 and triglycerides were 396, which supported the diagnosis of Chylous effusions. The rate of accumulation of fluid was felt to be due to refeeding him with breast milk and due to the reaccumulation, the left chest tube was replaced. On [**2-23**], the patient was found to have a pneumothorax on the right side. This was thought to be due to frequent manipulations of the chest tube before drainage of the Chylous effusions. Attempts were made to aspirate the pneumothorax that day but were unsuccessful. In an effort to decrease the positive pressure that was probably contributing to the pneumothorax, the patient was electively weaned to extubation and extubated on [**2-25**]. However, his increased work of breathing escalated. He required reintubation the following day. After re-intubation, the pneumothorax was again aspirated successfully and confirmed by chest x-ray. His ventilator settings were weaned down over the course of the next several days and the patient was extubated to room air on [**2-28**]. He has remained on room air since then. He does have a baseline work of breathing. A chest x-ray done on [**3-8**] showed no pleural fluid reaccumulation. This was done since feeds were restarted this time with [**Known lastname 37300**] on [**3-5**]. Finally, a CT scan done on [**2162-3-15**], showed minimal atelectasis with no fluid reaccumulation and normal anatomy with no vascular abnormalities. 2. Cardiovascular: The patient has had no cardiovascular issues on this admission. 4. Fluid, Electrolytes and Nutrition: The patient was tolerating fluids of 140 cc per kilo per day in the beginning part of [**Month (only) 404**] and was NPO being fed with parenteral nutrition and added lipids. He was started on feeds on [**2-11**] and reached full feeds on [**2-16**], at which time he was changed to breast milk. Shortly thereafter, the pleural fluid reaccumulated to the point of requiring a chest tube and at that time also was again made NPO. He continued to be NPO for a 14 day course in an attempt to decrease his pleural effusions. Feeds were restarted again on [**3-5**] with [**Known lastname 37300**] and he has tolerated this without reaccumulation of his pleural fluid. Initially, after starting feeds, he had some episodes of feeding intolerance with spitting and vomiting, therefore feeds were advanced slowly. Since then, he has had no feeding intolerance issues. He is currently p.o. ad lib on demand of [**Known lastname 37300**]. He is taking at least 120 cc per kilo per day averaging closer to 160 cc per kilo per day. Due to the fact that he is on [**Known lastname 37300**], the Pulmonary team had recommended supplementation with Vitamins A, D, E and K. These fat soluble vitamins should be at 1 cc q. day. However, due to a hospital shortage of A, D, E, K, he was not started in the Neonatal Intensive Care Unit at this time on those vitamins. The patient does have reflux symptoms but has been growing well and is not currently on any reflux medications. 4. Infectious Disease: At the beginning of the month of [**Month (only) 404**], the patient was on a rule out sepsis with Vancomycin and Gentamicin secondary to a temperature of 101.7 F., on [**2-8**]. These antibiotics were discontinued after 48 hours. On [**2-13**], he had a peripheral intravenous central catheter line site that was noted to be edematous and erythematous. He was started on a five day course of Vancomycin and Gentamicin. His blood cultures remained negative during that time. On [**2-24**], the patient spiked a temperature to 101.4 F. A rule out sepsis was performed again. Gram positive cocci, likely coagulase negative Staphylococcus grew out of his blood pressure and he completed a course of Vancomycin and Gentamicin for seven days. Subsequently blood cultures have been negative today. 5. Hematology: The patient had a blood transfusion on approximately [**2-15**], secondary to a low hematocrit and pallor. Because it was felt that he would be losing immunoglobulins through his Chylous effusions, serum quantitative immunoglobulins were drawn on [**2-18**], which showed a low IgG of 238, IVIG 500 mg per kilogram was given at that time. His most recent complete blood count was on [**2-24**], which showed a white blood cell count of 46. He was in the middle of a rule out sepsis at that time. His hematocrit was 33.7 and his platelet count was 505. This was the most recent hematocrit obtained on this patient. Repeat serum immunoglobulins just prior to discharge were in the normal range. 6. Neurology: The patient was initially on a Fentanyl drip and continued through the beginning part of [**Month (only) 404**] in which he was weaned off of Fentanyl. He was then switched over to p.o. neonatal morphine. He has slowly weaned off this and has been off all sedation since approximately [**2162-3-4**]. He has had no signs or symptoms of withdrawal. 7. Access: The patient went for a Broviac placement approximately two weeks ago. He underwent this procedure without any complications at [**Hospital3 1810**] in [**Location (un) 86**]. The surgery was done by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7860**]. His Broviac was discontinued on [**2162-3-16**]. 8. Sensory: A) Audiology: A hearing screen was performed with an automated auditory brain stem response. Results were that the baby passed his hearing screen in both ears. CONDITION AT DISCHARGE: He is in good condition on room air, taking full p.o. feeds of [**Known lastname 37300**] ad lib on demand. DISCHARGE INSTRUCTIONS: 1. He is to follow-up with his primary pediatrician, who is Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 37303**] this week. The phone number is [**Telephone/Fax (1) 37304**]. 2. He is also to follow-up with the Primary Pulmonology Team in approximately one month; that physician's name is Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**]. He can be reached at the Pulmonary Clinic at [**Hospital3 1810**] of [**Location (un) 86**]. CARE AND RECOMMENDATIONS: 1. Feeding at discharge: Would continue feeding [**Known lastname 37300**] ad lib p.o. on demand. We are filling out a letter of medical necessity and providing the family with a prescription for [**Known lastname 37300**] due to his medical condition. 2. State Newborn Screen status was normal. 3. Immunizations received in the hospital included Hepatitis B vaccine as well as receiving a dose of Synagis. 4. Immunizations recommended: 1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks; 2) born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or with preschool siblings or, 3) with chronic lung disease. We chose to give Synagis at this time due to patient's continued baseline work of breathing and the potential for having effusions reaccumulate and feeling that medical necessity for RSV prophylaxis was indicated in this special case. Whether or not the Synagis is to be continued will be at the discretion of the primary pediatrician. 2. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENTS SCHEDULED: 1. With Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 37303**] for one week. 2. Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] for one month. DISCHARGE DIAGNOSES: 1. Respiratory distress. 2. Bilateral Chylous pleural effusions. 3. Hydrops fetalis. 4. Staphylococcus coagulase negative sepsis. [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**] Dictated By:[**Last Name (NamePattern1) 37229**] MEDQUIST36 D: [**2162-3-15**] 15:21 T: [**2162-3-15**] 15:45 JOB#: [**Job Number 37306**]

[ "771.8", "038.19", "V50.2", "V30.01", "778.0", "457.8", "779.3", "770.2", "769" ]

icd9cm

[ [ [] ] ]

[ "34.04", "64.0", "96.72", "99.15", "96.04", "95.43", "34.91" ]

icd9pcs

[ [ [] ] ]

16451, 16852

7461, 14098

14247, 14740

14766, 14778

244, 7442

14793, 15182

15210, 16430

70,251

128,149

53079

Discharge summary

report

Admission Date: [**2141-5-15**] Discharge Date: [**2141-5-15**] Date of Birth: [**2089-8-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hematochezia Major Surgical or Invasive Procedure: Flexible sigmoidoscopy History of Present Illness: 51-year-old male with DM, HLD, and GERD who is s/p routine colonoscopy [**2141-5-3**] presenting with BRBPR. Pt states that he had colonoscopy for routine cancer screening on [**2141-5-3**] without complications. A polyp was found in the distal sigmoid colon that was removed. He did not notice any BRBPR or melena until day of admission when he had two episodes of BRBPR. Describes frank blood without stool that was painless. He had hemorrhoids in the past but has not had difficulties with constipation recently. He does note that he had been drinking more alcohol lately. He had gone on a business trip from Wed to Fri where he was drinking about 5 glasses of wine each night. He also has been taking ibuprofen recently for headaches (approximately three 200mg tablets daily). At the ED, initial vitals were 98.4 95 151/101 14 99% RA. He had another episode of frank rectal bleeding (250-300cc) in the ED. GI was called who felt that bleeding was likely from polypectomy site and recommended tap water enemas for flexible sigmoidoscopy. . On arrival to the MICU, pt reports feeling well. Denies abdominal pain, N/V, chest pain, SOB, headache, lightheadedness. Past Medical History: DM GERD HLD Social History: Lives with wife; they have three children. Works as an attorney. Quit smoking in [**2110**]. Usually minimal alcohol intake but recently drank more during business trip. No recreational drug use Family History: Great grandfather: gastric cancer No family hx of colon cancer Physical Exam: On discharge: T 98.1, HR 100s - 110s, 146/86, 17, 99% on RA General: Alert, oriented x 3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Pertinent Results: Labs upon admission: [**2141-5-14**] 11:15PM BLOOD WBC-7.2 RBC-4.27* Hgb-13.5* Hct-39.3* MCV-92 MCH-31.6 MCHC-34.3 RDW-12.6 Plt Ct-217 [**2141-5-14**] 11:15PM BLOOD Neuts-62.2 Lymphs-32.0 Monos-4.0 Eos-1.5 Baso-0.3 [**2141-5-15**] 01:26AM BLOOD PT-9.4 PTT-31.4 INR(PT)-0.9 [**2141-5-14**] 11:15PM BLOOD Glucose-228* UreaN-15 Creat-0.9 Na-140 K-4.2 Cl-103 HCO3-24 AnGap-17 [**2141-5-15**] 05:24AM BLOOD CK(CPK)-65 [**2141-5-14**] 11:15PM BLOOD cTropnT-<0.01 [**2141-5-15**] 05:24AM BLOOD CK-MB-1 cTropnT-<0.01 [**2141-5-15**] 05:24AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 Labs upon discharge: [**2141-5-15**] 05:24AM BLOOD WBC-5.8 RBC-3.79* Hgb-11.3* Hct-34.9* MCV-92 MCH-29.9 MCHC-32.5 RDW-12.6 Plt Ct-187 [**2141-5-15**] 05:24AM BLOOD Glucose-187* UreaN-14 Creat-0.8 Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 Flex Sig: [**2141-5-15**]: At 15 cm a 2cm clot was noted over an ulcerated polypectomy site. The area was treated with clips and gold probe cautery with successful hemostasis. Spot ink was also applied to the area for tattooing (endoclip, thermal therapy, injection) Otherwise normal sigmoidoscopy to distal sigmoid colon Recommendations: The polypectomy site was the likely source of bleeding. Hemostasis was achieved. Avoid nsaids for the next 14 days. Follow up with Dr. [**First Name (STitle) 572**]. Brief Hospital Course: 51 year old man with type 2 diabetes mellitus, hyperlipidemia, and GERD who presented with hematochezia after recent polypectomy (completed on [**2141-5-3**]). His hematocrit trended from 39 -> 34 -> 29. He was admitted to the MICU, but remained hemodynamically stable throughout his hospital course with exception of sinus tachycardia with ambulation. He was given intravenous hydration. Pathology from the polypectomy revealed an adenoma with high grade dysplasia. Repeat flexible sigmoidoscopy on [**2141-5-15**] was completed which showed clot at site of prior polypectomy. Further excision of the base of the prior polyp was completed with cautery and clips. The area was tatooed. His diet was advanced and he was discharged with follow up with his PCP and his [**Date Range **]. Follow up hematocrit on [**2141-5-15**] after the sigmoidoscopy was 29. It was recommended that he stay one more night in the hospital to ensure that his hematocrit was stable and bleeding has stopped, but the patient elected to leave against medical advice. Patient was informed of possible risks of leaving against medical advice including but not limited to hemorrhage, hypotension, shock, MI, and death. He has persistent headaches after drinking alcohol. Recommended avoiding alcohol and NSAIDS for 2 weeks to prevent further bleeding. Patient will follow up with his PCP regarding work up for his chronic headaches. His oral diabetes mellitus medications were held and he was controlled on insulin during hospitalization. Home medications restarted on discharge. He was full code for this admission. Medications on Admission: GLIPIZIDE - 5 mg Tablet - one Tablet(s) by mouth daily METFORMIN - 500 mg Tablet - one Tablet(s) by mouth in the am , one in the evening and two at bedtime PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. metformin 500 mg Tablet Sig: One (1) Tablet PO 1 tab in AM, 1 tab in PM, 2 tabs at bedtime. 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day as needed for headache: do not drive or operate heavy machinery while taking this medication. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Post-polypectomy bleed Colon polyp with high grade dysplasia Secondary: Diabetes Mellitus Hyperlipidemia GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because of bloody stool, which was a result of your recent polypectomy. The pathology report from the removed polyp returned as "adenoma with high grade dysplasia." This pathology infers a high risk of progression to colon cancer, therefore our gastroenterologists preformed a flexible sigmoidoscopy to re-examine the polypectomy site. During the procedure they removed as much as possible from the base of the polyp and also marked the area with dye for repeat procedures. You will need to follow up closely with your [**Date Range **] Dr. [**First Name (STitle) 572**] in the next coming weeks. Please avoid ibuprofen and all other NSAIDS due to risk of further bleeding. Please take tylenol as needed for headache, if the tylenol does not help, you can take tramadol. Please avoid alcohol as this is worsening your headaches. Your hematocrit (marker of anemia) dropped from 39 to 29 during your hospitalization. We recommended you stay one night more in order to ensure that the bleeding does not continue. We would like to monitor you further and check additional blood counts. However, you decided to leave AGAINST MEDICAL ADVICE. If you have any further bleeding, lightheadedness, or abdominal pain, please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] immediately or come back to the emergency department. Followup Instructions: Dr. [**First Name (STitle) 572**] will schedule follow up with you, but if you do not hear from him by the end of this week, please call to confirm a follow up appointment. Dr. [**Last Name (STitle) 2204**] [**2141-5-19**] at 12PM Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 2205**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "211.3", "V15.82", "401.9", "272.4", "998.11", "250.00", "E878.8", "530.81" ]

icd9cm

[ [ [] ] ]

[ "48.23", "39.98" ]

icd9pcs

[ [ [] ] ]

6433, 6439

3828, 5436

324, 349

6603, 6603

2493, 2500

8163, 8738

1824, 1889

5791, 6410

6460, 6582

5462, 5768

6754, 8140

1904, 1904

1918, 2474

272, 286

3083, 3805

377, 1555

2514, 3066

6618, 6730

1577, 1591

1607, 1808

55,308

131,281

38662

Discharge summary

report

Admission Date: [**2130-6-13**] Discharge Date: [**2130-6-30**] Date of Birth: [**2103-6-21**] Sex: F Service: SURGERY Allergies: Monistat 1 / gabapentin Attending:[**First Name3 (LF) 598**] Chief Complaint: pedestrian struck Major Surgical or Invasive Procedure: [**2130-6-14**] 1. Washout and debridement open fracture right ulna down to and inclusive of bone. 2. ORIF right ulnar fracture with Monteggia dislocation of radial head. 3. IM nail right humeral shaft fracture. History of Present Illness: This patient is a 26 year old female who is brought in byEMS for pedestrian struck by car. History is per EMS and hermother as she is lethargic. Apparently, her mother heard her being struck by a car, came outside and saw her on the ground unresponsive. Per EMS, she had improvement of mental status upon their arrival. She did have difficult access, however, and thus an IO was placed in her left tibia in transport. On arrival to the [**Hospital1 18**] ED, she is moaning and localizing to pain, with an overall GCS of 8. Past Medical History: Neck fx 2 yrs ago as a result of an mvc treated non-op, depression, miscarriage years ago at 5 months Social History: Per psychology note [**6-18**]: Born oldest of two, has 13 yr old half sister, her mother raised both of them on her own. Was a happy kid, but difficult during teen years. They moved around a lot, seem to have had considerable relational and financial tumult during her childhood. Finished high school but was not a good student. Started radiology program, dropped out, then finished hair styling school, but stopped this due to MVC 2 yrs ago. Has had boyfriends, broke up with one in past year, also miscarriage several months ago. Recently moved again, is living with her mother. [**Name (NI) **] been a more and less heavy drinker, depending on her mood, has h/o DWI in past few months. Question of oxycontin abuse over past 2 yrs. Remote hx of experimentation with other drugs, but no abuse/dependence. Family History: non-contributory Physical Exam: On arrival to [**Hospital1 18**] ED: HR: 130 BP: 120/93 Resp: 22 O(2)Sat: 100% Normal Constitutional: Minimally responsive HEENT: Large right cephalhematoma with 6 cm scalp laceration, right pupil 3 mm left pupil 2 mm Chest: Clear to auscultation Cardiovascular: Tachycardic, regular Abdominal: Soft, tender right upper quadrant, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: Right elbow with gross deformity and swelling, 2+ radial pulse, IO in left tibia Skin: Abrasions over left flank, right upper quadrant, scapula Neuro: Somnolent, in response to pain moans, will answer her name, moves all extremities equally Psych: Somnolent, GCS 8 Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Physical examination upon discharge: [**2130-6-30**]: vital signs: t=98.6, hr=100, bp=137/81, oxygen sat. 95% room air General: Conversant, moving gingerly CV: ns1, s2, -s3, -s4 LUNGS: clear ABDOMEN: soft, non-tender EXT: + dp bil., no calf tenderenss bil., no pedal edema, mild edema right arm, + rad. bil., fingers warm bil., decreaseed sensation dorsal surface of right hand, clean suture line right shoulder, suture line post. aspect of right lower arm clean with no exudate, localized tenderness right knee with limited knee flexion, limited ROM right shoulder, wrist, and elbow., full ROM left arm, shoulder, and wrist NEURO: pleasant, conversant Pertinent Results: Labs on admission: [**2130-6-12**] 10:01PM WBC-15.4* RBC-4.59 HGB-12.7 HCT-40.6 MCV-88 MCH-27.6 MCHC-31.3 RDW-12.5 [**2130-6-12**] 10:01PM PT-11.0 PTT-31.5 INR(PT)-1.0 [**2130-6-12**] 10:01PM PLT COUNT-362 [**2130-6-12**] 10:01PM FIBRINOGE-354 [**2130-6-12**] 10:00PM PH-7.34* COMMENTS-GREEN [**2130-6-12**] 10:00PM GLUCOSE-108* LACTATE-2.0 NA+-140 K+-4.3 CL--101 TCO2-30 [**2130-6-12**] 10:00PM HGB-14.1 calcHCT-42 O2 SAT-76 CARBOXYHB-4 MET HGB-0 [**2130-6-12**] 10:00PM freeCa-1.07* [**2130-6-12**] 10:01PM LIPASE-96* [**2130-6-12**] 10:01PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2130-6-12**] 10:01PM UREA N-11 CREAT-0.9 CT C-SPINE W/O CONTRAST Study Date of [**2130-6-12**] 9:56 PM IMPRESSION: Nondisplaced fractures of the right transverse processes of C7 and T1 with no evidence of other fractures or prevertebral soft tissue swelling. CT HEAD W/O CONTRAST Study Date of [**2130-6-12**] 9:56 PM IMPRESSION: 1. Punctate foci of intraparenchymal hemorrhage in the right inferior frontal and bilateral temporal lobes. 2. Subarachnoid hemorrhage within the temporal lobes bilaterally and the left inferior frontal lobe. 3. Large right frontoparietal subgaleal hematoma with foci of gas consistent with laceration. 4. No evidence of herniation. No acute fractures. CT ABD & PELVIS WITH CONTRAST Study Date of [**2130-6-12**] 9:57 PM IMPRESSION: 1. Linear hypodensities in the right lobe of the liver and the caudate lobe consistent with liver lacerations. Additionally, a small amount of hemorrhage is noted surrounding the inferior vena cava inferior to the liver as well as in the intrahepatic portion of the IVC. No active extravasation is identified. 2. Adjacent to the region of hemorrhage surrounding the inferior vena cava, the medial lobe of the right adrenal gland is not clearly identified and injury to this structure cannot be excluded. 3. Fractures involving the right scapula and right proximal and distal humeral diaphysis. Fractures of the right C7 and T1 transverse processes are better assessed on the concurrent CT of the cervical spine. 4. Low lying endotracheal tube for which slight retraction is recommended. CT UP EXT W/O C Study Date of [**2130-6-13**] 1:00 AM IMPRESSION: 1. Right scapular fracture 2. Comminuted right humerus fracture as described above. 3. Right radial head fracture. 4. Small ground glass focus in right upper lung lobe, non specific, but compatible with a small lung contusion. WRIST(3 + VIEWS) LEFT PORT Study Date of [**2130-6-13**] 5:16 AM IMPRESSION: No fracture. KNEE (2 VIEWS) RIGHT Study Date of [**2130-6-20**] 6:01 PM AP and two lateral non-standing views of the right knee are normal. No fracture, bone destruction, joint space narrowing, osteophytes, or effusion. [**2130-6-26**]: right shoulder films: Satisfactory appearance status post ORIF. [**2130-6-26**]: right humerus: Satisfactory appearance status post ORIF. [**2130-6-26**]: chest x-ray: FINDINGS: As compared to the previous radiograph, all monitoring and support devices have been removed. There is no pneumothorax, no pleural effusion. The lung parenchyma shows normal structure and transparency. There is no evidence of pneumonia. Normal size of the cardiac silhouette. Normal appearance of the hilar and mediastinal structures. Brief Hospital Course: Upon arrival to the emergency room, the patient was found to be moaning and showing some localization to pain. Her overall GCS was 8, for which she was intubated. She was initially tachycardic to the 130s (SBP >100), for which she received 3L crystalloid, with subsequent improvement. She underwent radiographic imaging and was reported to have sustained an intercerebral hemorrhage, liver laceration, C7/T1 transverse process fracture, and a right comminuted humerus/ulna and scapular fracture. Because of the extent of her injuries, she was admitted to the intensive care unit for monitoring. She was evaluated by the Neurosurgical service, with recommendations for non-operative management of her intracranial hemorrage. She was transfused 2u PRBC for a decrease in hematocrit (41->26.5), which subsequently stablized at 30. Follow-up recommendations in outpatient clinic recommended. On HD# 2, she was taken to the operating room by the Orthopedic Surgery team and underwent ORIF of the right ulnar fracture and intra-medullary nailing of the right humeral shaft fracture. Postoperatively, she was extubated, but subsequently required re-intubation due to hypersomnolence and inadequate ventilation. She was transfused an additional 2u PRBC for a postoperative decrease in hematocrit (30->19), again increasing appropriately to 26. Subcutaneous heparin was restarted. On HD#3, with the use of Precedex drip, she was successfully extubated. She showed mild confusion and emotional lability but was protecting her airway well and ventilating well. Over the next 24 hours, her hematocrit again trended down (26->21), for which she received another 2u PRBC with appropriate response and subsequent stablization thereafter. On HD#4 her mental status continued to improve. She passed a speech/swallow evaluation and tolerated a regular diet well. Her home medications were restarted, although the Klonopin dosing was decreased secondary to sedation. Her Foley was removed without difficulty in voiding. She was transferred to the floor on HD #5. On the floor she had hallucinations and delusions and therefore psychiatry was consulted. It was thought that these were likely manifestations of delirium, which was due to both her head injury and to medications given to treat pain and agitation. It was recommended that her clonazepam be discontinued and her ativan be tapered off. This was done and she was started on zyprexa [**Hospital1 **] for agitation. On [**6-20**]-6/27 she expressed suicidal ideation and a 1:1 sitter was initiated. Upon re-evalation on [**6-21**] it was determined that the patient did not meet criteria for involuntary psychiatric hospitalization at this point and that was not actively suicidal and the 1:1 sitter was discontinued. She continued to progress. Her vital signs remained stable. She was evaluated by physical therapy and an exercise regimen was started. Her surgical pain was not well controlled and the pain service was consulted for recommendations. Her pain medication was changed and she reported a decrease in her pain and was able to participate in ADL's. On HD #16 she was preparing for discharge, but was noted to have a localized erythematous rash on her neck and became tachycardic. Initiallly, she was afebrile, but later spiked a temperatiure to 102. Blood cultures, urine, and a chest x-ray were completed. The blood culture results are still pending. Urine specimen showed contaminated specimen. Her wound sites were inspected and the thought was that the increased temperature source was arising from her right arm operative site and she was started on vancomycin. Orthopedics was reconsulted and after inspection of her arm, recommended outpatient follow-up and a 2 week course of keflex. At discharge, she was afebrile and hemodynamically stable. She was tolerating a regular diet and voiding without difficulty. Her mother has been at her bedside providing additional support and assistance. She is being discharged home with instructions to follow-up with Orthopedics, Neurology, and cognitive neurology. She will also schedule an appointment for outpatient occupational/ physical therapy. Medications on Admission: oxycodone 10mg Q 4-6 hrs PRN for neck pain, Klonapin 3-4mg PRN anxiety, effexor 100mg daily(recently increased) Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Senna 1 TAB PO BID:PRN constipation 4. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN Pain Per CPS recs. Hold for sedation or O2sat<93% or RR<12 RX *oxycodone 30 mg 1 Tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 5. Lidocaine 5% Patch 1 PTCH TD DAILY Shoulder Pain Apply to shoulder as needed RX *Lidoderm 5 % (700 mg/patch) apply patch to right shoulder every 12 hours on , off every 12 hours Disp #*16 Not Specified Refills:*0 6. Cephalexin 500 mg PO Q6H Duration: 12 Days last dose 7/17 RX *cephalexin 500 mg 1 Capsule(s) by mouth every six (6) hours Disp #*48 Capsule Refills:*0 7. OLANZapine 2.5 mg PO BID:PRN anxiety or agitation RX *olanzapine 2.5 mg 1 Tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 8. Outpatient Physical Therapy evaluation for ROM right arm, right wrist 9. Outpatient Occupational Therapy please evaluate ROM right arm, elbow, and shouler 10. Venlafaxine 50 mg PO BID Discharge Disposition: Home Facility: [**Hospital 38**] [**Hospital 731**] Rehabilitation and Nursing Center - [**Location (un) 38**] Discharge Diagnosis: trauma: s/p pedestrian struck Injuries: -3cm laceration over L temporal region w/ underlying subgaleal hematoma -R frontal and b/l temporal punctate intraparenchymal hemorrhage -L frontal and b/l temporal subarachnoid hemorrhage -Liver lacerations involving the right and caudate lobes -R scapula fracture -R proximal and distal humerus fractures -R mid-shaft ulna fracture, open -R radial head dislocation -R C7 and T1 transverse process fractures Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after being struck by a car. You sustained an injury to your head, fractures to your right arm and shoulder blade, fractures to the bony processes of 2 of your vertebrae, and an injury to your liver. Regarding your liver injury: You should go to the nearest Emergency department if you suddenly feel dizzy or lightheaded, as if you are going to pass out. These are signs that you may be having internal bleeding from your liver injury. Your liver injury will heal in time. It is important that you do not participate in any contact sports or any other activity for the next 6 weeks that may cause injury to your abdominal region. Avoid aspirin producs, NSAID's such as Advil, Motrin, Ibuprofen, Naprosyn, or Coumadin for at least 1-2 weeks unless otherwise directed as these can cause bleeding internally. Regarding your head injury: Take your pain medicine as prescribed. Exercise should be limited to walking; no lifting, straining, or excessive bending. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (colace) while taking narcotic pain medication. Unless directed by your doctor, DO NOT take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen, etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: New onest of tremors or seizures. Any confusion, lethargy or changes in mental status. Any numbness, tingling, weakness in your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2130-7-6**] at 2:20 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2130-7-6**] at 2:40 PM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 18**] - Cognitive Neurology Unit Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Dr. [**Last Name (STitle) 1702**] office is working on a follow up appointment within a month to follow up on your head injury. You will be called with the appointment date and time. If you have not heard from the office or have questions please call the office number listed below. Phone: ([**Telephone/Fax (1) 1703**] Department: RADIOLOGY When: THURSDAY [**2130-8-10**] at 1:15 PM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2130-8-10**] at 2:15 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please keep your appointment with your Physiatrist for next week. Please schedule an appointment with outpatient occupational/physcial therapy. The telephone number is #[**Telephone/Fax (1) 44928**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2130-7-5**]

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icd9cm

[ [ [] ] ]

[ "79.32", "96.71", "79.42", "86.59", "79.11", "86.28" ]

icd9pcs

[ [ [] ] ]

12208, 12321

6850, 11022

300, 514

12817, 12817

3484, 3489

14760, 16642

2037, 2055

11185, 12185

12342, 12796

11048, 11162

13002, 14737

2070, 2821

243, 262

2838, 3465

542, 1070

3504, 6827

12832, 12978

1092, 1196

1212, 2021

79,923

147,293

53779

Discharge summary

report

Admission Date: [**2157-7-20**] Discharge Date: [**2157-7-26**] Date of Birth: [**2094-3-28**] Sex: F Service: MEDICINE Allergies: latex Attending:[**First Name3 (LF) 1115**] Chief Complaint: Intubation s/p IP procedure Major Surgical or Invasive Procedure: bronchial stent removal bronchoscopy History of Present Illness: 63 year old woman with h/o stage I lung cancer, GERD, HTN, thromboembolic disease, ex-smoker, tracheobronchomalacia with recent discharge from MICU on [**7-14**] s/p Y-stent removal and replacement by IP, now being transferred from the PACU after new Y stent removal. The patient was discharged from [**Hospital1 18**] after placement of endobronchial Y stent on [**2157-6-13**], discharged to rehab, then transferred back to [**Hospital1 18**] on [**7-4**] for worsening dyspnea and audible stridorous respirations. She improved with BiPAP. Eval by IP revealed cervicomalacia. The patient underwent removal of Y-stent and placement of a new longer stent reaching up into cervical trachea. She remained stridorous and wheezy, making her a poor candidate for surgical intervention as the cause of these paroxysms are less likely to be associated with tracheobronchomalacia in the absence of improvement with stent placement. In addition, she had an episode of significant respiratory distress requiring bedside bronchoscopy, revealing significant mucous plugging along the length of the stent and at carina. She was started on mucomyst therapy, continued albuterol, ipratropium, mucinex, hypertonic saline nebulizer treatments, and BiPAP, and was able subsequently to tolerate the stent with no subsequent episodes concerning for mucous plugging. ENT was consulted for evaluation of potential vocal cord dysfunction as etiology of symptoms, and found no evidence to support this diagnosis. They did, however, note a Left true / false vocal fold mass, likely granulation but given h/o smoking could not rule out neoplastic process. The patient was discharged to pulmonary rehab for a planned two week trial with the new Y stent. . She represented today as an outpatient for stent removal. Per IP, the stent was removed, with a lot of surrounding granulation tissue. She had significant vocal cord swelling. She developed significant laryngospasm during bronch, so she was intubated in the OR by anaesthesia. She received 10 IV dexamethasone and transferred to the MICU. . On arrival to the MICU, she is intubated and sedated. Past Medical History: GERD TBM HTN Pulmonary embolus [**2151**], no longer anti-coagulated (developed peri-malignancy) Tracheobronchomalacia s/p endobronchial Y stent [**2157-6-13**] stage I lung cancer LUL, s/p thoracotomy wedge resection [**2153**] s/p CCY s/p achilles tendon repair right bilat carpal and cubital tunnel repair chronic headaches s/p cervical fusion chronic low back pain anxiety depression Social History: Prior to recent admission [**5-/2157**], the patient lived at home. 10 yr pack y/o smoking, rare etoh, now lives at rehab. Family History: CAD, COPD, Lung CA Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: 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, finger-to-nose intact . DISCHARGE EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly 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, finger-to-nose intact Pertinent Results: ADMISSION LABS: [**2157-7-20**] 03:50PM BLOOD WBC-10.2 RBC-3.78* Hgb-11.5* Hct-34.8* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.3 Plt Ct-291 [**2157-7-20**] 03:50PM BLOOD PT-11.1 PTT-28.5 INR(PT)-1.0 [**2157-7-20**] 03:50PM BLOOD Glucose-153* UreaN-17 Creat-0.9 Na-139 K-4.3 Cl-99 HCO3-31 AnGap-13 [**2157-7-20**] 03:50PM BLOOD Calcium-9.0 Phos-2.5*# Mg-2.3 . DISCHARGE LABS: . MICRO: [**2157-7-21**] Urine culture: E. coli >100,000 organisms/ml . IMAGING: [**2157-7-20**] CXR: In comparison with study of [**7-5**], the tip of the endotracheal tube lies approximately 4.5 cm above the carina, little change in the appearance of the heart and lungs. Pleural scarring with mild atelectatic changes is again seen at the left base. . [**2157-7-22**] CXR: There are low lung volumes. Cardiac size is top normal. The size is accentuated by the low lung volumes. NG tube tip is out of view below the diaphragm. ET tube is in a standard position. Bibasilar atelectasis are stable. There is no evident pneumothorax. Brief Hospital Course: 63 year old woman with stage I lung cancer s/p wedge resection, cervicomalacia s/p Y stent removal, intuabted for significant airway and laryngeal swelling after procedure requiring ICU stay for respiratory stabilization. Patient will require physical therapy and pulmonary rehab. Active Issues: # Cervicomalacia and laryngeal swelling: S/p Y stent removal complicated by laryngeal swelling and granulation tissue seen on bronch, requiring intubation. Patient was treated with dexamethasone 10mg IV Q6h for 3 days ([**Date range (1) 36193**]). She was taken back to the OR on [**7-22**] for a repeat bronch which showed some supraglottic edema and was successfully extubated. Per IP, plan is to repeat bronchoscopy in [**3-4**] weeks. Patient will also follow-up with ENT for vocal cord lesion. . #Oral ulcer: the patient noted a painful oral ulcer on her left posterior gum. She was advised to use salt water gargles. Should the ulcer persist for greater than a week, further evaluation is advised. # UTI: Pan-sensittive E. coli >100,000 organisms/ml. Patient treated with ciprofloxacin for 3 days. Inactive Issues: # Diabetes: Continued sliding scale. . # GERD: Continued omeprazole and ranitidine. . # Hypertension: Continued metoprolol, hold lasix. . # Hyperlipidemia: Continued simvastatin. . # Depression: Continued citalopram. Transitional Issues: Patient will need to follow-up with IP for cervicomalacia and ENT for vocal cord lesion. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H:PRN fever/pain 2. acetylcysteine *NF* 20% (200mg/mL) 4 cc nebulized tid Reason for Ordering: Per interventional pulm/MICU; the patient has essentially no mucociliary clearance due to a 13cm tracheal stent, failing other mucolytic therapy spoke with pharmacy @ [**Pager number 110376**] regarding this 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing, sob 5. Benzonatate 200 mg PO BID 6. Calcium Carbonate 500 mg PO BID 7. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN cough 8. Citalopram 20 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 11. Furosemide 80 mg PO DAILY hold for sbp <100 12. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 13. Ipratropium Bromide Neb 1 NEB IH Q6H 14. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety Hold for sedation, rr<10, change in mental status 15. Metoprolol Tartrate 50 mg PO BID hold for hr <60, sbp <100 16. Mucinex *NF* (guaiFENesin) 1,200 mg Oral [**Hospital1 **] Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 17. Omeprazole 20 mg PO BID 18. Racepinephrine 0.5 mL NEB Q8H:PRN coughing/breathing attack 19. Ranitidine 300 mg PO HS 20. Senna 1 TAB PO BID:PRN constipation 21. Simvastatin 40 mg PO DAILY 22. Sodium Chloride 3% Inhalation Soln 15 mL NEB TID Supplied by Respiratory 23. Vitamin D [**2145**] UNIT PO DAILY 24. Hydrocodone-Acetaminophen (5mg-500mg [**1-31**] TAB PO Q6H:PRN pain) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN dyspnea 3. Benzonatate 200 mg PO BID 4. Citalopram 20 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 7. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 8. Metoprolol Tartrate 50 mg PO BID 9. Omeprazole 20 mg PO BID 10. Ranitidine 300 mg PO HS 11. Senna 1 TAB PO BID:PRN constipation 12. Simvastatin 40 mg PO DAILY 13. Acetylcysteine 20% *NF* 4 cc Other TID 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 15. Calcium Carbonate 500 mg PO BID 16. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN cough 17. Furosemide 80 mg PO DAILY Hold for SBP<100 18. Hydrocodone-Acetaminophen (5mg-500mg [**1-31**] TAB PO Q6H:PRN pain 19. Ipratropium Bromide Neb 1 NEB IH Q6H 20. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety 21. Mucinex *NF* (guaiFENesin) 1,200 mg Oral [**Hospital1 **] Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 22. Racepinephrine 0.5 mL IH Q8H:PRN coughing/breathing attack 23. Vitamin D [**2145**] UNIT PO DAILY 24. Nystatin Oral Suspension 5 mL PO QID swish and swallow Hold in mouth for as long as possible 25. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat Discharge Disposition: Extended Care Facility: Country Estates of [**Location (un) 15116**] Discharge Diagnosis: Laryngotracheomalacia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 13143**], You were admitted to the [**Hospital1 69**] for removal of a Y-stent placed earlier this month to treat your laryngotracheomalacia. The removal was complicated by larygospasm, a tightening of the throat that can occur during procedures involving the airway, which required intubation and respiratory support in the medical intensive care unit after the procedure. You were in the ICU for three days before you were extubated and transferred to the general medicine floor for further observation. At the time of your transfer your no longer required oxygen at all times. The interventional pulmonology service would like to follow up in [**3-4**] weeks when your airway has had time to heal. If you feel uncomfortable breathing at any time before this appointment, please seek care immediately. The following changes were made to your home medications: 1. Start Nystatin It was a pleasure participating in your care at [**Hospital1 18**]. Followup Instructions: Name: [**First Name11 (Name Pattern1) 26540**] [**Initials (NamePattern4) **] [**Last Name (un) 110377**], MD When: Wednesday [**8-10**] at 12:30 Address: [**Location (un) 110378**], [**Location **],[**Numeric Identifier 110379**] Phone: [**Telephone/Fax (1) 110380**] Department: OTOLARYNGOLOGY-AUDIOLOGY When: THURSDAY [**2157-8-18**] at 9:45 AM With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2157-8-18**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "33.78", "33.23", "96.71", "96.04", "96.05" ]

icd9pcs

[ [ [] ] ]

9818, 9889

5353, 5635

294, 332

9955, 9955

4331, 4331

11110, 12036

3054, 3075

8471, 9795

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6832, 8448

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360, 2486

6477, 6694

4347, 4681

9970, 10082

2508, 2897

2913, 3038

24,629

114,632

7947+55898

Discharge summary

report+addendum

Admission Date: [**2188-5-14**] Discharge Date: [**2188-6-9**] Date of Birth: [**2118-1-9**] Sex: M Service: PODIATRY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18867**] Chief Complaint: Right heel necrotic gas gangrene Major Surgical or Invasive Procedure: [**5-14**] s/p R heel debridement [**5-20**] s/p R angio [**5-23**] s/p R AK [**Doctor Last Name **]-DP [**5-29**] s/p R heel debridement & VAC History of Present Illness: The patient is a 70-year-old male who presented to the emergency room with a chief complaint of a painful right heel with fevers and chills. The patient is a diabetic with previous history of ulceration. X-rays taken at that time showed gas in the subcutaneous tissue. The patient was taken to the operating room by Dr. [**Last Name (STitle) **]. Past Medical History: HTN, DM, PVD, CABG '[**84**], creat 1.0-1.4, LVEF >55%, mild MR; episodes of Wenckebach [**5-25**] Social History: N/A Family History: N/A Physical Exam: Gen: A&Ox3 CV: RRR Pulm: CTA b/l Abd: S/NT/ND, BS Present LE: Nonpalpable pedal pulses, cellulitis Painful Right heel Abscess. The subcutaneous tissue was [**Doctor Last Name 352**], necrotic, and foul-smelling in appearance with purulent drainage. The entire soft tissue in this region appeared to have been necrotic. Pertinent Results: [**2188-5-14**] 06:10AM GLUCOSE-475* UREA N-40* CREAT-1.3* SODIUM-131* POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-21* ANION GAP-20 [**2188-5-14**] 06:10AM CALCIUM-8.7 PHOSPHATE-2.4* MAGNESIUM-1.7 IRON-12* [**2188-5-14**] 06:10AM calTIBC-159* VIT B12-349 FOLATE-11.4 FERRITIN-606* TRF-122* [**2188-5-14**] 06:10AM TSH-1.5 [**2188-5-14**] 06:10AM WBC-22.3* RBC-3.04* HGB-8.8* HCT-26.9* MCV-89 MCH-28.9 MCHC-32.6 RDW-13.5 [**2188-5-14**] 06:10AM PLT COUNT-216 [**2188-5-14**] 06:10AM PT-13.1 PTT-29.3 INR(PT)-1.1 [**2188-5-14**] 01:11AM COMMENTS-GREEN TOP [**2188-5-14**] 01:11AM LACTATE-2.1* [**2188-5-14**] 01:00AM GLUCOSE-421* UREA N-43* CREAT-1.4* SODIUM-129* POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16 [**2188-5-14**] 01:00AM WBC-20.3*# RBC-3.09* HGB-9.1*# HCT-26.9*# MCV-87# MCH-29.4 MCHC-33.8 RDW-13.6 [**2188-5-14**] 01:00AM NEUTS-90.6* LYMPHS-4.8* MONOS-4.5 EOS-0 BASOS-0 [**2188-5-14**] 01:00AM PLT COUNT-230 Brief Hospital Course: 1. Right Diabetic Foot Infection/Ulceration 70 yo M after presenting to ED c gas in tissue on x-ray was taken to the OR immediately for debridement. The subcutaneous tissue at this time was noted to be [**Doctor Last Name 352**], necrotic, and foul-smelling in appearance with purulent drainage. The entire soft tissue in this region appeared to have been necrotic. A sterile probe was used to see where this purulence probed to. The purulence probed laterally, and a lateral incision was made. This wound was tracked laterally to the lateral-most edge of the right heel. Medially, however, the wound probed more proximally, and an incision was made which extended beyond the medial-most border of the calcaneus. A rongeur was then used to remove all devitalized tissue from the wound. At this time, it should be noted that the wound appeared necrotic and foul-smelling with copious amounts of drainage. A 15 blade was used to further debulk the tissues that appeared devitalized. A pulse irrigator was then used to irrigate the wound. After the wound had been irrigated, it was packed open with ortho solution-soaked gauze. This was then dressed with sterile gauze, Kling, an abdominal pad, and an Ace bandage. A vascular evaluation was obtained and continuous Doppler ultrasonography and pulse volume recordings were obtained, revealing normal inflow into the left lower extremity with moderate right SFA and tibial disease. The patient was therefore taken by vascular to the OR for a Right below knee popliteal to anterior tibial bypass graft with reversed saphenous vein graft. He was initially taken to the VICU for recovery. After stabilized, he was transferred back to floor status. Now after revascularization, he had an open wound under his right heel that is extensive with exposed calcaneus. At this point, an Incision and drainage of right foot abscess and Partial calcanectomy right foot was performed. Afterwards, this infection became stabilized and it was decided at that point to apply a VAC dressing. VAC dressing and wound care was performed for the duration of his hospital stay. He was maintained on IV antibiotics that were tapered to his wound cultures and was d/c'ed on IV Zosyn for broad coverage as he did initially have gas gangrene. Plastics was also consulted for flap/closure options and it was felt that there were no current viable options until a longer period of VAC therapy. Pt responded very well to VAC therapy and plastics plan was to cont VAC for an additional 1-2 weeks with f/u with plastics as an out-pt for future flap considerations after improved granulation tissue. Pt will also f/u c Dr. [**Last Name (STitle) **] within one week. He was sent to rehab with a PICC on Zosyn IV and VAC dressing changes. 2. Peripheral Vascular Disease A vascular evaluation was obtained and continuous Doppler ultrasonography and pulse volume recordings were obtained, revealing normal inflow into the left lower extremity with moderate right SFA and tibial disease. The patient was therefore taken by vascular to the OR for a Right below knee popliteal to anterior tibial bypass graft with reversed saphenous vein graft. He was initially taken to the VICU for recovery. After stabilized, he was transferred back to floor status. He recovered without complication from his bypass graft with vascular service following. 3. Diabetes Mellitus Type 1 The patient presented with very labile blood glucose levels and [**Last Name (un) **] was therefore consulted. His lantus was increased on [**5-26**] due to hyperglycemia. On [**5-31**] BG was 109 mg/dL in am and before lunch BG was 92 mg/dL. [**6-1**] Low overnight. But pt preferred no changes to his regimen. On [**6-2**]- his lantus was decreased to 30 for persistant am CBG lows. His lantus was further decreased to 27 on [**6-5**] and then on [**6-6**]-still decreased to 25 tonight. He remained stable. 4. HTN The patient was maintained on his outpatient regimen as well as a peri-op beta blocker. An Echo was obtained which showed an LVEF >55%, mild MR. Pt had episodes of Wenckebach [**5-25**], cardiology evaluated and felt there was no necessary intervention. He had no other episodes or complications throughout his hospital stay. 5. Chronic Renal Insufficiency The pt remained at his baseline creatinine throughout his hospital stay of [**12-29**].4. Medications on Admission: Alphagan gtt OS", lisinopril 20, Lopressor 50", HCTZ 25, Zocor 10, Lantus 34, B12, Fe, Soothe gtt OS Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 4. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every eight (8) hours for 2 weeks. Disp:*2 weeks* Refills:*0* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. Disp:*5 vials* Refills:*2* 8. Humalog 100 unit/mL Solution Sig: Per insulin sliding scale sliding scale Subcutaneous per sliding scale: Please print out sliding scale for rehab. Disp:*2 vials* Refills:*2* 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Lifecare of [**Location (un) 2199**] Discharge Diagnosis: [**5-14**] s/p R heel debridement [**5-20**] s/p R angio [**5-23**] s/p R AK [**Doctor Last Name **]-DP [**5-29**] s/p R heel debridement & VAC Discharge Condition: Stable Discharge Instructions: Make and keep all follow up appointments. Take all medication as prescribed. PICC CARE per PICC Protocol Zosyn IV through PICC Line Non-weight bearing to right lower extremity VAC Dressing to change every 3 days, keep at 125mmHg continuous suction. Followup Instructions: 1. Podiatric Surgery: Dr. [**Last Name (STitle) **] within one week of discharge at [**Telephone/Fax (1) 543**] 2. Plastic Surgery: Dr. [**Last Name (STitle) **] [**Hospital1 18**]/Plastic Surgery [**Location (un) 830**], 707E [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 20278**] [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**] DPM 48-121 Completed by:[**2188-6-6**] Name: [**Known lastname **],[**Known firstname 389**] M Unit No: [**Numeric Identifier 4737**] Admission Date: [**2188-5-14**] Discharge Date: [**2188-6-9**] Date of Birth: [**2118-1-9**] Sex: M Service: PODIATRY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4353**] Addendum: Patient remained in hospital over the weekend secondary to rehab/insurance issues. There were no incidents or changes. The VAC dressing was changed on [**2188-6-9**] and pt is ready for d/c to rehab when bed is available. Discharge Disposition: Extended Care Facility: Lifecare of [**Location (un) 654**] [**First Name11 (Name Pattern1) 2892**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DPM 48-121 Completed by:[**2188-6-9**]

[ "V45.81", "414.00", "280.0", "401.9", "440.23", "682.7", "250.71", "040.0", "593.9" ]

icd9cm

[ [ [] ] ]

[ "86.04", "77.88", "88.48", "99.04", "38.93", "86.22", "39.29" ]

icd9pcs

[ [ [] ] ]

9847, 10079

2357, 6723

347, 492

8417, 8425

1387, 2334

8722, 9824

1027, 1032

6874, 8143

8250, 8396

6749, 6851

8449, 8699

1047, 1368

275, 309

520, 868

890, 990

1006, 1011

32,725

131,525

2520

Discharge summary

report

Admission Date: [**2193-8-19**] Discharge Date: [**2193-9-22**] Date of Birth: [**2125-4-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Left Foot Ulcer Major Surgical or Invasive Procedure: Tunnelled Hemodialysis Catheter Placement Angiogram of Left Leg BKA History of Present Illness: The patient is a 67 yo M with PMH of HTN/Hyperlipidemia/DM on insulin, CAD s/p multiple MIs and CABG in [**2187**], PVD, CVA, atrial fibrillation on coumadin, ESRD s/p LRRT in [**2181**] on cyclosporine, and CHF with LVEF=30% recently admitted in [**2-/2193**] for volume overload/CHF now presents with infected heel ulcer. . During admission in [**2-/2193**], his heel ulcers were noted and evaluation at that time was negative for infection. He was seen by podiatry, vascular and wound care. He was discharged to rehab and during this time, he states that the wound worsened. he also continued to follow-up with vascular surgery as outpatient. He was treated with Keflex for nearly one month for apparent infection of the left heel ulcer. Two weeks ago, he was started on ciprofloxacin and has just finished a course. On Sunday ([**8-18**]) prior to admission, while standing on the foot, he started bleeding profusely through the bandage. His wife was able to stop the bleeding and he did not seek medical attention. Then, today on day of admission ([**8-19**]), he went to a scheduled appointment to have hyperbaric oxygen treatment for his ulcers, but at that appointment, his left foot ulcers were noted to be necrotic with large eschar and foul smell. He was sent the the OSH ED and then transferred to [**Hospital1 18**] due to his history of care here. . At the OSH ED hreceived IV levofloxacin. In [**Hospital1 **] ED, T 96.3, HR 68, BP 99/59, RR18, 97%RA. He received Vanc X 1, cyclosporine, lipitor, and morphine 4 mg X 1. Pulses were dopplerable. . On the floor, he reports feeling fatigued but otherside at baseline. He checks temp every day and is always at 96.7. He denies and fever, chills, abd pain, N/V, cough. He does occasionally feel pain in his feet in certain positions. No diarrhea, CP, palpiatations. ROS toherwise negatve. Past Medical History: -Type II DM -Hypertension -CAD s/p MIx5-PCI to mid RCA, s/p CABG [**2187**] -Chronic systloic congestive heart failure EF 30% Systolic and Diastolic dysfunction -Living Related Renal transplant [**2181**] (Son was donor) -CVA [**2189**] with residual word slurring -history of atrial fibrillation -Peripheral Vascular Disease s/p several tibial bypasses in the left leg; Open digital amputation of first toe of the left foot -CHF "since [**2178**]" -Hyperlipidemia -Adenomatous colonic polyps-removed -cataracts, vitreous hemorrhage L eye -CVA with residual slurred speech/right sided weakness Social History: Social history is significant for tobacco: 1 1/2ppdx20 yrs, quit in [**2165**]. He is retired, married and currently at a long term care facility. Occasional ETOH use. He uses a walker to ambulate but has been unable to do so recently [**2-23**] heel ulcers. Family History: There is no family history of premature coronary artery disease or sudden death. Mother: died [**Name (NI) **] CA at age 80. Physical Exam: PE: % O2 Sats Gen: pleasant, NAD HEENT: Clear OP, MM slightly dry NECK: Supple, No LAD, No JVD CV: irregular, irreg. II/VI systolic murmur LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: 2+ edema. 2+ DP pulses BL by doppler SKIN: L foot: 2 large, deep ulcerations, larger extending over 10 cm in length with eschar and red, beefy edges R foot: healing small, quater sized ulcer NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2193-8-19**] 10:20PM WBC-7.0 RBC-2.87* HGB-8.0* HCT-25.5* MCV-89 MCH-28.1 MCHC-31.6 RDW-19.6* CRP-173.3* SED RATE-76* CK-MB-NotDone cTropnT-0.35* CK(CPK)-52 GLUCOSE-85 UREA N-146* CREAT-3.7*# SODIUM-131* POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-21* ANION GAP-21* [**2193-8-21**] 06:15AM BLOOD cTropnT-0.45* proBNP-GREATER THAN [**Numeric Identifier **] REFERENCE VALUES VARY WITH AGE, SEX, AND RENAL FUNCTION AT 35% PREVALENCE, NTPROBNP VALUES < 450 HAVE 99% NEG PRED VALUE >1000 HAVE 78% POS PRED VALUE SEE ONLINE LAB MANUAL FOR MORE DETAILED INFORMATION PERFORMED AT WEST STAT LAB [**2193-8-21**] 06:15AM BLOOD calTIBC-178* Ferritn-397 TRF-137* UNILAT LOWER EXT VEINS LEFT Study Date of [**2193-8-20**] 8:28 AM IMPRESSION: No evidence of left lower extremity DVT. ART DUP EXT LO UNI;F/U Study Date of [**2193-8-21**] 8:35 AM IMPRESSION: 1. Aortobiiliac disease. 2. There is more distal disease as well including tibial disease,the proximal aortoiliac disease and noncompressible vessels do not allow an indication of the exact locations of additional arterial disease involving both lower extremities. Brief Hospital Course: Vascular Surgery Course: Mr. [**Known lastname 12863**] is a 68 year old man with CKD V now s/p failed renal transplant who was initially admitted to the medical service on [**2193-8-20**] with osteomyelitis of his left heel. He required transfer to the MICU for progressive renal failure resulting in reinitiation of renal replacement therapy (CVVH) and withdrawl of immunosuppressants, worsening hypotension requiring norepinephrine infusion, a brief GI bleed which has yet to be worked up, and progression of his left heel ulcer ultimately culminating in a below-the-knee amputation on [**2193-9-16**] at which time he was transferred from the MICU service to the CVICU. Post-operatively, he had been doing well with a resolution in his oxygen requirement. He was initially put on vancomycin, ciprofloxacin, and metronidazole for empiric coverage for his osteomyelitis. He was noted to have a pre-operative blood culture from [**2193-9-14**] which grew VRE; linezolid was written for on [**2193-9-20**] though the patient has yet to receive a dose. Also of note, he had been on a heparin drip for anticoagulation given his atrial fibrillation; the morning of his re-transfer, his PTT was noted to be >150 seconds and his heparin drip was discontinued at 11am. At approximately 1pm today, the patient was noted to be unresponsive shortly after being given a tray of food. He was presumed to have aspirated and was emergently intubated. A subsequent bronchoscopy found masticated food partciles in his airways which were suctioned out. For ongoing management of his respiratory failure, he was transferred back to the MICU service. PLAN: # Diabetic ulcer: Initial concern for ostemyolitis by xray. ESR/CRP 76/173. The patient was initially started on vancmycin and zosyn which was quickly changed to vancomycin/unasyn. Vascular surgery and podiatry consults were placed. Blood cultures were negative. Superficial wound cultures were positive for MRSA. Podiatry noted bone exposure and recommended [**Hospital1 **] dressing changes but felt intervention was not possible without vascular assessment. LENIs were w/o evidence of DVTs and non-invasive vascular studies demonstrated on doralis pulse and only monophasic flow through the L popliteal artery. The patient underwent an angiogram of the left leg which showed good blood flow to the left heel. All abx were stopped on [**9-11**]. Went to the OR on [**9-16**] with Vascular surgery for BKA. #Acute on chronic renal failure/ESRD s/p failed renal transplant: The patient was s/p LRRT in [**2181**] and was on immunosuppressive therapy for this transplant. On arrival, the patient was found to be in renal failure, with a creatinine of 3.7. Urine lytes were consistant with a pre-renal etiology. The patient's diurectic therapy (Bumex) was discontinued. The patient was followed by transplant team and his kidney function worsened over his initial hospital course. Renal ultrasound was concerning for graft rejection vs. ATN. His home regimen of immunosupression (prednisone, cyclosporin, azathioprine) was decreased. It was felt that the patient's renal function was related to his poor Cardiac output and it was suspected that improving his cardiac output would improve renal function. Diuresis with high dose IV lasix was attempted over 3 days, and the patient was placed [**Female First Name (un) **] 1L fluid restriction. Renal function continued to decline with a max creatinine to 4.1 and hemodialysis was initiated on [**8-27**]. Pt was transitioned to CVVH because of need to offload more fluid in the setting of hypotension. Pt required levophed inorder to maintain pressures of SBP > 80. . # Atrial Fibrillation/Anticoagulation: The patient was on coumadin as an outpatient but was found to be supratherapeutic on with an INR of 4.2 on admission. It was felt that his might be related to recent changes in his antibiotic therapy. Coumadin was held on presentation pending possible procedures. As his INR trended down, the patient was placed on a heparin gtt, but this was discontinued on [**8-25**] when the patient was reported to have an occult blood positive and possibly melanotic stool. Heparin was discontinued and GI was consulted. The patient remained on a subcutaneous heparin with the goal of restarting therapeutic anticoagulation after his amputation. . # Anemia/GI Bleed: The patient has a documented baseline hematocrit of 29-30. At the time presentation, the patient's HCT was 25. Given the patient's poor cardiac fucntion and possible perfusion related renal failure, the patient was transfused 2 units of PRBCs witn an appropriate rise in and HCT to 29. On [**8-25**] the patient was reported to have a large, heme positive stool with the question of melena. The GI service was consulted. Twice a day PPI therapy was initiated. Hematocrit was stable and endoscopy was deferred given the patient's other health risks. . # Hypertension/CAD/Aortic Stenosis: EKG on admission with new QRS prolongation and left axis. Repeat EKG without interval changes and there was low suspicion for acute CAS. Troponins were elevated but flat and felt to be high due to renal failure. pro-BNP was >7000. Echocardiogram showed worsening of the patient's LVEF from 25-30% to 20-25% as well as a worsened aortic stenosis. The patient was initially maintained on his home antihypertensive regimen of Imdur. Cardiology was consulted regarding medical management of his CHF and afterload reduction reduction with hydralazine was recommended. Over the hospital course, the patient he was intermittantly hypotensive requiring both imdur and hydralazine to be largely non-administered. . # DM: The patinet was continued on home lantus dose. He was allowed to do his own carb counting for the insulin sliding scale. Blood sugars were relatively well controlled. FIRST MICU COURSE: 1. Hypotension: unclear how accurate this was given his likely diffuse vascular disease. An arterial line for more accurate hemodynamic monitoring was placed and correlated with the cuff pressures indicating that the hypotension was likely a true [**Location (un) 1131**]. Initially were concerned for sepsis vs CHF as cause of hypotension but cultures failed to grow any significant bacteria and and ECHO showed markedly decreased LV function so thought low BPs likely caused poor forward flow in the setting of CHF. All anti-hypertensives were held. Patient was started on CVVH to off-load the extra fluid and levophed was started simultaneously to keep his pressures at goal SBP of 80. . 2. Hypothermia: Pt was pan-cultured to assess for sepsis. Grew MRSA from a wound culture and yeast from a urine culture. Was initially treated with antibiotics including vancomycin and ceftazidime, but as cultures from blood never grew any bacteria and patient remained stable and afebrile for several days these were d/c'd. Thought likely [**2-23**] CVVH fluid being cold. . 3. Hypoxia: likely pulmonary edema in the setting of acute-on-chronic systolic and diastolic CHF. Improved with fluid taken off with CVVH. . 4. Osteomyelitis: wound swab with MRSA. Abx as above. Vascular surgery was consulted and took patient to the OR for BKA on [**9-16**]. . 5. Acute blood loss anemia due to GI bleed: hematocrit remained stable in ICU. Held warfarin. . 6. Atrial fibrillation: CHADS2 score of 5 indicating high risk for future cardioembolic phenomenon. Planned to resume warfarin following amputation. . 7. CKD V: renal transplant now considered failed and he is back on hemodialysis. Started on CVVH to take off excess fluid. . 8. Thrombocytopenia: etiology unclear, though could be due to azathioprine (recently stopped); PF4 antibody negative . Nutrition: low Na/diabetic/renal diet . Glycemic Control: initially on glargine 18units [**Month (only) **] + ISS. Sugars were uncontrolled (250s) so was started on inusulin gtt . Lines: PICC line, dialysis catheter . Prophylaxis: . DVT: pneumoboots . Stress ulcer: pantoprazole . Communication: with patient, wife [**Name (NI) 2013**] [**Name (NI) 12863**], and daughter . Code status: Full code . SECOND MICU COURSE: . ## Shock: Differential included septic shock, adrenal insufficiency, and cardiogenic shock. Started early goal directed therapy for septic shock. Patient required 6 pressors (neo, levophed, dobutamine, dopamine, vasopressin, and epi) to keep MAP >60. Received 2units pRBCs with appropriate inc in hct (23->29), and one bag of platelets. Started on vanc (MRSA), dapto (VRE), zosyn and cipro (hospital acq PNA), flagyl (c. diff. ID consulted recommended tobramycin, flagyl, linezolid, meropenem, fluconazole. Left Hd line was pulled and cultured. Pan cultures were sent. TTE to eval for endocarditits as well as cardiogenic shock was no change with EF 15% and no tamponade or vegetations. [**Last Name (un) 104**] stim was abnormal and treated with 50mh Hydrocrotisone Q6H. Pan-cultured including C diff. . ## Respiratory failure: due to acute aspiration event, though it's unclear what triggered him to aspirate since his mental status had reportedly been normal and he had been on room air. Now complicated by shock. Intubated for airway protection s/p aspiration. . ## Osteomyelitis: - On multiple abx. Had new ulcer on lateral right foot. Vascular surgery continued to follow. . ## CKD V: CVVH necessary for fluid balance but needed to be stopped transiently in setting of shock requiring multiple pressors. . ## Acute-on-chronic systolic CHF: volume being managed by CVVH; on amiodarone for beta blockade. TTE in setting of shock showed no change with EF15%, no vegetations, and no tamponade. . ## Chronic atrial fibrillation: - on amiodarone for rate control - holding heparin due to coagulopathy . ## Coagulopathy: likely due to heparin infusion - recheck PTT and cont holding heparin; likely doesn't need heparin bridging and can simply resume warfarin once stable. . ## Thrombocytopenia: presumed due to azathioprine therapy, though this has persisted in spite of withdrawl of azathioprine - P4 negative . ## DM2: Started on insulin drip as sugars not well-controlled on ISS in setting of steroids and shock. . ## Acute blood loss anemia due to GI bleed - no active bleeding - cont ppi and readdress once more stable . ##Ventricular fibrillation: On [**2193-9-22**] around 11am Mr. [**Known lastname 12863**] went into pulsless Vfib. A code was called and CPR was done. After three shocks, amiodarone, and 30 minutes of compressions he was perfusing and more or less stable with a perfusing rhythm with frequent runs of VT. He was placed on an amiodarone drip. A family meeting was held and it was decided that he would be DNR once his eldest son arrived from [**Name (NI) 1727**]. He was very unstable thereafter and was on maximum doses of pressors. Ultimately he went into a pulseless Vfib and then asystole and passed with his family at the bedside. Medications on Admission: Aspirin EC 81 once a day. Imdur 30 mg once a day. Pantoprazole 40 mg daily Prednisone 5 mg daily Atorvastatin 10 mg daily Cyclosporine Modified 50 mg [**Hospital1 **] Azathioprine 75 mg daily Docusate Sodium Iron 325 mg TID Bumetanide 1 mg daily Miconazole Nitrate 2 % Powder Topical TID Warfarin 5 mg daily Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily). Trazodone 50 mg HS PRN Lantus 18 U [**Name (NI) **] Pt calorie counts and determines his Humalog needs. Epogen 20,000 unit/mL QMonday. Discharge Disposition: Expired Discharge Diagnosis: Sepsis, ventricular fibrillation, heart failure, renal failure, adrenal insuff Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none Completed by:[**2193-9-22**]

[ "V45.81", "427.41", "440.24", "440.4", "427.31", "578.1", "038.9", "414.00", "272.4", "790.92", "585.6", "428.43", "584.9", "424.1", "276.1", "250.60", "287.5", "996.81", "507.0", "403.91", "427.5", "995.92", "707.14", "428.0", "285.1", "518.81", "730.27", "255.41", "785.52", "V12.72", "V58.67", "438.19" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.91", "99.05", "84.17", "00.14", "38.95", "99.62", "39.95", "96.04", "96.71", "99.60", "88.48" ]

icd9pcs

[ [ [] ] ]

16471, 16480

4999, 15895

329, 398

16602, 16612

3867, 4976

16665, 16700

3190, 3318

16501, 16581

15921, 16448

16636, 16642

3333, 3848

274, 291

426, 2279

2301, 2897

2913, 3174

12,008

100,853

24608

Discharge summary

report

Admission Date: [**2166-3-25**] Discharge Date: [**2166-4-2**] Date of Birth: [**2111-5-16**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2074**] Chief Complaint: STEMI (Chest Pain) Major Surgical or Invasive Procedure: Cardiac Catherization Swan Ganz Catheter Arterial line History of Present Illness: 54F HTN, tobacco abuse, h/o pulmonary embolism, neurofibromatosis, alcohol abuse, transferred to [**Hospital1 18**] for cath from OSH following diagnosis of STEMI. Usual state of health until the morning prior to admission, had substernal chest pain, [**7-26**], with nausea and diaphoresis. Patient waited 2-3 hours, however, pain persisted, and so she called EMS, who brought her to [**Hospital1 487**] and was found to have ST elevations in I,II, V2-3. Patient was transferred to [**Hospital1 18**] for catheterization. Upon arrival to cath lab, pressures were low 100s SBP. Total occlusion LAD, 90% in OM3, RCA 70%. LAD was stented w/ heparin coated stents X 2 and Reopro such that Plavix could be DC'd if needed in the setting of acute GI bleed. Following intervention, patient dropped SBP to 70s, and was started on dopamine drip, w/ HR in 120s-130s, and bolused w/ 1400cc NS. Heparin was stopped, and no additional IIB/IIIA inhibitor given due to history of BRBPR X few days and decreased hematocrit. Of note patient had BRBPR by rectal exam in cath lab, as well as at home on tissue. No blood in toilet bowl at home, no melena or hematemesis. Does have nausea and vomiting but able to tolerate liquids. Has lost 60 pounds over last 6 months. Patient has had claudication after walking 10 feet, sleeps on [**1-17**] pillows for "breathing". Past Medical History: - Neurofibromatosis - Hypertension - Pulmonary embolism [**2158**] - Malignant nerve sheath tumor (s/p removal from left anterior chest wall [**6-19**] and radiation [**2166**]) - Depression - Hypothyroidism - Pneumonia in [**2-18**] - Hypercalcemia - Alcoholism - Schizoaffective disorder Social History: Tobacco: 1PPD Alcohol: Quit 8 years ago, but history of abuse. Family History: Neurofibromatosis in multiple family members with history of early death Physical Exam: 97.3 84 93/60 20 99%RA General: No acute distress, lying in bed, comfortable. Diffuse neurofibromas from head to toe. Cafe [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28584**] spots in axillae. CV: S1, S2, regular, no murmurs rubs or gallops. JVD not appreciable Lungs: CTAB, no wheezes, rales or rhonchi Abdomen: Active bowel sounds, Soft, NT, ND, no rebound or guarding. Scar on left anterior chest wall. Extremities: Warm, no clubbing cyanosis or edema. DP and PT pulses 2+ bilaterally. Neuro: Alert and oriented X 3, strength and sensation grossly intact. Walks with walker as per baseline. Pertinent Results: [**2166-3-25**] 11:09PM URINE HOURS-RANDOM [**2166-3-25**] 11:09PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2166-3-25**] 10:14PM TYPE-ART PO2-93 PCO2-29* PH-7.37 TOTAL CO2-17* BASE XS--6 [**2166-3-25**] 10:14PM O2 SAT-97 [**2166-3-25**] 10:12PM TYPE-MIX [**2166-3-25**] 10:12PM O2 SAT-69 [**2166-3-25**] 10:06PM SODIUM-141 POTASSIUM-3.6 CHLORIDE-115* [**2166-3-25**] 10:06PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2166-3-25**] 10:06PM HCT-32.2* [**2166-3-25**] 07:56PM TYPE-ART RATES-/16 PO2-77* PCO2-23* PH-7.44 TOTAL CO2-16* BASE XS--5 INTUBATED-NOT INTUBA [**2166-3-25**] 07:56PM K+-3.5 [**2166-3-25**] 07:56PM HGB-9.4* calcHCT-28 O2 SAT-96 [**2166-3-25**] 07:40PM WBC-10.2 RBC-3.27* HGB-9.7* HCT-27.7* MCV-85 MCH-29.6 MCHC-35.0 RDW-16.5* [**2166-3-25**] 07:40PM NEUTS-79.6* LYMPHS-15.6* MONOS-3.5 EOS-0.9 BASOS-0.3 [**2166-3-25**] 07:40PM ANISOCYT-1+ MICROCYT-1+ [**2166-3-25**] 07:40PM PLT COUNT-262 [**2166-3-25**] 07:40PM PT-19.1* PTT-150* INR(PT)-2.4 [**2166-3-25**] 06:56PM TYPE-ART PO2-164* PCO2-18* PH-7.54* TOTAL CO2-16* BASE XS--3 INTUBATED-NOT INTUBA [**2166-3-25**] 06:56PM K+-3.1* [**2166-3-25**] 06:56PM O2 SAT-98 [**2166-3-25**] 06:50PM GLUCOSE-137* UREA N-19 CREAT-0.9 SODIUM-140 POTASSIUM-3.1* CHLORIDE-111* TOTAL CO2-15* ANION GAP-17 [**2166-3-25**] 06:50PM CK(CPK)-215* [**2166-3-25**] 06:50PM CK-MB-32* MB INDX-14.9* cTropnT-0.41* ECG Study Date of [**2166-3-25**] 7:28:12 PM Baseline artifact. Sinus rhythm. Ventricular ectopy with ventricular couplets. Left axis deviation. Anterior Q waves with a late transition consistent with prior anterior myocardial infarction. Diffuse non-specific ST-T wave changes. No previous tracing available for comparison. C.CATH Study Date of [**2166-3-25**] 1. Selective coronary angiography of this right dominant system revealed multi vessel disease. The LMCA contained mild, diffuse disease. The LAD was totally occluded after the first diagonal branch. The LCX was without flow limiting disease but gave off an OM3 branch with 90% lesion. The RCA contained a 70% proximal lesion. 2. Resting hemodynamics revealed an elevated mean PCPW of 25mmHg with a low cardiac index of 2.3 l/min/m2. 3. Left ventriculography was not performed. 4. Successful PTCA/stenting of the proximal/mid LAD with 2.5x18mm and 2.5x18mm overlapping Hepacoat stents. Final angiography revealed no residual stenosis, no dissection and TIMI-3 flow (see PTCA comments). 5. Distal aortography revealed severe bilateral iliac and common femoral disease procluding the potential placement of IABP. 6. At completion of the case, the patient's HCT was noted to be 28, down from 40 at case start. A rectal exam revealed gross blood. The patient's blood pressure transiently dropped to SBP in the 80s, but responded to fluid boluses, blood transfusion, and dopamine. The patient left the lab hemodyamically stable on low dose dopamine. ECHO Study Date of [**2166-3-26**] EF 25- 30% There is moderate to severe regional left ventricular systolic dysfunction with akinesis of the antero-septum and entire distal LV including the apex. The remaining segments are hyperdynamic. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad, with a superimposed trivial pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: 54F neurofibromatosis, HTN, hypothyroidism, recent PNA, transferred here w/ ?STEMI, revasc LAD, hypotension post intervention. * HYPOTENSION: Initially hypotensive in cath lab following procedure. Required initiation of dopamine, then addition of levophed on hospital day 2. Of note, CI was never low (>3.0) and SVR was intermittently 600s-700s during episodes of hypotension (SVR increased appropriately with uptitration of pressors). Although this was physiology consistent with sepsis or adrenal insufficiency, patient was never febrile, CXR and pan-cultures were negative, and cosyntropin stimulation yielded appropriate secretion of cortisol. Rec'd one unit of blood on HOD2 for Hct 29->35->32. Spontaneously weaned off of dopamine on hospital day 3 without complications. Indeed, patient became hypertensive to SBP160s, and was started easily on carvedilol and lisinopril at that point. Intermittently, however, patient continued to have episodes of asymptomatic hypotension while sleeping at night. Given this clinical picture, patient's initial hypotension post STEMI was thought to be secondary to cardiogenic shock despite Swan-Ganz values, and as patient's cardiac function recovered, blood pressure improved appropriately. * ACID BASE DISTURBANCE: When patient arrived, had AG of 14, potassium of 3.1 and ABG 7.54/18/164 suggesting a respiratory alkalosis w/ mixed gap and non gap metabolic acidemia. This may have been due in combination to cardiogenic shock and volume repletion with saline. RTA Type II was felt to be a possibility, and bicarb load was considered- however, this was not attempted given patient's cardiac issues and need for euvolemic status. As patient's clinical status improved, gap continued to close and bicarb normalized, and other than hypotension early during course, patient never had any signs or symptoms localizing metabolic disturbance. Of note patient's laboratory values often fluctuated within hours, suggesting large fluid shifts (intra->extravascular) of unclear etiology. Further, cosyntropin stim revealed no adrenal insufficiency that would explain patient's condition. Given resolution without clear clinical etiology, further workup of this issue was deferred to outpatient. * ISCHEMIA: Occluded LAD reopened with hepacoat stents, OM3 and RCA significant unrevascularized disease. Patient was started on ASA, Plavix, Lipitor 80, and carvedilol and lisinopril as hypotension resolved. Although further intervention could be pursued, given high grade malignant peripheral nerve sheath tumor and multiple nodules noted on MRI and CT at [**Hospital1 2025**] and [**Hospital3 1443**], it was felt that patient would be best served with workup and thorough staging and prognostic evaluation of malignancy to further determine utility of revascularization. Followup was arranged with Dr. [**Last Name (STitle) 5686**] in [**Hospital1 487**] within one month of discharge. * Pump: EF 30% bedside echo w/ anterior hypokinesis post cath. Hypotensive but weaning dopamine, continue IV fluids for now. Wedge ~20 in lab. As noted above, as hypotension improved, patient was started on carvedilol and lisinopril to improve cardiac remodeling. * Rhythm: While on dopamine, patient was in continuous sinus tachycardia (110s-140s). However, patient did have one isolated episode NSVT X 14 beat run. With weaning of dopamine and uptitration of carvedilol, patient's heart rate improved to 60s-80s at the time of discharge. Further consideration for prophylactic ICD placement would pend revascularization of remaining 2 vessel disease. * PVD: Severe iliac disease seen on cath, as correlates with patient's baseline claudication (can walk 10ft). This was not intervened upon at the time of catheterization given patient's hemodynamic instability. Again, further intervention of these lesions would depend upon patient's malignancy and prognosis. * BRBPR: Following catheterization, patient was noted to have BRBPR and required one unit of packed red cells. However, following this acute episode, patient had guaiac negative stools and no longer required any further transfusions. It was recommended to the patient that she undergo outpatient colonscopy for further evaluation. * Hypothyroidism: TSH 8.7 and Free T4 0.5. Patient was empirically started on 100mcg levothyroxine given history of noncompliance and unclear dose to reach euthyroid level (patient intermittenly on 50-200mcg levothyroxine [**First Name8 (NamePattern2) **] [**Hospital1 487**] records). On this, patient was clinically euthyroid, but would require followup thyroid function test evaluation following discharge. * COMMUNICATION: Extensive communication with son [**Name (NI) 915**] [**Name (NI) 805**] [**Telephone/Fax (1) 62116**] At the time of discharge, patient was hemodynamically stable with no further episodes of chest pain or GI bleeding. Patient was to followup with oncologist for PET/CT evaluation of malignant peripheral nerve sheath CA. Medications on Admission: Toprol XL 50 Levoxyl Albuterol Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*35 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Quetiapine Fumarate 25 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). Disp:*120 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: ST Elevation Myocardial Infarction Malignant peripheral nerve sheath tumor Hypothyroidism Neurofibromatosis Cardiogenic shock Anorectal bleeding Discharge Condition: Good - no further episodes of chest pain, shortness of breath. Continued to have episodes of asymptomatic hypotension at night while sleeping. Discharge Instructions: Please take all medications as directed. Followup Instructions: Colonoscopy - Recommend followup colonoscopy given anorectal bright red blood to rule out malignancy as outpatient. . Hypothyroidism - Recommend repeat thyroid function tests to monitor thyroid replacement. . Oncology: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2025**] ([**Telephone/Fax (1) 62117**] as scheduled on Please go for your PET scan and CT of the chest and abdomen at [**Hospital1 2025**] as scheduled by Dr.[**Name (NI) 62118**] office. . Cardiology: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**] at ([**Telephone/Fax (1) 62119**] as scheduled on Tuesday, [**4-15**] at 11:15am on the [**Location (un) 1385**] of [**Hospital3 1443**] Hospital.

[ "305.03", "401.9", "V10.89", "427.1", "414.01", "443.9", "578.9", "244.9", "311", "787.2", "237.70", "998.0", "410.11", "305.1", "280.0", "458.29", "790.5", "295.70" ]

icd9cm

[ [ [] ] ]

[ "99.04", "37.23", "36.01", "36.06", "88.56" ]

icd9pcs

[ [ [] ] ]

12966, 13028

6758, 11754

290, 347

13217, 13361

2859, 6735

13451, 14232

2139, 2213

11836, 12943

13049, 13196

11780, 11813

13385, 13428

2228, 2840

232, 252

375, 1728

1750, 2042

2058, 2123

29,059

171,662

53920

Discharge summary

report

Admission Date: [**2187-12-13**] Discharge Date: [**2187-12-19**] Date of Birth: [**2143-2-26**] Sex: M Service: MEDICINE Allergies: Trazodone Attending:[**First Name3 (LF) 358**] Chief Complaint: multiple complaints - L chest pain, n/v, melena, leg pain Major Surgical or Invasive Procedure: endoscopy History of Present Illness: 44 yo M with long psych history, depression, anxiety, h/o narcotic abuse, cocaine, IVDA, panic attacks, DM type 2, hep C (not treated, not followed here at liver service), hypothyroidism, a fib who comes in with multiple complaints. Almoost all of these complaints started on Monday, a time in which he was also having to move residences because his relationship was breaking up. All around this same time he had nausea, intermittent episodes of squeezing chest pain worse with inhalation (lasting about 20 minutes or so), crampy abdominal pain, and nausea. He vomited 1-2 times and says that he vomited some blood. He states that he had some loose, dark black stools; his stools were guiaic positive but brown in ED. + chills, night sweats, no fevers. Non-productive cough. In the ED he gave a history of L sided pleuritic CP radiating to neck X 3 days. Unable to eat due to poor appetite and nausea. Has not taken any insulin with FS in 300s. L leg numbness and tingling since Monday without back pain. +knee buckling; a neighbor saw him fall, and called EMS. Last EtOH 1 month ago, denies any drug abuse. But tox screen positive - pt admits to xanax, percocet, tramadol. . In the ED BP 115/58, HR 92, RR 20, O2 sat 100% on RA. He was tachycardic to 106, with some afib noted in the ED but not on EKG; BPs nl, O2 sat 100%. Guaiac pos soft brown stool, good rectal tone. Would not tolerate NGL. Some decreased sensation to L4 dermatome. Got 3 L IVFs. EKG without ischemic changes, trops negative. Labs were also significant for Hct 37.5, BUN 72, Cr 1.3, CK 4011, D-dimer 2670, urine tox positive for benzos and opiates. An EKG was negative for any ischemic changes. Pt refused NGL, seen by GI who recommended PPI, serial Hcts, and EGD in am. . Given elevated d-dimer and pt's reported contrast dye allergy, V/Q scan performed that was mod probability for PE (subsegmental V/Q mismatch in superior aspect of b/l upper lobes and posterior basal segment of LLL). Bilateral LENIs were negative for DVT. He was given 3L IVFs, protonix 40 mg IV X 1, morphine 6 mg IV, zofran 4 mg IV X 2, and 4 units regular insulin for FS 241. Given the ED's concern for not having a clear explanation for the pt's multiple complaints, and given that some of these complaints might point to acute problems, he was admitted to the ICU for closer monitoring. Past Medical History: Depression - multiple psychiatric admissions in past with suicide attempts H/O assaultiveness towards significant others, past street fights Past dx of panic attacks, PTSD, agoraphobia Anxiety IDDM (type 2) Hep C Hypothyroidism PAF not on coumadin Sciatic pain L leg Chronic pain s/p R tib/fib fx s/p several MVAs with ruptured discs in back s/p multiple head injuries s/p appendectomy . PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital1 2177**] Social History: Currently homeless, previously had been living with girlfriend, now ex-girlfriend. In the past he has sometimes stayed with mother who lives in [**Location 686**]; in the last week he has been staying with a friend. When asked who he would want to make healthcare decisions for him if he was incapacitated, he says, "probably my ex". Keeps in touch with mother, sees her 1-2x/month. For income he is on disability, which he has been on since [**2169**]. . He has been jailed multiple times for drugs, fights and as a result of domestic issues requiring a restraining order. Family History: father with depression and alcoholism both of pt's brothers have drug and alcohol problems one of his brothers attempted suicide. Physical Exam: afebrile, VSS. GEN: NAD HEENT: Anicteric, EOMI, PERRL, OP clear with MMM NECK: No JVD HEART: RRR, no m.r.g LUNGS: CTAB, good air movement throughout with full excursions ABDOMEN: Soft, non-distended, no organomegaly. Mild tenderness to palpation in LLQ. No rebound tenderness. SKIN: No rashes or petichiae EXTREMITIES: No edema NEURO: nonfocal Pertinent Results: [**2187-12-13**] 02:00PM WBC-3.7* RBC-4.25* HGB-13.5* HCT-37.5* MCV-88 MCH-31.8 MCHC-36.0* RDW-13.4 [**2187-12-13**] 02:00PM NEUTS-70.9* LYMPHS-21.7 MONOS-4.5 EOS-2.3 BASOS-0.6 [**2187-12-13**] 02:00PM PLT COUNT-305 [**2187-12-13**] 02:00PM GLUCOSE-280* UREA N-72* CREAT-1.3* SODIUM-137 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-19 . [**2187-12-13**] 03:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2187-12-13**] 03:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2187-12-13**] 03:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 . [**2187-12-13**] 05:44PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG . [**2187-12-13**] 08:50PM CK-MB-19* MB INDX-0.8 cTropnT-<0.01 [**2187-12-13**] 08:50PM CK(CPK)-2507* [**2187-12-13**] 02:50PM D-DIMER-2670* [**2187-12-13**] 02:50PM PT-12.8 PTT-28.1 INR(PT)-1.1 EKG - NSR @ 95 bpm, nl axis, nl intervals, no ST dep or elev, no qs, no TWIs, no S1Q3T3, unchanged from prior on [**1-25**] Port CXR [**12-13**] - Cardiomediastinal and hilar contours are normal. Lungs are clear without focal consolidation or pulmonary edema. There is no pleural effusion. Osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. V/Q Scan [**12-13**] - Subsegmental perfusion/ventilation mismatch involving the superior segments of both upper lobes and the posterior basal segment of the left lower lobe. Findings represent a moderate probability for pulmonary embolus of undetermined chronicity. If clinically indicated, further evaluation with lower extremity ultrasound to assess for DVT and a repeat VQ scan in 24-48 hours could be performed. B/L LENIs [**12-13**] (prelim read) - negative for DVT [**2187-12-17**] 06:10AM BLOOD WBC-5.1 RBC-3.33* Hgb-10.6* Hct-29.5* MCV-89 MCH-31.9 MCHC-36.0* RDW-12.8 Plt Ct-275 [**2187-12-17**] 06:10AM BLOOD Glucose-162* UreaN-11 Creat-0.9 Na-135 K-4.1 Cl-102 HCO3-27 AnGap-10 [**2187-12-17**] 06:10AM BLOOD ALT-95* AST-52* AlkPhos-57 [**2187-12-15**] 06:40AM BLOOD CK-MB-7 cTropnT-0.03* [**2187-12-15**] 06:40AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.1* [**2187-12-14**] 05:00AM BLOOD Cryoglb-NEGATIVE [**2187-12-14**] 05:00AM BLOOD %HbA1c-8.5* [**2187-12-14**] 05:00AM BLOOD TSH-3.3 [**2187-12-13**] 08:50PM BLOOD Acetmnp-NEG [**2187-12-13**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no abnormalities. Perfusion images in the same 8 views show no areas of decreased perfusion. Chest x-ray shows no areas of consolidation. The above findings are consistent with a normal study. IMPRESSION: Interval resolution of previously seen perfusion/ventilation subsegmental defects. Normal study. Brief Hospital Course: 44 yo M with hepatitis C, hypothyroidism, PAF, depression, anxiety, and h/o past narcotic, benzo, and IVDA who presents to the ED with multiple complaints including L pleuritic chest pain, nausea, possible hematemesis and melena, found to have intermediate probability study for PE on V/Q scan, admitted to [**Hospital Unit Name 153**] for close observation overnight. . # L chest pain - Described as pleuritic in nature with elevated d-dimer to 2670 in ED. V/Q scan with subsegmental V/Q mismatch in superior segments of both upper lobes and in posterior basal segment of LLL. Bilateral LENIs negative for evidence of DVT. Otherwise, clinical suspicion for acute PE is relatively low given lack of hypoxia, no EKG changes (S1Q3T3). Pt is tachycardic, but there are other possible explanations for this including melena, poor po intake, pain, and possible benzo withdrawal. No evidence of cardiac ischemia on EKG, troponins flat. CXR without evidence of enlarged mediastinum. Repeat V/Q low probability/normal study and chest pain resolved spontaneously. # Melena: EGD with esophagitis, GI recommended 4 week repeat EGD, [**Hospital1 **] ppi x 1 mo, avoid NSAIDS. Appointment arranged for follow up on discharge. # Leg weakness: Has history of sciatic pain in left leg. Also has past back injury with L4-L5 disk bulging. Sensory/strength exam possibly concerning for L4-5 deficit. PT, supportive care. . # Acute renal failure: prerenal, resolved with fluids. . # Diabetes mellitus type 2: resumed home dose of metformin with good control. # Transaminitis: Elevated liver enzymes along with elevated CK, ALT is at a peak relative. Combination of transaminitis with elevated CK could be concerning for toxic or medication effect, might be statin effect. Discontinued statin and LFTs trended down, near normal at discharge. Should be repeated in 4 weeks to assure normalization. # Hypothyroidism: normal TSH. # PAF: Currently in NSR. Not on coumadin as outpt. On metoprolol 12.5 mg po bid. # Homelessness/Substance abuse: psychiatry evaluated patient and initially recommended inpatient psychiatry after medical clearance, but subsequently felt he did not require hospitalization. He was arranged to go to a safe house by social work, but refused. He was discharged to the street with options for homeless shelters. # Psych: reinitiated home psych meds. Medications on Admission: ASA 325 daily Synthroid 75 daily Metoprolol 50 mg PO BID Lipitor 20 daily Xanax 1 mg TID Lisinopril - does not remember dose Percocet - PRN, dose unknown Discharge Medications: 1. Levothyroxine 75 mcg 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 Q12H (every 12 hours) for 1 months. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: 1. esophagitis with GI bleeding 2. depression 3. knee pain, NOS Discharge Condition: stable Discharge Instructions: Please return to the hospital if you have chest pain, shortness of breath, blood in your stool, or any other alarming symptoms. If you experience priapism for more than 4 hours, go to the emergency room. Followup Instructions: Follow up with the gastroenterologists for endoscopy on [**1-17**] at 8:30AM, [**Hospital Ward Name 517**], [**Hospital Ward Name 121**] [**Location (un) **]. Call your PCP for follow up after discharge from inpatient psychiatry. [**First Name9 (NamePattern2) 24314**] [**Last Name (LF) 24315**],[**First Name3 (LF) **] K [**Telephone/Fax (1) 11463**]

[ "786.59", "530.82", "276.51", "311", "070.70", "V15.81", "V60.0", "V58.67", "584.9", "530.11", "250.00", "300.00", "790.4", "305.90", "724.3", "275.2", "719.46", "244.9", "301.7" ]

icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

10583, 10589

7294, 9659

329, 341

10697, 10706

4379, 7271

10958, 11315

3868, 4000

9863, 10560

10610, 10676

9685, 9840

10730, 10935

4015, 4360

232, 291

369, 2707

2729, 3261

3277, 3852

11,561

189,600

18520+18521

Discharge summary

report+report

Admission Date: [**2185-9-27**] Discharge Date: [**2185-10-11**] Service: Medicine, [**Location (un) **] Firm HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old female with a past medical history significant for atrial fibrillation and status post a stroke in [**2185-1-5**], who presented status post fall from her wheelchair. The patient is status post a stroke in [**Month (only) 404**]. She developed bilateral weakness (right greater than left) and aphagia. The patient had a prolonged hospital course complicated by pneumonia and recurrent urinary tract infections. She is incontinent of urine and feces and has an indwelling Foley catheter. Currently, her left side has recovered some function from the stroke in [**Month (only) 404**], the patient is left with residual right-sided paralysis and some speech difficulties. On [**2185-9-26**] (on the day prior to admission), the patient was being wheeled by her granddaughter down a ramp and fell out of her wheelchair. She rolled onto her neck. It was a mild fall; per her granddaughter. The patient denies loss of consciousness or a change in mental status. She did have persistent neck pain following the fall. She was taken to [**Hospital3 15174**] where she was noted to have full range of motion in her neck. However, she was transferred to the [**Hospital1 69**] after a computed tomography scan showed a C2 fracture. In the Emergency Department, at [**Hospital1 188**], she was noted to have elevated creatine kinase levels and troponin levels with a troponin level of 1.02 and a CK/MB level of 19. She was seen by Cardiology who felt no intervention was needed at this time. The patient was already anticoagulated on Coumadin due to her history of atrial fibrillation. She was also on a beta blocker and aspirin. In addition, the patient also aspirated in the ambulance on the way to [**Hospital1 69**]. She underwent a computed tomography scan which showed an oblique fracture involving the body of C2. The lamina of C2 on the right was fractured. A computed tomography scan of the head showed no acute intracranial hemorrhage of mass effect. There was a large left frontal scalpel hematoma. There were remote old infarctions identified. There was a calcified meningioma at the left posterior fossae. PAST MEDICAL HISTORY: 1. Atrial fibrillation with an ejection fraction of approximately 20%. 2. Breast cancer; status post mastectomy in [**2178**]. 3. Colon cancer; status post hemicolectomy in [**2175**]. 4. Status post radiation therapy for a bone lesion in [**2180**]. MEDICATIONS ON ADMISSION: Celexa, lactulose, atenolol, lisinopril, digoxin, Coumadin, and Glyburide. ALLERGIES: SULFA. SOCIAL HISTORY: The patient denies alcohol or recent tobacco use. She lives with her granddaughter who provides day-to-day care. FAMILY HISTORY: No history of malignancy or coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed head, eyes, ears, nose, and throat with dry mucous membranes. Pupils were equal, round, and reactive to light. Extraocular movements were intact. The chest examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs, or gallops appreciated on examination. The abdomen was obese, soft, nontender, and nondistended. Extremity examination revealed no clubbing or cyanosis. There was 1+ edema in the legs bilaterally and 1+ edema in the hands bilaterally. Neurologic examination revealed the patient was minimally responsive. Her strength was [**3-9**] in her right hand and 3+/5 in her left arm and left leg. The patient was unable to move her right leg. Per granddaughter, this was unchanged from her baseline. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's white blood cell count was 18.6, her hematocrit was 36.9, and her platelets were 365. Her prothrombin time was 22.4, her partial thromboplastin time was 31.4, and her INR was 3.3. Chemistry-7 revealed her sodium was 142, potassium was 3.8, chloride was 107, bicarbonate was 20, blood urea nitrogen was 19, creatinine was 0.7, and blood glucose was 247. Her CK/MB was 19, MB index was 14.1, and her troponin I was 102. Her digoxin level was 0.8. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the head and neck as described above; oblique fracture involving the body of C2. A magnetic resonance imaging of the head revealed multiple old infarctions involving the brain stem, the right cerebral peduncle, internal capsule on the right side, and the left occipital lobe. Possible new infarction in the right cerebellar hemisphere. An echocardiogram revealed left ventricular cavity was dilated, ejection fraction of 20% to 30%, apical hypokinesis, ascending aorta dilated, moderate aortic regurgitation, and moderate pulmonary artery hypertension. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Medicine [**Hospital1 **]. She was seen by the Neurosurgery Service who recommended a hard collar for the patient's C2 fracture. The patient's family did not want any surgical intervention to be done to repair her C2 fracture. It was unclear whether or not the patient would have been a candidate for surgery. The patient was placed in a hard collar which was then switched to an Aspen hard collar. The patient was started on heparin for her elevated creatine kinase and troponin levels. Warfarin was held. She was continued on her beta blocker, ACE inhibitor, and aspirin. She was also started on levofloxacin for her history of recent aspiration and her history of urinary tract infections. Flagyl was then added to her regimen. Over the next several days the patient's cardiac enzymes trended down; however, her INR rose in the setting of being started on levofloxacin and Flagyl. At this time she was not taking Coumadin. Her INR reached a high of 6.7; at which time she was reversed with 10 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 10451**] Dictated By:[**Last Name (NamePattern1) 50899**] MEDQUIST36 D: [**2185-10-11**] 08:15 T: [**2185-10-11**] 08:22 JOB#: [**Job Number 50900**] Admission Date: [**2185-9-27**] Discharge Date: [**2185-10-11**] Service: ADDENDUM HOSPITAL COURSE: The patient's INR reached a high of 6.7 at which time she was reversed with Vitamin K. Her white blood cell count continued to be elevated on her antibiotic regimen. The patient's neurologic exam remained unchanged. She complained of persistent neck pain which was eventually treated with Oxycodone. The patient was started on tube feeds. While on tube feeds, she developed a mild hypernatremia and was treated with free-water boluses. In addition, she appeared dehydrated with decreased urine output, FeNa less than 1, and elevated BUN to creatinine ratio. She was treated with intravenous fluid hydration. Her electrolytes normalized. During the [**Hospital 228**] hospital course, she had several episodes of atrial fibrillation. Her beta-blocker was thus titrated up from 50 b.i.d. to 70 t.i.d. over her hospital stay. In addition, the patient was restarted on Coumadin with close monitoring of her INR, and Heparin was discontinued. On [**2185-10-4**], the patient was admitted to the Medical Intensive Care Unit for worsening respiratory distress. At this time, a chest x-ray showed increased opacities throughout her left lung field. This was consistent with either pleural effusion, parenchymal abnormality or left lower lobe lung collapse. In the Intensive Care Unit, the patient underwent an ultrasound with a plan to tap any fluid collection found; however, no fluid was found. Results were consistent with a left lung infiltrate, atelectasis or organized pleural fluid collection. A follow-up CT scan was then obtained. This CT scan revealed no evidence of pulmonary embolism. It did show a small left loculated pleural effusion with associated atelectasis. It also showed a collapse of the posterior segment of the left lower lobe. The patient's respiratory status improved over the following few days with aggressive chest physical therapy and suctioning of airway secretions. She was transferred back to the Medicine Team on [**2185-10-6**]. On the floor, the patient's respiratory status continued to improve, and she was weaned off oxygen and had good oxygen saturation on room air. The patient also sustained normal sinus rhythm at this time. An induced sputum was obtained which showed Methicillin resistant Staphylococcus aureus; however, this was likely contaminant due to poor sample with several epithelial cells and few polys. The patient however was started on Vancomycin given her elevated white blood cell count. In addition, a Plastic Surgery consult was obtained as the patient developed a sacral decubitus ulcer. It was the impression of the Plastic Surgery Team that there was also a Stage II 6 x 7 cm ulcer with eschar with no fluctuants or surrounding cellulitis. They felt that the ulcer was appropriately addressed with Duoderm and that no further intervention was needed at the time. Lastly, the patient has had elevated blood glucose levels during her hospital stay. Initially she was on Glyburide at presentation; however, she was started on Insulin as her sugars remained elevated. On discharge, her regimen was 20 U NPH q.a.m. and 20 U q.p.m. Her sugars seemed reasonably well controlled with this regimen. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSIS: 1. C2 fracture. 2. Status post stroke with residual paralysis. 3. Sacral decubitus ulcer, Stage II. 4. Demand ischemia with elevation of CK and troponin. FOLLOW-UP: The patient is to follow-up with Neurosurgery and is to have repeat imaging studies in four weeks. DISCHARGE MEDICATIONS: Insulin NPH 20 U q.a.m. and 20 U q.p.m., Vancomycin 1 g q.12 hours, Morphine Sulfate 1-2 mg IV q.4 hours p.r.n. pain, Furosemide 20 mg p.o. b.i.d., Docusate Sodium 100 mg p.o. b.i.d., Warfarin 3 mg p.o. q.h.s., Senna 1 tab p.o. b.i.d. p.r.n., Metoprolol 75 mg p.o. t.i.d., Albuterol nebs, [**Last Name (un) 33962**] dermal wound p.r.n., Chlorhexidine Gluconate 15 ml p.o. t.i.d., Calcium Carbonate 500 mg p.o. t.i.d., Ascorbic Acid 500 mg p.o. b.i.d., Vitamin D 400 U p.o. q.d., Zinc Sulfate 220 mg p.o. q.d., Somantadine 20 mg p.o. b.i.d., Citalopram 20 mg p.o. q.d., Digoxin 0.125 mg p.o. q.d., Lisinopril 20 mg p.o. q.d., Aspirin 81 mg p.o. q.d. Dictated By:[**Last Name (NamePattern1) 50901**] MEDQUIST36 D: [**2185-10-11**] 08:47 T: [**2185-10-11**] 09:11 JOB#: [**Job Number 50902**]

[ "424.0", "427.31", "410.71", "518.81", "507.0", "599.0", "707.0", "276.1", "805.02" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

2860, 4922

9980, 10782

9685, 9956

2614, 2710

6410, 9591

4951, 6392

151, 2309

2331, 2587

2727, 2842

9616, 9664

61,213

103,476

1801

Discharge summary

report

Admission Date: [**2148-10-30**] Discharge Date: [**2148-11-16**] Date of Birth: [**2083-1-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: malaise, dry cough Major Surgical or Invasive Procedure: DCCV avj modification Intubation and mechanical ventilation central line placement Swan Ganz placement FNA of right axillar lymph node pounch biopsy of anterior mass/nodule Throcentesis arterial line placement History of Present Illness: This is a 65 year old male with a PMH significant for HTN, dyslipidemia, DMII, who presented to the ED with malaise, poor appetite, and dry cough for 5 days PTA. 3 days prior to admission he noted onset of bilateral lower extremity edema. 1 day prior to admission, noted severe generalized weakness. He notes he has been sleeping in a chair for the last 2 nights because he could not get into bed. He denies any recent HA, visual changes, chest pain, palpitations, shortness of breath, orthopnea, PND, abd. pain, N/V/D, fevers, chills, rash, or dysuria. He sleeps on 2 pillows normally and this has not changed. He notes prior to this episode that he was able to walk for 30 minutes a day without any symptoms. . In the ED, initial vitals were 97.8, 118/90, 88, 96% RA. However, shortly there after he went into a.fib with RVR, rates in the 130s to 150s. Given diltiazem 10 x 3, without improvement. Then given metoprolol 5 x 1 without improved. Started on amiodarone load but stopped due to hypotension, with SBP in the 80's. Then he was given 100mg PO metoprolol and levofloxacin for ? infiltrate on exam. Received KCL 60 mg and 2L IVF. Noted to be more tachypneic after the fluids with cxr showing large heart, ? effusion. He was then admitted to the CCU for further management of RVR with hypotension. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. . On arrival the patient states that he feels generally weak but otherwise well. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes Mellitus II, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: . -OTHER PAST MEDICAL HISTORY: - Arthritis - Gout - Obesity Social History: He is a retired funeral home director. Lives with wife, and son. [**Name (NI) **]-time helps his son with his work. The patient has never smoked. One to two cans of beer per month, never more, no drinking recently. No illicits. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. The patient is married with two children ages 26 and 28 who are healthy and well. Family history of hypertension and mother died of reported questionable food poisoning at age 38. Physical Exam: VS: 98, 94/67, 140, 98% 2L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to just below angle of the jaw. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Tachy, [**Last Name (un) **], normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 3+ bilateral LE edema No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2148-10-30**] 08:50AM BLOOD WBC-5.4 RBC-3.84*# Hgb-10.6*# Hct-30.9*# MCV-81* MCH-27.6 MCHC-34.2 RDW-16.7* Plt Ct-196 [**2148-11-16**] 06:19AM BLOOD WBC-12.1* RBC-3.00* Hgb-8.0* Hct-23.7* MCV-79* MCH-26.8* MCHC-33.9 RDW-17.3* Plt Ct-68* [**2148-10-30**] 08:50AM BLOOD Neuts-57 Bands-1 Lymphs-31 Monos-8 Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-2* [**2148-10-30**] 08:50AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-OCCASIONAL Target-1+ Tear Dr[**Last Name (STitle) 833**] [**2148-10-30**] 08:50AM BLOOD PT-13.0 PTT-24.8 INR(PT)-1.1 [**2148-11-4**] 03:06AM BLOOD Fibrino-960* [**2148-11-8**] 08:55PM BLOOD Fibrino-1004*# [**2148-11-9**] 11:34PM BLOOD Fibrino-1061*# [**2148-11-12**] 11:19AM BLOOD Fibrino-957* [**2148-11-12**] 11:19AM BLOOD FDP-40-80* [**2148-11-4**] 03:06AM BLOOD CD5-DONE CD23-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE Kappa-DONE CD10-DONE CD19-DONE CD20-DONE Lambda-DONE [**2148-11-4**] 03:06AM BLOOD CD3%-DONE [**2148-11-1**] 06:46AM BLOOD Ret Aut-2.3 [**2148-11-8**] 04:17AM BLOOD Ret Aut-1.1* [**2148-11-12**] 01:43PM BLOOD Fact V-133 FacVIII-345* [**2148-10-30**] 08:50AM BLOOD Glucose-236* UreaN-46* Creat-1.2 Na-135 K-2.8* Cl-89* HCO3-33* AnGap-16 [**2148-11-16**] 06:19AM BLOOD Glucose-223* UreaN-115* Creat-2.5* Na-133 K-4.1 Cl-88* HCO3-29 AnGap-20 [**2148-10-31**] 01:05AM BLOOD ALT-50* AST-69* LD(LDH)-4410* CK(CPK)-230* AlkPhos-143* TotBili-0.6 [**2148-11-15**] 02:05AM BLOOD ALT-71* AST-109* LD(LDH)-4210* AlkPhos-213* TotBili-1.0 [**2148-10-30**] 08:50AM BLOOD CK-MB-7 proBNP-2677* [**2148-10-30**] 08:50AM BLOOD cTropnT-0.07* [**2148-10-31**] 01:05AM BLOOD CK-MB-7 cTropnT-0.06* [**2148-10-31**] 11:02PM BLOOD CK-MB-7 cTropnT-0.06* [**2148-10-30**] 08:50AM BLOOD Calcium-9.5 Phos-5.6* Mg-2.6 [**2148-11-8**] 08:55PM BLOOD Calcium-9.0 Phos-4.6* Mg-2.1 UricAcd-7.1* [**2148-11-16**] 06:19AM BLOOD Calcium-7.7* Phos-6.2* Mg-2.0 [**2148-10-30**] 03:30PM BLOOD calTIBC-239 Hapto-460* Ferritn-GREATER TH TRF-184* [**2148-11-4**] 03:06AM BLOOD D-Dimer-9918* [**2148-11-12**] 01:43PM BLOOD D-Dimer-[**Numeric Identifier 10112**]* [**2148-11-12**] 11:19AM BLOOD Hapto-270* [**2148-10-30**] 08:50AM BLOOD TSH-2.2 [**2148-11-4**] 03:06AM BLOOD Cortsol-32.7* [**2148-10-30**] 08:14PM BLOOD [**Doctor First Name **]-NEGATIVE [**2148-11-5**] 04:23AM BLOOD Digoxin-1.4 [**2148-10-30**] 04:53PM BLOOD pO2-52* pCO2-41 pH-7.49* calTCO2-32* Base XS-7 [**2148-11-15**] 06:12AM BLOOD Type-ART Temp-37.4 Rates-20/0 Tidal V-600 PEEP-12 FiO2-50 pO2-110* pCO2-49* pH-7.43 calTCO2-34* Base XS-6 -ASSIST/CON Intubat-INTUBATED [**2148-10-30**] 08:57AM BLOOD Glucose-228* [**2148-10-30**] 03:30PM BLOOD Lactate-2.2* K-3.4* [**2148-11-15**] 06:12AM BLOOD Lactate-1.9 [**2148-11-10**] 05:25PM BLOOD freeCa-1.11* [**2148-11-15**] 02:12AM BLOOD freeCa-1.07* Portable TTE (Complete) Done [**2148-10-30**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. RV with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Dilated cardiomyopathy (tachycardia mediated?) Portable TEE (Complete) Done [**2148-10-31**] IMPRESSION: No left atrial/appendage thrombus. Severely depressed left ventricular systolic function (EF 20%). UNILAT LOWER EXT VEINS PORT LEFT Study Date of [**2148-11-1**] FINDINGS: Please note, the study is somewhat limited due to patient's inability to Valsalva. Grayscale and Doppler evaluation of the left common femoral, superficial femoral, and popliteal veins was performed. There is normal compression, augmentation and flow. The posterior tibial and peroneal veins are also visualized and patent. IMPRESSION: No evidence of DVT. ECG Study Date of [**2148-11-2**] Sinus rhythm. Left atrial abnormality. Left bundle-branch block. Compared to the previous tracing of [**2148-11-1**] sinus rhythm has appeared. There is occasional atrial ectopy. Clinical correlation is suggested. CT CHEST/ABDOMEN/PELVIS W/CONTRAST Study Date of [**2148-11-2**] IMPRESSION: 1)Multiple subcutaneous nodules with larger necrotic masses in the right axilla and further nodules in the left perinephric region are highly suspicious for metastases, possible melanoma. Biopsy of the right axillary lymph node is recommended. 2)Loculated large left pleural effusion with atelectasis in the left lung and small right pleural effusion. 3)Moderately large pericardial effusion in the presence of moderate cardiomegaly. Subcentimeter hypodensities in the liver and lower pole of the left kidney could be cysts. Brief Hospital Course: # Atrial fibrillation with RVR: Pt was admitted with symptoms of HF for several months and was found to be in afib with RVR. During the admission, he was cardioverted several times without success, loaded on amiodarone, and also administered an esmolol gtt during periods of refractory tachycardia, which did not help improve his rate but did make him hypotensive. In general, the above interventions were ineffective at controlling his rate until he was fully loaded on amiodarone and went for partial AV nodal ablation and pacemaker placement, at which point he remained in sinus rhythm for several days. Shortly thereafter he was also started on low dose digoxin. He had periods of return to AF c RVR, initially rate controlled with PO amiodarone, digoxin and PRN metoprolol, with rates generally in the 90s-100s and stable BPs. Later in the hospital course the patient developed RVR refractory to amiodarone gtt + IV metoprolol. The etiology of his refractory afib was unclear but likely resulting from chronic hypertension. There was also concern for tumor mets or catecholamine surge from neuroendocrine tumor that may be contributing to his refractory afib. He continued to have periodic atrial fibrillation that respond to metoprolol or self-resolves throughout the rest of his hospitalization. # Cardiomyopathy: Newly found EF of 20% with globally dilated RV. The etiology of his cardiomyopathy was unclear. [**Name2 (NI) **] was treated with rate control as above and diuresis with lasix gtt and PRN lasix boluses + PRN metolazone. # Hypotension: Patient became significantly hypotensive during this admission and required substantial pressor support while on nodal agents to control his arrhythmia. The etiology of his hypotension was thought to be cardiogenic vs. septic shock. He continued to require pressors to the time of his passing. # [**Location (un) 5668**] cell tumor: Mr [**Known lastname 10113**] had multiple concerning nodules on exam and by CT which were biopsied and showed [**Location (un) 5668**] cell carcinoma. Later in the hospitalization pOncology was consulted but given his tenuous state treatement was deferred. CT scan and MRI of the head was performed and multiple intracranial metastasis were found with a possible intraparenchial bleed in the cerebellum. # Respiratory distress: Pt was intubated early in the admission out of concern for changing mental status and inability to protect his airway. On [**11-4**], pt had increasing oxygen requirements and was found to have white-out of the left lung by CXR. 600 ccs were drained from L pleural effusion. He was also bronched out of concern for a mucus plug and secretions were removed from his airways with subsequent improvement of his respiratory status. However, he was not able to come off the ventilator. # Altered mental status: On admission to the hospital, pt was alert and oriented x3 but his mental status rapidly deteriorated and he required intubation to help protect his airway. CT head was obtained on [**11-4**] and showed no acute intracranial proccess, no bleed, but did showed extra-axial lesions which were concerning for meningiomas vs. metastiatic cancer. Additionally, his hypoxia/hypercarbia were likely contributing to his altered mental status, as well as his poor perfusion in the context of cardiogenic shock. . # Fever: most likely represents B sxs related to his new malignancy, however also concerning for infection in the context of sputum cxs growing gram neg rods and gram positive cocci as well as positive influenza testing. He was treated with 6 day course of vanc/cefepime/cipro, then ID consulted for persistent fevers despite abx tx. These antibiotics were then discontinued and he was started on ceftriaxone given that there was no growth in any other cultures. # Influenza: pt tested positive for influenza A, which may explain the URI sxs that the patient complained of the week prior to admission. He was placed on droplet percautions and treated with osteltamavir and ramantidine. Samples sent to state lab for further analysis and results were pending. # Anemia: No clear source of bleed during the admission however crit was lower than baseline and pt required PRBCs to stabilize his crit. # Hyperlipidemia: Cholesterol not well controlled according to last lipid panel measured in [**11-24**]. Chol: 295, LDL: 192, HDL: 79, TG: 120. His statin dose was increased to 80 mg PO daily. # DMII: Last A1c in [**2-26**] was 7.4%. He was initially treated with long acting insulin/ISS but later transitioned to insulin gtt for better control of his sugars. # LE edema: LE doppler performed early in the admission out of concern for DVT unequal edema of the LEs, however studies were negative and the LE edema was attributed to his heart failure and he was treated with diuresis. # Epistaxis: pt with significant nosebleed and was seen by ENT who packed the bleed. No further bleeding after this intervention. # Thrombocytopenia: HIT abx negative. DIC labs WNL. # Arthritis: Stable. # Gout: Stable. Allopurinol continued Medications on Admission: MEDICATIONS: - allopurinol 600mg PO daily - glipizide 10mg PO BID with meals - hydrochlorothiazide 50mg PO qam - lisinopril 10mg PO qam - metformin 500mg SR daily with dinner - salsalate 500mg PO TID - simvastatin 20mg PO qhs - verapamil 180mg SR PO daily Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: shock Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "278.01", "482.83", "584.9", "425.4", "287.5", "780.97", "784.7", "428.43", "259.2", "250.00", "401.9", "785.51", "285.29", "276.8", "274.9", "428.0", "272.4", "209.36", "511.81", "487.1", "716.90", "518.81", "427.31", "427.32", "209.75", "V66.7" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "40.11", "96.6", "21.03", "99.62", "34.91", "86.11", "37.34", "96.72", "88.72", "38.93", "33.24", "37.78" ]

icd9pcs

[ [ [] ] ]

15062, 15071

9628, 12459

335, 546

15120, 15129

4203, 9605

15182, 15189

2980, 3275

15023, 15039

15092, 15099

14743, 15000

15153, 15159

3290, 4184

2598, 2665

277, 297

574, 2472

12474, 14717

2687, 2718

2734, 2964

42,733

170,614

44103

Discharge summary

report

Admission Date: [**2143-7-19**] Discharge Date: [**2143-7-24**] Date of Birth: [**2075-11-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6195**] Chief Complaint: anemia Major Surgical or Invasive Procedure: 1. Endoscopy 2. Colonoscopy History of Present Illness: 67M with DMII and HTN who was admitted initially to MICU with HCT of 15, believed to be secondary to slow GIB. Patient presented to his PCP [**Last Name (NamePattern4) **] [**7-19**] where CBC showed HCT of 18. He underwent normal EGD the following day, and was subsequently referred to the ED for transfusion. In the ED, initial labs were notable for HCT of 15.8. Patient was given 1U PRBCs in ED, then 2 U PRBCs while in MICU. At the time of transfer, the patient's HCT was 23.6. On the floor, he is without abdominal pain, nausea, or vomiting. No diarrhea, constipation, melena or hematochezia. Of note, had colonoscopy in [**2130**] with adenomatous polyps but never had repeat colonoscopy afterwards. Past Medical History: Type 2 DM Hypertension Anemia Shoulder pain Social History: Retired custodian. Smokes 1 pack per month (previously [**11-19**] PPD) and has been smoking x 50yrs. Drinks 2 beers/day on weekends. Denies illicits. Family History: Denies FH of GI malignancy, IBD. Denies other malignancies or cardiovascular disease. Physical Exam: Admission Physical Exam: Vitals: 79 121/54 16 99%RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Lungs: CTAB, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. 3 cm abscess over right buttock draining small amount of pus. Discharge Physical Exam: Tm 101 at 1400 [**2143-7-23**], Tc 98.9, HR 78-111, BP 127-158, RR 18, 100%RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Lungs: CTAB, no wheezes, rales, ronchi Abdomen: diffusely tender, non-distended, bowel sounds present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. 3 cm abscess over right buttock draining small amount of pus. Pertinent Results: Admission labs: [**2143-7-19**] 01:06PM BLOOD WBC-11.4* RBC-2.17* Hgb-4.2* Hct-15.8* MCV-73* MCH-19.2* MCHC-26.3* RDW-18.5* Plt Ct-819* [**2143-7-19**] 01:06PM BLOOD Neuts-72.4* Lymphs-22.4 Monos-4.2 Eos-0.7 Baso-0.3 [**2143-7-19**] 01:06PM BLOOD PT-11.2 PTT-26.2 INR(PT)-1.0 [**2143-7-19**] 01:06PM BLOOD Glucose-95 UreaN-11 Creat-1.0 Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 [**2143-7-18**] 08:46AM BLOOD ALT-5 AST-13 AlkPhos-76 TotBili-0.1 [**2143-7-19**] 08:19PM BLOOD Albumin-3.1* Calcium-7.6* Phos-2.1* Mg-1.9 [**2143-7-18**] 08:46AM BLOOD calTIBC-572* Ferritn-5.6* TRF-440* [**2143-7-18**] 08:46AM BLOOD %HbA1c-LESS THAN [**2143-7-18**] 08:46AM BLOOD HDL-37 CHOL/HD-2.2 LDLmeas-<50 [**2143-7-18**] 08:46AM BLOOD TSH-1.4 [**2143-7-18**] 08:46AM BLOOD PSA-0.7 Discharge labs: [**2143-7-24**] 03:47PM BLOOD WBC-14.8* RBC-3.29* Hgb-8.2* Hct-26.4* MCV-80* MCH-24.8* MCHC-31.0 RDW-20.8* Plt Ct-708* [**2143-7-24**] 03:47PM BLOOD Neuts-81.5* Lymphs-12.9* Monos-4.2 Eos-1.1 Baso-0.2 [**2143-7-24**] 03:47PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-3+ Polychr-1+ Ovalocy-OCCASIONAL Target-OCCASIONAL [**2143-7-24**] 03:47PM BLOOD Plt Ct-708* [**2143-7-24**] 07:40AM BLOOD Glucose-60* UreaN-6 Creat-1.0 Na-138 K-3.9 Cl-104 HCO3-27 AnGap-11 [**2143-7-24**] 07:40AM BLOOD Glucose-60* UreaN-6 Creat-1.0 Na-138 K-3.9 Cl-104 HCO3-27 AnGap-11 [**2143-7-24**] 07:40AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9 Pertinent Micro/Path: [**2143-7-21**] 3:50 pm ABSCESS Source: right buttock. **FINAL REPORT [**2143-7-27**]** GRAM STAIN (Final [**2143-7-21**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2143-7-27**]): This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. STAPH AUREUS COAG +. SPARSE GROWTH. 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [**2143-7-27**]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. None isolated. [**2143-7-19**] EGD Biopsy results: Gastrointestinal mucosal biopsies: A. Stomach: Chronic active gastritis with organisms morphologically compatible with H. pylori. No intestinal metaplasia identified. B. Duodenum: Within normal limits. [**2143-7-23**] Colonscopy Biopsy results: Results pending Pertinent Imaging: [**2143-7-19**] EGD Findings: Impression: Normal EGD to the third portion of duodenum. Biopsies were taken from the stomach and duodenum [**2143-7-23**] Colonoscopy Findings: Impression: Polyp in the ascending colon (polypectomy) Polyp in the transverse colon (polypectomy) Mass in the cecum (biopsy) Otherwise normal colonoscopy to cecum [**2143-7-23**] 2:03 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # [**Clip Number (Radiology) 94672**] Reason: cancer staging, looking for mets Contrast: OMNIPAQUE Amt: 130 [**Hospital 93**] MEDICAL CONDITION: 67 year old man with anemia and cecal mass REASON FOR THIS EXAMINATION: cancer staging, looking for mets CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: 67-year-old male with anemia and cecal mass. Evaluate for metastatic disease. COMPARISONS: None. TECHNIQUE: MDCT images were obtained from the thoracic inlet to the pubic symphysis after administration of oral and 130 cc of IV Omnipaque contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. DLP: 845 mGy-cm. FINDINGS: CHEST: The visualized portion of the thyroid is unremarkable. No axillary, supraclavicular, hilar, or mediastinal pathologically enlarged lymph nodes are present. The heart and mediastinum are unremarkable. The great vessels are unremarkable. Nonspecific ground-glass opacities are seen in the left upper lobe (3:29). Linear opacities in the lung bases are compatible with scarring. Bilateral pleural effusions, left greater than right, are small in size. No focal consolidation, pneumothorax, or pneumomediastinum is seen. Airways are patent to segmental levels. The esophagus is normal. The soft tissues of the chest wall are unremarkable. ABDOMEN: The liver is normal without focal or diffuse abnormality. A 2.1-cm non-enhancing soft tissue density (73 [**Doctor Last Name **]) lesion within the gallbladder neck is compatible with a non-calcified calculus or sludge ball, although a focal adenomyoma may have a similar appearance. The intra- and extra-hepatic bile ducts, pancreas, spleen, and adrenal glands are unremarkable. Bilateral hypodense renal lesions, measuring up to 1.4 cm in the left kidney and 1.2 cm in right kidney, are compatible with simple renal cysts. The kidneys enhance homogeneously and excrete contrast promptly. The ureters are normal in course and caliber. A small hiatal hernia is present. The small and large bowel enhance homogeneously and have a normal course. The appendix is normal. There is asymmetrical wall thickening of the cecum (3:86), compatible with a cecal mass, which is better characterized on endoscopy. There is adjacent pericecal fat stranding. Two lymph nodes are present in the right lower quadrant immediately anterior to the psoas muscle (3:86). One of these nodes is rounded, measuring to 1.0 cm, and the other is ovoid, measuring 4 mm. No other retroperitoneal or mesenteric lymphadenopathy. The portal and intra-abdominal systemic vasculature are normal. No free abdominal fluid, pneumoperitoneum, or abdominal wall hernia. No omental or peritoneal nodularity is seen. PELVIS: The bladder is unremarkable. The prostate gland and seminal vesicles are unremarkable. A small amount of free non-hemorrhagic pelvic fluid is present. No inguinal hernia. No pelvic sidewall or inguinal lymphadenopathy. OSSEOUS STRUCTURES: Thoracic spine DISH is present with flowing osteophytes along the right aspect of the thoracic vertebral bodies. There is mild thoracolumbar dextroscoliosis. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Asymmetric wall thickening of the cecum, compatible with known cecal malignancy. Adjacent pericecal fat stranding may be expected in the setting of colonoscopy with cecal biopsy, but neoplastic serosal involvement may have a similar appearance. Rounded 10-mm right lower quadrant lymph node is suspicious for metastatic involvement. 2. Small non-hemorrhagic free pelvic fluid is present, unusual for this gender and age group. There is no other evidence for peritoneal or omental metastases. 3. Small nonspecific left upper lobe ground-glass opacities, compatible with an infectious or inflammatory process. Malignancy, particularly metastatic is significantly less likely. Brief Hospital Course: Reason for Hospitalization: 67M with DM and HTN who presents with severe anemia, found to have normal EGD. Believed to have slow LGIB, likely from colonic polyp or malignancy. Active Issues: # Anemia: The patient was originally admitted for blood tranfusion following a finding of Hct 18 at PCP office and EGD negative for acute bleed. His anemia was thought to be due to a slow GI bleed given his gradual weight loss and worsening weakness/lightheadedness. He was transfused pRBCs on multiple occasions of his stay, with frequent hematocrit checks. On [**2143-7-23**] a colonoscopy was performed which showed a 5cm bleeding cecal mass. A CT torse was done for staging, showing no obvious mets, but some fluid in the pelvis and an enlarged LN concerning for metastasis. He and his family were informed of the results. Social work was consulted to help them cope with the news. Dr. [**First Name (STitle) **], the patient's PCP, [**Name10 (NameIs) **] Dr. [**Last Name (STitle) 1120**], Colorectal surgeon, met with the patient to answer questions and arrange close outpatient follow up. The patient's Hct was stabilized. He was discharged with VNA services and instructions to have Hct checks q48-72 hours and frequent vital signs checks. # Fever and tachycardia: One day prior to discharge, the patient developed fever and tachycardia. He was pan-cultured and had a chest XR done showing no acute process. However, given the CT chest finding of possible GGOs in the LUL, he was started on levoquin for possible PNA. He did not complain of cough, and physical exam was free of crackles and he was satting well. UA was negative. Blood cultures pending at time of discharge. His symptoms resolved prior to discharge, and he was sent out to complete a 5 day course of levoquin as an outpatient. #Leukocytosis: During hospitalization, the pt had occasional spike in his WBC with no clinical signs of infection. It would tend to occur following his transfusions, accompanied by elevated platelets. In [**11-19**] days, his counts would normalize. This was thought to be due to bone marrow reaction versus infection. He was treated empirically for infection as above. On discharge, his WBC count was downtrending. #Abscess: Pt presented with chronic, draining R buttock abscess. It was nontender with no fluctuance or induration on exam. Nursing care performed frequent dressing changes. The fluid was cultured, growing coag positive staph aureus and mixed flora. He did not receive antibiotic therapy for this issues, as it was draining. He was discharged with VNA services for dressing changes. Chronic Issues: # T2DM: Held home glipizide and ordered ISS. # HTN: Continued home dose of ramipril. Transitional Issues: - H pylori positive on EGD. Consider starting triple therapy in future once biopsy results are available and Levaquin course is completed. - Levaquin for 5 days for possible CAP - Follow up cecal mass biopsies - Trend Hct, transfuse as necessary - Follow up blood cultures Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. GlipiZIDE XL 5 mg PO DAILY 2. Ramipril 20 mg PO DAILY 3. Aspirin 81 mg PO DAILY Discharge Medications: 1. Ramipril 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. GlipiZIDE XL 5 mg PO DAILY 4. Levofloxacin 750 mg PO DAILY Duration: 5 Days day 1 = [**7-23**] RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnoses: 1. Anemia 2. Cecal mass Secondary diagnoses: 1. Diabetes 2. Hypertension 3. Right buttock abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to [**Hospital1 18**] for anemia requiring blood transfusion. You received multiple units of blood and your anemia improved. A colonoscopy was performed to look in the colon for a source of blood loss. A 5cm mass was found in your colon. Biopsies of the mass were taken and are pending. You will need to follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on Friday morning about this new finding and to review the biopsy results. Your appointment times are below. While you were in the hospital you had a fever and a chest x-ray showed what might be the beginning of a pneumonia. We started you on an antibiotic, Levaquin, for this infection. You will take this for a total of 5 days. You received 2 days of treatment in the hospital, so please continue this for 3 more days. Your last dose is Saturday, [**7-27**]. Followup Instructions: Please see your PCP, [**Name10 (NameIs) **] [**First Name (STitle) **], at the time below: Department: [**Hospital3 249**] When: Friday [**2144-7-25**] at 8:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will get your blood drawn at this time. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**] Completed by:[**2143-7-27**]

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icd9cm

[ [ [] ] ]

[ "45.42", "45.16", "45.25" ]

icd9pcs

[ [ [] ] ]

13800, 13857

10311, 10488

312, 342

14018, 14018

2436, 2436

15099, 15715

1331, 1418

13546, 13777

6514, 6557

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370, 1080

2453, 3199

14033, 14144

12924, 13012

1102, 1147

1163, 1315

1926, 2417

8,252

188,680

16450

Discharge summary

report

Admission Date: [**2122-12-4**] Discharge Date: [**2122-12-14**] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is an 83-year-old gentleman with a past medical history significant for hypertension, hyperlipidemia, history of several transient ischemic attacks over the past year, unilateral renal agenesis, status post open reduction of the right leg at the age of 30, and status post resection of several skin cancers. This 83-year-old male was in his usual state of health until this past [**Month (only) **] when he began developing extreme dyspnea associated with substernal chest burning on exertion which resolved with rest. Since that time he has had no further chest discomfort; however, he has noticed increased shortness of breath on exertion. He underwent an exercise stress test, at which he had to cease exercising after 2 minutes and 46 seconds due to anginal symptoms. The test was notable for anterior ST depressions and a reversible apical defect, at which time he was referred for cardiac catheterization. A cardiac catheterization was performed on [**2122-12-4**] which revealed 80% left main coronary artery disease, 90% left anterior descending artery disease involving the first diagonal, and 90% mid right coronary artery disease. Left ventricular systolic function was normal with an ejection fraction of 70%. The patient was subsequently referred to the Cardiac Surgery Service for coronary artery bypass grafting. HOSPITAL COURSE: The patient underwent coronary artery bypass grafting times four on [**2122-12-7**] with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to the posterior descending artery, saphenous vein graft to first obtuse marginal, and saphenous vein graft to the diagonal. Total cardiopulmonary bypass time was 92 minutes. Total cross-clamp time was 58 minutes. The patient was transferred in stable condition to the Cardiac Surgery Recovery Unit. The patient's blood pressure was initially labile, requiring Neo-Synephrine, nitroglycerin, and some fluids, with the patient's nitroglycerin drip increasing to 4 mcg/kg per minute, which was eventually switched to Nipride to maintain a systolic blood pressure of 110 to 120. Of note, the patient had a right femoral hematoma which had not changed in size since surgery. On postoperative day one, no significant events over the last 24 hours. The patient was afebrile, and vital signs were stable, with an adequate urine output. Physical examination was benign aside from the right groin hematoma which no expansion and no bruit. The patient's white blood cell count was 17.7, hematocrit was 24.7, and platelet count was 118. Sodium was 134, potassium was 5.5, blood urea nitrogen was 18, creatinine was 0.8, and blood glucose was 121. The patient was transferred to the floor on postoperative day one with no complaints. He was administered one unit of packed red blood cells which was administered with Lasix. On postoperative day two, the patient was afebrile, in a normal sinus rhythm at 98. Otherwise, vital signs were stable. On physical examination, the patient had crackles at the left lower base of the lungs. Marginal urine output. He had decreased urine output the night prior. Lasix was administered with little results. The plan was to continue to diurese the patient, increase the patient's Lasix, and to discontinue the patient's Foley catheter as we continued to monitor the patient's urine output. On postoperative day three, the patient with no complaints. The patient was afebrile. Vital signs were stable. In a sinus rhythm at 84. The patient was alert and oriented times three. The patient still with coarse breath sounds bilaterally. A chest tube was still in place. On postoperative day four, the patient was alert and oriented times three. Vital signs were stable. In a normal sinus rhythm in the 90s. On physical examination, the patient still with scattered rales with mild wheezing at the left base. On postoperative day five, the patient with complaints of mild pain with coughing; for which Percocet provided relief. Still with coarse breath sounds bilaterally with wheezing on exertion. The patient was treated with nebulizer treatments as well as chest physical therapy. A chest x-ray was ordered. The patient was urinating well. Upon ambulation, the patient desaturated to 89% with 2 liters of oxygen. His heart rate was in the 80s to 100s with premature atrial contractions during ambulation. On postoperative day six, the patient was afebrile. In sinus tachycardia at 100. Otherwise, vital signs were stable. Physical examination was benign. The patient with no complaints of pain and voiding well. On postoperative day seven, the patient was without complaints. The patient was discharged home with visiting nurse services. Physical examination revealed the patient with clear breath sounds bilaterally. In a normal sinus rhythm. The patient still with oxygen saturations to the mid 80s on room air with ambulation; however, it was felt that no home oxygen was necessary. The patient was not short of breath upon ambulation, and the patient's lungs sounded clearer. At rest, the patient was saturating at 93% on room air. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home. MEDICATIONS ON DISCHARGE: 1. Lasix 40 mg p.o. b.i.d. (for seven days). 2. Ascorbic acid 500 mg p.o. b.i.d. 3. Simvastatin 20 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. 5. Percocet one to two tablets p.o. q.4-6h. as needed (for pain). 6. Colace 100 mg p.o. b.i.d. 7. Metoprolol 50 mg p.o. b.i.d. 8. Polysaccharide-Iron Complex tablets 150 mg p.o. q.d. 9. K-Dur 20 mEq p.o. b.i.d. (for seven days). DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 70**] in four weeks. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting times four. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Doctor Last Name 2011**] MEDQUIST36 D: [**2123-3-25**] 12:11 T: [**2123-3-26**] 08:55 JOB#: [**Job Number 46776**]

[ "753.0", "V10.82", "401.9", "414.01", "998.12", "794.31", "272.0" ]

icd9cm

[ [ [] ] ]

[ "89.68", "88.53", "88.56", "36.13", "39.61", "37.22", "36.15" ]

icd9pcs

[ [ [] ] ]

5932, 6318

5417, 5794

1495, 5290

5829, 5911

5305, 5391

136, 1477

30,282

167,711

5525

Discharge summary

report

Admission Date: [**2116-9-27**] Discharge Date: [**2116-10-2**] Service: [**Last Name (un) **] ADMITTING DIAGNOSES: 1. Lower gastrointestinal bleed. 2. Diverticular disease. 3. Gastroesophageal reflux. 4. Hypothyroidism. 5. History of pulmonary embolus. 6. Hypertension. 7. Coronary artery disease. PAST SURGICAL HISTORY: 1. Percutaneous coronary intervention. 2. Abdominal aortic aneurysm repair in [**2101**]. 3. Colon cancer status post resection in [**2114**]. 4. Bilateral inguinal hernia repairs. MEDICATIONS ON ADMISSION: Benicar 20 mg once a day, pravastatin 10 mg once a day, paroxetine 20 mg once a day, levothyroxine 50 mcg once a day, propranolol 40 mg once a day, metoprolol 25 mg once a day, Flomax 0.4 mg once a day, aspirin 81 mg once a day. CHIEF COMPLAINT: Lower GI bleed. HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old male known to our hospital who was transferred here with a history of a lower GI bleed from an outside hospital. He was admitted there for five days in work-up for this lower GI bleed and both endoscopies from above and colonoscopy failed to reveal the source of the bleed, so he was transferred to our hospital. At that hospital, he received four units of blood. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 98.5, heart rate of 61, blood pressure 141/67, respiratory rate 18 and saturation 97 on room air. In general, he was in no acute distress, alert and oriented x3. HEENT: Normocephalic, atraumatic, injected sclerae, dry mucous membranes. Cardiovascular: He had a regular rate and rhythm with no orthostatic signs. Pulmonary: Chest was clear to auscultation bilaterally. Abdomen was soft. There is a midline incision noted. He was nontender and nondistended. He had good bowel sounds. He had gross blood on rectal exam. Extremities: No clubbing, cyanosis or edema, and he had warm and well- perfused feet. BRIEF HOSPITAL COURSE: The patient was admitted on the [**9-27**] for treatment of his lower GI bleed. Initially, his hematocrit was 27.7 and this steadily declined to 25 over the ensuing day. On hospital day two, he had significant hematochezia and at that time he was transfused two units of blood and was immediately transferred to the [**Hospital Ward Name 517**] in anticipated of a tagged red cell scan and subsequent angiography to attempt embolization of the bleeding vessel. He underwent the tagged red cell scan but this study failed to show the source of the bleed. He was admitted to the surgical ICU for close monitoring after this negative test. On hospital day three, he again suffered colonic bleeding and was again taken for a tagged red cell scan to try to identify the source of the bleed. Again, this test was negative. On hospital day four, he had a 1300 cc hematochezia and also hypotension which prompted a third red cell scan to attempt to identify the source of the bleed. The gastroenterology team made preparations to perform an endoscopy and potential colonoscopy earlier, but as he had appeared to stabilize, these studies were post-poned. The third tagged red cell scan was negative and we brought the patient to the ICU for esophagogastroduodenoscopy. This test was also negative despite the fact that the patient was scoped all the way to the beginning of the jejunum. Thereafter, a CT scan of the abdomen and pelvis were ordered to ensure that the patient did not have an aortoenteric fistula. The patient did have a history of a distant AAA repair back in the [**2098**]. This study also proved negative and was considered to be a normal study. On hospital day five, the patient again had a massive bleed and at this point it was decided, due to two negative EGDs at the outside hospital, one negative EGD here, and a negative colonoscopy at the outside hospital, a negative CT scan here, three negative tagged red cells scans, to directly take the patient to the operating room for a planned total abdominal colectomy which was potentially the only procedure that could save his life. During the 4 day admission to [**Hospital1 18**], he had recieved at least 12 units of transfusion. Initially the patient's family had declined surgery but agreed to proceed if a straightforward outcome could be assured. The patient was taken to the operating room on [**2116-10-1**]. Please refer to the operative note for details of this operation. He appeared to have a fistula from an infected distal aorto-iliac graft to common iliac anastamosis to the appendix, requiring division of his graft. An appendectomy was performed. There was insufficient inflow to the left femoral artery to perform a femoral-to-femoral bypass graft. After discussion with his family, it was elected to not perform an axillo-bifemoral bypass graft. After the patient was returned to the ICU from the operating room, he had threatened limb ischemia bilaterally. The family and staff discussed at length the options and the prognosis for Mr. [**Known lastname 770**], and it was decided to make him comfort measures only. He was extubated in the early afternoon on the [**10-2**] and expired shortly thereafter with his family present. The family declined autopsy. The medical examiner was notified of the death and declined the case. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed. 2. Diverticular disease. 3. Gastroesophageal reflux. 4. Hypothyroidism. 5. History of pulmonary embolus. 6. Hypertension. 7. Coronary artery disease. 8. Iliac-appendiceal fistula. 9. Peripheral vascular disease. 10.Threatened limb ischemia. DISPOSITION: Expired. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Doctor Last Name 9032**] MEDQUIST36 D: [**2116-10-2**] 17:23:33 T: [**2116-10-2**] 19:42:48 Job#: [**Job Number 22300**]

[ "331.0", "414.01", "996.62", "447.2", "568.0", "E878.6", "530.81", "244.9", "553.3", "440.24", "998.11", "E878.2", "V12.51", "584.9", "401.9", "996.1", "V45.82", "569.81", "998.2", "562.10", "V10.05", "294.10", "458.9" ]

icd9cm

[ [ [] ] ]

[ "39.49", "45.13", "56.82", "54.59", "47.09" ]

icd9pcs

[ [ [] ] ]

1910, 5231

5252, 5814

544, 774

335, 517

792, 809

838, 1254

1269, 1886

7,309

118,047

18951

Discharge summary

report

Admission Date: [**2120-2-1**] Discharge Date: [**2120-2-2**] Date of Birth: [**2086-2-18**] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 3283**] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 33 male with HIV/AIDS (CD4 298, VL <50 [**11-29**]), history of cerebral toxoplasmosis ([**2118**]), who presents with a several week history of intermittent headache. Mr. [**Known lastname 51812**] states that he began to experience a bifrontal headache originally on [**2120-1-19**], which has waxed and waned. The headache has been accompanied by "blurry vision", which he states that the has had with prior episodes of HA. He beleves that he had a 'cold' approximately one week ago, with cough, rhinorrhea and subjective fevers. In that setting, his HA increased from a [**2-5**] last week to a [**10-5**] today. Pt was evaluated in ED on [**2120-1-29**] for a presumed viral syndrome (chest film negative for PNA), and was given 2L of IVF. Since his ED visit, his HA has continued, and he experienced several episodese of emesis (two on [**2120-1-30**], one on [**2120-1-31**]). He characterizes the HA as bifrontal and constant. He denies photophobia. He is no longer having rhinorrhea. No teeth pain. Mr. [**Known lastname 51812**] was originally diagnosed with HIV [**7-28**] in the setting of a headache, blurred vision, eventually thought to be secondary to CNS toxoplasmosis (serology IgM-/IgG+, though he had multiple ring-enhancing lesions on MRI). He was treated empirically and was also noted to have elevated CMV VL, treated with valgancyclovir. He has had intermittent headache since that time, including an admission in [**7-29**] for HA, with a negative LP, though MR with several anomalies (multiple areas of susceptibility with minimal ring enhancement. ?cystercarcosis). He was managed conservatively, with improvement in his symptoms. With regards to his HIV, he has been maintained on HAART x 1 year, and has been compliant with regimen. He has also taken his daily Bactrim dose. Azithromycin ppx was d/c'd [**11-29**], given elevated CD4 count. Pt's ED course was notable for administration of 2 grams of ceftriaxone empirically. CT scan was negative for bleed, and LP was performed. LP opening pressure was 12, and tube 4 had two wbc (96% lymphs), 4RBC. He was given a total of 8mg morphine IV. ROS is negative for changes in hearing, abdominal pain, changes in bowel habits, myalgia, arthralgia, or rash. Past Medical History: 1. HIV- as above. HIV, diagnosed [**7-28**]. CD4 nadir 9 [**8-28**]. On HAART x 12 months, adherent with regimen. Discontinued MAC prophylaxis per ID [**11-29**]. H/O CNS toxo ([**2118**]) and presumed CMV meningitis ([**2118**]). Folled by Drs. [**Name5 (PTitle) 8697**]/[**Doctor Last Name **]. 2.CNS toxoplasmosis - presumed, based on mult ring enhancing lesions on MR, though serology with IgG+/IgM- . Responded to empiric therapy with sulfadiazine/leucovorin/pyrimethamine. Complicated hospital course with ? brain herniation requiring mannitol/steroids and ICU care. 3. Hepatis B (positive serology). ?CNS CMV - CMV VL=25,000 [**8-28**], undetectable following valgancyclovir. Social History: Pt left [**Country 2045**] in [**2116**] and came to the U.S. as an illegal immigrant. Also in the U.S. are a brother and sister who live in [**Name (NI) 86**], with whom he had been living until he received his diagnosis of HIV, at which time they kicked him out of their apartment. He subsequently found an apartment in [**Hospital1 392**], where he has been living with a male roommate. However, this roommate is about to get married this month and will move out, so Mr. [**Name14 (STitle) 51813**] will not be able to pay for the apartment on his own. He has been unemployed for several months, relying on food vouchers. He lost his job at a supermarket when his employer fired him for time lost during his hospitalization. Pt. says that at this point he feels he has no one he can talk to, no friends, and lots of worries. He does have one thing he says, and that is his faith. He says that his belief in G-d would never allow him to entertain suicide and he denies SI. He identified his "first worry" to be not his headache but his social stressors, noting that he thinks they cause his HA's, and the HA's then take his mind off of his stressors. Pt no longer communicates with his brother, sister, or his ex-wife. No tobacco. No EtOH. No cigarettes. Family History: Non-contributory Physical Exam: VS: T: 98.2; P:60; BP:130/86; RR: 16; O2:100% on RA General: Young black male, sitting on bed watching television in NAD HEENT: NCAT; PERRL; pt got headache when trying to assess EOM so unable to initially assess. No sinus tenderness. Neck: Left anterior cervical adenopathy, painful CV : RRR S1S2. No M/R/G Lungs: CTA b/l. Good air entry. No changes in percussion. Abd: +BS. Soft, ND. LLQ tenderness to deep palpation. No rebound, no guarding. Neuro: CN II-XII tested: All intact, though EOMI not initially able to be tested. Further tested and were normal. Strength: [**5-30**] upper and lower extremities b/l. Reflexes: brachioradialis, biceps, and patellar all [**2-28**]. Pertinent Results: Labs on admission: [**2120-2-1**] 04:50AM GLUCOSE-95 UREA N-7 CREAT-1.0 SODIUM-139 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11 [**2120-2-1**] 04:50AM PHOSPHATE-4.3 MAGNESIUM-1.9 [**2120-2-1**] 04:50AM WBC-3.2* RBC-4.07* HGB-13.6* HCT-40.6 MCV-100* MCH-33.4* MCHC-33.5 RDW-13.6 [**2120-2-1**] 04:50AM PLT COUNT-279 __________________________ CSF labs: [**2120-1-31**] 09:25PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-4* Polys-0 Lymphs-96 Monos-4 [**2120-1-31**] 09:25PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-69 [**2120-1-31**] 12:03PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY PCR-PND [**2120-1-31**] 12:03PM CEREBROSPINAL FLUID (CSF) EBV-PCR-PND [**2120-1-31**] 12:03PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS - PCR-PND [**2120-1-31**] 9:25 pm CSF;SPINAL FLUID TUBE # 3 [**Country **] INK STAIN HSV. GRAM STAIN (Final [**2120-2-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2120-2-3**]): NO GROWTH. [**2120-1-31**]- Serology blood-RAPID PLASMA REAGIN TEST Negative [**2120-1-31**] CSF fluid- FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Pending): CRYPTOCOCCAL ANTIGEN (Final [**2120-2-3**]): CRYPTOCOCCAL ANTIGEN NOTDETECTED. [**2119-2-1**]- Blood-CRYPTOCOCCAL ANTIGEN NOT DETECTED. _________________________ Radiology: [**2120-1-31**]- CT Head without contrast-There is no evidence of intracranial hemorrhage, midline shift, or mass effect. The ventricles are stable in size. Stable small areas of hypoattenuation in the right caudate and putamen, likely related to prior lacunar infarct. There is evidence of calcification within the basal ganglia. The [**Doctor Last Name 352**]- white matter differentiation remains intact. No acute fracture. There is mucosal thickening within the right maxillary sinus and possibly a small mucosal polyp in the left maxillary sinus. The remainder of the sinuses are well aerated. _________________________ Labs on discharge: [**2120-2-2**] 06:26AM BLOOD WBC-3.5* RBC-4.10* Hgb-13.8* Hct-41.0 MCV-100* MCH-33.7* MCHC-33.7 RDW-13.6 Plt Ct-277 [**2120-2-2**] 06:26AM BLOOD Glucose-101 UreaN-11 Creat-1.1 Na-139 K-4.2 Cl-102 HCO3-27 AnGap-14 [**2120-2-2**] 06:26AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0 [**2120-2-2**] 06:26AM BLOOD VitB12-428 Folate-9.4 [**2120-2-2**] 06:26AM BLOOD TSH-4.0 Brief Hospital Course: 1. Headache Differential diagnosis on admission included migraine, tension headache, HIV related infection, meningitis, or a psychiatric manifestation. A lumbar puncture was performed with protein and glucose not consistent with a meningitis. Gram stain and culture did not grow any thing out. CSF was negative for RPR and cryptococcal antigen. CMV PCR, toxoplasmosis PCR, and EBV PCR are still pending at the time of this discharge summary. Given that pt has a CD4 count > 200 (298 in [**11-29**]) this was thought to unlikely due to toxoplasmosis, though pt does have a history of it. We did not start antibiotics as there was nothing definitive that we were treating. Pt remained afebrile throughout his hospitalization. Upon further speaking with patient, and secondary to his recurrent headaches with negative workups in the past, we further explored pt's social situation (see psychiatry below). Infectious disease consulted and saw Mr. [**Known lastname 51812**]. They did not believe that this was infectious in etiology. MRI was not done as there was no clear indication for it given the negative workup. 2. Psychiatry- Upon speaking with patient, it was clear that he has depressive symptoms and his social and psychological state was a large contributor to his headache. Pt was kicked out of his family's home when they found out that he had HIV. Additionally, pt lost his job secondary to the long hospitalization, and pt has little social support. He admitted to the attending and the medical student that he gets his headache when he thinks about his situation and that it remits when he was talking to them. Because pt had a negative workup of an infectious etiology, it was thought that his symptoms could be attributable to this, as had been thought about in the past by his infectious disease doctors. Pt said that he had decreased concentration, insomnia, and poor appetite. He denied suicidal ideations, saying that he would never consider it because he has a lot of faith and he is a religious man. Vitamin B12, RPR, Folate, and TSH were all normal. Psychiatry saw patient in the hospital. They believed that he had a mood disorder secondary to his medical condition of HIV. He was given follow up with a psychiatrist as an outpatient and psychiatry agreed that pt was not a threat to himself or others. 3. "Blurry vision"- Possibilities on admission included CMV retinitis, migraine, amongst others. CMV retinitis was highly unlikely as CD4 count was >200. Pt had no focal neurological deficits, no change in mental status, and blurry vision remitted. This was likely due to the above as well. Previous work-ups had been negative. The blurry vision resolved upon discharge. 4. HIV- We continued pt's current HAART regimen and Bactrim for prophylaxis. ID saw patient, as above. 5. Pain - Pt had back pain secondary to the LP and also with a headache ([**10-5**]). Pt required morphine in the ED for headache and back pain. The back pain resolved upon discharge. Pt did not complain of headache after the first hospital day and took Tylenol as well. 6. Nausea - Pt was written for prn Compazine. He was not actively nauseous and did not require medication. 7. [**Name (NI) 51814**] Pt was on a bowel regimen and ambulated. 8. F/E/[**Name (NI) **] Pt was on a house diet. Electrolytes were checked. 9. Code [**Name (NI) 13115**] Pt's code status was Full Code. 10. Social Work- Social work was asked to see pt given his lack of housing, and lack of job. He was discharged to a shelter and given the name of someone at [**Hospital1 8**] Cares About AIDS (CCAA), whom he had spoken to before, to help with housing search. Medications on Admission: lamivudine 300 daily stavudine 80 daily atazanavir 400 daily Trimethoprim-Sulfamethoxazole 80-400 mg daily Discharge Medications: 1. Lamivudine 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Stavudine 40 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. Atazanavir Sulfate 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Headache not otherwise specified Depressive symptoms Secondary diagnosis: HIV Discharge Condition: [**Name (NI) 14658**] Pt's headache is a little better. He was seen by both infectious disease department and psychiatry while in the hospital Discharge Instructions: -Please call your doctor or go to the emergency room if you have fevers, chills, worsening headache, vomiting, visual changes, problems walking, dizziness, neck stiffness, feel like you want to hurt yourself, or any other health concern. -Please follow up at your appointments as below. -Please take your medications as prescribed. Followup Instructions: 1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2120-2-8**] 1:30 2. You are set up for a psychiatric appointment. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-3-20**] 10:30 If you cannot make the appointment you should call [**Company 191**] at [**Telephone/Fax (1) 250**] to change the date. 3. You should call your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment. You have one scheduled with him for [**2120-3-15**] at 3:30.

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8552

Discharge summary

report

Admission Date: [**2140-10-11**] Discharge Date: [**2140-10-18**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Black stools, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. H/O GIB w most recent admission on [**2140-9-12**]. Now with black stools since MN accompanied by mid-sternal CP with radiation to left arm. Took all BP meds this AM (per pt, usual BP in the 90s range). Also c/o lightheadedness and SOB. . In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black stool. Patient received morphine for CP with mild improvement in pain. EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L IVFs. Seen by Cards in ED, recommennd echo in AM, . On arrival to the MICU, pt states his discomfort has imporved,d own from [**8-21**] to [**4-21**], described as dull ache in chest, non-radiating, constant since 11 PM last night, as well as discomfort in the lower abdomen (identical to past abd pain in setting of past GIB x 2). + nausea. Past Medical History: --CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] --s/p VT/VF arrest, s/p ICD placement in [**2135**] --Ischemic cardiomyopathy with an ED of 20%, s/p BiV pacer [**10-18**] --Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection --PAF --CKD with baseline Cr. 1.6-2 --Hyperlipidemia --Asthma --Anxiety --Alzheimer's dementia --Hypothyroidism --GI bleed of unknown etiology [**2138**]. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. No ulcers. --Diverticulosis --GERD --S/P Cholecystectomy Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Worked as an off-set printer in [**Location (un) 686**], where he continues to live with his wife. Father of five children. Retired 6 years ago, and since his recent heart problems, says he rarely leaves the house. Most of his time is spent in front of the television with his wife handling their affairs at home. No history of smoking, past or present. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory. Physical Exam: VS: afebrile Heart rate: 75 paced Normotensive and satting well on room air GEN: Elderly male, NAD, lying in bed HEENT: PERRL, anicteric NECK: Supple, no JVD CHEST: CTAB CV: s1s2 + SEM, + heave with lateral displacement of the PMI ABD: +BS, soft, ND, mild TTP lower quadrants bilaterally, no rebound or guarding BACK: No CVAT Rectak: Trace guaiac positive black stool EXT: WD/WP, no pedal edema NEURO: A&O x 3, MAE, speech fluent, nonfocal Pertinent Results: CBC: [**2140-10-11**] 12:45PM BLOOD WBC-9.9 RBC-4.59* Hgb-13.3* Hct-39.8* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.2 Plt Ct-149* [**2140-10-13**] 06:38AM BLOOD WBC-7.8 RBC-4.02* Hgb-11.7* Hct-34.7* MCV-87 MCH-29.0 MCHC-33.6 RDW-14.0 Plt Ct-121* [**2140-10-18**] 05:27AM BLOOD WBC-6.6 RBC-4.06* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.2 MCHC-33.8 RDW-14.9 Plt Ct-152 Coags: [**2140-10-11**] 12:45PM BLOOD PT-24.7* PTT-29.8 INR(PT)-2.4* [**2140-10-14**] 04:45AM BLOOD PT-18.4* PTT-29.4 INR(PT)-1.7* [**2140-10-17**] 04:55AM BLOOD PT-15.2* PTT-31.5 INR(PT)-1.3* Chemistry: [**2140-10-11**] 12:45PM BLOOD Glucose-102 UreaN-31* Creat-2.0* Na-140 K-3.9 Cl-100 HCO3-30 AnGap-14 [**2140-10-13**] 06:38AM BLOOD Glucose-68* UreaN-26* Creat-1.5* Na-142 K-4.1 Cl-103 HCO3-27 AnGap-16 [**2140-10-18**] 05:27AM BLOOD Glucose-85 UreaN-22* Creat-1.7* Na-141 K-3.9 Cl-102 HCO3-30 AnGap-13 [**2140-10-11**] 12:45PM BLOOD Calcium-9.5 Phos-2.7 Mg-2.2 [**2140-10-14**] 04:45AM BLOOD Calcium-8.6 Phos-1.8* Mg-2.1 [**2140-10-17**] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.8 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD CK(CPK)-97 [**2140-10-12**] 03:22AM BLOOD CK(CPK)-90 [**2140-10-12**] 10:26PM BLOOD CK(CPK)-102 LFTs: [**2140-10-11**] 07:15PM BLOOD ALT-24 AST-38 CK(CPK)-92 AlkPhos-86 Amylase-72 TotBili-0.3 Lipase: [**2140-10-11**] 07:15PM BLOOD Lipase-35 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD cTropnT-0.01 [**2140-10-12**] 03:22AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2140-10-12**] 10:26PM BLOOD CK-MB-4 cTropnT-0.01 Digoxin: [**2140-10-11**] 12:45PM BLOOD Digoxin-0.4* ECG: Sinus rhythm with demand ventricular pacing Ventricular premature complexes Since previous tracing of the same date, QRS width shorter, assess LV pacing CXR: FINDINGS: The pacer/defibrillator leads are again seen terminating in the right ventricle and coronary sinus. There are median sternotomy wires. An additional disconnected pacer wire is seen within the left chest wall, as on prior. There is no evidence of pneumonia. There is cardiomegaly, without CHF. There is no pneumothorax or pleural effusion. Degenerative changes are seen at the right humeral head. The bones are otherwise unremarkable. IMPRESSION: No acute intrathoracic process. Cardiomegaly without CHF. ECHO: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with akinesis of all inferior and inferolateral segments and of the basal lateral segments. The other segments are severely hypokinetic. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe focal and global LV systolic dysfunction. Moderate to severe aortic stenosis. Moderate mitral regurgitation. Abdominal XR: FOUR VIEWS OF THE ABDOMEN: There are moderately dilated loops of small bowel, and multiple air-fluid levels are demonstrated on the left lateral decubitus. There is no evidence of free air. Cholecystectomy clips in the right upper quadrant and the right hip arthroplasty are again identified. There is air within the rectum. The left hip demonstrates moderate degenerative change. Midline sternotomy wires and a pacing device are identified. IMPRESSION: Moderately dilated loops of small bowel and air-fluid levels are consistent with ileus or early/partial small-bowel obstruction. Brief Hospital Course: The patient was admitted to the MICU for monitoring and serial Hcts. His BP reamined in the 90-110 systolic range. A Hct drop from 39 to 32 was noted, which then stabilized. GI saw the patient, no plan for emergent scope. Cardiology saw the pt and recommended an echocardiogram. Cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. Diuretics and anti-hypertensives were held. . A/P: 72 yo M with MMP including CAD, CHF, CRI admit with GIB, abdominal pain, and chest pain, now callout from MICU. . # GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI showed erosions in stomach and duodenum c/w NSAID gastropathy, had a normal [**Last Name (un) **] in [**Month (only) 547**]. Hct stable and has not required transfusion. No evidence of active bleed. LFTs normal on admit. Mesenteric ischemia was considered as patient stabalized this was not pursed. He had some persistent nausea which improved with reglan. He was discharged in omeprazole. . # Chest pain: with extensive CAD and CHF history. Echo done this admit as above. He was ruled out for an MI. . # Systolic heart failure: Focal akinesia as above. He was satting well on room air and did not have clinical evidence of heart failure . # Afib: Medications were continued, coumadin was stopped. . # Chronic renal insufficiency: Baseline cr 1.6-2. Currently at baseline. . # Hyperlipidemia: - continue statin . # Hypothyroidism: - continue levothyroxine . # Asthma: - continue home meds . CODE: Full (confirmed with patient) . Communication: Pt, wife [**Doctor First Name **] [**Telephone/Fax (1) 30058**]) Medications on Admission: Sotalol 80mg [**Hospital1 **] Lipitor 20mg daily Donepezil 5mg daily Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS Celexa 60mg daily Protonix 40mg daily ASA 81mg daily Clonazepam 0.5mg TID PRN Lisinopril 5mg daily Digoxin 125mcg, [**1-13**] tab daily K-Dur daily Spironolactone 25mg daily Levothyroxin3e 112mcg daily Trazodone 25mg qHS Mexiletine 150mg TID Albuterol MDI 2puf q6hPRN Fluticasone 110mcg 2puff [**Hospital1 **] Toprol SL 50mg daily Lasix 40mg TID Coumadin Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 5. Quetiapine 25 mg Tablet Sig: as directed Tablet PO three times a day: take 2 tabs every morning, 1 tab at noontime, and 3 tabs at bedtime. 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 9. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain: as previously directed, take up to 3 tabs five minutes apart. 15. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 20. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for nausea. Disp:*45 Tablet(s)* Refills:*2* 21. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 22. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gastrointestinal bleeding . Congestive heart failure, systolic dysfunction, chronic Coronary artery disease Atrial fibrillation Chronic kidney disease Alzheimer's dementia Discharge Condition: Stable Discharge Instructions: You were admitted with bleeding, likely from your stomach. We think that this was in part related to taking coumadin and after much discussion, we have stopped this medication. You blood counts have been stable. . Please return to the hospital or call your doctor if you have worsening abdominal pain, pain after eating, blood in your vomit or stools, dark colored stools, chest pain, shortness of breath, or any new symptoms that you are concerned about. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. . Since you were admitted we have made the following medication changes: * Please stop taking COUMADIN. * Your lasix dose was increased to 80 mg daily. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26894**], to schedule a followup appointment within 2 weeks. . You also have the following upcoming appointments at [**Hospital1 18**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-4**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-25**] 8:40 DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2140-12-19**] 1:00

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icd9cm

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[ "99.07" ]

icd9pcs

[ [ [] ] ]

11456, 11514

7073, 8774

341, 347

11730, 11739

3196, 4235

12472, 13070

2696, 2715

9298, 11433

11535, 11709

8800, 9275

11763, 12449

2730, 3177

4544, 7050

277, 303

375, 1401

1423, 2048

2064, 2680