ChanBeDu/relevant_section_length · Datasets at Hugging Face

63,368

175,479

52211

Discharge summary

report

Admission Date: [**2197-6-2**] Discharge Date: [**2197-6-7**] Date of Birth: [**2122-6-14**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Attending Info 90680**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization Endotracheal intubation History of Present Illness: 74 F has hx COPD, SLE, recent SBO and resection, CAD with demand myocardial necrosis event in [**1-5**], known systolic dysfunction LVEF 45% last echo demonstrating inferolateral hypokinesis with 2+ MR, moderate [**Last Name (un) 6879**] w/ mild right ventricular cavity dilation, [**2-5**] perfusion stress demonstrating medium area of myocardial scar in the distribution of the LCX/OM coronary artery, with mild associated peri-infarct ischemia who presents with several days of volume overload since discharge from SBO resection being treated at rehab with lasix 80 mg [**Hospital1 **], who had acute worsening of shortness of breath yesterday morning requiring 3L NC of O2 to maintain O2 sat of 93%, no previous O2 requirement. Of note, pt states this is how she felt during her NSTEMI event earlier this year. She denies presence of chest pain, lightheadedness, dizziness, palpitations, orthopnea. Endorses shortness of breath, much worsening fatigue, typically pt very active, but yesterday unable to do much of anything, also with cough. . In ED, 97.6 99 149/93 40 100% 15L nrb, got duonebs, solumedrol 125, azithromycin, tachypnea a little better, put on bipap 5/5 fi02 40% very wheezy on exam, got azithro for CHF flare, lasix 20IV. EKG demonstrated new V1, V2, V3 V4 concave down ST segment elevation 2-3 mm which is all new compared to prior EKG, worsened ST segment depression in V5 and V6, and worsened II, III, and aVF ST segment depression. Pt was transferred for COPD exacerbation. Recent vitals 80 102/64 20 100% on bipap fi02 40% . On arrival to [**Name (NI) 153**], pt reports feeling well, much improved compared to earlier, breathing well on bipap. Denies chest pain. Family reports pt with poor appetite since SBO but passing stool and with flatus. No fevers, chills, sputum production. Given concerning EKG changes, pt given 325 aspirin, started on heparin, repeat EKG confirmed new changes, stat cardiology c/s and echo performed. Echo demonstrated new LVEF 25% with moderate to severe regional left ventricular systolic dysfunction, most c/w multivessel CAD. Patient was transferred to the [**Hospital Ward Name **] for cardiac catheterization and further evaluation of her disease. In the cath lab the patient was found to have a tight circumflex and LAD lesion. The circ lesion was felt to be the culprit lesion. The circ was ballooned and while trying to stent the circ the patient went into PEA arrest. CPR started and one round of epi given, intubated, IABP placed and dopamine started ROSC occurred, and dopamine stopped. Circ was ballooned multiple times, but difficulty getting stent deployed and LAD went down transiently and patient pressures dropped so dopamine started. Patient was stabilized on 5 mcg/kg/min of dopamine. Able to place 1 bare metal stent from left main to LAD, no circ stents placed. Reshooting the vessels showed good flow through LAD, crcumflex and RCA was filling by collaterals. Venous sheath still in place. During this event the patient was aware of what was going on and was intubated for prophylaxis purposes other than urgent need. Transferred to the CCU for further management. Past Medical History: COPD (chronic obstructive pulmonary disease) Coronary artery disease NSTEMI (non-ST elevated myocardial infarction) Systemic lupus Dermatitis GASTRIC ULCER: history of GASTROINTESTINAL BLEEDING EPICONDYLITIS, LATERAL HUMERAL PULMONARY NODULES / LESIONS - MULT COLONIC POLYP DIVERTICULOSIS MAMMOGRAM MICROCALCIFICATION ARTHRALGIA - HAND-RT PISIFORM TOBACCO DEPENDENCE DEPRESSIVE DISORDER HEARING LOSS, SENSORINEURAL HYPERTENSION - ESSENTIAL DUPUYTREN'S CONTRACTURE HEADACHE, MIGRAINE MENOPAUSE POSITIVE PPD Social History: Smoking: Quit recently, 60 pack-year history Alcohol: No Adv Directives: DNR/DNI Very active, lives at home, worked at [**Hospital1 **] as behavioral counselor until this past summer. Now taking classes at [**Hospital1 498**]. Was doing yoga and walking daily up until 3 weeks ago. Family History: Depression, breast cancer, alcoholism Physical Exam: On Admission: General: intubated and sedated, not opening eyes to command HEENT: PERRL, sclera anicteric, contuctiva pink Neck: supple, JVP unable to assess CV: Regular rate and rhythm, normal S1 + S2, difficult to auscultate heart sounds and murmurs over balloon pump sounds Lungs: Clear to auscultation bilaterally in anterior lung fields Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: Foley in place Ext: Warm, well perfused, 1+ pulses, no pitting edema Neuro: PERRL, unable to assess other neuro exam due to sedation On Discharge. Afebrile and no longer intubated. Alert and oriented x3. Neuro exam nonfocal. Balloon pump and foley removed. Exam otherwise unchanged. Pertinent Results: ADMISSION LABS: [**2197-6-2**] 10:05AM BLOOD WBC-9.1 RBC-3.21* Hgb-9.7* Hct-30.9* MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5* Plt Ct-341# [**2197-6-2**] 10:05AM BLOOD Neuts-85.6* Lymphs-10.8* Monos-3.1 Eos-0.2 Baso-0.3 [**2197-6-2**] 10:05AM BLOOD PT-18.2* PTT-30.5 INR(PT)-1.7* [**2197-6-2**] 10:05AM BLOOD Glucose-137* UreaN-11 Creat-0.6 Na-132* K-4.9 Cl-93* HCO3-29 AnGap-15 [**2197-6-2**] 10:05AM BLOOD CK(CPK)-131 [**2197-6-2**] 10:05AM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 108016**]* [**2197-6-2**] 02:14PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.4* [**2197-6-2**] 02:21PM BLOOD Type-ART Temp-39.2 pO2-157* pCO2-43 pH-7.48* calTCO2-33* Base XS-8 Intubat-NOT INTUBA CARDIAC ENZYME TREND: [**2197-6-2**] 10:05AM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 108016**]* [**2197-6-2**] 10:05AM BLOOD cTropnT-0.03* [**2197-6-2**] 02:14PM BLOOD CK-MB-6 cTropnT-0.03* [**2197-6-2**] 08:30PM BLOOD CK-MB-6 cTropnT-0.06* PERTINENT REPORTS: TTE [**2197-6-2**] Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with inferolateral, anterior and anteroseptal hypo- to akinesis. The remaining segments contract normally (LVEF = 30%). The right ventricular cavity is mildly dilated with normal free wall contractility. 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. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate to severe regional left ventricular systolic dysfunction, most c/w multivessel CAD. Moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2197-1-12**], regional LV wall motion abnormalities in the LAD distribution are new. The RCA (or dominant LCx)-supplied segments remain hypokinetic. Overall LV systolic function has significantly deteriorated. Findings discussed with Dr. [**Last Name (STitle) **] at 1545 hours on the day of the study PTCA COMMENTS [**2197-6-2**]: Initial angiography showed an origin 95% stenosis of the LCx extending back into LMCA. After discussion with referring cardiologist, we planned to treat this lesion with PTCA and stenting. Heparin was continued with therapeutic ACT. A 5F XB LAD 3.5 guiding catheter provided adequate though suboptimal support for the procedure. A Prowater wire crossed the lesion with minimal difficulty into distal LCx. The lesion was dilated with a 2.5x12mm Apex RX balloon at 12 atms however a waist remained. We further dilated the lesion with a 2.5x8mm NC Quantum apex Mr balloon at 10 atms without complete expansion likely due to calcification of the artery. We then dilated the lesion with a 2.5x10mm Angiosculpt EX balloon at 14 atms for 30secs. After the balloon was deflated, the blood pressure was noted to be extremely low and PEA arrest noted. CPR was started and epinephrine given. A pulse returned and an IABP was placed from the RFA approach. Anesthesia proceeded to intubate the patient. The blood pressure improved and dopamine was stopped. Interval angiography showed little to no flow in the LCx. The Lcx was re-wire with the Prowater wire and flow was restored. The ostium of the LCx was dilated with a 1.5x12mm Apex Push balloon. We then attempted in multiple different ways to deliver a stent to the ostium of the LCx, however were unsuccessful. A 3.0x15mm Integrity bms or a 3.0x12mm Integrity. WE then placed a Choice Floppy wire in the LCx as a buddy wire, but again could not deliver even a short 3.0x9mm integrity bms. We then attempted to dilate the lesion again with a 3.0x12mm NC Quantum apex balloon however, just as the balloon crossed the lesion (prior to inflation) the patient again became hypotensive requiring dopamine and angiography showed slow flow in the LAD. The balloon was immediately removed and the wire was redirected down the LAD. Integrilin was started at this point (renally dosed). The proximal LAD was dilated with the 3.0x12mm balloon at 6 atms for suspected LM dissection and flow was restored in the LM-LAD. Given suspicion for LM dissection, we decided to stent LM into LAD. A 3.0x22mm RX Integrity BMS was deployed in LM into LAD at 12 atms. We then re-wired the LCx through the strut and dilated the origin of the LCx with a 2.25x12mm NC Quantum apex balloon at 15 atms. With the wire in LAD we postdilated the proximal stent segment in LMCA with a 3.5x8mm NC Quantum apex balloon at 12 and 16 atms. Final angiography showed no residual stenosis in the LMCA or LAD. There was 60% residual stenosis in the origin LCx. There was no angiographically apparent dissection and TIMI 3 flow in LAD and LCx. The patient's blood pressure improved and the patient was transferred to CCU. TTE [**2197-6-5**] Conclusions The left atrium is mildly elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokensis of the basal inferior and inferolateral walls. The remaining segments contract normally (LVEF = 45%). [Intrinisic left ventricular systolic function may be more depressed given the severity of mitral regurgitation. ] The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with reduced regional function consistent with CAD (PDA or LCX distribution). Moderate mitral regurgitation. Pulmonary artery hypertension. Compared with the prior study (images reviewed) of [**2197-6-2**], regional and global left ventricular systolic function have improved. The estimated PA systolic pressure is now higher. DISCHARGE LABS: [**2197-6-7**] 06:28AM BLOOD WBC-6.8 RBC-3.47* Hgb-10.9* Hct-33.6* MCV-97 MCH-31.4 MCHC-32.4 RDW-16.3* Plt Ct-217 [**2197-6-7**] 06:28AM BLOOD PT-15.0* PTT-28.3 INR(PT)-1.4* [**2197-6-7**] 06:28AM BLOOD Glucose-81 UreaN-11 Creat-0.6 Na-138 K-3.9 Cl-97 HCO3-37* AnGap-8 [**2197-6-7**] 06:28AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: 74 yo woman admitted with shortness of breath, found to have ST elevations and new wall motion abnormality concerning for STEMI who had PEA arrest during cardiac cath now s/p BMS to LM/LAD and PTCA to the [**Hospital **] transferred to the CCU on dopamine, intubated, sedated and with IABP. # Cardiac Arrest: Patient with PEA arrest in the setting of cardiac catheterization. There was some concern that while accessing the left circumflex there was plaque that went off the left main down the LAD resulting in PEA arrest. CPR was started, epinephrine was given, and she was rescucitated within 5 minutes. Intra-aortic ballon pump (IABP) was placed and patient was transferred to CCU on heparin and dopamine drips with normal HR and SBP's in the 130's. Her IABP was removed on [**6-3**] after there was blood noted in the pump tubing and heparin was discontinued. Dopamine was discontinued the morning [**6-4**], and she was extubated later that day without event. She remained hemodynamically stable the remainder of her hospitalization. # ST elevation myocardial infarction (STEMI): Pt presented with shortness of breath, similar presentation to her NSTEMI in [**Month (only) 404**]. She was noted to have STE anteriorly in V1 and V2 and q waves V1-V3 with depressions in V5, V6, II, III, and AVF. Echo revealed new wall motion abnormality in the distribution of the LAD. She was brought emergently to the cath lab given concern for STEMI. In the cath lab, she had severe occlusion of circumflex with narrowing of his proximal LAD. She had bare metal stent (BMS) placed to left main/left anterior descending artery (LM/LAD) and angioplasty (PTCA) to circumflex (see report for further details). She underwent PEA arrest and was resuscitated as above. She was started on aspirin 325, plavix 75, and atorvastatin 80mg. Integrellin was started in the cath suite and continued for 12 hours in the CCU. Metoprolol and lisinopril were initially held in the setting of hypotension. Metoprolol was started on [**6-4**] following the discontinuation of the dopamine drip. Lisinopril was started on [**6-5**] and aspirin was decreased to 81 mg daily. TTE showed mild regional left ventricular systolic dysfunction with hypokensis of the basal inferior and inferolateral walls and LVEF of 45%. # Acute on chronic systolic and diastolic dysfunction: Patient with bilateral pleural effusions and fluid overload on presentation to CCU, likely due to acutely decreased LVEF as seen on TTE on [**6-2**]. She was diuresed with 40mg IV before transition to her home dose of 60mg daily. Repeat TTE showed mild regional left ventricular systolic dysfunction with hypokensis of the basal inferior and inferolateral walls and LVEF of 45%. She was started on metoprolol and lisinopril as above. # Hct drop: Patient's HCT noted to drop to 24.1 from 30 in the setting of heparin gtt, IABP with blood in tubing, and blood loss during procedure. Heparin was stopped when IABP was discontinued and she received 1 unit pRBC with appropriate increase in her HCT. HCT remained stable during remainder of hospitalization. CHRONIC ISSUES: # COPD: Continued albuterol and iptratroprium nebulizers as need while in house. She was continued on her home dose of Spiriva on discharge. # Hyperlipidemia: Patient was continued on her home dose of atorvastatin 80mg daily. She may continue to take her fish oil upon discharge. # SLE: Stable, continued hydroxychloroquine. TRANSITIONAL ISSUES: - Would check HCT on FU to ensure stability - Would monitor volume status carefully and adjust lasix dosing as needed Medications on Admission: Fish oil 1200 mg PO BID Omeprazole 20 mg Po daily Aspirin 81 mg PO daily Metoprolol XL 25 mg daily Atorvastatin 80 mg po daily Duonebs q4h Lasix 60 mg PO Qam and sometimes received 20mg prn Recently stopped levaquin and flagyl on [**5-31**] for 7 day course. COMPLETED. Ativan 1 mg Q6h PRN anxiety and at bedtime Lisinopril 2.5 mg Oral Tablet 1 TABLET PO DAILY Nitroglycerin 0.4 mg Sublingual Tablet, Sublingual 1 tablet sublingually as needed for chest pain; may repeat every 5 min x 3 doses (never used) Hydroxychloroquine 200 mg Oral Tablet 1 tab daily Citalopram 40 mg Oral Tablet TAKE ONE TABLET DAILY Alendronate 35 mg Oral Tablet take 1 tablet every week Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or Wheeze 2. Fish Oil (Omega 3) 1200 mg PO BID 3. Omeprazole 20 mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg daily Disp #*30 Tablet Refills:*3 6. Atorvastatin 80 mg PO HS 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheeze 8. Lorazepam 2 mg PO HS:PRN sleep 9. Lisinopril 2.5 mg PO DAILY Please hold for SBP < 100 10. Nitroglycerin SL 0.4 mg SL PRN chest pain [**Month (only) 116**] repeat every 5 minutes for 3 doses. RX *Nitrostat 0.4 mg as directed for chest pain Disp #*25 Tablet Refills:*0 11. Hydroxychloroquine Sulfate 200 mg PO DAILY Start: In am 12. Citalopram 40 mg PO DAILY Start: In am 13. Alendronate Sodium 35 mg PO 1X/WEEK (MO) 14. Tiotropium Bromide 1 CAP IH DAILY 15. Clopidogrel 75 mg PO DAILY for the recommended duration RX *Plavix 75 mg daily Disp #*90 Tablet Refills:*3 16. Furosemide 40 mg PO DAILY Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: ST elevation myocardial infarction Lupus Mitral regurgitation Emphysema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 6129**], You were admitted to the hospital because you were having shortness of breath. We found that you were having a heart attack. We brought you to the cardiac catheterization lab and placed a stent in one artery in your heart and opened up another artery with a balloon angioplasty. During the procedure, you heart briefly stopped pumping but we were able to resuscitate you quickly. You temporarily had a pump placed to help your heart pump blood and a breathing tube to help you breathe. Both of these were removed and you have done very well since. Followup Instructions: Name: [**Last Name (LF) 14147**],[**First Name3 (LF) **] E. Location: [**Location (un) 2274**] [**Location **] [**Location 29702**] Care Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 20035**] ****Please call Dr [**Last Name (STitle) **] office once you are home to book a follow up appointment within a week of discharge. Name: [**Name (NI) **], [**Name (NI) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) 2274**] [**Location (un) **]-Cardiology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] ***The office is working on an appt for you in the next [**1-28**] weeks and will call you at home with the appt. IF you dont hear from them by Friday, please call the office directly to book.

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Discharge summary

report

Admission Date: [**2201-12-4**] Discharge Date: [**2201-12-11**] Date of Birth: [**2139-12-17**] Sex: F Service: CARDIOTHORACIC Allergies: Seroquel / Milk Of Magnesia Attending:[**First Name3 (LF) 5790**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: [**2201-12-4**] Tracheoplasty [**2201-12-7**] Bronchoscopy History of Present Illness: Ms. [**Known lastname 45465**] is a 61 year-old female with severe TBM complicated by recurrent pneumonias. She has had interval evaluation for swallowing difficulties. She was also seen by [**First Name8 (NamePattern2) **] [**Doctor Last Name **] of Cardiology on [**8-14**]. Dr.[**Last Name (STitle) **] stated that there is no need for any further testing prior to her undergoing tracheobronchoplasty as she has stable symptoms. She recommended that she remain on statin and Norvasc throughout the perioperative period and aspirin be discontinued for surgery and resumed when safe from the surgical standpoint. Currently, she is at her baseline. She stills gets SOB walking 10 to 15 feet. Past Medical History: Severe TBM Schizophrenia Anxiety/depression H/o sexual abuse Asthma COPD S/p ASD repair [**2151**] S/p L hip replacement [**2191**] S/p multiple R leg fractures [**2191**] Social History: Lives in group home in [**Location (un) **] ("[**Doctor First Name **] House"). Lives with a roommate. Mother lives nearby in family home; they are very close and see each other 1-2x/week. She has a h/o tobacco 3ppd x 10years, quit 10 years ago. Denies EtOH or other drug use. Has a h/o sexual abuse while in a hospital in the [**2161**]'s, and has been seeing the same psychiatrist ([**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 100807**]) for 30 years. Family History: GM died of lung ca, mother survivor of lung ca Physical Exam: VS: T: 98.9, P: 92, BP: 124/70, 18, 96% 1LNC Physical Exam: Gen: pleasant in NAD sitting in chair, with baseline facial discoloration Lungs: clear bilaterally t/o to ausc. Chest: right thoracotomy incision healing without redness, purulence or drainage. CV: RRR, S1, S2, no MRG or JVD Abd: Active BS x 4 quadrants, distended but non tender to palpation Ext: warm, pulses intact, without edema. Pertinent Results: [**2201-12-10**] 06:25AM BLOOD WBC-9.2 RBC-3.35* Hgb-9.4* Hct-28.7* MCV-86 MCH-28.2 MCHC-32.8 RDW-14.8 Plt Ct-487* [**2201-12-10**] 06:25AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-24 AnGap-16 CXR [**2201-12-10**] Impression: 1. Increased opacification of the left base likely secondary to atelectasis. 2. No significant change in the right basilar opacity. 3. Multiple loops of distended bowel, better seen on the lateral projection. Brief Hospital Course: Ms. [**Known lastname 45465**] was admitted on [**2201-12-4**] where she underwent thoracic tracheoplasty with mesh right mainstem bronchus/bronchus intermedius bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, flexible bronchoscopy and bronchoalveolar lavage, by Dr. [**Last Name (STitle) **]. Please see operative report for full details. The patient recovered in the Intensive Care unit. She was extubated post operative day 0. She had an epidural which was managed and followed by acute pain service, discontinued [**2201-12-9**]. On [**2201-12-7**] she underwent bronchoscopy for aspiration of secretions. The patient was transfered to the floor on [**2201-12-8**], undergoing further therapeutic bronchoscopy for secretions on [**2201-12-9**]. The patient had aggressive pulmonary toilet with chest physiotherapy. Her foley was dc'd after her epidural, with two straight catheterizations for retained urine, last [**2201-12-11**] at 3am, although she has voided well since. Her main issue is constipation. She had not had a bowel movement for days, despite aggressive bowel regimine. This is an ongoing issue for the patient. She did however have 4 small BM's on the date of discharge. She has tolerated a regular diet. Regarding her mood: the patient has been appropriate and resumed on her psych medications. She should follow up with her psychiatrist when discharged home. Physical therapy saw the patient while on the floor and recommended rehab, which she is cleared to go to. The patient was started on levaquin for possible mediastinitis which is due to end [**2201-12-13**]. It is noted that the patient is cleared by insurance for a less than thirty day rehab stay, per our case manager. Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours): Take until [**2201-12-13**] last dose . 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours). 3. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for secretions. 4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Chlorpromazine 100 mg Tablet Sig: Twelve (12) Tablet PO QHS (once a day (at bedtime)). 15. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for groin and breast area. 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). units 21. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day) as needed for anxiety. 22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed for constipation. 23. Magnesium Citrate 1.745 g/30mL Solution Sig: Three Hundred (300) ML PO once a day as needed for constipation. 24. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 25. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 26. Aspirin 81 mg po daily Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare-[**Location (un) 86**] Discharge Diagnosis: 1. Tracheobronchomalacia 2. COPD 3. GERD 4. Schizophrenia 5. Osteoarthritis 6. Skin discoloration from longtime thorazine use 7. Anxiety 8. Asthma 9. PTSD 10. Chronic constipation. Discharge Condition: stable Discharge Instructions: Ambulate with physical therapist or assistant 3 times per day. Use your incentive spirometer 10 times every hour. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] in two weeks. [**Doctor Last Name 2048**] with Dr.[**Name (NI) 14679**] office will call to arrange appointments with your rehab. Eat nothing after midnight the night before to anticipate a bronchoscopy. Dr.[**Name (NI) 14679**] office number: [**Telephone/Fax (1) 10084**] Dr.[**Name (NI) 2347**] office number: [**Telephone/Fax (1) 2348**] Completed by:[**2201-12-11**]

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icd9cm

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76,034

186,063

40415+58368

Discharge summary

report+addendum

Admission Date: [**2141-7-17**] Discharge Date: [**2141-8-1**] Date of Birth: [**2072-8-22**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 473**] Chief Complaint: painless jaundice, gallbladder carcinoma Major Surgical or Invasive Procedure: [**2141-7-17**] - ERCP - biliary evaluation with biopsy [**2141-7-20**] - percutaneous transhepatic cholangiography [**2141-7-21**] - esophagogastroduodenoscopy (EGD) with duodenal stenting [**2141-7-27**] - percutaneous transhepatic biliary drainage with right-biliary tree catheter exchange [**2141-7-28**] - percutaneous transhepatic biliary drainage with left and right metal biliary stent placement History of Present Illness: This is a pleasant 68-year old female who intially presented six weeks ago to an outside hospital with RUQ pain concerning for acute cholecystitis. Surgery was deferred due to co-morbidities and a percutaneous cholecystostomy drain was placed. The patient was then discharged to [**Hospital 582**] Rehab with a plan for possible outpatient cholecystectomy once the inflammation resolved. At rehab the perc chole tube was unintentionally removed. Approximately 1.5 wks ago the patient became increasingly jaundiced. She was again evaluated at [**Hospital3 20284**] Center in [**Hospital1 189**] where CT and MRI showed dilated intrahepatic ducts and CBD with proximal narrowing near the cystic duct concerning for Mirizzi's syndrome. The patient was referred to Dr. [**Last Name (STitle) 48587**] for ERCP/decompression. ERCP was attempted but unsuccessful as the scope could not pass an edematous duodenal bulb. Ms. [**Known lastname 4135**] was then transferred to [**Hospital1 18**] for further management. Past Medical History: PMH: A.fib (not anticoagulated), DM2, HTN, dyslipidemia, anemia PSH: percutaneous cholecystostomy tube, wisdom tooth extraction, cataract surgery, ERCP - at [**Hospital3 **] (date unknown), ERCP - [**2141-7-14**] aborted, ERCP [**2141-7-17**] [**Hospital1 18**] Social History: No tobacco or recreational drug use. Social alcohol use. Resides in an [**Hospital3 **] facility. Family History: Mother - Breast CA, Father - CAD Physical Exam: PHYSICAL EXAM (on admission): VS: HR: 68 BP: 162/68 RR: 18 SaO2: 97% Gen: markedly jaundiced, sclera icteric, NAD Neuro: A&O Resp: CTA b/l CV: RRR, no M/R/G Abd: soft, non-tender, non-distended, no masses or hernias Extrem: no peripheral edema, feet WWP Pertinent Results: [**2141-7-31**] 03:59AM BLOOD WBC-9.5 RBC-2.45* Hgb-8.0* Hct-24.3* MCV-99* MCH- 32.6* MCHC-32.8 RDW-19.5* Plt Ct-508* [**2141-7-27**] 05:56AM BLOOD PT-13.2 PTT-28.8 INR(PT)-1.1 [**2141-7-31**] 03:59AM BLOOD Glucose-74 UreaN-6 Creat-0.5 Na-136 K-4.2 Cl-101 HCO3-28 AnGap-11 [**2141-8-1**] 05:30AM BLOOD ALT-46* AST-34 AlkPhos-610* TotBili-8.4* [**2141-7-28**] 04:44AM BLOOD Lipase-65* [**2141-7-31**] 03:59AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.6 [**2141-7-18**] 06:50AM BLOOD CEA-134* AFP-2.1 [**2141-7-18**] 06:50AM BLOOD CA [**49**]-9 -Test [**2141-7-18**] CT ABDOMEN/PELVIS WITH CONTRAST - Moderate-to-severe intrahepatic biliary duct dilatation. Dilatation of the proximal common bile duct with abrupt cutoff of the lumen at the level of the liver hilum. Markedly abnormal gallbladder with irregular enhancing wall thickening. Enhancing soft tissue extending to the liver hilum and second portion of the duodenum, encasing the duodenum. Due to the extensive soft tissue extension the appearance is concerning for gallbladder carcinoma, differential diagnosis includes Mirizzi syndrome although this is considered less likely. Gallstones are not seen on CT and ultrasound would be helpful to document an obstructing stone in the cystic duct. Bilateral small pleural effusions. Soft tissue stranding along the right paracolic gutter; uncertain clinical significance, this may be postsurgical, however peritoneal metastases canot be entirely excluded. Thrombosis of the middle hepatic vein with corresponding wedge-shaped hypoperfusion of the liver. [**2141-7-27**] CT ABD & PELVIS WITH CONTRAST - Persistent mild dilatation of the left biliary ducts which is improved from the [**2141-7-18**] CT. Significantly improved appearance to the right biliary ducts which are decompressed by the indwelling percutaneous biliary catheter. Unchanged appearance to the gallbladder, again most consistent with invasive gallbladder carcinoma. Findings remain highly suspicious for peritoneal disease along the right paracolic gutter. Unchanged extension to the portal hilum and second portion of the duodenum as noted previously. Interval increase in size to moderate right and small left pleural effusion. Moderate ascites within the pelvis. Brief Hospital Course: Mr. [**Known lastname 4135**] is a 68 year-old female who intially presented to an outside hospital with RUQ pain concerning for acute cholecystitis. A percutaneous cholecystostomy tube was placed given her poor surgical candidacy, and she was discharged to [**Hospital 582**] Rehab facility. Her perc cholecystostomy tube was removed unintentionally at rehab. She noticed worsening jaundice and represented to [**Hospital3 20284**] Center in [**Hospital1 189**] where a CT and MR imaging showed dilated intrahepatic ducts and dilated CBD with proximal narrowing, concerning for Mirizzi's syndrome initially. She was referred for ERCP and decompression but this was unsuccessful as the scope could not pass the edematous duodenal bulb. She was transferred to [**Hospital1 18**] for further management. She was admitted on [**2141-7-17**] for management of her obstructive jaundice. On [**2141-7-17**], an ERCP was re-performed and a circumferential infiltrating mass causing near complete obstruction was noted at the second part of duodenum and biopsies were performed which yielded chronic duodenitis, but no malignancy. A CT scan performed on [**7-18**] demonstrated moderate-to-severe intrahepatic biliary duct dilatation. Dilatation of the proximal common bile duct with abrupt cutoff of the lumen at the level of the liver hilum was noted. A markedly abnormal gallbladder with irregular enhancing wall thickening was noted. Enhancing soft tissue extending to the liver hilum and second portion of the duodenum, encasing the duodenum, was noted. Due to the extensive soft tissue extension the appearance was concerning for gallbladder carcinoma. On [**7-20**], PTC was performed showing occlusion of the upper CBD with biliary dilitation above. The duodenum at the ampulla was not well opacified but the third and fourth portions appeared within normal limits. Uncomplicated right-sided PTBD with 8-French internal-external drain placement was performed. A this point, EGD with duodenal stenting was performed on [**2141-7-21**], to bypass the obstructing duodenal mass noted above. From [**Date range (1) 32604**] the biliary drain was capped and her diet was advanced from clears to full liquids. She tolerated this well initially. She did have poor ability to clear secretions and given her extensive hospitalization, there was concern for poor respiratory status. She had a CXR on [**7-23**] which demonstrated findings concerning for RLL pneumonia and she was monitored closely with chest PT and encouragement of IS. She was afebrile at that time. On [**7-24**], a trigger alert was called and the patient was doing poorly. Her mental status was diminished and she was minimally interactive. Her blood pressure dropped and her HR was elevated. There was concern for sepsis. In an effort to determine the source, the biliart drain was uncapped, revealing foul-smelling bilious drainage and laboratory studies, along with cultures, were obtained. As noted above, her RLL infiltrate was of concern and work-up at the time demonstrated findings consistent with a UTI. Given all infectious sources, she was fluid resuscitated, started on IV Vancomycin and Zosyn following obtained cultures and transferred to the surgical ICU for further care. She was transferred back to the floor on [**7-25**] after clinical improvement and antibiotic coverage. Her bile culture speciated MRSA which was treated with Vancomycin and Zosyn. On [**7-27**], repeat PTC was performed and PTBD demonstrated persistent dilatation of the left biliary system, thus metal stenting was not attempted. The patient underwent a CT scan again on [**7-27**] showing persistent mild dilatation of the left biliary ducts which is improved from the [**2141-7-18**] CT. Significantly improved appearance to the right biliary ducts which are decompressed by the indwelling percutaneous biliary catheter. Unchanged appearance to the gallbladder, again most consistent with invasive gallbladder carcinoma. Given these findins, repeat PTBD was performed on [**7-28**] and left and right metal biliary stent placement was successful, and IR left an external drainage route at that time given her previous cholangitic issues and MRSA infection. On [**5-27**] her PTBD drain remained capped with her metal biliary and duodenal stents in place on cholangiography. She was then advanced from clear liquids to a regular diet with supplementation. She was evaluated by physical therapy and was noted to be suitable for a rehab facility. She will be scheduled to follow-up with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 189**] Oncologist regarding her likely invasive gallbladder carcinoma for proper staging and possible treatment. She was to complete a 2-week course of Vancomycin and Zosyn given her RLL pneumonia concerns and her biliary MRSA infection. She was looking well prior to discharge. Medications on Admission: metoprolol (50''), insulin (Lantus 10 QHS/Regular per SS), Omeprazole (20'), Oxycodone Hydrochloride (5'''), OTCs: Tylenol, Iron, Bowel maintenance. Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 3. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. insulin aspart 100 unit/mL Solution Sig: per sliding scale see sliding scale Subcutaneous with meals as needed for hyperglycemia. 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous every twelve (12) hours: end date [**2141-8-6**]. 11. Zosyn 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every eight (8) hours: end date [**2141-8-6**]. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Hospital1 189**] Discharge Diagnosis: 1. Invasive gallbladder carcinoma 2. Right lower lobe pneumonia 3. Pressure ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-20**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . PTBD Drain Care: *Keep drain capped *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . 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: Provider: [**Name10 (NameIs) 706**] CARE,NINE [**Name10 (NameIs) 706**] CARE UNIT Phone:[**Telephone/Fax (1) 446**] Date/Time:[**2141-8-7**] 11:00 [**Hospital Ward Name 121**] building [**Location (un) **], [**Hospital Ward Name **] Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2141-8-7**] 12:30 You will be given instructions regarding follow-up with an outpatient oncologist for your gallbladder carcinoma. If you are unable to contact a physician regarding your carcinoma, please call Dr.[**Name (NI) 9886**] office at [**Telephone/Fax (1) 2835**] and we can facilitate this appointment setup. Name: [**Known lastname 8180**],[**Known firstname 779**] Unit No: [**Numeric Identifier 14058**] Admission Date: [**2141-7-17**] Discharge Date: [**2141-8-1**] Date of Birth: [**2072-8-22**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4987**] Addendum: Follow up appointment: Provider: [**Name10 (NameIs) 14059**], MD (Oncology) Phone: [**Telephone/Fax (1) 12389**] Date/Time: [**2141-8-9**] 10:15 AM, [**Street Address(1) 14060**] [**Doctor Last Name 14061**] 4, [**Hospital1 **], [**Numeric Identifier 14062**] Discharge Disposition: Extended Care Facility: [**Location (un) 176**] of [**Hospital1 1612**] [**Name6 (MD) 116**] [**Last Name (NamePattern4) 4988**] MD [**MD Number(1) 4989**] Completed by:[**2141-8-1**]

[ "576.2", "518.0", "535.60", "707.03", "427.31", "537.3", "V02.54", "156.0", "486", "041.12", "707.23", "567.81", "453.0" ]

icd9cm

[ [ [] ] ]

[ "45.13", "51.10", "51.12", "97.05", "45.14", "87.54", "38.93", "46.86", "87.51", "51.98" ]

icd9pcs

[ [ [] ] ]

14731, 14946

4799, 9678

342, 747

11352, 11352

2535, 4776

13382, 14708

2206, 2241

9878, 11130

11247, 11331

9704, 9855

11535, 13359

2256, 2516

262, 304

775, 1787

11367, 11511

1809, 2074

2090, 2190

1,945

129,605

9636

Discharge summary

report

Admission Date: [**2179-3-1**] Discharge Date: [**2179-3-22**] Date of Birth: [**2115-3-19**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1283**] Chief Complaint: fatigue, dyspnea Major Surgical or Invasive Procedure: TVR History of Present Illness: Ebstein's anomaly, s/p TVR in [**2155**], increase in fatigue & dyspnea, workup revealed TV stenosis, and MR. Past Medical History: Diabetes mellitus type II Hypothyroid Cerebrovascular accident Osteoarthritis Hyperparathyroid Osteoporosis [**Doctor Last Name 15769**] anomaly Deep Vein thrombosis Atrial Fibrillation Tricuspid valve replacement at age 41 Permenant pacemaker Hysterectomy Restless leg syndrome Sleep apnea Social History: Retired. Lives with husband in [**Name (NI) **].Quit smoking at age 36 after an 18 pack year history. Family History: No known family history of cardiac disease Physical Exam: unremarkable pre-op exam Pertinent Results: [**2179-3-19**] 06:58AM BLOOD WBC-9.8 RBC-3.41* Hgb-10.4* Hct-31.4* MCV-92 MCH-30.3 MCHC-33.0 RDW-15.6* [**2179-3-22**] 06:20AM BLOOD PT-14.8* PTT-34.1 INR(PT)-1.4 [**2179-3-22**] 06:20AM BLOOD Glucose-82 UreaN-19 Creat-1.7* Na-137 K-3.9 Cl-98 HCO3-30* AnGap-13 [**2179-3-17**] 06:58AM BLOOD ALT-12 AST-22 AlkPhos-123* Amylase-20 TotBili-0.8 Brief Hospital Course: To OR on [**2179-3-4**] for TVR (tissue), placement of epicardial pacing leads, and left femoral artery repair (intra-op). Post-op required short term Levophed for hypotension. Ultimately weaned off pressors and transferred to telemetry floor on POD # 4 Over next few days was aggressively diuresed, PT initiated, and pt. began to progress from a rehab standpoint. EPS service (Dr. [**Last Name (STitle) **] following re: PPM Started on heparin (for AF)on POD # 7 Coumadin was being held for possible pacemaker change. On POD # 10, pt. had approx. 6 second run of NSVT (felt to be Torsades preceded by PVC's) 2 days after starting amiodarone, accompanied by dizziness, no LOC. Amiodarone was d/c'd, lopressor was started. Perm pacemaker low rate was subsequently increased to 80/min. Also, pt. was noted to have fungal rash in groins, and was started on miconazole powder. Rheumatology consult was obtained on POD # 11 due to increasing right knee pain w/swelling. Pt. started on colchicine for presumed gout with some improvement, but WBC elevated. She was then started on antibiotics for presumed cellulitis. Her WBC started to decrease, as did the knee pain and swelling. She has continued to progress from a rehab standpoint, and has remained hemodynamically stable. She is ready to be discharged home today. Medications on Admission: Actos 45 QD Fosamax 70 Qweek Lasix 40mg QD Lisinopril 20 QD Lasix 40 QD Glucotrol XL 5 QD Metformin 1500 Qam, 1000 Qpm Warfarin 5mg QD 5X/week, 6mg 2X/week Mirapex 0.125 Q HS Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q3-4H () as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*1 bottle* Refills:*0* 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*1 vial* Refills:*0* 7. Pramipexole Dihydrochloride 0.125 mg Tablet Sig: One (1) Tablet PO qhs (). Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 11. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO once a day. Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2* 12. Warfarin Sodium 5 mg Tablet Sig: 1 [**12-27**] Tablet PO once a day for 2 days: then check with Dr.[**Last Name (STitle) 32623**] office for continued dosing. Disp:*90 Tablet(s)* Refills:*2* 13. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: TV stenosis Type 2 DM AF Discharge Condition: good Discharge Instructions: no creams, lotions or powders to any insicions may shower, no bathing or swimming for 1 month no driving or lifting > 10 # for 1 month [**Last Name (NamePattern4) 2138**]p Instructions: with Dr. [**Last Name (STitle) 32624**] in [**12-27**] weeks with Dr. [**Last Name (Prefixes) **] in 3 weeks ([**Telephone/Fax (1) 1504**] with Dr. [**Last Name (STitle) **]/device clinic in 3 weeks ([**Telephone/Fax (1) 32625**] with Dr. [**Last Name (STitle) 32622**] in [**1-28**] weeks with Dr. [**First Name (STitle) **] in [**1-28**] weeks Completed by:[**2179-3-22**]

[ "274.0", "440.20", "284.8", "682.6", "250.00", "427.31", "997.1", "424.0", "397.0", "117.9", "V45.01", "244.9", "427.1", "746.2" ]

icd9cm

[ [ [] ] ]

[ "81.91", "39.59", "37.74", "35.27", "39.61", "37.33" ]

icd9pcs

[ [ [] ] ]

4577, 4640

1369, 2691

305, 311

4709, 4715

1003, 1346

899, 943

2917, 4554

4661, 4688

2717, 2894

4739, 4876

4927, 5304

958, 984

249, 267

339, 450

472, 764

780, 883

30,750

145,962

5899

Discharge summary

report

Admission Date: [**2146-9-20**] Discharge Date: [**2146-10-6**] Date of Birth: [**2108-7-23**] Sex: M Service: SURGERY Allergies: Amoxicillin Attending:[**First Name3 (LF) 3376**] Chief Complaint: Chronic drainage/infection of EC fistulae Major Surgical or Invasive Procedure: s/p ex-lap/LOA, resection of ileum, re-siting of ileostomy History of Present Illness: The patient is a 38-year-old male with Crohn's disease who has previously undergone a total abdominal colectomy and end ileostomy. He had a midline ventral hernia by palpation. He has been treated with Remicade somewhat successfully for parastomal fistulae. He abruptly developed five new fistulae with evidence of infection and abdominal wall phlegmon. He was admitted to the hospital, treated with IV antibiotics, local care and TPN. Local symptoms dramatically improved and resection of this portion of bowel and reciting was recommended. Past Medical History: Crohn's disease dx [**2118**], s/p total colectomy [**2138**], enterocutaneous fistula Peri-stomal inflammation/absesses/ECF treated with Remicaid/Antibiotics (ECF now closed) perianal fistulas status post parastomal hernia repair w/ mesh [**2142**] status post open ccy complicated by small bowel injury (primary repair) Appendectomy in [**2122**] s/p cholecystecomy [**2128**] Social History: No tobacco, occasional alcohol Family History: Noncontributory No FH of IBD Physical Exam: ED EXAM Vitals: T-99.6, HR-107, BP-146/85, RR-16, O2 sat-98% RA Const: A/Ox 3, NAD HEAD/Eyes: EOMI Resp: CTAB CV:nml S1/S2, no m/r/g ABD:soft, RLQ ostomy, stoma pink. Ostomy site surrounded by several areas of drainage/pus/cellulitis, marked erythema, entire lower area Extrem: no edema Skin: dry intact besides cellulitis described above Psych: normal mood/mentation Pertinent Results: [**2146-10-5**] 07:47AM BLOOD WBC-10.9 RBC-4.14* Hgb-11.2* Hct-33.4* MCV-81* MCH-27.0 MCHC-33.5 RDW-15.9* Plt Ct-343 [**2146-10-2**] 03:31AM BLOOD WBC-25.3* RBC-4.74 Hgb-12.7* Hct-38.1* MCV-80* MCH-26.7* MCHC-33.3 RDW-16.0* Plt Ct-293 [**2146-9-20**] 05:35PM BLOOD WBC-15.9*# RBC-5.23 Hgb-14.5 Hct-43.0 MCV-82# MCH-27.7# MCHC-33.6 RDW-15.8* Plt Ct-405 [**2146-10-5**] 07:47AM BLOOD Neuts-81* Bands-1 Lymphs-10* Monos-5 Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2146-10-3**] 02:02AM BLOOD PT-15.4* PTT-33.1 INR(PT)-1.4* [**2146-10-5**] 07:47AM BLOOD Glucose-73 UreaN-19 Creat-0.9 Na-135 K-4.0 Cl-104 HCO3-24 AnGap-11 [**2146-9-20**] 05:35PM BLOOD Glucose-94 UreaN-13 Creat-1.1 Na-140 K-3.9 Cl-104 HCO3-28 AnGap-12 [**2146-9-22**] 09:55AM BLOOD ALT-29 AST-29 AlkPhos-75 TotBili-0.2 [**2146-10-5**] 07:47AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0 [**2146-9-22**] 09:55AM BLOOD calTIBC-276 Ferritn-62 TRF-212 [**2146-9-24**] 04:14PM BLOOD Triglyc-152* [**2146-9-22**] 09:55AM BLOOD Triglyc-85 [**2146-9-28**] 12:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2146-10-2**] 03:43AM BLOOD Lactate-1.4 [**2146-9-20**] 05:49PM BLOOD Lactate-2.1* [**2146-10-2**] 03:43AM BLOOD freeCa-1.06* . RADIOLOGY Final Report CT PELVIS W/CONTRAST [**2146-9-20**] 10:50 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST CLINICAL INDICATION: Patient with Crohn's with peristomal fistula and abscess. IMPRESSION: Findings consistent with inflammation of the patient's neoterminal ileum as detailed above with suggestion of small abscess and possible sinus tracts as noted. . Pathology Examination Procedure date [**2146-9-30**] DIAGNOSIS: Ileostomy and small bowel resection (A-D): 1. Chronic severely active ileitis with ulceration and transmural inflammation extending to the ileostomy site and margins of separate small bowel resection. (See note.) 2. Changes consistent with ileostomy. Note: The features are consistent with Crohn's disease in the appropriate clinical setting. Clinical: Enterocutaneous fistula. . [**2146-10-3**] MRSA SCREEN MRSA SCREEN-FINAL--NO GROWTH [**2146-10-3**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL [**2146-10-3**] MRSA SCREEN MRSA SCREEN-FINAL--NO GROWTH [**2146-10-2**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL--NO GROWTH [**2146-9-30**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC CULTURE-FINAL [**2146-9-20**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {YEAST, VIRIDANS STREPTOCOCCI} [**2146-9-20**] URINE URINE CULTURE-FINAL--NO GROWTH [**2146-9-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL--NO GROWTH [**2146-9-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL--NO GROWTH Brief Hospital Course: Mr. [**Known lastname 23299**] was evaluated in ED, and admitted for management of cellulitis, draining fistulae, and possible abscess at fistula site acording to ABD/PELVIC CT scan obtained in ED. Blood and urine cultures were collected. . HD1-3:He was evaluated per GI on HD1. According to GI recommendations, he was managed with IV antibiotics, NPO status, and Remicade was held due to possible surgery for ostomy re-location. All cultures and Vancomycin levels were followed, and PICC insertion was initiated. The patient initially refused the PICC. After discussion with his attending GI MD, he was agreeable to the procedure. He was maintained on this regimen for almost 2 weeks to decrease fistula output, decrease inflammation indicated by a normal WBC. . HD4-11:He required encouragement & constant reminders to keep NPO. He had a PICC line inserted on [**2146-9-23**], and started on TPN. He was evaluated per Nutrition, and recommedations were provided for adequate TPN formulation. He tolerated the TPN well. Fistula/ostomy output decreased. He was seen by the ostomy RN for ostomy/fistula care (refer to note in OMR). After discussion between GI and Gen Surgery Attending with patient, surgery was scheduled for Thursday [**2146-9-30**]. On [**2146-9-28**], he was seen by ostomy RN for new stoma site marking. . HD12/POD0-He went to the OR for 1. Laparotomy, extensive lysis of adhesions, takedown ileostomy, resection of ileostomy and terminal ileum and reciting of ileostomy to the left lower quadrant.2. Reconstruction of the abdominal wall using SurgiSis patches. His operative course was extensive due to adhesions, but uncomplicated, and he was routinely monitored in the PACU. . PAIN:His pain was an issue throughout this admission. He has a h/o chronic pain issues. He was managed on multiple agents including his home regimen when indicated. He rated his pain between [**2149-3-29**]. He did report relief with pain medication regimen, but required frequent breakthrough pain medication. The Acute Pain Service was consulted for post-op pain management. He was started on a Bupiv epidural and IV Dilaudid PCA. His pain was not well managed. Ketamin was added to PCA, and his pain was better managed temporarily. He became tachycardic in PACU, bolused with decrease in HR. His pain continue to be an issue. He was transferred to ICU for pain managment and fever elevation to 103. . ICU/POD1-4-His temp was treated with IV antibiotics. His blood pressure was managed with IV Lopressor. Repeat cultures were collected, and pain was managed with IV Ketamine drip. Chronic pain service was consulted, and followed his case to discharge. He was re-started on TPN. Otherwise stable, and transferred to [**Hospital Ward Name **]. . [**Wardname **]/POD5-Discharge:He remained A/Ox3 on floor. Both his cardiac and respiratory status remained stable. His anit-hypertensives were discontinued. His Abdomen was appropriately tender. His incision was OTA. His stoma remained pink & viable with stool production. The ostomy RN continued with teaching. His diet was advanced as his bowel function resumed. He was able to tolerate regular food, and his TPN was weaned.Once he was able to tolerate PO intake, he was weaned from Ketamine drip, and switched to Dilaudid PCA. His pain medication was transitioned to oral medication per recommendations of Chronic Pain Service. He reported adequate pain control, and was discharged with this regimen. He was to able to ambulate per baseline. He was dicharged home with VNA for assessment of stoma and ostomy function. He will follow-up with Dr. [**Last Name (STitle) 1120**] in 2 weeks, and with Gastroenterology. Medications on Admission: Methadone 20mg PO TID, Percocet 10/325 QID, B12 inj 1000mcg SC Q2weeks, Remicade 400mg Q6weeks (last infusion [**2146-7-23**]), Cipro 500mg PO BID (started friday [**9-16**]), Flagyl 500mg TID (for past 1.5mos per GI due to inc fistula drainage) Discharge Medications: 1. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day) for 2 weeks. Disp:*126 Tablet(s)* Refills:*0* 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 2 weeks. Disp:*42 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health and Hospice Discharge Diagnosis: Prirmary: Crohns, with strictured ileostomy & resultant EC fistulae, peristomal abscess . Secondary: Anxiety, chronic pain, polytendinomyopathy,perianal fistulae, recurrent SBO's, peristomal abscesses Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medciation 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. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) **] in 2 weeks. 2. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23300**], Pain Clinic, [**Telephone/Fax (1) 23301**] in 2 weeks. 3. Please follow-up with your primary care doctor as needed. Completed by:[**2146-11-16**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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313, 374

9467, 9545

1846, 4582

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8298, 8545

9569, 10401

1458, 1827

232, 275

402, 946

968, 1348

1364, 1397

5,197

181,082

25071

Discharge summary

report

Admission Date: [**2150-9-4**] Discharge Date: [**2150-10-6**] Date of Birth: [**2095-2-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: dyspnea/hypoxia Major Surgical or Invasive Procedure: chest tube insertion History of Present Illness: 55 yo male with h/o cirrhosis (hep C v. autoimmune) transferred from [**Hospital1 **] with SOB x 1 week, pneumonia on CXR, elevated lactate and hypoxia. He notes worsening SOB for past week with pleuritic chest pain in R side. He also complains of fatigue and dysuria. He has some cough but only occasionally brings up sputum. He went to [**Hospital3 4107**] and was given ceftriaxone, azithro and solumedrol. He was also found to be in acute renal failure with Cr 4.9, K 5.7. Tox screen positive for opiates. He was transferred to [**Hospital1 18**] on NRB bc they did not have any ICU beds available. he denies fevers, chills. He does complain of itchy skin. . On arrival to [**Hospital1 18**] ED, his vital signs were T97.6 P104 BP105/57 R28 94% on NRB. He was given zosyn, vitamin K 10 mg SQ, kayexalate Past Medical History: Cirrhosis: autoimmune v. Hep C with possibility of alcoholic hepatitis(s/p tx with interferon and ribiviron 18 mos ago with recurrence). Seen by Dr. [**Last Name (STitle) 10924**]. chronic hepatitis C diagnosed on routine blood work (genotype 3 and had a liver biopsy on [**2150-4-3**] noting grade [**7-8**] and stage [**3-2**]) Alcohol excess, quit 20 years ago Pancreatitis Hard of hearing, wears a hearing aid Splenic rupture secondary to a fall off a roof Bilateral lower leg edema Diverticulosis by history Left femur fx with ORIF Appendectomy Social History: He is single, has a 29 year old son, is on disability, used to work as a roofer X 30 years He stopped smoking 20 years ago. No alcohol in 24 years. Family History: Mother is living, age 77, macular degeneration Father is living, age 80, has glaucoma and DJD He has 4 brothers, 3 living, one deceased in [**2147**] from AIDS No sisters Physical Exam: VS: Tc 97.9 Tm 98.4 RR 62-75 BP 105-140/61-84 RR 14-31 O2Sat 95% on 5L Gen: WDWN man sitting in bed crying HEENT: Head-excoriations on head from scratching, PERRLA, EOMI, OP clear Neck: no JVD CV: RRR, nl s1, s2, no m/g/r Lungs: decreased R base breath sounds, crackles bilaterally midway up back Abd: BS+, soft, NT, ND, no hepatomegaly Ext: Bilateral 1+ pedal edema, + asterixis Pulses: 2+ radial and DP A/P 55 yo Male admitted with pneumonia on CXR w/ complicated effusion s/p chest tube placement on Vancomycin/Daptomycin. Pertinent Results: RADIOLOGY . US ABD LIMIT, SINGLE ORGAN [**2150-9-4**] 1. Slightly and coarse liver consistent with patient's known history of cirrhosis. 2. No intra- or extra-hepatic bile duct dilatation. 3. The gallbladder is not distended but the wall is edematous. These are most likely secondary to periportal hypertension. Clinical correlation is recommended. 4. Moderate-sized right pleural effusion. 5. No evidence of ascites. CHEST (PORTABLE AP) [**2150-9-4**] IMPRESSION: Moderate right pleural effusion. Right middle and lower lobe consolidation may represent pneumonia or compressive atelectasis. Left basilar atelectasis versus pneumonia. RENAL U.S. [**2150-9-7**] 3:09 PM Reason: MRSA BACTEREMIA ,EVAL FOR ABSCESS IMPRESSION: Normal-sized kidneys. Splenomegaly. No evidence of perirenal abscess. ************ CT PELVIS W/CONTRAST [**2150-9-9**] 4:15 PM 1. Interval placement of a right-sided chest tube. There is a small associated right pneumothorax. There has been interval decrease in the degree of atelectasis in the right lung. No definite empyema is identified. 2. Findings consistent with cirrhosis, including nodular liver, and ascites. No enhancing fluid collections within the liver or within the abdomen, to suggest the presence of an intra-abdominal source of infection. ***************** BONE SCAN [**2150-9-14**] Reason: 55 YR OLD MAN W/ HEP C CIRRHOSIS W/ MRSA PNEUMONIA W/ EMPYMA PLEASE EVAL FOR OSTEO L HIP IMPRESSION: No evidence for osteomyelitis. Small amount of increased uptake in the right anterior lower ribs suggests prior trauma. . CARDIOLOGY . ECHO Study Date of [**2150-9-8**] 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function cannot be reliably assessed. 3. The aortic valve leaflets are mildly thickened. The aortic valve is not well seen. Mild (1+) aortic regurgitation is seen. 4. No obvious evidence of endocarditis seen. . ECHO Study Date of [**2150-9-14**] Conclusions: The left atrium is dilated. No spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: No valvular vegetations seen. CYTOLOGY . Cytology Report PLEURAL FLUID Procedure Date of [**2150-9-5**] NEGATIVE FOR MALIGNANT CELLS. Numerous neutrophils, scant reactive mesothelial cells and inflammatory cells. . Cytology Report PERITONEAL FLUID Procedure Date of [**2150-9-17**] NEGATIVE FOR MALIGNANT CELLS. Macrophages, mesothelial cells and blood. Brief Hospital Course: 55 yo male with h/o cirrhosis (hep C v. autoimmune) transferred from [**Hospital1 **] with SOB x 3 week and R sided chest pain, pneumonia on CXR, elevated lactate and hypoxia. He notes worsening SOB for past week with pleuritic chest pain in R side. He also complains of fatigue and dysuria. He has some cough but only occasionally brings up sputum. He went to [**Hospital3 4107**] and was given ceftriaxone, azithro and solumedrol. He was also found to be in acute renal failure with Cr 4.9, K 5.7. Tox screen positive for opiates. He was transferred to [**Hospital1 18**] on NRB bc they did not have any ICU beds available. He denied fevers, chills, but complained of itchy skin. In the MICU, he was started on Vanc, Levo and Ceftriaxone, which was eventually broadened to include flagyl. A noncontrast CT showed a RLL consolidation and R pleural effusion without evidence of loculation. Thoracic surgery was consulted and they placed a chest tube [**9-5**] with development of small basilar PTX --> small R lateral PTX [**9-7**], with drainage of ~1.2 L. Pleural fluid showed 51,500 WBC, 74% PMNs, 2% Bands, 23% monos, 16,900 RBC, TP 4.4, LDH 5108, Glucose 6, Amylase 21, Albumin 2.1 and grew out MRSA. Blood cultures and Urine cultures also grew out MRSA. Serial cultures have since been NGTD from [**9-6**] and [**9-7**]. His Abx regimen was changed to Vanc and Levo. His ARF was thought to be prerenal and he was gently hydrated with IVF with a CVP between [**9-9**] to keep CVP > 12. Urine eos were negative. A renal ultrasound was also ordered given MRSA in his urine to assess for renal abscess and was negative, revealing only trace ascites and an enlarged spleen. His BUN/Cr eventually improved from 85/4.2 to 65/1.2 Hepatology was called because of his hx of Hep C hepatitis vs. Autoimmune hepatitis with AST 79, ALT 71, Alk Phos 151, Bili 7.1 and believed that it was more likely an HCV flare with hepatic encephalopathy and cholestasis. They recommended lactulose TID to QID, volume resuscitation, holding aldactone until after IVF resuscitation and stress dose steroids as well as variceal screening once his respiratory status had improved (MELD 31). His Liver panel improved to AST 89, ALT 58, Alk Phos 130, Bili 4.6. He was started on labetalol and his aldactone was restarted. On [**9-7**], he was d/c'ed to the floor. 55yo man with history of cirrhosis likely secondary to hepatitis C presented with RML/RLL pneumonia, complicated parapneumonic effusion, and high grade MRSA bacteremia. # MRSA pneumonia This was heralded by progressive dyspnea, fever, pleuritic symptoms, and hypoxia. He was found to have RML and RLL pneumonia. Sputum cultures grew out MRSA. Additionally, he had a complicated parapneumonic effusion, which required the placement of a chest tube for drainage. Pleural fluid grew out MRSA as well. He was initially treated with vancomycin/levaquin/flagyl, which was tapered down to vanco/levaquin. He made progressive improvement and was weaned from NRB to 5L nasal canula. . # High grade MRSA bacteremia Initial blood cultures were significant for 4/4 bottles with MRSA. He was continued on vancomycin. TEE did not show any vegetations. He also had a renal US to rule out a perinephric abscess, as he had MRSA in the urine as well which is not uncommon with MRSA bacteremia. He was also started on Gentamycin and Daptomycin as his bacteremia did not clear with Vancomycin. Subsequently his Vanc was D/C'ed as patient responded to Daptomycin. Gentamycin was D/C'ed as patient developed acute renal failure most likely related to gentamycin toxicity. Daptomycin to be continued for 4 weeks after its initiation on [**2150-9-16**]. . # Acute renal failure: most likely ATN [**12-31**] Gent toxicity; urine sed showed brown muddy casts. FeNa intially did improve with hydration and so was thought to be prenal most likely Hepato-renal. However given the brown muddy casts and improving FeNa, most likely ATN. negative urine eos consistently. 25 g IV albumin given [**2150-9-17**]. Peak Creatinine was 6.6 which started trending down at the time of discharge. He did not have any signs of uremia or severe volume overload and so was not started on HD. Will need to check Creatinine every 3-4 days. . # [**Hospital **] Medical regimen was optimized with beta blocker for variceal bleeding prophylaxis, aldactone for diuresis, and lactulose titrated upward for encephalopathy. Liver team was following. Bilirubin peaked at 8.9. EGD negative for varices, but showed some gastritis - was on PPI. U/S [**9-7**] showed small amount of ascites --> CT [**9-9**] showed large amount of ascites --> diagnostic/therapeutic paracentesis removed 2 L with SAAG of -0.2. Hepatology of opinion that this was not unusual for bad cirrhosis. Vit K 10 mg SC x 3 days finished without improvement in INR. . # Hyponatremia: Sodium of 132 on admission, was likely [**12-31**] to portal hypertension from cirrhosis. Low albumin can cause dilutional effect . He was on free water fluid restriction at 1.5 L. . # Thrombocytopenia - Plt ct of 97 on admission. likely due to cirrhosis with secondary hypersplenism (large spleen on U/S). Was not on heparin gtt during this course of hospital admission. . # Anemia - HCT of 36.3 on admission, macrocytic anemia. Likely secondary to cirrhosis and anemia of chronic disease. Hemolysis labs [**9-11**] showed Indirect bili 4.2, Retic % 2.6% (RI 1.6 - inadequate), LDH 283 (slightly high), but Haptoglobin 110. Given splenomegaly - believe this to be hemolysis in spleen from cirrhosis. He was Guaiac negative. He was being transfused for hct < 24. . # COPD: continued on nebs . # Psych: He was occasionally agitated (likely component of hepatic encephalopathy) with labile mood and expressed feelings of hopelessness, depression. No active suicidal ideation, though expressed thoughts of "if only I just didn't wake up". No HI. Was continued on sertraline. . # Pruritus - Derm was consulted. Most likely from Hyperbilirubinemia, Uremia. Recommended sarna, hydroxyzine, (hydrocortisone tried for pruritus without much effect). Also had herpes II positive (back lesion) -> holding on Acyclovir as pt in renal failure. Did not consider increasing doxepine to 50 mg QHS (as recommended by derm) because of renal/hepatic toxicity. . # RLE slight warmth and swelling - mostly pitting edema. RLE U/S negative for DVT. Not on heparin because of thrombocytopenia. Continued on pneumoboots, heparin sq . # Diarrhea - likely from all of his lactulose, but given recent low grade fever and multiple Abx, a c diff was negative. . # PPX: PPI, pneumoboots, heparin sq Medications on Admission: Meds Spironolactone 50 mg (for leg swelling) Lactulose (for constipation) Zyrtec Zoloft 200 mg Protonix 40 mg daily Prednisone 10 mg daily Ibuprofen prn Vicodin prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: [**11-30**] Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) 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). 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 6. Lactulose (for Encephalopathy) 10 g/15 mL Solution Sig: Three Hundred (300) ML PO Q3-4H (Every 3 to 4 Hours) as needed. 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Outpatient Lab Work Please check your Creatinine every 5 days and report it to your primary care physician or your kidney doctor. 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 14. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 16. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 17. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 18. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 4 weeks. 19. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day): Please apply to itching area. 20. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 21. Ketoconazole 2 % Shampoo Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 22. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 23. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 24. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 25. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical TID (3 times a day). 26. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day). 27. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 28. Fluocinolone 0.01 % Solution Sig: One (1) Appl Topical TID (3 times a day) as needed for scalp itching. 29. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-30**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 30. Pramoxine 1 % Lotion Sig: One (1) Topical QID (4 times a day). 31. Pramoxine-Hydrocortisone [**11-29**] % Cream Sig: One (1) Topical QID (4 times a day) as needed for pruritis. 32. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 33. Daptomycin 500 mg Recon Soln Sig: One (1) Intravenous once a day for 12 days. Discharge Disposition: Extended Care Facility: [**Location (un) **] healthcare center Discharge Diagnosis: 1. cirrhosis 2. MRSA pneumonia, complicated parapneumonic effusion 3. high grade MRSA bacteremia 4. hepatic encephalopathy 5. acute renal failure Discharge Condition: stable Discharge Instructions: 1. Continue to take your medications as prescribed 2. Call your doctor or return to the emergency room for any fever/chills/chest pain/cough/trouble breathing/ or any other concerning symptoms. 3. You should take your antibiotic for 4 weeks from [**9-16**]. 4. Please check your Creatinine every 5 days to monitor its trend and report it to your PCP or your kidney doctor. Followup Instructions: Please make an appointment to see your Primary Care physician [**Last Name (NamePattern4) **] [**1-1**] weeks. . For your chest tube drainage and collection: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1533**],[**First Name3 (LF) **] [**Doctor First Name 25090**] MULTI-SPECIALTY THORACIC UNIT-CC9 Phone:[**0-0-**] Date/Time:[**2150-10-20**] 1:30 . Infectious Disease Specialist: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2150-10-30**] 10:00 . Kidney Disease Specialist: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2150-11-19**] 3:00 . If you wish to see the Dermatologist, you can call [**Telephone/Fax (1) 250**] to make an appointment with Dr. [**First Name8 (NamePattern2) 62915**] [**Name (STitle) **] who saw you as an inpatient. Completed by:[**2150-10-6**]

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icd9cm

[ [ [] ] ]

[ "38.91", "34.04", "34.91", "38.93", "45.13", "99.07", "54.91", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

15679, 15744

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42854

Discharge summary

report

Admission Date: [**2145-11-21**] Discharge Date: [**2145-11-24**] Date of Birth: [**2104-8-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9160**] Chief Complaint: Seizures, personality changes Major Surgical or Invasive Procedure: intubation, History of Present Illness: Patient is a 40 year old man with a PMHx s/f newly diagnosed DM and recent admission [**Date range (1) 92551**] for HHS/DKA who presented to the [**Hospital3 **] Emergency Room with a tonic clonic seizure after acting inappropriate at home with periods of inattention and depersonalization. Today Mr. [**Known lastname 19219**] was found by his family to be violent and acting inappropriately after several episodes of "staring into space" and arm flailing. EMS was called after a witnessed seizure, and upon EMS arrival he was found to be seizing. At the [**Hospital3 **] ED, he was found to have persistent tonic-clonic seizures. He was found to be acidemic to 6.8 with a bicarb of 8. He was intubated for airway protection in light of his mental status, was given 1gm of dilantin and 6mg of ativan as well as 2L IV NS. He was also found to have a leukocytosis to 17.6. Urine was negative for ketones, and glucose elevated at 338. He was then transitioned to propofol and bicarbonate drips and transferred to the [**Hospital1 18**] ED. [**Location (un) 86**] Med flight gave him fentanyl 200mcg, . In the ED, He was seen by neurology who felt his seizures were secondary to poorly controlled DM and recommended admission to the MICU. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: DM OSA non-compliant with CPAP HTN HLD B12/Vit D deficiency Social History: Patient is a policeman who is currently on leave for personal issues. He lives alone. Currently, his girlfriend denies that he drinks alcohol, smoking, or illicits. Family History: Father with DM and epilepsy Physical Exam: Upon Admission: Vitals: T: 99.2 BP: 131/82 P: 76 R: 18 O2: 99% on PSV 5/5, FiO2 100% General: intubated sedated gentleman, does not respond to verbal or painful stimuli HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, pinpoint pupils/midline, Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley inserted with copious amounts of clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Intubated/sedated, pinpoint pupils, doll's head maneuver with EOMI, no clonus, appropriate bulk/tone Pertinent Results: Admission Labs: [**2145-11-21**] 02:16AM BLOOD WBC-13.6* RBC-3.36* Hgb-10.4* Hct-30.9* MCV-92 MCH-30.8 MCHC-33.5 RDW-12.5 Plt Ct-111* [**2145-11-21**] 02:16AM BLOOD UreaN-12 Creat-1.4* [**2145-11-21**] 06:21AM BLOOD Glucose-124* UreaN-13 Creat-1.7* Na-140 K-3.9 Cl-108 HCO3-24 AnGap-12 [**2145-11-21**] 02:16AM BLOOD CK(CPK)-4566* [**2145-11-21**] 06:21AM BLOOD Calcium-7.4* Phos-4.5 Mg-3.0* [**2145-11-21**] 02:31AM BLOOD freeCa-0.97* [**2145-11-21**] 02:31AM BLOOD Glucose-200* Lactate-4.9* Na-136 K-4.1 Cl-107 [**2145-11-21**] 07:55AM BLOOD %HbA1c-16.5* eAG-427* [**2145-11-22**] 06:02PM BLOOD calTIBC-168* VitB12-1117* Folate-9.3 Hapto-218* Ferritn-1103* TRF-129* Discharge Labs: [**2145-11-24**] 06:50AM BLOOD WBC-8.8 RBC-3.66* Hgb-11.3* Hct-32.9* MCV-90 MCH-30.9 MCHC-34.4 RDW-13.3 Plt Ct-167 [**2145-11-24**] 06:50AM BLOOD Glucose-92 UreaN-10 Creat-2.5* Na-148* K-3.8 Cl-113* HCO3-25 AnGap-14 [**2145-11-24**] 06:50AM BLOOD CK(CPK)-2947* Pertinent Results: Chest X ray: Previous mild pulmonary edema has cleared. Lungs are low in volume, but caliber of the pulmonary vasculature and cardiac silhouette is probably normal. Left infrahilar consolidation could be pneumonia or atelectasis and should be followed. ET tube is in standard placement. Nasogastric tube passes into the stomach and out of view. No pneumothorax or pleural effusion. MRI Head (preliminary read): No acute intracranial abnormality. No abnormality identified on the MRI to explain the patient's seizures. Renal Ultrasound: The right kidney measures 12.1 cm, the left kidney measures 10.6 cm without evidence of hydronephrosis, stones, or masses. The urinary bladder is normal. IMPRESSION: No hydronephrosis. CT sinus/mandible: FINDINGS: There is anterior dislocation of the right mandibular condyle and anterior subluxation of the left mandibular condyle, which appears partially reduced compared to yesterday's outside hospital head CT. There is no evidence of fracture. Aerosolized secretions are seen in the left frontal sinus and left ethmoid air cells. Mucosal thickening is seen in the ethmoid air cells bilaterally and maxillary sinuses bilaterally. Air-fluid levels and mucosal thickening are seen in the sphenoid sinuses bilaterally. The ostiomeatal complexes are occluded bilaterally. Soft tissue thickening of the uvula and posterior pharynx is noted. This study is not optimized for evaluation of intracranial structures; within this limitation, no large abnormalities are detected. IMPRESSION: 1. Anterior dislocation of the right mandibular condyle and anterior subluxation of the left mandibular condyle without evidence for acute fracture. 2. Aerosolized secretions in the left frontal sinus and left ethmoid air cells with air-fluid levels in the sphenoid sinuses bilaterally, which are likely secondary to retained secretions from recent intubation. However, acute sinusitis cannot be excluded. 3. Soft tissue thickening of the uvula and posterior pharynx, which likely represents edema secondary to recent intubation. EEG: No evidence of seizure activity. Focal slowing consistent with toxic metabolic syndrome. [**2145-11-21**] 02:16AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2145-11-21**] 02:16AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Blood cultures: PENDING Uurine culture: No growth (FINAL) Brief Hospital Course: Mr. [**Known lastname 19219**] is a 40 year old with a past medical history significant for newly diagnosed diabetes and recent admission for HHS versus DKA at an OSH who presented with status epilepticus and poorly controlled diabetes. # Status Epilepticus: Presumed secondary to electrolyte disturbances secondary to DKA/HHS decreasing the patient's seizure threshold. There was no clear source of infection and the patient was without localizing symptoms; infection was not thought to explain the patient's symptoms, and no lumbar puncture was done. Preliminary read of the EEG shows generalized slowing while on propofol drip. Neurology followed the patient through hospital course. Patient was weaned from Keppra through the hospitalization, and on day of discharge this medication was discontinued. Brain MRI was done which showed no structural abnormality of the brain to explain seizures. Patient had no further seizure activity while hospitalized. He was discharged with outpatient neurology follow-up scheduled. # Altered Mental Status: Patient was admitted intubated and sedated. He was weaned off sedation, and upon arrival to the floor, the patient's mental status was noted to have waxing/[**Doctor Last Name 688**] attention. Patient's mental status improved through the admission with correction of his hyperglycemia. # DM: Excellent control was maintained through hospital admission with 20 units of NPH/Regualr (70/30) twice daily. Patient received teaching regarding the importance of compliance and careful control of his blood sugars. Patient is being discharged home on above regimen with follow-up arranged at [**Last Name (un) **]. # Acute Kidney Injury: Patient admitted with serum creatinine 1.4 which increased to 3.1. Acute kidney injury was thought to be multifactorial related to poor oral intake and rhabdomyolysis in the setting of tonic-clonic seizures. CK was elevated in the 5000s was noted to be down trending on day of discharge. However, the Cr slowly rose and then slowly improved, suggesting possible ATN, although there is no prolonged hypotension documented, and he never required pressors. Patient made good urine output in the latter part of the admission. Renal ultrasound showed no hydronephrosis. Follow-up regarding serum creatinine will need to be done on an outpatient basis. By day of discharge, patient's serum creatinine had trended down to 2.5. # Mild Thrombocytopenia: Etiology is unclear but may be related to critical illness. Platelets trended up to 167 by time of discharge. He was not on medications that would cause thrombocyotpenia. Of note, thrombocytopenia developed prior to heparin administration so is unlikely secondary to HIT. Patient without evidence of DIC on labs. TTP/HUS in the setting of renal failure was ruled out. # Anemia: Previously diagnosed with B12 deficiency though baseline was unknown. Records of the patient's hematocrit/hemoglobin were unable to be obtained during the admission. B12 level was high on this admission. Iron studies are consistent with anemia of chronic inflammation. Folate was within normal limits. Anemia remains stable through admission with H/H 11.0/32.4. It is unclear why this apparently healthy host would have anemia of chronic disease. Retic count is depressed with suggestive a myelosuppressive state, though the patient is not currently on medications that would cause a myelosuppressive state. # Fever and leukocytosis: Afebrile since admission to the floor. Patient had fever to 100.2 at midnight on [**2144-11-22**]. Likely secondary to seizures, but differential also includes infectious etiology such as pneumonia (given possible RUL infiltrate on CXR with poor inspiration). However, his respiratory status markedly improved and he his on RA, and there was no indication for further work-up. Leukocytosis was thought to be secondary to stress response from seizure and DKA/HHS. WBC trended down on day of admission. Urine culture was negative. Final blood cultures were still pending on day of discharge. # Jaw dislocation: Likely occurred during intubation. There is no fracture see on CT of the mandible. [**Date Range 40530**] was consulted during the admission. No acute intervention was warranted. The patient was placed on a soft, pureed diet while in house with instructions to continue this while at home. Patient will be contact[**Name (NI) **] with follow-up appointment by [**Name (NI) 40530**]. # rule out ACS: Given acute neurologic event, cardiac risk factors, and diffuse ST elevations on EKG there was concern for ACS. Troponins were negative times three during this admission, so no further action was taken, especially in absence of chest pain. # OSA: He carries a diagnosis of OSA but is not compliant with CPAP. Encouraged compliance with CPAP during hospitalization. #Transition of Care Issues: - Follow-up with Neurology as an outpatient regarding seizure activity. Patient will also have outpatient routine EEG done. These appointments have been scheduled. - Follow-up with [**Last Name (un) **] regarding patient's diabetes. - Follow-up with primary care physician on [**2145-11-29**] regarding recent hospitalization and follow-up of patient's chemistry panel with serum creatinine to ensure that serum creatinine continues to trend down. - Follow-up with Oral/Maxillary/Facial Surgery regarding jaw dislocation. Patient will be contact[**Name (NI) **] by [**Name (NI) 40530**] with appointment time and date. - Follow-up of pending blood cultures Medications on Admission: ASA 81mg Insulin 70/30 20 units [**Hospital1 **] Vitamin B12 500mg daily Calcium plus Vitamin D Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a day. 3. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 4. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Twenty (20) units Subcutaneous at breakfast daily. 5. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Twenty (20) units Subcutaneous at dinner daily. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Tonic-clonic seizures Secondary diagnosis: Rhabdomyolysis Acute kidney injury Insulin dependent diabetes Hypertension Hyperlipidemia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital3 **] because of seizures. We believe the cause of your seizures was due to electrolyte imbalance influenced by your underlying diabetes. An MRI of your head was done to determine if there was a brain abnormality that was causing your seizures, but no abnormality was identified. You are not being discharged home on anti-seizure medications. However, you do have follow-up with neurology for a routine EEG as an outpatient (once discharged from the hospital). Your EEG has been scheduled for [**Last Name (LF) 766**], [**11-29**] at 3:00PM. Your hair must be clean and dry. Please eat lunch before the EEG. The office is located on [**Hospital Ward Name 517**] [**Hospital Ward Name **] 5. Given that you recently had a seizure, you are NOT permitted to operate a motor vehicle for the next 6 months unless you are medically cleared by the neurologist, with whom you have follow-up. When you were intubuated, your jaw was dislocated. You were seen by the oral surgeons who had recommended correcting the dislocation however before the procedure could be performed your jaw returned to [**Location 213**] position without surgical intervention. For the next two weeks, it is important that you do not eat foods that require chewing and that you avoid yawning. The oral surgeons will call you regarding a follow-up appointment in the next 2 weeks. Your kidneys sustained an injury after the seizures known as rhabdomylosis. Your serum creatinine, a marker of your kidney function, is improving. Please avoid taking ibuprofen whiel your kidneys recover from injury. Please have your primary care doctor follow-up your kidney function at your next appointment on [**11-29**]. Please take all medications as instructed. Note the following medication changes: NONE. Please keep all follow-up appointments as scheduled. Followup Instructions: You already have an appointment scheduled with your primary care doctor [**First Name8 (NamePattern2) 1494**] [**Last Name (NamePattern1) 1492**] on Janurary 9th. Keep this appointment. . Name: [**Last Name (LF) **], [**Name8 (MD) **] NP Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] When: Tuesday, [**11-30**], 2:00 PM Department: NEUROLOGY When: WEDNESDAY [**2145-12-15**] at 4:30 PM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 3506**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]

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icd9cm

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Discharge summary

report

Admission Date: [**2149-5-5**] Discharge Date: [**2149-5-9**] Date of Birth: [**2068-1-1**] Sex: F Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 689**] Chief Complaint: s/p mechanical fall w/ L-knee hematoma Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 17926**] is an 81-year old female w/ COPD, CHF, A-fib (s/p failed DCCV) on Coumadin, who presented to [**Hospital3 **] this AM after sustaining a mechanical fall off of her commode at approximately 1 AM. She states she was on the commode at home (in [**Location (un) 2624**] where she lives w/ her daughter) in the middle of the night when she reached down to pick something up that had fallen and reportedly felt dizzy, struck her head on the edge of the bathtub and then fell onto her knees, injuring her left knee the most. CT scan at OSH was negative for ICH. She reports having had knee X-rays done at OSH but no records were sent with her documents. She developed large L-knee hematoma and was found to have INR of 11 at OSH. She was given 10mg IV Vitamin K and 1 u FFP prior to transfer to [**Hospital1 18**] for further evaluation and work-up of possible compartment syndrome given large ecchymoses on L and absence of pulses by report. She denies LOC at time of the fall and remembers everything that occured at the time. She notes having dizzy episodes in the past due to decreased PO intake and imbalances in her "electrolytes". In the [**Hospital1 18**] ED, initial VS: 95.8; 80; 81/60; 20; 100% on 2L NC. Patient was given 500cc NS, had basic labs (no imaging). Orthopedics evaluated pt in ED who thought there was no current sign of compartment syndrome, and that this was a large hematoma in the setting of supratherapeutic INR. They recommended conservative management w/ RICE, WBAT. She was originally admitted to medicine service but was transferred to ICU For low blood pressures and further hemodynamic monitoring, although it was noted her blood pressure normally runs low. Per ED records, pt's BP did not respond adequately to 500cc NS [**Last Name (LF) 1868**], [**First Name3 (LF) **] was transferred to ICU for further care. Pt has ? hx CHF so additional boluses were not given. Of note, pt reports starting a new antibiotic 4 days ago (does not recall the name) for urinary tract infection. States INR was around 2.2 when last checked on [**First Name3 (LF) 2974**] ([**5-2**]). On ROS, pt denies CP, SOB, GI Sx. C/o pain in her L-knee and dysuria. Past Medical History: 1. COPD 2. CHF 3. Afib s/p failed DCCV, on Coumadin 4. PVD 5. Lymphedema (chronic) 6. peripheral neuropathy (not diabetic) 7. GERD w/ hiatal hernias 8. achalasia 9. hx candidal esophagitis? 10. glaucoma Social History: Lives w/ daughter in [**Name (NI) 2624**], MA. No hx tobacco, EtOH, drugs. Limited ambulation at baseline. Family History: NC Physical Exam: Vitals: afebrile, HR 92-102 (a-fib) BP 103/62 RR SaO2 100% on 2 L NC GEN: well-appearing elderly F in NAD HEENT: Sclera anicteric, PERRLA MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: irregularly irregular rhythm, no murmurs Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place (pt requested) Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema B/L lymphadema. L- LE bandaged w/ ACE wrap, large ecchymoses over L-knee, hard to palpation non-tender Neuro: A&Ox3, no focal neuro deficits, [**Name (NI) 14245**] ptosis (chronic, has glaucoma) Pertinent Results: Trop-T: <0.01 [**Age over 90 **] |111| 34 -------------< 174 4.4 |21 | 1.1 Ca: 8.5 Mg: 2.1 P: 2.8 MCV: 103 8.8 10.4 >------< 218 28.5 N:76.6 L:16.8 M:5.8 E:0.4 Bas:0.4 PT: 23.3 PTT: 29.3 INR: 2.2 Micro: NONE [**Hospital3 **] REPORTS: 1. X ray L- tib/ fib- no fx or dislocation 2. L-wrist, 3 views- no acute abnormality 3. R-knee, 4 views- mod adv OA, no acute abnl 4. CXR- no acute cardiopulmn process 5. CT spine w/ contrast- no fx or subluxation 6. CT head w/o contrast- no acute intracranial process. 7. L-knee, 4 views- OA, no fx, disloc or joint effusion 8. R tib-fib, 2 views- asymm widening of lat tibiotalar junction, suggesting some R-ankle ligamentous injury, otherwise no fx or dislocation EKG:A-fib w/ PVCs, rate 95 nl Axis, nl intervals, no ST-T changes. Brief Hospital Course: Ms. [**Known lastname 17926**] is an 81-year old lady with atrial fibrillation who was admitted to the ICU for hypotension, after sustaining a mechanical fall resulting in a large L-knee hematoma in the setting of supratherapeutic INR. 1. HYPOTENSION- Ms. [**Known lastname 17926**] was sent to the ICU because of blood pressure in the 80s- the pt's baseline is 110s. This was likely in the setting of hypovolemic shock from profuse blood loss as pt was bleeding into her L-knee space as evidenced by large hematoma. Pt's chronic lymphedema contributed to inadequate drainage of the site. Pt's hypotension improved with aggressive volume resuscitation with IVF and blood products and remained stable in 120s by ICU day 2, on day of transfer to general medical wards. Her home diuretics (for lymphedema) were initially held in the setting of hypotension, but they were restarted prior to discharge. She remained normotensive throughout the rest of her admission. 2. L- KNEE [**Name (NI) 85512**] Pts L-knee hematoma was large in the setting of lymphedema and supratherapeutic INR. At [**Hospital1 2519**], there was concern for compartment syndrome due to poorly palpable pulses and pain. Therefore, pt was transferred to [**Hospital1 18**] for orthopedic surgery evaluation. Ortho evaluated pt in the ED and felt conservative management with ACE wrap and elevation was important, and that compartment syndrome was unlikely. Pt received a total of 5u PRBCs and 3u FFP during her 1st 24 hours in the ICU as her hematocrit had not increased appropriately, likely in the setting of active bleeding. Prior to transfer to the general medical wards, her HCT had been stable at 28-29 for 24 hours. She continued to be followed by orthopedics and had an ultrasound of her leg which showed the presence of a complex collection likely representing a clot with edema within the suprapatellar bursa of her left leg. The clot was not drained as the patient stated that her pain was improved. She was given percocet and standing tylenol for pain. She was evaluated by PT who thought that she would benefit from inpatient rehabilitation. However, the patient did not wish to go to rehab. She lives with her children and they were taught how to transfer the patient out of bed. She was set up with home PT 3 times a week. She had a follow up appointment scheduled with her PCP on [**2149-5-16**]. 3. SUPRATHERAPEUTIC INR- At [**Hospital3 **], pt's INR was supratherapeutic at 11. She was given 1u FFP and 10mg IV vitamin K. Her INR was likely elevated in the setting of recent initiation of fluconazole for esophageal candidiasis as this interacts with the cytochrome P450 system. In the ICU she required 3 units of FFP to reach therapeutic INR. Coumadin was held throughout her ICU course and was restarted at 2.5 mg Q day while inpatient on the medical wards. She was monitored and her INR was 1.1 the day of discharge. She was set up to have her home VNA check her INR over the weekend. She was told to discontinue the fluconazole which had likely precipitated the elevated INR due to its metabolism interaction with coumadin. She also was told to stop the Bactrim that she had been taking prior to admission. She was started on Ciprofloxacin for a UTI (see below) and therefore will need close monitoring of her INR while she is on this medication wihch can also interact. 4. ATRIAL [**Name (NI) **] Pt initially was in atrial fibrillation with rate in the 110s-120s. Rate was elevated likely in the setting of hypovolemia from blood loss. Initially metoprolol was held, but was restarted on [**5-7**] as pt became more hemodynamically stable, and rate was well-controlled in the 70s. She had no further issues. 5. URINARY TRACT [**Name (NI) **] Pt had been taking Bactrim for prophylaxis of frequent UTIs however c/o dysuria. U/A and UCx were sent, which grew out Citrobacter resistent to Bactrim on [**5-7**]. Therefore, prophylactic bactrim was discontinued and pt was started on a 7 day course of ciprofloxacin. Pt and family were informed of quinolone interaction with coumadin, though coumadin was being held for bleed, and the need to have her INR monitored. 6. ESOPHAGEAL [**Name (NI) 85513**] Pt has known achalasia and large hiatal hernia. She had recent esophgeal washings c/w candidiasis and started a course of fluconazole, which likely caused elevated INR (as above). Fluconazole was discontinued on admission and she remained asymptomatic. Omeprazole was continued. A follow up appointment was made with her GI doctor who should decide if she needs to complete the course of fluconazole. 7. CHRONIC [**Name (NI) 85514**] pts home diuretic regimen was continued. 8. [**Name (NI) 85515**] pts home xalatan (latanoprost) was continued. Medications on Admission: 1. Coumadin 2.5mg daily 2. Metoprolol tartrate 25 mg PO BID 3. Acetazolamide 250mg PO daily 4. Furosemide 40mg PO daily 5. Spironolactone 100mg PO daily 6. Potassium chloride 20mg PO daily 7. Colchicine 0.6mg PO daily 8. Oxybutynin 5mg PO BID 9. Carisoprodol 350mg PO BID 10. Zolpidem tartrate 10mg PO QHS 11. Percocet 1 tab PO QID 12. Latanoprost 0.05 mg/ml soln' 1 gtt OU HS 13. Bactrim DS 1 tab PO daily 14. B12 1000 mcg injection monthly 15. Fluconazole 200mg PO daily 16. Omeprazole 20mg PO daily Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Primary diagnosis: Left knee hematoma Supratheraputic INR Secondary diagnosis: Lymphedema COPD Atrial fibrilation GERD Achalasia Sciatica 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 you fell and bruised your knee. You were found to have a very high INR from an interaction with your coumadin and an antibiotic. You were given medicines and blood products to stop the bleeding. You had xrays that showed no broken bones. You were evaluated by our orthopedic service who did not think that you needed surgery. You worked with our physical therapists who showed you exercises and how to get up out of bed. You will have a home nurse come to check your blood over the weekend. You will also have home physical therapy three times a week. You were also found to have a urinary tract infection. We are treating you with an antibiotic called ciprofloxacin. You should take it for 4 more days. please stop the Bactrim during this time and follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 11370**]g it. We also stopped your fluconazole. you have an appointment with your GI doctor [**First Name8 (NamePattern2) **] [**5-27**]. Please talk with him about the need to restart this medication. We have changed some of your medications. Please note the fololowing changes: ** STOP FLUCONAZOLE ** STOP BACTRIM ** START Tylenol 650 mg three times a day ** START CIPROFLOXACIN 250 mg twice a day for 4 more days Followup Instructions: Primary Care Doctor Appointment When: [**Last Name (LF) **], [**5-16**], 2:15PM With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] When: Tuesday, [**5-27**] at 3:15pm With:,[**First Name11 (Name Pattern1) 1955**] [**Last Name (NamePattern4) 85516**] MD Specialty: Gastroenterology Address: [**Street Address(2) 4472**]. [**Apartment Address(1) 31103**], [**Hospital1 **],[**Numeric Identifier 4474**] Phone: [**Telephone/Fax (1) 52520**]

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icd9cm

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Discharge summary

report

Admission Date: [**2176-11-6**] Discharge Date: [**2176-11-9**] Date of Birth: [**2107-8-31**] Sex: F Service: NEUROLOGY Allergies: Nifedipine / amlodipine Attending:[**First Name3 (LF) 5018**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 69 year old woman with a history of COPD on 2L NC, CAD (EF >55% [**2176-10-28**]) s/p AAA repair [**3-/2176**] complicated by ischemic bowel, with subsequent colostomy complicated by ischemia s/p multiple abdominal surgeries, most recently colectomy and end ileostomy [**2176-10-25**] who presents with several days of dyspnea on exertion and 2 episodes of acute shortness of breath. Reports recent dry cough but denies sputum production, fevers/chills, sick contacts; Reports more frequent use of albuterol nebulizer at home over the last several days and has required constant O2 via nasal cannula which she had previously used only at night. Has not yet been able to obtain her prescribed fluticasone and symbicort. Denies chest pain, nausea/vomiting, abdominal pain, increased ostomy output. Reports improving lower extremity edema since discharge last week and stable 3 pillow orthopnea for many years. Has spent most of the time since recent discharge in bed. She initially presented to [**Hospital3 **], found to have a negative troponin, BNP 379; given nitrates and Lasix without much relief. In the ED, initial VS were: 97 92 141/75 22 96% 2L. CXR demonstrated hyperinflation, EKG with NSR. Exam with Faint bibasilar crackles on examination, prominent end expiratory wheezing bilaterally. Surgery saw her in the ED and recommended admission to medicine for possible COPD flare and agreed with steroids if medically indicated. She recieved 500mg Azithromycin, 60mg prednisone, as well as albuterol/ipratropium nebs for a presumed COPD exacerbation. Past Medical History: - CAD (TTE [**6-16**] w EF 60%) - DM2 - HTN - COPD on home O2 - Recurrent PNA - h/o interstitial lung disease of hypersensitivity pneumonitis s/p prednisone ~ [**2174**] s/p wedge resection of RML [**6-/2174**] - GERD - Hx thyroid dz - previous smoker - L thalamic ICH w residual mild RLE weakness ([**10/2174**]) - Concern for cryptogenic cirrhosis - lactose intolerance - s/p TAH/BSO unknown - s/p Appy unknown - Tonsillectomy unknown - L lumpectomy [**2171**] - s/p Lung biopsy [**2174**] - s/p open infrarenal AAA repair w/ dacron (Kechejian-[**2175-3-31**]) - s/p Sigmoid colectomy end colostomy ([**Doctor Last Name **]-[**2175-4-2**]) - s/p Hartmann's reversal, SBR, bladder repair, liver bx ([**Doctor Last Name **]-[**2175-11-16**]) - s/p take down of the ileostomy in [**2-/2176**] Social History: - lives at home with boyfriend, [**Name (NI) **] [**Telephone/Fax (1) 88094**] - Does not report a substance use history - Says that she is a social drinker and does not drink very often - Had long smoking history but stopped smoking 5 years ago Family History: Father died age [**Age over 90 **] w/complications of Alzheimer's. Mother is aged 97 w/mild memory issues and is retired RN. Physical Exam: ADMISSION PHYSICAL EXAM: VS 98.1 HR 95 BP 186/92 R 22 O2 97% 2L NC GEN Cachectic female, Alert, oriented, no acute distress HEENT NCAT dry mucous membranes EOMI sclera anicteric, OP clear NECK supple, JVP @ 10cm, no LAD PULM distant lung sounds, + rales to mid lung fields posteriorly, no wheezes CV RRR normal S1/S2, no mrg ABD ostomy in place with surrounding erythema c/d/i, midline surgical incision dressing c/d/i, soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, mild pitting edema bilateral lower extremities to mid shin NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Pertinent Results: [**2176-11-6**] 07:42PM WBC-5.1 RBC-3.41* HGB-9.1* HCT-28.6* MCV-84 MCH-26.5* MCHC-31.7 RDW-17.2* [**2176-11-6**] 07:42PM PLT COUNT-337 [**2176-11-6**] 07:42PM PT-11.7 PTT-35.2 INR(PT)-1.1 [**2176-11-6**] 10:30AM GLUCOSE-118* UREA N-8 CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-37* ANION GAP-8 [**2176-11-6**] 10:30AM estGFR-Using this [**2176-11-6**] 10:30AM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-182 ALK PHOS-137* TOT BILI-0.3 [**2176-11-6**] 10:30AM CK-MB-2 cTropnT-<0.01 proBNP-4293* [**2176-11-6**] 10:30AM ALBUMIN-2.5* CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.5* [**2176-11-6**] 10:30AM WBC-5.4 RBC-3.18* HGB-8.6* HCT-26.6* MCV-84 MCH-27.0 MCHC-32.3 RDW-17.2* [**2176-11-6**] 10:30AM NEUTS-92.3* LYMPHS-4.8* MONOS-2.8 EOS-0.1 BASOS-0.1 [**2176-11-6**] 10:30AM PLT COUNT-325# [**2176-11-8**] 04:05AM BLOOD WBC-6.7 RBC-3.44* Hgb-8.9* Hct-28.9* MCV-84 MCH-26.0* MCHC-30.8* RDW-17.2* Plt Ct-372 [**2176-11-8**] 03:20AM BLOOD WBC-6.2 RBC-3.27* Hgb-8.9* Hct-27.4* MCV-84 MCH-27.1 MCHC-32.4 RDW-17.2* Plt Ct-363 [**2176-11-7**] 09:00AM BLOOD WBC-8.5# RBC-3.17* Hgb-8.3* Hct-26.4* MCV-83 MCH-26.3* MCHC-31.5 RDW-17.2* Plt Ct-336 [**2176-11-8**] 04:05AM BLOOD Plt Ct-372 [**2176-11-8**] 03:20AM BLOOD Plt Ct-363 [**2176-11-8**] 03:20AM BLOOD PT-11.1 PTT-35.3 INR(PT)-1.0 [**2176-11-7**] 09:00AM BLOOD Plt Ct-336 [**2176-11-8**] 04:05AM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-136 K-3.9 Cl-96 HCO3-36* AnGap-8 [**2176-11-7**] 09:00AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-137 K-3.6 Cl-96 HCO3-36* AnGap-9 [**2176-11-7**] 09:00AM BLOOD ALT-12 AST-20 AlkPhos-151* TotBili-0.2 [**2176-11-8**] 04:05AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1 [**2176-11-7**] 09:00AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.4 [**2176-11-8**] 05:12AM BLOOD Type-ART Temp-36.8 pO2-87 pCO2-48* pH-7.48* calTCO2-37* Base XS-10 [**2176-11-8**] 05:12AM BLOOD Glucose-106* Lactate-0.8 [**2176-11-8**] 05:12AM BLOOD O2 Sat-96 Brief Hospital Course: Ms. [**Known lastname **] is a 69 year old woman with COPD, AAA repair c/b ischemic bowel s/p multiple abdominal surgeries including recent colectomy and end ileostomy [**2176-10-25**] who presents with several day h/o progressive DOE and 2 episodes of acute SOB and evidence of small subsegmental PE on CTA who experienced a hemorrhagic stroke of the pons and transferred to the neurology service. . #Pontine stoke- on [**11-7**] the patient had SBP- from 150-180, asymptomatic, no neurologic deficits, denied headache, chest pain, dyspnea or vision changes with normal mental status and orientation. Standing Labetalol was increased to 300mg TID and she was given 100mg extra dose twice for asymptomatic SBP of 180 the night of [**11-7**]. Early AM on [**11-8**] the patient experienced acute mental status change and right sided weakness. She was transferred to the neuro ICU after a code stroke was called. Once in the ICU she developed left sided weakness as well with a dilated right pupil and began having extensor posturing. CT scan showed a pontine hemorrhage. It was thought that her hemorrhage was most likely attributed to coagulopathy attributed to the use of LMWH for her pulmonary embolism. She was intubated and given mannitol. The following morning the patient's exam was very poor, indicating compression of the midbrain. The poor prognosis was communicated to the family. They decided to make the patient CMO in accordance with her clearly stated wishes and the patient was extubated on [**11-8**]. She passed during the night. . # Shortness of breath: high suspicion for PE on admission given recent surgery and subsequent immobilization as well as acute nature of SOB episodes. CTA chest this showed small subsegmental PE LUL and worsening bilateral effusions. Deconditioning and bibasilar atelectasis related to recent surgery and immobilization also likely contributing factors.Was treated with heparin drip and was transition ed to Lovenox and Coumadin bridge with normal renal function. . # Bilateral Pleural effusions: Likely exacerbating current SOB. CHF possible given pro-BNP elevation to the 1000s although TTE earlier this month showed no abnormality. Diuresed with good symptomatic effect with 2 bolus's of 20mg IV lasix until the stroke per above. . # COPD: On 2L home O2. - continued home tiotropium, Flovent, albuterol nebs; symbiot non formulary . # Recent Colectomy/ileostomy: - pain control with oxycodone # CAD: - continued ASA and simvastatin # Depression: - continued home Celexa Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Citalopram 10 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Acetaminophen (Liquid) 650 mg PO Q6H 6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 7. Labetalol 250 mg PO TID 8. OxycoDONE Liquid 2.5-5 mg PO Q4H:PRN pain 9. Omeprazole 20 mg PO DAILY 10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation TID 11. Vitamin D 1000 UNIT PO DAILY 12. Ferrous Sulfate 160 mg PO DAILY 13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Pontine Hemorrhage Discharge Condition: deceased Discharge Instructions: The patient was initially admitted for a pulmonary embolism. She was started on blood thinners for this. In the middle of the night on [**11-8**] she suddenly had right sided weakness. She was found to have a bleed in her brainstem. She was intubated and brought to the ICU but unfortunately there were signs that the blood was significantly compressing the brain stem. The patient's family made her wishes clear that she did not wish to be rescusitated or have a prolonged intubation. In accordance with her wishes she was made CMO. Followup Instructions: n/a [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

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Discharge summary

report

Admission Date: [**2177-10-12**] Discharge Date: [**2177-10-17**] Date of Birth: [**2129-10-5**] Sex: F Service: MEDICINE Allergies: Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra / Lisinopril / Naprosyn / Bactrim Ds / Phenytoin / Nitrofurantoin / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 6701**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 48 y/o AAF w/ spina bifida, MR, paraperesis, and urostomy p/w intense crampy abdominal pain and nausea w/ NBNB vomiting that started this morning. She states she feels her abdomen has been distended for an uncertain amount of time. She is also complaining of bilateral buttock pain and feels she has "cuts" on her buttocks. She is a poor historian given mental retardation. She denies fevers, chills, chest discomfort or difficulty breathing. . Of note, patient was recently admitted for abdominal pain that presented similarly and had a negative work up including CT abdomen, RUQ U/S and HIDA scan. She was treated w/a an aggressive bowel regimen and discharged after having daily stools. . In the ED VS: 97.1 70 104/63 16 98% RA. Exam was notable for distended abdomen that was diffusely tender to palpation and tenderness over her bilateral buttock ulcers, which did not appear infected but center having some necrotic tissue, per ED. U/A showed evidence of infection. As patient is allergic to zosyn, quinolones, ceftriaxone, flagyl and bactrim, she was treated with macrobid in the ED, and also given morphine and zosyn for her pain and nausea. CT abd/pelvis in the ED showed moderate bilateral hydronephrosis, with diffuse bilateral hydroureters all the way to the ileual conduit which was concerning for distal obstruction. Urology was consulted and evaluated pt in ED. They felt that since the pt had normal renal function, surgical intervention was not urgent and they would continue to follow her on the floor. . On the floor, pt is lying on her side complaining of pain, worse in her buttocks but also diffusely over her abdomen which she complains is distended. . All other ROS negative except as above. . Past Medical History: 1. Asthma/COPD 2. Hypertension 3. GERD 4. Urostomy 5. h/o VRE pyelonephritis 6. Spina bifida (myelomengiocele) 7. Paraplegia (documented, though patient can walk) 8. Depression 9. Mild mental retardation 10. Psychogenic dysarthria and tremor 11. [**First Name3 (LF) **] vs. pseudoseizures - EEG work-up at [**Hospital3 **] in [**2165**] frequent runs of regular bifrontal sharp delta activity although the clinical events which occurred during the record were not associated with EEG change 12. Atopic dermatitis 13. Back pain 14. Genital herpes 15. Uterine fibroid 16. Uterine prolapse 17. Diverticulosis 18. External hemorrhoids Social History: Lives alone in an apartment in [**Location (un) 86**]. She is able to transfer w/ wheelchair. No assistance at home currently, noting that she does everything on her own. She reports compliance with her meds. No assistance at home currently, noting that she does everything on her ownTobacco: 1 PPD EtOH: Drinks 2-3 beers a day. Illicits: Denies IVDU ever. History of smoking crack cocaine. Family History: Per previous report: 3 healthy children. Mother - died of lung cancer. Father - killed by his girlfriend. Not in contact with her brother and sister. Physical Exam: VS: 97.2 136/74 66 18 98 % RA . GEN: obese AAF in mod distress [**3-4**] pain, lying on L side HEENT: EOMI, PERRLA no scleral icterus CV: RRR nl S1 S2 LUNGS: CTAB/L ABD: +BS soft but distended, diffusely TTP all over abd EXT: warm, well perfused 2+ distal pulses b/l NEURO: A&Ox3, able to answer questions appropriately SKIN: large area of skin breakdown and ulceration almost covering the entirity of buttocks worse on the right than left buttock, skin breakdown revealing pink granulation tissue w/ some central greyish-white necrosis but no obvious drainage or purulence, surrounding skin is not erythematous but is exquisitely TTP Pertinent Results: CT AB/Pelvis with contrast IMPRESSION: 1. Interval development of mild hydronephrosis and moderate hydroureter bilaterally with ureteral dilatation extending to the ileal conduit which is mildly distended compared to prior studies. Clinical correlation is recommended to exclude a possible distal obstruction of the urostomy, resulting in upstream dilatation of the collecting systems due to reflux and back pressure. No mechanical obstruction of the urostomy on this CT, however, is identified. 2. Unchanged bilateral renal cortical thinning, compatible with scarring from prior infectious or ischemic insults. 3. No intra-abdominal abscess. 4. Fibroid uterus. 5. Spina bifida with meningocele. Urine Culture [**2177-10-11**] **FINAL REPORT [**2177-10-18**]** Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. [**Month/Day/Year **] Susceptibility testing requested by DR. [**Last Name (STitle) **] #[**Numeric Identifier **] [**2177-10-15**]. SENSITIVE TO [**Month/Day/Year **] ( MIC=0.032 MCG/ML). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . Skin, right posterior shoulder, biopsy (A-B): [**2177-10-13**] 1. Subepidermal bulla with superficial dermal edema and mixed neutrophilic, eosinophilic, and lymphocytic infiltrate (see note). 2. Neutrophilic folliculitis. Note: Neutrophilic microabscesses are present in the superficial epidermis and within a follicle. No bacteria or fungi are seen on Gram and PAS stained sections, however the involved follicle is not present on these section. No interface dermatitis to suggest a fixed drug reaction is seen. The changes most suggest a bullous hypersensitivity reaction. The neutrophilic microabscesses may represent a feature of this reaction, however focal superinfection cannot be excluded. While clinically less likely, the histologic differential diagnosis includes an immunobullous disorder . . Tissue Biopsy [**2177-10-11**] GRAM STAIN (Final [**2177-10-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2177-10-16**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. POTASSIUM HYDROXIDE PREPARATION (Final [**2177-10-14**]): NO FUNGAL ELEMENTS SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2177-10-14**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): . [**2177-10-17**] 07:35AM BLOOD WBC-14.0* RBC-3.41* Hgb-10.5* Hct-31.4* MCV-92 MCH-30.7 MCHC-33.3 RDW-15.5 Plt Ct-282 [**2177-10-11**] 08:10PM BLOOD WBC-9.2 RBC-4.08* Hgb-12.1 Hct-38.7 MCV-95 MCH-29.7 MCHC-31.3 RDW-14.9 Plt Ct-296 [**2177-10-14**] 03:33AM BLOOD Neuts-95.8* Lymphs-3.4* Monos-0.4* Eos-0.3 Baso-0.2 [**2177-10-11**] 08:10PM BLOOD Neuts-69.0 Lymphs-21.7 Monos-2.7 Eos-5.7* Baso-0.9 [**2177-10-17**] 07:35AM BLOOD Glucose-74 UreaN-12 Creat-0.7 Na-139 K-4.0 Cl-102 HCO3-31 AnGap-10 [**2177-10-11**] 11:08PM BLOOD Glucose-90 UreaN-15 Creat-0.8 Na-137 K-4.5 Cl-107 HCO3-19* AnGap-16 [**2177-10-14**] 03:33AM BLOOD ALT-27 AST-16 AlkPhos-115* TotBili-0.5 [**2177-10-12**] 08:20AM BLOOD ALT-50* AST-67* LD(LDH)-197 AlkPhos-159* TotBili-0.4 [**2177-10-17**] 07:35AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.3 [**2177-10-11**] 11:08PM BLOOD Calcium-8.0* Phos-3.8 Mg-2.1 [**2177-10-11**] 08:19PM BLOOD Lactate-1.4 [**2177-10-12**] 03:41AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [**2177-10-11**] 09:30PM URINE Blood-SM Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-SM [**2177-10-12**] 03:41AM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1 [**2177-10-11**] 09:30PM URINE RBC-[**4-4**]* WBC-[**12-20**]* Bacteri-MANY Yeast-NONE Epi-0 Brief Hospital Course: RASH: On the morning of HD3, Ms. [**Known lastname **] developed a rash on her bilateral axilla concerning for drug reaction versus cellulitis. She also had a new leukocytosis overnight with a fever to 103. She was given tylenol and morphine for fever and abdominal pain and blood cultures were drawn. This morning, dermatology was consulted given previous history of drug sensitivity rashes. Nitrofurantoin was discontinued. She was not on any other new drugs other than PRN morphine for abdominal pain. Over the course of the morning her rash worsened, spreading from her axilla to her drunk and developing bullae on the left hip. She has developed hypersensitity rashes during past admissions thought to be in relation to phenytoin. During her last admission for a rash on her thigh, she developed hypotension and was intubated for airway protection and transferred to [**Hospital6 **] Burn Unit for evaluation of her evolving rash. She was started on Meropenem, Clindamycin and Vancomycin during that admission. Imaging studies were not consistent with necrotizing facititis. Review of [**Hospital1 756**] discharge summary revealed skin biopsy pathology consistent with hypersensitivity reaction. In the setting of worsening rash, hypotension, and fever in the context of her past history she was transferred to the MICU for further evaluation and treatment. In the MICU, Ms. [**Known lastname **] [**Last Name (Titles) 53183**] well to fluid bolus and she was hemodynamically stable. She was initiated on Meropenem and Vancomycin for urinary tract infection and concern for superinfection of her skin. Dermatology was consulted and biopsied her skin and recommended IV methylprednisone for likely hypersensitivity reaction. As Ms. [**Known lastname **] [**Last Name (Titles) 54251**] and her rash improved she returned to the general medicine floors. IV methylprednisone was change to oral prednisone, 60mg daily. Vancomycin was discontinued as her rash did not appear infected. In preparation for discharge to home, meropenem three times a day was changed to daily [**Last Name (Titles) 49799**]. She was observed for 24 hours after initiating [**Last Name (Titles) 49799**] for possible drug reaction. She was discharged home and will complete her 14 days of antibiotic therapy. She will complete a steroid taper at home and follow up at her primary care physician. . ABDOMINAL PAIN/DISTENTION- Etiology of abdominal discomfort and distention concerning for symptoms secondary to her urinary obstruction versus colicky pain from cholelithiasis versus constipation. Work up in [**Month (only) 547**] of this year, including a CT scan, HIDA scan, and RUQ were unremarkable. Absence of leukocytosis or h/o fevers not concerning for infectious process. CT on admission remarkable only for hydronephrosis and chlolelithiasis. History of nausea and vomiting yesterday without diarrhea or different eating habits. Nausea and vomiting resolved on admission. Pain is well controlled with Tylenol and IV morphine 2mg for break through pain. She was continued on a bowel regiment with senna, colace, miralax, bisacodyl. Lactulose was held as it may acutely worsen abdominal cramping. She was initially kept NPO with IV maintenance fluids. Over her hospital stay, Ms. [**Known lastname **] abdominal pain and distention improved. She was able to tolerate regular foods and had regular bowel movements. . URINARY TRACT INFECTION- WBC and few bacteria in urine were concerning for urinary tract infection in a patient with a urostomy and hydronephrosis. Ms. [**Known lastname **] has multiple allergies to medications. Urine Cultures have grown out pan-sensitive proteus in the past. Pt has severe uterine prolapse with protruding cervix per night float admission. Ms [**Known lastname **] was started empirically in the ED on macrobid given allergy hx. She developed a drug allergy to likely Macrobid after 24 hours of treatment and developed fevers and a leukocytosis concerning for hypersensitivity or urosepsis. She was briefly transferred to the ICU for evaluation and treatment. Antibiotic therapy was changed to Meropenem and the switched to [**Known lastname **] for treatment at home once daily. She tolerated both of these antibiotics well without evidence of reaction. . BILATERAL BUTTOCKS ULCERS- Although Ms. [**Known lastname **] reported these ulcers are new, past notes reveal long history of pressure ulcers. It does not appear Ms. [**Known lastname **] has significant home suport. On admission, no leukocytosis or history of fevers on admission and exam does not look infected intially. Wound care was consulted and assessed right side wound to be stage 3 ulcer due to sloughing of skin and left side to be stage 2. Her wounds were dressed daily by wound care with recommendations forwarded to Ms. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 269**] services. Ms. [**Known lastname **] will need education regarding frequent position changes to prevent further development of pressure ulcers at home. . 5. ASTHMA/COPD- Ms. [**Known lastname **] asthma flare on admission requiring several nebulizer treatments. She was continued on home Singulair. Medications on Admission: on last discharge [**2177-6-25**]: Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN skin irritation Montelukast Sodium 10 mg PO/NG DAILY Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever Pantoprazole 40 mg PO Q24H Order date: [**6-15**] @ 1209 Citalopram Hydrobromide 20 mg PO/NG DAILY Quetiapine Fumarate 25 mg PO/NG HS Docusate Sodium 100 mg PO BID Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Heparin 5000 UNIT SC TID Thiamine 100 mg PO/NG DAILY Discharge Medications: 1. [**Hospital1 **] 1 gram Recon Soln Sig: One (1) Recon Soln Injection q24hrs () as needed for UTI for 10 days. Disp:*10 Recon Soln(s)* Refills:*0* 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for skin irritation. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Prednisone 10 mg Tablets, Dose Pack Sig: As directed PO once a day for 11 days: Take 6 pills (total 60mg) on day 1 [**2177-10-18**]. Take 3 pills (total 30mg) daily for 5 days starting [**2177-10-19**]. Take 1.5 pills (total 15 mg) daily for 5 days starting [**2177-10-24**]. Disp:*29 Tablets, Dose Pack(s)* Refills:*0* 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for skin irritation. 13. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every six (6) hours as needed for pain for 10 days: Do not drive or operate heavy machinery while using this medication. Disp:*15 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary: Bullous hypersensitivity reaction Secondary: Urinary tract infection Mild hydronephrosis and moderate hydroureter suggestive of urinary tract outflow obtruction. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Able to walk short distances with a walker. Discharge Instructions: You were admitted with abdominal and buttock pain. You had ulcers which were evaluated and treated by Wound Care. You were found to have mildly enlarged kidneys and urinary tract; Urology recommended outpatient follow-up as your labs to assess kidney function remained normal. You were also found to have a urinary tract infection. This was treated with an antibiotic, nitrofurantoin (Macrobid), that caused an allergic reaction on your skin. You were transferred briefly to the intensive care unit to care for you as recovered from this reaction. Macrobid was discontinued and you were given steroids to help control your skin reaction per Dermatology's recommendation. You were started on [**Last Name (LF) 49799**], [**First Name3 (LF) **] antiobiotic to complete treatment of your urinary tract infection. You were kept overnight to make sure you did not develop a reaction to this new drug. The following changes were made to your medication list: - Please continue to take [**First Name3 (LF) 49799**] for a total of ten more days. - Please continue your prednisone taper for 11 more days as directed. - Please take all your other medications as prescribed and review them with your primary care physician. Followup Instructions: Department: Primary Care Name: Dr. [**First Name (STitle) **] [**Name (STitle) 5240**] When: Wednesday [**2177-10-29**] at 10 AM Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 798**] Department: DIV OF ALLERGY AND INFLAM When: [**Telephone/Fax (1) **] [**2177-10-20**] at 9:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9703**], RNC [**Telephone/Fax (1) 9316**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**] Campus: OFF CAMPUS Best Parking: Parking on Site Department: SURGICAL SPECIALTIES When: THURSDAY [**2177-11-13**] at 9:00 AM With: DR. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 3752**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]

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icd9cm

[ [ [] ] ]

[ "38.93", "86.11" ]

icd9pcs

[ [ [] ] ]

15991, 16066

8565, 13771

428, 435

16282, 16282

4084, 6883

17748, 18797

3262, 3413

14281, 15968

16087, 16261

13797, 14258

16503, 17725

3428, 4065

7212, 8542

7060, 7179

374, 390

463, 2183

6919, 7027

16297, 16479

2205, 2837

2853, 3246

1,561

125,145

28227

Discharge summary

report

Admission Date: [**2188-12-8**] Discharge Date: [**2188-12-16**] Service: SURGERY Allergies: Iodine / Penicillins Attending:[**First Name3 (LF) 695**] Chief Complaint: Hepatocellular carcinoma Major Surgical or Invasive Procedure: Partial left lateral segmentectomy, intraoperative ultrasound History of Present Illness: This is 82-year-old gentleman who was in his usual state of health when he underwent a workup for anemia on [**2188-8-12**]. As part of his workup, he underwent a colonoscopy which showed a resection of part of the rectosigmoid from prior surgery, some diverticulosis, and angiodysplastic lesion at the base of the cecum which was cauterized. However, he did not have any evidence of active bleeding. He also underwent an EGD, which showed two small benign appearing polyp-like lesions at the GE junction which were biopsied and showed a well-differentiated adenocarcinoma at the squamoglandular junction. He had previously undergone an MRI of the abdomen, which had shown a 3-cm left hepatic lobe lesion. As part of his staging workup for the esophageal adenocarcinoma, he underwent an abdominal CT scan on [**2188-8-27**] which showed the same left lower lobe mass which had grown in size. He also underwent a CT of the chest on [**2188-9-8**] which showed nonspecific ground-glass opacities in the left lower lobe. He underwent a liver biopsy on [**2188-9-8**] which showed poorly differentiated carcinoma most consistent with hepatocellular carcinoma. He underwent a PET scan on [**2188-9-30**], which did not show any abnormal uptake in the region of the patient's known hepatocellular carcinoma. He followed up with Dr. [**Last Name (STitle) **] on [**2188-11-19**], and a resection of his lesion was planned for [**2188-12-8**]. Past Medical History: 1. History of colon cancer, status post colon resection in [**2165**], complicated by leakage lead to a colostomy. This was subsequently taken down 6 months later. 2. Hepatocellular carcinoma as noted above. 3. Endocarditis in 12/[**2186**]. 4. Abdominal aortic aneurysm status post repair in [**2166**]. 5. Status post cholecystectomy. 6. Status post appendectomy. 7. Status post prostatectomy for BPH. 8. Insulin-dependent diabetes mellitus greater than 20 years. 9. Hypertension. 10. History of cataracts and glaucoma. 11. History of basal cell carcinoma right scapula, bilateral ears, and neck. 12. Status post carotid endarterectomy 6 years ago. Social History: The patient is a previous smoker, quit 7 years ago. He has a 90-pack-year smoking history. He worked in receiving room of a pharmaceutical company. Denies any occupational exposures. He lives with his family. He has not had any alcohol use since [**2165**]. Family History: Significant for mother who died of breast cancer, father with stroke, sister had question of cancer that does not know which one, and brother had coronary artery disease. Pertinent Results: [**2188-12-8**] 10:22AM BLOOD WBC-15.0*# RBC-4.00* Hgb-11.4* Hct-32.8* MCV-82 MCH-28.5 MCHC-34.8 RDW-16.9* Plt Ct-248 [**2188-12-8**] 10:22AM BLOOD Plt Ct-248 [**2188-12-8**] 10:22AM BLOOD Glucose-206* UreaN-13 Creat-0.8 Na-137 K-4.0 Cl-106 HCO3-24 AnGap-11 [**2188-12-8**] 10:22AM BLOOD ALT-123* AST-149* AlkPhos-96 TotBili-0.3 [**2188-12-8**] 10:22AM BLOOD Albumin-3.4 Calcium-8.6 Phos-2.8 Mg-1.5* [**2188-12-8**] 10:17PM BLOOD CK-MB-9 cTropnT-<0.01 [**2188-12-9**] 06:18AM BLOOD CK-MB-12* MB Indx-6.5* cTropnT-<0.01 [**2188-12-9**] 02:36PM BLOOD CK-MB-7 cTropnT-<0.01 Brief Hospital Course: Mr. [**Known lastname 33813**] was admitted to the hospital after undergoing a left lateral hepatic segmentectomy on [**2188-12-8**]. Initially, he was followed in the PACU, where EKG changes were noted, and he was transferred to the surgical intensive care unit to manage his blood pressure and evaluate these changes. His cardiac enzymes were not indicative of any myocardial ischemia. During this time, he was also experiencing nausea and burping. A nasogastric tube was placed, alleviating these symptoms. On POD1, he was transferred to [**Hospital Ward Name 121**] 10, and was resting comfortably. However, that evening, he was noted to have a heart rate to 140 in atrial fibrillation. He received 30 mg of IV metoprolol, and converted to sinus rhythm. This did recur during the night, and he was transferred back to the SICU in order to be treated with an IV diltiazem drip. On POD2, Cardiology's input was requested, and the recommendation to wean his diltiazem and initiate beta-blockade. In the immediate postoperative period, it was felt that initiating anticoagulation therapy or reinstituting statins was contraindicated. His NGT was removed. His heart rate recovered, and his rhythm converted to normal sinus. He was then transferred to the floor on POD4. While on the floor, he experienced a fever to 102.1 F. He was placed on levofloxacin, and he defervesced. He continued to do well, and was evaluated by physical therapy on POD6. The assessment was that he would do well at home (will be at his daughter's home). He continued to do well, eating a regular diet and having normal bowel movements. He was discharged to his daughter's home on [**Hospital3 **] on POD8. He had a JP drain in place in his right lower quadrant throughout his admission. The output from this drain had decreased consistently throughout his stay. He was discharged with this drain in place with instructions to follow up with Dr. [**Last Name (STitle) **] within one week. He will start on oral iron suppplement. In house Cardiology has recommended starting on low dose aspirin, and may restart statin. Follow-up with his cardiologist is recommended in one month. Anticoagulation may restart at that time. Medications on Admission: Metformin 500 mg p.o. q.a.m., 1000 mg p.o. q.h.s., Actos 45 mg p.o. daily, Humulin 16 units subcutaneous daily, glyburide 5 mg p.o. daily, Lipitor 10 mg p.o. daily, vitamin B12 p.o. daily, Nifedical 90 mg p.o. daily, and losartan 50 mg p.o. b.i.d., Ativan 1 mg p.o. q.h.s., and Protonix 40 mg p.o. daily. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 2. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 30 days. Disp:*30 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*2* 7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous at bedtime. Disp:*1 bottle* Refills:*2* 13. Insulin Syringe Syringe Sig: One (1) syringe Miscell. once a day: For NPH insulin QPM. Disp:*1 Box* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 635**] vna Discharge Diagnosis: Hepatocellular carcinoma, s/p left lateral segmentectomy Discharge Condition: Good Discharge Instructions: Please return to the Emergency Room if you experience: Fever greater than 101.5 F Increased drain output Nausea and/or vomiting Increasing redness, pain, or drainage at your incision Inability to pass stool or urine Any other concerns Continue Blood sugar regimen as you were at home. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2188-12-24**] 3:40 Cardiology: Please call your cardiologist for follow-up appointment in one month [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "V10.05", "250.00", "427.31", "151.0", "V10.83", "V58.67", "997.1", "424.1", "155.0", "V12.72", "443.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "50.22", "96.07" ]

icd9pcs

[ [ [] ] ]

7738, 7792

3561, 5787

252, 316

7893, 7900

2965, 3538

8245, 8628

2774, 2946

6143, 7715

7813, 7872

5813, 6120

7924, 8222

188, 214

344, 1790

1812, 2478

2494, 2758

6,020

127,735

3468

Discharge summary

report

Admission Date: [**2117-7-16**] Discharge Date: [**2117-8-9**] Date of Birth: [**2061-9-6**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fever.sob Major Surgical or Invasive Procedure: Bronchoscopy, intubation History of Present Illness: This is a 55M with Mantle Cell Lymphoma , D+35 s/p an autologous stem cell transplant. He was in his USOH until 2 days ago when he developed worsening non-productive cough, SOB and low grade fever. His Temp in the clinic yesterday was 100.5. Blood cxs were taken and he was started on azithromycin and vancomycin. Today he was worse and atovaquone was added to his abx. However this evening he had a temp of 102 at home and he also was more dyspneic even at rest and he went to the ED. Last week he had diarrhea which improved after he was started on Lomotil. Last week he was also noted to have transaminitis and his fluconazole was held. He denies LE edema, chest pain, shortness of breath, nausea, vomiting. Past Medical History: 1. Lipoid nephrosis at age 27, resolved with prednisone 2. Lichen Planus, resolved after chemotherapy, no h/o Hep C 3. Rectal fissures, resolved after sphincterotomy per pt 4. Sciatica, resolved after exercises and stretches . Past Oncology History: He was diagnosed with mantle cell lymphoma by bone marrow biopsy [**10-12**] when he was found to have an elevated white count on routine labs. His cytogenetics showed a 11:14 translocation. He has been treated with 3 cycles of hyperCVAD, first two were complicated by volume overload and hyponatremia. He has also received 2 doses of rituximab. His course was also complicated by splenic laceration ([**2116-12-20**]) from splenomegally secondary to neulasta and hyperleukocytosis. Underwent cycle 3A of hyperCVAD (cytoxan, vincristine, adramycin, decadron) in [**Month (only) 404**]. On [**2117-5-5**] underwent high dose cytoxan for stem cell harvesting prior to his autologous stem cell transplantation. Social History: He continues to work managing a computer database at [**University/College 15978**]. He quit smoking 30 years ago, at which point he had been smoking [**4-10**] ppd for 10 years. He drinks 1-2 drinks per evening. Distant h/o MJ use. No IVDA. He lives with his wife, no children, one dog. Family History: His mother had a precancerous condition of the breast which was treated with bilateral mastectomy. His father is well. He has no children and has one healthy brother. There is no known family history of blood disorders or actual cancers. Physical Exam: VS: 99.1 (AX), HR:124, BP:162/80,RR:16,SpO2:88 [AC, FiO2 100%, TV:500, RR:16, PIP:18, PEEP:10] General: Middle aged male, sitting in bed, in significant respiratory distress, using accessory muscles, anxious. HEENT: PERRL EOMI. No scleral icterus. MMdry OP clear without thrush or lesions. Neck: No JVD. No appreciable LAD. Lungs: +diffuse fine crackles, L>R with diffuse inspiratory and expiratory rhonchi CV: RRR S1 and S2 barely audible (above rhonchi) w/out m/r/g Abd: Soft, NT, ND, NABS, No masses. EXT: 2+ DPs. No C/C/E NEURO: nonfocal, AOX3 . Pertinent Results: CXR ([**7-15**]): New diffuse bilateral increased interstitial markings suggestive of an atypical infection of viral etiology in this neutropenic patient . CT chest on [**7-17**]: IMPRESSION: 1. Diffuse bilateral consolidation of all lobes with relative sparing of the apices consistent with multifocal pneumonia or possibly ARDS. 2. Moderate right and small left layering pleural effusions. . U/S abd ([**7-16**]): Splenomegaly. Otherwise, unremarkable abdominal ultrasound. Brief Hospital Course: 55 y/o male on s/p autoSCT for mantle cell lymphoma who was initially admitted with fever and hypoxemia with bilateral infiltrates and effusions. The following events were addressed during his admission. 1. Hypoxemia On arrival to the floor, patient was sating about 90% on 4 liters. ABG was done that showed 7.47/34/38 on RA. A Ventury mask was started and his oxygenation improved. X ray showed new diffuse bilateral increased interstitial markings suggestive of an atypical infection of viral etiology. Patient was started on broad spectrum antibiotics, TMP-SMX to cover PCP, [**Name10 (NameIs) **] steroids. Pulmonary was consulted who felt that the process was more likely a viral or atypical pneumonia. In order to bronch him, they felt that he would have to be intubate at that point and after discussion with him and the family it was decided to defer it. CT scan showed diffuse bilateral consolidation of all lobes with relative sparing of the apices consistent with multifocal pneumonia or possibly ARDS and moderate right and small left layering pleural effusions. His respiratory status decompensated and on [**7-18**] he had to be transferred to the ICU for intubation. [**Hospital Unit Name 153**] Course [**7-18**] to [**7-22**]: The pt was admitted to the [**Hospital Unit Name 153**] for intubation after developing progressive hypoxia, likely secondary to ARDS vs multifocal PNA. His oxygen saturation prior to admission was 80% on 13L ventimask and NC. The pt was sedated and intubated by anesthesia. He underwent an A-line placement. Pt had a bronchoscopy that showed evidence of prior DAH, and patient was initiated on high dose Solumedrol 100 mg IV bid. An TTE with bubble study was negative for any PFO or ASD that was causing persistent hypoxemia despite adequate ventilation. A CTA was negative for any PE. His daily CXR continued to be consistent with ARDS of unknown etiology combined with DAH. His BAL cultures remained NGTD, and all other cx data remained negative. Patient was continued on Cefepime and Vanco for treatment of his neutropenic fever, although no etiology to his fevers could be found. Eventually, patient's WBC count returned to [**Location 213**], and his fevers resolved. He self-extubated himself on [**7-22**] and was transitioned initially to BiPap and then to face mask as tolerated. He was eventually weaned down to 6L NC on transfer to the [**Month/Year (2) 3242**] floor. His steroid dose was quickly tapered down given his immunocompromised state, and at time of transfer, was on SoluMedrol 100mg IV daily. At that point he had completed a 10 day course of cefepime and vancomycin on [**2117-7-25**]. Night prior to transfer to the floor patient spiked fevers and it was decided to continue with empiric antibiotic coverage. His steroids were decreased upon transfer. On the [**Date Range 3242**] floor, his respiratory status was tenous and his fevers continued. His given ? of new infiltrates in x ray prior to transfer a CT was ordered. It showed marked improvement of consolidations and septal wall thickening in comparison to the previous CT, but rapid worsening during the last three days in comparison to the chest x-ray suggest pulmonary edema. Infectious process should also be included in the Dx. On [**2117-7-27**] he had an episode of low sats to 88% and increase shortness of breath. Chest X ray showed worsening bilateral pulmonary opacities with progression to frank alveolar consolidation. Report suggested recurrent pulmonary hemorrhage or pulmonary edema. He was given lasix however his respiratory status did not improved much. Echocardiogram was also done that showed no change LVEF >55%, and moderate pulmonary hypertension. Basically unchanged from prior. Given his persistent fevers and unclear etiology of pulmonary infiltrates pulmonary was re-consulted and Infectious disease service. Given lack of clear of positive data from Blood cx, urine cx and BAL, it was decided to continue treating empirically for CAP, PCP, [**Name10 (NameIs) **] Diffuse Alveolar Hemorrhage. Patient was continued on Cefepime, Vancomycin, Clindamycin and primaquine were added for PCP coverage, AmBisome, and steroid dose was increased. Next day X ray was checked and showed marked improvement, however o2 requirement still present with sats 92-94% on 40%FIO2. Given this rapid changes on x ray infiltrates, ID and pulmonary feel at this point that is less likely to be infectious. Despite being on broad antibiotic coverage, his respiratory status again declined on [**2117-7-31**]. His steroids were increased. He was diuresed with Lasix. ABx and steroids were continued. Unclear what was causing his episodes of respiratory distress. Transferred back to oncology floor. On the AM of [**2117-8-6**], he became more hypoxic and was again transferred to the [**Hospital Unit Name 153**]. Continued to diurese. Continued on ABx. CT revealed worsening disease, B/L airspace opacities. He was then started on BiPAP. He was intubated around 3PM on [**2117-8-9**]. Bronchoscopy was attempted at 4:30PM. Pt became bradycardic and hypotensive during bronchoscopy. Code Blue was called and CPR was initiated. Family decided to change his code status to DNR/DNI. Pt expired at 6:25PM. 2. Fevers: As stated above. Blood cx, BAL and Urine Cx all negative. 3. Elevated LFT/Alk phosph: slightly elevated on admission. Trending up over the course of hospitalization. U/s was done on [**2117-7-16**] that was normal. Hep b and C was negative in [**2116-11-7**]. Repeated serologies were sent and were negative. Thought to be medication related. Medications on Admission: [**Last Name (un) 1724**]: Famvir 500mg qd, protonix 40mg qd, azithromycin (started on [**7-15**]), vancomycin (started on [**7-15**]), atovaquone (started on [**7-16**]), ativan prn, tylenol#3 prn . MEDS on Transfer: . Acetaminophen 650 mg PO X1 PRN prior to PRBC tx Hydrocodone-Acetaminophen [**2-8**] TAB PO Q4-6H:PRN Acetaminophen 500 mg PO Q6H:PRN Lorazepam 0.5-1 mg PO/IV Q4-6H:PRN Azithromycin 250 mg PO Q24H MethylPREDNISolone Sodium Succ 100 mg IV Q 12H Ceftriaxone 1 gm IV Q24H Pantoprazole 40 mg PO Q24H Order date: [**7-17**] @ 0228 DiphenhydrAMINE HCl 25 mg PO/IV X1 PRN prior to PRBC tx Famvir *NF* 500 mg Oral DAILY Sulfameth/Trimethoprim 420 mg IV Q8H Guaifenesin-Codeine Phosphate [**6-16**] ml PO Q6H:PRN cough Vancomycin HCl 1000 mg IV Q 12H Discharge Medications: Pt expired. Discharge Disposition: Expired Discharge Diagnosis: Pt expired. Discharge Condition: Pt expired. Discharge Instructions: Pt expired. Followup Instructions: Pt expired. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2119-10-3**]

[ "790.4", "486", "799.4", "276.1", "284.8", "202.80", "518.81", "251.8", "E932.0", "427.5", "511.9", "428.0", "786.3", "443.0", "V42.82" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.05", "96.72", "33.24", "99.60", "99.04", "99.15", "96.04" ]

icd9pcs

[ [ [] ] ]

10144, 10153

3689, 9296

284, 310

10208, 10221

3186, 3666

10281, 10459

2359, 2601

10108, 10121

10174, 10187

9322, 9522

10245, 10258

2616, 3167

235, 246

338, 1051

1073, 2037

2053, 2343

9540, 10085

18,846

104,006

6081

Discharge summary

report

Admission Date: [**2139-11-28**] Discharge Date: [**2139-12-29**] Date of Birth: [**2074-2-1**] Sex: F Service: MEDICINE Allergies: Penicillins / Ceftriaxone / Strawberry / Bleach Attending:[**First Name3 (LF) 602**] Chief Complaint: groin abcess, hypotension Major Surgical or Invasive Procedure: ERCP with stent placement IR procedure(percutaneous cholecystostomy tube placement) History of Present Illness: 65F w/ IDDM, ESRD, morbid obesity, and history of multiple line infections who recently had an I&D of a groin abscess on [**11-24**]. She presented to the ED today after undergoing HD at [**Hospital 7137**] per repacking of her abscess but was found to be hypotensive w/ sbps in the 80s. Ms. [**Known lastname **] reports recent nausea and vomiting related to her abx (doxy and bactrim). She reports an undocumented fever past wednesday but none since. She has had a productive cough since yesterday with yellowish-brown sputum. She denies any CP, myalgias, pain. per the abscess she has been to the ED twice for dressing and reports improvement. She has a history of constipation and last moved her bowels a few days ago. She has some abdominal discomfort in that she feels bloated, and has localized TTP in the LLQ. No recent dx of diarrhea. In the ED, patient became hypotensive to 80/40, subjectively feels "not right" but no reports of dizziness (no change in symptoms from presentation). Given 250cc bolus of NS X 2. However, she was not felt to be fluid responsive and was started on levophed and central line was placed. Also labs came back acidotic with bicarb of 11, repeat 15 on green top. Her EKG demonstrated junctional rhythm at 62 bpms, LAD, NI, consistent with prior. She had a normal lactate. Was given cipro, flagyl,. CT Abdomen and CXR were "unremarkable". She recieved a total of 2L in ED. . In the MICU, she was vitally stable on a levophed drip. . Review of sytems: (+) Per HPI, + LLQ pain, constipation with last BM 3 days prior (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - atrial tachycardia: seen by Dr. [**Last Name (STitle) **] in [**10-24**] and felt to be atrial tachy [**2-18**] illness, no indication for ablation - hemorrhagic pericardial effusion - Bilateral internal jugular thromboses, restarted on coumadin [**8-24**] - h/o bilateral lower extremity DVT's - ESRD on HD T, Th, Sat - IDDM - Diastolic heart failure - Pulmonary hypertension - Hypercholesterolemia - OSA, noncompliant with CPAP as outpatient (on 2L home O2) - OA - h/o C. Diff - GERD - Depression - Morbid obesity - Fibroid uterus; vaginal bleeding - h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc - h/o Multiple line infections . Micro Hx: **[**2135-12-17**]: Providencia, treated with 4 wk course of aztreonam **[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin and gentamicin **[**2136-5-17**]: Staph bacteremia tx with vanc x 6 weeks **[**2136-8-17**]: Proteius mirabilis and MSSA, treated with ceftaz and vanc Social History: Patient denies tobacco, alcohol or illicit drug use. She lives in a nursing home ([**Hospital3 2558**]) since the last 4 years. She is separated from her husband. She has 5 children in [**Location (un) 86**] [**Doctor Last Name **] area. Family History: Two children with asthma. Otherwise non-contributory. Physical Exam: On Admission: Vitals: T: 99.4/37.4 BP: 86/58 P: 81 R:17 O2: 100% on 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley - well healing abscess Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly intact in all extremities Discharge exam: VS - Temp 98.5 F, 83 HR , 15 RR , 116/42 BP , 99 O2-sat % 2L GENERAL - obese woman NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - diminished breath sounds bilat, no r/rh/wh, poor air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/obese, ttp in RUQ with deep palpation, no masses or HSM, no rebound/guarding, +BS EXTREMITIES - WWP, no c/c, mild 1+ edema, 2+ peripheral pulses (radials, DPs), L sided femoral tunnelled dialysis catheter in place CDI SKIN - numerous SC calcifications in b/l LE LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-21**] throughout, sensation grossly intact throughout, DTRs 2+ Pertinent Results: =================== LABORATORY RESULTS =================== On Admission: WBC-7.1 RBC-3.55* Hgb-11.8* Hct-40.0 MCV-113* RDW-14.0 Plt Ct-327 --Neuts-79.4* Lymphs-14.6* Monos-3.9 Eos-1.8 Baso-0.3 PT-34.1* PTT-34.3 INR(PT)-3.4* Glucose-102* UreaN-17 Creat-3.4*# Na-137 K-6.0* Cl-111* HCO3-11* ALT-23 AST-24 AlkPhos-174* TotBili-0.2 Lipase-58 Calcium-9.9 Phos-6.0*# Mg-1.9 On Discharge: [**2139-12-29**] 06:26AM BLOOD ALT-14 AST-11 LD(LDH)-137 AlkPhos-164* TotBili-0.2 [**2139-12-29**] 06:26AM BLOOD Glucose-111* UreaN-38* Creat-7.0*# Na-135 K-4.8 Cl-97 HCO3-29 AnGap-14 [**2139-12-29**] 06:26AM BLOOD WBC-6.4 RBC-2.28* Hgb-7.2* Hct-24.3* MCV-107* MCH-31.7 MCHC-29.8* RDW-15.6* Plt Ct-337 ============= MICROBIOLOGY ============= Blood Culture * 3 [**2139-11-29**]: No Growth Urine Culture [**2139-11-29**]: URINE CULTURE (Final [**2139-11-30**]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. GRAM NEGATIVE ROD(S). ~[**2128**]/ML. Blood Cultures 1/3 [**2139-12-1**]: Blood Culture, Routine (Final [**2139-12-4**]): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**] ([**Numeric Identifier 8022**]) REQUESTS SNESITIVITY TESTING TO AZTREONAM , TETRACYCLINE AND Tigecycline [**2139-12-3**]. Tigecycline = 2 MCG/ML = SENSITIVE, Tigecycline Sensitivity testing performed by Etest. AZTREONAM = RESISTANT. AZTREONAM & TETRACYCLINE sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMIKACIN-------------- 16 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 8 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- I TETRACYCLINE---------- I TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [**2139-12-1**]): Reported to and read back by [**Doctor First Name **] [**Doctor Last Name 10280**] @ 1518 ON [**12-1**] - CC6D. GRAM NEGATIVE ROD(S). Urine Culture [**2139-12-1**]: URINE CULTURE (Final [**2139-12-4**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- 8 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Catheter Tip Culture [**2139-12-1**]: No Growth Blood Culture *3 [**2139-12-3**]: No Growth Bile Culture [**2139-12-4**]: GRAM STAIN (Final [**2139-12-4**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2139-12-7**]): ESCHERICHIA COLI. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 8 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [**2139-12-8**]): NO ANAEROBES ISOLATED. Blood Culture * 4 [**2139-12-6**]: No Growth ============== OTHER STUDIES ============== ECG [**2139-11-28**]: Possible junctional rhythm. Left anterior fascicular block. Compared to the previous tracing P waves are no longer visible suggesting junctional rhythm. The other findings are similar. CT Abdomen and Pelvis with Contrast [**2139-11-28**]: IMPRESSION: 1. Choledocholithiasis and stable dilated CBD to 12 mm. 2. No colonic diverticulitis. 3. Fibroid uterus. CT Chest W/Contrast [**2139-11-29**]: IMPRESSION: 1. Enlarged pulmonary artery in keeping with pulmonary hypertension. Moderate cardiomegaly. 2. Small bilateral pleural effusions with overlying consolidation and atelectasis within the lower lobes bilaterally. 3. Multinodular goiter with bilateral thyroid nodules. CT Right Lower Extremity With Contrast [**2139-11-29**] IMPRESSION: 1. Skin thickening and irregularity along the right inguinal fold at site ofprevious I&D. No evidence of abscess. 2. Fibroid uterus. 3. Moderate calcification of the common femoral, superficial femoral and profunda femoral arteries bilaterally. Femoral Line Placement and PTC [**2139-12-4**]: IMPRESSION: 1. Exchange of the left femoral temporary hemodialysis catheter with a new 14 French, 24 cm temporary hemodialysis catheter. The line is ready for use. 2. Placement of an 8 French internal-external biliary drainage catheter via a right posterior biliary duct with its retention pigtail loop in the duodenum. ERCP: Impression: A peri-ampullary diverticulum was present. A stent was seen extruding from the ampullary orifice - This corresponds to patient's known internal-external PTC drain. Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. A moderate diffuse dilation was seen at the biliary tree with the CBD measuring 15 mm. Several filling defects were seen in the CBD consistent with stones. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Balloon sphincteroplasty was then performed with a wire-guided CRE balloon and the ampulla/distal CBD was successfully dilated to 15 mm. Several balloon sweeps were then performed with successful extraction of two 8 mm stones. As the bile duct was very large and complete opacificiation was not possible, it was unclear whether there were any retained stones. Thus, a 5cm by 10FR dougle pigtail biliary stent was placed successfully. Recommendations: NPO overnight with aggressive IV hydration with LR at 200 cc/hr. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ([**Pager number 8437**]) Further management of PTC drain as per IR. Repeat ERCP in 1 month for stent removal and complete duct clearance. Pending Studies: Wound Swab Culture from [**2139-12-29**]. Brief Hospital Course: 65 yo woman presenting from nursing facility with recent well-healing groin abcess, admitted with cholangitis, Klebsiella bacteremia, septic shock, and hypercarbic respiratory failure. Hospital course was also notable for deep venous thrombosis. #Cholangitis/Klebsiella bacteremia/Septic Shock/Choledocholithiasis: Patient was admitted to the Medical Intensive Care Unit in septic shock requiring vasopressor support and found to have Klebsiella bacteremia. LFTs were normal, but an abdominal ultrasound showed a dilated common bile duct. Bedside ERCP was unsuccessful but a percutaneous biliary drain was placed and the patient improved with drainage and antibiotics and was able to be taken off vasopressors. Once the patient was hemodynamically stable a repeat ERCP was performed which was notable for choledocholithiasis and a sphincterotomy with stone extraction was performed and a biliary stent was placed. Patient completed a 2 week course of Meropenem prior to discharge. Patient will return for stent removal in one month from discharge. #Hypercarbic Respiratory Failure/Obstructive Sleep Apnea: This was felt to be related to the patient's sepsis. She was intubated and then extubated when sepsis improved. Following treatment of her infection she was maintained on [**1-18**] L oxygen by nasal canula. Following second ERCP the patient did require transfer to ICU as anesthesia did not feeel comfortable extubating patient immediately after the procedure. She was extubated without incident however. She has obstructive sleep apnea and was instructed to wear her BIPAP at night once discharged. #Lower extremity Deep Venous Thrombosis/End stage Renal Disease on Hemodialysis: Patient was found to have left lower extremity DVT in the same leg as her femoral hemodialysis line. Given the patient's problems with access in the past, the decision after discussion with Nephrology was to keep the line in and continue anticoagulation. Since Coumadin was held for the patient's ERCP, the patient required a heparin gtt bridge to Coumadin until INR was therapeutic at goal [**2-19**]. This will be followed by providers at patient's extended care facility. #Groin abcess: The patient has a groin abcess, looked well healed. Wound care was consulted and followed the patient. On day of discharge there was pus noted from around the hemodialysis line. Renal was made aware and cultures were taken but the Renal team did not want to start empiric antibiotics. The cultures will be followed by outpatient Nephrology and antibiotics started as indicated. # Pruritis: Upon transfer to the [**Hospital Ward Name **] prior to second ERCP, Ms. [**Known lastname **] began to note pruritis of her back. There existed a maculopapular rash on the regions of her back which contact[**Name (NI) **] her sheets. She remembers an allergy to bleach. Her pruritis improved with discontinuation of bleached sheets, sarna lotion, and a short course of topical clobetasol. She also was placed on miconazole power for fungal groin rash. . #DEPRESSION: Paxil was continued. #GERD: PPI was continued. #Hx of atrial tach: Amiodarone was continued. #Diabetes mellitus type 2: continued home NPH and ISS TRANSITIONAL ISSUES: - Patient is having intermittent vaginal bleeding, she should be evaluated by GYN as an outpatient for possible endometrial biopsy - Patient's left tunneled line was noted to have mild possibly purulent discharge at dialysis on [**2139-12-29**]. Cultures were obtained and will need follow up. There were however no other symptoms or signs of infection. Medications on Admission: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO at HD. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebulizer Inhalation q8h:prn as needed for shortness of breath or wheezing. 8. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Insulin Please continue your previous insulin regimen of NPH 20 units qam and Novolog SS. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Lab Work Please check daily INR and CBC on [**12-31**] to ensure that patient is therapeutic on warfarin and that hct is not downtrending (last Hct on discharge was 24.3). 13. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) Subcutaneous qam. 14. insulin lispro 100 unit/mL Solution Sig: as directed by sliding scale Subcutaneous ASDIR (AS DIRECTED). 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain/fever. 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 20. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 21. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q8H (every 8 hours) as needed for itching. 22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritus. 23. Coumadin 1 mg Tablet Sig: Five (5) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. Cholangitis 2. Respiratory failure 3. Diabetes Mellitus 4. End stage renal disease requiring dialysis 5. 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: Dear Ms. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted with a severe bacterial infection because of an obstruction of your bile ducts(cholangitis). You had a biliary drain(cholecystostomy) placed by interventional radiology to drain infected bile, but the drain was removed after a few days when you had the ERCP procedure. During the ERCP procedure, a stent was placed in your bile duct. The following changes have been made to your medications: START Warfarin for the clot in your leg (duration to be determined by your primary care physician) START benadryl as needed for itching START nephrocaps for nutrition START sarna lotion as needed for itching START miconazole as needed for itching or skin-based yeast infections Please make sure INR is checked on dialysis days for next two weeks to ensure that it is in therapeutic range. Followup Instructions: 1. You will be admitted to a medical acute care facility where a physician will continue to follow your care. 2. The gastroenterology department will be scheduling a follow up procedure(ERCP) and will contact you with the date/time. Department: TRANSPLANT CENTER When: MONDAY [**2140-1-25**] at 9:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report+report+addendum

Admission Date: [**2125-3-6**] Discharge Date: [**2125-3-16**] Date of Birth: [**2083-4-1**] Sex: M Service: [**Company 191**] CHIEF COMPLAINT: Shortness of breath, chest pain. HISTORY OF THE PRESENT ILLNESS: The patient is a 41-year-old male with a history of diabetes mellitus type 1, history of DKA, alcohol abuse, and borderline personality disorder with schizotypal features who presented to the Emergency Department post being seen by primary care physician the afternoon of admission with increasing chest pain, shortness of breath, and found to be tachypneic, tachycardiac, and hypoxic, with room air sat of about 86%. The patient is sedated on Ativan at the time of admission as he was recently discharged from [**Hospital1 2177**] for alcohol detox and DKA. He was discharged to [**Hospital1 **] House. Since last week, the patient has been complaining of chest pain. He received a five day course of Zithromax at the [**Hospital6 **] without significant relief of symptoms. The chest x-ray, per report, was negative at that time. In the Emergency Department, the patient was febrile to 101.5, tachycardiac, and hypoxic on room air. The chest x-ray showed left lower lobe consolidation and the patient was started on ceftriaxone. The chest x-ray also showed increase in cardiomegaly. A bedside ultrasound was done and was negative for effusion. At the time of admission, the patient complains of chills. He says that he last drank about two weeks prior to admission. He denied recent drug use. He denied headaches, dysuria, denied abdominal pain. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Borderline personality disorder with schizo-affective disorder. 3. Diabetes mellitus with history of DKA. 4. History of suicide attempts. 5. Depression with paranoia. 6. Seizure disorder. 7. History of macrocytic anemia. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: The patient is divorced. The patient has one child. Positive history of alcohol abuse, IV drug use. Positive tobacco, about one-half a pack per day. The patient lives at [**Hospital1 **] House. FAMILY HISTORY: Noncontributory. MEDICATIONS ON ADMISSION: 1. Thiamine 100 mg p.o. q.d. 2. Folate 1 mg p.o. q.d. 3. Multivitamin one tablet p.o. q.d. 4. Remeron 15 mg p.o. q.d. 5. Neurontin 600 mg p.o. t.i.d. 6. Risperdal 0.5 mg p.o. b.i.d. p.r.n. 7. Nicotine 14 mg transdermal p.r.n. 8. Paxil 40 mg p.o. q.d. 9. Insulin sliding scale, NPH 36 units q.a.m., 20 units q.p.m. ALLERGIES: Haldol, morphine, and Navane. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 101.5, blood pressure 156/99, pulse 125, respiratory rate 20, 02 saturation 91% on room air going to 94% on 2 liters. General: The patient is a middle-aged male in mild distress, diaphoretic. HEENT: Pupils 5 mm, minimally reactive. The sclerae were anicteric. The oropharynx was clear. The mucous membranes were moist. Lungs: Diminished breath sounds at the left base with rales at the left base, clear on right. Cardiovascular: Tachycardiac, regular rhythm, normal S1, S2, no murmurs, rubs, or gallops. No muffled heart sounds. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: Warm, no edema. Skin: No lesions. Neurologic: Unable to assess initially secondary to inattentiveness. LABORATORY DATA/STUDIES: Chest x-ray on admission showed right subclavian line with tip in inferior SVC. No pneumothorax. Cardiac silhouette increased in size compared with prior with dense consolidation in left lower lobe and lingula with associated volume loss and new left effusion with possible left hilar AP window mass with secondary deviation of trachea to the right. White blood count 17.0, hematocrit 29.9, platelets 546,000, polys 82.5, 0 bands, lymphs 10.3. Sodium 133, potassium 4.2, chloride 98, bicarbonate 24, BUN 13, creatinine 0.6, glucose 122. Blood cultures times two are pending. Urine cultures times two are pending at the time of admission. The urinalysis showed trace protein, glucose of 250, negative ketones, no RBCs, white blood cells 0-2, bacteria none. EKG revealed sinus tachycardia at 117, normal axis, normal intervals, Q in III which is unchanged, early R wave progression, no ST changes, no T wave inversions. IMPRESSION: The patient is a 41-year-old male with a history of alcohol abuse, diabetes mellitus type 1 with recent DKA admitted with left lower lobe pneumonia, hypoxia, and cardiomegaly on chest x-ray. HOSPITAL COURSE: 1. PNEUMONIA: Initially it was suspected to be an aspiration pneumonia given the history of alcohol abuse, although the patient denied any recent drinking history. The patient was initially started on ceftriaxone and clindamycin for aspiration coverage. The patient underwent a chest CT which showed loculated left pleural effusion with left lower lobe pneumonia and left lower lobe atelectasis and rightward mediastinal shift secondary to mass affect from pleural effusion. Interventional and Pulmonary were consulted and a bedside thoracentesis was done on [**2125-3-7**] which yielded pus. CT Surgery was consulted and a single left-sided chest tube was placed. The patient was febrile and hypoxic since admission. Initially treated with ceftriaxone and clinda which was changed to levofloxacin and Flagyl. Despite antibiotics, CT drainage, the patient's increasing hypoxia, the patient was transferred to the MICU on [**2125-3-8**]. On [**2125-3-9**], the patient underwent VATS/decortication by Dr. [**Last Name (STitle) 954**] and had four chest tubes placed. The postoperative course was complicated by DKA requiring an insulin drip and hypotension likely secondary to propofol requiring pressors. The patient was maintained on a vent until [**2125-3-11**] when he was extubated without event. On transfer, the patient was saturating 96% on 3 liters nasal cannula and was transitioned to subcutaneous insulin without any evidence of DKA. The Neo-Synephrine was weaned to off after the discontinuation of Propofol. The patient's pleural fluid culture grew out methicillin-sensitive Staphylococcus aureus and was switched over to Oxacillin and Clindamycin for his antibiotic coverage. The AFB smear was negative times three. PPD was negative. Speech and swallow evaluation on [**2125-3-12**] was negative for aspiration and the patient is currently improving with decreasing oxygen requirement. The chest tubes will likely be pulled on [**2125-3-19**] by Dr. [**Last Name (STitle) 954**] as it seems that he is doing well with minimal drainage from these tubes. Antibiotics are to be continued for methicillin-sensitive Staphylococcus aureus and oxygen will continue to be weaned. 2. DIABETES: The patient had a short course of diabetic ketoacidosis while in the Medical Intensive Care Unit which was corrected with IV fluids and an insulin drip was transitioned to a standing dose of NPH insulin as well as insulin sliding scale. Of note, the patient had several episodes of refusing to take his insulin as he was concerned that his sugars would bottom out. Consequently, his a.m. sugars were often significantly elevated including on [**2125-3-16**] with a fingerstick of 505 in the morning. The patient was explained the importance of regular insulin dosing as he has type 1 diabetes mellitus and could potentially go into DKA once again. He agreed to continue taking his insulin as scheduled. 3. ANEMIA: Likely this is anemia of chronic disease. The patient required 1 unit of blood transfusion of packed red blood cells while he was in the Medical Intensive Care Unit and has had a stable hematocrit since then. The rest of the hospital course as well as the discharge diagnosis, condition, and medications will be dictated at a later date by .................... [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**] Dictated By:[**Name8 (MD) 4630**] MEDQUIST36 D: [**2125-3-16**] 06:25 T: [**2125-3-16**] 20:43 JOB#: [**Job Number 95672**] Admission Date: [**2125-3-6**] Discharge Date: [**2125-3-26**] Date of Birth: [**2083-4-1**] Sex: M Service: HOSPITAL COURSE: 4. Finger fracture: The patient had injured his finger while he was in the hospital. This incident was not described well. This patient underwent film of the right fourth finger which indicated a fracture, and the patient was taken for hand surgery for fixation of the fracture. The patient tolerated the procedure well. The patient apparently sustained this fracture while ambulating in the hospital and falling. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-924 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2125-3-26**] 11:47 T: [**2125-3-26**] 13:25 JOB#: [**Job Number 95673**] Name: [**Known lastname 243**], [**Known firstname **] Unit No: [**Numeric Identifier 15158**] Admission Date: [**2125-3-6**] Discharge Date: [**2125-3-26**] Date of Birth: [**2083-4-1**] Sex: M Service: HOSPITAL COURSE: 1. Pneumonia - The patient's empyema was improving with four chest tubes remaining. The remaining chest tubes were incrementally discontinued and on [**3-22**], the patient's last chest tubes were discontinued seeing that the chest x-ray appearance of empyema was improved. He was switched from Oxacillin and Clindamycin to p.o. Dicloxacillin and remained afebrile for four days prior to discharge. He was to continue on p.o. Dicloxacillin for a total of three weeks, which would be one more week of Dicloxacillin at 500 mg p.o. q 6 hours. He does not have follow up with Cardiothoracic Surgery. His O2 saturation was stable upon discharge. He did have one episode of narcotic overdose due to the fact that he got double his dose of Oxycontin on the morning of the event and continued to get prn narcotics throughout the day. This quickly resolved without use of Narcan and the patient's opioid dependence continued to be weaned as the chest tubes were discontinued. On the day before discharge, he only required Tramadol for pain and no longer required any Oxycodone or Oxycontin. He will be discharged on Tylenol and no Tramadol. I expressed that the [**Hospital1 **] House will not take any medications such as Tramadol and Oxycodone and he would only be given Tylenol 1 gram. The patient expressed understanding of this. 2. Diabetes mellitus - The patient's blood sugars remained in good range between the 150s and 200s. On the morning of discharge, his blood sugar was elevated to 486 and this was due to the fact that he refused his evening NPH the night prior. His blood sugars did subsequently come down prior to discharge to the 300 range. 3. Anemia - The patient had some anemia but with a stable hematocrit during his hospital stay. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To [**Hospital1 **] House. DISCHARGE DIAGNOSIS: 1. Empyema. 2. Borderline personality disorder. 3. Alcohol abuse. 4. Schizo-affective disorder. 5. Diabetes mellitus with history of diabetic ketoacidosis. 6. History of suicide attempts. 7. Depression. 8. Question of seizure disorder. DISCHARGE MEDICATIONS: 1. Insulin NPH 32 units at breakfast and 16 units of NPH at bedtime with regular Insulin sliding scale. 2. Nicotine Transdermal 14 mg q d. 3. Lactulose 30 mg p.o. q 8 hours prn constipation. 4. Albuterol metered dose inhaler two puffs inhaled q 4 prn. 5. Atrovent metered dose inhaler two puffs inhaled q.i.d. 6. Multi-vitamin one capsule p.o. q d. 7. Dicloxacillin 500 mg p.o. q 6 hours, last day [**2125-4-2**]. 8. Remeron 15 mg p.o. q hs. 9. Neurontin 600 mg p.o. t.i.d. 10. Risperdal 0.5 mg p.o. b.i.d. prn. 11. Paxil 40 mg p.o. q d. 12. Tylenol 500 to 1000 mg p.o. 6 hours prn fever or pain. 13. Docusate 100 mg p.o. b.i.d. FOLLOW UP: The patient is to follow up with his Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15171**] Dictated By:[**Name8 (MD) 74**] MEDQUIST36 D: [**2125-3-26**] 11:42 T: [**2125-3-26**] 13:15 JOB#: [**Job Number 15172**]

[ "816.01", "E885.9", "458.2", "482.41", "511.1", "285.29", "295.72", "250.11", "510.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "79.14", "34.51", "96.71", "34.91", "34.04" ]

icd9pcs

[ [ [] ] ]

10896, 10950

2126, 2144

11239, 11878

10971, 11216

2170, 2558

9110, 10874

1887, 1894

11890, 12341

166, 1591

2573, 4487

1613, 1863

1911, 2109

68,704

109,773

28380+57590

Discharge summary

report+addendum

Admission Date: [**2181-12-4**] Discharge Date: [**2181-12-24**] Date of Birth: [**2118-10-20**] Sex: F Service: NEUROSURGERY Allergies: Percocet Attending:[**First Name3 (LF) 1854**] Chief Complaint: left arm weakness Major Surgical or Invasive Procedure: Microsurgical stereotactic volumetric tumor resection of right precentral metastatic tumor She underwent a T6 vertebrectomy, Anterior arthrodesis T5-T6 & T6-T7 and posterior fusion of T2-T10 History of Present Illness: Ms. [**Known lastname **] is a 63 year old woman with renal cell carcinoma, who presented to clinic on [**2181-12-3**] for follow up, at which time she complained of progressive left arm weakness and sensation of coldness in her left hand for the last two weeks. She reports subjective leg weakness (although no problems with ambulation), imbalance (with one fall). She was empirically started on dexamethasone 4mg [**Hospital1 **] and had a stat MRI last evening which demonstrated a 14mm mass in the right frontal lobe with extensive edema and midline shift, along with a 4mm mass in the left occipital lobe and a 2mm mass in the superior right frontal lobe. Decadron was increased to 6mg TID, with the plan to follow up on Monday with neuro-oncology. However, given multiple questions from family members and no dramatic improvement, the decision was made today for direct admission. Past Medical History: ONCOLOGIC HISTORY: Her oncologic history began in [**2179-1-27**] when a right kidney mass was suspected on angiography (status post superficial femoral angioplasty and stenting). In [**2179-6-29**], she underwent abdominal/pelvic CT which revealed a right kidney mass. Chest CT in [**2179-7-30**] revealed 2 small pulmonary nodules suspicious for metastatic disease. She underwent left lower lobe wedge resection in [**2179-8-29**] with pathology revealing renal cell carcinoma of clear cell type. She underwent laparoscopic right radical nephrectomy on [**2179-10-4**] with pathology revealing renal cell carcinoma, clear cell type, [**Last Name (un) 9951**] grade [**1-2**] with extension into the renal vein. She was followed on observation with stable pulmonary nodules until [**2181-2-27**] when progression was noted. She was planned for high-dose IL-2 therapy with stress echo showing anterior ischemia. She underwent cardiac catheterization with a 90-95% stenosis of the proximal LAD noted. She had a balloon angioplasty and stenting of the LAD. She recovered well without cardiac issues and passed follow- up stress test to meet eligibility for the high-dose IL-2 select trial. She is status post one cycle of high-dose IL-2. She had a CT scan done of the torso on [**2181-8-27**] and this showed interval slight increase in the size of her multiple pulmonary nodules. There also was slight interval increase in the size of the left hilar node. The decision was made to stop IL-2 at that point. PAST MEDICAL HISTORY: - Diabetes - Hyperlipidemia - Hypertension - Peripheral vascular disease, s/p R superficial femoral artery stenting x 2 - CAD, cardiac catheterization revealing a 95-99% proximal stenosis of the LAD; s/p PCI stenting in [**2181-3-29**] Social History: She continues to live in [**Hospital1 392**] and will occasionally help out at her relatives' Chinese restaurant answering phones. Family History: non-contributory Physical Exam: VITALS: T 97.9F, HR 80, BP 140/80, RR 16, Sat 97%RA, finger stick 209, wt 134lbs GENERAL: Well-appearing, no acute distress HEENT: OP clear, anicteric, EOMI, PERRL NECK: No JVD appreciated CARD: RRR, no m/r/g RESP: CTA bilaterally; mildly tender to palpation along anterior right costal margin ABD: Soft, non-tender BACK: Two demarcated areas of hyperpigmentation, mildly pruritic EXT: Warm, well-perfused. mild ankle edema. Rash along medial aspect of right ankle, mildly pruritic NEURO: 5/5 strength in both upper and lower extremity on right and in left lower extremity; [**1-31**] in left upper extremity, more marked in distal muscle groups (e.g. flexion/extension at wrist). CN II-XII intact, with ? decreased sensation over right face. Normal finger-to-nose. Negative Romberg. Gait not tested secondary to patient feeling "unsteady". Pertinent Results: LABS: [**2181-12-4**] 11:55PM BLOOD WBC-10.2# RBC-4.13* Hgb-9.7* Hct-29.7* MCV-72* MCH-23.6* MCHC-32.8 RDW-14.9 Plt Ct-271 [**2181-12-10**] 05:37AM BLOOD WBC-12.2* RBC-4.39 Hgb-10.4* Hct-31.7* MCV-72* MCH-23.6* MCHC-32.7 RDW-14.8 Plt Ct-242 [**2181-12-4**] 11:55PM BLOOD PT-11.7 PTT-24.5 INR(PT)-1.0 [**2181-12-3**] 05:00PM BLOOD Glucose-193* Creat-1.2* [**2181-12-10**] 05:37AM BLOOD Glucose-85 UreaN-30* Creat-1.0 Na-140 K-4.7 Cl-104 HCO3-23 AnGap-18 [**2181-12-4**] 11:55PM BLOOD Calcium-9.5 Phos-2.9 Mg-2.3 [**2181-12-10**] 05:37AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2 IMAGING: MR [**Name13 (STitle) 430**] ([**12-3**]): IMPRESSION: 14 mm enhancing lesion in the right frontal lobe with extensive surrounding edema and mild shift of midline structures. 4-mm left occipital lobe enhancing lesion with surrounding edema, 2 mm right superior frontal lobe enhancing lesion. Overall, findings consistent with metastatic renal cell carcinoma. CXR ([**12-5**]): IMPRESSION: No evidence of osseous metastasis. Multiple similar size pulmonary nodules consistent with metastatic disease. MR [**Name13 (STitle) 430**] ([**12-7**]): IMPRESSION: Limited pre-op WAND study, for resection, demonstrating the dominant 15-mm right frontovertex enhancing lesion with large zone of associated vasogenic edema, additional punctiform enhancing lesion in the right frontal corona radiata, at the dorsal margin of the edematous zone, and 5.5-mm enhancing lesion with adjacent vasogenic edema in the left occipital pole. CT Head ([**12-8**]): IMPRESSION: Expected postsurgical changes status post right frontal craniotomy and lesion resection. No large intracranial hemorrhage. MR [**Name13 (STitle) 430**] ([**12-9**]): Pending Brief Hospital Course: The patient is a 63year old woman with a history of renal cell carcinoma with known metastasis to the occipital lobe/T6 vertebrae and lungs, CAD s/p DES to proximal LAD on [**4-5**], DM, hypertension, and hyperlipidemia who presented with left arm pain and outpatient MRI head on [**12-3**] showing a 14 mm enhancing lesion in the right frontal lobe with extensive surrounding edema and mild shift of midline structures, 4-mm left occipital lobe enhancing lesion with surrounding edema, and 2 mm right superior frontal lobe enhancing lesion. Her Dexamethasone had been increased at home from 4 mg [**Hospital1 **] to 6 mg tid. Neuro-oncology was consulted who recommended resection of the dominant right frontal lesion. Her Aspirin and Plavix were discontinued. Pre-op MRI WAND study was limited, but showed the dominant 15-mm right frontovertex enhancing lesion with large zone of associated vasogenic edema, additional punctiform enhancing lesion in the right frontal corona radiata, at the dorsal margin of the edematous zone, and 5.5-mm enhancing lesion with adjacent vasogenic edema in the left occipital pole. She underwent a MRI and CT scan demonstrated a T6 metastasis with involvement of the [**5-5**] foramen. She was determined to be symptomatic and at risk for instability. She underwent a T6 vertebrectomy, Anterior arthrodesis T5-T6 & T6-T7 and posterior fusion of T2-T10. Post operatively she was full strength, her incision was clean and dry she tolerated a regular diet and was voiding without difficulty. She was noted to have a bump in creatinine and renal was consulted she was treated with fluid and her diovan and bactrim were dc'd. Her creatinine on dc was 0.7, she was treated with Levaquin for a UTI. She was allowed to go home with PT. She is scheduled as an outpatient for CyberKnife on [**12-28**], she should also follow up with Dr [**Last Name (STitle) 4253**] in one month. Medications on Admission: - Dexamethasone 6mg TID - Plavix 75mg daily - Glipizide 10mg [**Hospital1 **] - Pioglitazone 30mg daily - Simvastatin 80mg daily - ASA 81mg daily - Calcium 500 + 400U Vitamin D - Multivitamins daily - Omega-3 fatty acids - Telmisartan 20mg daily Discharge Medications: 1. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Oxycodone 5 mg Capsule Sig: [**11-30**] Capsules PO every six (6) hours as needed for pain. Disp:*30 Capsule(s)* Refills:*0* 4. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Calcium 500 + D 500 (1,250)-400 mg-unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. Omega-3 Fatty Acids Oral 9. Telmisartan 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. Outpatient Physical Therapy Outpatient physical therapy for renal cell carcinoma with brain metastases. 14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 16. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 4 doses. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*40 Capsule(s)* Refills:*0* 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 19. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): start on [**12-26**]. Disp:*40 Tablet(s)* Refills:*2* 20. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 21. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) for 2 days: Stop on [**12-26**] and change to new dose see other RX. Disp:*2 Tablet(s)* Refills:*0* 22. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 23. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 25. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: PRIMARY: Renal Cell Carcinoma with Brain Metastases (14 mm right frontal, 4 mm left occipital, 2 mm right superior frontal) and left pedicle and left transverse process of T6 SECONDARY: Hypertension Hyperlipidemia Diabetes PVD UTI Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. 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, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: You have an radiosurgery appointment on Friday [**12-28**] @ 3pm. If you have any questions please call Dr.[**Name (NI) **] at [**Telephone/Fax (1) 9710**] and a nurse will call from his office. ***You need to increase your Decadron on [**12-26**] for that appointment see prescription**** You have a follow up appointment with Dr. [**Last Name (STitle) **] in Hematology/Oncology ([**Telephone/Fax (1) 22**]) on [**2181-12-31**] at 2:30 pm in the [**Hospital Ward Name 23**] Center, [**Location (un) 24**]. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 6 weeks. ??????You will need a CT scan of the brain without contrast. You will need to see Dr [**Last Name (STitle) 548**] in 6 weeks scan call [**Telephone/Fax (1) 2992**] for an appointment PLEASE RETURN TO THE OFFICE IN 7 days for REMOVAL OF YOUR STAPLES call [**Doctor Last Name **] for an appointment [**Telephone/Fax (1) 1669**] for an appointment Make an appointment with Dr [**Last Name (STitle) 4253**] (Neuro Onc) in 1 month call [**Telephone/Fax (1) 1844**] for an appointment Completed by:[**2181-12-24**] Name: [**Known lastname **],[**Known firstname **] [**Doctor First Name **] Unit No: [**Numeric Identifier 11777**] Admission Date: [**2181-12-4**] Discharge Date: [**2181-12-24**] Date of Birth: [**2118-10-20**] Sex: F Service: NEUROSURGERY Allergies: Percocet Attending:[**First Name3 (LF) 3656**] Addendum: The discharge medications were modified to the following: Discharge Medications: 1. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Oxycodone 5 mg Capsule Sig: [**11-30**] Capsules PO every six (6) hours as needed for pain. Disp:*30 Capsule(s)* Refills:*0* 4. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Calcium 500 + D 500 (1,250)-400 mg-unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. Omega-3 Fatty Acids Oral 9. Telmisartan 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*40 Capsule(s)* Refills:*0* 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 19. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): start on [**12-26**]. Disp:*40 Tablet(s)* Refills:*2* 20. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 21. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) for 2 days: Stop on [**12-26**] and change to new dose see other RX. Disp:*2 Tablet(s)* Refills:*0* 22. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 23. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 25. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 1066**], [**First Name3 (LF) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**] Completed by:[**2181-12-24**]

[ "V10.52", "276.7", "348.5", "197.0", "401.9", "V45.82", "250.00", "414.01", "198.3", "584.9", "443.9", "272.4", "198.5" ]

icd9cm

[ [ [] ] ]

[ "81.04", "99.04", "99.79", "81.05", "80.99", "01.59", "81.63" ]

icd9pcs

[ [ [] ] ]

16383, 16622

5986, 7895

293, 486

11100, 11124

4251, 5963

12697, 14282

3355, 3373

14305, 16360

10845, 11079

7921, 8168

11148, 12674

3388, 4232

236, 255

514, 1402

2952, 3190

3206, 3339

78,307

118,967

54070

Discharge summary

report

Admission Date: [**2118-6-3**] Discharge Date: [**2118-6-24**] Date of Birth: [**2045-10-10**] Sex: M Service: MEDICINE Allergies: morphine Attending:[**First Name3 (LF) 2751**] Chief Complaint: GIB Major Surgical or Invasive Procedure: Interventional Radiology embolization of R gastroepiploic artery 2 EGDs Secretin Stimulation Test History of Present Illness: 72yo M with h/o prostate ca with bone mets on chemotherapy (taxotare) monthly and steroids (decadron) with chronic pain on Naprosyn at home, presented to [**Location (un) **] on the 17th with 48hrs of hematemesis and melena. Hct on arrival was 20.4 and BP only in the 50s. Given IVF and pRBCs. EGD showed ulcerative gastropathy with multiple ulcers but no active source of bleeding so no intervention. These were felt [**1-12**] chronic steroids and naprosyn use. He was started on PPI and sucralfate and monitored in ICU for 1-2 days. Hcts stabilized at 25 (after 5 units) but BUN continued to rise suggesting continued bleeding. On [**6-1**] another EGD showed an arterial bleed in the post-bulbar region. It could not be clipped but was injected with epinephrine which stopped the bleeding at least intraporcdurally. However, the patient was dizzy and hypotensive on [**6-2**]. Hematocrt found to be 17 so given more transfusions and went to the OR for an ex lap where they did a duodenectomy and oversewing over arterial bleed site in the ulcer. Since surgery the patient has been hemodynamically stable however his hct has trended from 32 to 25 today. Today he got a unit of blood but he only bumped to 26.5 and concerned that he may be oozing from somewhere so transferred here for further care including possibly an angiogram and embolization. Last episode of melena was the night prior to transfer. He received a total of 18units pRBCs and 2units of FFP while at the other hospital. Other issues while he was hospitalized was surrounding his pain. He had a dilaudid pca but was not using it well (forgetting to hit the button) so was switched to fentanyl boluses (50-100mcg every couple of hours). In addition he had a leukocytosis that was attributed to a leukamoid reaction from stress reaction from the GIB. He also had a urine culture that grew ESBL sensitive to bactrim, ceftazadime, amikacin. He had been being treated with levoquin but the Ecoli was resistent to this and since it was presumed bacteriuria this was stopped. There is no mention of whether the foley was changed. . On the floor, patient was feeling ok. His only complaint was dry mouth and pain in the abdomen around his insertion site. . Review of systems: (+) Per HPI (-) Denies fever. Denies cough, shortness of breath, or wheezing. Denies constipation - last BM last night. Past Medical History: (per records) Prostate CA complicated by bone mets received chemotherapy monthly at [**Hospital3 328**], was due [**2118-6-20**] IDDM HTN Chronic renal insufficiency Obesity OSA not on CPAP at home Depression Anxiety history of urosepsis from obstruction Recent neck abscess drained in may with continued dressing changes Chronic left facial droop and left-sided weakness 2/2 myelitis Social History: Lives at home with wife. [**Name (NI) **] 4 children and 9 grandchildren. Uses wheelchair at baseline. - Tobacco: Never - Alcohol: None in 20 years - Illicits: None. Family History: Not contributory Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, very dry MM, oropharynx clear, NGT in place draining blackish red fluid Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [**1-16**] SM RUSB. No rubs, gallops Abdomen: soft, TTP along surgical site without rebound or guarding. Surgical site with no erythema, induration, JP drain in place draining serosanguinous fluid. non-distended per patient he has a "big belly" at baseline, bowel sounds present but hypoactive GU: foley in place Ext: Sacral edema bilaterally with lower extremity edema worse on left than right (per patient the lower extremity edema on left is baseline) NEURO: left facial droop and left partial paralysis (patient still able to write but with difficulty). A+OX3. Able to describe entire history. DISCHARGE EXAM: VS: T:98.2 BP:158/78 HR: 62 RR:18 O2sat:99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [**12-16**] SM RUSB. No rubs, gallops Abdomen: soft, TTP along surgical site without rebound or guarding. Surgical site with minimal erythema, noinduration, tension sutures in place. non-distended, bowel sounds present GU: no foley Ext: 1+ LE edema bilaterally NEURO: left facial droop and left partial paralysis (patient still able to write but with difficulty). A+OX3. Pertinent Results: From OSH: WBC 32, HCT 26, PLT 179K, NA 145, K4.3, Cl 121, Bicarb 22, BUN 40, Creatinine 1.6, Calcium 8.2, Mg 1.9, INR 1.3, PTT 16.3 . Micro: cultures including urine pending from OSH. [**6-4**] Urine Cx: e.coli, H. pylori negative, CMV viral load pending Images: Upper extremity venous study: no DVT in upper extremity CT ABD and EGD also done - no report in the records from osh CXR: Report with LLL atelectasis . EKG from OSH (report no actual image sent over): NSR with LAFB and marked ST abnormality suggesting possible inferior subendocardial injury new from prior. These changes resolved on repeat after pRBC transfusions. IR embolization for GI bleed: 1. Right common femoral arteriotomy. 2. Celiac, SMA, angiograms and subselective gastroduodenal, right gastroepiploic and inferior pancreaticoduodenal arteriograms. 3. Embolization of the distal right gastroepiploic artery with Gelfoam. 4. Post-procedure angiography. Findings: 1. Blush but no active extravasation seen in the distal right gastroepiploic. Gelfoam embolization of the distal right epiploic. 2. Variant anatomy of the splenic and left gastric with takeoff after a long segment celiac axis. 4. No active extravasation seen from the GDA, inferior hepatic pancreaticoduodenal or visualized branches of the SMA. IMPRESSION: Successful Gelfoam embolization of the distal portion of the right gastroepiploic artery. Pathology: DIAGNOSIS: Gastric ulcer: Fundal mucosa with focal chronic inactive inflammation; multiple levels taken. Stains for cytomegalovirus are negative (controls satisfactory). Stain for H. Pylori will be sent as an addendum-see note.. Note. Dr. [**Last Name (STitle) **] notified [**2118-6-11**], 10:55 a.m. with diagnosis of unremarkable fundal mucosa---"will do levels and cytomegalovirus stain". ADDENDUM: Stains for H. pylori (A) are negative; controls satisfactory. Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Date: [**2118-6-15**] Clinical: Melena. Anemia. Gross: The specimen is received in one formalin-filled container, labeled with the patient's name, "[**Known lastname **], [**Known firstname **]", the medical record number and "gastric ulcer." It consists of multiple tissue fragments measuring up to 0.3 cm entirely submitted in cassette A. EGD Report [**2118-6-16**] Blood in the fundus and cardia Ulcers in the stomach body (biopsy) Oversewn Duodenal Ulcer seen, with protruding sutures. No active bleeding seen from this site. Ulcer in the second part of the duodenum Erythema and congestion in the duodenum There was intermittent fresh blood in duodenum noted. This suggested intermittent active bleed. No clear source in the duodenum could be identified. A large clot in the fundus/cardia could not be washed off and may have obscured a source of bleeding. Otherwise normal EGD to third part of the duodenum EGD Report [**2118-6-10**] 2 esophagitis in the distal compatible with erosive esophagitis (injection) Punctate erythema in the stomach compatible with gastritis Ulcers in the body (injection) Erythema in the bulb compatible with duodenitis Ulcer in the 11 0clock Ulcer in the duodenal bulb - suture material present Polyp in the distal duodenum beyond ampulla Otherwise normal EGD to third part of the duodenum [**2118-6-22**] 05:54AM BLOOD WBC-5.7 RBC-2.73* Hgb-8.5* Hct-25.0* MCV-92 MCH-31.2 MCHC-34.1 RDW-15.2 Plt Ct-283 [**2118-6-23**] 05:32AM BLOOD WBC-5.7 RBC-2.73* Hgb-8.4* Hct-25.7* MCV-94 MCH-30.7 MCHC-32.5 RDW-15.3 Plt Ct-304 Brief Hospital Course: 72 yo M with h/o prostate cancer with bone mets, HTN transferred from outside hospital for upper GI bleed s/p duodenectomy with continued upper GI bleed # GI Bleed: He was initially admitted to the ICU on [**6-4**] and was noted to have about 220ccs of bright red blood from his NG tube. Vitals remained stable. Underwent angiography at that time and had R gastroepiploic artery embolized with gel foam. While in the ICU, he was transfused several units of PRBC and was on Pantoprazole gtt and NPO initially, then transferred to [**Hospital1 **] PPI and clears. Serum H pylori and CMV viral load were negative. Started on TPN for nutrition. GI, IR and surgery consult teams were following. After transfer to the floor, Hct was 24 but Hct continued to slowly trend down and he was noted to have liquid black stool, so he was made NPO once again and received several transfusions with 2 units per day for several days. EGD was performed on Also was noted to have liquid black stool, so had an EGD on [**6-10**] that showed fresh blood but no source of active bleeding. Eventually Hct stabilized around 28, however began to drop again. NG lavage was performed and was negative, and patient was taken to EGD for a second time on [**6-16**]. EGD showed erosive esophagitis, which was injected with epinephrine, gastritis, and multiple ulcers, and a bleeding sessile polyp in the duodenum (which was not biopsied). After this EGD, pt continued to have occasional melena however Hgb and Hct remained stable around 25-26. Patient received a total of 16 units PRBC while hospitalized at [**Hospital1 18**]. Hct 25.2 on discharge. He will be discharged to an LTACH where he will continue to have daily Hct checks. He will also continue pantoprazole 40 mg IV BID after discharge. # Ulcer/bleeding workup: Given numerous bleed sources and multiple ulcers, workup was performed for Zollinger [**Doctor Last Name 9480**] syndrome with serum gastrin level, which was normal, but given high suspicion secretin stimulation test was done which is still pending on discharge. Biopsy of ulcer was performed that showed no evidence of malignancy and was negative for H. pylori. Heme/onc service was consulted as well for workup of possible bleeding diathesis, vWF, factor XIII, bleeding time, fibrinogen all within or near normal limits and thought not to have bleeding disorder by the heme/onc team. Patient took only one dose of naproxen and denied other NSAID use prior to admission, so this is unlikely to be source of multiple ulcers. # Pain control/ s/p duodenectomy: Patient had duodenectomy and ex lap on [**6-1**] at outside hospital. Wound remained clean, dry and intact with staples and retention sutures in place. Staples were removed prior to discharge, per Dr. [**Last Name (STitle) **] (surgeon from [**Hospital **] Hospital who performed operation), however retention sutures are to remain in for one month after surgery and should be removed on [**2118-7-1**]. Pain control was attained with IV dilaudid PRN initially and was transitioned to PO dilaudid when able to take PO. Also received tylenol three times a day. # Hypertension: Initially home lisinopril was held given active GI bleed, but was restarted at low dose during admission. He was restarted on lisinopril and is being uptitrated to his home dose of 60 mg daily, now at 20mg daily on discharge. # Fluid overload: Reportedly at the OSH he had anasarca and was given 20mg IV lasix. Further diuresis was initially held to ascertain hemodynamic stability in the MICU. When the patient arrived to the floor he continued to be very edematous from the continued transfusions he required. We continued to monitor his fluid status as well as his vitals which remained stable during the rest of this admission, however pt was given several doses of IV lasix on the floor for symptomatic relief given anasarca. # Leukamoid reaction: Patient was on decadron but WBC count has trended upward to a peak of 32. Per OSH records they felt this was [**1-12**] stress reaction from GIB. Patient also had asymptomatic bacteriuria with ESBL growing from catheterized urine during ICU course, was not treated given no symptoms or fever. His foley catheter was discontinued and his WBC decreased throughout hospital course. # Presumed acute renal failure: Unknown baseline but patient had creatinine up to 2.3 at OSH presumed [**1-12**] hypotension/hypovolemia. Trended down to 1.1 at time of MICU transfer and has remained stable on the floor. # Neck Abscess: treated at OSH, on admission was treated with wet-dry dressings # Prostate CA complicated by bone mets: Held naproxen and steroids given acute GI bleed, although patient denied taking any NSAIDS except for one single dose of naproxen prior to admission. Was due for chemotherapy on [**6-22**], however given patient was still hospitalized this was not done. Outpatient oncologist was contact[**Name (NI) **] to update. # DM blood glucose was well-controlled on ISS along with regular insulin in TPN # HL: initally statin was held, restarted when able to take PO # Depression: prozac was held initially while patient was NPO then restarted once diet was advanced. Oxazepam was also continued when patient able to take PO # Transitional Issues: -Please keep wife informed of patient care: His wife is [**Name (NI) **]: [**Telephone/Fax (1) 110835**] -Please continue the TPN: Non-Standard TPN Volume(ml/d): 2050 Amino Acid(g/d):110 Dextrose(g/d):385 Fat(g/d):55 Trace Elements will be added daily and Standard Adult Multivitamins NaCL:80 NaAc:0 NaPO4:10 KCl:50 KAc:0 KPO4:0 MgS04:16 CaGluc:8 Insulin(units): 55 This is the total volume of solution per 24 hours. -Please remove the abdominal retention sutures 1 month after surgery (on [**2118-7-1**]) after contacting Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 110836**] -Please follow up with medical oncologist, Dr. [**Last Name (STitle) 10132**] at [**Hospital1 4601**] at [**Telephone/Fax (1) 110837**] within 2 weeks of discharge . Medications on Admission: (From records) Acetaminophen with codeine 1 tab Q6H Compazine 10mg PO Q6H Decadron Tapered off just prior to admission Dilaudid 1mg Q4H Lantus 10 units SC QHS and regular 4units before meals Lisinopril 60mg daily Ativan 0.5mg Q6H PRN Naproxen 250mg [**Hospital1 **] norvasc 5mg daily Oxazepam 5mg QHS Prozac 20mg daily Zocor 80mg daily Zofran PRN . Medications on transfer: Octreotide gtt at 50mcg an hour Pantoprazole gtt at 9mg per hour Benadrl 25mg IV PRN Fentanyl 50-100mcg IV Q12H Fluoxetine 20mg daily Hydralazine 10 IV Q6H PRN Metoprolol 5mg IV q4H standing Novolog ISS Maalox 30mL Q4H Reglan 10mg IV Q6H PRN Oxazepam 15mg PO QHS Simvastatin 80mg QPM Carafate 1gm Q6H Discharge Medications: 1. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 6. cortisone 1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for skin rash. 7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 9. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 10. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1) Injection three times a day. 13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 15. sodium chloride 0.9 % 0.9 % Piggyback Sig: One (1) ML Intravenous Q8H (every 8 hours) as needed for line flush. 16. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING port. 17. insulin lispro 100 unit/mL Solution Sig: ASDIR Subcutaneous ASDIR (AS DIRECTED): as directed per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Upper gastrointestinal bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred to our facility after experiencing a gastrointestinal bleed. The source of your bleed has been difficult to ascertain but we were able to find and treat several areas thought to be bleeding on the last endoscopic procedure performed. Since that time you gastrointestinal bleeding has appeared to stop. Changes to your medications STOP taking Acetaminophen with codeine STOP taking Compazine STOP taking Decadron STOP taking Dilaudid STOP taking Naproxen CHANGE to Lisinopril 20mg daily, but the next hospital should slowly increase to your home dose of Lisinopril 60mg daily; STOP taking your insulin; the next hospital will tell you what to take and right now you are getting insulin in your TPN; (at home, please continue your Lantus 10units injected QHS and Regular Insulin 4units before meals) Followup Instructions: Please make an appointment with your medical oncologist Dr. [**Last Name (STitle) 10132**] at [**Hospital1 4601**] at [**Telephone/Fax (1) 110837**] two weeks after discharge. Please see your Primary care provider [**Name Initial (PRE) 176**] 2 weeks of discharge Name: [**Last Name (LF) 15817**],[**First Name3 (LF) **] R. Location: [**Hospital **] MEDICAL ASSOCIATES-[**Location (un) **] Address: 325 RIVER RIDGE DR, [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 8506**] Please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 110836**] regarding retention suture removal that should occur on [**2118-7-1**]. Also call Dr. [**Last Name (STitle) **] to determine if you need a follow up surgical appointment.

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icd9cm

[ [ [] ] ]

[ "45.16", "44.43", "99.15", "42.33", "44.44", "88.47" ]

icd9pcs

[ [ [] ] ]

16895, 16967

8504, 13759

273, 372

17040, 17040

4966, 8481

18130, 18932

3379, 3397

15305, 16872

16988, 17019

14605, 14954

17223, 18107

3412, 4293

4309, 4947

2644, 2766

230, 235

400, 2625

17055, 17199

13782, 14579

14979, 15282

2789, 3176

3192, 3363

26,839

125,755

27896

Discharge summary

report

Admission Date: [**2199-6-12**] Discharge Date: [**2199-6-19**] Service: MEDICINE Allergies: Macrobid Attending:[**First Name3 (LF) 1162**] Chief Complaint: Pancreatic cancer, hypotension Major Surgical or Invasive Procedure: ERCP IR guided CBD percutaneous drainage History of Present Illness: 84 yo F with a h/o HTN, hyperlipidemia, asthma, and inoperable ampullary cancer s/p ERCP w/ CBD stent placement in [**2197**] presented to [**Hospital1 18**] on [**6-12**] for palliative ERCP to treat recurrent obstructive jaundice. Per her daughter she has been doing very poorly in the past 2 weeks with increasing abdominal pain, N/V, poor PO intake. . She underwent an ERCP on [**6-12**] with an ulcerated mass and pus noted at the major papilla with unsuccessful cannulation of CBD. She had received 5 UFFP for an elevated INR >2. She remained hypotensive with SBP 80-90s post procedure and throughout the evening and morning of [**6-13**]. In the morning her LLE was thought to be swollen, L LE LENI was negative for a DVT. She then underwent IR guided CBD percutaneous drainage under general anesthesia. Pre-op she was hypotensive SBP 66, required levophed 0.3mcg/kg/min for 30 min intra-op. She was extubated successfully, remained in PACU with SBP 80s. Upon transfer to floor, within 1-2 hours her SBP dropped to 64/40, she was placed in T-[**Doctor Last Name **], hypoxia noted 85% RA. She was put on a NRB, received 1.5L NS with minimal response SBP 70s and transferred to [**Hospital Unit Name 153**] for hypotension and closer monitoring despite DNR/DNI code status. Past Medical History: PMH: -GERD -Degenerative spinal disease -HTN -Asthma -UTI (currently on Zosyn for tx) -Ampullary cancer dx'ed [**5-/2198**] -->Path: Adenocarcinoma with signet ring features -->Deemed inoperable by Dr. [**Last Name (STitle) **] [**6-/2198**] -->s/p ERCP for stent placement shortly thereafter -->No chemo or XRT . PSH: -s/p cholecystectomy -s/p TKR -s/p back surgery -s/p hysterectomy -s/p bladder surgery -s/p ERCP x2, PTBD as above Social History: -Lives on [**Hospital3 **] with daughter -[**Name (NI) **] current smoking or ETOH Family History: Non-contributory Physical Exam: VS: 99.3 BP 81/43 HR 84 RR 24 99%NRB GEN: Ill appearing elderly woman, uncomfortable in T-[**Doctor Last Name **] HEENT: Icteric sclera, Dry MM RESP: CTABL, no wheezing or crackles anteriorly CV: Reg Nml S1, S2, no M/R/G ABD: Soft, distended, diffusely tender to palpation with Percutaneous biliary drain in place (bilious material in external bag), hypoactive bowel sounds EXT: 1+ pitting edema at ankles, warm, 1+DP pulses b/l NEURO: Arousable, Oriented x3, no focal deficits, following basic commands Pertinent Results: Admission labs: [**2199-6-12**] 12:30PM WBC-16.7*# RBC-3.72* HGB-10.0* HCT-29.6* MCV-80* MCH-26.8* MCHC-33.7 RDW-17.5* [**2199-6-12**] 12:30PM NEUTS-94.9* BANDS-1.0 LYMPHS-2.0* MONOS-2.0 EOS-0 BASOS-0 [**2199-6-12**] 09:10PM GLUCOSE-113* UREA N-10 CREAT-0.4 SODIUM-135 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-12 [**2199-6-12**] 12:30PM ALT(SGPT)-75* AST(SGOT)-101* ALK PHOS-464* AMYLASE-11 TOT BILI-10.0* [**2199-6-12**] 12:30PM LIPASE-12 [**2199-6-12**] 12:30PM PT-25.8* INR(PT)-2.6* . Imaging: ERCP report [**2199-6-12**] 1. Ulcerated mass in the major papilla 2. Pus in the major papilla 3. Previous sphincterotomy in the major papilla 4. Cannulation of the biliary duct was unsuccessful using a free-hand technique due to the ampullary tumor . ERCP BILIARY&PANCREAS BY GI UNIT [**2199-6-12**] 3:26 PM Opacification of the biliary tree or the pancreatic duct was seen. . PTBD [**2199-6-13**] 2:01 PM IMPRESSION: Left percutaneous cholangiogram demonstrated distal CBD obstruction with dilatation of CBD and both intrahepatic ducts. Left external PTBD with 8-French pig tail catheter with tip in CBD. When LFT's and cholangitis have improved after a few days on external drainage, we could attempt to internal-external drainage tube placement or internal biliary stent placement as inpatient or SDA procedure if patient is discharged. . US ABD LIMIT, SINGLE ORGAN [**2199-6-13**] 8:36 AM A limited portable study was performed to assess for biliary dilatation. In the region of the gallbladder fossa, the common hepatic duct/common bile duct is noted to be dilated and slightly folded upon itself measuring up to 2 cm in caliber, similar to [**2197**] CT examination. Intrahepatic ducts are also noted to be diffusely dilated with the proximal CBD measuring approximately 1.2 cm and intrahepatic ducts measuring up to 10 mm. A distinct gall bladder was not identified. Limited examination of the liver parenchyma was otherwise unremarkable with no focal masses identified. Portal vein is patent with normal hepatopetal flow. Brief Hospital Course: 84 yo F with a h/o HTN, hyperlipidemia, asthma, and inoperable ampullary cancer s/p ERCP w/CBD stent placement in [**2197**] presented to [**Hospital1 18**] on [**6-12**] for palliative ERCP to treat recurrent obstructive jaundice, transfered to the [**Hospital Unit Name 153**] with hypotension. Now CMO. 1. Hypotension/shock. Pt has been hypotensive since admission with several SBP measures in the 60's with highest SBPs in the 90's with fluid resuscitation. This is most likely biliary septic shock given pus noted on ERCP, fevers, elevated WBC w/left shift, hypotension, and borderline tachycardia. Pt has received amp, gent, and zosyn prior to arrival. SBP minimally responsive to 2-3L on floor and o/n in [**Hospital Unit Name 153**]. Given pt's poor prognosis and DNR/DNI status, pt's daughter decided to shift to comfort care. 2. Comfort Measures Patient was initially placed on a morphine gtt and has maintained cognition with adequate pain control and stable blood pressure. She has also been receiving tylenol PR for low grade fevers as well as ativan as needed for agitation. She was transitioned to Fentanyl TD yesterday and subsequent titration off of the morphine gtt in case she loses IV access and to prevent further access needs. . 3. Communication: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (1) 67967**] . 4. Code: CMO Medications on Admission: -Prilosec 20mg QD -Oxycontin 80mg TID -Gabapentin 600mg TID -Atenolol 35mg QD -MVI QD -Lovastatin 20mg QD -Dilaudid PRN Q4H -Prednisone 5mg QD -Fentanyl patch Q72H Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 15-30mg SL Q2H (every 2 hours) as needed. 2. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q4H (every 4 hours) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO/PR Q4H (every 4 hours) as needed for fever. 4. Ativan 0.5 mg Tablet Sig: 1-2 mg PO every four (4) hours as needed: Sublingual (liquid form). 5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day: [**Month (only) 116**] use elixir form for sublingual dosing. 6. med Haldol 0.5-2mg Sublingual q 4 hours PRN agitation (liquid form) 7. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Transdermal every seventy-two (72) hours. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: ampullary signet ring cell adenocarcinoma Discharge Condition: guarded Discharge Instructions: Patient is currently CMO and is receiving palliative care. Followup Instructions: none Family declines autopsy in the event of death

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icd9cm

[ [ [] ] ]

[ "51.10", "51.98" ]

icd9pcs

[ [ [] ] ]

7133, 7200

4804, 6200

247, 289

7286, 7296

2728, 2728

7403, 7456

2171, 2189

6414, 7110

7221, 7265

6226, 6391

7320, 7380

2204, 2709

177, 209

317, 1598

2744, 4781

1620, 2055

2071, 2155

117

164,853

18181

Discharge summary

report

Admission Date: [**2133-11-13**] Discharge Date: [**2133-12-1**] Date of Birth: [**2083-12-28**] Sex: F Service: MEDICINE Allergies: Cyclobenzaprine Attending:[**First Name3 (LF) 3266**] Chief Complaint: End Stage Liver Disease Major Surgical or Invasive Procedure: none History of Present Illness: 49F PMH ESLD [**3-2**] Hep C, esophageal varices, history of SBP on daily PPX, h/o hepatic encephalopathy, s/p TIPS ([**4-2**]), admitted to OSH MICU ([**Date range (1) 50267**]) with hepatic encephalopathy. With treatment for encephalopathy at OSH, NH3 243 -> 11, however, worsening hyperbilirubinemia (8.1 -->16.3), xferred to [**Hospital1 18**] for consideration of possible transplant. Patient transfered to MICU after development of hypotension and respiratory failure. Past Medical History: PmHx: HCV genotype IA refractory to IFN x 2 ascites grade I esophageal varices (EGD [**11-1**]) h/o esophageal candidiasis s/p ccx DM II HTN asthma hypothyroid depression amenorrhea migraines Echo [**4-2**]: EF >65%, no WMA, trivial TR. ETT [**5-3**]: no ischemic EKG changes, no perfusion defects at good target HR, EF ~60%, no WMA. Social History: h/o ETOH abuse h/o IVDU quit tobacco 1 yr ago on disability Physical Exam: 97.9 120/50 102 22 94% 2L Gen: lying in bed, jaundiced, obese HEENT: no JVD Pulm: decreased breath sounds on right side, otherwise CTA Cardiac: RRR, S1, S2 Abd: obese, distended, diffusely tender, no rebound Ext: anasarca Neuro: AO x self, hospital, thinks year is "[**2103**]", otherwise non-focal Brief Hospital Course: A/P: 49F ESLD [**3-2**] HCV, s/p TIPS for refractory ascites, admitted for rising TBili who subsequently developed respiratory failure and was transfered to the MICU. 1. Sepsis: upon initial admission to the ICU the patient was started on a 10 day, broad spectrum course of antibx prophylactically given an episode of hypotension. The patient completed this course of antibx. However on HD 17 the patient became hypotensive with elevated wbc, and lactic acidosis to 15. She was reinitiated on broad spectrum antibx and pressors. She was initally started on levophed but her BP's continued to decrease and was then started on neosynephrine. Given the patient's critically ill state at this time, the patient family was called. The family decided to withdraw support and the patient passed away peacefully several hours later. 2. Respiratory Failure: likely secondary to a pleural effusion which was tapped. Pleural fluid analysis was consistent w/ a transudate likely from ascites/liver failure. Over the course of several weeks the patient's respiratory status improved and was successfully extubated on HD 15. However, the patient was reintubated on HD 17 after she developed sepsis from which she died on HD 18. 3. ESLD: Acute on chronic liver failure. Liver (Dr. [**Last Name (STitle) 497**] and Transplant were following. Given the patient's critically ill state, she was not amenable to transplant during her hospital course. Lactulose was continued for hepatic encephalopathy. 4) Coagulopathy/Thrombocytopenia - secondary to ESLD. The pt was transfused FFP, cryroprecipitate, platelets, and pRBCs PRN. 5) ARF: Hepatorenal syndrome versus ATN (granular casts in urine). UOP was poor. Renal was consulted and the patient was initiated on CVVHD. 6) DM2: Insulin GTT. 7) Asthma: Cont nebs PRN. Medications on Admission: Aldactone lactulose reglan protonix levoxyl lasix magnesium glargine Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: deceased Discharge Instructions: N/A Followup Instructions: N/A

[ "572.3", "287.5", "486", "518.82", "570", "286.7", "584.9", "401.9", "276.7", "070.44", "995.92", "276.1", "263.9", "572.4", "511.8", "244.9", "303.93", "112.2", "038.9", "571.2", "250.00", "280.0" ]

icd9cm

[ [ [] ] ]

[ "99.07", "38.93", "89.64", "96.6", "39.95", "96.04", "38.95", "96.72", "99.04", "34.91", "99.15", "00.14", "99.05" ]

icd9pcs

[ [ [] ] ]

3554, 3563

1596, 3407

302, 308

3610, 3620

3672, 3678

3526, 3531

3584, 3589

3433, 3503

3644, 3649

1264, 1573

239, 264

336, 814

836, 1172

1188, 1249

5,060

141,913

24289

Discharge summary

report

Admission Date: [**2180-4-28**] Discharge Date: [**2180-5-1**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 24927**] is a 35 yo M w/PMHx sx for alcohol abuse, depression, anxiety, and hepatitis C who presented to the ED after being found down for unspecified period of time after drinking alcohol today. Patient drinks 1 gallon of vodka a day, and blacks out on a daily basis. Patient states that he does not remember the events immediately preceding the LOC with this episode. He is unsure whether he hit his head, but does not think so. He denies headache, fevers, [**Known lastname **], vomiting, diarrhea, abdominal pain. He does note diffuse body aching, jitteriness, and anxiety, as well as visual hallucinations of spots across his visual field. He states that his last alcohol use was six hours prior to the ED visit, his last heroin use was at the 1st of the month. He is unsure when he last used benzos. He denies any recent IVDU. His last episode of DTs was several months ago, and his last seizure, per his report, was two weeks ago, unwitnessed. He does note bilateral hand swelling as well. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs. Social History: Drinks regularly, 1 gallon of vodka per day. Uses heroin and benzodiazepines occasionally. Homeless, living in the [**Location (un) **] area. Family History: Father with depression and alcoholism. Mother died of DM complications Physical Exam: VS: 97.9 HR 98 BP 134/86 RR 20 O2sat 98% RA Gen: Sleeping, lethargic, difficult to arouse but able to wake for short period before falling back asleep. Disheveled HEENT: MMM. No nystagmus. No oral ulcers or lesions. Neck supple. Heart: RRR. No m/r/g Lungs: CTAB Abd: Soft, nontender, nondistended. No organomegaly. + BS Ext: No obvious tremor. Warm, moist/diaphoretic skin Neuro: Unable to perform given lethargy Pertinent Results: Studies: [**2180-4-30**] RUQ U/S: IMPRESSION: Unremarkable liver ultrasound. No son[**Name (NI) 493**] evidence of bile duct obstruction, portal vein thrombosis, or cirrhosis. . . Labs: Admission labs: WBC-5.4 RBC-4.73 Hgb-14.1 Hct-39.2* MCV-83 MCH-29.9 MCHC-36.1* RDW-15.3 Plt Ct-273 Neuts-32.7* Bands-0 Lymphs-60.3* Monos-3.6 Eos-2.7 Baso-0.6 . PT-12.8 PTT-40.1* INR(PT)-1.1 . Glucose-110* UreaN-11 Creat-0.8 Na-145 K-4.1 Cl-103 HCO3-28 Calcium-9.4 Phos-1.5*# Mg-2.3 . ALT-1227* AST-1624* LD(LDH)-468* CK(CPK)-144 AlkPhos-108 Amylase-95 TotBili-0.5 Lipase-90* Albumin-4.7 . ASA-NEG Ethanol-391* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Serologies: HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE HCV Ab-POSITIVE . Discharge labs: WBC-6.1 RBC-3.95* Hgb-11.9* Hct-33.6* MCV-85 MCH-30.3 MCHC-35.5* RDW-15.1 Plt Ct-139* . Glucose-106* UreaN-7 Creat-0.7 Na-138 K-3.4 Cl-103 HCO3-25 Calcium-9.4 Phos-3.7 Mg-1.9 . ALT-470* AST-298* LD(LDH)-226 AlkPhos-93 Amylase-137* TotBili-1.0 Lipase-68* Albumin-4.0 Brief Hospital Course: Mr. [**Known lastname 24927**] left from the MICU AMA. . Mr. [**Known lastname 24927**] is a 35 year old male with a history of ETOH abuse now with ETOH withdrawals. . # ETOH abuse/Alcohol withdrawal- Pt with a history of heavy ETOH abuse and withdrawals with seizures and DT's. He last drink was [**4-28**] and arrived to ED with ETOH level of 391 and showing signs of withdrawal. He was initially mildly tachycardic, mildly hypertensive, and diaphoretic. At times as been quite anxious with tremors. He was given MVI, thiamine, folate and placed on withdrawal and seizure precautions. He was intially cared for on the medical floor but was transferred to the MICU as he was requiring higher and higher dose of benzos to control his withdrawals. He was receiving around 20-40mg diazepam every [**2-8**] hrs. On day 2 in the MICU his CIWA was elevated mostly secondary to agitation and not many other symptoms. He was seen by social work and addiction counseling was called. The plan was to transfer him to the floor and try to find an inpatient detox center for him. On day 2 and 3 of admission he was threatening to leave AMA, but the risks were explained to him and he kept agreeing to stay. On the last day of admission, he dressed himself and left AMA. He was explained all the risks of leaving including death, but he insisted. . # Transaminitis: He had significant elevation in AST/ALT on admission (to the 1200,1600 range) which quickly improved over an 18 hour period to the 200's. Given significant elevations in AST/ALT concern for other process besides ETOH alone, ? new hepatitis(patient reports being HCV positive). His tox screen was negative for toxins including acetaminophen except for alcohol. There was also concern for portal vein thrombosis or dilated ducts. He was too unstable to go for ultrasound initially, but eventually this was completed and was found to be normal. His synthetic function was intact as coags, albumin, tbili are normal. A hepatitis panel was sent which was not back at the time of discharge, but eventually returned showing an old hepatitis A infection, hepatitis B and hepatitis C. . # Code- FULL Medications on Admission: none Discharge Medications: None as patient left AMA and refused to stay for discharge instructions or medications or follow up appointments or phone numbers to rehab. Discharge Disposition: Home Discharge Diagnosis: alcohol withdrawal hepatitis B hepatitis C polysubstance abuse Discharge Condition: normal VS Discharge Instructions: patient left AMA and refused to wait for paperwork or for prescriptions or appointment or phone numbers for rehab or detox. Followup Instructions: patient left AMA and refused to wait for paperwork or for prescriptions or appointment or phone numbers for rehab or detox. Completed by:[**2180-5-3**]

[ "V69.8", "291.0", "304.02", "303.01", "070.30", "300.4", "V60.0", "070.1", "V18.0", "070.70" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5700, 5706

3325, 5481

290, 296

5812, 5823

2260, 2448

5995, 6148

1739, 1811

5536, 5677

5727, 5791

5507, 5513

5847, 5972

3034, 3302

1826, 2241

232, 252

324, 1344

2464, 3018

1366, 1564

1580, 1723

40,703

117,124

42394

Discharge summary

report

Admission Date: [**2129-2-21**] Discharge Date: [**2129-2-25**] Date of Birth: [**2066-8-5**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: mitral regurgitation Major Surgical or Invasive Procedure: [**2129-2-21**] - Mitral Valve Repair (34mm Annuloplasty ring) History of Present Illness: This 62 year old gentleman with no signficant past medical history has had a heart murmur for most of his life. He was diagnosed with mitral valve prolapse and regurgitation 3 years ago. At that time he began to be followed with serial echocardiograms. His mitral regurgitation has worsened over time with his most recent echo showing severe mitral regurgitation with partial flail of anterior mitral leaflet. Given the severity of his mitral valve regurgitation he has been referred for surgical management. He denies any symptoms of exertional dyspnea, fatigue, chest pain,orthopnea or palpitations. Past Medical History: Mitral valve prolapse/regurgitation Undescended testicle - Left Nephrolithiasis Basal Cell skin cancer Inguinal hernia repair Social History: Last Dental Exam: Recent exam/cleaning Lives with: Wife in [**Name2 (NI) 5450**] Contact: Phone # Occupation: Carpenter Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [] [**1-11**] drinks/week [X] >8 drinks/week [] Illicit drug use Family History: Father died of MI at 57 Physical Exam: Vital Signs sheet entries for [**2129-2-9**]: BP: 141/93. Heart Rate: 81. Resp. Rate: 18. Pain Score: 0. O2 Saturation%: 99. Height: 5'[**27**]" Weight: 165lbs General: NAD Skin: Dry [X] intact [X] Recent face peel which has left him with a sunburned appearance. HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign, teeth in good repair. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, III/VI holosystolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit - Transmitted vs. Bruit Pertinent Results: [**2129-2-24**] 06:00AM BLOOD WBC-5.6 RBC-3.56* Hgb-10.3* Hct-30.9* MCV-87 MCH-28.8 MCHC-33.3 RDW-13.3 Plt Ct-119* [**2129-2-21**] 11:02AM BLOOD WBC-11.7*# RBC-3.24*# Hgb-9.2*# Hct-27.9*# MCV-86 MCH-28.5 MCHC-33.1 RDW-13.0 Plt Ct-151 [**2129-2-24**] 06:00AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-137 K-4.2 Cl-103 HCO3-27 AnGap-11 [**2129-2-21**] 12:01PM BLOOD UreaN-20 Creat-0.8 Na-142 K-4.3 Cl-113* HCO3-26 AnGap-7* 3/19/12PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Please note the global LV systolic function might be reduced in the presence of 3+ MR. [**Name13 (STitle) 167**] 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 to 40 cm from the incisors. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. There is moderate/severe anterior leaflet mitral valve prolapse. The entire leaflet was prolapsing almost suggestive of a parachute appearance. An eccentric, posteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen. The posterior leaflet appeared normal. There was no mitral annular calcification. The mitral annulus in the AP direction was 40mm.T here is no pericardial effusion. Dr.[**Last Name (STitle) **] was notified in person of the results before surgical incision.. POST-BYPASS: Patient was on propofol only. Preserved biventricular systolic function. LVEF 55%. The mitral ring is in place, stable and functioning well. No gradient across the mitral valve during diastole. [**Doctor Last Name **] was a mild residual MR that was conveyed to the surgeon. Both the leaflets appeared to coapt very well. Two neo chords supporting the anterior leaflet going to both the papillary muscles was visualized. Rest of the valves appear unchanged from the prebypass period. Intact thoracic aorta. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2129-2-21**] for surgical management of his mitral valve disease. He was taken directly to the Operating Room where he underwent repair of his mitral valve using a 34mm annuloplasty ring. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The Physical Therapy service was consulted for assistance with his postoperative strength and mobility. He did pass 2 kidney stones on POD 2. This, apparently, is not unusual for him and he will give them to his PCP for analysis. He continued to progress and was ready for discharge on POD4. All follow up appointments were made and instructions given. He did have some mild supraventricular ectopy and this resolved with the addition of oral Amiodarone. Medications on Admission: None Discharge Medications: 1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* 7. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg(2tablets) twice daily for two weeks,then 200mg(one tablet) twice daily for two weeks, then 200mg(one tablet )daily until directed to discontinue. Disp:*100 Tablet(s)* Refills:*2* 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Mitral valve prolapse/regurgitation s/p Mitral valve annuloplasty h/oNephrolithiasis h/o Basal Cell skin cancer s/p orchiopexy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Edema:none Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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: [**2129-3-3**] at 10AM in [**Hospital Unit Name **], [**Hospital Unit Name **] Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2129-3-30**] at 1:15PM Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] [**2129-3-9**] at 2pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 62438**]([**Telephone/Fax (1) 51033**]) in [**3-10**] 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:[**2129-2-25**]

[ "429.5", "592.0", "V10.83", "424.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

6909, 6958

4661, 5715

330, 395

7129, 7299

2388, 4638

8188, 8877

1515, 1541

5770, 6886

6979, 7108

5741, 5747

7323, 8165

1556, 2369

270, 292

423, 1027

1049, 1177

1193, 1499

721

185,697

4236

Discharge summary

report

Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-15**] Date of Birth: [**2075-2-23**] Sex: M Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old male who developed sudden onset of severe headache approximately three to four weeks ago. The patient describes having constant headache without a history of head trauma. There is a positive family history of aneurysm. The patient was admitted for diagnostic angio. PHYSICAL EXAMINATION: Notably, his neuro exam was essentially nonfocal. HOSPITAL COURSE: A diagnostic angio was performed. The patient's cerebral vasculature, it was noted that there was a left internal carotid artery aneurysm. The patient received endovascular placement of stent and coil. The patient did extremely well postoperatively. The sheath was removed on postop day #1 without any evidence of hematoma formation. The patient was continued on heparin until the day prior to discharge when it was DC'd. However, he was continued on aspirin and Plavix. The patient was discharged in stable condition. He was ambulating, voiding and defecating without difficulty. His neurologic exam remained stable throughout. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Aneurysm, status post aneurysmal clipping, coiling and stenting. DISCHARGE MEDICATIONS: 1) Plavix 75 mg qd, 2) aspirin 325 mg po qd, 3) colace 100 mg po bid, 4) percocet 1-2 tabs q 4-6 h prn. FOLLOW-UP: Scheduled with Dr. [**Last Name (STitle) 1132**] in one week. The patient was instructed to call to schedule this appointment. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 18430**] MEDQUIST36 D: [**2114-5-15**] 13:56 T: [**2114-5-18**] 13:02 JOB#: [**Job Number 18431**]

[ "998.2", "437.3", "724.5" ]

icd9cm

[ [ [] ] ]

[ "39.72", "39.50", "39.90", "88.41" ]

icd9pcs

[ [ [] ] ]

1224, 1262

1374, 1878

1284, 1350

564, 1202

495, 546

174, 472

62,487

147,391

35544

Discharge summary

report

Admission Date: [**2124-3-11**] Discharge Date: [**2124-3-29**] Date of Birth: [**2045-6-29**] Sex: F Service: NEUROLOGY Allergies: Nsaids / Morphine / Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Right sided weakness and aphasia Major Surgical or Invasive Procedure: PEG placement per interventional radiology - self discontinued. History of Present Illness: 78 F with hx AF, recently stopped coumadin 7 days ago for a R-mastectomy and was supposed to re-start it tomorrow, hx prior stroke in mid-90's (daugher unclear how it manifested, possibly as R-weakness, but remembers that it was mild and resolved completely), HTN, and COPD, was last seen normal at 9 pm last night, and was found by family members this morning slumped to the right and unable to produce speech. She was taken to [**Hospital3 4298**] Hosp where NIHSS was rated as 16, and she received a NCHCT c/w a L-MCA infarct. She was intubated electively for airway protection and subsequently sedated. Per her daughter's report, she was moving her left side normally, and was able to understand speech and follow commands, however was unable to produce any words. Past Medical History: HTN COPD AF prior stroke R-mastectomy Social History: Smokes [**12-17**] ppd, (+) EtOH use, amt unknown, no drugs Family History: NC Physical Exam: T- 97.5F BP- 130/82 HR- 86 RR- 12 O2Sat 100% intubated Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: in C-collar, no carotid or vertebral bruit CV: irreg irreg, Nl S1 and S2, no murmurs/gallops/rubs Lung: mild wheezes bilaterally Abd: +BS, soft, nontender Ext: No c/c/e Neurologic examination: Mental status: intubated, not on continuous sedation, but has gotten 100 mcg fentanyl and unknown amt of versed. opens eyes briefly to sternal rub. Moves LUE and LLE spontaneously. Squeezes and releases left hand to command. Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. BTT on the left but absent on the right. (+) VOR. Eyes move spontaneously midline to left, but do not move spontaneously right. (+) weak corneals B/L. (+) cough. Motor: Normal bulk bilaterally. Tone increased in RLE. No observed myoclonus or tremor Moves LUE and LLE spontaneously anti-gravity. No mvmt of RUE or RLE even to noxious. Sensation: responds with moving LUE and LLE to noxious in all 4 ext. Reflexes: In the UE, brisker on the right than left (2+ vs 2). At the patella, 3 on the right with crossed adduction and 2 on the left. 0 at the Achilles B/L. Right toe mute, Left toe up Pertinent Results: [**2124-3-11**] 01:05PM BLOOD WBC-13.0* RBC-4.48 Hgb-14.3 Hct-41.2 MCV-92 MCH-32.0 MCHC-34.8 RDW-13.6 Plt Ct-298 [**2124-3-11**] 01:05PM BLOOD PT-12.6 PTT-25.2 INR(PT)-1.1 [**2124-3-11**] 01:05PM BLOOD Glucose-115* UreaN-23* Creat-0.7 Na-136 K-4.3 Cl-101 HCO3-26 AnGap-13 [**2124-3-11**] 05:39PM BLOOD %HbA1c-5.6 Bronchoalveolar lavage: HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. >100,000 ORGANISMS/ML. CT HEAD ([**3-11**]): 1. Subtle findings suggestive of left MCA infarct, including loss with insular ribbon and vanishing basal ganglia. Equivocal density within the left MCA may represent a thrombus. An MRI is recommended to confirm these findings. No evidence of intracranial hemorrhage or mass effect. MRI/A of HEAD and NECK: 1. Large left MCA territory acute infarction. There is no significant midline shift. There is no hemorrhagic transformation. 2. MRA of the neck demonstrates no hemodynamically significant stenosis. 3. MRA of the circle of [**Location (un) 431**] demonstrates lack of flow in the distal petrous, proximal cavernous, supraclinoid ICA, left MCA and left proximal ACA likely on a thromboembolic basis. TTE: The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the basal anterior wall, mid to distal anterior wall and anterior septum. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Sub-optimal image quality due to tachycardia, atrial fibrillation and poor echo windows. No cardiac source of embolism seen. No ASD or PFO seen but cannot exclude on the basis of this study. Mild to moderate focal LV systolic dysfunction. Brief Hospital Course: Patient is a 78 F with hx AF, recently stopped coumadin 7 days ago for a R-mastectomy and was supposed to re-start it tomorrow, hx prior stroke in mid-90's (daugher unclear how it manifested, possibly as R-weakness, but remembers that it was mild and resolved completely), HTN, and COPD, was found this morning slumped to R and unable to produce speech with NCHCT c/w a possible L-MCA infarct. Most likely source of the infarct is cardio-embolic in light of her recent Coumadin holiday. Patient was intubated while at [**Hospital3 **] Hospital before her transfer to [**Hospital1 18**]. She was admitted to the ICU and MRI/A showed a large L MCA distribution stroke and given large infarct, she was not bridged with heparin drip for risk of hemorrhagic transformation. She was restarted on her home Coumadin dose and ASA for bridging until therapeutic. She was extubated on HD#2 but within several hours, developed increased sputum with respiratory distress hence re-intubated and sputum culture initially grew 3+ GNR and 1+ GPCs plus leukocytosis with WBC up to 16K hence broad antibiotics of Vancomycin and Zosyn were started which was switched to ampicillin-sulbactam once H.influenzae was isolated on [**3-15**]. Last day of ABX was [**3-19**]. Patient was successfully extubated on [**3-15**] afternoon but patient required frequent suctioning for poor handling of secretions. She also failed speech and swallow evaluation on [**3-16**] which was repeated on [**3-20**] given that patient was only recently extubated. Also, on HD #3, patient was found to have tachycardia hence EKG was obtained which showed no acute change but cardiac enzymes were elevated hence most consistent with NSTEMI. Cardiology was consulted who recommended medical management including rate control with metoprolol and adding digoxin. Her Coumadin was stopped and she was started on Lovenox 50mg [**Hospital1 **] instead also in anticipation for possible PEG placement during this admission. Her CPK peaked in the 200's then trended down. Patient was then transferred to the step down unit. Repeat swallow evaluation again resulted in recommendations for strict NPO hence IR was consulted for PEG placement. She was planned for PEG on [**3-21**] but her coag panel showed elevated INR of 5.8. Hematology/oncology was consulted and DIC panel was checked. There were no signs of DIC and hematology felt that it was most likely combination of poor nutrition, antibiotics (she was on Unasyn for H.flu pneumonia) and vitamin K deficiency. Her INR improved drastically with 5mg of Vitamin K and she successfully underwent [**3-23**] but she self-DC'd the PEG on the night of placement despite restraining of her strong/non-paretic hand. Prior to the PEG placement, she pulled out several NG tubes as well. Surgery and GI were also consulted given concern for leak and perforation. Patient had rectal tube placed and received multiple enemas for decompression of cecal distention. Although aphasic, given patient's obvious refusal for nutrition intervention, family meeting was held again to discuss patient's wish for herself. Family including HCP, [**Name (NI) 16883**] reports that the patient always was clear about not wanting heroic measures hence given poor prognosis and her previous stated wishes, plan of care was changed to maximize comfort on [**3-26**]. She was made comfort measures only. Palliative care was consulted as well. Given that family lives in [**Hospital3 80928**] transfer to hospice care was sought but patient passed away on [**3-29**]. Family declined autopsy. Medications on Admission: Coumadin 1 mg Qday (has been held [**1-17**] her sx, last dose 3/19) Norvasc 5 mg Qday Toprol XL dose uncertain, but daugher thinks 25 mg Qday Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Left MCA stroke likely cardioembolic origin NSTEMI hx of breast cancer s/p right mastectomy Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2124-4-4**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "33.24", "96.04", "43.11", "96.71" ]

icd9pcs

[ [ [] ] ]

8682, 8691

4870, 8459

354, 420

8827, 8836

2625, 4847

8889, 8924

1374, 1378

8653, 8659

8712, 8806

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282, 316

448, 1218

1945, 2606

1718, 1929

1703, 1703

1240, 1280

1296, 1358

16,549

110,196

28518

Discharge summary

report

Admission Date: [**2112-10-25**] Discharge Date: [**2112-11-4**] Date of Birth: [**2049-12-4**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**10-28**] S/P Coronary Artery Bypass Graft x4 (Left internal mammary artery -> left anterior descending, Saphenous vein graft -> diagonal, saphenous vein graft -> obtuse marginal, saphenous vein graft -> posterior descending artery) History of Present Illness: 62 year old female presented to OSH with shortness of breath and cough for two days. Denied chest pain but had [**6-28**] back pain - cardiac enzymes with peak troponin 6.88. Underwent cardiac catherization at OSH which revealed 3 vessel disease. Past Medical History: Asthma Hypertension Cerebral vascular accident Gastroesophageal Reflux disease Diabetes mellitus Neuropathy Renal insufficiency Social History: Primary language spanish, lives with spouse denies alcohol denies tobacco Family History: NC Physical Exam: Admission Vitals: 97.8, 140/72, HR 70, RR 18, RA sat 97% wt 71.5kg General well developed, no acute distress Skin: red nonraised rash under bilateral breast, feet with dry scaly skin no breakdown HEENT: PERRLA, EOMI Neck: Full ROM, supple, no lymphadenopathy Lungs: Clear to auscultation bilaterally anterior and posterior decreased at right base Cardiac: RRR no murmur/rub/gallop Abdomen: Soft, nontender, nondistended, no palpable mass Ext: warm, CR < 3 sec, trace lower extremity edema, pulses palpable Neuro: alert and oriented nonfocal Pertinent Results: [**2112-10-25**] 09:03PM BLOOD WBC-9.6 RBC-3.93* Hgb-11.6* Hct-33.2* MCV-85 MCH-29.4 MCHC-34.7 RDW-16.7* Plt Ct-202 [**2112-10-25**] 09:03PM BLOOD PT-11.5 PTT-23.2 INR(PT)-1.0 [**2112-10-25**] 09:03PM BLOOD Plt Ct-202 [**2112-10-25**] 09:03PM BLOOD Glucose-389* UreaN-33* Creat-1.5* Na-134 K-5.0 Cl-97 HCO3-26 AnGap-16 [**2112-10-25**] 09:03PM BLOOD ALT-27 AST-39 LD(LDH)-245 AlkPhos-239* TotBili-0.3 [**2112-10-25**] 09:03PM BLOOD %HbA1c-9.8* [Hgb]-DONE [A1c]-DONE 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 Conclusions: PRE-BYPASS: 1. Overall left ventricular systolic function is low normal (LVEF 50-55%). 2. Mild to moderate ([**1-11**]+) mitral regurgitation is seen. 3. Aortic valve leaflets (3) are mildly thikened. 3. Mild spontaneous echo contrast is present in the left atrial appendage with no evidence of a clot. 4. No atrial septal defect is seen by 2D or color Doppler. 5. Right ventricular chamber size and free wall motion are normal. 6. There are simple atheroma in the descending thoracic aorta. Trace aortic regurgitation is seen. POST-BYPASS: 1. Preserved biventricular function, LVEF 50-55% 2. No change in wall motion 3. Mitral regurgitation remains [**1-11**]+ (mild to moderate) 4. Aortic contours remain intact 5. Remaining exam unchanged 6. All findings discussed with surgeons at the time of the exam Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2112-10-30**] 15:16. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Transferred in from OSH after undergoing cardiac catherization that revealed 3 vessel disease. She underwent preoperative work up and [**Last Name (un) **] was consulted for diabetes management. On [**10-28**] she was tranferred to the operating room and underwent coronary artery bypass graft surgery without complications, please see operative report for further details. She was then transferred to CSRU for hemodynamic monitoring. Within the next 24 hours she was weaned from sedation, awoke neurologically intact, and was extubated. She was wened from vasopressors and milirone. She remained in CSRU for respiratory, glucose, and hemodynamic management. On post operative day 3 she was transferred to [**Hospital Ward Name **] 2 and continued to progress. Medications were adjusted for blood pressure management. Physical therapy worked with her and evaluated for rehab. Continued to diuresis and [**Last Name (un) 387**] continued to follow for diabetes management. She continued to do well and on [**2112-11-4**] she was ready for discharge to rehab for continued physical therapy. Medications on Admission: [**Last Name (LF) 6196**], [**First Name3 (LF) **], Aldactone, Lisinopril, Lasix, Labetolol, Norvasc, Catapress, Iron Sulfate, Hydrochlorothiazide, Metformin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. 15. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) Units Subcutaneous at bedtime. 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) vial Injection four times a day: sliding scale AC & HS: BS 120-150 = 3U 151-200 = 5U 201-250 = 7U 251-300 = 10U. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 1110**] Discharge Diagnosis: Coronary artery disease Diabetes Mellitus Hypertension Gastroesophageal reflux disease Neuropathy Renal insufficiency h/o CVA Asthma Discharge Condition: good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23070**] in 1 week ([**Telephone/Fax (1) 69090**]) please call for appointment Cardiologist in [**2-12**] weeks please call for appointment Completed by:[**2112-11-4**]

[ "250.92", "493.90", "585.9", "414.01", "356.9", "401.9", "410.71", "428.0", "530.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6294, 6381

3463, 4563

342, 579

6558, 6565

1697, 3406

7031, 7366

1117, 1121

4771, 6271

6402, 6537

4589, 4748

6589, 7008

1136, 1678

283, 304

607, 857

3440, 3440

879, 1009

1025, 1101

60,739

180,716

34834

Discharge summary

report

Admission Date: [**2181-12-4**] Discharge Date: [**2182-1-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Exploratory Laparotomy with L colectomy, [**Doctor Last Name 3379**] pouch, and end colostomy History of Present Illness: 87 yoM w/ a h/o CAD, HTN, DM presents with shortness of breath x 1 day, shortness of breath was at rest. Over the past two days he has noted epigastric discomfort with exertion, while on the treadmill he feels this discomfort after 2-4 minutes, he then stops for 2-4 minutes and the pain subsides and he can continue again for the same amount of time. No rest symptoms at all. The symptoms do not radiate. No shortness of breath prior to today. No PND, + nocturia worsening over past few weeks. Stable 2 pillow orthopnea, slightly worsening pedal edema over past 5 days but has been present for 4-5 years in total. No claudication symptoms. Syncope 5 weeks ago, seen at [**Hospital3 **] with no clear diagnosis. In the ED the patient was started on BiPAP and given vanc / zosyn / levofloxacin given the leukocytosis, started on a nitro drip and 2 uPRBC. In addition given lasix 40mg IV x 2 and was started on a PPI drip. (at [**Hospital3 **] also got lasix 80-120mg IV x 1) and aspirin 325mg x 1. Past Medical History: - Coronary artery disease - Hypertension - Diabetes Mellitus - Hyperlipidemia - Osteoporosis - Chronic renal disease Social History: -Tobacco history: smoked in past, quit 40 years ago -ETOH: per family had "heavy" ETOH use in past, was told he has evidence of cirrhosis 30 years ago and since then continues to drink but has cut down. His family is unsure of quantity, he says occasionally. -Illicit drugs: none Family History: Non-contributory Physical Exam: VS: T 97.7 BP 119/57 HR 77 RR 21 O2sat 100% on FiO2 100%, BiPAP [**1-16**]. GENERAL: NAD, AOX3 HEENT: JVP of 12cm but obscured by mask CARDIAC: PMI non displaced. RRR, [**3-14**] crescendo / decrescendo murmur @ USB, [**3-14**] HSM at apex LUNGS: Dullness at L base, rales [**3-11**] way up bilaterally symmetrical ABDOMEN: moderate distension, liver edge palpable 3cm below costal margin, no fluid wave, BS+, non tender EXTREMITIES: WWP, trace bilat pedal edema R > L Pertinent Results: Imaging Studies: CXR: [**12-4**] - Acute CHF CXR [**2181-12-26**]- FINDINGS: Status post reposition of the nasogastric tube. The tube is now in correct position. All other monitoring and support devices are also unremarkable. The transparency of the lung parenchyma is increased as compared to the previous examination. Abdominal U/S: [**12-6**] - IMPRESSION: Mildly heterogeneous echogenic liver, which may be compatible with fatty infiltration. Please note, other forms of liver disease and more advanced liver disease such as hepatic fibrosis/cirrhosis cannot be excluded on the basis of this examination. LENIs: [**2181-12-8**]: No DVTs Head CT: [**2181-12-12**] - IMPRESSION: No acute intracranial hemorrhage. Head CT: [**2181-12-27**] - IMPRESSION: No acute intracranial abnormality. CT Abdomen/Pelvis: [**2181-12-13**] IMPRESSION: 1. Severe predominalty distal colitis, with some relative preservation of the proximal colon. 2. Questionable incomplete small-bowel obstruction, or ileus. 3. Eccentric dilatation of the portions of the sigmoid and descending colon (locations given above), which might suggest small self-contained perforation or large diverticulum. 4. Trace of ascites. 5. Bilateral pleural effusion with some adjacent small basilar atelectasis, and evidence of prior asbestos exposure. 6. No free air in the peritoneal cavity. Air in the abdominal wall in the subcutanous tissue anteriorly. We recommend to repeat CT abdomen, to follow oral contrast distribution and to further evaluate items 2 and 3. Follow-up CT Abdomen/Pelvis: [**2181-12-14**] 1. Focus of eccentric dilatation of descending colon, in the left lower quadrant, with asymmetrical distribution of contrast and air and significant fat tissue stranding, which either represents acute diverticulitis or perforation realted to colitis. There is currently no evidence of freee intraperitoneal spillage or air. Surgical consult is recommended. Results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 2. Second eccentric dilatation, which might be site of giant sigmoid diverticulum.No inflammation is seen around this and while contrast is seen within it it does not appear to represent an acute finding. 3. There is no small-bowel obstruction, the dilated loops of the small bowel are likely due to ileus. 4. Severe pancolitis-relative sparing proximally. 5. Bilateral pleural effusion with some adjacent small basilar atelectasis, and evidence of prior asbestos exposure. Results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and surgical consult was recommended. Results were also discussed with the surgical resident. KUB: [**2181-12-18**] IMPRESSION: 1. Large amount of free air under the right hemidiaphragm. 2. Progressive dilatation of multiple loops of small bowel. Review of notes in OMR demonstrate these findings were known to hte treating physicians, and that the patient has already been taken to surgery. Microbiology Review: All blood cultures [**Date range (1) 79766**] (7 cultures) negative for growth to date All urine cultures: negative for growth to date, last on [**12-27**] showed limited yeast. joint fluid: PMNs on gram stain, no organisms seen MRSA screen: neg x4 C. difficile toxin assay: + on [**12-12**], - x3 ([**12-24**], [**12-25**]/, [**12-26**]) Peritoneal wound: [**12-19**]: ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2181-12-23**]): NO ANAEROBES ISOLATED. CBC on discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2182-1-1**] 09:21AM 11.0 3.17* 9.4* 27.5* 87 29.5 34.0 16.6* 457* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2182-1-1**] 05:56AM 83 18 1.3* 145 3.4 110* 28 10 Brief Hospital Course: Hospital Course: This is an 87 yo M with multiple risk factors for CAD s/p NSTEMI [**3-10**] demand ischemia from an acute GIB whose hospital course was complicated by a C. difficile infection and colonic perforation. Patient underwent an exp-lap with L colectomy, end colostomy, and [**Doctor Last Name 3379**] pouch. He was transferred back to cardiology floor 8 days after surgery for management of volume overload, delerium, and acute on chronic renal failure. The patient was treated for all of these medical issues and was discharged to rehabilitation. #. NSTEMI: Patient has multiple risk factors for coronary artery disease including HTN, HLD, and PVD. However, his NSTEMI was thought to be due to demand ischemia from his GI bleed. Because of his multiple risk factors and hemodynamic instability from the bleed, he was not considered a candidate for cardiac catherization. He was medically managed with an aspirin, beta blocker, and statin. ACE inhibitor was held in setting of his renal failure and can be restarted as an outpatient. Troponins were stable and EKG without acute ischemic changes on discharge. #. GI bleed: Patient had melanotic stools and hematocrit drop. GI was consulted for endoscopy, but the etiology of his GI bleed (upper versus lower) was unclear as patient was deemed a high risk candidate and never underwent endoscopy. [**Month (only) 116**] have had some component of mesenteric ischemia, given his PVD, which contributed to his colonic perforation. Patient had appropriate access, hematocrit was monitored q6-q8H, and patient was transfused with 6 [**Location **] throughout his hospital stay. Continued on high dose proton pump inhibitor. His hematocrit stabilized in the high 20s. He should have an upper endoscopy as an outpatient to assess for etiologies of his GIB after discharge/rehabiliation (this has been scheduled at [**Hospital1 18**] in [**Month (only) 1096**]). #. Colonic perforation. Patient trigged for AMS and fever to 104 on [**12-11**] and was transferred back to the CCU. Found to be C. difficile positive and was started on PO Vancomycin, IV Flagyl, and Zosyn for broad coverage. Serial CT abdomens on [**12-13**] was concerning for descending colon/sigmoid colitis with a contained area of perforation. Surgery was consulted at the time and recommended conservative medical managemant without surgical intervention. The patient did well until [**12-18**] when he was noted to have sudden onset rigid abdomen. KUB showed air under the R hemidiaphraghm consistent with GI perforation. Patient was taken emergently to surgery where he was noted to have a perforated sigmoid diverticulitis & underwent a L colectomy with end colostomy and [**Doctor Last Name 3379**] pouch. He was maintained in the T-SICU intubated from [**Date range (1) 79767**], during which time he was continued on the above antibiotics. Linezolid was added for a peritoneal wound swab showing VRE. After patient was diuresed in the T-SICU, he was transferred to the medicine floor. ID was consulted who recommended discontinuation of all other antibiotics once patient was clinically improved from colonic perforation, and continuation of PO Vancomycin for two weeks (start date [**2181-12-29**]-end date [**2181-12-13**]). Patient was afebrile, leukocytosis had improved, and abdominal exam was non-surgical on discharge. He should follow up w/ Dr. [**Last Name (STitle) 1120**] as an outpatient (see discharge paperwork). #. Acute on chronic diastolic heart failure: EF 50% with acute on chronic diastolic heart failure. Patient had evidence of volume overload including elevated JVP, crackles on exam, and lower extremity edema. He also was 8L positive after his SICU stay. He was diuresed with IV lasix while in the CCU and post-operatively. He was transitioned to oral lasix. Continued on beta blocker. Held ACE inhibitor while in renal failure. Na restricted diet, daily weights, strict Is and Os, fluid restriction < 1500 ccs/day. #. Rhythm: Patient had an episode of atrial fibrillation while in house. Hemodynamically stable. Treated with IV metoprolol with appropriate cardioversion to normal sinus rhythm. No evidence of atrial fibrillation afterwards, was in NSR throughout. CHADS score or 4 demonstrates patient needs anticoagulation, but coumadin is contraindicated in him given his recent GI bleed. Starting coumadin can be re-assessed by his outpatient cardiologist. He was continued on a beta blocker (labetolol) and monitored on telemetry #. Acute on Chronic Renal Failure: Had underlying CRI likely in setting of diabetes. Baseline Cre unknown, but has been as low as 1.2. Likely pre-renal in setting of hypotension (had GIB and may have been transiently septic from colonic perforation) leading to intrarenal failure/ATN (FeUrea 50%). Patient was also being diuresed. Unlikely contrast induced nephropathy as he had not received contrast through radiology studies and was never cathed. [**Last Name (un) **] was held and all meds were renally dosed. Lasix was transitioned to oral and titrated down to 20 mg PO BID. Patient underwent post ATN diuresis and his creatinine improved to 1.3 on discharge. #. Hypernatremia: Patient had mild hypernatremia likely in the setting of poor PO intake and diuresis. Electrolytes were followed, and he was given gentle maintenence fluids as needed. #. Agitation: Patient had appropriate mental status prior to hospital admission, and acute developed waxing and [**Doctor Last Name 688**] mental status changes after his colonic perforation, consistent with delerium. Likely multifactorial (ICU delerium, infection associated from colonic perforation and C. difficile infection, surgical pain/abdominal distension). Other etiologies included toxic metabolic (acute on chronic renal failure without evidence of metabolic acidosis). All head CTs without evidence of acute intracranial processes or bleed. Neuro exam without focal abnormalities. No evidence of bacteremia or urosepsis (blood, urine cultures all negative for growth.) Stopped all altering medications such as percocet and famotidine. Patient was frequently re-orientated with emphasis on sleep wake cycle. He was kept on standing tylenol 1 gm TID for pain control, which was stopped once the patient was able to mentate and say he had no pain. Haldol was given transiently in the SICU for sundowning, and was stopped on the floor. Patient's mental status returned to baseline after three days on the floor (alert and oriented to name and place "hospital/rehab" and somewhat to time "[**Month (only) 321**]/[**January 2182**]".) . #. Hypertension: Labile BPs, was on four different anti hypertensives at home. Likely has PVD and renal artery stenosis. All home hypertensives were held and labetolol was uptitrated to 600 mg PO BID on discharge. Had good BP control in 120-130s on discharge. # Diabetes: [**Last Name (un) **] consulted for peri/post operative control of blood sugars. Continue HISS with 24 U Lantus QHS. #. Folliculitis: Dermatology consulted inititally for concern of drug reaction. Diagnosed as folliculitis. Started topical clindamycin per derm recs. . #FEN: Transitioned from TPN to TFs to oral PO intake. Speech and Swallow followed. #PPX: Heparin SQ TID. Pneumoboots. Colostomy Bag. Fall and Aspiraton Precautions. #Access: PICC #Code: Full Code #Dispo: to rehabilitation center Medications on Admission: Lasix 40mg Junuvia 50mg daily Insulin (lantus 7u qhs) Glimeperide 2mg po bid Lipitor 30mg daily Norvasc 5mg daily ASA 325mg daily Actos 45mg po daily Hydralazine 10mg po qid Lopressor 100mg po bid Diovan 160mg po daily Magoxide 400mg daily Vitamin D 400IUdaily Niaspan 1000mg daily Catapress q week (tuesday) Fosamax 70mg daily Discharge Medications: 1. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 2. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: thursday. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q4H (every 4 hours) as needed. 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Three Hundred (300) mg PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 13. 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. 14. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days: start date: [**2182-1-2**] end date: [**2182-1-11**]. 15. Insulin Lispro 100 unit/mL Cartridge Sig: as directed Subcutaneous four times a day: per insulin sliding scale. 16. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous at bedtime. 17. Heparin (Porcine) 25,000 unit Powder Sig: 5000 (5000) Units Miscellaneous TID (3 times a day): administer subcutaneously three times a day for DVT prophylaxis. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: CHF Exacerbation (Acute on Chronic Diastolic Heart Failure) Non ST Elevation Myocardial Infarction C. difficile infection Colonic/sigmoid perforation GI Bleed/Acute Blood Loss Anemia Delerium Acute on Chronic Renal Failure 2' Diagnosis Hypertension Left Knee gout flare Diabetes Mellitus Type 2 Coronary Artery Disease Discharge Condition: afebrile, hemodynamically stable, stable mental status on discharge. Discharge Instructions: You were admitted with shortness of breath. You were diagnosed with a heart attack, a GI bleed, and congestive heart failure. Your heart attack was likely in the setting of reduced perfusion of blood to your heart as a result of the GI bleed. You were managed on cardioprotective medications. Your heart failure was treated with removal of fluid from your body. You had an infection of your GI tract with a bacteria called Clostridium difficile. You also had a perforation of your colon which required emergent surgery and removal of the L side of your colon. You were also treated with antibiotics and will require antibiotics (oral Vancomycin) after discharge as listed below. You recovered from this surgery and were discharged to rehabilitation in stable condition. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet. Fluid Restriction: < 1500 ccs/day The following changes were made to your medications: STOP: Januvia, Glemiperide, Actos, Niacin STOP: Norvasc, Hydralazine, Lopressor, and Catapress INCREASE: Lantus from 7 U at night to 24 U at night START: Insulin sliding scale as directed START: Oral Vancomycin for treatment of your colon infection for the amount of time listed below. START: Labetolol 600 mg by mouth twice a day START: Iron supplementation and Protonix 40 mg by mouth twice a day. CHANGE: Lipitor 30 mg daily to Simvastatin 10 mg by mouth daily CHANGE: Lasix 40 mg by mouth daily to Lasix 20 mg by mouth twice a day DECREASE: Aspirin from 325 mg to 81 mg by mouth daily CONTINUE: Vitamin D, calcium, and fosamax CONSIDER: Restarting Diovan 160 mg by mouth daily when your renal function returns to basline. Please return to the hospital or call your primary care physician if you experience any of the following symptoms - shortness of breath, chest pain, blood in your stools, worsening abdominal pain or distension, poor or increased drainage of your colostomy bag, poor urine output, light headedness or loss of consciousness, fevers > 101, chills, or any other symptoms not listed here that are concerning to you and warrant physician [**Name Initial (PRE) 2742**]. Followup Instructions: Cardiology: please follow up Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within [**2-7**] weeks after discharge from your rehabilitation center. We have scheduled you for an appointment on Tuesday [**2182-2-5**] at 1:00 PM. Please call [**Telephone/Fax (1) 62**] if you cannot make this appointment. Please discuss restarting your [**Last Name (un) **] (Diovan 160 mg by mouth daily) at this time. Primary Care: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] [**Telephone/Fax (1) 41901**]. within [**2-7**] weeks after discharge from the rehabilitation center. You have been scheduled for an appointment on [**2182-1-23**] at 11 am. Please call if you cannot keep this appointment. You will need to have an upper GI endoscopy as an outpatient. We have scheduled you for an upper endoscopy here at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on Monday, [**2182-1-21**]. Please arrive at 9:15 AM for a 10:15 AM procedure with Dr. [**Last Name (STitle) 349**]. Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2182-1-21**] 10:15 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] (ST-3) GI ROOMS Date/Time:[**2182-1-21**] 10:15 Please follow up with surgery within 2-3 weeks after surgery (beginning to mid-[**Month (only) 1096**]). Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 160**] to make an appointment at your convenience. You do not need to follow up with infectious diseases. Completed by:[**2182-1-1**]

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36815

Discharge summary

report

Admission Date: [**2173-7-23**] Discharge Date: [**2173-8-10**] Date of Birth: [**2113-9-21**] Sex: M Service: MEDICINE Allergies: erythromycin / Heparin Agents / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 3256**] Chief Complaint: Hip fracture Major Surgical or Invasive Procedure: Left hip hemiarthroplasty Endotracheal Intubation and Mechanical Ventilation History of Present Illness: 59yoM with a history of mitral valve prolapse, atrial fibrillation s/p MAZE and mitral valvuloplasty in [**10/2171**] at [**Hospital1 112**] that was complicated by a right MCA CVA, RLE DVT treated with coumadin presenting status post fall during transfer and fracture of his left hip. Patient underwent arthroplasty of the left hip on [**2173-7-23**]. After the operation, he developed a new oxygen requirement and was on 4L NC for the past 2 days until he was found to have a HR of 140s on tele on [**2173-7-25**] at 1830 and an O2 sat of 71% on 4L NC. He was given 40mg IV lasix and 5mg IV lopressor, which was repeated when heart rates did not decrease with another 5mg IV lopressor. He diuresed 1 L of urine and his oxygen saturations increased to 100% on the non-rebreather. On arrival to the MICU, O2 sats are 100% on non-rebreather and patient has a new fever of 101.2. Patient denies chest pain, dyspnea, headache, or pleuritic pain. He is only AAO x name, and is unclear where he is or why he is here. His family is very involved in his care and were involved with this history taking. Past Medical History: - [**2171-11-26**]: AFib and went to [**Hospital1 756**] were mitral valvuloplasty/L atrial maze and L atrial appendage resection were done. After this surgery on post-po day 1 he suffered a long-standing post-op seizure tonic clonic and found on imaging a R+ MCA CVA. --- Pt reports that his Vimpat is being de-escalated and that he hasn't had a seizure since his initial seizure. - [**2172-1-13**]: pseudoaneurysm from R common femoral artery (discovered after going to the hospital bc swelling of L+ ankle) and DVT in R+ lower extremity. - Mitral valve prolapse - h/o DVT on Coumadin - Bilateral inguinal hernia repair - L+ knee arthroscopic surgery - h/o heparin-induced thrombocytopenia Social History: Lives in [**Location 745**] with his wife. [**Name (NI) **] 2 children that live in [**Country **]. [**Hospital1 **] Orthodox. Retired from financial management. Denies tobacco, alcohol, illicits. Family History: non-contributory Physical Exam: Vitals: T: 101.2 BP:100/52 P:118 R:21 O2: 100% on non-rebreather General: Alert, oriented only to person, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi, although upper airway sounds throughout. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, teds and SCDs in place Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities on right, 3+ on left, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge exam: Pertinent Results: [**2173-7-23**] 07:05PM GLUCOSE-115* UREA N-12 CREAT-0.7 SODIUM-139 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14 [**2173-7-23**] 07:05PM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.6 [**2173-7-23**] 07:05PM WBC-21.8*# RBC-3.79* HGB-11.4* HCT-34.0* MCV-90 MCH-30.2 MCHC-33.6 RDW-12.7 [**2173-7-23**] 07:05PM PLT COUNT-223 [**2173-7-23**] 07:05PM PT-12.8* PTT-27.5 INR(PT)-1.2* [**2173-7-23**] 12:48PM HCT-36.6* [**2173-7-23**] 12:48PM HCT-36.6* [**2173-7-23**] 11:50AM GLUCOSE-87 UREA N-12 CREAT-0.8 SODIUM-139 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 [**2173-7-23**] 11:50AM estGFR-Using this [**2173-7-23**] 11:50AM WBC-10.8# RBC-4.34*# HGB-13.0*# HCT-38.1*# MCV-88 MCH-29.9 MCHC-34.1 RDW-12.5 [**2173-7-23**] 11:50AM NEUTS-82.4* LYMPHS-13.6* MONOS-3.0 EOS-0.9 BASOS-0.1 [**2173-7-23**] 11:50AM PLT COUNT-247 [**2173-7-23**] 11:50AM PT-11.3 PTT-30.0 INR(PT)-1.0 [**2173-7-23**] 11:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.004 [**2173-7-23**] 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [**7-23**] Path Gross: The specimen is received fresh in a container labeled with the patient's name, "[**Known lastname **], [**Known firstname 43984**]", the medical record number, and additionally labeled "left femoral head". It consists of a normally shaped femoral head without a portion of femoral neck that measures 5.5 x 4.5 x 4.5 cm. The articular surface is unremarkable. Osteophytes are not present. The femoral neck margin is irregular. The specimen is cut along its length perpendicular to the articular cartilage. The cut surfaces reveal yellow-tan hemorrhagic cut surfaces. A fragment of femoral neck is also received in the container and measures 4.5 x 4.0 x 2.5 cm. It is cut perpendicular to the articular surface to reveal hemorrhagic bone marrow. Tissue is not present. Representative sections of the specimen are submitted for decalcification as follows: A= representative sections of femoral head, B = representative sections of femoral neck. [**7-23**] ECG: Sinus bradycardia. Intraventricular conduction defect. Left axis deviation, possibly due to left anterior fascicular block. Diffuse non-specific ST-T wave abnormalities. Compared to tracing #1 the heart rate is decreased but there are no other significant changes. TRACING #2 Intervals Axes Rate PR QRS QT/QTc P QRS T 56 0 132 468/461 0 -57 85 [**7-23**] Hip Xray: FINDINGS: Single frontal view of the pelvis and three views of the left hip were obtained. a complete fracture of the left femoral neck is present with mild varus angulation. No dislocation is identified. Vague lucencies of the left femoral shaft is suggestive of osteopenia. No radiopaque foreign bodies. IMPRESSION: 1. Left femoral neck fracture with mild varus angulation. 2. Left femoral shaft lucencies suggestive of osteopenia in the setting of decreased weght bearing from prior stroke. [**7-23**] CXR: FINDINGS: Single portable view of the chest compared to previous exam from [**2172-3-20**]. The lungs are clear of focal consolidation or effusion. Cardiomediastinal silhouette is within normal limits. Median sternotomy wires are again noted. The osseous and soft tissue structures otherwise unremarkable. IMPRESSION: No acute cardiopulmonary process. [**7-25**] Knee xray No prior studies for comparison. FINDINGS: Three views of the left knee demonstrate no evidence of acute fracture, dislocation, joint effusion, or soft tissue foreign body. [**7-25**] Cpine xrays CERVICAL SPINE, [**2173-7-25**] No prior studies for comparison. On the lateral view, all seven cervical vertebral bodies are visualized, but the superior aspect of T1 is obscured and cannot be assessed. Prevertebral soft tissue structures are within normal limits. Bone mineral density is apparently slightly decreased throughout. Multilevel degenerative changes are present with small anterior osteophytes particularly at the C3 through C6 levels, as well as very minimal disc space narrowing. Reversal of the normal cervical lordosis is evident at C4-C5. Flexion and extension views demonstrate no evidence of instability. Incidental note is made of an oval-shaped calcification posterior to the spinous processes of C4 and C5, which may represent ossification or calcification of the posterior longitudinal ligament. IMPRESSION: 1. Multilevel degenerative changes in the cervical spine as described. No acute fracture or dislocation identified, but CT of the cervical spine is much more sensitive than conventional radiographs for detecting traumatic abnormalities and would be suggested if there is persistent clinical suspicion for a cervical spine injury. 2. Exam is limited by absence of an odontoid view and lack of visualization of C7-T1 disc space and top of T-1. AP CXR on [**7-25**] IMPRESSION: AP chest compared to [**7-23**]: Lungs are appreciably smaller and there is greater but symmetric opacification in the lower lungs. Contributing to elevation of the diaphragm is a stomach severely distended with air and fluid. Since there is also increased upper lobe vascular congestion, and new small left pleural effusion, appearance could be explained by either bibasilar pneumonia or a combination of atelectasis and edema. Subsequent chest CT reported separately has findings of left lower lobe atelectasis, right lower lobe pneumonia and multifocal small regions of peribronchial opacification, probably bronchopneumonia. It shows vascular congestion but no pulmonary edema, and a stomach severely distended with air and fluid. CT Chest: FINDINGS: The thyroid gland, aorta and major branches, heart and pericardium are unremarkable with the exception of changes of mitral valve annuloplasty. No pericardial effusion is seen. The esophagus is patulous and fluid filled. There is no axillary, hilar, or mediastinal adenopathy. Gynecomastia is noted bilaterally. Though this study is not tailored for subdiaphragmatic evaluation, imaged upper abdomen reveals distended stomach. The trachea and central airways are patent to the segmental level. The pulmonary arterial tree is well opacified without filling defect to suggest pulmonary embolism, though evaluation of the subsegmental vessels is limited due to respiratory motion. Small bilateral pleural effusions are dependent and nonhemorrhagic. Right greater than left basal opacities with milder opacification of the dependent segment of the right upper lobe and right middle lobe are concerning for multifocal pneumonia which likely includes the anterior subpleural opacities. OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion to suggest osseous malignancy. IMPRESSION: 1. No pulmonary embolism or acute aortic pathology. 2. Multifocla pneumonia with opacities in the lower lobes and left upper lobe. 3. Patulous esophagus, correlate with symptoms of dysphagia and outpatient esophagram can be obtained if indicated. Echo [**7-26**] The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with normal gradient. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Well seated mitral annuloplasty ring with normal gradient and mild mitral regurgitation. Pulmonary artery hypertension. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. AP CXR [**7-26**] FINDINGS: As compared to the previous radiograph, there is a substantial increase in extent and severity of the pre-existing multifocal pneumonia. These changes are evident at both lung bases. The lung apices are bilaterally spared from the pathologic process. Unchanged borderline size of the cardiac silhouette. Minimal fluid overload cannot be excluded. No larger pleural effusions. No pneumothorax. Mild over distention of the stomach, unchanged normal alignment of the sternal wires. ECG [**7-28**] Sinus tachycardia. Left anterior fascicular block. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2173-7-23**] the heart rate has increased, ST-T wave abnormalities have improved. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 103 146 128 336/411 47 -45 78 AP CXR [**7-28**] Last of 3 for the day There is again seen diffuse air space opacities bilaterally, more confluent in the right lung and have increased slightly since the prior study. Atelectasis at the left lung base is again seen. There are low lung volumes with poor inspiratory effort. There are no pneumothoraces. Median sternotomy wires are present. AP CXR [**7-30**] FINDINGS: A new left PICC terminates approximately 1 cm beyond the cavoatrial junction. Dense consolidation of the entire right lung as well as right-sided pleural effusion are unchanged. There is a persistent retrocardiac opacity as well as worsening consolidation of the left upper lobe when compared to the prior study from yesterday. There is improved aeration at the left costophrenic angle. There is no pneumothorax. Heart size is top normal and unchanged. Sternotomy cerclage wires are intact. IMPRESSION: 1. New left PICC should be withdrawn by 1.5 cm to ensure proper positioning in the lower SVC. 2. Multifocal pneumonia, slightly worse in the left upper lobe. BAL [**7-31**] Bronchioalveolar lavage: NEGATIVE FOR MALIGNANT CELLS. Numerous neutrophils, bronchial cells, and pulmonary macrophages. No viral cytopathic changes or fungi seen. AP CXR [**7-31**] CHEST, SINGLE AP PORTABLE VIEW The patient is status post sternotomy. An ET tube is present, tip in satisfactory position approximately 4.3 cm above the carina. A left-sided PICC line is present, tip over distal SVC. An NG tube is present, tip and side port beneath diaphragm, extending off film. There is diffuse alveolar opacity and air bronchograms throughout the right lung, with relative sparing of the right lung apex and minimal residual lucency at the right base. This has progressed compared with [**2173-7-30**]. Possibility of an associated effusion cannot be excluded. There is also prominent focal interstitial and alveolar opacity in the left upper zone, which appears more confluent than on the earlier film. There is increased retrocardiac density, with obscuration of the left hemidiaphragm, unchanged. The small left effusion is slightly more prominent on this exam. There is relative lucency at the left lung apex. However, I doubt this represents a pneumothorax. IMPRESSION: Interstitial and alveolar opacities in both lungs, progressed compared with [**2173-7-30**] at 12:09 p.m. Differential diagnosis includes multifocal pneumonic infiltrates, ARDS and CHF. CHEST: Imaged portions of the thyroid gland appear within normal limits. There is a left upper extremity PICC line with its tip terminating in the SVC. The patient is status post endotracheal intubation with the tip of the ET tube lying approximately 4.9 cm above the carina. An NG tube is seen with its tip terminating in the stomach. There is no axillary, mediastinal, or hilar lymphadenopathy. The cardiac [**Doctor Last Name 1754**] appear grossly within normal limits. There are no filling defects within the central pulmonary arterial tree. The patient is status post median sternotomy and mitral valve replacement. There are large bilateral pleural effusions with adjacent compressive atelectasis, right greater than left. Patchy pulmonary opacities are noted in the remainder of the inflated upper lobes with hint of appearance of crazy pavement (series 2, image 13) in the left upper lobe and also within the right upper lobe (series 2, image 17) suggestive of pulmonary edema. There is no pneumothorax. Additional scattered regions of ground-glass opacification are also seen scattered within the lungs, for example, on series 2, image 35, suggestive of edema. FINDINGS IN THE ABDOMEN AND PELVIS: In the liver, there are two focal hypodensities seen centrally (series 2, image 56), which are less than a centimeter in size and are not well characterized on the current examination. There is no intra- or extra-hepatic biliary ductal dilatation. The portal vein is patent. The spleen is within normal limits in size. The adrenal glands, pancreas, and kidneys appear unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy. There is minimal quantity of perihepatic fluid as well as a small quantity of fluid tracking into the right paracolic gutter. The gallbladder is distended and there is a small quantity of pericholecystic fluid (2, 82). Minimal periportal edema is seen in the liver. There is a small quantity of fluid in the dependent pelvis (2, 108). The urinary bladder demonstrates no obvious abnormalities. A Foley catheter is seen in place. No obvious abnormalities are seen in the colon. The stomach is slightly decompressed with NG tube in place, limiting evaluation. Small bowel appears within normal limits. There is subcutaneous soft tissue edema, most predominantly noted in the gluteal region as well as in the upper thighs. There are flame-shaped opacities involving the retroareolar regions suggestive of gynecomastia. Left hip replacement arthroplasty is seen. There are no suspicious osteolytic or osteoblastic lesions seen to suggest tumor. Surgical staples are seen in the left gluteal region. IMPRESSION: Large bilateral pleural effusions with adjacent compressive atelectasis. Crazy pavement changes in the lungs suggestive of mild pulmonary edema. Additional multifocal regions of atelectasis and consolidation, underlying pneumonia is not excluded. No intra-abdominal abscess. Distended gallbladder with small amount of pericholecystic fluid. Findings are nonspecific. If there is clinical concern for acute cholecystitis, this can be further evaluated with right upper quadrant son[**Name (NI) **]. Minimal quantity of perihepatic and pelvic fluid, which could be related to third spacing. Additional diffuse regions of subcutaneous soft tissue edema in the pelvic girdle. CXR [**8-4**] INDICATION: Pneumonia, questionable ET tube placement. COMPARISON: [**2173-8-4**]. FINDINGS: As compared to the previous radiograph, the monitoring and support devices are constant. The tip of the endotracheal tube projects 4.9 cm above the carina. The parenchymal opacity at the left lung apex is minimally decreasing in extent. The extensive right-sided opacity is unchanged. Moderate cardiomegaly with borderline size of the cardiac silhouette and unchanged minimal blunting of the left costophrenic sinus, potentially reflecting a small pleural effusion. No evidence of pneumothorax. Brief Hospital Course: 59 y/o M with a history of mitral valve prolapse, atrial fibrillation s/p MAZE and mitral valvuloplasty in [**10/2171**] that was complicated by a right MCA CVA and a RLE DVT presented status post fall and fracture of his left hip on [**2173-7-23**]. His hip was repaired with a L hemiarthroplasty on [**2173-7-23**], and in the post-operative setting, he had persistent high oxygen requirements. He progressed to respiratory failure secondary to multifocal pneumonia and pulmonary edema, requiring re-intubation and transfer to the MICU. He was treated with a 10 day course of antibiotics and aggressive diuresis, as well as vasopressors until he improved. He was extubated and gradually weaned off oxygen. Once medically stable, PT advised further inpatient physical therapy in subacute rehab. Active Problems: # Respiratory Failure: Multifocal PNA (aspiration?) and pulmonary edema. Following extubation from his orthopedic procedure, patient was maintained on 5L nasal canula on the floor. The evening of [**2173-7-25**], he developed respiratory distress, not responsive to lasix. Patient was then transferred to the MICU, meeting SIRS criteria by RR, temperature, and heart rate. Pt was evaluated for a PE; CTA showed no evidence of PE, but did show a multifocal PNA. He was placed on broad-spectrum antibiotics (including vancomycin, and, at different points, cefepime, levofloxacin, and Meropenem). Blood, urine, and sputum cultures did not grow out any organism. The patient also developed hypotension and was volume-recusitated aggressively. His tachypnea increased, and he became hypoxic on BiPAP and required intubation on [**2173-7-31**]. Cultures from bronchoscopy following intubation were unremarkable, and visual inspection of the airways did not demonstate purulence. Further imaging with chest CT showed large bilateral pulmonary effusions, multifocal PNA, and pulmonary edema. He received a 10-day course of antibiotics for VAP coverage. As his pneumonia improved, concern lingered for pulmonary edema. He was started on Lasix drip for diuresis, and was extubated on [**2173-8-5**]. By [**2173-8-6**], he was was able to oxygenate well on 2L by NC. By [**2173-8-9**] he was stable on room air. . # Hip Fracture: His hip was repaired with a L hemiarthroplasty on [**2173-7-23**]. Orthopedic surgery followed the patient throughout his stay in the MICU. His surgical wound healed well, and staples were removed on [**2173-8-6**], there was no concern for infection. Physical therapy began working with the patient when he was weaned off sedation prior to being extubated. They continued working with him during the remainder of his hospitalization and recommended subacute rehab after discharge. . # Pain Control: Patient had post-operative pain in his left thigh and hip. Before and during intubation and after extubation, the patient had pleuritic chest pain as well. At different points during his hospitalization, his pain was controlled with morphine, fentanyl, ibuprofen, IV Tylenol, and/or lidocaine patch. He will be discharged on tylenol and morphine prn. . # Fever/Thrombocytosis: Likely reactive to pneumonia versus drug reaction. The patient continued to spike fevers during his MICU stay. Initially the fever was c/w PNA and sepsis. However, even as his PNA resolved, he continued to spike fevers. He also developed a thrombocytosis to the 900s. The fever and thrombocytosis are thought to be due to systemic inflammation in the setting of resolving PNA. His platelets were down-trending by day of discharge. He has been afebrile for several days. . # Persistent sinus tachycardia in the MICU: This tachycardia was likely due to hypovolemia versus sepsis versus hypoxia. The patient's home metoprolol was held in the setting of hypotension. Troponins were sent and were negative. When the patient was extubated and his tachycardia resolved, he was restarted on metoprolol, and switched to metoprolol 75mg XL daily the day of discharge. However his dose was held on discharge due to his SBP in the ~90s. . # Hypotension: In the setting of SIRS and multifocal PNA. He required norepinephrine drip, but this was discontinued in the MICU when his BP improved with MAPs in the 70s. He was normotensive on transfer to the floor and his Metoprolol was held with his SBP in the ~90s. . # Nausea/GERD: Likely mutifactorial, with components of GERD, clinical illness, and not taking POs for several days. Patient with history of GERD. Pt was initially on IV Protonix, then was switched to PO PPI. He was treated with Zofran, calcium carbonate, Aluminum-Magnesium Hydrox, and simethicone. On CTA of the chest, patulous esophagus was also seen (see transitional issues below), which may have also contributed to his difficulty taking POs. His symptoms had resolved by day of discharge. . # Rash: Over back, consistent with heat-induced follicullitis. First noted and resolved in the MICU. . # Altered mental status: On arrival to MICU, question hypoxia precipitating versus history of previous stroke. Per family, patient was initially off baseline, but improved with oxygen saturations, although patient still having episodes of confusion prior to intubation. He was treated with quetiapine, and his mental status improved while he weaned off sedation when he was intubated and then improved further after extubation. On transfer to the medical floor he was stable and remained oriented. . # Dropping HCT: HCT dropped from 28 on [**7-30**] to 22 on [**8-2**] without a source of bleeding. This may have been dilutional, but the patient was transfused with 1 unit PRBCs on [**8-2**]. From that point, his HCT has been increasing. . Chronic Problems: # History of DVT: Pt has a hx of DVT and was treated previously with Coumadin. This was held during his hospitalization. Due to his history of being HIT antibody +, he was not treated with unfractionated heparin. He was treated with aspirin 81 mg PO/NG DAILY and Fondaparinux Sodium 2.5 mg SC DAILY. . # BPH: On Flomax at home. This was initially held, but was restarted on [**8-6**] The patient's Foley was removed on [**8-7**] and he maintained urine output on discontinuation of the Foley. . # History of stroke and seizures: The patient remained clinically stable on his home Lacosamide 50 mg PO/NG DAILY, Pravastatin 20 mg PO HS, and Aspirin 81 mg PO/NG DAILY. . # History of seasonal allergies: Inactive during this hospitalization. Home medications were initially held, but were restarted on discharge. . # History of depression: The patient remained clinically stable. His home Duloxetine 60 mg PO DAILY was held initially but restarted on [**8-5**] . . # Skin conditions: Pt on several home medications that were continued, including Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN intching, Ketoconazole 2% 1 Appl TP DAILY, and Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **] to scalp as needed. . Transitional issues: # The patient responds well to diuresis with IV furosemide 20mg if there are signs of fluid overload. # The patient's metoprolol 25mg tid was consolidated to metoprolol succinate 75 once a day, but his SBP has been in the high 90s towards the end of his hospital stay, so antihypertensives had been held. # Patulous esophagus seen on CTA Chest [**7-25**]: outpatient esophagram can be obtained if indicated # The patient will need rehab for his left hip surgery. Medications on Admission: -Lacosamide (VIMPAT) 100 mg Oral Tablet [**1-25**] tab daily -Fluticasone 50 mcg/actuation Nasal Spray, Suspension Use 2 sprays in each nostril once daily -Tamsulosin (FLOMAX) 0.4 mg Oral Capsule, Ext Release 24 hr 1 tablet daily 30 minutes after breakfast -Nystatin (MYCOSTATIN) 100,000 unit/g Topical Powder use [**Hospital1 **] -Duloxetine (CYMBALTA) 60 mg Oral Capsule, Delayed Release(E.C.) 1 tab qd -Fluocinonide 0.05 % Topical Solution Apply twice daily as directed -Fexofenadine ([**Doctor First Name **]) 180 mg Oral Tablet Take 1 tablet daily as needed. Available over the counter. -Pravastatin (PRAVACHOL) 20 mg Oral Tablet 1 tablet in the evening -Metoprolol Tartrate 25 mg Oral Tablet 3 tablets daily total 75mg -Ketoconazole (NIZORAL) 2 % Topical Cream Apply twice daily -Ketoconazole (NIZORAL) 2 % Topical Shampoo Shampoo 5 minutes 2 to 5 times per week or as directed -Dantrolene (DANTRIUM) 25 mg Oral Capsule as directed -Triamcinolone Acetonide 0.1 % Topical Lotion apply [**Hospital1 **] to the scalp as needed -Lorazepam (ATIVAN) 0.5 mg Oral Tablet [**1-25**] tablet q 6hrs as need for anxiety -Acetaminophen (TYLENOL EXTRA STRENGTH) 500 mg Oral Tablet 2 tablets [**Hospital1 **] -Docusate Sodium (COLACE) 100 mg Oral Capsule once daily -SENNOSIDES (SENNA LAXATIVE ORAL) one tablet daily as needed for constipation -MULTIVITAMIN ORAL once a day -ASPIRIN 81 MG TAB Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain or fever patient may refuse 2. Albuterol Inhaler [**4-30**] PUFF IH Q6H:PRN SOB, wheezing 3. Aspirin 81 mg PO DAILY 4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 5. Calcium Carbonate 500 mg PO BID calcium supplement please do not administer within 2 hours of Cipro doses 6. Docusate Sodium 100 mg PO BID 7. Duloxetine 60 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Fondaparinux Sodium 2.5 mg SC DAILY 10. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN intching 11. Ketoconazole 2% 1 Appl TP DAILY 12. Lacosamide 50 mg PO DAILY 13. Lidocaine 5% Patch 1 PTCH TD DAILY 14. Miconazole Powder 2% 1 Appl TP [**Hospital1 **] 15. Morphine Sulfate IR 7.5 mg PO Q6H:PRN pain 16. Multivitamins 1 TAB PO DAILY 17. Omeprazole 40 mg PO DAILY 18. Ondansetron 4 mg IV Q6H:PRN nausea 19. Pravastatin 20 mg PO HS 20. Prochlorperazine 10 mg PO Q6H:PRN nausea Caution oversedation 21. Quetiapine Fumarate 25 mg PO TID:PRN agitation 22. Senna 1 TAB PO BID 23. Simethicone 40-80 mg PO QID:PRN abdominal discomfort 24. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 25. Tamsulosin 0.4 mg PO DAILY 26. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **] to scalp as needed 27. Vitamin D 800 UNIT PO DAILY 28. Metoprolol Succinate XL 75 mg PO DAILY Hold if SBP<100, HR<60 Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Primary: Left Hip Fracture, Respiratory Failure, Pneumonia, Pulmonary Edema Secondary: Depression, Congestive Heart Failure, 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: Dear Mr. [**Known lastname **], It was a pleasure caring for you at [**Hospital1 827**]. You were admitted because you had a broken hip which required surgery. Your recovery was complicated by pneumonia, pulmonary edema (fluid in your lungs), and respiratory failure, which required that we insert a breathing tube and provide mechanical ventilations in the medical ICU. We also treated you with oxygen, antibiotics for the pneumonia and diuretic medications, which remove fluid from your body. We also gave you medications to maintain your blood pressure. . You responded to treatment well, except for some confusion known at ICU delirium. Once you improved, we transferred you to the general medicine floor and monitored you for several more days until your oxygen was stopped completely. Please note the following changes in your medications: You should START Fondaparinux to prevent blood clots, as managed by your orthopedic surgeon. You should CHANGE Metoprolol to Metoprolol 75mg XL once a day for high blood pressure. You should START the skin ointments and powders for your rashes, as needed, for 1-2 weeks until they resolve. You may START acetaminophen and morphine for pain control, as needed. You may continue the rest of your medications as previously prescribed. Followup Instructions: *Please schedule a PCP appointment on discharge from your Rehab facility. *Please schedule an appointment with a dermatologist if your skin rashes do not resolve in [**1-25**] weeks. Orthopedic Surgery followup: Department: ORTHOPEDICS When: THURSDAY [**2173-8-26**] at 10:20 AM 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 [**2173-8-26**] at 10:40 AM 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 Completed by:[**2173-8-10**]

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Discharge summary

report+addendum

Admission Date: [**2143-10-7**] Discharge Date: [**2143-10-29**] Date of Birth: [**2080-12-11**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 800**] Chief Complaint: Left lower extremity non healing ulcer Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, Mr. [**Known lastname 14586**] is a 62 yoM with h/o complicated DM,(suspected type I though not verified, CKI and MMP including severe PVD s/p R-AKA who was admitted on [**2143-10-7**] electively for IV antibiotics for a LLE non-healing ulcer. Reportedly, at the time of admission, the patient denied pain, fever, purulent discharge and erythema of that leg; the ulcer has been there for ~8 months. . Morning of [**10-10**] pt went to BR and started to feel nauseous and light-headed. He came back to bed and RN noted he was "seizing." They check his BP and found it to be in 230s. He was put on telemetry and after about one hour they noted an asystolic alarm. At bedside pt appeared to be seizing however when he was evaluted he was awake and alert. Patient then had emesis and large volume brown liquid. Later that day he became progressively more bradycardic until asystole was noted with a 4.4 second pause. Following emesis, ECG showed a.fib with RVR. Pt was transferred to ICU. In the ICU patient converted to NSR. Troponin was elevated to trop of 0.22 thought to be related to demand ischemia in setting of A. fib. No EKG changes were identified. Patients Atenolol was stopped. . Morning of [**10-15**], patient was noted by nursing to be irritable spaking in Russian and Englishm unwilling to follow commands. Appears to be focused on [**10-11**] and the end of the universe and the impending holocaust. Throughout the day yesterday the patient continued to have pressured speech and expressed wishes of harming himself. Pscyh consulted and thought this was a delirium secondary to multiple toxic-metabolic causes including infection, fluctuation in blood sugars, blood pressure. CT was performed and negative for intracranial bleed. Throughout this hospitalization patient has had elevations up to and greater that systolic >200. Blood sugars also appear to be poorly controlled with FS approx 300-400. . Today, patient is able to communicate very little. Pt sister is in the room with him currently and is very concerned because this is very different from how the patient normally behaves. She notes no previous changes in his thiking like this in the past. Pt continues to perseverate on [**Country **] and repeats that he "hates this place." He can follow directions without difficulty but does have difficulty orienting to time and place. Patient unable to communicate complaints. He states that he is currently in no pain. Past Medical History: DMI x 50 yrs (retinopathy, neuropathy) [**12-7**] HgBA1C 5.7% PVD see surgeries below Hypertension Hypercholesterolemia PUD CKD Cr 1.5-1.8 BPH PSH: s/p R Fem-[**Doctor Last Name **] with svg (in LA [**2126**]), S/p left fem-[**Doctor Last Name **] with [**Doctor Last Name 4726**]-TEX 97, re do left profunda-PT with in situ vein by Dr. [**Last Name (STitle) 1391**] [**2133**]. s/p RLE angiography [**2142-6-18**], right CFA-AKpop bpg with arm vein [**2142-6-21**], Right BKA [**2142-6-27**] Social History: Pt. has been in the US for 12 years, worked in computer industry before becoming disabled. Pt. lives alone but has son and son's family very nearby. Patient does not smoke, drink alcohol, or use illicits Family History: Significant for DM Physical Exam: PE: 97.1, 55, 156/80, 18, 98% on room air Gen: no distress, alert and oriented HEENT: NC, AT Neck: supple, no bruits heard Chest: RRR, systolic [**3-8**] murmur, lungs clear Abdomen: soft, nontender, nondistended, + bowel sounds Ext: R AKA stump healed with a foul smelling sock which was removed and he was instructed no longer to wear it, Left leg with 1+ edema to knee, left foot warm to touch, motor and sensation intact, 1st toe amp site healed, 4x2cm shallow ulcer with a no exudate on the lateral aspect of the lower leg, there is no erhythema surrounding the ulcer, some erythema and a blister on the left knee. Pulses Fem [**Doctor Last Name **] PT DP [**Name (NI) 2325**] 2+ 1+ 1+ 2+ Right 2+ - - - Pertinent Results: Labs: [**10-7**]: WBC-4.6 RBC-3.97* Hgb-12.1* Hct-36.2* MCV-91 MCH-30.4 MCHC-33.3 RDW-13.3 Plt Ct-176 [**10-12**]: WBC-5.7 RBC-4.09* Hgb-13.0* Hct-38.4* MCV-94 MCH-31.7 MCHC-33.8 RDW-13.7 Plt Ct-174 [**10-17**]: WBC-7.2 RBC-3.95* Hgb-12.1* Hct-37.2* MCV-94 MCH-30.5 MCHC-32.4 RDW-14.8 Plt Ct-211 [**10-14**]: PT-12.9 PTT-70.2* INR(PT)-1.1 . [**10-7**]: Glucose-182* UreaN-34* Creat-1.9* Na-135 K-4.8 Cl-101 HCO3-26 AnGap-13 [**10-12**]: Glucose-249* UreaN-28* Creat-1.3* Na-137 K-4.6 Cl-107 HCO3-21* AnGap-14 [**10-16**]: Glucose-336* UreaN-29* Creat-1.3* Na-137 K-5.2* Cl-105 HCO3-15* AnGap-22* [**10-17**]: Glucose-386* UreaN-25* Creat-1.2 Na-140 K-5.2* Cl-110* HCO3-18* AnGap-17 [**10-10**]: CK(CPK)-150 [**10-16**]: ALT-86* AST-59* AlkPhos-81 TotBili-0.2 . [**10-10**]: CK-MB-4 cTropnT-<0.0109/10: CK-MB-16* MB Indx-10.7* cTropnT-0.22* [**10-11**]: CK-MB-13* MB Indx-10.0* cTropnT-0.32* [**10-13**]: CK-MB-NotDone cTropnT-0.27* [**10-17**]: cTropnT-0.06* . [**10-17**]: VitB12-1331* Folate-GREATER TH [**10-17**]: TSH-1.9 . Microbiology: . [**2143-10-7**] 4:46 pm SWAB, LEFT LE GRAM STAIN (Final [**2143-10-7**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2143-10-11**]): 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.. PROTEUS MIRABILIS. MODERATE GROWTH. STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. SENSITIVITIES PERFORMED ON CULTURE # 280-6641V [**2143-10-2**]. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). QUANTITATION NOT AVAILABLE. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R . ANAEROBIC CULTURE (Final [**2143-10-11**]): NO ANAEROBES ISOLATED. . Urine Culture [**2143-10-15**] and [**2143-10-17**]: No growth. RPR [**2143-10-21**]: Non-reactive Blood cx x 2 [**2143-10-16**]: No growth. . Radiology Reports: . [**2143-10-9**]: ARTERIAL DUPLEX ULTRASOUND LEFT LOWER EXTREMITY: Monophasic Doppler waveforms were seen at the proximal and distal anastomosis of the [**Month/Day/Year **] as well as throughout the entire length of the [**Month/Day/Year **]. Peak systolic velocities throughout the [**Month/Day/Year **] ranged between 61 and 139 cm/sec. No areas indicative of stenosis were identified. A slight increase in the systolic velocity at the distal tibial [**Month/Day/Year **] to tibial anastomosis was noticed. In [**Month (only) 205**], that velocity was 59 cm/sec and now it is 139 cm/sec. COMPARISON: Compared to the [**2143-8-12**] study, there has been no significant change. IMPRESSION: Patent left lower extremity bypass [**Year (4 digits) **] with velocities described above. . [**2143-10-10**]: Portable TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild diastolic LV dysfunction. Minimal calcific aortic stenosis. Mild left atrial dilation. Compared with the report of the prior study (images unavailable for review) of [**2142-7-18**], aortic transvalvular gradient is slightly higher. . [**2143-10-13**]: CHEST (PORTABLE AP) The current study demonstrates decreased lung volumes compared to the prior study, which may explain increase in the cardiac contour. If clinically warranted, correlation with echocardiography to exclude pericardial effusion might be suggested. Lungs are essentially clear with no pleural effusion or pneumothorax. There is no evidence of pulmonary edema. . [**2143-10-16**]: CHEST (PORTABLE AP): Allowing for extreme apical lordotic projection, cardiomediastinal contours are stable from the prior study. Lungs are grossly clear, and there are no pleural effusions or pneumothoraces. . [**2143-10-13**]: PORTABLE ABDOMEN: Five views of the abdomen were reviewed including supine and decubitus views. There is no evidence of bowel dilatation. There is extensive fecal content along the colon. There are no pathologic air-fluid levels. There is air within the rectum. IMPRESSION: No evidence of obstruction. Extensive amount of stool within the colon. . [**2143-10-17**]: CT Head: No evidence of acute intracranial abnormalities. . [**2143-10-20**]: MRI HEAD W/O CONTRAST: 1. No acute infarction. No evidence of other acute intracranial abnormalities. 2. Progression of chronic microvascular infarcts since [**2135**]. . [**2143-10-21**]: Left Upper Extremity Doppler: No deep venous thrombosis within the left upper extremity. . [**2143-10-22**]: EEG: This is an abnormal routine EEG due to rare bifrontal synchronous spike and slow wave discharges in drowsiness. These findings are suggestive of a potential for electrographic seizures and if clinically indicated, would consider 24 EEG monitoring for further evaluation of confusion. There were no areas of prominent focal slowing or electrographic seizures. . [**2143-10-26**]: EEG: This telemetry captured 10 events of rhythmic activity in the left anterior temporal region lasting for up to one minute with no associated clinical features. This activity represents an electrographic artifact from facial movements in this area. Interictally, there were no epileptic features seen. The background activity was intermixed with slow activity suggestive of either a mild encephalopathy or excessive drowsiness. . [**2143-10-28**]: EEG: There was one pushbutton for unknown reasons. It was not associated with a significant change on EEG or on obvious examination physically by video. The routine record appeared to be within normal limits. Brief Hospital Course: 62yo M hx Type I DM, CKI, PVD s/p multiple LE bypasses, R AKA admitted to vascular surgery service for IV abx for non-healing LE ulcer then developed episode of bradycardia with pause followed by new onset a-fib concerning for tachy-brady syndrome. Finally, pt developed alterations in mental status after returning to the hospital floor. . Vascular Surgery/CCU ([**10-7**] - [**10-16**]): [**2143-10-7**] Patient was admitted to Vascular Surgery Dr. [**Last Name (STitle) 1391**] service for L LE ulcer and cellulitis. Was started on broad spectrum antibiotics (Vanco,Cipro,Flagyl), home meds, routine wound care. Wound cultures. . [**Date range (1) 14587**] HD2-3: No acute events. Continued broad spectrum antibiotics(Vanco,Cipro,Flagyl). NIAS was done on LLE- demonstrated patent left lower extremity bypass [**Date range (1) **] with elevated velocities. Wound vac placed on L leg wound. . [**2143-10-10**] HD4: Patient had an acute vomiting spell wherein he was found diaphoretic and incoherent but responsive w/ HR in the 30's and BP in the 200's. Bradycardia resolved without intervention. BP was treated w/ Hydralazine IV x1. Approximately 1 hour later he had another episode, now caught by telemetry and [**Location (un) 1131**] as asystole, code blue was called, review of telemetry strip showed bradycardia again in the 30's. Patient was again incoherent at that time, which resolved in a matter of minutes. On the code monitor patient's HR was in A-fib confirmed by a 12 lead ECG. BP in the 160's, was given IV boluses of Metoprolol. Cardiac enzymes and lytes were sent. Patient was transferred to the CCU for further management. Wound vac was removed during the process of his bradycardic event, sent out to CCU w/ a wet to dry dressing. . [**2143-10-10**]: Converted to NSR @1pm. Echo showed mild LAE, mild symmetric LVH with Grade 1 diastolic dysfunction, EF >55%. Second set of cardiac markers showed CKMB 16, trop 0.22 (up from <0.01). Continued heparin gtt overnight. Remained in NSR, no other events. . [**2143-10-11**] HD5: No indication for ICD placement currently (not pacemaker candidate because of active infection), but needs an ischemia evaluation as outpatient. Syncope was likely vagal in etiology. Needs anticoagulation with Coumadin (currently on heparin ggt), close cardiology followup with Dr. [**Last Name (STitle) 171**] as outpatient for possible brady-tachy syndrome. Troponin elevation was likely demand ischemia in the setting of Afib in RVR. Enalapril restarted. Patient should not be on Beta [**Last Name (STitle) 7005**] in the future. Cipro stopped microorganism in cultures-resistant to Cipro, cefepime started. Continued w/ anticoagulation w/ Heparin drip. Started Coumadin. Patient was transferred back Vascular Surgery and physically transferred to [**Hospital Ward Name 121**] 5. wound was replaced. . 9/12-14/09 HD6-7: No acute events. Continued with wound vac, and IV antibiotics. Continued w/ Heparin drip and continued to dose w/ Coumadin. Patient was noted to be occassionally confused. . [**2143-10-15**] HD8: Patient became acutely delirious, verbalized suicidal ideation 1:1 observer was placed. Psych was consulted, recommended a head CT which did not show any acute bleed. Continued Heparing drip, dosed w/ Coumadin. Given Haldol for agitation. Placed on telemetry and VICU status. Social work consult for coping. Cardiology called regarding need for a pacemaker-no need for one at this time as long as patient is off beta [**Last Name (LF) 7005**], [**First Name3 (LF) **] FU w/ Cardiology OP as previously planned. . [**2143-10-16**] HD9: Patient continued to be delirious. Discontinued anticoagulation due to patient safety issues, patient had been refusing blood draws. Antibiotics also d/c'd. Transferred to Medicine service for further management. . Transferred to Medicine for evaluation of Altered Mental Status ([**2143-10-16**]): . # Altered Mental Status: Etiology is likely delirium. CT negative for intracranial bleed. Other considerations include toxic/metabolic changes and infection. Patient was afebrile with a normal white count. This patient developed a metabolic acidosis with a compensatory respiratory alkalosis secondary to poor glycemic control and possible diabetic ketoacidosis. Other electrolytes were stable. Patient was not on any narcotics. The other consideration however less likely would be a vascular event. Given the recent hx of elevated blood pressure and asystole the possibility of a ischemic event seems possible, however on exam patient has no focal neurologic deficits, and MRI did not reveal acute ischemia. During hospitalization with medicine service blood sugars were better controlled and the small anion gap closed. Blood pressure while still elevated was better controlled with an increase in Enalapirl to 40mg Daily and Clonidine patch started. Amlodipine was stopped secondary to family request, given concern it was contributing to the patient's change in mental status. The patient was treated empirically with ciprofloxacin based on a borderline U/A. Head area showed only worsening of chronic ischemic changes. Neurology and Psychiatry were both consulted and agreed that these mental status changes were consistent with delirium. EEG was performed, and initially, there was concern for epileptic activity, although later, this was felt to be artifact. . # Anemia: Iron studies were suggestive of deficiency. B12, TSH, and Folate were normal. Started ferrous sulfate 325 mg PO daily at time of discharge. . # LE Ulcer: Patient was admitted with left lower extremity ulcer for IV antibiotics. Wound vac was applied. Wound vac was replaced every 3 days. No surgical intervention needed at this time. Will be followed closely by Dr. [**Last Name (STitle) 1391**] and the Vascular service as an outpatient and will require Q3 day vac changes. . # DM Type 1: During admission patient was continued on Lantus and sliding scale insulin. [**Last Name (un) **] was consulted given difficult blood sugar control. Patient will follow up with [**Last Name (un) **] as an outpatient. See attached for current sliding scale. . # Hypertension: Blood pressure was poorly controlled on Enalapril 20mg and Amlodipine 10mg. Family had concern that Amlodipine which had been started in the CCU was contributing to the patient's change in mental status. Enalapril was increased to 40mg daily and Clonidine patch was started. Throughout patient reguired IV Hydralazine for BP control. BP control remained poor. Terazosin 1 mg PO QHS was started at the of discharge, with improved BP control on the morning of discharge. Terazosin can be titrated up slowly to patient's former dose 4 mg PO at night, as tolerated by blood pressure. . # Tachy-brady syndrome: Given evidence of sinus node dysfunction earlier in admission complicated by CCU admission, beta blockers were avoided. Anticoagulation was considered but it was felt that the risk of this outweighed the potential benefit in the setting of acutely altered mental status. Cardiology did not feel that there was an acute need for a pacemaker, but the patient should follow up with cardiology for consideration of this question and for follow-up of other cardiac issues as an outpatient. . # Hyperlipidemia: Patient was continued on home Simvastatin 40 po daily. . # BPH: While hospitalized terazosin was held with concern for orthostatics. At discharge this medication was restarted at a starting dose of 1 mg PO QHS. This can be titrated up slowly to patient's former dose of 4 mg PO QHS, as tolerated by patient's blood pressure. . # Peptic Ulcer Diseae: Patient was continued on proton pump inhibitor while inpatient. Pt noted no abdominal pain. No melanotic stools. Medications on Admission: atenolol 50mg [**Hospital1 **], enalapril 10mg daily, folate 1mg daily, lasix 40mg prn lower extremity edema, lantus 30u (patient states he takes 18u qhs), simvastatin 40mg daily, terazosin 4mg qhs, vit C, aspirin 325mg daily, B12, humulog Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 325 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) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 11. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday): remove previous patch and apply this patch which should be left on for the week and replaced every Sunday. Order was filled by pharmacy with a dosage form of Patch Weekly and a strength of 0.2MG/24HR . 12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. Lantus Insulin ..... 14. Humalog Insulin Per Sliding Scale Attached 15. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 16. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous QAM. 17. Humalog 100 unit/mL Solution Sig: as directed per sliding scale units Subcutaneous QACHS: see attached sliding scale. 18. Lantus 100 unit/mL Solution Sig: Nine (9) units Subcutaneous QPM. 19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 169**] Discharge Diagnosis: Primary: Left lower extremity non healing ulcer Tachy-Brady Syndrome, No pacemaker needed, Do not use Beta-[**Location (un) **] Delirium - multifactorial Atrial Fibrillation Paroxysmal Discharge Condition: Stable. afebrile. mental status improving, patient is oriented yet continues to have delusional thoughts (ie. The television is speaking with him, his family is the 'Master of the Universe') Discharge Instructions: You were admitted to the hospital to receive IV antibiotics for a left lower extremity ulcer. During the hospitalization you developed heart rhythms that required you to be managed in the cardiac intensive care unit. In the cardiac intensive care unit you were diagnosed with "Tachy-Brady Syndrome" a disorder where your heart rate varies. In the ICU your beta [**Location (un) 7005**] was stopped. Cardiology did not feel that you needed a pacemaker. During your hospitalization you developed a change in your thinking and you were transferred to the internal medicine service. We worked up this change in thinking and did not find a clear cause for this change. It is well known that while hospitalized patients can become delirious secondary to changes in there sleep/wake cycle, foreign environment, and multiple medical conditions. We believe you should return to your baseline level of thinking with time. The following changes were made to your medications. - Start Thiamine 100 mg PO DAILY - Start Seroquel 25mg QHS - Start Clonidine 0.2 mg/24 hr Patch Weekly, Apply one patch every Sunday. Remove previous patch and apply this patch which should be left on for the week and replaced every Sunday. - Start Pantoprazole 20mg Daily - STOP Atenolol 50mg Twice Daily - CHANGE Enalapril from 10mg Daily to 40mg Daily Return to the hospital or contact your physician if you develop chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, new neurological changes, or new changes in your thinking. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2143-10-28**] 3:00 Follow up with your Primary Care Physician: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7480**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 9347**] Date/Time:[**2143-11-7**] 10:00 . Follow up with your cardiologsit:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2143-11-27**] 2:20 . MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] Specialty: Vascular Surgery Date and time: Wednesday, [**11-6**] @10:15am Location: [**Hospital Ward Name 517**], [**Hospital Ward Name **] Office Bldg.,[**Last Name (NamePattern1) 14588**] Phone number: [**Telephone/Fax (1) 14589**] . MD: Dr. [**First Name8 (NamePattern2) 14590**] [**Name (STitle) 14591**]** Specialty: [**Last Name (un) 14592**] Clinic Date and time: Friday, [**11-15**] @2;30pm Location: [**Hospital **] Clinic, 2nd fl., One [**Last Name (un) **] Place Phone number: [**Telephone/Fax (1) 2490**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Name: [**Known lastname 2317**],[**Known firstname 2318**] Unit No: [**Numeric Identifier 2319**] Admission Date: [**2143-10-7**] Discharge Date: [**2143-10-29**] Date of Birth: [**2080-12-11**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 877**] Addendum: *Anemia* - On further review of laboratory data, more consistent with anemia of chronic disease. Therefore, did not discharge on and iron supplement. Discharge Disposition: Extended Care Facility: [**Location (un) 1353**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 878**] MD, [**MD Number(3) 879**] Completed by:[**2143-10-29**]

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icd9cm

[ [ [] ] ]

[ "93.59" ]

icd9pcs

[ [ [] ] ]

25003, 25211

11398, 15313

307, 314

21481, 21674

4345, 9953

23247, 24980

3546, 3566

19418, 21179

21273, 21460

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114,245

37996

Discharge summary

report

Admission Date: [**2200-11-26**] Discharge Date: [**2200-12-1**] Date of Birth: [**2145-9-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2200-11-26**] - Coronary artery bypass grafting x5. (LIMA>LAD,SVG>diag Y>OM1,SVG>OM2,SVG>PLB) History of Present Illness: 55 yo M who presented to his PCP's office in early [**Month (only) **] [**2200**] with chest pain and EKG changes. Pt was sent to the ED at [**Hospital3 1443**], subsequently admitted, and transferred to [**Hospital1 18**] for cardiac catheterization which revealed severe three vessel coronary artery disease. Surgery was delayed secondary to persistent fevers. He was found to C. Diff and was treated with flagyl. Workup at that time was also notable for multiple pulmonary emboli and he has been placed on lovenox until his surgery. He returns today for evaluation and rescheduling of surgery. He has felt very well since discharge and denies any symptoms of fever, chest pain or dyspnea. Past Medical History: Coronary Artery Disease, Ischemic Cardiomyopathy Hypertension Hyperlipidemia History of MI 6 years ago Pulmonary Emboli Social History: -Tobacco history: none -ETOH: none -Illicit drugs: none Works as a cook. Family History: Father died at 69 with MI, mother died at 72 from MI. Physical Exam: Pulse:58SB Resp:18 O2 sat: 99% B/P Right: 148/76 Left:140/70 Height:5'5" Weight:81.6 kg, 180 lbs General: middle aged male in no acute distress Skin: Dry [x] intact [x]. Healed burn on L hand, no surrounding erythema, a few maculopapular lesions/petechiae in R and L antecubital fossae. A few erythematous small (1-2mm) papules on R anterior chest.Blanching erythematous patch mid sternal line. HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] No Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 2 Left: 2 PT [**Name (NI) 167**]: 2 Left: 2 Radial Right: 2 Left: 2 Carotid Bruit Right/Left: none Discharge: VS: T: 98.0 HR: 62 SR BP: 120/70 Sats: 95% RA General: sitting in chair no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: RRR normal S1,S2 no murmur Resp: bilateral crackles 1/4 up otherwise clear GI: benign Extr: warm tr edema Incision: sternal and LLE clean dry intact Neuro: non-focal Pertinent Results: [**2200-11-26**] ECHO PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with anterior, anteroseptal and apical hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild to moderate ([**2-14**]+) mitral regurgitation is seen. A very eccentric posterior directed MR was seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm 1. Biventricular function is normal 2. Eccentric MR still present 3. Aorta is unchanged post decannulation 4. Other findings are unchanged [**2200-11-27**] BC-17.0* RBC-3.27* Hgb-9.7* Hct-28.2 lt Ct-211 [**2200-11-26**] WBC-12.4*# RBC-2.92*# Hgb-8.8*# Hct-25.4* Pt [**Name (NI) **]188 [**2200-11-30**] PT-15.9* INR(PT)-1.4* [**2200-11-29**] PT-14.6* PTT-29.7 INR(PT)-1.3* [**2200-11-28**] PT-14.4* INR(PT)-1.2* [**2200-11-26**] PT-16.6* PTT-35.3* INR(PT)-1.4* [**2200-11-29**] Glucose-97 UreaN-22* Creat-1.2 Na-142 K-4.4 Cl-103 HCO3-30 Mg-2.1 CXR [**2200-11-29**]: Marked cardiomegaly is unchanged. Postoperative mediastinal widening is stable. There is no pneumothorax. Small bilateral pleural effusions are associated with adjacent bibasilar atelectases. Standard wires are aligned. Patient is post CABG. Small left pneumothorax has decreased in size. There is mild vascular congestion. [**2200-11-29**] 07:10AM BLOOD WBC-13.4* RBC-3.02* Hgb-8.9* Hct-27.1* MCV-90 MCH-29.6 MCHC-33.0 RDW-15.7* Plt Ct-190 [**2200-11-26**] 03:40PM BLOOD WBC-12.4*# RBC-2.92*# Hgb-8.8*# Hct-25.4*# MCV-87 MCH-30.2 MCHC-34.8 RDW-15.4 Plt Ct-188 [**2200-12-1**] 06:05AM BLOOD PT-17.4* INR(PT)-1.6* [**2200-11-26**] 03:40PM BLOOD PT-16.6* PTT-35.3* INR(PT)-1.4* [**2200-11-29**] 07:10AM BLOOD Glucose-97 UreaN-22* Creat-1.2 Na-142 K-4.4 Cl-103 HCO3-30 AnGap-13 [**2200-11-27**] 01:57AM BLOOD Glucose-111* UreaN-10 Creat-0.9 Na-140 K-3.8 Cl-109* HCO3-26 AnGap-9 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2200-11-26**] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent coronary artery bypass grafting to five vessels(Left Internal Mammary Artery >Left Anterior Descending artery ,Saphenous Vein Grafted >diag Y>Obtuse Marginal 1,>OM2,SVG>PLB). Please refer to Dr[**Last Name (STitle) **] operative report for further details. Postoperatively he was transferred to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed.All lines and drains were discontinued in a timely fashion. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. His electrolytes were repleted as needed. He was started on Coumadin for a history of PE. On POD2 he experienced rapid atrial fibrillation converted to sinus rhythm with amiodarone IV converted to PO. The ACE was restarted. Physical therapy was consulted for evaluation of increasing mobility and strength and cleared him for discharge to home. POD4 he had a brief episode of atrial fibrillation with spontaneous conversion to sinus rhythm. The remainder of his postoperative course was essentially uneventful. He continued to progress and was cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA on POD# 5. Dr.[**Last Name (STitle) 5686**] will follow the Coumadin dosing, with first INR draw to be done on Thurs. [**12-4**]. All follow up appointments were advised. Medications on Admission: Lovenox 70", Lisinopril 20', Lopressor 150", Simvastatin 80', ASA 325', Colace 100' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: then 200 mg daily. Disp:*60 Tablet(s)* Refills:*1* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: INR Goal 2.0-3.0. Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. 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: [**Hospital 119**] Homecare Discharge Diagnosis: CAD s/p CABG Ischemic Cardiomyopathy Hypertension Hyperlipidemia History of MI 6 years ago Pulmonary Emboli Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: -Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] -Please follow-up Dr. [**Last Name (STitle) 5686**] in [**3-18**] weeks. ***-Coumadin dosing/INR draws will be followed by Dr. [**Last Name (STitle) 5686**], first INR draw to be done via VNA on Thursday [**12-4**], with results called to Dr.[**Last Name (STitle) 5686**] #[**Telephone/Fax (1) 11554**]. Completed by:[**2200-12-1**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7846, 7904

4996, 6647

332, 431

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282, 294

459, 1153

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1313, 1390

68,381

106,763

25564

Discharge summary

report

Admission Date: [**2118-12-13**] Discharge Date: [**2118-12-27**] Date of Birth: [**2033-2-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10682**] Chief Complaint: Acute blood loss anemia Major Surgical or Invasive Procedure: - ERCP [**12-14**] - Selective mesenteric arteriography and coil and gelfoam embolization of distal GDA branches [**12-15**] - Intubation peri-ERCP [**Date range (1) 63832**] - Trauma RIJ [**Date range (1) 63833**] - Right radial arterial line [**Date range (1) 24019**] History of Present Illness: 85M with DM, AFib on coumadin, and recent diagnosis (on [**12-10**]) of cholangitis and cholecystitis s/p ERCP, sphincterotomy, and distal CBD stone extraction at [**Hospital1 18**] on [**12-11**] transferred from [**Hospital3 3583**] for acute blood loss anemia. Periampullary diverticulum was also noted during ERCP. Initially returned to [**Hospital3 3583**] post-procedure and did well for the first 24 hours. Treated with zosyn. The plan was to proceed with cholecystectomy but Hct dropped 28%->22% overnight into [**12-13**]. He denies feeling fever, chills, sweats, dizziness, lightheadedness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, melena, or hematochezia. Underwent EGD [**12-13**] showing active bleeding at the base of the sphincterotomy site with blood in the stomach and the duodenum. Treated with SC epi injection and gold probe BICAP for hemostasis. Tranfused a total of 3U pRBC prior to transfer. Upon arrival, patient is without complaints. Past Medical History: DM CAD AFib s/p PPM Chronic diastolic CHF Cerebral aneurysm repair CKD Social History: Former employee at Proctor & Gamble. No tobacco or ETOH. Family History: Mother died at 93 of CAD. Physical Exam: Physical Exam on [**Hospital Unit Name 153**] Admission VS: T 97.2 HR 72 BP 128/54 RR 15 92%2L GEN: Appears comfortable, resp nonlabored HEENT: icteric sclera, OP clear, dry MM RESP: R>L bibasilar rales no wheeze/rhonchi CV: reg rate nl S1S2 no m/r/g ABD: soft obese NTND normoactive BS EXT: warm, dry no edema NEURO: AAOx3 Pertinent Results: Admission labs: [**2118-12-13**] 08:44PM WBC-6.0 RBC-3.13* HGB-9.6* HCT-27.5* MCV-88 MCH-30.8 MCHC-35.1* RDW-15.3 [**2118-12-13**] 08:44PM NEUTS-78.8* LYMPHS-13.4* MONOS-5.3 EOS-2.2 BASOS-0.3 [**2118-12-13**] 08:44PM PLT COUNT-154 [**2118-12-13**] 08:44PM GLUCOSE-119* UREA N-49* CREAT-1.8* SODIUM-141 POTASSIUM-5.1 CHLORIDE-109* TOTAL CO2-24 ANION GAP-13 [**2118-12-13**] 08:44PM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.8 [**2118-12-13**] 08:44PM ALT(SGPT)-91* AST(SGOT)-61* ALK PHOS-193* TOT BILI-2.9* [**2118-12-13**] 08:44PM LIPASE-74* [**2118-12-13**] 08:44PM PT-13.9* PTT-30.9 INR(PT)-1.2* Discharge labs: [**2118-12-27**] 6:15AM WBC 6.8, Hgb 9.6, HCT 29.4, Plt ct 338 [**2118-12-27**] 6:15AM INR 1.3, PTT 77.7 [**2118-12-26**] Glu 125, BUN11, Cr 1.2, Na 140, K 3.9, Cl 109, HCO3 25 [**2118-12-23**] ALT 26, AST 26, LDH 246, Alk phos 130, TB 0.9 MRSA SCREEN (Final [**2118-12-18**]): STAPH AUREUS COAG +. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ============ IMAGING ============ [**2118-12-13**] - CXR: There is enlargement of the cardiac silhouette. Left transvenous pacemaker leads terminate in standard position, although the tip of the one that goes to the right ventricle is not visualized. There is mild interstitial pulmonary edema. The left lateral CP angle was not included on the film. There is no evidence of large pleural effusions. There are no focal consolidations. [**2118-12-14**] - Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-5 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate symmetric left ventricular hypertrophy with normal biventricular systolic function. Moderate aortic regurgitaiton ============ INTERVENTION ============ [**2118-12-14**] - ERCP: Evidence of a previous sphincterotomy was noted in the major papilla and active bleeding was noted at the apex on the left side of the sphincterotomy. Previous cautery marks were visible at the base of the sphincterotomy. The area was thoroughly irrigated. Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. The common bile duct, common hepatic duct appeared unremarkable. In order to keep patency of the CBD, A 7cm by 10FR Cotton-[**Doctor Last Name **] biliary stent was placed successfully. After insertion of a CBD stent, approximately 20mL of 1:10,000 epinephrine was injected at the apex of the sphincterotomy with significant slowing of the bleeding. Bipolar cautery using a Gold probe was applied at 26Watts with successful complete hemostasis. [**2118-12-15**] - IR: The common hepatic arteriogram showed brisk reflux of contrast into the large splenic artery. There was some resistance to antegrade flow in the hepatic arteries noted and intrahepatic arteries were attenuated and irregular consistent with either edema or possibly changes related to infection and/or ischemia. A plastic stent was seen in the right upper quadrant and arterial phase of the gastroduodenal opacification shows active extravasation from the distal branches of the pancreaticoduodenal arcade. This corresponds with the expected site of the ampulla and corresponds to findings at the ERCP. With the microcatheter out distally, active extravasation was not seen, but Gelfoam and coil embolization were performed and final images shows coils proximal and distal to the site of extravasation. The initial post-embolization showed antegrade flow at the level of the extravasation though no active bleeding was seen at that time, however therefore additional embolization was performed and the final post-embolization arteriogram taken from the level of the proximal GDA showed no further antegrade flow in anterior and posterior branches. In addition, post-embolization study of the superior mesenteric arteries showed no anterograde flow or extravasation at the area embolized. More detailed study of the SMA was not performed. Incidental note is made of pacer wires and tortuosity of the lower abdominal aorta and iliac arteries. CONCLUSION: 1. Mesenteric arteriography is showing active contrast extravasation (bleeding) from the distal branches of the gastroduodenal artery corresponding to the site of the ampulla. 2. Successful microcoil and Gelfoam embolization proximal and distal to the site of extravasation with post-embolization imaging showing no further anterograde flow in this region. 3. Note made of of abnormal hepatic arterial supply the branches of which are attenuated and mildly tortuous distally suggesting some combination of edema, possible underlying cirrhosis and/or changes related to known recent infection/ischemia. 4. Aortoiliac atherosclerosis. CXR [**2118-12-17**]-IMPRESSION: AP chest compared to [**12-13**] through 19: Severe cardiomegaly and vascular congestion suggests cardiac decompensation is responsible for mild interstitial edema. A right supraclavicular introducer ends in the right brachiocephalic vein. Right atrial and left ventricular pacer and right ventricular pacer defibrillator leads are in standard placements. Pleural effusion is small, if any. No pneumothorax. ECG Study Date of [**2118-12-16**] 7:15:44 AM Atrial fibrillation. Left bundle-branch block. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 96 0 158 374/437 0 -34 178 Brief Hospital Course: 85M with DM, AFib on coumadin, and recent diagnosis (on [**12-10**]) of cholangitis and cholecystitis s/p ERCP, sphincterotomy, and distal CBD stone extraction [**12-11**] transferred for further evaluation and management of acute blood loss anemia, s/p ERCP and IR embolization. # GIB/Acute blood loss anemia. During the [**Hospital Unit Name 153**] course, patient required IVF boluses for hypotension and a total of 10 units of pRBC. He initially underwent repeat ERCP with cauterization of the bleeding site. However, his hematocrit continued to drop requiring blood transfusion as well as an IR embolization procedure. His last unit of pRBC was received on [**2118-12-18**]. He continued to pass dark black, dark maroon colored stool at times during the ICU stay although his Hct has remained stable. His pantoprazole was increased to 40 mg [**Hospital1 **] for a short period for concern of also PUD, but was later decreased back to 40 mg daily as his symptoms improved and gastritis was not found on EGD. Pt's aspirin and coumadin were restarted with a heparin bridge as he has a CHADS2 score of 4. Risk of stroke is high enough in this patient to warrant retrial of anticoagulation. Pt's HCT remained stable and there were no signs of active bleeding. HCT upon discharge was 29.4. # Cholangitis/cholecystitis. Given the recent diagnosis of cholangitis/ cholecystitis s/p initial ERCP, he was placed on ciprofloxacin and flagyl (D1, [**2118-12-13**]) for medical management given that he was not a surgical candidate in the setting of acute GIB. His AST, ALT, Alk phos normalized toward the end of his ICU stay. Surgery was following patient and planning to have an ultimate cholecystectomy for prevention of futuer gallstones and cholangitis, pending stabilization of the bleeding. Called over to [**Hospital3 3583**] as pt stated that he had a surgery schedule at [**Hospital3 **] this week. Spoke to Dr. [**Last Name (STitle) 63834**] there, who stated that given pt's recent course of bleeding and ICU stay, he should follow up in clinic with Dr. [**Name (NI) 63835**] at [**Hospital3 3583**] to determine further care and when/if cholecystectomy can be performed. In addition, pt will need his biliary stent removed 4 weeks from placement on [**2118-12-14**]. This has been scheduled. # Acute on Chronic Kidney Disease. Likely [**3-1**] pre-renal and renal hypotension induced ATN initially. His Cr improved over time. His medications were renally dosed and nephrotoxins were avoided. Creatinine remained stable. CR at discharge was 1.2. # Chronic systolic/diastolic CHF. No acute CHF while in the ICU. Patient received multiple fluid boluses as well as pRBC transfusions with the addition of Lasix. His weight actually came down from admission weight of 107.9 kg to 94.5 kg upon call out to the floor. He was restarted on sotalol 40 mg [**Hospital1 **] and nifedipine on [**12-16**] after extubation as he was hypertensive. His Coreg 6.25mg [**Hospital1 **] was restarted on [**2118-12-22**]. His home dose of Lasix 40 mg was restarted on [**2118-12-27**]. # Atrial fibrillation. He was restarted on sotalol and Coreg as mentioned above as his hemodynamics improved. Digoxin and anticoagulation were held as his HR was mostly in the 70s and SBP mostly 100-130s. Anticoagulation therapy was held initially given GIB. Given CHADS2 score of 4, risk of stroke was considered high enough that anticoagulation was resumed-coumadin with heparin gtt and aspirin. INR at discharge was 1.3. He will resume heparin bridge at LTAC. # History of CAD. Patient was restarted on sotolol and nifedipine (see above) on [**12-16**] post extubation. Lipitor was initially held given LFT elevation. Lipitor, coreg, and aspirin were restarted. # Delirium: This was thought to be likely secondary to delirium with disrupted sleep-wake cycle. Patient's mental status was noted to be waxing and [**Doctor Last Name 688**], worse than his baseline per family (son) while in the ICU. His CXR did not show consolidation suspicious for pneumonia and has been afebrile without respiratory symptoms. He responded to Zyprexa in the evening when he had agitation. Of note, he was initially transferred to the floor on [**2118-12-20**] but later returned to the [**Hospital Unit Name 153**] for increased somnolence and hypotension SBP 80s requiring bolus fluid. Hct on the floor was 14.3 but upon quickly repeating Hct was 29.6, likely a falsely low value. He responded well to the fluid bolus with improved mentation. His neurological exam was also without focal deficits. Toxic metabolic encephalopathy much improved. Pt was continued home home dose risperdol. This did not reoccur on the medical floor. #Benign hypertension: Coreg, nifedipine, and Lasix were restarted. # Diabeties mellitus. Pt continued on insulin sliding scale. # Hypothyroidism. Pt continued on home levothyroxine. # Code status: Full Medications on Admission: Medications at home (per OSH records, patient cannot recall) Warfarin Sotatol 40 mg [**Hospital1 **] Levothyroxine 25 mcg daily Allopurinol 200 mg daily Lasix 40 mg daily Protonix 40 mg daily Coreg 6.25 mg [**Hospital1 **] Nifedipine CR 90 mg daily Celexa 20 mg daily Digoxin 125 mcg daily Combivent 2 puffs QID Risperdal 1 mg daily Lipitor 80 mg daily ASA 81 mg daily MVI Discharge Medications: 1. sotalol 80 mg Tablet Sig: 0.5 Tablet PO twice a day. 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. 11. meds asa/coumadin 12. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 18. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 days. 19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. 20. insulin lispro 100 unit/mL Solution Sig: 0-12 units Subcutaneous ASDIR (AS DIRECTED): pls see attached sliding scale. 21. heparin (porcine) in NS Intravenous Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Major: Acute blood loss anemia related to gastrointestional bleed Cholangitis Minor: Type 2 diabetes with complication Coronary artery disease Atrial fibrillation Chronic diastolic heart failure Chronic kidney disease, stage 3 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: Dear Mr. [**Known lastname 63836**], It was a pleasure taking care of you. You were admitted with cholangitis (infection of the bile ducts) and a large bleed related to your ERCP procedure. You were transferred from another hospital. You received blood transfusions an interventional radiology procedure to stop the bleeding and your blood counts are now stable with no signs of current bleeding. For your cholangitis that had already been known, you were continued on antibiotics (Cipro and flagyl). You will need your biliary stent removed 4 weeks from the date it was placed ([**2118-12-14**]), around [**2119-1-11**]. Your will need another ERCP for this. Please call the number below to schedule this follow up appointment. Your aspirin and coumadin were resumed. You will need close monitoring of your INR level and blood counts. You should be evaluated by general surgery for consideration of gallbladder removal. Please see the contact number below. Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 25821**] to schedule a follow up within 1 week of discharge from the facility. Name: NP [**First Name5 (NamePattern1) 63837**] [**Last Name (NamePattern1) 63838**] Address: [**Apartment Address(1) 63839**], [**Location (un) **],[**Numeric Identifier 40624**] Phone: [**Telephone/Fax (1) 25821**] Appointment: Monday [**2119-1-2**] 1:30pm Name: [**Last Name (un) 63840**],[**Name6 (MD) 63841**] F MD Address: [**Street Address(2) 63842**], [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 63843**] Appointment: Wednesday [**2119-1-4**] 3:30pm Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2119-1-12**] at 11:00 AM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: THURSDAY [**2119-1-12**] at 11:00 AM *** YOU MUST ARRIVE FOR THIS APPOINTMENT AT 9:30am ***

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icd9cm

[ [ [] ] ]

[ "39.79", "51.87", "44.43", "88.47" ]

icd9pcs

[ [ [] ] ]

16094, 16191

9138, 14071

342, 614

16463, 16463

2201, 2201

17727, 18965

1815, 1842

14494, 16071

16212, 16442

14097, 14471

16646, 17704

2828, 9115

1857, 2182

279, 304

642, 1630

2217, 2812

16478, 16622

1652, 1724

1740, 1799

52,622

129,176

26618

Discharge summary

report

Admission Date: [**2160-8-28**] Discharge Date: [**2160-9-8**] Date of Birth: [**2088-2-28**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2160-8-30**] exploratory laparotomy and extensive enterolysis History of Present Illness: Per the patient, his abdominal pain began at 5 pm on [**2160-8-27**], and he described the pain as "constant", "dull", and a [**7-15**]. He was able to sleep through the night, though upon waking at 9:30 am he vomited. The vomit was green and non-bloody. He felt increasing nausea and vomited again at noon, which he described as green and black. He had one BM in the morning of [**2160-8-28**] but has passed no gas since then. He has noticed no change in frequency or texture of BMs. His pain is currently a [**5-15**] across his lower abdomen and does not radiation. He feels bloated and has not eaten since the morining of [**2160-8-28**], when he had crackers. Denies chills and fevers. Past Medical History: - COPD: GOLD stage III COPD s/p 2 intubations - Moderate pulmonary HTN - Diastolic CHF: EF>55%, markedly dilated RA - Schizophrenia - follwed by Dr. [**Last Name (STitle) 7111**] at [**Hospital1 **]/Mass Mental - Cirrhosis ([**Hospital1 **] notes indicate alcohol related) with portal HTN, splenomegaly, periportal varices - Pyruvate kinase deficiency c/b splenomegaly, macrocytic anemia - Prostate cancer: previously on lupron - Mediastinal LN's noted on CTA [**11/2158**] - Large inguinoscrotal hernia: PCP aware [**Name Initial (PRE) **] [**Name Initial (PRE) **]/o compression fracture s/p vertebroplasty - Aspiration risk per video swallow on [**2159-6-25**] showing aspiration of nectar-thick foods Social History: Lives at Hearth group home at [**Last Name (un) 65661**]in [**Location (un) 14307**]. Smokes 2 ppd. No etoh for many yrs. No illicits. Ex-wife [**Name (NI) **] [**Name (NI) 65646**] (HCP) cell [**Telephone/Fax (1) 65650**], pager [**Telephone/Fax (1) 65653**] Family History: Pt denies fam hx of CAD Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R. PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, distended, nontender, mid abdominal staple line intact and without erythema or edema Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2160-9-7**] 11:10AM BLOOD WBC-5.4 RBC-3.45* Hgb-11.8* Hct-36.1* MCV-105* MCH-34.2* MCHC-32.6 RDW-14.8 Plt Ct-291 [**2160-9-7**] 11:10AM BLOOD Plt Ct-291 [**2160-9-7**] 11:10AM BLOOD Glucose-70 UreaN-17 Creat-1.0 Na-142 K-5.1 Cl-97 HCO3-27 AnGap-23* [**2160-9-7**] 11:10AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2 [**2160-9-4**] 11:10AM BLOOD WBC-2.9* RBC-2.83* Hgb-9.9* Hct-29.7* MCV-105* MCH-35.0* MCHC-33.4 RDW-15.1 Plt Ct-211 [**2160-9-3**] 05:46AM BLOOD WBC-3.9* RBC-2.60* Hgb-8.9* Hct-27.5* MCV-106* MCH-34.5* MCHC-32.6 RDW-15.3 Plt Ct-206 [**2160-9-2**] 01:53AM BLOOD WBC-4.1 RBC-2.53* Hgb-8.7* Hct-26.4* MCV-104* MCH-34.3* MCHC-33.0 RDW-16.0* Plt Ct-167 [**2160-8-28**] 02:45PM BLOOD WBC-10.3 RBC-3.54* Hgb-12.5*# Hct-36.6*# MCV-104* MCH-35.3* MCHC-34.1 RDW-15.5 Plt Ct-277 [**2160-8-28**] 02:45PM BLOOD Neuts-88.7* Lymphs-6.0* Monos-3.5 Eos-1.6 Baso-0.3 [**2160-9-4**] 11:10AM BLOOD Plt Ct-211 [**2160-8-30**] 11:55PM BLOOD PT-11.8 PTT-24.4* INR(PT)-1.1 [**2160-9-4**] 11:10AM BLOOD Glucose-133* UreaN-10 Creat-0.7 Na-140 K-3.0* Cl-94* HCO3-40* AnGap-9 [**2160-9-3**] 05:46AM BLOOD Glucose-61* UreaN-10 Creat-0.5 Na-140 K-3.6 Cl-99 HCO3-31 AnGap-14 [**2160-8-28**] 02:45PM BLOOD Glucose-121* UreaN-13 Creat-1.3* Na-133 K-4.4 Cl-92* HCO3-31 AnGap-14 [**2160-9-4**] 11:10AM BLOOD Calcium-8.6 Phos-1.8* Mg-1.7 [**2160-9-2**] 02:06AM BLOOD Lactate-0.6 [**2160-9-2**] 02:06AM BLOOD freeCa-1.14 [**2160-8-28**]: cat scan of abdomen and pelvis: IMPRESSION: 1. Small-bowel obstruction with a transition point seen within distal ileum within the patient's pannus anterior to the pubic symphysis at that level. 2. Growing soft tissue in the pre-sacral fat is again noted, concerning for recurrence. 3. Splenomegaly, unchanged [**2160-9-1**]: chest x-ray: CONCLUSION: 1. Mild pulmonary edema is unchanged. 2. Stable right small pleural effusion. 3. Stable bibasilar consolidation, more prominent on the right side could be due only to atelectasis; however, superimposed infection or aspiration cannot be excluded [**2160-9-2**]: chest x-ray: FINDINGS: As compared to the previous radiograph, there is an increasing signs suggestive of pulmonary edema, notably on the right, which might be caused by a change in patient position. On the other hand, the opacities on the left have mildly decreased in severity. There still is a small right pleural effusion with evidence of right atelectasis, as well as moderate cardiomegaly. The nasogastric tube is in unchanged position. No newly appeared parenchymal opacities. Brief Hospital Course: The patient was admitted to the hospital with abdominal pain and vomiting. Upon admission, he was made NPO, given intravenous fluids, and underwent imaging. Cat scan showed a small-bowel obstruction with a transition point seen within the distal ileum. He was placed on bowel rest and had placement of a [**Last Name (un) **]-gastric tube. His white blood cell count was normal. His [**Last Name (un) **]-gastric tube was removed on HD #2. He required replacement of the [**Last Name (un) **]-gastric tube for abdominal distention. Because his abdominal pain and distention were not resolving, and because he continued to have high [**Last Name (un) **]-gastric tube output, he was taken to the operating room on HD # 3 where he underwent an exploratory laparotomy and lysis of adhesions. His operative course was notable for a large fluid requirement. He received 700 RBC, 750cc 5% albumin, 1600 cc intravenous fluids. He had a 300 cc blood loss. Intra-op, he required levophed for blood pressure support. He was transferred to the intensive care unit after the procedure for monitoring and continual resuscitation. For full details of the procedure please see the operative report dated [**2160-8-30**]. On POD #1, he was extubated. He had intermittent episodes of hypoxia and his intravenous fluids were discontinued. His surgical pain was controlled with a dilaudid PCA. On POD #3, he experienced bouts of confusion and was started on his home psychiatric medications, at which time, his [**Last Name (un) **]-gastric tube was removed. His anxiety seemed to decrease after starting on his medications. His vital signs stabilized and he was transferred to the surgical floor later that day. During his post-operative course, he was reported to have bouts of oxygen desaturation to the 80%'s both at rest and with ambulation. Along with this, he had a decreased urine output and was given intermittent doses of lasix with good results. On POD #5 his diet was advanced to clears and he was seen by PT who recommended short term rehab. On POD #6, he had a recurrence of emesis and required replacement of the [**Last Name (un) **]-gastric tube. On POD#7 his lasix were held as his Cr increased from 0.5-0.8 to 1.0. He continued to have O2 sats in the 88-93% range on 3L O2 by nasal cannula. He was given reglan and methylnaltrexone and his NGT was clamped and subsequently removed on POD #8. His diet was advanced to regular and his foley catheter was removed. He was discharged to rehab on POD #9 with instructions to follow up in the acute care surgery clinic on [**2160-9-18**] for staple removal. At the time of discharge to rehab his O2 sats were 92-93% on 2L by nasal cannula. Medications on Admission: albuterol prn, benztropine 1', buproprion 150'', clonazepam 0.5 qhs, Advair 250/50, folic acid, lidodern 700', Miralax prn, risperidone 3 qhs, Risperdal Consta 37.5 q2weeks, Spiriva, acetaminophen, calcium, Vit D, senna, colace, furosemide 40' Discharge Medications: 1. Benztropine Mesylate 1 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Clonazepam 0.5 mg PO QHS:PRN insomnia RX *clonazepam 0.5 mg 1 tablet(s) by mouth At night Disp #*30 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID hold for loose stools 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 6. Risperidone (Disintegrating Tablet) 3 mg PO HS 7. Senna 1 TAB PO BID hold for loose stools 8. Tiotropium Bromide 1 CAP IH DAILY 9. Furosemide 40 mg PO Q 8H Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with abdominal pain and vomitting. You underwent a CT scan of the abdomen which showed a small bowel obstruction in the lower part of your small bowel. You were placed on bowel rest and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube was placed. You continued to have high output from your stomach and you were taken to the operating room for an exploratory laparotomy and removal of adhesions which were causing your obstruction. Your fluid status was monitored in the intensive care unit after the surgery. After your vital signs stabilized, you were transferred to the surgical floor. You are slowly recovering from your surgery. You have required medication to remove additional fluid from your body. You were evluated by the physical therapists who recommended that you go to a short term [**Last Name (NamePattern4) **] facility. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *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 an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 10784**] Date/Time:[**2160-9-30**] 10:30 Please call [**Telephone/Fax (1) 600**] to schedule a follow up appointment in the acute care surgery clinic on [**2160-9-18**] for staple removal

[ "496", "560.81", "416.8", "428.0", "572.3", "997.49", "428.32", "560.1", "295.60", "V10.46", "571.5", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "54.59" ]

icd9pcs

[ [ [] ] ]

8510, 8582

5014, 7702

317, 383

8650, 8650

2458, 4991

12019, 12328

2132, 2158

7996, 8487

8603, 8629

7728, 7973

8833, 10712

11506, 11996

2173, 2439

10744, 11491

263, 279

411, 1105

8665, 8809

1127, 1838

1854, 2116

2,034

159,872

1001

Discharge summary

report

Admission Date: [**2198-3-9**] Discharge Date: [**2198-3-15**] Date of Birth: [**2135-2-26**] Sex: M Service: ICU/ACOVE REASON FOR ADMISSION: Sepsis, aspiration pneumonia. HISTORY OF PRESENT ILLNESS: This is a 63-year-old gentlemen with end stage liver disease secondary to NASH, diabetes mellitus, esophageal varices, status post banding, who was recently hospitalized at [**Hospital6 256**] from [**2198-2-28**] through [**2198-3-6**] for spontaneous bacterial peritonitis and anemia. He was then discharged to a skilled nursing facility where he was found to have a change in mental status on the morning of admission ([**2198-3-9**]). Fingerstick glucose was found to be 40. He was given glucagon, oral glucose and sent to [**Hospital6 4620**]. A chest x-ray there showed likely aspiration pneumonia and fingerstick glucose was noted to be 30 with an oxygen saturation of 77% on room air. He was given Zosyn, put on a nonrebreather face mask and transferred to [**Hospital1 **]. At the [**Hospital6 256**] Emergency Room he was placed into the sepsis protocol. He received a total of 8 liters of intravenous fluids, 1 gram of vancomycin. His systolic blood pressure was in the 60s to 70s and then he was placed on a Levophed drip with increase in the blood pressure to a systolic blood pressure to the 90s. His temperature was noted to be 103 with course rigors. He was oxygenating at 95% on a 15 liter nonrebreather face mask. The patient does not recall the events leading up to hospitalization. He does recall some shaking chills starting the day prior to admission at the skilled nursing facility, but denies any subjective fevers. He had had some increased diarrhea prior to admission about [**7-9**] bouts per day, baseline 2-3 times per day. He has not been eating well secondary to poor appetite and had a very small dinner the night prior to admission. In terms of his insulin regimen, he did take NPH at his standard dose the night prior to admission and he was noted to be "shaking" by the registered nurse with a fingerstick glucose of 40 as described above. REVIEW OF SYSTEMS: No cough, no dry heaves, no chest pressure, palpitations. Positive nausea without emesis, some mild shortness of breath. No abdominal pain, no bright red blood per rectum. PAST MEDICAL HISTORY: 1. End state liver disease secondary to non alcoholic steatohepatitis now off of the transplant list due to lack of social support and noncompliance with medications. His last Mel score was noted to be 13, despite having end stage disease. 2. Esophageal varices with an esophagogastroduodenoscopy on [**2198-3-1**] demonstrating Grade 1 varices, portal gastropathy, duodenitis, status post banding of Grade [**1-2**] varices in [**2195-10-31**] and [**2196-9-30**]. 3. Colonoscopy on [**2198-3-5**] with sigmoid and descending colic polyps. 4. Stress echocardiogram in [**2196**] showing an ejection fraction of 65% and no evidence of ischemia. 5. Diabetes mellitus type 2: Controlled on NPH 25 q.a.m. and 25 q.p.m. and regular 10 q.a.m. and 5 q.p.m. insulin. Last hemoglobin A1C 6.9 on [**2197-12-6**]. 6. Ask-upmark kidney (unifocal reflex nephropathy, status post left nephrectomy). ALLERGIES: No known drug allergies. MEDICATIONS AT THE TIME OF ADMISSION: 1. Lactulose 30 mg po t.i.d. 2. Protonix 40 mg po q.d. 3. Aldactone 50 mg q.d. 4. Flagyl 250 mg po b.i.d. 5. Lasix 20 mg q.d. 6. Colace 100 mg b.i.d. 7. Percocet prn. 8. Propanolol 10 mg t.i.d. 9. Ciprofloxacin 750 mg q. Tuesday. 10. NPH 25 mg q.a.m., 25 mg q.p.m. 11. Regular insulin 10 mg q.a.m., 5 mg q.p.m. 12. Insulin sliding scale. SOCIAL HISTORY: The patient is self-employed, but recently lost a great deal of money through faulty stock investments. He is separated from his wife, who has been his primary care taker 24 hours a day for the past four years. He has two daughters, one in [**State 2690**] and one in [**Name (NI) 6607**], who are both very involved. He has no known tobacco history. No new alcohol use in the past two years. FAMILY HISTORY: No known malignancy, heart disease,diabetes mellitus, or other medical issues. PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: Temperature 99.8 rectally. Blood pressure 96/49 increasing to 115/54. Baseline blood pressure from prior records was noted to be systolic in the 90s. Heart rate 70 and regular. Oxygen saturation 95% on 15 liters nonrebreather face mask. General: Shaking diffusely, rigoring, mild to moderate respiratory distress at bed height angle of 30 degrees. Head, eyes, ears, nose and throat: Anicteric, pupils are equal, round, and reactive to light and accommodation, moist mucous membranes, prominent anasarca. Neck supple, questionable bruit on the right (? radiation of murmur). No lymphadenopathy. Chest: Bilateral basilar rales at left greater than right [**12-2**] of the way up, dullness at the left base. Cardiovascular: Regular rate, [**2-3**] holosystolic murmur. No obliterating the S2 at the right base, radiating to the right carotid artery, but heard throughout the precordium, no evidence of rubs, clicks or gallops. Abdomen distended, nontender, dull to percussion with a positive fluid wave bilaterally. Positive bowel sounds, no peritoneal signs. Extremities: Trace lower extremity edema bilaterally. Neurological: Alert and oriented times three. Questionable asterixes (difficult to assess given the patient's rigors). Cranial nerves II through XII are grossly intact. Rectal exam in the Emergency Room: Brown guaiac positive stool. LABORATORY DATA ON ADMISSION: White blood cell count 6.3 with a differential of 82% neutrophils, 50% bands, 3% lymphocytes, hematocrit 39.5, platelet count 94,000. INR 1.7. Chemistries: Sodium 142, potassium 4.6, bicarbonate 107, BUN 26, creatinine 11, 1.1, 117. Calcium, magnesium and phosphorus 8.5/3.2/1.9. AST 55, ALT 20, total bilirubin 3.9, alkaline phosphatase 67, albumin 3.4, amylase 134, lactate 2.4. Chest x-ray: Left lower lobe atelectasis versus consolidation. Electrocardiogram: Right bundle branch block with normal sinus rhythm with an underlying sinus rhythm, unchanged compared with prior from [**2198-1-29**]. Questionable pseudonormalization of the T waves in V2 through V4. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was initially admitted to the [**Last Name (un) 6608**] Intensive Care Unit and then transferred to the floor on [**2198-3-10**]. 1. Sepsis: The patient was placed on a sepsis protocol with a goal central venous pressure of [**9-13**]. Serial lactates were monitored. The patient was given aggressive fluid resuscitation. He was initially placed on Ceftriaxone, vancomycin and Flagyl. Levophed was titrated to a mean arterial pressure greater than 60. his Lasix, Aldactone and propanolol were held. Blood cultures (final report) showed no evidence of bacteremia. The septic shock was thought to be secondary to aspiration pneumonia, although, the chest x-ray was significant only for mild left lower lobe atelectasis versus consolidation. A paracentesis was performed and was negative for SVP. A urinalysis was negative for urinary tract infection. Stool cultures, Clostridium difficile and sputum cultures are all negative at the time of dictation. The Levophed was weaned off on [**3-10**]. The vancomycin, Ceftriaxone and Flagyl were stopped on [**3-11**]. The patient was maintained on levofloxacin and Flagyl for a 14 day course for aspiration pneumonia. His Ciprofloxacin will be continued after this course has been completed, just once a week q. Tuesday for SVP prophylaxis. 2. Hypotension: The patient was weaned off of Levophed as above. As a result of the aggressive fluid resuscitation with his previous hypotension to the 60s, he had a resulting non gap metabolic acidosis. Please see below. His Aldactone was restarted on [**2198-3-12**] and his Lasix was restarted as well. These were titrated up to a dose of Lasix 40 mg po q.d. and Aldactone 100 mg po q.d. with the patient able to maintain normal blood pressure control. The propanolol was not restarted at the recommendation of the Liver Service given the patient's lower extremity edema and only Grade 1 varices. 3. Question of cardiac ischemia: The patient did have some pseudonormalization of the T waves in leads V2 through V4. He was ruled out by enzymes for an myocardial infarction and he had no significant events on telemetry. 4. Hypoxia/persistent bibasilar crackles: Despite the lung findings, the patient did maintain adequate oxygenation throughout his hospital course. Though, crackles did diminish somewhat when the Lasix and Aldactone were titrated up. As stated above, he will be treated with a 14 day course of levofloxacin and Flagyl for aspiration pneumonia. There is some question as to underlying interstitial lung disease, but no further information is available at this time on that speculation. 5. Cough: The patient did have persistent dry cough that was somewhat controlled with Tessalon pearls and Robitussin. It did improve after diuresis on the floor. 6. Gastrointestinal bleed: Initially the patient was noted to have a hematocrit drop from 39 to 28 in the Emergency Room. This was felt to be likely dilutional post 7 liters of intravenous fluid. However, given the patient's guaiac positive state and questionable bloody emesis in the Emergency Room, Gastroenterology was consulted and they did not feel that the patient had an active gastrointestinal bleed and had only Grade 1 varices, therefore, they recommended maintaining him on Protonix and falling hematocrit. The patient's hematocrit was 30.8 on [**2198-3-14**]. It did range from a nadir of 22.9 to a maximum of 39.5. He was transfused for a hematocrit goal greater than 27. 7. Coagulopathy: he does have an underlying coagulopathy secondary to hepatic dysfunction. He was given subcutaneous Vitamin K for a total of three days. However, his INR was persistently in the 1.6 to 1.8 range. Given his lack of frank bleeding, no additional doses of Vitamin K were administered on the floor. 8. Change in mental status: It is most likely that the patient's change in mental status is secondary to hypoglycemia. Other considerations would be delirium versus medications versus sepsis. He was maintained on lactulose t.i.d. titrated to three bowel movements a day. He does have a history of hyperammonemia in the past, and his ammonia level at the time of admission was 38. Although, this is not a very specific finding. 9. Decreased urine output: Initially the patient had decreased urine output, and there was some concern for hepatorenal syndrome, however, after aggressive fluid resuscitation, his urine output returned to [**Location 213**] with greater than 1 cc/kg/hour of urine output. 10. SVP: The patient did have a history of SVP and a paracentesis was performed on [**2198-3-9**] which showed no evidence of SVP. The acidic fluid contained 345 white blood cells, 275 red blood cells, 6% polys, 29% lymphocytes, 23% monocytes, 9% mesothelial cells, 33% macrophages and was felt to be negative for SVP. Nevertheless, as a prophylactic measure, he will be maintained on 750 mg of Ciprofloxacin q. week. 11. Diabetes mellitus: Initially the NPH and regular insulin standing doses were held given his hypoglycemia and mental status changes. He was maintained on an insulin sliding scale in house with good effect, his total insulin requirement per day. The patient was requiring approximately 20 units of regular insulin per day. He will be placed on 5 units of NPH q.a.m., 5 units NPH q.p.m. with further monitoring in the outpatient setting for effect, titrated up as tolerated. 12. Fluid, electrolytes and nutrition/metabolic acidosis: Initially the patient had a primary metabolic acidosis likely secondary to lactic acidosis secondary to septic shock with compensatory respiratory alkalosis. Following the resolution of the patient's sepsis, he had a normal anion gap acidosis likely secondary to aggressive fluid hydration as well as diarrhea with a urine anion gap that was less than 12. 13. Prophylaxis: He was maintained on Pneumoboots while in bed. 14. Social support: The patient has multiple social stressors at home at the moment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from Social Work was consulted and numerous discussions were conducted with the patient's family, both in the Intensive Care Unit and then on the floor regarding his impending divorce, as well as the stress of being taken off of the liver transplant list. At this time, the family is extremely frustrated with the level of care that the patient requires. He will likely need long-term care. 15. Goals of care: There were numerous discussions regarding the patient's code status and goals of care in the Intensive Care Unit and on the floor. The patient did at times state that he would not want to be on a ventilator, but then the next moment would state that he would want to be on the ventilator. Given the uncertainty of the patient's true goals of care in the setting of change in mental status and hospitalization, he was maintained as a full code throughout his hospital stay. It is recommended that these issues be re-addressed in the outpatient setting when the patient is able to think through his goals of care more clearly. DISCHARGE STATUS: To acute rehabilitation facility. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Insulin NPH 5 q.a.m., 5 q.p.m. 2. Insulin sliding scale. 3. Albuterol 1-2 puffs q. 6 hours. 4. Zolpidem tartrate 5 mg po q.h.s. prn. 5. Spironolactone 100 mg po q.d. Please hold for systolic blood pressure less than 100. 6. Furosemide 40 mg po q.d. Please hold for a systolic blood pressure of less than 100. 7. Levofloxacin 500 mg po q.d. for a total 14 days with the last dose on [**2198-3-20**]. 8. Metronidazole 500 mg po b.i.d. for a total of 14 days with the last dose on [**2198-3-20**]. 9. Ciprofloxacin 750 mg q. week starting on [**2198-3-20**]. 10. Benzonatate 100 mg po t.i.d. 11. Dextromethrophan guaifenesin sugar free 5 mL po q. 6 hours. 12. Cepacol lozenges po q. 4 hours prn cough. 13. Protonix 40 mg po q. 12 hours. 14. Prochlorperazine 10 mg intravenous q. 6 hours prn. 15. Tylenol 325 mg po q. 6 hours prn with a maximum Tylenol dose in 24 hours of 2 grams. 16. Lactulose 30 mL po t.i.d. Titrate to [**2-1**] bowel movements per day. FINAL DIAGNOSES: 1. Septic shock. 2. End stage liver disease. 3. Aspiration pneumonia. FOLLOW-UP PLANS: The patient will be discharged to a rehabilitation facility. He should follow-up as needed with the Hepatology Service, however, he is no longer a candidate for orthotropic liver transplant at this time. The patient should also follow-up with his primary medical doctor within two weeks of leaving the hospital. He is advised to inform his doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] of any confusion, chest pressure, shortness of breath, palpitations, edema, fevers, chills, nausea, or vomiting. DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-988 Dictated By:[**Last Name (NamePattern1) 1811**] MEDQUIST36 D: [**2198-3-15**] 01:41 T: [**2198-3-15**] 13:21 JOB#: [**Job Number 6609**]

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Discharge summary

report

Admission Date: [**2167-7-29**] Discharge Date: [**2167-8-7**] Date of Birth: [**2105-12-24**] Sex: F Service: MEDICINE Allergies: Augmentin / Erythromycin Base Attending:[**First Name3 (LF) 2291**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Open Reduction Internal Fixation [**2167-7-30**] History of Present Illness: 61 year old female with PMHx developmental delay (baseline [**1-5**] word responses), epilepsy who was admitted [**2167-7-29**] after mechnical fall and right femoral fracture, s/p ORIF on [**2167-7-30**], with difficult extubation thereafter, increased coughing, on 3L via NC since then and spiking fever to 102.6 overnight. UA showed few bacteria and 2 WBCs, CXR with bilateral opacities concerning for PNA. Febile to 102. Transfered to medicine with concern for PNA and possible sepsis. VS: T 100.5 BP 112/52 HR 80s; lungs w bibasilar rales; CXR with opacities. ROS: unable to elicit from patient due to severe developmental delay. Past Medical History: At baseline, pt ambulates with walker and is interactive only to two words ORIF - Right femur [**2167-7-30**] s/p bilateral cateract repair in [**2162**] Epilepsy sp Vagus nerve stimulator GERD Osteoporosis Anxiety Hypertension Social History: No ETOH, Illicit drugs, or tobacco. Lives in [**Hospital3 **] group home. Sister is health care proxy. Family History: Unknown Physical Exam: ADMIT EXAM: VS - Temp 102.7F, BP 108/58, HR 96, R 24, O2-sat 94% on 2L GENERAL - Disheveled woman lying on bed, interactive at times HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat ant HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, ORIF bandage on RLE SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-9**] throughout, sensation grossly intact DISCHARGE EXAM: VS - T 99.4, BP (94-165)/(68-100), HR 72, R 18, O2-sat 93-98% on RA GENERAL - child-like woman lying on bed, interactive at times, vocalizations range from grunts to simple one word answers. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTAB anteriorly HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, ORIF bandage on RLE, area c/d/i, edematous RLE, distal pulses intact. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-9**] throughout, sensation grossly intact, horizontal nystagmus. Pertinent Results: Admission Labs: [**2167-7-29**] 07:40PM BLOOD WBC-9.7 RBC-2.95* Hgb-9.9* Hct-30.5* MCV-103* MCH-33.5* MCHC-32.3 RDW-12.3 Plt Ct-165 [**2167-7-29**] 07:40PM BLOOD Neuts-74.5* Lymphs-19.7 Monos-4.7 Eos-0.8 Baso-0.3 [**2167-7-29**] 07:40PM BLOOD PT-12.6* PTT-27.3 INR(PT)-1.2* [**2167-7-29**] 07:40PM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-145 K-4.2 Cl-107 HCO3-28 AnGap-14 [**2167-8-1**] 07:15PM BLOOD ALT-9 AST-26 LD(LDH)-203 AlkPhos-48 TotBili-0.5 [**2167-7-29**] 07:40PM BLOOD Calcium-8.6 Phos-5.5* Mg-2.3 [**2167-8-1**] 04:18AM URINE CastHy-4* [**2167-8-1**] 04:18AM URINE RBC-35* WBC-2 Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 [**2167-8-1**] 04:15PM URINE RBC-25* WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 [**2167-8-1**] 04:18AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG [**2167-8-1**] 04:15PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [**2167-8-1**] 04:18AM URINE Color-DKAMB Appear-Clear Sp [**Last Name (un) **]-1.029 [**2167-8-1**] 04:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.027 Other Pertinent Labs: [**2167-8-2**] 12:42AM BLOOD CK(CPK)-584* [**2167-8-2**] 09:03AM BLOOD ALT-11 AST-26 CK(CPK)-421* AlkPhos-50 TotBili-0.5 [**2167-8-2**] 03:27PM BLOOD CK(CPK)-332* [**2167-8-2**] 12:42AM BLOOD CK-MB-2 cTropnT-<0.01 [**2167-8-2**] 09:03AM BLOOD CK-MB-1 cTropnT-<0.01 [**2167-8-2**] 09:03AM BLOOD Albumin-2.2* Calcium-8.5 Phos-3.1 Mg-2.1 [**2167-8-2**] 09:03AM BLOOD TSH-2.0 [**2167-8-1**] 10:10AM BLOOD Valproa-60 [**2167-7-31**] 06:45AM BLOOD Valproa-29* [**2167-8-1**] 10:10AM BLOOD Carbamz-3.5* [**2167-7-31**] 06:45AM BLOOD Carbamz-4.9 Discharge Labs: [**2167-8-7**] 06:50AM BLOOD WBC-6.5 RBC-2.73* Hgb-8.2* Hct-26.5* MCV-97 MCH-30.2 MCHC-31.2 RDW-18.3* Plt Ct-358 [**2167-8-7**] 06:50AM BLOOD Plt Ct-358 [**2167-8-7**] 06:50AM BLOOD PT-14.5* PTT-25.5 INR(PT)-1.4* [**2167-8-7**] 06:50AM BLOOD Glucose-85 UreaN-27* Creat-0.8 Na-146* K-4.0 Cl-116* HCO3-22 AnGap-12 [**2167-8-7**] 06:50AM BLOOD Calcium-7.2* Phos-3.7 Mg-2.1 Microbiology: [**8-1**] BCx: PND [**8-1**] UCx: PND [**8-2**] MRSA Screen: PND Imaging: CXR [**2167-8-4**]: An AP single view of the chest has been obtained with patient in semi-upright position. A left-sided PICC line has been placed which reaches well into the right atrium. It is recommended to withdraw the line by 5 cm. No other interval change can be seen on the chest examination in comparison with the supine image of [**2167-8-1**]. Page was placed at 3:40 p.m. KUB [**2167-8-2**]: There is scattered air within non-dilated loops of small and large bowel with no air-fluid levels on the semi-erect study to suggest bowel obstruction. Findings are nonspecific. There are degenerative changes in the lumbar spine.A dynamic hip screw is partially visualized with in the right femoral neck and head. If the patient's symptoms persist, followup imaging should be considered. CXR [**8-1**]: Cardiac silhouette remains enlarged and is accompanied by pulmonary vascular congestion and asymmetrical perihilar and basilar opacities, left greater than right. Although potentially due to asymmetrical pulmonary edema, infection is an additional consideration given clinical history of fever. Standard PA and lateral chest radiographs may be helpful for more complete evaluation when the patient's condition allows. CXR [**7-31**]:FINDINGS: Vagal nerve stimulator device noted overlying the left hemithorax. There is retrocardiac/left lower lobe hazy opacity which may represent pneumonia or atelectasis. Minimal patchy opacity also seen at the right lung base, but the assessment is limited due to relative [**Name (NI) 76419**]/technique. CONCLUSION: Possible bilateral lower lobe atelectasis/pneumonia. Followup recommended. CXR [**7-29**]:Vagal nerve stimulator projects over the left chest wall. Severe scoliosis results in suboptimal evaluation of the chest due to rotated appearance of the cardiomediastinal silhouette. There is no definite consolidation, large effusion, or pneumothorax. No overt pulmonary edema. IMPRESSION: No overt pathology. Limited exam. CXR EKG: SR at ~80bpm with episodes of bigeminy on rhythm strip EKG [**2167-8-1**] pm: afib w/ RVR to ~130bpm (converted to sinus) TTE [**2167-8-4**]:The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 65%). 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: []BRIEF CLINICAL HISTORY: In brief this is a 61yoF with h/o developmental delay and epilepsy who initially presented to [**Hospital1 18**] on [**7-29**] after falling. She was found to have right femoral fracture and was taken to OR on [**7-30**]. Per report, patient was difficult to extubate. On [**7-31**], she was noted to be febrile to 102 and hypoxic. CXR at that time revealed ?opacities and patient was started on vancomycin and cefepime. She was persistently febrile and, therefore, was transferred to medicine. While on medicine floor, she was broadened to Flagyl. Also noted to be aspirating while given liquids. Patient was made NPO and medications were made IV. Neuro was consulted to help manage medications while NPO and suggested IV ativan. On [**8-1**], patient went into atrial fibrillation with HRs in 130s. She was started on metoprolol 2.5mg IV BID. She reported converted back to sinus rhythm that same day. However on day of transfer she again was febrile to 101.8 and was converted back to afib with HRs in 140s. Metoprolol was uptitrated to 5mg [**Hospital1 **]. Patient also noted to have poor access; however, 2 peripheral IVs (a 20 and a 22) were placed. On evaluation, patient was resting comfortably. She responded to verbal stimulus. VS on evaluation were Tm 102 Tc 99.1 130/70 115 99%2LNC. Decision was made to transfer patient to MICU for close monitoring. MICU course- In the MICU patient had poor IV access and received a PICC line for access and to receive treatment for her pneumonia. She recieved a eight day course of antibiotics. She was transferred to the MICU with atrial fibrillation with rapid ventricular rate and concern for hypoxia. While in the MICU she was maitaining good oxygenation on room air and her heart rate was controlled on metoprolol tartrate 37.5 mg four times daily and started on a baby aspirin. She was asymptomatic with the afib. An echo performed on [**2167-8-4**] showed no evidence of valvular dysfunction or left atrial enlargement. []ACTIVE ISSUES: #Tachycardia with atrial fibrillation and rapid ventricular rate (Afib with RVR): On [**2167-8-1**], pt had afib with RVR at 145bpm and converted spontaneously to sinus rythm with bigeminy. Pt had recurrent episodes of Afib with RVR on tele and converted to sinus spontaneously each time. Electrolytes were repleted. Pt started on metorpolol 5mg IV considering continued episodes. and was sent to MICU for further management. While in MICU, patient was started on metoprolol 5mg IV every six hours and uptitrated to 37.5mg four times daily with good effect. She maintained good blood pressures despite this tachycardia and had no chest pain. Unclear what the precipitant of this event was, possibly her infection. She underwent a trans-thoracic echocardiogram on [**8-4**] which was normal. -rate controlled on 37.5mg metoprolol QID overnight, switched to 75mg [**Hospital1 **] dosing to prepare for home. For anticoagulation, Coumadin is not indicated based on her CHADS2 score, Aspirin is sufficient. She was monitored on telemetry and had no documented events during her stay on the medicine floor after being discharge from the MICU. #Aspiration Pneumonia: Most likely pneumonia secondary to peri-extubation aspiration. Her max temperature was 102.7 and pt continued to be febrile on [**2167-8-1**] and [**2167-8-2**]. Pt. had evdience of opacities on chest xray. The patient was emprically started on HCAP treatment (Vanc/Cef/Flagyl, day 1 = [**2167-8-2**]). A urinalysis was not suggestive of infection. Pt was on and off of oxygen throughout her MICU stay. While in the MICU she received IV vancomycin, cefepime and flagyl for hospital aquired pneumonia coverage and aspiration pneumonia coverage. The patient was discharged on RA, satting in mid 90's, on cefepime/flagyl, day [**6-12**]. She had a negative MRSA screen. # Elevated Creatinine Kinase: This was thought to be secondary to her open reduction and internal fixation. She was given normal saline and creatinine kinase has downtrended since then to normal ranges. # Open Reduction and Internal Fixation of the right femur: Orthopedic surgery followed pt post-operatively for wound checks. Her pain was well controlled, and no signs of infection were noted. Patient is to f/u with ortho in two weeks, appointment scheduled and information is in discharge worksheet. # Seizures: Pt was initially unable to take depakote, lamotrigine, and tegretol orally so was on ativan 1mg IV. Neurology recommended inserting [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube (NGT) to give home seizure medications. She was unable to tolerate NGT, so speech and swallow evaluation was placed, which revealed she would be able to tolerate pills. #IV Access: Pt. has difficult access and was initially unable to tolerate PO. Central access was foregone on [**8-2**] due to patient non-compliance. Multiple attempts were made at placing peripheral IVs. Finally a PICC was placed which remained throughout her MICU stay. Transitional Issues: - Ortho F/U - REHAB IS ACADEMY MANOR **Rehabilitation is anticipated to last less than 30 days.** Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Group Home. 1. Carbamazepine 400 mg PO BID 2. Divalproex (DELayed Release) 500 mg PO QID 3. LaMOTrigine 125 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Carbamazepine 400 mg PO BID 2. Divalproex (DELayed Release) 500 mg PO QID 3. LaMOTrigine 125 mg PO BID 4. Acetaminophen 1000 mg PO TID do not exceed 4g in 24 hours 5. Aspirin 81 mg PO DAILY 6. Bisacodyl 10 mg PR TID:PRN constipation 7. Codeine Sulfate 15-30 mg PO Q4H:PRN antitussive Hold for sedation 8. Enoxaparin Sodium 30 mg SC Q12H 9. Ipratropium Bromide Neb 1 NEB IH Q6H 10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 11. Levofloxacin 750 mg PO DAILY Duration: 3 Days 12. Metoprolol Tartrate 75 mg PO BID hold for SBP < 90, or HR <60 13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 14. Senna 1 TAB PO BID:PRN constipation 15. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Disposition: Extended Care Facility: Academy Manor of [**Location (un) 7658**] - [**Location (un) 7658**] Discharge Diagnosis: Primary: Femur fracture Secondary: Fever, atrial fibrillation with rapid ventricular response 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 Ms. [**Known lastname 79662**], It was a pleasure to take care of you at [**Hospital1 18**]. You were admitted because of a fracture of your femur bone. You underwent surgery to repair this and the surgery was complicated by fevers and difficulty weaning from the ventilator. You were transferred to the medicine service for management of fever and you received antibiotics. You were noted to have an irregular rhythm and were given medicine to slow your heart rate, which worked well. We have made the necessary changes to your medications. We wish you and your family the best. Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2167-8-20**] at 1:40 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 [**2167-8-20**] at 2:00 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

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icd9cm

[ [ [] ] ]

[ "79.35", "38.97" ]

icd9pcs

[ [ [] ] ]

13958, 14053

7791, 9799

296, 346

14191, 14191

2831, 2831

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13261, 13935

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374, 1011

2847, 3955

3978, 4517

14206, 14342

1033, 1262

1278, 1382

14,748

182,675

7053

Discharge summary

report

Admission Date: [**2135-2-16**] Discharge Date: [**2135-2-21**] Date of Birth: [**2079-1-30**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26350**] is a 57-year-old male with diabetes mellitus complicated by end-stage renal disease status post transplant, coronary artery disease, gastroesophageal reflux disease, gastroparesis, hypertension, who had actually been recently admitted on [**2135-2-14**] for coffee ground emesis. He had had an esophagogastroduodenoscopy showing mild gastritis and esophagitis and then he was discharged on [**2135-2-15**]. On the evening of the 25th he went to be early complaining of nausea. He was unable to tolerate food on the evening of the 25th and vomited. On the 26th he took half his normal NPH Insulin and had worsening nausea and vomiting. He also complained of epigastric pain. He denied fever, cough, shortness of breath or any localizing symptoms of infection. In the Emergency Department he was found to have glucose greater than 500, anion gap of 20 and a bicarbonate of 80. He also had an EKG with sinus tachycardia at 102, normal axis, ST depression in the lateral leads which resolved with treating his tachycardia. He was admitted to the medical intensive care unit and placed on an insulin drip and given intravenous fluids and electrolyte repletion. On [**2135-2-17**] at 3 AM his troponin was found to be 1.9. The first two sets had been flat. His CKs were flat, maxing out in the 80s. He had no chest pain, no shortness of breath, no congestive heart failure. His troponin peaked at 7 at 1 PM on the 27th. By the 28th he had been taken off his insulin drip, had no anion gap, was tolerating p.o.'s and was chest pain free. He was transferred to the medicine team for further management of his non-ST elevation myocardial infarction. MEDICATIONS ON ADMISSION: 1. Zestril 20 p.o. q.d. 2. CellCept 1,000 mg p.o. b.i.d. 3. Protonix 40 mg b.i.d. 4. Lipitor 20 mg p.o. q.d. 5. Neoral 5 mg p.o. q.d. 6. Zantac 150 mg p.o. b.i.d. 7. Aspirin 81 mg p.o. q.d. 8. Atenolol 25 mg p.o. q.d. 9. Humulin 44 units subcutaneous in the AM and 12 units subcutaneous in the PM both with meals. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus complicated by retinopathy and neuropathy. 2. End-stage renal disease secondary to the diabetes mellitus status post renal transplant in [**2127**] on chronic immunosuppression. 3. Gastroparesis in the past, but the patient said that it has not been a problem since [**2127**] since he had his renal transplant. 4. Gastroesophageal reflux disease. 5. Coronary artery disease. His last catheterization in [**2127**] revealed proximal left anterior descending coronary artery 30-40% stenosis, diffuse 50% right coronary artery, left circumflex coronary artery clean, D1 30-40%. He had a negative stress test in [**2131**] with a normal ejection fraction at [**Doctor First Name **] protocol of nine minutes. 6. Hyperlipidemia. 7. Hypertension. 8. Recent gastritis/esophagitis likely secondary to non-steroidal anti-inflammatory drugs. PAST SURGICAL HISTORY: 1. Renal transplant in [**2127**]. 2. Eye surgeries, two cataracts, one for retinal detachment and multiple laser procedures. FAMILY HISTORY: Notable for cancer in his father and arthritis in his mother. His sister is healthy. SOCIAL HISTORY: The patient reports six to eight glasses of champagne per week, no tobacco use. He is married with two children. He is an ex-banker/financier. He is now on disability. PHYSICAL EXAMINATION: On transfer from the medical intensive care unit to the floor his heart rate was 70-75, blood pressure 174/83, breathing at 12, 90% on room air, weight 84 kg. He was not in acute distress. He was hard of hearing and anxious. HEENT: He had moist mucous membranes. Extraocular movements intact, anicteric, no lesions in the oropharynx, no jugular venous distension. Neck: Supple. Heart: Regular rate and rhythm, S1 and S2, no murmurs, gallops, or rubs. Lungs: Clear to auscultation except for minor crackles at the bases. Abdomen: Soft, obese, nontender, no distention, normal active bowel sounds. Extremities: He had [**1-23**] dorsalis pedis pulses, no cyanosis, clubbing or edema. Neurologic: Cranial nerves two through 12 were intact, alert and oriented x 3. He was anxious. Strength was normal. The patient had an ECG on the [**2-16**] showing sinus tachycardia at 102, normal axis, ST depressions in 1, 2, V5 to V5. He had one on the 28th which showed sinus at 70, normal axis, no ST changes, Q's or T wave inversions. We also repeated the EKG when the patient was experiencing nausea and vomiting to make sure this wasn't an anginal equivalent and the patient similarly had a normal sinus rhythm with normal axis and no EKG changes, peaked Q's or T wave inversions. LABORATORY DATA: On the day of admission the patient's hematocrit was 41.9, hemoglobin 13.7. On the day of discharge hemoglobin was 13.1, hematocrit 37.9. White count was 9.9 on the day of admission, 7 on the day of discharge. On the day of admission he had 93% neutrophils, 5% lymphocytes, 1.5% monocytes, 0.2% eosinophils and 0.2% basophils. Platelet count was 180. Urinalysis was negative for leukocyte esterase, negative for nitrite, negative for white blood cells and no bacteria. At presentation his chem-7 was glucose 431, urea 33, creatinine 1.2, sodium 143, potassium 4.7, chloride 111, total bicarbonate 6 and anion gap of 26. On the day of discharge sodium was 136, urea 13, creatinine 0.9, chloride 97, bicarbonate 29, potassium 4.1. On the 26th, on the day of admission the patient had a chest x-ray. Heart size was slightly enlarged, no evidence of congestive heart failure, flattening of diaphragms consistent with chronic obstructive pulmonary disease, minimal bibasilar atelectasis, no pulmonary consolidation or pleural effusion. IMPRESSION: The patient was a 56-year-old male who presented to the Emergency Department status post nausea and vomiting with diabetic ketoacidosis. He was treated for the diabetic ketoacidosis in the medical intensive care unit and soon after ruled in with non-ST elevation myocardial infarction with peak troponin of 7. CK was never higher than 80s. He was chest pain free throughout his whole stay and hemodynamically stable. It was unclear exactly if the myocardial infarction precipitated the nausea and vomiting and diabetic ketoacidosis or vice-versa. It seems due to the timing of the troponin leak that it was most likely secondary to the diabetic ketoacidosis. HOSPITAL COURSE: 1. Coronary artery disease; non-ST elevation myocardial infarction. Cardiology consultation weighed. Dr. [**Last Name (STitle) **] saw the patient. The patient's metoprolol was 25 b.i.d. Heart rate was in the low 70s. The Zestril was increased from 20 p.o. q.d. to 30 p.o. q.d. for increased blood pressure control. The patient was on 225 q.d. of aspirin. Cholesterol panel was checked with triglycerides 124, HDL 38, LDL 65, cholesterol:HDL ratio of 3.4. The patient is to have a stress test on Thursday, [**2-24**] as an outpatient. Appointment has been made for the patient and instructions were given to the patient. The patient will follow up with Dr. [**Last Name (STitle) **] early the following week after the stress test or earlier if there is an abnormal result. 2. Congestive heart failure: No evidence on examination throughout his whole stay despite vigorous hydration for diabetic ketoacidosis. 3. Valve: No issues. 4. Rhythm: The patient was placed in telemetry with no ectopy. 5. Renal: He was continued on his outpatient Neoral and CellCept doses. Creatinine was stable. Cyclosporine trough was 44. Random level was 83. The patient is to follow up with Dr. [**First Name (STitle) 10083**] within a week following discharge from the hospital. 6. Diabetes mellitus: The patient was weaned off the insulin drip and as he was tolerating p.o.'s his NPH Insulin dose was also increased slowly. He likely was prior to the day of discharge not still on his full normal outpatient regimen, having taken less of NPH Insulin the evening prior to discharge with higher than his regular blood glucoses in the morning. 7. GI: The patient was without any episodes of coffee ground emesis. Protonix was switched to Prilosec at the patient's request. The patient was discharged with Prilosec 20 p.o. b.i.d. This will be weaned down to 20 q.d. after one more week after having been two weeks after the initial gastritis. He will take Zantac 150 q.p.m. as he has been doing normally. The patient had Reglan added to his regimen for possible gastroparesis that may be resulting in his nausea and vomiting. The patient had stable GI function since his transplant but EGD was notable for some retention of food and pill material. The patient was initially on 10 q.i.d. This was decreased to 10 b.i.d. as he was doing very well at the time of discharge. The covering attending, Dr. [**First Name (STitle) 1726**], was to contact Dr. [**Last Name (STitle) **] regarding this matter and see if the patient would need a follow-up emptying study at a future date. 8. Hematology: Hematocrit was stable. He was guaiac positive, possibly reflecting his old gastritis, but his hematocrit and hemoglobin were very stable during the hospital course. 9. Prophylaxis: He was on subcutaneous heparin, antiemetics and physical therapy walked with the patient and then he walked by himself. On the day of discharge he was ambulating down the hallway and was able to do steps. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Non-ST elevation myocardial infarction. 2. Diabetic ketoacidosis. 3. Insulin dependent diabetes mellitus complicated by neuropathy. 4. Renal failure status post renal transplant. 5. Hyperlipidemia. 6. Hypertension. 7. Gastritis. 8. Gastroesophageal reflux disease. 9. Possible gastroparesis. DISCHARGE FOLLOW-UP: The patient is to have a stress test on Thursday, [**2-24**]; an ETT MIBI, and this has been scheduled. The patient has follow-up information, where to go for the tests and given descriptions regarding how to prepare for the tests, n.p.o., half-dose insulin, etc on the morning of the test. The patient has a follow-up appointment with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 10083**] the week after discharge. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 1659**] MEDQUIST36 D: [**2135-2-21**] 12:57 T: [**2135-2-21**] 13:14 JOB#: [**Job Number 26351**]

[ "250.61", "410.71", "535.40", "357.2", "593.9", "996.81", "536.3", "337.1", "250.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9631, 9638

3271, 3358

9659, 10677

1874, 2197

6613, 9609

3126, 3254

3570, 6595

160, 1847

2220, 3102

3375, 3547

69,006

160,110

37014

Discharge summary

report

Admission Date: [**2174-2-2**] Discharge Date: [**2174-2-11**] Date of Birth: [**2130-3-17**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3227**] Chief Complaint: Left Cerebellar Mass Major Surgical or Invasive Procedure: [**2174-2-4**]: L suboccipital crani for mass resection History of Present Illness: This is a 43 year old right handed male with past medical history significant for leukemia diagnoses at age 5 s/p whole body XRT, chemotherapy, and BMT who was seen in the ER for dizziness. MRI showed large L cerebellar mass. The patient has been feeling off balance over the last 3 weeks. He feels as though he is walking sideways. He has also felt lightheaded and has woken up in the mornings with a headache posteriorly. He was seen by a covering PCP yesterday who ordered an outpatient MRI head with contrast. This showed a large enhancing mass involving nearly the entire left cerebellar hemisphere. He was immediately sent to the ER at [**Hospital1 18**]. On interrogation he recalls falling [**12-11**] weks ago, striking his head on a radiator. He and his mother refer to a [**Name (NI) 39447**] 8 years ago where he was struck from behind. Imaging was done. The mother recalls some sort of intracranial hemorrhage and work up with Dr. [**First Name (STitle) **], a neurologist in [**Hospital1 1474**]. His office was contact[**Name (NI) **] and no records were available. Past Medical History: Past Medical History: Leukemia age [**4-20**] s/p whole body XRT, chemotherapy, and BMT transplant from his identical twin brother. Hyperlipidemia, Osteoporosis, low testosterone, radiation induced cataracts, LBBB with systolic and diastolic dysfunction with LVEF of 45%. Cardiac cath [**5-6**]: Mild systolic and diastolic left ventricular dysfunction. Social History: Lives with mother. In college. Non-smoker. Family History: Non-contributory Physical Exam: Physical Exam: Vitals: T 98.4; BP 114/75; P 115; RR 16; O2 sat 100% General: lying in bed, short stature, appears older than stated age HEENT: NCAT, moist mucous membranes Neck: supple Extremities: no c/c/e. RLE larger than LLE. Neurological Exam: Mental status: A & O x3, difficulty with MOYB. Fluent speech with no paraphasic or phonemic errors. Adequate comprehension. Follows simple and multi-step commands. Repetition intact (no ifs, ands or buts). Able to name low and high frequency objects. No left/right mismatch. No apraxia/neglect. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. optic discs sharp. VFF. III, IV, VI: EOMI. fatiguable endgaze nystagmus. V, VII: facial sensation intact, facial strength VIII: hearing intact b/l to finger rubbing. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: SCM [**4-13**] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. No pronator drift. Full strength throughout Sensation: intact to light touch and temperature. Reflexes: Bic T Br Pa Ac Right 2 2 2 1 1 Left 2 2 2 1 - Toes downgoing bilaterally. Coordination: FNF intact. Gait: Romberg mild lists to the left. Narrow based w/ good arm swing. Upon Discharge: Same as above. Improving L dysmetria. Occipital incision well healed, clean warm and dry. Pertinent Results: On Admission Labs: 141 105 31 - - - - - - gluc 111 4.3 27 1.0 Ca: 10.3 Mg: 2.0 P: 3.8 WBC 10.1 HCT 41.3 PLT 234 N:54.8 L:35.7 M:6.3 E:2.7 Bas:0.4 PT: 11.7 PTT: 20.7 INR: 1.0 Discharge labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2174-2-10**] 04:50AM 12.9* 3.62* 11.5* 33.9* 94 31.8 34.0 13.6 282 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2174-2-10**] 04:50AM 108*1 30* 1.1 137 4.4 102 29 13 MRI Brain [**2174-2-2**]: MRI head - large enhancing L cerebellar mass with partial effacement of 4th ventricle and displacement of pons and medulla. CTA Brain [**2174-2-2**]: Large amorphous left cerebellar mass demonstrates heterogeneous enhancement and areas of possible calcification versus hemorrhage, and necrosis versus cystic change. This mass exerts substantial mass effect and partially displaces the fourth ventricle and quadrigeminal cistern on the left. Minimal descending ectopia of the left tonsil is also noted, resulting in mild narrowing of left posterior aspect of foramen magnum Post op MRI [**2174-2-5**]: 1. Extensive post-surgical changes related to the recent partial resection of the extensive infiltrating process in the left cerebellar hemisphere; however, allowing for this, there is persistent nodular and ring-like enhancement at the inferomedial aspect of the resection bed, highly suspicious for residual tumor. Brief Hospital Course: Mr. [**Known lastname 83461**] is a 43 yr old male who presented to the ER with a 4 week history of gait inbalance and speech slurring. Work up included a head CT that revealed a left cerebellar mass. He was admitted to the ICU for observation and MR imaging was performed: This demonstrated a heterogeneous mass lesion at the left cerebellar hemisphere with multiple areas of irregular enhancement and areas with high signal intensity on T2, possibly related with a combination of necrosis and cystic transformation. There was significant mass effect and narrowing of the fourth ventricle, effacementof the posterior perimesencephalic cisterns and left side of the foramen magnum. The differential diagnosis included primary cerebellar neoplasm versus metastatic lesion. On [**2-4**] he was taken to the OR for a left craniotomy for tumor resection with Dr. [**First Name (STitle) **]. Post-operatively, the patient remained neurologically unchanged relative to the preopertive examination. He was observed in the ICU for three days prior to transfer to the floor. Neuro and Radiation oncology were consulted to guide treatment. PT and OT therapy were consulted as well, and he was determined to be safe for discharge with outpatient therapy. He was discharged on [**2174-2-11**] with instructions for outpatient PT. Medications on Admission: Simvastatin 80 mg daily, Meclizine 12.5 mg daily, Tylenol. Bisphosphonate, azithromycin. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headach. Disp:*40 Tablet(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. Disp:*40 Tablet(s)* Refills:*0* 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 8. 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:*0* 9. Outpatient Occupational Therapy 10. Outpatient Physical Therapy Discharge Disposition: Home with Service Discharge Diagnosis: Left Cerebellar Mass: prelim pathology Glioma Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound closure is dissolvable sutures, you must keep that area dry for 10 days. No removal is necessary, they will dissolve. ?????? 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 are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: Follow-Up Appointment Instructions ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2174-2-21**] at 1:00pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain as this was done during your inpatient hospitalization * you will need an MRI of the abdomen, as this was not done as an inpatient. This is for screening purposes. Your MRI has been scheduled for [**2174-2-18**] at 3:00 at the [**Hospital Ward Name 2104**] Building, in the Felberg/[**Hospital Ward Name 1827**] Complex on the [**Location (un) 470**] radiology department. Completed by:[**2174-2-11**]

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icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

7257, 7276

4809, 6133

296, 354

7366, 7390

3322, 3325

8725, 9628

1926, 1944

6273, 7234

7297, 7345

6159, 6250

7414, 8702

3525, 4786

1974, 2191

2210, 2210

236, 258

3212, 3303

382, 1469

2527, 3196

3342, 3509

2225, 2511

1514, 1848

1864, 1910

72,532

122,781

52605

Discharge summary

report

Admission Date: [**2144-2-6**] Discharge Date: [**2144-2-12**] Date of Birth: [**2089-2-14**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6565**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 54 F history of metastatic non small cell lung CA sp chemo and RXT with invasion of esophagus and recent admission for dysphagia sp dilation, ulcerative colitis on asacol, who presents to ED with dyspnea. Dyspnea started yesterday acutely. She was lying in bed and felt 1 hr of SOB, felt sensation of labored breathing. Her Dyspnea resolved on its own yesterday after 1 hr. No pleuritic chest pain, no chest pain, no diapharesis. She has had a nonproductive cough for 1-2 weeks. Denies fevers/chills, denies nausea/vomiting, denies abdominal pain. This AM, pt awoke, and felt another episode of dyspnea x 2 hrs. Denies any palpitations during this time. Symptoms resolved on their own. She came to the ED for evaluation. . Recent admission [**Date range (1) 44469**] for dysphagia: Pt was admitted for dysphagia to solids, on [**1-28**] had EGD for evluation and dilation. During that admission, she underwent repeat endoscopy and dilation on [**1-31**] with improvement of symptoms. Biopsy of esophgeal nodule showed squamous cell CA. Pt was discharged with follow up with oncologist. . In the ED inital vitals were, 96.8 150 158/95 18 99% RA. Pt never had episode of oxygen desaturation. She had CTA showing no PE, and questionable pna, so she was given: 3 L IVF, Levoflox, Vancomycin. Mild movement in HR but continued in 120, always in NSR. Formal echo performed by cardiology: pericardial effusion (new, small, no tamponade physiology). Pulsus=8. Troponin neg x1, EKG with no ST depressions or TWI, showed sinus tachycardia. She was also given zyprexa for anxiety, guafinesin for cough. Reportedly, she does have a history of chronic tachycardia in the 120s, possibly from underlying malignancy. Vitals prior to transfer: 98.3 128 135/77 22 99% 2LNC Pt transfered to the ICU for tachycardia, dyspnea. . On arrival to the ICU, pt reports feeling comfortable, with improved breathing but still with some mild subjective feeling of dyspnea. She denies any sensation of tachcyardia or palpitations. However, she does note that whenver she comes to the ED, her HR 150s. During her hospitalizations, doctors have told [**Name5 (PTitle) **] that her HR is often 110-120s. Pt denies any productive cough, but does have a dry cough x 1-2 weeks. Denies any choking or aspiration episodes in the last few days-weeks. She states difficulty swallowing the last day, says the pills seem to get stuck in her throat. Prior to that, she had no problems swallowing solids after her recent EGD and dilation on [**1-31**]. She has not been taking her pills over the last day due to her feeling of dysphagia. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Past Oncologic History: -presented with back & right sided flank pain & was found to have lung nodules on CXR, prompting chest CT that showed a LLL nodule and mediastinal & hilar lymphadenopathy. Thoracic spine MRI showed expansile T9 lesion c/w metastatic disease.s/p palliative radiation to T7-11 spine & right ilium through [**2143-7-29**]. She underwent Brain MRI [**2143-7-30**] which was (-) for metastatic disease. Tumor was tested and EGFR mutation (-), KRAS wild-type, and ALK (-). S/p 4 cycles of taxol, carboplatin and bevacizumab last given on [**2143-10-17**] -[**1-/2144**]: Pt with dysphagia. Esophageal nodule bx showed squamous cell CA. . Past Medical Hx: -Ulcerative colitis x8 years, well controlled on Asacol. Never required steroids -GERD -COPD -Esophageal stricture-dilation c/b tear requiring left thoracotomy and repair: [**2-/2141**], pt had dysphagia, which was further evaluated with EGD, which demonstrated patchy mild erythema in the duodenal bulb and in the 2nd part of the duodenum. A mild Schatzi ring was found in the GE junction. Dilation of the esophagus was attempted and complicated by acute perforation of distal esophagus, resulting in need for thoracic surgery for repair. Social History: Lives with fiance previously in [**Location (un) 2624**], MA, now in [**Location (un) **], MA. Patient has three children, lives with her 18 yr old son. Used to work in IT for State of [**State 350**]. Quit tobacco in [**2136**] with a 50 pack year history. No etoh or illicits. Feels safe in relationship. Other children are age 30, 26. Family History: mother had [**Name2 (NI) 499**] cancer and [**Name (NI) 5895**] father's medical history unknown Physical Exam: Vitals: T: afebrile BP: 137/90 P:132 R:20 18 O2:99%2L General: Alert, oriented, no acute distress, comfortable, cachectic appearing HEENT: Sclera anicteric, MMM, oropharynx clear, pale conjunctiva. Pt with white plaques in posterior pharynx, hard palate, tongue, consistent with thrush Neck: supple, JVP not elevated, no LAD Lungs: decreased breath sounds in bases, L>R, no crackles, no rhonchi CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops, JVP 7 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS: On admission: [**2144-2-6**] 08:00AM BLOOD WBC-12.0* RBC-3.86* Hgb-11.1* Hct-34.9* MCV-90 MCH-28.7 MCHC-31.7 RDW-15.8* Plt Ct-174 [**2144-2-6**] 08:00AM BLOOD Neuts-88.6* Lymphs-6.3* Monos-2.7 Eos-2.1 Baso-0.2 [**2144-2-6**] 08:00AM BLOOD PT-11.5 PTT-26.6 INR(PT)-1.1 [**2144-2-6**] 08:00AM BLOOD Glucose-110* UreaN-8 Creat-0.4 Na-134 K-3.6 Cl-99 HCO3-23 AnGap-16 [**2144-2-6**] 08:18PM BLOOD CK(CPK)-16* [**2144-2-6**] 08:00AM BLOOD cTropnT-<0.01 [**2144-2-6**] 08:18PM BLOOD CK-MB-2 cTropnT-<0.01 [**2144-2-6**] 08:00AM BLOOD TSH-1.5 [**2144-2-6**] 08:59AM BLOOD Lactate-1.9 . IMAGING: . [**2-6**] ECHO: The estimated right atrial pressure is 5-10 mmHg. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a very small to small, circumferential pericardial effusion measuring up to 1 centimeter in greatest dimension. There are no echocardiographic signs of tamponade. IMPRESSION: Limited study/Focused views. Very small to small, circumferential pericardial effusion without echocardiographic evidence of tamponade. . [**2-6**] CXR: IMPRESSION: Left pleural effusion and worsening left basilar consolidation, the latter concerning for pneumonia. . [**2-6**] CTA chest: IMPRESSION: 1. No evidence of pulmonary embolism, as questioned clinically. 2. Findings compatible with disease progression compared to PET-CT [**2143-11-19**]. Extensive mediastinal adenopathy and confluent hilar soft tissue have enlarged, as has a large soft tissue mass invading the esophagus in its mid portion, obliterating the lumen. It is unclear if this represents metastatic disease or primary esophageal neoplasm and correlation with pathology is recommended. Also progressed are numerous pulmonary nodules, as detailed above. 3. Extensive perihilar and paramediastinal consolidation, which has progressed substantially from [**2143-11-9**] but is essentially unchanged from [**2144-1-18**]. Given the short term stability, infectious etiologies are less likely, though still possible. More likely differential considerations include developing radiation pneumonitis, as suggested by the paramediastinal distribution, or alternatively direct extension of hilar metastases. Correlation with radiation history is recommended. 4. New occlusion of the left lower lobe bronchus, with persistent significant left lower lobe collapse. 5. Narrowing multiple pulmonary veins, with a focal filling defect compatible with thrombus, bland or tumor, in a branch of the left superior pulmonary vein. 6. Little change of bilateral pleural and pericardial effusions. 7. Stable pathologic compression fracture of the T9 vertebral body. 8. Redemonstration of apical-predominant emphysema with bullous change. . [**2-7**] Echo: Left ventricular wall thicknesses are normal. The left ventricle is small. Overall left ventricular systolic function is normal (LVEF 65%). The right ventricular free wall thickness is normal. The right ventricle is small, with normal free wall contractility. There is a small pericardial effusion. There is brief right atrial diastolic collapse. Although frank cardiac tamponade is not present, the findings of tachycardia, brief right atrial diastolic invagination, and small ventricles warrant close clinical and echocardiographic followup. . [**2-7**] CXR: IMPRESSION: Since [**2144-2-6**], moderate left pleural effusion which is partially loculated and left basilar consolidation is unchanged, right infrahilar consolidation and presumed small right pleural effusions have worsened. . MICRO STUDIES: [**2144-2-6**] 5:02 pm SPUTUM Site: EXPECTORATED Source: Expectorated. **FINAL REPORT [**2144-2-6**]** GRAM STAIN (Final [**2144-2-6**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2144-2-6**]): TEST CANCELLED, PATIENT CREDITED. . [**2144-2-6**] 11:30 am URINE Site: CLEAN CATCH **FINAL REPORT [**2144-2-7**]** URINE CULTURE (Final [**2144-2-7**]): <10,000 organisms/ml. . BLOOD CULTURES [**2144-2-6**] NGTD (pending at time of discharge) . LAST LABS PRIOR TO DISCHARGE: [**2144-2-8**] 06:12AM BLOOD WBC-8.0 RBC-3.19* Hgb-9.5* Hct-29.0* MCV-91 MCH-29.7 MCHC-32.7 RDW-15.6* Plt Ct-138* [**2144-2-8**] 06:12AM BLOOD Glucose-102* UreaN-4* Creat-0.4 Na-134 K-3.5 Cl-104 HCO3-24 AnGap-10 [**2144-2-8**] 06:12AM BLOOD Calcium-7.2* Phos-2.7 Mg-2.3 Brief Hospital Course: 54F with hx of metastatic non-small cell lung CA s/p chemo and RXT, Ulcerative colitis on asacol, recent admission for dysphagia s/p EGD and dilation with esophageal bx revealing squamous cell CA, who presents with acute onset dyspnea episodes of 1 day duration . # Dyspnea: Etiology most likely from worsening of known pulmonary disease NSCLC and COPD, and also lobar collapse from extrinsic compression or mucous plugging. There was a question of post-obstructive pneumonia on CT from enlarging lung mass compressing left lower lobe bronchus. PE ruled out on CTA . ACS ruled out with no EKG changes and neg trop. Small pericardial effusion but no tamponade physiology on echo. She was started on empiric coverage for HCAP with levo/vanc/cefepime, continued for first 4 days of hospitilzation but then DC'ed as there was no benefit with treatment. Given albuterol, ipratropium and fluticasone nebs. IP was consulted to see if the stenting of obstructed LLL bronchus would be worthwhile, however they felt that they could only cauterize, not stent, which would only be a temporizing measure and may not even provide much benefit. Patient was trasnferred to the floor after 2nd day of hospitalization, primary Oncologist Dr. [**Last Name (STitle) 3274**] was contact[**Name (NI) **] by [**Name (NI) 153**] team, updated on patient's hospitalization who advised that patient should be moved towards palliation given extent of tumor burden and lack of options chemo/radiation. Patient remained stable on 2LO2 NC sats above 94%. Patients status was discussed with the family extensively, including that likely her pulmonary status would no longer improve. Patient initialy with dry cough improved with codeine syrup, she was offered lidocaine inhaled but chose not to take as she did not want to have numbing in her throat. Patient and family (including Fiancee who is HCP) initially had agreed to hospice care, then day prior to discharge had spoken with hospice and wanted re-evaluation as they were not happy with what the hospice had told them. Palliative care was consulted, who spoke at length with the patient regarding her code status (DNR/DNI) and her wishes. Patient and fiancee decided that they would like to go home with VNA services instead of hospice servcies. The VNA services resumed prior to discharge. . # Sinus tachcyardia: Pt reportedly has baseline sinus tachy in 120s, minimally responsive to fluids. Likely due to underlying malignancy, also anxiety regarding illness. At baseline HR currently. ACS ruled out with enzymes, TSH was normal. Patient remained tachy in the 120's to 130's range. . #. Metastatic NSCLC: CTA revealed mediastinal mass with multiple enlarging nodules. Again showed new esophageal mass obliterating the lumen, unclear if this is a new primary to extension/mets of lung cancer (path on last biopsy was equivocal). Increasing size of mass has now caused extrinsic compression of LLL bronchus, unclear if this is the cause of her dyspnea but certainly likely. Controlled pain and anxiety with dilaudid. Radiation and medical oncologist both felt that palliative care consult was warranted in order to discuss goals of care. The plan was initially home with hospice, but changed as above. . #. Dysphagia/Thrush: On admission, had trouble swallowing pills and was only able to tolerate small sips of clear fluids. CT showed near complete obliteration of esophageal lumen from mass, even after recent dilation procedure. Also found to have thrush on exam, raising concern for possible esophageal candidiasis, fluconazole was started. Patient will complete a total of a 14 day course. . #. Ulcerative colitis x8 years, well controlled on Asacol. Has never required steroids in past. Patient without diarrhea while inpatient. . #. GERD: Continued home lantsoprazole dissolving tablet. . #. Anxiety: Pt with history of anxiety. Continued olanzapine (Disintegrating Tablet) 5 mg PO TID:PRN nausea,anxiety. Added lorazepam standing and PRN for anxiety as well. . TRANSITIONAL ISSUES: 1) Patient sent home with VNA services 2) VNA to manage pain regimen with morphine vs dilaudid, also Oncology fellow following patient to write fluid orders Medications on Admission: Medications (per recent discharge summary, confirmed with patient): dextromethorphan poly complex 30 mg/5 mL Suspension, Extended Rel 12 hr [**Name (NI) **]: One (1) PO Q12H (every 12 hours) as needed for cough. fluticasone 110 mcg/Actuation Aerosol [**Name (NI) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). (Not taking) hydromorphone 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q3H (every 3 hours) as needed for pain, cough. olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO TID (3 times a day). Asacol 400 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Three (3) Tablet, Delayed Release (E.C.) PO three times a day. lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: [**2-10**] Capsule, Delayed Release(E.C.)s PO twice a day: take 2 tablets in the AM, 1 in the evening. loperamide 2 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO four times a day as needed for diarrhea. prednisone 20 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO once a day to be completed on [**2143-2-9**]. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Year (4 digits) **]: One (1) inhaler Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Medications: 1. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup [**Year (4 digits) **]: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*60 ML(s)* Refills:*0* 2. fluticasone 110 mcg/Actuation Aerosol [**Year (4 digits) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*0* 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheezing. Disp:*20 ampules* Refills:*0* 4. fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours) for 12 days: please crush tablet. Disp:*12 Tablet(s)* Refills:*0* 5. olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for anxiety, nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0* 6. hydromorphone 2 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q4H (every 4 hours) as needed for standing dose. Disp:*30 Tablet(s)* Refills:*0* 7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: Two (2) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] [**Name (STitle) 4962**] (once a day (in the morning)). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] [**Name (STitle) 7918**] (once a day (in the evening)). Disp:*20 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 9. ipratropium bromide 0.02 % Solution [**Name (STitle) **]: One (1) inhalation Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*20 ampules* Refills:*0* 10. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 12. senna 8.6 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 13. docusate sodium 50 mg/5 mL Liquid [**Name (STitle) **]: Five (5) mL PO BID (2 times a day) as needed for constipation. Disp:*60 mL* Refills:*0* 14. Dilaudid 2 mg Tablet [**Name (STitle) **]: 1-2 Tablets PO q2 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 15. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Name (STitle) **]: 2.5-20 mg PO every four (4) hours as needed for pain or shortness of breath. Disp:*60 mL* Refills:*0* 16. Lorazepam Intensol 2 mg/mL Concentrate [**Name (STitle) **]: 0.5-1 mg PO three times a day as needed for standing dose. Disp:*30 mL* Refills:*0* 17. Lorazepam Intensol 2 mg/mL Concentrate [**Name (STitle) **]: 0.5 mg PO every four (4) hours as needed for anxiety or nausea. Disp:*30 mL* Refills:*0* 18. IV FLUIDS Please provide 500 cc normal D51/2NS IV fluid over 3 hours if patient feels dehydrated PRN up to 5 times a week. 19. Hospital Bed 20. Oxygen 2-4L as needed 21. potassium chloride 20 mEq Tablet, ER Particles/Crystals [**Name (STitle) **]: One (1) Tablet, ER Particles/Crystals PO twice a day. Disp:*60 Tablet, ER Particles/Crystals(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Physicians Home Care Discharge Diagnosis: Primary Diagnosis: -Non-Small Cell Lung Cancer -Dysphagia Secondary Diagnosis: -COPD -GERD -Ulcerative Colitis 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: Dear Ms. [**Known lastname 108595**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted due to shortness of breath. After consultation with the pulmonary team, and evaluation with a CT scan we believe the most likely cause of your shortness of breath is progression of your lung cancer. We gave you additional inhaler medications and increased your pain medications in order to make sure that you were comfortable. After consultation with your family and yourself, it was decided that you would go home with continuation of your VNA services. The following changes were made to your medications: - START dextromethorphan/guaifenesin for cough every 6 hours as needed - START senna as prescribed for constipation - START docusate as prescribed for constipation - START fluconazole as prescribed - START lorazepam for anxiety as prescribed - START ipratropium for breathing as prescribed - Finally, your pain medications have been adjusted in conjunction with the palliative care team. Please take your dilaudid and morphine medication as prescribed Follow-up with your oncologist will need to be scheduled after your hospitalization, please see below. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call to rescheudle your appointment within 2-3 weeks [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

19228, 19279

10392, 14403

311, 317

19435, 19435

5734, 5740

20824, 21264

4943, 5041

15875, 19205

19300, 19300

14608, 15852

19618, 20801

5056, 5715

14424, 14582

2960, 3332

264, 273

345, 2941

19380, 19414

19319, 19359

5754, 10369

19450, 19594

3354, 4569

4585, 4927

80,637

131,656

27955

Discharge summary

report

Admission Date: [**2138-7-14**] Discharge Date: [**2138-7-25**] Date of Birth: [**2097-1-9**] Sex: M Service: MEDICINE Allergies: Morphine Sulfate / Penicillins / Adhesive Tape Attending:[**First Name3 (LF) 99**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Endotracheal Intubation, mechanical ventilation Bronchoscopy Insertion of arterial line, femoral TLC History of Present Illness: Mr. [**Known lastname 3451**] is a 41yo gentleman with h/o melanoma metastatic to his lung, liver, heart, skin, and bone recently treated at an OSH for pneumonia who presents with shortness of breath and fevers. . Much of the history was obtained from the patient's wife as the patient was very sleepy upon arrival to the unit. The patient was admitted to a hospital in [**State 2748**] [**Date range (1) 38269**] with pneumonia. He was discharged on a course of cefuroxime, flagyl, and levofloxacin, which he has since completed. In addition, he was given a 5 week course of prophylactic PO vancomycin given a history of severe C diff colitis in the past. He had been doing well at home, getting about with a walker or wheelchair and improving his PO intake. About two or three days ago, he began to have increased work of breathing. He was having some fevers at home as well but no shaking chills. In addition, he had a cough that was productive, at one point of foul-smelling green sputum. There were times he had some blood-streaked sputum as well. . In the ED, initial VS were: 101.8 rectal 110/70 119 22 99%. CTA chest was negative for PE but showed airspace consolidation suggestive of RLL pneumonia. He was given vancomycin, cefepime, and levofloxacin. In addition, IP was contact[**Name (NI) **] for possible flexible bronchoscopy in the morning to help relieve any obstruction. Because the team was anticipating the possibility of a PE, they also obtained a non-contrast head CT, which unfortunately demonstrated likely new brain mets. Both the patient and his oncologist were informed about this. . His ED course was also notable for an episode when his wife stated he did not respond to verbal or tactile stimuli x 1 minute. This occurred after 1mg IV dilaudid followed 45 minutes later by 1mg IV ativan. When the MD arrived to assess the patient, he was awake and responsive but somewhat consfused. He improved after a dose of narcan. Finally, he received 2L of NS and was started on a NS infusion at 150cc/hr. . Upon arrival to the ICU, he was pleasant but sleepy. He did not feel particularly short of breath. . Of note, Mr. [**Known lastname 3451**] was seen by his oncologist on [**2138-6-11**] and given a 7 day course of levofloxacin for incidentally-noted LUL infiltrate on staging chest CT. . On review of systems, his wife notes that he has had episodes recently of being unresponsive after getting his fentanyl patch similar to what happened in the ED. He also has been having some loose stool lately. Past Medical History: Melanoma metastatic to lung, liver, heart, skin, and bone (spine) s/p high-dose IL-2 x 4 cycles, CTLA-4 antibody in [**5-6**] x 2, then EBRT to T7-T12 spine [**3-9**], currently receiving palliative XRT to hip mets (next dose due [**7-15**]) Hypercholesterolemia Hypothyroidism Sinus tachycardia at baseline Diabetes mellitus [**3-3**] study drug, developed in [**2-7**], diet-controlled h/o C diff colitis h/o severe neuropathy from CR-01 immunotoxin, now improving s/p Right knee surgery s/p Tonsillectomy Recent b/l upper lobe pneumonia treated in CT [**2138-5-30**] . Oncologic History: Pt developed a broken rib in [**2133**],was treated conservatively at the time, intermittently treated with anti-inflammatory agents. He then noticed a small bump adjacent to his sternum, which began to grow through [**2135-4-30**] at which time he was evaluated at [**Hospital 33316**] Hospital in [**Location (un) **], [**State 2748**]. A surgeon performed a FNA biopsy of the parasternal mass which showed metastatic melanoma. Per his most recent oncology note, his prior treatments include: . 1. Biopsy of a parasternal mass at the site of a pathologic sternal fracture which revealed metastatic melanoma in 05/[**2135**]. The patient had no prior history of melanoma and no suspicious skin lesions. 2. Partial sternectomy with resection of the parasternal mass in 07/[**2135**]. 3. High-dose IL-2 at the National Cancer Institute Surgery Branch in 12/[**2135**]. The patient was enrolled in a protocol that involved the administration of TIL generated from the resected tumor. However, no TIL could be grown from the tumor specimen and the patient therefore received only IL-2. 4. Medarex anti-CTLA-4 biomarker trial. Treatment was complicated by several autoimmune side effects including colitis, fever, arthralgias, and elevated transaminases. 5. CyberKnife treatment to an isolated right medial pulmonary mass which was at the time the only growing tumor. 6. Radiation therapy to T7-12. 7. A second cycle of the CTLA-4 antibody in 06/[**2137**]. This treatment was complicated by autoimmune colitis and later, the development of a superimposed C. difficile colitis that failed to respond to Flagyl and required oral vancomycin. 8. Cryoablation of a large LLL mass by Dr. [**First Name (STitle) 4702**] of the Interventional Pulmonary Department in [**Location (un) **], [**State 2748**]. The procedure was complicated by the development of a pneumothorax that required the placement of a Pleurx catheter, which has long since been removed. 9. Treatment at [**Hospital1 56915**] with the CR-001 immunotoxin. This treatment gave rise to a severe peripheral neuropathy that is slowly improving. 10. Off-study Sutent therapy. Social History: Lives in CT with his wife and daughter. [**Name (NI) **] cats and dogs. No alcohol, smoking, or IV drug use. Has home health aide. Family History: Father with melanoma in his 30s. Physical Exam: 97.2 110 117/76 38 99% 2L Very thin, pale man in moderate respiratory distress. Otherwise appears comfortable but very sleepy. +Temporal wasting. No scleral icterus. EOMI. Face symmetric. OP clear, MMM. Neck supple, no JVD, no thyroid enlargement, no palpable cervical adenopathy. S1, S2, regular tachycardia, hyperdynamic PMI, no murmur. Lungs with diffuse coarse crackles throughout, expiratory wheeze R>L. Tachypneic and appears to be using accessory muscles although respiratory pattern somewhat affected by history of excision of part of sternum. +BS, soft, not tender or distended. + hepatomegaly. No LE edema. Distal pulses palpable and extremities warm. Skin is very pale without appreciable rash. Pertinent Results: LABS ON ADMISSION: [**2138-7-14**] 04:30PM BLOOD WBC-9.4 RBC-2.72* Hgb-7.5* Hct-24.2* MCV-89 MCH-27.5 MCHC-30.9* RDW-19.8* Plt Ct-218 [**2138-7-14**] 04:30PM BLOOD PT-15.3* PTT-28.7 INR(PT)-1.3* [**2138-7-14**] 04:30PM BLOOD Glucose-102 UreaN-16 Creat-0.5 Na-134 K-5.5* Cl-98 HCO3-23 AnGap-19 [**2138-7-14**] 04:30PM BLOOD ALT-107* AST-174* LD(LDH)-319* CK(CPK)-29* AlkPhos-503* TotBili-0.5 [**2138-7-14**] 04:30PM BLOOD Albumin-3.0* Calcium-8.3* Phos-4.1 Mg-1.8 . RADIOLOGY: CT Head: IMPRESSION: Interval development of a 12 x 7 mm hyper-attenuating focus located in the right occipital lobe given history of metastatic melanoma is highly concerning for a focus metastasis. This can be more fully characterized with MR examination as clinically indicated. . CTA Chest: 1. Overall, progression of disease in the diffuse metastatic disease involving hilar, mediastinal, and axillary lymphadenopathy, pulmonary metastasis, cardiac, osseous, and hepatic metastases. 2. New multifocal parenchymal airspace consolidation involving the posterior aspect of the right lower lobe, the right middle lobe, that likely represents in multifocal superimposed infection. 3. Post-obstructive changes involving the left upper lobe with associated collapse. 4. No evidence of pulmonary embolism. Brief Hospital Course: Shortness of breath and fevers: Pneumonia. The patient was treated with a course of broad spectrum abx for nosocomial PNA. His fevers improved. He was noted to have hemoptysis and was intubated for resp distress as well as for need for bronchoscpoy. He had tumor bleeding in the RLL and underwent rigid bronchoscopy x 3 for argon treatments and photocoagulation, these were temporarily successful. Finally underwent RLL embolization. This was technically sucessful but hemoptysis continued, patient was extubated w/ a plan for no further reintubation and comfort measures. Patient died on [**7-25**] at 19:27 secondary to pulmonary hemorrhage causing respiratory arrest which is all related to his underlying metastatic melanoma. Medications on Admission: Lexapro 10mg daily Esomeprazole 40mg daily Fentanyl patch 50 mcg per hour Q48H Dilaudid 2 mg Q4H prn pain (very rare use) Maalox, Lidocaine, Benadryl mouthwash Lorazepam 1mg PO Q4H prn (very rare use) Metoprolol succinate 50mg [**Hospital1 **] Sunitinib 50 mg daily currently on day 4 of 10 day course Albuterol inhaler Q2H prn Combivent inhaler Q6H Colace 100mg [**Hospital1 **] Humalog sliding scale (not getting doses b/c sugar not high enough) On vancomycin PO taper: 125mg Q6H x 3 days, then 125mg Q12H x 7 days, then 125mg daily x 7 days Discharge Medications: pt expired Discharge Disposition: Expired Discharge Diagnosis: pt expired Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired

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icd9cm

[ [ [] ] ]

[ "99.29", "33.23", "96.04", "96.72", "96.6", "32.28" ]

icd9pcs

[ [ [] ] ]

9383, 9392

8015, 8754

312, 414

9446, 9458

6713, 6718

9517, 9530

5918, 5952

9348, 9360

9413, 9425

8780, 9325

9482, 9494

5967, 6694

265, 274

442, 2993

7198, 7992

6732, 7189

3015, 5751

5767, 5902

17,088

157,127

27210

Discharge summary

report

Admission Date: [**2110-4-22**] Discharge Date: [**2110-4-25**] Date of Birth: [**2038-6-17**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 297**] Chief Complaint: transfer from [**Hospital3 105**] Major Surgical or Invasive Procedure: Rigid bronchoscopy with removal of tracheal granulation tissue, tracheal dilation and tracheostomy tube change History of Present Illness: 71F transferred from [**Hospital3 105**] for evaluation of blocked tracheostomy tube, increasing ventilatory pressures. Initially at [**Hospital1 **] with trach in place and then she had increasing PEEP and bronch showed 90% stenosis distal to ostomy site. Pt sent to [**Hospital3 **] to have trached changed. On [**3-28**], pt sent to [**Hospital1 1774**] where trach changed to Shiley #7. Bronchoscopy there showed granulation tissue and edema. Transferred back to [**Hospital1 **] and tolerated trach for a while and then became increasingly difficult to ventilate, now granulation tissue at distal portion of trach. On [**4-18**] RT noticed increased airway pressure and replaced T tube with Portex #7 fenestrated tube. Today pt had respiratory arrest and had ET tube passed and non-fenestrated tube placed. Transferred for another change of trach in OR. Transferred on AC 600 X 12 FiO2 50%. Past Medical History: -- Admitted [**12-9**] to [**Location (un) 48951**]with respiratory failure. Found unresponsive at home, intubated in the field. In ED found to be in 3rd degree HB with rate of 20 requiring external PCM. Pt also had R sided PNA and MRSA bacteremia. Tx with Vancomycin and ceftriaxone and transferred to [**Hospital1 **] for vent weaning. Failed vent weaning and was trached. Also with Klebsiella UTI/PNA. Tx with Vanc and Imipenem. Pt then found to have LLL infiltrate with pleural effusion (Klebsiella empyema) that was drained by thoracentesis and then chest tube placed (removed [**2110-3-14**]). -- DM c/b DM nephropathy -- CAD s/p MI -- Anemia of chronic dz -- CRI -- Obesity -- Depression -- Pulm HTN -- CHF -- s/p PEG placement Physical Exam: VS: 99.6 HR 100 BP 197/78 AC 12 X 500 P 10 FiO2 0.5 Peak 50s Gen: NAD, follows commands, answers yes/no questions HEENT: EOMI, PERRL Neck: supple, trach in place, small amount of bleeding around trach Chest: crackles at bases bilaterally CV: RRR, bradycardic, no mrg Abd: soft, NT, +ventral hernia, G tube in place, no drainage around tube Ext: non-pitting edema to Neuro: moves all 4 Pertinent Results: [**2110-4-22**] 132 94 66 AGap=13 ------------< 94 5.4 30 1.6 Ca: 9.3 Mg: 2.5 P: 3.9 98 7.0 \ 11.4 / 221 / 33.6 \ PT: 11.5 PTT: 24.8 INR: 1.0 [**2110-4-24**] 04:24AM BLOOD Glucose-117* UreaN-66* Creat-1.8* Na-134 K-4.8 Cl-97 HCO3-28 AnGap-14 [**2110-4-24**] 04:24AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.5 [**2110-4-24**] 07:09PM BLOOD Type-ART pO2-79* pCO2-46* pH-7.30* calHCO3-24 Base XS--3 Intubat-INTUBATED [**2110-4-24**] 04:24AM BLOOD WBC-5.2 RBC-3.31* Hgb-10.5* Hct-32.2* MCV-97 MCH-31.8 MCHC-32.7 RDW-19.6* Plt Ct-233 [**2110-4-24**] 04:24AM BLOOD TSH-2.2 [**2110-4-24**] 04:24AM BLOOD Free T4-1.4 CHEST (PORTABLE AP) [**2110-4-22**] 1:58 PM CHEST AP: A lucency is visualized in the right apex and at the right lung base. Due to the marked obliquity of this chest x-ray. There is cardiomegaly. The patient is status post tracheostomy. Right-sided effusion is visualized. Emphysematous changes are present. IMPRESSION: Lucencies in the right apical and basilar regions, which could represent a pneumothorax. Due to marked obliquity of this examination, the assessment is difficult. A repeat chest x-ray is recommended. CT HEAD W/O CONTRAST [**2110-4-23**] 1:09 PM IMPRESSION: No evidence of hemorrhage or infarction. CT TRACHEA W/O C W/3D REND [**2110-4-23**] 1:08 PM IMPRESSION: 1. High-grade tracheal stenosis immediately below the tracheostomy which its lower part most probably is due to extensive granulation tissue. High-grade narrowing above the tube insertion may be due to granulation tissue and/or edema. 2. Moderate right-sided pneumothorax. These findings were reported to Dr. [**First Name (STitle) **]. 3. Loculated moderate right pleural effusion and small left one which suggests lung atelectasis. 4. Cardiomegaly. 5. Suspected splenic artery aneurysm. Hypodense lesion in the left kidney, further evaluation with ultrasound is recommended. CHEST (PORTABLE AP) [**2110-4-24**] 6:29 PM IMPRESSION: 1) Tracheostomy tip advanced, now approximately 3 cm above the carina. 2) Ovoid lucencies in the right medial upper lung zone and large lucency at the right lung base likely residual pneumothorax, allowing for differences in positioning, not significantly changed from the prior study. 3) Opacity in the right lower lung zone, corresponds to the known loculated effusion seen on the prior CT. 4) Retrocardiac oapcity, likely effusion and/or consolidation. CHEST (PORTABLE AP) [**2110-4-24**] 8:02 AM IMPRESSION: Improvement of the right pneumothorax. Cardiology Report ECHO Study Date of [**2110-4-24**] 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Brief Hospital Course: 1) Tracheal stenosis: The patient was admitted with tracheal stenosis confirmed by bronchoscopy and tracheal CT. This was relieved [**4-24**] by trach change to longer 8 [**Doctor Last Name 66741**] without complication. She was discharged on pressure support [**10-9**] on 30% oxygen breathing comfortably. She should return in approximately 1 month for another trach replacement. 2) Right sided ptx: Incidentally noted was a right sided pneumothorax. This was followed with serial chest X-rays and thoracentesis or chest tube were not felt to be indicated. 3) Splenic aneurism and kidney hypodensity, incedental. The patient was noted to have these findings on CT. Outpatient ultrasound can be considered to follow up these findings. 4) Hyptertension: the patient was noted to have hypertension to the 130-170s and was treated with her usual medications (clonidine patch, coreg, lasix), except captopril was discontinued in favor of hydralazine as her creatinine was increasing. 5) History of CHF: She is on bet blockade but no ACE inhibitor, which was not felt to be necessary as her echo showed EF 60%, 1+AR, no WMA. She was continued on lasix 40 [**Hospital1 **]. 6) DM2: She was continued on lantus 24 QHS with TFs (Glucerna), ISS, and reglan for gastroparesis. 7) Depression: Celexa was continued. 8) Anemia of chronic disease: She is on iron and Epo 9) Code: Full Medications on Admission: Meds on admission: Tylenol 650 mg q 4 prn [**1-6**] NTP prn for BP > 160 Combivent q 4 hours Iron 325 mg TID Lasix 40 mg PO BID Epo 20K Monday and Friday Lantus 24 units qHS RISS Clonidine patch (due 0.3 mg QWednesday) Prevacid 30 mg PO qD Reglan 10 mg PO Q8H ASA 81 Heparin 5000 SC TID captopril 12.5 mg TID Coreg 3.125 mg Po BID Celexa 20 mg PO QD Glucerna TF 70 ml/hr continuous, 200 ml free water Q12H Beneprotein 1 scoop [**Hospital1 **] Vitamin C 500 QD Zinc 220 mg QD Xenaderm [**Hospital1 **] to sacral area Bacitracin to G tube site Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection injection Injection TID (3 times a day). 6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for G tube site. 10. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Four (24) units Subcutaneous at bedtime. 11. Insulin Regular Human Injection 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol 90 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation Q6H (every 6 hours) as needed. 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation QID (4 times a day). 15. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 17. Lidocaine HCl 1 % Solution Sig: One (1) ML Injection Q1-2H () as needed. 18. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO DAILY (Daily). 19. Sodium Chloride 0.9 % Solution Sig: One (1) flush Injection DAILY (Daily) as needed. 20. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours: hold for systolic pressure less than 100. Disp:*0 * Refills:*0* 21. Epogen Injection Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary tracheal stenosis Secondary diabetes respiratory failure hypertension CHF depression anemia Discharge Condition: patient was ventilated on PS 10/0 30% and appeared comfortable, alert and oriented, and vital signs were stable. Discharge Instructions: You may return to [**Hospital3 105**] and have your previous care resumed. Please see discharge summary for notes about your hospitalization. Followup Instructions: With your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 66742**] to be coordinated by [**Hospital3 105**]. Also, please return to [**Hospital1 18**] pulmonary division or MICU in approximately 1 month for replacement and inspection of your tracheal tube.

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icd9cm

[ [ [] ] ]

[ "33.21", "31.99", "96.6", "97.23", "96.71", "31.5" ]

icd9pcs

[ [ [] ] ]

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5487, 6869

305, 418

9492, 9606

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33282

Discharge summary

report

Admission Date: [**2118-4-8**] Discharge Date: [**2118-4-14**] Date of Birth: [**2052-8-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: jaundice/abdominal swelling Major Surgical or Invasive Procedure: hemodialysis line placement History of Present Illness: HPI: 65 yo M with h/o HTN p/w increasing abdominal girth and jaundice found to have liver failure and erythrocytosis. Pt was in his USOH until approximately 4 weeks ago when he developed increasing abdominal swelling, yellowed skin and worsening fatigue. He gained approximately 10 pounds over 2 weeks before seeing his PCP who noted some abnormal labs. Pt recalls that he had an elevated creatinine and bilirubin. He was referred by his PCP to [**Name Initial (PRE) **] gastroenterologist. Pt had an EGD performed which demonstrated no varices per the pt, though it did demonstrated "small ulcers." Pt also had a CT torso [**2118-3-25**] at [**Hospital1 **] showing an enlarged and heterogeneous liver, indicating either cirrhosis with regenerating nodules or dysplastic nodules. The pt was started on diuretics and lost approximately 12 pounds. The patient's gastroenterologist recommended the pt be electively admitted to [**Hospital1 18**] for further evaluation. . In the ED, vitals: t95, bp 110/64, hr 56, rr 16, sat 97% ra. Labs notable for hct initially 70->66, plt 146. BUN 75, cr 3.5. AG 23. INR 3.5. AST 184, ALT 48. T bili 55, d bili 30, AP 238. S/U tox negative. U/A with 3-5 wbcs, mod bacteria. CXR neg for an acute process. Abd u/s with portal vein thrombosis and cirrhotic liver. ekg: nsr@61 bpm, rbbb. Heme saw pt for erythrocytosis and phlebotomized one unit from pt. Pt transferred to the MICU for further management. . ROS: As above, otherwise denies CP/SOB/fever. Past Medical History: hypertension Social History: sh: lives with wife, [**Name (NI) **] 1 ppd x 50 yrs, etoh: 4 drinks/wk, no illicits, mechanical engineer Family History: fh: Father with polycythemia or hemachromatosis,treated with periodic phlebotomy until death at 74yrs. Mother with DM2, HTN. Daughter with MS. Physical Exam: Temp 97.1 BP 94/55 Pulse 62 Resp 20 O2 sat 96% ra Gen - comfortable, no acute distress HEENT - PERRL, sclera icteric, mucous membranes dry Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs appreciated Abd - palpable liver extending 8 cm below costal border and across midline, mildly tender to palp, distended, normoactive bowel sounds Extr - trace edema in LEs. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, no asterixis Skin - + jaundice, +palmar erythema rectal: in ED, black stool, guaiac positive Pertinent Results: ekg: nsr@61 bpm, rbbb . abd u/s: IMPRESSION: 1. Left portal vein thrombosis. This finding appears to have been present on prior ultrasound and CT examinations. . 2. Biliary sludge and stones but no secondary findings to suggest acute cholecystitis. Trace amount of pericholecystic fluid and hepatic dome ascites. . 3. Diffusely heterogeneous and coarsened liver echotexture with nodular external contour, likely related to underlying cirrhosis. No focal underlying intrahepatic masses were identified. A biopsy may be of benefit for pathologic evaluation. . cxr: IMPRESSION: No acute intrathoracic pathology including no pneumonia . [**2118-4-8**] 10:35PM HAPTOGLOB-LESS THAN [**2118-4-8**] 09:30PM URINE HOURS-RANDOM [**2118-4-8**] 09:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2118-4-8**] 09:30PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 [**2118-4-8**] 09:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-1 PH-7.0 LEUK-TR [**2118-4-8**] 09:30PM URINE RBC-[**6-28**]* WBC-[**3-23**] BACTERIA-MOD YEAST-NONE EPI-[**6-28**] TRANS EPI-[**3-23**] RENAL EPI-[**3-23**] [**2118-4-8**] 09:30PM URINE BILICRYST-MOD [**2118-4-8**] 06:50PM WBC-6.8 RBC-6.67* HGB-21.5* HCT-66.7* MCV-100* MCH-32.2* MCHC-32.1 RDW-22.9* [**2118-4-8**] 06:50PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-2+ STIPPLED-1+ HOW-JOL-1+ PAPPENHEI-1+ [**2118-4-8**] 06:50PM PLT SMR-LOW PLT COUNT-146* [**2118-4-8**] 05:50PM estGFR-Using this [**2118-4-8**] 05:50PM LIPASE-38 [**2118-4-8**] 05:50PM ALBUMIN-3.7 IRON-85 [**2118-4-8**] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2118-4-8**] 05:50PM WBC-7.37 RBC-7.08* HGB-22.3* HCT-70.6* MCV-100* MCH-31.5 MCHC-31.6 RDW-21.1* [**2118-4-8**] 05:50PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-2+ STIPPLED-1+ PAPPENHEI-1+ [**2118-4-8**] 05:50PM PLT SMR-LOW PLT COUNT-147* [**2118-4-8**] 05:50PM PT-33.8* PTT-58.8* INR(PT)-3.5* Brief Hospital Course: 65 year old man with history of hypertension p/w increasing abdominal girth and jaundice found to have liver failure, renal failure and erythrocytosis . Liver failure: On admission, the ultrasound demonstrated that the patient's liver was diffusely heterogeneous with no discreet mass. Imaging was consistent with cirrhosis, though biopsy would be needed to confirm diagnosis. The differential diagnosis was broad, including infectious disease, autoimmune disease, and inherited disorders, such as hemosiderosis, which was strongly considered given the positive family history. The liver service was consulted and a full work-up was initiated. Hepatitis serologies were unremarkable. An AFP> 1 million was concerning for HCC. Iron studies were suggestive of hemochromatosis and hemochromatosis gene analysis was positive for a homozygous C282Y mutation. An abdominal MRI demonstrated background hemosiderosis, a large left lobe liver mass compatible with hepatoma invading left portal vein with left portal vein thrombosis, and additional multifocal areas of signal abnormality scattered throughout both lobes of liver compatible with multifocal hepatoma. It was felt that the patient had developed cirrhosis secondary to hemochromatosis and in turn developed malignant transformation. The liver oncology service was consulted and felt that given the multifocal involvement, locoregional therapies or transplantation were not indicated. Sorafenib was felt to be of limited benefit. The patient declined further aggressive chemotherapy and elected to be comfort measures only. He was discharged home with hospice. . erythrocytosis: The differential diagnosis included polycythemia [**Doctor First Name **] vs. epo producing neoplasm such as hepatocellular carcinoma. The patient had an elevated epo level and evidence of HCC as above. The patient was treated with serial phlebotomy per the hematology service. . renal failure: The renal service was consulted. The patient was felt to have hepatorenal syndrome. Dialysis was initiated in-house and was discontinued on discharge given the change toward hospice care. . portal vein thrombus: Felt to likely be associated with HCC. Anti-coagulation was initially held given the patient's occult blood positive stool. Further therapy was held given the patient's change in goals of care toward palliation. . hypertension: The patient's home medications were held given his borderline blood pressures throughout the admission. . FEN: The patient was placed on a renal diet. He was given dextrose IV as needed for hypoglycemia. . ppx: The patient was placed on heparin sc throughout the admission. . Communication: Multiple family meetings were held with the patient, his wife and children involved. Medications on Admission: Toprol XL another antihypertensive - name not known 2 new diuretics, name unknown Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Comfort medications per discharge planning sheet. Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: liver failure, suspected hepatocellular carcinoma hepatorenal syndrome erythrocytosis Discharge Condition: The patient is comfortable. Discharge Instructions: The patient is being discharged home with hospice.

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icd9cm

[ [ [] ] ]

[ "38.95", "38.99", "39.95" ]

icd9pcs

[ [ [] ] ]

8026, 8077

4927, 7671

342, 372

8207, 8237

2827, 4904

2063, 2208

7803, 8003

8098, 8186

7697, 7780

8261, 8314

2223, 2808

274, 304

400, 1887

1909, 1923

1939, 2047

10,852

128,289

50265

Discharge summary

report

Admission Date: [**2127-4-22**] Discharge Date: [**2127-4-25**] Date of Birth: [**2065-3-16**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Albuterol Attending:[**First Name3 (LF) 1899**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation/extubation History of Present Illness: 62 yo [**Location 7979**] female with history of morbid obesity, diastolic congestive heart failure, type II diabetes mellitus, HTN, h/o afib and PE on coumadin (recently transition to Lovenox from warfarain for a scheduled OPT colonoscopy), pulmonary HTN and HLD who BIBEMS with HTN urgency with findings consistent with flash pulmonary edema. . Per pt's daughter, pt was undergoing bowel prep for her colonoscopy the night prior and was not wearing her BIPAP at home when she went to bed. PT awoke around 3AM, not wearing home BIPAP, acutely SOB and hypertensive to 220/140 per EMS report, got 12 SL nitro on transfer. There was no reported Chest pain per daughter the night prior, unclear if there is associated CP during the acute episode. For her scheduled opt [**Last Name (un) **], she was transitioned to lovenox from warfarin recently. She was on warfarin for her history of Afib and PE. She is also on amiodarone for her Afib. . ED Course: Patient's initial vitals were 103 224/104 28 97% on BIPAP, off BIPAP 76%. She was fighting the BIPAP and had vomitting episodes prior to recieving zofran, no observed aspiration event per report. Nitro gtt was started. EKG: ST@100 LBBB c/w prior EKGs. pCXR: bilat lower lobe whiteout. Given concern for ventilation and airway protection, she was intubation w/ Etomidate 40 Succ 160. pCXR: ETT and OGT in place. Her vitals prior to transfer: 64 91/56 17 99% on CMV (PEEP 10, FiO2 100%, RR 15 TV550; pH 7.29 pCO2 55 pO2 83 HCO3 28) off propafol now on fentanyl and versed. She also recieved Lasix 150 IV x1 for treatment of her pulmonary edema. Contact: [**Telephone/Fax (1) 104829**] [**Doctor Last Name **] daughter. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes (DM), +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: CATH '[**23**] (no intervention) -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Costochondritis Coronary Artery Disease Pulmonary Hypertension h/o PE Diastolic Congestive Heart Failure (EF >55% 03/09) OSA (cpap 7cm H2o at home with O2) Bradycardia DM II Hypertension Dyslipidemia AFib on coumadin (recently started on lovenox for a colonoscopy) Possible renal infarct presumably due to cardiac source of embolus s/p hysterectomy ~20 yrs ago for fibroids Social History: No tobacco, EtOH, substance abuse. Lives in [**Location 686**] with her daughter. [**Name (NI) **] 5 children, 15 grandchildren. Previously a preschool teacher, but working to get disability d/t her MMP. Family History: mother: brain tumor, osteoporosis father: lung CA (smoker) 8 sisters, 2 brothers; one sister with "[**Last Name **] problem, smoker", HTN; another sister with "tumor removed from brain, breast, stomach" Physical Exam: On admission: VS: T=98.7 BP=121/70 HR=60 RR=15 O2 sat=98% on CMV GENERAL: intubated, sedated, moving all 4 extremities freely. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, unable to assess JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: intubated, b/l breath sounds noted. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On discharge: _________ Pertinent Results: Labs: WBC: [**2127-4-22**] 05:00AM BLOOD WBC-14.7*# RBC-4.48 Hgb-13.0 Hct-40.8 MCV-91# MCH-29.1 MCHC-31.9 RDW-15.3 Plt Ct-437# [**2127-4-23**] 05:28AM BLOOD WBC-8.4 RBC-3.51* Hgb-10.3* Hct-31.5* MCV-90 MCH-29.4 MCHC-32.8 RDW-15.4 Plt Ct-295 [**2127-4-24**] 06:00AM BLOOD WBC-6.9 RBC-3.45* Hgb-10.5* Hct-31.1* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.5 Plt Ct-291 [**2127-4-25**] 06:00AM BLOOD WBC-6.6 RBC-3.72* Hgb-11.2* Hct-33.8* MCV-91 MCH-30.1 MCHC-33.1 RDW-15.7* Plt Ct-309 BASIC COAGULATION (PT, PTT, PLT, INR): [**2127-4-22**] 05:00AM BLOOD PT-14.1* PTT-21.1* INR(PT)-1.2* [**2127-4-23**] 05:28AM BLOOD PT-14.8* PTT-27.5 INR(PT)-1.3* [**2127-4-24**] 06:00AM BLOOD PT-14.5* PTT-26.9 INR(PT)-1.3* [**2127-4-25**] 06:00AM BLOOD PT-15.2* PTT-27.0 INR(PT)-1.3* Chemistry: [**2127-4-22**] 05:00AM BLOOD Glucose-240* UreaN-13 Creat-1.5* Na-142 K-2.8* Cl-99 HCO3-22 AnGap-24* [**2127-4-22**] 02:44PM BLOOD Glucose-141* UreaN-16 Creat-1.6* Na-143 K-4.4 Cl-107 HCO3-23 AnGap-17 [**2127-4-23**] 05:28AM BLOOD Glucose-154* UreaN-17 Creat-1.6* Na-141 K-3.9 Cl-104 HCO3-30 AnGap-11 [**2127-4-23**] 03:08PM BLOOD Glucose-246* UreaN-18 Creat-1.6* Na-140 K-4.3 Cl-103 HCO3-29 AnGap-12 [**2127-4-24**] 06:00AM BLOOD Glucose-167* UreaN-22* Creat-1.5* Na-140 K-3.8 Cl-101 HCO3-30 AnGap-13 [**2127-4-25**] 06:00AM BLOOD Glucose-142* UreaN-19 Creat-1.4* Na-145 K-4.1 Cl-105 HCO3-31 AnGap-13 Cardiac Enzymes: [**2127-4-22**] 05:00AM BLOOD CK-MB-4 proBNP-806* [**2127-4-22**] 05:00AM BLOOD cTropnT-0.01 [**2127-4-22**] 02:44PM BLOOD CK-MB-5 cTropnT-0.08* [**2127-4-22**] 10:04PM BLOOD CK-MB-4 cTropnT-0.05* Elements: [**2127-4-22**] 02:44PM BLOOD Calcium-8.4 Phos-3.6 Mg-1.5* [**2127-4-23**] 05:28AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8 [**2127-4-23**] 03:08PM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0 [**2127-4-24**] 06:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9 [**2127-4-25**] 06:00AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.8 TFTs: [**2127-4-22**] 02:44PM BLOOD TSH-10* [**2127-4-23**] 05:28AM BLOOD Free T4-1.3 [**2127-4-22**] 02:44PM BLOOD T4-9.0 Microbiology: [**2127-4-22**] MRSA Screen NEGATIVE [**2127-4-21**] VRE Screen NEGATIVE Urine: [**2127-4-22**] 10:32AM URINE Osmolal-368 [**2127-4-22**] 10:32AM URINE Hours-RANDOM UreaN-277 Creat-83 Na-76 K-47 Cl-98 [**2127-4-22**] 10:32AM URINE Eos-NEGATIVE [**2127-4-22**] 06:45AM URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2127-4-22**] 06:45AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 Imaging: - Portable TTE (Complete) Done [**2127-4-22**] at 1:00:00 PM FINAL Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.1 cm <= 5.2 cm Right Atrium - Four Chamber Length: *7.6 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: 0.30 >= 0.29 Left Ventricle - Ejection Fraction: 50% >= 55% Left Ventricle - Lateral Peak E': *0.05 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *27 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A ratio: 2.40 Mitral Valve - E Wave deceleration time: 211 ms 140-250 ms TR Gradient (+ RA = PASP): *36 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2125-3-5**]. LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded, although in the short-axis views there is a suggestion of focal inferoseptal hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Hypertrophied and mildly dilated left ventricle with borderline systolic function, most consistent with hypertensive heart. No clinically-significant valvular disease seen. Mild pulmonary hypertension. - ECG Study Date of [**2127-4-22**] 4:50:26 AM Marked baseline artifact. P waves are poorly visible but there appears to be a P wave with prolonged A-V conduction in lead V1 which is not visible in any other lead. Complete left bundle-branch block with secondary ST-T wave changes. Compared to the previous tracing of [**2125-7-12**], though the heart rate has increased, there are no other diagnostic interval changes. - CHEST (PORTABLE AP) Study Date of [**2127-4-22**] 4:55 AM IMPRESSION: Severe pulmonary edema with some pleural effusion and bibasilar atelectasis. - CHEST (PORTABLE AP) Study Date of [**2127-4-23**] 7:25 AM FINDINGS: As compared to the previous radiograph, there is no relevant change. Moderate cardiomegaly, moderate pulmonary edema. No pleural effusions. No newly occurred focal parenchymal opacities. - ECG Study Date of [**2127-4-24**] 4:26:00 AM Sinus rhythm. Left bundle-branch block. Borderline Q-T interval prolongation. Non-specific ST segment changes in the high lateral leads. Compared to the previous tracing of [**2127-4-23**] the ventricular response rate has increased. Brief Hospital Course: 62 yo [**Location 7979**] female with history of morbid obesity, diastolic congestive heart failure with an EF of 55%, type II diabetes mellitus, HTN, h/o afib and PE on Coumadin (recently transition to Lovenox from warfarin for a scheduled OPT colonoscopy), pulmonary HTN and HLD who BIBEMS with HTN urgency with findings consistent with flash pulmonary edema, was intubated in ED for airway protection. . # HTN urgency: On arrival, the patient's BP was noted to be 220/140 per EMS, with a CXR with bilateral lower lobe whiteout. The concern was for flash pulmonary edema in the setting of hypertension. The cause of the patient's hypertension was unclear, although it might be have been attributable to the large volume fluid shift in the setting of her bowel prep for colonoscopy, scheduled to take place the day of her admission. The patient was brought up to the CCU on a nitro gtt, which was eventually weaned off. She was also intubated in the ED given the concerns for ventilation and airway protection. She was given IV Furosemide in the ED, and upon transfer to the ICU was given 150 mg IV Lasix x 2, with a small response in urine output less concerning for volume overload and more consistent with flash pulmonary edema. She was extubated the same afternoon with good oxygenation on 4 L, which apparently is her home dose of O2 as well. While an inpatient, we started the patient on a wean off her clonidine, and discontinued the patient's nifedipine, isosorbide mononitrate, and metoprolol. By her discharge, we had increased her furosemide to 100 mg [**Hospital1 **] from 80 mg [**Hospital1 **], and had started the patient on Labetalol 200 mg TID, in addition to Amlodipine 10 mg QHS. On this regimen, the patient's blood pressures were slightly better control, with systolics in the 120s to occasionally the 180s. As an outpatient, the patient will require further titration of her blood pressure medication, but will also require a work-up for causes of secondary hypertension; we suggest starting with a renal MRI to assess for fibromuscular dysplasia versus renal artery stenosis, with a plan to explore other potential causes such as adrenal adenoma in the future if inital work-up is negative. # dCHF: Likely worsened in the setting of hypertensive urgency, which tipped the patient over into flash pulmonary edema. Repeat ECHO showed overall left ventricular systolic function is low normal (LVEF 50-55%). The patient was continued on Lasix for diuresis, a beta-blocker, and [**First Name8 (NamePattern2) **] [**Last Name (un) **]. The patient's beta-blocker was transitions to Labetalol for better BP control # CAD: [**2123**] cath showed no CAD. The patient had a ROMI with troponin peaking at 0.08, and downtrending to 0.01. EKG did not have any concerning ST elevations or depressions, although in the setting of LBBB this was difficult to determine. The patient did have an episode of chest pain 2 nights prior to her discharge: EKG at that time did not show any concerning ST depression or elevation, and the patient's pain was reproducible to palpation, and resolved with 2 mg IV morphine. The patient was discontinued on aspirin 325 daily as well as Atorvastatin 40 mg daily, in addition to her BB, and [**Last Name (un) **]. . # RHYTHM: Patient remained in atrial fibrillation during her hospitalization. She was continued on her home dose of amio and a beta-blocker, ulitmately transitioned to Labetalol. She was started on Lovenox given that her INR was not therapeutic, as she had been getting lovenox as an outpatient in preparation for her colonscopy. She was DC'ed on lovenox bridge to her high dose coumadin, followed by [**Hospital 197**] Clinic. # Pulm HTN/history of PE: The patient is on a home dose of warfarin 40 mg daily, consistent with warfarin resistance. She was discharged on Lovenox, with a plan to discontinue Lovenox once her INR became therapeutic. She is followed by a [**Hospital 197**] Clinic, who was notified her discharge. # [**Last Name (un) **]: Thought to be secondary to poor forward flow and altered hemodynamics. This improved slightly during her admission from 1.6 to 1.4, although not yet back her baseline around 1.2. She will need outpatient follow-up of her creatinine on her current diuretic regimen; her urine studies did not reveal any evidence of AIN # Hypothyroidism: Most consistent with sick euthyroid with TSH of 10 and free T4 of 1.3, did not change home dose of continue levothyroxine at 25mcg daily. # Loose tooth: The patient's left superior incisor fell out of her mouth in the emergency department when the ED had scissored open jaw in order to evaluate airway for intubation. She will require outpatient dental evaluation to see if a replacement can be made and if there has been any underlying trauma to her jaw bone. # HCM: Repeat colonoscopy; last colonoscopy was 3 years ago and revealed adenomas; patient was unable to complete her colonscopy secondary to the above events. ## Transitions of care - Changed patient's home dose of metoprolol to Labetalol, follow BPs carefully - Dental visit to evaluate tooth trauma during intubation - As outpatient, perform MRA of renal arteries to r/o FMD - As an outpatient, perform colonoscopy Admission weight: not performed [**1-29**] intubation Discharge weight: 132.3 kg Medications on Admission: aspirin 325 mg daily clonidine 0.2 mg TID Coumadin "as directed" 30-40 mg daily Diovan (valsartan) 320 mg daily Klor-Con 40mEq [**Hospital1 **] Lantus 52 units QHS levothyroxine 25 mcg daily nifedipine 60 mg [**Hospital1 **] Novolog (insulin aspart) Solution 100 unit/mL : 1 unit TID per sliding scale Toprol XL (metoprolol succinate) 150 mg daily Vitamin D (ergocalciferol (vitamin d2) 50,000 unit weekly amiodarone 200mg daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days: Then decrease to 0.1 mg daily for 3 days, then d/c. 3. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO twice a day. 5. insulin glargine 100 unit/mL Solution Sig: Fifty Two (52) units Subcutaneous once a day. 6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. insulin lispro 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day: per sliding scale . 8. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours): take twice daily until [**Doctor First Name **] at coumadin clinic tells you to stop. Disp:*8 syringe* Refills:*2* 12. amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 13. furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Disp:*150 Tablet(s)* Refills:*2* 14. Outpatient Lab Work Please check Chem-7, PT/INR on Monday [**2127-4-28**] wtih results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 62**] and [**Doctor First Name **] at [**Hospital **] [**Hospital **] clinic at [**Telephone/Fax (1) 104830**] 15. warfarin 5 mg Tablet Sig: Eight (8) Tablet PO Once Daily at 4 PM. 16. atorvastatin 40 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: Acute on chronic Diastolic CHF Hypertensive emergency Diabetes Mellitus Type 2 Dyslipidemia 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 diastolic congestive heart failure, likely from the bowerl prep for the colonoscopy. You were intubated to support your breathing and diuresed with a lasix infustion. Your weight at discharge is 291 pounds. We have adjusted your medicine to help you get rid of additional fluid slowly to get to your dry weight of about 270 pounds. Weigh yourself every morning, call Dr. [**Last Name (STitle) 4888**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your blood pressure was very high which also contributed to your congestive heart failure. We have changed your medicine regimen to help better control your blood pressure. Please buy a blood pressure cuff and check your blood pressure 2-3 times per day. Record results and bring them to all your doctor's appts. . We made the following changes to your medicines: 1. Wean off clonidine by taking 0.1 mg [**Hospital1 **] for 3 days, then 0.1 mg daily for 3 days, then d/c. 2. Discontinue Nifedipine, Isosorbide mononitrate and Metoprolol 3. Increase Furosemide to 100 mg twice daily 4. STart labetolol at 200 mg three times a day for your high blood pressure. 5. Continue Lovenox injections twice daily at home until [**Doctor First Name **] tells you to stop. 6. Start taking Amlodipine 10 mg at night for your high blood pressure 7. Please continue to take 40 mg warfarin daily. [**Doctor First Name **] will call you at home with further instructions. 8. Decrease the Atorvastatin to 40 mg daily because of an interaction with the amiodarone Followup Instructions: Department: LIVER CENTER When: THURSDAY [**2127-5-15**] at 9:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: MONDAY [**2127-4-28**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**] Phone: [**Telephone/Fax (1) 3581**] Appt: [**5-8**] at 2:15pm [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]

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Discharge summary

report+addendum

Admission Date: [**2193-5-10**] Discharge Date: [**2193-5-15**] Service: MEDICINE Allergies: Fentanyl / Penicillins / Ace Inhibitors Attending:[**First Name3 (LF) 4309**] Chief Complaint: hypertensive urgency, chest pain Major Surgical or Invasive Procedure: Left subclavian central line placement History of Present Illness: 84 yo woman with PMH DM/HTN sent in from [**Hospital 100**] Rehab after she awoke this morning with left sided/substernal chest pain. The pain radiated to her back and was pressure like. She got some relief with nitroglycerin and maalox. She also felt nauseated and diaphoretic. She denies shortness of breath, leg pain. . Since hip surgery in [**12-4**], she has had multiple falls. In the ED, SBPs >240 and she had chest pain. EKG was thought to show TW She was on ntg gtt and given morphine IV and Labetalol 20mg x 2 with SBPs still >200. The cardiology fellow was consulted who did not feel she was having an acute coronary event, so she was transferred to the ICU for management of her hypertensive urgency/emergency and chest pain. . ROS: She reports dull abdominal pain and nausea as her current top complaint, [**7-7**]. Her chest pain is slightly better, non quantitated. She vomited twice today. She has constant lower back pain, at baseline. She has had blurry vision for the last 2 weeks. She denies fever, chills, shortness of breath, numbness, weakness. Past Medical History: CAD, s/p CABG [**2176**], MI [**2176**], persistent angina. EF 65%, normal valves [**12-4**] at [**Hospital1 882**] Total hip replacement [**2192-12-28**] at NEBH diabetes mellitus GERD lumbar stenosis/chronic lower back pain diverticulosis bleed [**6-/2192**] HTN H/O CVA optic nerve with seizure - [**2170**] hashimotos thyroiditis interstitial pneumonitis blurred vision note [**2193-4-23**] bilateral edema hyponatremia malnutrition anemia frequent falls CKD baseline creat 1.6 Social History: resident at [**Hospital 100**] Rehab, widowed for >30 years, quit smoking 20 years ago, denies alcohol Family History: Father died at 51 of heart disease, 3 brothers and 1 sister died of heart disease, daughter is alive and healthy Physical Exam: PE: V: 96.8 BP 185/76 (max SBP 250) P82 R20 97% RA Gen: sleeping, no apparent distress when asleep or awake HEENT: Pupils equal round and reactive, OP clear, MMM Neck: right IJ with IV in place Resp: Clear bilaterally CV: RRR nl s1s2 no murmurs Abd: soft, nontender, no organomegaly Ext: trace bilateral edema. left elbow with bandage in place Neuro: alert, oriented to "[**Hospital3 **] ICU" and "[**5-10**]". Pertinent Results: Admission Lab results: [**2193-5-10**] 09:45AM WBC-5.8 RBC-3.98* HGB-12.4 HCT-35.2* MCV-89 MCH-31.1 MCHC-35.1* RDW-16.2* [**2193-5-10**] 09:45AM NEUTS-79.3* LYMPHS-12.5* MONOS-6.4 EOS-1.3 BASOS-0.4 [**2193-5-10**] 09:45AM GLUCOSE-135* UREA N-31* CREAT-1.2* SODIUM-128* POTASSIUM-7.5* CHLORIDE-96 TOTAL CO2-24 ANION GAP-16 [**2193-5-10**] 11:17AM K+-4.6 [**2193-5-10**] 09:45AM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.1 [**2193-5-10**] 09:45AM PT-10.9 PTT-25.8 INR(PT)-0.9 [**2193-5-10**] 09:45AM cTropnT-<0.01 [**2193-5-10**] 06:45PM cTropnT-<0.01 [**2193-5-11**] 08:34AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2193-5-10**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2193-5-10**] 12:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2193-5-10**] 12:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-0 YEAST-NONE EPI-0 . Other pertinent Lab results: [**2193-5-14**] 10:00AM BLOOD ALT-9 AST-23 AlkPhos-102 Amylase-40 TotBili-0.7 [**2193-5-14**] 10:00AM BLOOD Lipase-31 [**2193-5-14**] 10:00AM BLOOD calTIBC-192* Ferritn-1881* TRF-148* [**2193-5-14**] 10:00AM BLOOD TSH-5.1* [**2193-5-14**] 10:00AM BLOOD Free T4-1.6 [**2193-5-13**] 09:58AM BLOOD Cortsol-27.5* [**2193-5-11**] 04:07PM BLOOD Lactate-1.1 [**2193-5-14**] 10:00AM BLOOD Metanephrines (Plasma)-PND . Basic Labs Prior to discharge: [**2193-5-14**] 10:00AM BLOOD WBC-12.3* RBC-3.79* Hgb-11.4* Hct-33.5* MCV-89 MCH-30.1 MCHC-34.1 RDW-16.3* Plt Ct-245 [**2193-5-14**] 10:00AM BLOOD Glucose-105 UreaN-15 Creat-0.9 Na-129* K-4.0 Cl-92* HCO3-24 AnGap-17 [**2193-5-14**] 10:00AM BLOOD Calcium-8.6 Phos-2.6*# Mg-1.7 Iron-95 . Imaging: CTA Chest done [**2193-5-10**]: IMPRESSION: 1) No pulmonary embolus or aortic dissection. 2) Reticular interstitial and ground glass pattern in the lungs which is most compatible with pulmonary fibrosis. . CXR [**2193-5-11**] to check placement of left subclavian central line, r/o PTX Impression: CHEST: A left pneumothorax is present. . CXR checked daily, with slow resolution of small pneumothorax. . CXR [**2193-5-14**] Impression: 1. The left pneumothorax is not visualized. 2. Unchanged interstitial lung disease. No pulmonary edema. Brief Hospital Course: This is an 84 year old woman with history of CAD s/p CABG and HTN who presented with hypertensive urgency in the setting of chest pain, nausea, vomiting, and abdominal pain with new oxygen requirement and altered mental status. Hospital course by problem: . # Hypertensive urgency - The patient was initially put on a labetolol gtt, which was weaned off. She was continued on isosorbide mononitrate, losartan, and metoprolol. HCTZ was held due to hyponatremia. She had one episode of hypotension to SBPs mid 60s, for which a central line was placed, but her BP improved with fluid boluses, and she was subsequently hypertensive, requiring a labetolol gtt again. She never required vasopressors. She was quickly weaned off the labetalol gtt, and metoprolol was decreased to 75 mg PO tid because she was noted to have orthostatic hypotension. Hypertension responded well to Hydralazine PO 10mg QID PRN. On the day prior to discharge, she again became hypotensive, with unclear etiology (no new medications or combinations of meds that day, evidence of new infection). Blood pressure responded to fluid boluses. Blood pressure management was discussed with the patient's daughter and the geriatrics team. Hypertension seems to have a strong component of anxiety in this patient, and she responded well to small, 0.25mg doses of lorazepam. Given the risks of hypotension in this patient, and her ongoing labile blood pressure, it was decided to discharge her on her current antihypertensive regimen (metoprolol, losartan, and isosorbide mononitrate), and to treat acute elevations of blood pressure for anxiety, with small doses of ativan. Additional antihypertensive medications should be avoided if possible, particularly hydralazine which can contribute to delirium. . In addition, plasma metanephrines were sent at request of patient's PCP, [**Name10 (NameIs) **] results were pending at time of discharge. . # Altered mental status/delirium - This was initially thought likely due to receiving ativan and compazine in close proximity to each other. These were held for a time and MS improved, though she waxes and wanes during the day with periods of confusion and inattention. She does very well during the day, especially when she is with her daughters. She generally responds well to redirection, and in particular to talking with her daughter. . # Hypoxia - O2 sats improved after receiving IV furosemide, suggesting she was volume overloaded initially. Weaned off of Oxygen without difficulty. . # Dropped heart beats, possible Mobitz II block - Noted on telemetry to have occasional missed beats, with what appeared to be Mobitz II. Discussed with daughter who would prefer to hold off on cardiac consultation for this problem. [**Name (NI) 227**] that goals of care are moving toward comfort (see below), consideration of pacemaker placement is deferred for now. . # Chest pain - Pain was atypical in nature, but there was initial concern as she does have a history of CAD/CABG, and slight EKG changes were noted in the lateral leads, though this was noted only on 1 EKG and then normalized. CEs were neg X 3. She was continued on ASA, BB, [**Last Name (un) **], nitrate, and statin. . # Nausea, vomiting, abdominal pain - Abdominal pain seems to be primarily related to her chronic back pain, and per daughter she has had chronic nausea since [**Month (only) 547**]. Complained of RUQ pain, but LFTs and pancreatic enzymes were normal. Responded well to Compazine and Maalox. PPI increased to 20mg and pain improved. . # Anemia - Has had a chronic normocytic anemia. Iron studies showed normal iron stores, increased ferritin, low TIBC and low transferrin consistent with chronic inflammation. . # Diabetes - She was continued on 4 units glargine QHS, ISS, DM diet. . # back pain - She was continued on oxycontin. . # depression - She was continued on citalopram. . # Hyponatremia - Originally thought to be hypovolemic hyponatremia, and improved slightly with IVF, but then back to Na 128. HCTZ held, but she remained hyponatremic. Cortisol was elevated consistent with acute illness, TSH mildly elevated but free T4 was normal. Sodium has been stable 129-130 for the last several days of her hospital course. Will need repeat Na as an outpatient. . # Pneumothorax- The patient developed a pneumothorax after placement of a L CVL. This was followed with serial CXRs and resolved. . # Hypothyroidism - Continued levothyroxine. TSH was slightly elevated, but with normal free T4. . # code status - DNR/DNI, confirmed with daughter, who is HCP. Goals of care are moving toward comfort at this point. Palliative care consult at HSL might be appropriate (daughter expressed interest in this), if the geriatrics team agrees. Medications on Admission: -aspirin 81 po qd -calcium carbonate 650 po tid -tylenol 650 mg po q6h standing -vitamin d 1000 u po daily -celexa 20 mg po qd (incr from 10mg on [**2193-5-7**]) -colace 100 mg po daily (stopped [**2193-5-7**]) -flonase 1 sprays each nostril daily -hydrodiuril 50 mg po daily (decreased from 75mg on [**2193-5-7**]) -insulin glargine 4 units daily (decreased from 8 units on [**2193-5-5**]) -insulin regular sliding scale -imdur 120 mg po daily -levothyroxine 112 mcg po daily -ativan 0.25 mg po bid (stopped [**5-9**], was consistently [**Hospital1 **] before that time) -losartan 50 mg po bid -metoprolol 75 mg po bid (decreased from 100mg [**Hospital1 **] on [**2193-5-5**]) -prilosec 20 mg po daily -oxycontin 30 AM 20 HS mg po bid (incr from 20 [**Hospital1 **] on [**2193-5-7**]) -oxycodone 5 mg prn (twice daily on average) -compazine 10 mg po bid (stopped [**2193-5-2**]) -sennakot 2 tabs po qhs -simvastatin 20 mg po qhs (decreased from 40mg on [**2193-5-2**]) Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Calcium Carbonate 650 (1,625) mg Tablet Sig: One (1) Tablet PO three times a day. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 5. Citalopram 20 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). 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 8. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units Subcutaneous at bedtime. 9. Insulin Regular Human 100 unit/mL Solution Sig: as prescribed Injection four times a day: per sliding scale. 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO HS (at bedtime). 11. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for anxiety: for anxiety or for elevated blood pressure. 13. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 16. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QAM (once a day (in the morning)). 17. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QPM (once a day (in the evening)). 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 19. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 20. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO TID (3 times a day) as needed for heartburn or stomach upset. 22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary Diagnoses: Hypertensive urgency, chest pain, orthostatic hypotension, delirium, pneumothorax, hyponatremia. Secondary Diagnoses: Diabetes mellitus type 2. Discharge Condition: stable Discharge Instructions: You were hospitalized with chest pain and high blood pressure. Please take all medications as prescribed. We have made the following changes: -we have stopped your hydrodiuril (hydrochlorothiazide) -we have increased your metoprolol to 75mg three times a day -we have increased your omeprazole to 20mg twice a day If you experience chest pain, extremely high or low blood pressure, shortness of breath, or any other new or concerning symptoms, please call your doctor. Followup Instructions: Please followup with your doctor [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab. Name: [**Known lastname 11592**],[**Known firstname 779**] Unit No: [**Numeric Identifier 11593**] Admission Date: [**2193-5-10**] Discharge Date: [**2193-5-15**] Date of Birth: [**2108-9-3**] Sex: F Service: MEDICINE Allergies: Fentanyl / Penicillins / Ace Inhibitors Attending:[**First Name3 (LF) 5434**] Addendum: Prior to discharge, significant oozing was noted around the central line site. Coags were drawn, and the line was then pulled. Pressure was held for 15 minutes with good hemostasis. The dressing was then checked 60 minutes and 90 minutes later, with no evidence of further bleeding noted. PTT was noted to be elevated at 89, which may have resulted from heparin in the line. The patient will be discharged to [**Hospital **] rehab now, where she can be monitored for further evidence of bleeding. Coags can be repeated tomorrow to check for normalization. This plan was discussed with the geriatric service and the patient's PCP. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - LTC [**Name6 (MD) **] [**Last Name (NamePattern4) 5435**] MD [**MD Number(2) 5436**] Completed by:[**2193-5-15**]

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Discharge summary

report

Admission Date: [**2200-9-26**] Discharge Date: [**2200-11-5**] Date of Birth: [**2160-7-16**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 6169**] Chief Complaint: AML, admitted for sibling (sister) matched allo-BMT. Major Surgical or Invasive Procedure: Chemotherapy Intubation Initiation of Hemodialysis Blood transfusions Platelet transfusions Subclavian line placement Tunneled Hickman line placement x 2 History of Present Illness: Mrs. [**Known lastname 50789**] is a 40 yo F with AML, admitted for a sibling-matched [**Known lastname 51240**]. Onc history: She was first diagnosed with AML approximately 20 years ago when she presented with pancytopenia. She underwent 7+3+3 induction chemotherapy and two cycles of high dose cytarabine consolidation and attained a complete remission. She was lost to follow-up until she presented in [**8-17**] with pancytopenia and AML. She was re-induced with 7+3, received three cycles of high dose cytarabine consolidation, and went into complete remission. She remained in remission until [**6-19**] when she noted increasing lower extremity bone pain and fatigue and a CBC revealed a decreased white blood count with circulating blasts. She was admitted to [**Hospital1 18**], had a Hickman line placed, and was induced with 7+3, again attaining complete remission. Her post-induction course was complicated by E. coli bacteremia for which she was treated with a 14 day course of levofloxacin. Recent history: She had a tooth extraction on [**9-4**]. Following that, she developed some left facial numbness and was treated with Valtrex and clindamycin for possible shingles and tooth infection. She was admitted to [**Hospital1 18**] on [**9-11**] with a fever of unknown source. She was found to have suspected Nocardia bacteremia of an unclear etiology. Her Hickman line was removed, she was treated with Bactrim, became afebrile, and was discharged on [**9-17**] on Bactrim DS 2 tabs tid. Since her discharge she has felt well. She denies fevers, chills, or sweats. She does endorse a congestion sensation in her left sinus but denies any pain or pressure. She denies headaches, sore throat, cough, dyspnea, abd pain, dysuria, diarrhea, or new rashes. Past Medical History: 1. AML - dx 17 yrs ago. in remission after induction chemo. no consolidation therapy. relapsed in [**2198**]. 2. Panic attacks/anxiety 3. Peripheral neuropathy secondary to chemo, responsive to oxycodone. 4. Chronic left sided sinusitis, thought to be due to a structural problem. 5. Ovarian cyst. 6. H/O line infections with E. coli, Nocardia Surgical history: 1. s/p C4-6 fusion due to herniated disk in [**2193**] 2. s/p Tubal ligation. 3. s/p Tonsillectomy. Social History: She lives in [**Location 8117**], NH with her husband and two children, ages 12 and 15. She has previously lived in [**Location **], MA. She is not currently working. They have an adult dog with no medical issues, shots up to date. She has travelled to [**Location (un) 11177**], [**Country 149**] ([**2187**]), NY, ME, PA. No other foreign travel. She does not drink alcohol for a "long time" and smokes marijuana occasionally but quit 3 months ago. She quit smoking cigarettes 3 months ago. Family History: Her mother had a myocardial infarction and died of CVA at a young age. Her father had lung cancer. Physical Exam: T 97 P 70 BP 130/80 RR 18 O2 100% RA Genl: Lying in bed, pleasant, cooperative HEENT: Anicteric, MMM, OP clear Neck: Supple, no appreciable lymphadenopathy or thyromegaly Heart: RRR, nl S1, S2, no extra sounds Lungs: CTA bilaterally, no rales or ronchi Abd: Soft, non-tender, non-distended, normal BS, no hepatosplenomegaly Ext: No edema, cyanosis, or clubbing. 2+ dorsalis pedis pulses bilaterally Neuro: A&O x 3 Skin: Left triple lumen and right Hickman catheter sites with minimal dried blood, otherwise clean. No bruises or rashes. Pertinent Results: Labs on admission: wbc 3.6 N:54.8 L:37.3 M:4.5 E:2.2 Bas:1.2 h/h 11.0/32.2 plt 93 Na 141 Cl 104 BUN 16 glc 110 K 4.4 CO2 27 Cr 0.8 Ca: 9.9 Mg: 2.2 P: 4.2 ALT: 32 AP: 98 Tbili: 0.5 Alb: 4.7 AST: 22 LDH: 209 PT: 12.2 INR: 1.0 Serologies: HIV neg Toxo pos HBcAb neg, HBsAb neg HCV neg RPR neg HSV I IgG pos HIV II IgG neg VZV IgG pos CMV IgG pos EBV consistent with past infection . Imaging: [**2200-9-26**] Chest CT: 1. Partial resolution of multiple bilateral pulmonary nodules. Unchanged nodule in superior segment of left lower lobe. . Lower Ext dopplers [**10-24**]: Technically limited study. No evidence of left lower extremity DVT. . Abdominal Sono [**10-30**]: 1. [**Name2 (NI) **] portal veins are patent with hepatopetal flow. 2. Left and main hepatic veins are patent, with limited evaluation of phasicity secondary to patient respiration. The right hepatic vein is incompletely evaluated. 3. Slight interval decrease in right-sided pleural effusion. 4. Moderate intraabdominal ascites. 5. 2.2 x 1.6 x 1.9 cm hypoechoic lesion adjacent to IVC within right liver lobe. This was not seen on prior ultrasound, but is not significantly changed since prior CT dated [**2200-10-12**], and likely represents a hemangioma. 6. Interval significant decrease in gallbladder wall edema. 7. Stable size of spleen compared with prior CT dated [**2200-10-12**]. . X-ray foot [**10-30**]: Soft tissue changes as described. No fracture or cortical fragmentation . CT head [**11-3**]: No evidence of acute intracranial hemorrhage . CT Torso 9/19:1. Interval development and worsening of diffuse bilateral ground glass opacity within the lungs with multiple areas of more dense nodular opacity and collapse/consolidation of the right lower lobe with bilateral pleural effusions. Differential diagnosis is broad and includes infectious/inflammatory processes, CHF, and ARDS. 2. Splenic infarcts. 3. Large perfusion defect in the right lobe of the liver worrisome for hepatic infarct. The portal vein and hepatic arteries appear patent, although contrast enhancement is less brisk/robust compared to the prior study. The right hepatic vein stump is opacified with lack of opacification of the majority of the right hepatic vein, 4. Anasarca with increased ascites. 5. Bilateral expanded appearance of the flanks with loss of the normal fat plane between the flank musculature that may represent edema or swelling. A hematoma cannot be excluded. . CXR [**11-4**] (last CXR): Right and left central venous lines and ET tube are in stable position. Allowing for marked right-sided rotation, findings are not significantly changed. There are large bilateral pleural effusions and persistent pulmonary vascular congestion and pulmonary edema. No pneumothorax. IMPRESSION: No significant change from the previous exam. . Last Labs: [**2200-11-5**] 02:30PM BLOOD WBC-13.0*# RBC-3.04* Hgb-9.2* Hct-26.3* MCV-87 MCH-30.2 MCHC-34.8 RDW-23.7* Plt Ct-52* [**2200-11-5**] 04:00AM BLOOD Neuts-82* Bands-11* Lymphs-1* Monos-3 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-0 NRBC-124* [**2200-11-5**] 06:58PM BLOOD Plt Ct-24*# [**2200-11-4**] 09:09PM BLOOD FDP-160-320* [**2200-10-14**] 01:00AM BLOOD Gran Ct-4182 [**2200-11-5**] 04:00AM BLOOD Glucose-218* UreaN-78* Creat-1.6* Na-131* K-4.9 Cl-97 HCO3-12* AnGap-27* [**2200-11-5**] 04:00AM BLOOD ALT-1155* AST-2846* LD(LDH)-8580* AlkPhos-722* Amylase-72 TotBili-37.5* [**2200-11-5**] 04:00AM BLOOD Lipase-25 [**2200-10-15**] 12:30AM BLOOD CK-MB-5 [**2200-10-6**] 03:27PM BLOOD proBNP->[**Numeric Identifier **] [**2200-10-6**] 12:00AM BLOOD CK-MB-2 cTropnT-0.02* [**2200-11-5**] 04:00AM BLOOD Albumin-2.8* Calcium-8.2* Phos-5.5* Mg-2.0 [**2200-11-4**] 04:00AM BLOOD Hapto-<20* [**2200-11-5**] 04:00AM BLOOD Vanco-24.0* [**2200-11-5**] 04:00AM BLOOD Cyclspr-512* [**2200-11-5**] 07:50PM BLOOD Type-ART pO2-85 pCO2-39 pH-7.20* calHCO3-16* Base XS--11 [**2200-11-5**] 07:50PM BLOOD Lactate-6.5* [**2200-11-5**] 07:50PM BLOOD freeCa-0.90* Brief Hospital Course: 40 yo with AML admitted for thymoglobulin, cytoxan, and total body irradiation for sibling (sister) matched [**Month/Day/Year 51240**]. . Acute Myelogenous Leukemia: Patient was admitted for sister matched [**Name2 (NI) 51240**]. She received thymoglobulin [33mg on day -3 (0.5mg/kg), 132 mg on days -2, -1 (2mg/kg)], cytoxan 3720 mg (60mg/kg) [**Hospital1 **] on days -5 and-4, and TBI on days -3, -2,-1, and day 0. She received her cells on [**10-2**] (day 0). She experienced a fair amount of back pain with the ATG that was improved with pre-medication with methylprednisolone, up to 100 mg. Several hours following her stem cell transfusion she developed a syndrome of severe body aches (especially in her head, back, and legs), rigors, and tachycardia. This was thought to be a delayed reaction to the ATG and she felt better after being treated with Solu-Medrol, Benadryl, and Demerol. The Solu-Medrol was changed to methylprednisolone and weaned to [**11-19**] daily. After being transferred to the MICU on [**2200-10-22**] for treatment of progressive VOD ( SOS) the patient was continued on daily cyclosporine, initially at 48 mg daily then increased to 54 mg daily to maintain levels of 450-550. The patient was also continued on steroids of methylprednisolone decreased to 5 mg [**Hospital1 **]. Weekly CMV viral load assays were performed which were initially negative. CMV viral load on [**10-31**] was positive at 56,800, then 78,500. The patient was then started on Ganciclovir. The Bone Marrow Transplant team continued to follow the patient during the ICU stay. . Respiratory Failure: On day +2 following her stem cell transfusion she began to complain of a dry cough and required 1-2 L O2 by NC to maintain her sats in the mid 90s. A portable chest X-ray was suggestive of fluid overload but was also worrisome for a diffuse infectious process or an ATG effect. A chest CT scan showed moderate-sized bilateral pleural effusions, scattered nodules, ground-glass opacities in a predominantly perihilar distribution, increased septal lines and periportal edema. These findings were thought to be consistent with interstitial/pulmonary edema, potentially secondary to a diffuse infection. Since the differential included fluid overload, infectious process, and ATG effect, she was treated for all three possibilities with Lasix for diuresis, broad spectrum antibiotics, and Solu-Medrol for ATG effect. A pulmonary consult was also obtained and they agreed with the plan outlined above. Over the course of several days her cough resolved, she became less short of breath, and she did not require any supplementary oxygen. She was diuresed with Lasix with little improvement. Over the next 2 weeks, patient gained >30 pounds from excess volume. Aggressive diuresis was unable to keep the patients ins and outs completely even. The patient had a stable oxygen saturation on 2L, but her breathing became more labored. Eventually, the patient was transferred to the MICU for increasing respiratory distress on [**2200-10-22**]. The patient was electively intubated for airway protection due to worsening encephalopathy and shortness of breath. Patient was ventilated with assist control ventilation with low tidal volumes ranging from 400-500 and low FIO2 40-50%. Attempts to transfer to pressure support were unsuccessful due to patient agitation and discomfort therefore AC was maintained throughout her ICU admission. The differential for respiratory failure remained unchanged and still included fluid overload vs. diffuse infectious process vs. ATG effect. Patient also with low EF with MR [**First Name (Titles) **] [**Last Name (Titles) **] likely contributing to pulmonary edema. In terms of an infectious process there is concern for fungal infection as the patient was severely immunosuppressed. Serial CXR suggestive of pulmonary edema with bilateral infiltrates and round opacities suggestive of aspergillus. Galactomanin was negative, although drawn after initiation of antifungal therapy. Initially, the patient was placed on a Lasix drip increasing to 20 mg per hour with little improvement in diuresis. Patient was started on hemodialysis on day 2 of ICU admission for fluid removal and acute renal failure. Daily HD was performed with removal of up to 5 L of fluid daily with no hemodynamic compromise. Her vital signs remained stable. Patient was also maintained on high levels of pain control and sedation with Fentanyl and Midazolam since attempts to wean her sedation lead to agitation, tachycardia, and episodes of crying (likely secondary to severe pain). In terms of coverage for an underlying infectious process, the patient was treated with Meropenem, Caspofungin, and Acyclovir all dosed with HD. The decision was made not to switch to Voriconazole for coverage of Aspergillus since this medication is hepatotoxic and has numerous drug-drug interactions. The decision was also made to hold off on bronchoscopy for tissue diagnosis given the patient's coagulopathy and critical condition. Vancomycin was added on [**2200-10-28**] after blood cultures grew gram positive cocci in pairs and chains. Surveillance cultures were drawn from all central lines. Patient was also placed on contract precautions for MRSA. On [**10-27**] blood cultures came back positive for Enterococcus, from an unlabelled line. This was sensitive to Vancomycin however. the decision was made to treat through the lines since the risk of removing all lines and placing new lines was significantly higher given her risk of bleeding and coagulopathy. Patient also had a bronchoscopy with BAL performed on [**10-30**] which showed friable mucosa, no lesions or active bleeding. Cultures and cytology pending. The patient remained on mechanical ventilation until she passed away on [**2200-11-5**]. . Renal Failure: Following her transplant her creatinine rose, thought to be due to cyclosporin toxicity. Renal was consulted and with adjustment of cyclosporin, her Creatinine went as low as 1.5 (still above her baseline). The next week, it began to slowly rise, peaking at 3.7 upon admission to the ICU. The renal failure was thoought to be secondary to her progressive VOD. The renal team was reconsulted to assess need for hemodialysis and recommendations for diuresis. Her medications were all renally dosed and eventually dosed with HD. Her BUN and Cr improved with HD coming down to a Cr of 3.0. Renal continued to follow the patient in the ICU and was able to remove large amounts of fluid, up to 5 kg per day with HD. The decision was made to continue intermittent HD vs. CVVH due to the patient's participation in the Defibrotide study since the pharmacokinetics of the drug were unclear and the patient was not to have any procedures performed while receiving Defibrotide. She was continued on daily HD with removal of increasing amounts of fluid every day, up to 6.5 kg daily. Unfortunately, the patient had an obligate intake of over 4 L daily and therefore net fluid removal was approximately 1-2 L daily. Her creatinine remained elevated but decreased from peak to 1.2. Subsequently, the patient missed one day of HD on [**11-3**] due to problems with medication dosing, since the patient required Defibrotide which was restarted. On [**11-4**], HD was attempted by the patient became hypotensive and therefore it was discontinued. On [**11-5**], the decision was made to convert to CVVH due to her low blood pressures and in the hope to remove more fluid over an extended period of time. Unfortunately, CVVH was never started due to the patient's declining hemodynamic status. The patient passed away that same evening. . Venoocclusive disease (VOD) of Liver (Sinusoidal Obstructive Syndrome): During the week of [**10-12**], patient had an isolated slowly rising LDH. Liver ultrasounds were done which showed ascites and patent portal and hepatic vein flow. By [**10-17**] the patient's transaminases were also elevated, and her bilirubin exceeded 2.0. At this point the patient met clinic criteria for VOD (weight gain, bilirubin>2.0, RUQ pain and hepatomegaly). The patient was enrolled in a [**Hospital3 328**] clinical trial of defibrotide, randomized to high-dose treatment. The patient was followed by a study nurse with extensive study guidelines maintained in the patient's chart and a daily log was filled out in the chart. The patient was monitored for side effects including bleeding. In compliance with the study, daily labs were sent including CBC, Coags, LFTs with direct Bili, and Fibrinogen. Initially the patient received q 6 hourly labs including platelets, hematocrit and INR due to high transfusion requirements. The patient required ongoing platelet transfusions to maintain platelets greater than 50,000. The patient consumed platelets at a fast rate and therefore the parameter was reduced to 30,000 since she was not bleeding. The mechanism for her rapidly declining platelets was secondary to the VOD. Platelets were maintained due to the high risk of bleeding with Defibrotide. HIT antibody was sent which was negative. The patient was also transfused for Hct <35 in order to maintain liver perfusion and to optimize platelet function. She completed 14 days of the Defibrotide study on [**10-30**] but was maintained on the drug for continued treatment. Her transfusion requirements eventually decreased given the fact that she was rapidly consuming platelets. From [**10-29**] onwards the patient was transfused for platelets <30 and then <20. On [**10-31**], however, she began to having bleeding from an OG tube that was placed on [**10-30**] and from her ET tube and was transfused to maintained platelets >50. In terms of FFP, she was transfused approximately 1 unit daily to maintain and INR of 1.5 or less. She was transfused for Hct <30 and required one unit on [**10-31**] due to blood loss from her ET/NG tubes. Defibrotide was therefore held for several doses on [**10-31**] due to bleeding. After completing the study she had a RUQ ultrasound which showed no change in her liver and patent vasculature. After the patient stopped bleeding, Defibrotide was restarted at a lower dose. Then, CT scan performed on [**11-3**] showed infarction of a large portion of her liver on the right side with question of right hepatic vein thrombosis. Her liver function tests began to rapidly elevate again to the thousands. Defibrotide was continued in the last days of her life in an attempt to treat her preogressive VOD. Left foot dry gangrene/cellulitis: Initially, her left foot became dusky involving only the heal which became violacious and dark in color. It continued to progressto involve her entire sole and dorsal surface of her foot. Her toes seemed to be primarily involved and eventually became frankly necrotic with dry gangrene. Her right foot did not show similar changes but did have some superficial skin breakdown on the dorsal aspect. Pulses continued to be present with Doppler. Vascular surgery was consulted and continued to follow the patient, with no recommendations for surgery at that time. Most likely cause was the underlying microvascular obstruction from underlying VOD but an embolic source could not be ruled out. Lower extremity dopplers were done to r/out DVT which were negative. Little treatment could be offered due to her coagulopathy and low platelets. Meticulous wound care was performed in order to prevent infection. On [**10-30**], her shin and ankle appeared more erythematous and it appeared as though she was developing cellulitis of her LE which did not progress past her ankle and lower calf. Her plantar and dorsal surfaces of her left foot remained stable although her toes werer frankly gangrenous (dry). ID consult was placed regarding her multiple infections and they did not recommend any further changes to her antibiotic regimen. Meticulous wound care was continued. . Upper GI Bleed: On [**10-30**], NG tube was placed for initiation of a bowel regimen. The tube was placed without trauma, however, given the patient's low platelets and coagulopathy she started to have some bleeding from the OG tube. OG lavage was positive for moderate blood. She was started on IV PPI [**Hospital1 **]. She also developed some blood tinged secretions from her ET tube on [**10-31**]. These persisted throughout the day. She was transfused one unit of RBCs and several units of platelets to keep them greater than 50. DIC labs were sent, for which the interpretation was obscured given her underlying liver disease but were not frankly indicative of DIC (see pertinent labs), although fibrinogen remained elevated. She had intermittent bloody secretions from both her ET and OG tubes over the last few days of her life, on the last day she had dark brown material from her OG tube likely coffee grounds/blood vs. feculent matter. Her Hct remained relatively stable despite this and required minimal blood transfusions for this problem. . CHF/Cardiomyopathy: On day 3 of admission she complained of chest tightness and was noted to have a pericardial friction rub on exam. A TTE showed no pericardial effusion but did reveal moderate tricuspid and mitral regurgitation and global mild to moderate hypokinesis, new from previous echocardiogram. An EKG was unchanged from previous and cardiac enzymes were flat. A cardiology consult was obtained and they felt her chest pain was unlikely to be ischemic in origin or due to pericarditis. They felt that her decreased EF and valvular regurgitation was most likely due to toxicity from her chemotherapy and did not warrant any acute treatment. She continued to complain of mild chest tightness for several days but this gradually dissipated. The patient was chest pain free for the next 3 weeks, although she was tachycardic and hypertensive. Patient's pain was treated and a beta blocker was started on [**10-21**]. She required increased doses of beta blockers with Lopressor 5 mg IV q 6 hrs. Her blood pressure remained borderline high throughout around 140s/80s. Repeat ECHO was performed on [**11-4**] once the patient became hypotensive and CT showed infarction of her liver and spleen. This was essentially unchanged with an EF of 40-50%. It did not show any masses or thrombi. . Coagulopathy: Stable INR <2, also with thrombocytopenia [**3-19**] to hepatic failure and study drug Defibrotide. Patient was transfused with FFP approximately 1 unit daily and for plts <30, or <50 with active bleeding. Towards the last few days of her life, her INR steadily increased to >2.0 despite repeated transfusions of FFP. . Hypothermia: Patient with history of low temps in the past down to 92 F. She was treated with warming blankets when she was hypothermic. She had a long period of time when her temperature was stable, although she became hypothermic again, down to 94F during the last few days. . Gordonia/CMV/Enterococcus infections: Patient initially diagnosed with Nocardia line infection on past admission, incorrectly diagnosed, now thought to be Gordonia. Treated with imipenem, then switched to meropenem as her renal function declined. Likely complicating resp status. She was continued on Meropenum throughout her ICU stay for boad coverage given her immunocompromise. CMV viral loads were drawn weakly and eventually came back positive with 56,800 --> 78,500 copies/ml, which was previously undetectable. This was thought to be due to reactivation since the patient was IgG positive on past admission. In addition, Enterococcus grew from one of her central lines which was Vancomycin sensitive. She was therefore treated with Vancomycin without line removal since the line source was unknown. Surveillance cultures were drawn from each line and labelled but remained negative. It was decided that removal and replacement of her central lines would be far too great a risk given her coagulopathy, low platelets and immunocompromise. Both infectious disease and oncology teams agreed to treat her through the line. . . Rash: Patient noted to have erythematous area over her upper chest and shoulders, thought to be cellulitis, line infection or possibly the onset of GVHD. This rash remained stable, possibly less severe and was followed clinically with continued broad spectrum antibiotic treatment. . Encephalopathy/Altered Mental Status: Essentially unchanged throughout her ICU admission. Patient began to have auditory and visual hallucinations on [**10-8**]. She became agitated at night, showing evidence of delirium exacerbated by her baseline anxiety. Psychiatry was consulted and recommended Haldol. Other psychotropic medications were weaned and Haldol was started. During the next two weeks, the patient became increasingly agitated and confused. The patient's symptoms were felt to be related to uremia, hepatic encephalopathy, Haldol, benzodiazepines, and decreased clearance of morphine. The patient was changed to a fentanyl PCA on [**10-21**] to better control pain/agitation. On transfer to the MICU, patient was much less responsive, moving all extremities and withdrawing to pain, but not following commands. In the ICU, patient remained intubated and sedated. Attempts to wean sedation were unsuccessful since she became agitated, tachycardic, with episodes of crying, likely in a lot of pain. She was continued on heavy sedation for comfort with Fentanyl 50 mcg/hr and Midazolam 1 mg/hr. CT of the head was performed on [**11-3**] which was negative for any bleed or other intracranial changes. Patient remained heavily sedated for pain throughout her ICU admission. . Septic Shock: Patient with dropping blood pressures x 3 days which began on [**11-3**], requiring pressors with Levophed initially and then vasopressin. Her WBC rose to 19 with rising lactate to 7.8 thought to be due to underlying sepsis from her multiple known infections or possibly due to a new infection. On [**11-5**], the patient was on maximum pressors with still dropping blood pressures. On the evening of [**11-5**] her SBP dropped to 40s then not detectable by doppler prior to passing away. The differential remained broad but included pneumonia, line infection, intraabdominal infection given positive for enterococcus, CMV, and gordonia. Surveillance cultures were negative and she was treated with broad spectrum antibiotics, antivirals and antifungals. Her intravascular volume was also maintained with blood products including FFP, pRBCs and platelet transfusion. Eventually the patient also required IVF boluses although this was a last measure given her severe fluid overload. . Liver Infarction/Splenic infarcts: Initially, patient had dramatically elevated LFTs thought to be due to VOD, this improved with treatment with Defibrotide with essentially normalization of her liver function tests but with persistent hyperbilirubinemia. On [**11-1**] her LFTs started to rise slowly, and then very dramatically back into the thousands on [**11-5**]. CT of the abdomen was performed which showed a large area of infarction in the right portion of her liver with multiple splenic infarcts. An embolic source was considered and Echocardiography was performed which was negative for an embolic source. Most likely this was due to thrombosis of hepatic vein which was poorly visualized on sono and CT scan but suggestive of thrombosis. The mechanism for thrombosis was unclear given her severe coagulopathy and low platelets. Defibrotide was continued during her lasts days of life in an attempt to treat her liver disease. Official liver consultation was placed with recommendations for further imaging of the abdomen, however at that stage, the patient was so severely ill that further diagnostic measures were considered futile. . Abdominal distension: CT of the abdomen was negative for obstruction and showed old contrast from prior studies (almost one month prior) still in the colon. On [**11-5**] the patient was noted to have a firm, markedly distended abdomen. Prior exams were positive for edema and distension but her abdomen had always been soft. The patient had a dramatically rising lactate from 4.0 to 7.8 over the span of a few hours and therefore the diagnosis of bowel perforation or ischemia was considered. The decision was made with the ICU team and family to continue current treatment but not to provide any further interventions given her worsening status. Imaging by CT done the day prior did not reveal any obstruction or free air. Surgery was not an option at that stage given her severe hemodynamic compromise, coagulopathy, multiorgan failure as well as underlying infections and immunosuppression, therefore continue supportive measures were continued while treating underlying infections, maintaining blood pressure support and giving blood products as necessary. . Pain: Patient has a history of neuropathic pain in bilateral legs from prior chemotherapy. This was well-controlled during her last admission with oxycontin/oxycodone. She was continued on Oxycontin 10 mg [**Hospital1 **] with oxycodone 5-10 mg prn. After development of VOD/SOS, the patient was presumed to have significant pain from underlying hepatic capsule distension and morphine PCA was started. As her mental status declined, this was changed to a basal fentanyl PCA. Upon transfer to the MICU, she was placed under heavy sedation with Fentanyl and Midazolam. In addition, it was presumed that she had pain from necrosis of her left foot. Attempts at weaning sedation produced agitation and tachycardia with one episode of crying. As such she was maintained on these medications for comfort. She was monitored throughout for signs of pain including agitation and tachycardia. . FEN: Patient was seen by nutrition and started on TPN for nutrition. Careful monitoring of electrolytes which were subsequently managed with HD. Fluid balance was maintained with HD with volume only given as necessary for transfusion/medications. . Prophylaxis: Initially she was not receiving a bowel regimen since she was maintained on TPN. Protonix was given coagulopathy and later increased to [**Hospital1 **] with active GI bleeding. On [**10-30**] and OG tube was placed in order to initiate a bowel regimen. She had not had a BM since being admitted to the ICU but had only been receiving TPN for nutrition. OG tube placement was not difficult however patient did develop positive lavage with frank blood and clots the following morning. As such her bowel regimen was held. Insulin drip for strict glucose control. . Code status: Full. On [**11-5**] discussions with the family during a family meeting concluded that all treatments would be continued but that further treatment would be medically not indicated including cardiopulmonary resuscitation. . Access: R Hickman, L subclavian central line, R femoral HD catheter, A-line . Communication: With husband- ([**Telephone/Fax (1) 51241**] (home), ([**Telephone/Fax (1) 51242**] (cell). Medications on Admission: Bactrim DS 2 tabs po tid Celexa 20 mg po daily Klonopin 1 mg po tid Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: AML anxiety disorder Gordonia bacteremia Acute Renal Failure [**Last Name (un) **] Occlusive Disorder Discharge Condition: Patient passed away on [**11-5**] from cardiac arrest secondary to sepsis Discharge Instructions: none Followup Instructions: none

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Discharge summary

report

Admission Date: [**2149-7-5**] Discharge Date: [**2149-7-11**] Date of Birth: [**2097-7-8**] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Ketorolac / Naproxen Attending:[**First Name3 (LF) 5018**] Chief Complaint: Headache, worse than typical migraine HA Major Surgical or Invasive Procedure: None History of Present Illness: This is a 51yo W with a history of depression and anxiety with ongoing psychosocial stressors, history of pulmonary embolism and hypercoagulability, degenerative disc disease, hypertension and asthma who presents to the ED today with complaints of headache and malaise. The history was obtained from the patient herself, who had just received morphine (2.5mg) and reglan for pain and nausea. She was able to answer some questions related to history, but her answers were short and concise and her speech was quite slurred. She would often fall asleep while speaking with me. The history I was able to obtain was such that the patient was in her usual state of health this morning. This afternoon, she was at the cemetary placing flowers at her mother and grandmother's grave (died > 10 years ago). While walking back to her car, she felt "weird" as if she "was on cloud 9". She confirmed that she felt "high". While driving home, she had to pull over as she felt like her body was "detached" from itself. She described a sensation of feeling "Hot" in spite of "being the driver and sitting right in front of the AC". She had to sit on the side of the road for a while, and felt "sick" and vomitted twice. However, she had to drive her and her family home because there was no one else who was able to drive. At some point during these symptoms, she developed a severe headache (the history is not clear). She describes this as a left sided retroorbital severe dull pain that is unlike her prior migraines. She also described that her whole body hurt, and so EMS was called by son. She was able to admit to me that there have been some recent stressors at home. Her son has [**Name (NI) 3832**] syndrome. Her daughter has bipolar disorder and is currently in a manic phase. She just returned home from the psych hospital and has been difficult to control at home. During this time, she complained that her mouth was dry and asked for a glass of water. At this point during my evaluation, she had the sudden urge to urinate. I had not started a neurological or general physical examination. The nurse arrived and noted that her speech was more slurred than prior - I had not noticed an acute change during my interview, and assumed that the effect was related to opiate narcotics. Her behavior suddenly changed. She became more diaphoretic and agitated. She got up out of bed and started to writhe her arms and legs in a violent, incoordinated and nonpurposeful fashion. She turned to the side and started to vomit repeatedly, yellow contents without food. A trigger was called and the remainder of the team arrived into the room. She received 2mg of ativan and IV zofran, and was transferred to a trauma bay. At this time, she was somnolent, but following some simple commands. Her vitals were hemodynamically stable, but her blood pressure had increased to the 160s-180s range. She was moving all of her extremities well and responding to noxious equally in all four extremities. Her reflexes were symmetric and 2+ with downgoing toes and bilateral [**Doctor Last Name 937**] reflexes. The decision was made to endotracheally intubate this patient. While her airway at this time appeared to be well maintained, it was thought that an MRI and LP would not be possible without sedation and that it would be difficult to predict whether her airway would remain protected overnight. She was endotracheally intubated and sent for CT imaging, including CT/CTA and CTV. She was noted to have some tongue swelling following intubation, and received a dose of IV benadryl. During the CT scan, she was noted to require high amounts of sedation. Past Medical History: - migraines - h/o 3 DVTs and PEs on lifelong anticoagulation, currently on Lovenox since she was not complaint with INR checks. ?Etiology. - recurrent major depression - pulmonary nodule - low back pain [**3-13**] DJD - asthma - HTN - Mild renal insufficiency (baseline Cr 1.2) - hypothryoidism - pituitary microadenoma - anomalous pulmonary venous return - HL - nephrolithiasis - Multiple prior ED visits (see OMR) for varied neurological complaints, including left sided weakness, panpositive ROS, dizziness with limb heaviness, subjective dysesthesias. On examination, at those times, she has had functional neurological examinations, and discharged with neuro urgent care follow up. An MRI has not been done, but CT/CTA/CTPs have been done for at least two prior code strokes. Social History: lives with boyfriend. Daughter has been in psychiatric hospital for several months. 1 pk/day tobacco for 30 years. No EtOH or illicits. Family History: Daughter with bipolar disorder, in psychiatric hospital; son with autism or [**Name (NI) 3832**] Physical Exam: ADMISSION EXAM Physical Exam initially: V/s: HR 74, AF 97.2, 19, 100%, 157/60 General: Sleeping in bed underneath blankets, lights turned off, arousable easily HEENT: NC/AT, tenderness on passive range of motion of neck muscles. Mucous membranes dry, oropharynx is without obvious lesions Neck: Supple, no masses or lymphadenopathy Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: Obese, soft, NT/ND, no masses or organomegaly noted. Extremities: Warm and well perfused Skin: no rashes or lesions noted, no tattoos Neurologic (limited by events noted above) - Able to provide a brief history, with comprehensible dysarthria. No obvious language deficit. Would occasionally fall asleep during my initial examination, but arousable by calling her name loudly. Later, after patient was intubated and sedated. - Bilaterally reactive pupils, grossly full range of EOMs without nystagmus. Symmetric face with a midline tongue. - Moving all extremities well. Symmetric 2+ reflexes throughout. Bilateral Hoffmann's sign. -Sensory: Withdraws to noxious stimuli equally in all four extremities. - Plantar response: Down bilaterally -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred Pertinent Results: [**2149-7-5**] 08:10PM BLOOD WBC-12.8*# RBC-4.81 Hgb-13.2 Hct-42.5 MCV-88 MCH-27.4 MCHC-31.1 RDW-14.5 Plt Ct-275 [**2149-7-10**] 05:55AM BLOOD WBC-12.7* RBC-3.42* Hgb-9.6* Hct-30.4* MCV-89 MCH-28.0 MCHC-31.6 RDW-14.5 Plt Ct-228 [**2149-7-5**] 08:10PM BLOOD Neuts-77.7* Lymphs-18.1 Monos-3.4 Eos-0.3 Baso-0.4 [**2149-7-6**] 03:04AM BLOOD Neuts-73.5* Lymphs-20.5 Monos-5.1 Eos-0.4 Baso-0.5 [**2149-7-5**] 08:10PM BLOOD Plt Ct-275 [**2149-7-6**] 03:04AM BLOOD PT-11.9 PTT-24.5* INR(PT)-1.1 [**2149-7-10**] 05:55AM BLOOD PT-12.5 PTT-64.1* INR(PT)-1.2* [**2149-7-10**] 05:55AM BLOOD Plt Ct-228 [**2149-7-5**] 08:10PM BLOOD Glucose-128* UreaN-23* Creat-1.2* Na-143 K-3.6 Cl-105 HCO3-25 AnGap-17 [**2149-7-10**] 05:55AM BLOOD Glucose-90 UreaN-14 Creat-0.8 Na-140 K-3.4 Cl-105 HCO3-28 AnGap-10 [**2149-7-6**] 03:04AM BLOOD ALT-16 AST-19 LD(LDH)-173 AlkPhos-61 TotBili-0.4 [**2149-7-6**] 03:04AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.9 [**2149-7-10**] 05:55AM BLOOD Calcium-8.8 Phos-4.2# Mg-1.8 Cholest-PND [**2149-7-10**] 05:55AM BLOOD %HbA1c-5.8 eAG-120 [**2149-7-5**] 08:10PM BLOOD CRP-12.3* CTA Head/Neck IMPRESSION: 1. Hypodense area in the left cerebellar hemisphere. Please see subsequent MR head study for further details regarding the multiple acute infarcts. Correlate clinically for etiology. 2. Small focal filling defect in the left proximal vertebral artery with slightly heterogeneous enhancement beyond, however grossly patent more distal vertebral artery on the left. Diminutive right vertebral artery throughout, likely developmental. MR [**Name13 (STitle) 430**] IMPRESSION: 1. Several acute infarcts given the slow diffusion in the bilateral cerebellar hemispheres and in pons, of varying sizes. Mild surrounding edema around the larger area on the left side. No abnormal enhancement. Correlate clinically for etiology. Diminutive right distal vertebral artery. See details on CTA study. TTE No ASD or PFO seen with saline contrast injection at rest. The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No ASD or PFO seen. Symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. [**2149-7-6**] NCHCT IMPRESSION: Evolving infarcts in the bilateral cerebellum and left pons, with increased swelling, slight effacement of the basal cisterns, and slight effacement of the fourth ventricle, but no change in the supratentorial compartment. No acute hemorrhage. [**2149-7-7**] NCHCT FINDINGS: There is continued evolution of infarcts in the bilateral cerebellar hemispheres, left greater than right, and left pons. These areas demonstrate expected progressive hypodensity, without hemorrhagic transformation. Mild diffuse cerebral edema is unchanged, with stable appearance of sulci, ventricles, and basilar cisterns. Midline structures are preserved. Air-fluid levels persist in the sphenoid sinuses, possibly related to intubation. The mastoid air cells and middle ear cavities are clear. Orbits and intraconal structures are symmetric. IMPRESSION: Evolving infarcts in the cerebellum and pons. [**2149-7-8**] NCHCT FINDINGS: There are numerous confluent hypodensities involving the bilateral cerebellar hemispheres and pons, unchanged from most recent NECT. There is no acute hemorrhage, edema, or mass effect. The ventricles are stable in size, but remain slightly dilated compared to baseline. There is no shift of midline structures. Air-fluid levels in the sphenoid air cells likely relate to recent intubation. The remaining visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Evolving bilateral cerebellar and pontine infarctions, without hemorrhage or new infarction. [**2149-7-10**] NCHCT IMPRESSION: No significant change since the prior study of [**2149-7-9**] and bilateral cerebellar and pontine infarcts. Mild ventricular prominence of the temporal horns is again seen. No hemorrhage. [**2149-7-10**] 05:55AM BLOOD %HbA1c-5.8 eAG-120 [**2149-7-10**] 05:55AM BLOOD Triglyc-196* HDL-39 CHOL/HD-5.6 LDLcalc-142* [**2149-7-10**] 05:55AM BLOOD CK-MB-2 cTropnT-LESS THAN Brief Hospital Course: 51yoW h/o venous hypercoagulability, prior DVT/PE on lifelong enoxaparin p/w severe left retro-orbital headache, photophobia, and nausea/vomiting with acute bilateral pontine and cerebellar ischemic strokes while noncompliant with enoxaparin. She was initially intubated for airway protection and monitored in the ICU concerning the possibility of increased ICP. She was temporarily treated with IV mannitol. Fortunately, repeat NCHCTs and her clinical examination did not worsen. Her blood pressures were initially controlled with Nicardipine but this was weaned off. She was anticoagulated with Heparin which was changed to Enoxaparin. After much discussion, she was willing to take Enoxaparin [**Hospital1 **] again and be compliant with this medication after learning the indications for the medication and the reason she should use it. She does notably have bilateral vertebral artery stenoses which might be contributing to her risk for stroke. She was evaluated by Speech, PT, and OT and discharged to rehab. . She was given extensive stroke education and counseling by our team, but remains quite overwhelmed by her new diagnosis and her gait ataxia. We have been encouraging her as much as possible but she will definitely benefit from social work services at rehab. She is a primary caretaker for three family members (daughter with bipolar disorder, son with [**Name (NI) 97158**], father with dementia) and has neglected self-care to some degree due to this. She has no intent to harm herself, but she is discouraged by her current state. . PENDING STUDIES: None . TRANSITIONAL CARE ISSUES: [ ] Anticoagulation - The patient has been noncompliant with her Lovenox/Enoxaparin despite the indication for lifelong anticoagulation (3 DVTs/PEs). She requires anticoagulation and has agreed to continue twice daily dosing now that she understands the reason for taking this (but will require encouragement and guidance). Please consider referring her to Hematology as an outpatient for guidance in management of her venous hypercoagulability and anticoagulation. [ ] PCP Followup [**Name Initial (PRE) **] Please arrange for PCP follow for 1-2 weeks after her discharge from rehab. [ ] Speech - She is cleared for a soft dysphagia diet and thin liquids. Please monitor and advance as tolerated. [ ] Social Work - Please evaluate her, help her cope with her new diagnosis, and help find resources to help her at home if needed. . [ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack ] 1. Dysphagia screening before any PO intake? (X) Yes - () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented? (x) Yes (LDL = 142) - () No 5. Intensive statin therapy administered? (for LDL > 100) (x) Yes - () No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? (x) Yes - () No (Reason () non-smoker - () unable to participate) 7. Stroke education given? (X) Yes - () No 8. Assessment for rehabilitation? (X) Yes - () No 9. Discharged on statin therapy? (X) Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? (x) Yes (Type: () Antiplatelet - (x) Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A (different indication for anticoagulation) Medications on Admission: Atenolol - Lovenox 100mg [**Hospital1 **] - Levoxyl - Zoloft - Wellbutrin Discharge Medications: 1. levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO once a day. 3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. enoxaparin 100 mg/mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours): 100 mg twice daily for stroke/VTE prevention. 7. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, headache. 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Bilateral cerebellar infarctions SECONDARY DIAGNOSIS: Hypertension, Hyperlipidemia, Venous hypercoagulability Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neurologic: Limb ataxia, right greater than left. Discharge Instructions: Dear Ms. [**Known lastname 97159**], You were hospitalized due to symptoms of HEADACHE and NAUSEA/VOMITING resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. We are changing your medications as follows: 1. Please continue to take LOVENOX/enoxaparin 100 mg as an injection just under the skin TWICE DAILY for prevention of STROKE and VENOUS CLOTS. 2. Please take ATORVASTATIN 40 mg one tablet daily for better control of your cholesterol (LDL 142). This will replace your PRAVASTATIN, so stop taking the pravastatin after starting atorvastatin. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek medical attention. In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: NEUROLOGY Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2149-8-11**] 2:30pm, [**Hospital1 69**], [**Hospital Ward Name 23**] [**Location (un) **], [**Location (un) 830**], [**Location (un) 86**], MA [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "722.6", "747.41", "V12.51", "493.90", "781.2", "V58.61", "518.89", "784.51", "289.81", "787.22", "434.11", "780.09", "593.9", "V15.81", "787.01", "401.9", "244.9", "307.9", "272.4", "296.30" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.71", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

15652, 15722

11207, 12784

356, 363

15895, 15895

6431, 11184

18234, 18627

5006, 5105

14730, 15629

15743, 15743

14631, 14707

16128, 18211

5120, 6412

275, 318

12810, 14604

391, 4031

15816, 15874

15762, 15795

15910, 16104

4053, 4836

4852, 4990

25,696

198,770

11470

Discharge summary

report

Admission Date: [**2169-1-19**] Discharge Date: [**2169-2-1**] Date of Birth: [**2118-2-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9598**] Chief Complaint: LE pain and swelling Major Surgical or Invasive Procedure: suction thrombectomy and thrombolysis x 2 History of Present Illness: 50 yo male with hx of metastatic prostate CA to bone, hx of recurrent DVT and PE s/p IVC filter, OSA who presents with worsening LE pain and swelling. Pt was hospitalized [**Date range (3) 36625**] with worsening pain in buttocks, back and LE. LENIs revealed LLE DVT thought [**2-10**] the patient coming off of enoxaparin and multiple subtherapeutic INRs on warfarin. Back pain was thought to be due to spinal metastases, so the pain service was consulted and recommended pain augmenting medical regimen as listed below. He was discharged on enoxaparin for his LE DVT and represented on [**2169-1-19**] with worsening LE pain and swelling. This was felt to be due to clotting around his IVC filter so he was taken by IR on [**1-20**] for catheter thrombectomy of IVC with small amount of local tPA with mild clot lysis after IVC-gram revealed complete thrombosis of IVC filter with thrombus extending to iliacs bilaterally. Plan was then made for continuous localized IV tPA to IVC since pain and swelling were not much improved. During his stay he also developed worsening hematuria while on heparin gtt requiring 1 unit PRBC transfusion. Urology was consulted and felt that the patient may need CBI while on tPA but there was no absolute contraindication and no acute need for cystoscopy. Of note he was also started on ciprofloxacin for dysuria and UTI with Ucx growing E.Coli. After placement of the tPA catheter by IR on [**2168-1-26**], the patient was transferred to the [**Hospital Unit Name 153**] for closer monitoring during continuous tPA therapy. Past Medical History: 1. Metastatic prostate cancer to bone refractory to hormone therapy s/p cycle 1 of Carboplatin and Taxotere [**2168-12-15**]. Dx in [**2163**] as [**Doctor Last Name **] 8 s/p surgical prostatectomy with XRT to t9 spinal metastasis in [**11-11**] followed by hormonal therapy, Taxotere (2 cycles), ketoconazole, hydrocortisone, mitoxantrone, and DES. 2. Bilateral LE DVTs complicated by bilateral PE [**4-/2168**], treated with enoxoparin then warfarin, and status post IVC filter placement 04/[**2168**]. Last with DVT on [**2169-1-7**], now on enoxoparin 160mg daily. 3. Psoriasis 4. Hypercholesterolemia 5. Seasonal allergies 6. Obstructive sleep apnea on CPAP at home Social History: He lives at home with his wife and his 12 year-old son. [**Name (NI) **] does not smoke. Family History: Father had prostate cancer. He has noother relatives with psoriasis and denies thyroid disease,rheumatoid arthritis and lupus in his family. Physical Exam: T 99.5 HR 119 BP 128/79 RR 12 O2Sat 94% RA Gen- Awake, alert, oriented x3, mild distress over pain, pleasant, cooperative HEENT- NCAT, anicteric, EOMI, MM dry Hrt- RR, distant S1 S2, no appreciable murmurs Lungs- clear anteriorly Abd- obese, soft, NT, ND, normoactive bowel sounds Extrem- tight, pitting bilateral edema, dopplerable DP and PT waveforms bilaterally Neuro- A&Ox3, moves all extremeties Pertinent Results: Chem 7 138 101 11 127 AGap=14 4.3 27 1.2 Ca: 9.1 Mg: 1.9 P: 3.0 . WBC 4.8 Hgb 8.5 Plt 224 Hct 26.0 N:59.6 L:30.9 M:7.7 E:1.5 Bas:0.3 . ECG- tachycardic at ~110 bpm, nearly left axis, normal intervals, no LAA, no RAA, no LVH, no RVH, no pathologic Q waves in the lateral, inferior or anterior leads, no ST segment deviations in the lateral, inferior or anterior leads, T wave flattening in leads I and aVL, normal RWP, normal transition . [**2169-1-6**] LE Doppler: Noncompressible DVT in the left CFV, almost occluding the lumen. Normal flow, compressibility, and augmentations are seen in bilateral superficial femoral, and popliteal veins. Noncompressible clot in left greater saphenous vein. No DVT on right. Prior study in [**2168-5-4**] demonstrated bilateral clots. . [**2168-12-30**] MRI L-spine: Bony metastases are visualized in the lumbar vertebral bodies, sacrum and both iliac bones. No significant change is seen. No epidural abscess identified or new epidural mass seen. . [**2168-12-6**] MRI L-spine: Numerous metastatic tumor deposits, with possible small epidural lesions seen anterior to the thecal sac at the L4 and L5 levels, versus distended epidural veins secondary to a moderate posterior disc protrusion at L4-5. . [**6-/2168**] Bone scan: Widespread metastatic disease in multiple ribs, right iliac crest, and vertebra L4. . [**2169-1-6**] BLE U/S: 1. Noncompressible deep venous thrombosis in left common femoral vein almost occluding the lumen. No clot demonstrated distal to superficial femoral vein. 2. Clot in the left greater saphenous vein. 3. No evidence of DVT on the right. . [**2169-1-20**] IVG gram 1. Extensive occlusive thrombus from the common femoral veins bilaterally, involving external and common iliac veins on both sides and IVC to the level of the renal veins. There is complete thrombosis of an IVC filter. 2. Mechanical suction thrombectomy and pulse-spray bolus thrombolysis with partial improvement and better results on the left than on the right. The findings and the results and recommendations to place the patient on heparin were discussed with the managing team. Brief Hospital Course: 50 yo male with hx of metastatic prostate CA to bone, hx of recurrent DVT and PE s/p IVC filter, OSA who presents with worsening LE pain and swelling. . On admission, he had a CT scan that showed clot both cranially and caudally to the IVC filter and extending into the iliac veins bilaterally. On [**1-20**] he had a thrombectomy and local administration of TPA to the clot burden, with minimal result. He was placed on a heparin drip. On [**1-25**], he went back to interventional radiology for further thrombectomy and thrombolysis, accompanied by systemic TPA administration. He was transferred to the [**Hospital Unit Name 153**] for further monitoring given systemic TPA. After the second attempt, a small patency through the femoral veins and into the suprarenal IVC was created, with resolution of the patient's leg pain and swelling. His fibrinogen level, which was initially low, increased. He was placed again on a systemic heparin drip for several days; on [**1-30**] he was transitioned to lovenox 130mg [**Hospital1 **] for discharge. . He had some hematuria during this admission which had resolved by the time the patient was on lovenox. He did not require a foley catheter or continuous bladder irrigation. His appointment with urology was cancelled (as he was an inpatient); it should be rescheduled as an outpatient. . His pain was well-controlled after the procedure, and he was sent home on a minimally changed pain regimen. . On admission he was found to have a UTI with pansensitive Klebsiella; he was treated with a 7day course of ciprofloxacin. A later urinalysis showed >100,000CFU coag negative Staph. . He did have a low grade fever at several times during his hospital stay; all cultures and chest X-rays were negative, and he was not discharged on any antibiotics. Medications on Admission: Oupt meds- 1. Lidocaine 5% patch qd 2. Gabapentin 900mg tid 3. Morphine SR 45mg [**Hospital1 **] prn 4. Hydromorphone 8-16mg q8h 5. Atorvastatin 10 mg qd 6. Acetaminophen 325 mg q6h 7. Enoxaparin 160mg qd 8. Amitriptyline 50 mg qhs 9. Colace 100 mg [**Hospital1 **] 10. Senna 8.6 [**Hospital1 **] . Meds on transfer FoLIC Acid 1 mg PO DAILY Ferrous Sulfate 325 mg PO DAILY Multivitamins 1 CAP PO DAILY Lactulose 30 ml PO TID:PRN Senna 1 TAB PO BID Prochlorperazine 10 mg PO/IV Q6H:PRN [**1-21**] @ 1809 View Morphine SR (MS Contin) 75 mg PO Q8H Ciprofloxacin HCl 500 mg PO Q12H Heparin gtt Lidocaine 5% Patch 1 PTCH TD DAILY Bisacodyl 10 mg PO DAILY:PRN Docusate Sodium 100 mg PO BID Amitriptyline HCl 50 mg PO HS Acetaminophen 325-650 mg PO Q4-6H:PRN Atorvastatin 10 mg PO qd HYDROmorphone (Dilaudid) 8-16 mg PO Q3H:PRN Gabapentin 900 mg PO TID Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 5. Morphine 15 mg Tablet Sustained Release Sig: Five (5) Tablet Sustained Release PO Q8H (every 8 hours). Disp:*450 Tablet Sustained Release(s)* Refills:*0* 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lovenox 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y (120) mg Subcutaneous twice a day. Disp:*60 syringes* Refills:*2* 11. Lovenox 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous twice a day: Please take in combination with 1 80mg dose (total 120mg) twice daily. Disp:*60 syringes* Refills:*2* 12. Hydromorphone 4 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*200 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: IVC thrombus and bilateral common femoral vein thrombi Hematuria, now resolved Metastatic prostate cancer Discharge Condition: good, pain improved, ambulating Discharge Instructions: Please take all of your medications as prescribed. Please attend all of your follow up appointments. If you experience fever, worsening leg pain or swelling, shortness of breath, chest pain, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: 1) Oncology: You have 2 appointments on [**2169-2-16**]: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at 9:00am and RN [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) **] at 9:30am, [**Last Name (un) 469**] 9, ([**Telephone/Fax (1) 36626**] Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-3-9**] 9:00 [**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]

[ "696.1", "599.7", "V10.46", "327.23", "996.79", "453.41", "453.2", "V12.51", "599.0", "V15.3", "041.3", "338.3", "198.5", "453.8" ]

icd9cm

[ [ [] ] ]

[ "93.90", "99.10", "88.51", "99.04", "88.47" ]

icd9pcs

[ [ [] ] ]

9527, 9533

5528, 7324

334, 378

9683, 9717

3369, 5505

10029, 10582

2789, 2932

8222, 9504

9554, 9662

7350, 8199

9741, 10006

2947, 3350

274, 296

406, 1971

1993, 2667

2683, 2773

956

166,142

10714

Discharge summary

report

Admission Date: [**2151-8-19**] Discharge Date: [**2151-8-26**] Date of Birth: [**2088-9-11**] Sex: M Service: CARDIOTHORACIC Allergies: Vasotec Attending:[**First Name3 (LF) 1505**] Chief Complaint: 62M w/ increasing DOE Major Surgical or Invasive Procedure: MV repair(28mm Physio ring) [**2151-8-19**] History of Present Illness: This 62M has a history of CAD w/ prior MIs and has had increasing DOE and a murmur for the past 10 years. He has been followed by serial echos and a recent echo revealed severe MR. [**Name13 (STitle) **] had a cardiac cath [**2151-7-22**] which showed: 4+MR, an LVEF of 25%, a 30% RCA stenosis. He is now admitted for elective MVR with Dr. [**Last Name (STitle) **]. Past Medical History: CAD, s/p PTCA [**2140**] COPD BPH bladder ca gout HTN NIDDM psoriasis cardiomyopathy s/p MIx2 CHF GERD PVD w/LLE claudication s/p multiple cystoscopies s/p vasectomy and reversal of vasectomy s/p R eye tumor removal s/p L hand surgery s/p choley Social History: Pt. is a nurse who lives with his son and grandson. Cigs: smoked 3ppd for many years, currently smokes 4 cigs/day. ETOH: none x 5 years Family History: Sister w/ CAD Physical Exam: [**Male First Name (un) 4746**] in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no thyromegaly or lymphadenopathy, carotids 2+=bilat. without bruits. Lungs: Clear to A+P CV: RRR without R/G/M Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: no C/C/E, pulses: R fem and PT=1+ R DP and rad=2+ L Fem, DP, Rad.=2+ L PT=1+ Neuro: nonfocal Pertinent Results: [**2151-8-25**] 02:24AM BLOOD WBC-8.9 RBC-3.60* Hgb-9.3* Hct-28.4* MCV-79* MCH-26.0* MCHC-32.9 RDW-16.6* Plt Ct-306 [**2151-8-25**] 09:00AM BLOOD PT-19.3* PTT-63.5* INR(PT)-1.8* [**2151-8-25**] 02:24AM BLOOD Glucose-133* UreaN-18 Creat-1.0 Na-133 K-4.4 Cl-96 HCO3-27 AnGap-14 Brief Hospital Course: This pt. was admitted on [**2151-8-19**] and underwent MV repair with a 28mm CE Physio ring. He tolerated the procedure well and was transferred to the CSRU in stable condition on Dobutamine, Neo, and Propofol. He was extubated on POD#1 and had his chest tubes d/c'd as well. He remained on Dobutamine and this was weaned slowly over the next few days. He went into AF and was started on Amiodorone. He required respiratory therapy and was transferred to the floor on POD#4. He continued having intermittent AF and was anticoagulated with heparin and coumadin. His epicardial pacing wires were d/c'd on POD#5. He continued to progress and was discharged to home in stable condition on POD#7. Medications on Admission: Spiriva IH qd Advair 100/50 [**Hospital1 **] ASA 81 mg PO daily Vit C 1000 PO daily Folic Acid 400 PO daily Crestor 20 PO daily Toprol XL 50 PO daily Omeprazole 20 PO daily Lasix 20 PO BID KCl 10 mEq PO daily Allopurinol 300 PO daily [**Doctor First Name **] 60 PO daily Quinapril 80 PO daily Flomax 0.4 PO daily Albuterol IH prn Lidex cream 0.5% prn 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. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: Then decrease dose to 400 mg PO daily for 7 days, then decrease dose to 200 mg PO daily. Disp:*50 Tablet(s)* Refills:*0* 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Prilosec 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* 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 13. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Then take as directed by Dr. [**Last Name (STitle) **] INR of [**3-18**].5. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Coronary artery disease Mitral regurgitation Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**2-15**] weeks. Completed by:[**2151-8-26**]

[ "443.9", "427.31", "250.00", "414.01", "401.9", "274.9", "276.3", "V10.51", "530.81", "V45.82", "424.0", "496", "425.4", "428.0", "427.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.04", "88.72", "35.33" ]

icd9pcs

[ [ [] ] ]

5248, 5319

1982, 2682

296, 342

5407, 5414

1682, 1959

5687, 5846

1179, 1194

3083, 5225

5340, 5386

2708, 3060

5438, 5664

1209, 1663

235, 258

370, 740

762, 1009

1025, 1163

74,575

148,600

5050

Discharge summary

report

Admission Date: [**2195-10-20**] Discharge Date: [**2195-11-6**] Date of Birth: [**2135-4-25**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: increasing lower extremity weaknes Major Surgical or Invasive Procedure: [**10-21**]: 3rd Ventriculostomy per Dr. [**Last Name (STitle) **] [**10-27**]: Occipital craniectomy for posterior fossa tumor per Dr. [**Last Name (STitle) **] History of Present Illness: 60M who presented for elective admission, who normally resides in [**State 108**], but has been followed by Dr. [**Last Name (STitle) 957**] for many years. He has Type II Neurofibromatosis. He has previously had lower thoracic spinal meningioma removed at age 15, a trigeminal schwannoma on the left at the age of 22 and a series of operations for a cervical meningioma in [**2169**], [**2172**], [**2176**], and [**2177**]. A tentorial meningioma was radiated in [**2183**]. He was last seen by Dr. [**Last Name (STitle) 957**] in [**2192-4-29**], when he seemed to have a stable spastic paraparesis, worse on the left but able to transfer from a motorized scooter and was self-sufficient. He has had a complete C5 deficit on the left because of involvement of roots with his cervical meningioma. His last cervical MRI was [**2187**], when there was evidence of tumor in the upper brachial plexus on the left at C4-5 and C5-6, but not in the spinal canal. Last [**Month (only) 404**] he fell out of bed and broke his right ankle requiring fixation with plate and screws and a four month rehab hospitalization. His current complaint began after a fall last [**Month (only) 359**] when he believed he injured his left ankle, but nothing was found to be wrong. Since that time, he has had pain in his left groin which occurs especially when he is lying on his right side and adducts his left leg beyond the midline. It is a severe pain in the groin, sometimes radiating down his leg. He feels that both legs are weaker since they had been before and he is no longer able to stand and transfer as he had been. He is presently wheelchair bound, and requires the use of a handicapped [**Doctor Last Name **]. His wife thinks his right leg, previously the better, is now worse. He has had no beneficial change in the bladder function despite Ditropan usage. An MRI scan was done of the lumbar spine on [**6-7**], which shows no evidence of tumor or disc herniation in the spinal canal with a good view all the way up to the conus. He brought with him a hip MRI which did not reveal any significant pathology. Past Medical History: 1. Neurofibromatosis 2. s/p multiple brain and spinal surgery for meningiomas 3. hypertension 4. bladder dysfunction 5. s/p DVT [**2193**] after ankle surgery 6. s/p ORIF rt ankle Social History: Married, resides in [**Last Name (un) 1051**], FL with his wife. Family History: non-contributory. Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Pupils: PERRL EOMs FULL Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-2**] 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, 3mm to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: RUE full motor strength in all groups, LUE with full grip strength, however 0/5 for biceps, triceps, deltoid. B/L LE with 2/5 muscle strength. Sensation: reports asymmetric sensation of the LE(R>L). Pertinent Results: Labs on Admission: [**2195-10-21**] 06:15AM BLOOD WBC-9.1 RBC-4.59* Hgb-12.8* Hct-37.2*# MCV-81*# MCH-27.9 MCHC-34.4# RDW-14.4 Plt Ct-208 [**2195-10-20**] 07:45PM BLOOD PT-15.4* PTT-27.1 INR(PT)-1.4* [**2195-10-21**] 06:15AM BLOOD Glucose-125* UreaN-10 Creat-0.7 Na-137 K-4.4 Cl-104 HCO3-24 AnGap-13 [**2195-10-21**] 06:15AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1 Labs on Discharge: [**2195-11-5**] 06:05AM BLOOD WBC-15.7* RBC-3.73* Hgb-10.2* Hct-30.4* MCV-82 MCH-27.4 MCHC-33.6 RDW-13.9 Plt Ct-195 [**2195-11-5**] 06:05AM BLOOD Glucose-88 UreaN-25* Creat-0.5 Na-135 K-3.9 Cl-94* HCO3-37* AnGap-8 [**2195-11-5**] 06:05AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 Imaging: Head CT post-op ([**11-1**]): Status post occipital craniotomy with tumor resection. No interval development of hydrocephalus, mass effect, shift of normally midline structures, or acute hemorrhage. Resolution of pneumocephalus. MR of head ([**10-28**]): Status post resection of posterior fossa extra-axial mass with blood products noted in the resection cavity and along the left perimesencephalic cistern. No evidence for residual tumor identified. MR of head ([**10-21**]) - before occipital cranieotomy): Status post ventriculostomy with associated postoperative changes. No areas of hemorrhage seen. Interval increase in size of tentorial meningioma since [**2191**]. Moderate obstructive hydrocephalus unchanged since head CT of few hours prior. Brief Hospital Course: Patient with hx of neurofibromatosis was electively admitted to the neurosurgery service on [**10-20**] for scheduled 3rd ventriculostomy to address posterior fossa tumor recently identified this past summer. He underwent 3rd ventriculostomy per Dr. [**Last Name (STitle) **] on [**10-21**] and occipital craniectomy for posterior fossa tumor on [**10-27**] per Dr. [**Last Name (STitle) **]. He tolerated both procedures well but had post-operative complication after the craniectomy with tongue swelling which delayed extubation. ENT was consulted and swelling likely dependent edema from the procedure under prone position. Steroids were given post-operatively which also benefitted the tongue swelling. He was successfully extubated on POD #3 and transferred to floor. Nutrition was started via Dobhoff initially. He was evaluated per speech on [**11-2**] --> soft/dysphagia diet but given inadequate calorie intake per mouth, Dobhoff was kept. Then on [**11-6**] his intake increased and the Dobhoff was removed but nutrition recommends Ensure or Boost with each mean (~3 cans per day) to ensure adqate calorie intake. He was evaluated per PT/OT and was screened for rehab prior to return to [**State 108**]. He is to follow-up with Dr. [**Last Name (STitle) **] in 4 weeks with CT of head. Also, sutures from the occipital craniotomy removed prior to discharge. Medications on Admission: 1. Coumadin 5mg daily 2. Oxybutynin 5mg daily 3. Tamoxifen 10mg twice daily 4. Lipitor 10mg daily 5. Doxazosin 2mg at bedtime 6. Tenormin 12.5mg daily Discharge Medications: 1. Insulin SC 2. Acetaminophen 325-650 mg PO Q6H:PRN 3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN 5. LeVETiracetam 1500 mg PO BID 6. Atorvastatin 10 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO TID 8. Bisacodyl 10 mg PO/PR DAILY 9. Oxybutynin 5 mg PO DAILY 10. Calcium Carbonate 1000 mg PO DAILY 11. OxycoDONE (Immediate Release) 5-10 mg PO/NG Q6H:PRN for pain 12. Doxazosin 2 mg PO HS 13. Senna 1 TAB PO BID 14. Docusate Sodium 100 mg NG [**Hospital1 **] 15. Furosemide 40 mg PO BID 16. Tamoxifen Citrate 10 mg PO BID Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Neurofibramatosis Posterior Fossa Mass Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2195-11-6**]

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icd9cm

[ [ [] ] ]

[ "02.2", "96.6", "01.59" ]

icd9pcs

[ [ [] ] ]

7721, 7793

5556, 6931

355, 519

7876, 7900

4114, 4119

9313, 9602

2958, 2977

7133, 7698

7814, 7855

6957, 7110

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547, 2656

3431, 4095

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3154, 3415

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20,643

162,218

4814

Discharge summary

report

Admission Date: [**2102-5-12**] Discharge Date: [**2102-5-16**] Date of Birth: [**2039-3-10**] Sex: M Service: MICU He was originally on the MICU service and then transferred to the [**Hospital1 **] Medicine service. HISTORY OF PRESENT ILLNESS: This is a patient well known to me as I discharged him last week. Please refer to the previous discharge summary from [**2102-5-11**] for additional past medical history details. Basically, this is a patient who is 63 years old with a history of COPD on 4 liters of oxygen at home and multiple recent admissions for COPD flares. He reports the day after being discharged from his last hospitalization, the patient experienced increased respiratory distress and called EMS. He reports on this day that he woke up, and having trouble breathing, became confused, and was unable to take his prednisone that day or any of his inhalers. He called EMS with his Life Line system. In the field, the patient was hypertensive, tachycardic, tachypneic, and hypoxic at 92% on nonrebreather. In the ED, the patient was intubated and started on propofol, which resulted in hypotension. He was given several liters of fluid, Solu-Medrol, and propofol changed to Ativan drip and hypotension responded and improved. While in the Medical Intensive Care Unit, a CTA was performed and was negative for PE or pneumonia. The patient was extubated on [**5-14**], and was changed to p.o. prednisone on [**5-15**]. Additionally, he was ruled out for myocardial infarction during this time. Additional history: He reports no fevers, no chills. Does have a cough with some white sputum, but no chest pain, abdominal pain, diarrhea, or rash. No PND. He sleeps on two pillows, which has been unchanged for many years. No lower extremity edema. As far as risk factors for COPD flare, his wife does [**Name2 (NI) **] candles inside the house, which can cause poor air quality and in addition he has shagged carpet as well. He is also on metoprolol, a beta-blocker, which may be aggravating his symptoms. He nor his wife smoke. They have no pets, and there are no foods that he knows that aggravate his allergies. Upon my exam once he was admitted to the floor after his MICU course, his temperature was 97.2, blood pressure 148/72, heart rate 90, respirations 22. He was 97% on 5 liters nasal cannula, which is his baseline. In general, he is in no acute distress, sitting up in bed, talking in complete sentences. HEENT: Pupils are equal, round, and reactive to light. Clear oropharynx, no lymphadenopathy, no thyromegaly. Chest: Poor air movement throughout, but no wheezes or rales. Cardiovascular: Distant heart sounds, but regular, rate, and rhythm, no murmurs. Abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities: No edema. Dorsalis pedis and radial pulses 2+ bilaterally. Neurologic: Strength is [**5-10**] in all extremities and sensation to light touch and cold were intact bilaterally. He was alert and oriented times three. Cranial nerves II through XII are intact. Deep tendon reflexes 2+ throughout. No focal neurological deficits. LABORATORIES: His white count was 18 upon admission, nadired down to 10 and was 15 on the day I was seeing him. Hematocrit 34, platelets 237 with a MCV of 87. Chemistries essentially within normal limits. CKs and troponins were checked and were negative x3. Blood cultures from [**5-12**] showing no growth to date. Urine culture from the 7th showing no growth. He had a CTA of the chest during this hospitalization, which showed extensive bilateral emphysematous changes. No pulmonary embolus. Enlarged pulmonary arteries to suggest pulmonary hypertension and a small amount of basilar atelectasis. In summary, this is a 63-year-old male with a history of COPD on home O2 status post multiple admissions for COPD flares, now status post intubation for respiratory distress. No PE, no pneumonia, only emphysema and pulmonary hypertension seen on CTA. Thought this episode of respiratory distress was thought to be secondary to COPD flare. He was currently extubated and doing well on p.o. prednisone, but still with poor air movement on exam. HOSPITAL COURSE: 1. COPD exacerbation: Status post extubation yesterday, doing well, ambulating, speaking in full sentences. The patient ambulated with Physical Therapy on 4 liters of nasal cannula and ambulation of 350 feet. He desaturated to 88%. He was transitioned to p.o. prednisone and is on 60 mg a day. He should stay on this current dose with a very slow taper as his COPD flares appear to be quite dependent on prednisone. He has an appointment with his outpatient pulmonologist, Dr. [**Last Name (STitle) 575**] for three days from now on [**5-19**]. Taper is to be determined by Dr. [**Last Name (STitle) 575**]. He was continued on his albuterol and Atrovent MDIs with prn nebulizers. He has a nebulizer machine at home. He is also on Flovent as well. He was continued on oxygen and also maintained on a proton-pump inhibitor to eliminate reflux, which may cause bronchospasm. An inspiration spirometer was placed at bedside for atelectasis. Additionally, I went over his previous pulmonary function tests and they are consistent with emphysema with only moderate changes bronchodilators. 2. Steroid use: He was maintained on fingersticks q.i.d. with regular insulin-sliding scale. He may need to have an oral hyperglycemic [**Doctor Last Name 360**] added to his regimen by his primary care doctor if he continues to be maintained on steroids that cause hyperglycemia. He was also on calcium, vitamin D, and a proton-pump inhibitor for prophylaxis for his steroid use. 3. History of back pain: He is status post laminectomy 26 years ago. His neuro exam is nonfocal. He is very strong, and he was given prn Percocet. 4. Hypertension: He is on a beta-blocker and ACE inhibitor. The beta-blocker may worsen bronchospasm, but it is a good drug for him given his history of myocardial infarction. 5. CAD: He is continued on aspirin, ACE inhibitor, and beta-blocker. He tolerated the beta-blocker well while in house with no further episodes of respiratory distress. 6. FEN: Diabetic heart-healthy diet. 7. Prophylaxis: SubQ Heparin t.i.d. PPI and Colace. 8. Code: He is full code. 9. Disposition: To home with services. He already has home O2 setup. He has no need for pulmonary rehab given his excellent ambulation. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease flare. 2. Hypertension. 3. Hypercholesterolemia. 4. Coronary artery disease. 5. Steroid-induced hyperglycemia. 6. Chronic back pain, no neurological deficits. DISCHARGE STATUS: To home with VNA services. DISCHARGE CONDITION: Good. Stable. DISCHARGE FOLLOWUP: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] on [**5-19**], pulmonary breathing tests on [**5-19**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Cardiac services on [**5-23**] and Dr. [**Last Name (STitle) 8499**], his PCP. [**Name10 (NameIs) **] should call to make an appointment. DISCHARGE MEDICATIONS: 1. Albuterol/ipratropium MDI two puffs q.6h. 2. Fluticasone two puffs b.i.d. 3. Atorvastatin 10 mg once a day. 4. Aspirin 325 once a day. 5. Prednisone 60 mg q.d. Continue this dose until otherwise told by Dr. [**Last Name (STitle) 575**]. Appointment is in three days. 6. Metoprolol 25 mg p.o. b.i.d. 7. Lisinopril 5 mg a day. 8. Vitamin D 400 units once a day. 9. Calcium carbonate 500 mg 3x a day. 10. Percocet 5/325 1-2 tabs p.o. q.6h. as needed for back pain, dispensed 10 tablets only, no refills. 11. Pantoprazole 40 mg once a day. 12. Colace 100 mg p.o. b.i.d. while on Percocet. 13. Albuterol nebulizer treatment every 4-6 hours as needed for shortness of breath, dispensed 10 nebulizer units. This patient is also going home with home oxygen as well, which is already setup. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 9789**] MEDQUIST36 D: [**2102-5-16**] 18:56 T: [**2102-5-17**] 09:31 JOB#: [**Job Number 20171**] cc:[**Name Initial (MD) 20172**]

[ "401.9", "272.0", "518.81", "458.9", "251.8", "491.21", "414.01", "412", "724.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

6748, 6764

6478, 6726

7149, 8236

4214, 6457

6785, 7126

264, 4197

63,190

193,962

18286

Discharge summary

report

Admission Date: [**2174-9-6**] Discharge Date: [**2174-9-8**] Date of Birth: [**2142-6-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 41841**] is a 32 YOF with a history of stage III kidney disease secondary to IgA nephropathy, hypertension, and previous admission for hypertensive emergency [**3-14**] changes and CP who presented from her nephrologists office after found to have HTN to 230s with worsening renal function. Of note, the patient has been experiencing headaches, nausea, and vomiting in the early am over the past several weeks. She went in to see her PCP [**Last Name (NamePattern4) **] [**8-30**] who initiated a w/u for lymes but then found that her creatinine had doubled to 2.4 from previous (baselin 1.5). She referred the pt to her nephrologist, Dr. [**Last Name (STitle) **], who saw her in clinic today and noted a BP in the 230s so he referred her to the ED. . In the ED, initial vs were: T 97.4 P 52 BP 233/141 R 16 O2 sat 100%. Patient denied HA, CP, or SOB. EKG did not show any ST changes. Head CT showed no ICH but incidental finding of increased conspicuity of right frontal lobe white matter hypodensities (f/u with MRI). Renal ultrasound was unremarkable. She was started on nicardipine gtt and her BP was titrated down to 199/128. . On the floor, pt is comfortable but c/o mild HA. Otherwise denies blurry vision, cp, SOB, back pain, cough, palpitations, N/V, F/C. Denies increased salt intake, and in fact does not like salt. Recently started eating protein in form of chicken. She states that her urine has dropped in amount, but increased in frequency over the past few weeks. She also notes increased peripherall swelling in her ankles. . Review of systems: (+) Per HPI Past Medical History: Stage III CKD secondary to IgA nephropathy Hypertension Social History: Patient is a college graduate and has a masters in education and is an elementary school teacher of 5 year old children. She drinks occasionally, [**4-7**] drinks per week. Denies tobacco. No current or h/o illicit drug use. Family History: Father w/ DM. Grandmother (paternal side) with DM and HTN. Physical Exam: Vitals: T: 97 BP:213/137 P:72 R: 16 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric no erythema, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, IV/VII systolic murmur at left upper sternal border, no rubs, + S4 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley resent Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Plasma metanephrines: pending [**2174-9-6**] 05:05PM URINE UCG-NEGATIVE [**2174-9-6**] 05:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2174-9-6**] 05:05PM URINE BLOOD-TR NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2174-9-6**] 05:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**4-8**] [**2174-9-6**] 04:45PM GLUCOSE-85 UREA N-36* CREAT-2.4* SODIUM-137 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13 [**2174-9-6**] 04:45PM estGFR-Using this [**2174-9-6**] 04:45PM CALCIUM-9.5 PHOSPHATE-3.9 MAGNESIUM-2.5 [**2174-9-6**] 04:45PM WBC-6.4 RBC-4.30 HGB-12.8 HCT-38.2 MCV-89 MCH-29.9 MCHC-33.6 RDW-14.3 [**2174-9-6**] 04:45PM NEUTS-73.6* LYMPHS-21.4 MONOS-3.4 EOS-0.9 BASOS-0.7 [**2174-9-6**] 04:45PM PLT COUNT-181 CT head [**2174-9-6**]: 1. No acute intracranial hemorrhage. 2. Increased conspicuity of right frontal lobe white matter hypodensities, which are non-specific findings. Given the increased conspicuity, would recommend MRI for further evaluation. . Renal U/S [**2174-9-6**]: mild fullness of the right kidney but no hydronephrosis on either side. cortical thinning bilaterally with somewhat indistinct corticomedullary differentiation, likely due to the patient's underlying IGA nephropathy; simple cyst in the upper pole of the right kidney . . EKG: sinus bradycardia, 58 bpm, nml axis, nml PR and QRS interval, right side up t waves in V4, V5 (new from prior) no ST elevations/depressions [**2174-9-7**] 03:52AM BLOOD Neuts-75.7* Lymphs-18.9 Monos-3.2 Eos-1.2 Baso-1.0 [**2174-9-6**] 04:45PM BLOOD Glucose-85 UreaN-36* Creat-2.4* Na-137 K-4.5 Cl-101 HCO3-28 AnGap-13 [**2174-9-7**] 03:52AM BLOOD Glucose-89 UreaN-31* Creat-2.3* Na-138 K-4.0 Cl-100 HCO3-28 AnGap-14 [**2174-9-8**] 05:45AM BLOOD Glucose-92 UreaN-36* Creat-2.9* Na-136 K-3.8 Cl-99 HCO3-29 AnGap-12 [**2174-9-8**] 05:45AM BLOOD Calcium-8.1* Phos-5.0* Mg-2.4 [**2174-9-6**] 05:05PM URINE Blood-TR Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2174-9-6**] 05:05PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-[**4-8**] [**2174-9-7**] 04:05AM URINE Hours-RANDOM Creat-52 Na-99 K-33 Cl-84 Albumin-143.1 Alb/Cre-2751.9* [**2174-9-6**] 05:05PM URINE UCG-NEGATIVE Brief Hospital Course: # Hypertensive urgency: Pt had initial BP in ED of 233/141 HR 52, she denied HA, chest pain, SOB. She was started on a nicardipine drip in the ED and the SBP decreased to 200, at which point she was transferred to the MICU. ECG showed no changes, head CT no acute process (other than incidental finding of increased conspicuity of rgiht frontal lobe with white matter hypodensities). In the MICU pt's BP gradually came down and nicardipine was stopped at 3am on [**9-7**]. She was then started on amlodipine 5mg in addition to her home antihypertensives of losartan, lisinopril, and HCTZ which all decreased her SBP to the 130-150s. Pt was transferred to the medicine floor where her BP remained stable and she was asymptomatic. Amlodipine was dc'd and she was only continued on her home antihypertensives. Pt was given Rx for amlodipine to take at home only if her BP measured >160 and otherwise to continue her home regimen. She should follow with nephrology for w/u of secondary causes of HTN (pheo, etc). Plasma metanephrines from admission are pending and she will do 24-hr urine as outpt. She is following at [**Hospital **] clinic in [**Month (only) **]. # Acute on chronic renal failure: Likely worsening of IgA nephropathy. U/S showed cortical thinning bilaterally. On admission, pt's Cr was 2.4 over her baseline of 1.6 in [**2173**]. Creatinine remained stable during her ICU stay. Upon transfer to the floor Cr was found to be elevated to 2.9, which was likely [**3-8**] to a rapid decrease in BP over the past few days from a very elevated state during the HTN urgency. Dr [**Last Name (STitle) **] felt that the Cr would likely trend down over the next few days and he was comfortable purusing an outpt work-up. # Headache: Patient was initially treated with tylenol which did not help. She declined narcotics; however, noted improvement with lorazepam and oral intake of caffeine. On the floor, pt did not have more HAs while her BP was normalized. # Right frontal hypodensities on CT: Seen on previous head CT in [**2172**], outpatient followup was recommended by radiology and she was advised to follow up with PCP and to get an MRI after discharge. Medications on Admission: calcitriol 1 capsule 4 times weekly cozaar 100 mg q day hydroclorothiazide 25 mg q day lisinopril 40 mg Q day Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO four times weekly. 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive urgency Acute on chronic renal failure Secondary: IgA nephropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] because you were found to have very high blood pressure at your nephrologist's office (systolic >230) and worsening kidney function. When you came to the ER, you were given antihypertensive medications via IV and admitted to the ICU for monitoring. In the ICU, your blood pressure improved and the IV medication was stopped. You were started on amlodipine pill (another antihypertensive) in addition to your home blood pressure medications which further decreased your blood pressure to systolic 130s. You were then transferred to the general medicine floor where you were not having any more symptoms of headache/nausea and your blood pressure remained well controlled. The nephrologists feel that you may have some worsening of your IgA nephropathy or that there may be another process that is causing your episodic hypertension. Your rise in creatinine may be due to your blood pressure being lowered from such a high [**Location (un) 1131**] when you first came. We expect this to come down and you should have this followed up at your nephrology appt with Dr.[**Name8 (MD) 9920**] NP in [**Month (only) 216**] (see below for date). We feel comfortable having you evaluated further for this as an outpatient. A CT of your head was done which showed no acute bleeding, but did show an incidental finding of hypodensity in an area of your brain, this does not seem to be an acute problem but we recommend that you get an MRI when you leave the hospital to further evaluate. You will also need to do a 24-hr urine collection as an outpatient to check for metanephrines, which can be a sign of pheochromocytoma. Other causes of secondary hypertension should be worked up by your nephrologist. We want you to keep taking your home medications for blood pressure. We are giving you a prescription for another medication but want you to take it ONLY if your blood pressure at home is measuring around 150s-160s over a few readings. Please make sure you measure your blood pressure at home a few times a day until you follow up with your doctor. Amlodipine 5mg - 1 tablet daily You should follow up with your PCP and your nephrologist after you leave the hospital. Followup Instructions: Name: [**Location (un) **],[**Last Name (un) **] K. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 3329**] Appointment: Tuesday, [**9-20**], 1PM Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2174-9-22**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2174-9-8**]

[ "403.00", "583.9", "584.9", "585.3", "784.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8016, 8022

5283, 7457

332, 338

8155, 8155

2968, 5260

10535, 11321

2318, 2379

7617, 7993

8043, 8134

7483, 7594

8306, 10512

2394, 2949

1963, 1977

272, 294

366, 1944

8170, 8282

1999, 2056

2072, 2302

28,827

190,139

22004

Discharge summary

report

Admission Date: [**2169-10-22**] Discharge Date: [**2169-11-1**] Date of Birth: [**2105-10-10**] Sex: M Service: [**Year (4 digits) 662**] Allergies: Heparin Agents / Levofloxacin Attending:[**Last Name (NamePattern1) 15287**] Chief Complaint: Chief Complaint: SOB and AMS Reason for MICU transfer: Hypercarbic respiratory failure Major Surgical or Invasive Procedure: Intubation PICC Line Placement ERCP History of Present Illness: 64M with a hx of HIV and recent hospitilization for COPD exacerbation presented with nephew complaining of several days of worsening DOE, cough, and new AMS status this morning. Nephew notes pt has baseline SOB with 3L o2 rec over past few months with worsening cough over last several days. He cannot speak for myself as he is too short of breath. His relative states the patient has not had recent fever, fatigue/weakness but does note several sick contacts at home. Pt has increased smoking frequency recently, currently smoking 1ppd. Nephew also notes worsening AMS over last day, finding patient laying on bathroom floor and not oriented to name or place. Family notes similar episode of AMS in [**2165**] with [**Last Name (un) **]. In past documentation, has been compliant with HAART therapy and Bactrim PPx. On recent admission [**2169-9-15**], CD4 54 but HIV VL undetectable. In the ED, initial VS were:97.8 99 122/63 25. PE was notable for Patient has distant lung sounds without wheezes. CXR notable for possible left lower lobe consolidation. Pt placed on BiPap and ABG pH 7.16/82/106. CBC wnl, chem 7 remarkable for BUN 124 and Cr 6.4 with AG of 24, lactate of 1.8. On arrival to the MICU, he is sedated and intubated. Review of systems: Unable to obtain at this time Past Medical History: 1. HIV/AIDS, CD4 count 54 on [**2169-9-15**] 2. CKD with episodes of ARF. Baseline Cr 1.2-1.5. Atrophic L kidney. 3. COPD, on 3L at home with activity. 4. Tobacco abuse 5. Hep C 6. Hyperkalemia, baseline around 4.5 7. Costochondritis 8. Previous injury and cataract in R eye, wear eye patch 9. Poor dentition 10. HIT Social History: - Tobacco: 1ppd - Alcohol: heavy alcohol use in the past sober over 12 years - Illicits: IVDU in the 80's and early 90's Lives alone, retired stonemason. Performs ADLs at baseline. His sister and nephews lives in the same buidling with him. Family History: Kidney problems Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:97.8 BP:124/86 P:60 R:16 O2:97% Vent: TV: 500, RR:16, PEEP:10, Fio2:40% General: Intubated and sedated HEENT: Sclera anicteric, MMM, oropharynx clear, L cateract, R pupil 3mm, reactive Neck: supple, JVP not elevated, no LAD CV:Distant heart sounds. Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: LLL crackles and course breath sounds. no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place draing clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro:Pt withdraws to painful stimuli DISCHARGE PHYSICAL EXAM: Vitals: 98.6 163/82 95 18 93%3LNC General: Cachectic with buccal wasting, NAD CV: Regular rate and rhythm, normal S1, prominent S2, no murmurs, rubs, gallops Lungs: Diffuse rhonchi, no wheezes or crackles Abdomen: +BS, soft, non-tender, non-distended Ext: WWP, no edema Pertinent Results: ADMISSION LABS: [**2169-10-22**] 06:15PM BLOOD WBC-9.8 RBC-4.34* Hgb-13.9* Hct-42.4 MCV-98 MCH-31.9 MCHC-32.7 RDW-12.9 Plt Ct-197 [**2169-10-22**] 06:15PM BLOOD Neuts-90.3* Lymphs-5.3* Monos-3.8 Eos-0.2 Baso-0.3 [**2169-10-22**] 06:15PM BLOOD Plt Ct-197 [**2169-10-22**] 10:54PM BLOOD PT-10.8 INR(PT)-1.0 [**2169-10-22**] 06:15PM BLOOD Glucose-113* UreaN-124* Creat-6.4*# Na-140 K-4.7 Cl-95* HCO3-27 AnGap-23* [**2169-10-22**] 10:54PM BLOOD ALT-188* AST-137* LD(LDH)-471* AlkPhos-113 TotBili-0.2 [**2169-10-23**] 06:52AM BLOOD Lipase-15 [**2169-10-22**] 06:15PM BLOOD Calcium-8.4 Phos-7.8*# Mg-3.4* [**2169-10-23**] 06:52AM BLOOD Triglyc-135 [**2169-10-22**] 06:28PM BLOOD Type-ART pO2-106* pCO2-81* pH-7.16* calTCO2-30 Base XS--2 [**2169-10-22**] 05:45PM BLOOD Lactate-1.8 [**2169-10-22**] 07:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2169-10-22**] 07:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2169-10-22**] 07:30PM URINE RBC-7* WBC-2 Bacteri-MOD Yeast-NONE Epi-0 [**2169-10-24**] 02:34PM URINE Eos-NEGATIVE IMAGING [**10-28**] RUQ Ultrasound:1-cm stone in the distal common bile duct with distal dilatation of the CBD without intrahepatic ductal dilatation. [**10-23**] Renal US IMPRESSION: 1. No hydronephrosis. Stable asymmetry of renal sizes consistent with chronic scarring of left kidney. 2. Bladder not assessed due to foley catheter in place. 3. Pelvic ascites. [**10-23**] RUQ US IMPRESSION: 1. Gallbladder has been surgically removed. Stable dilatation of the common bile duct, unchanged compared to [**2166-3-16**]. Duct is well seen to the level of the ampulla and no stones are identified. 2. Doppler assessment of the main portal vein shows patency and hepatopetal flow. 3. Minimal perihepatic ascites identified. 4. Liver echotexture is normal and without a macronodular contour to suggest cirrhosis. [**10-22**] CXR IMPRESSION: Suboptimal study due to patient positioning. Interval development of left mid to lower lung patchy opacity may relate to infection or aspiration versus asymmetric edema. Trace blunting of the right costophrenic angle, trace pleural effusion not excluded. Consider PA and lateral views when/if patient able with better positioning. ECG Sinus rhythm. Normal ECG. Compared to the previous tracing atrial fibrillation has resolved and pacing is no longer appreciated. MICRO [**10-22**] Blood Cultures: Negative [**2169-10-23**] 6:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Venipuncture. BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2169-10-22**] 7:30 pm URINE **FINAL REPORT [**2169-10-24**]** URINE CULTURE (Final [**2169-10-24**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [**2169-10-22**] 9:45 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2169-10-27**]** GRAM STAIN (Final [**2169-10-23**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS IN SHORT CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2169-10-27**]): RARE GROWTH Commensal Respiratory Flora. STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH. Note: For treatment of meningitis, penicillin G MIC breakpoints are <=0.06 ug/ml (S) and >=0.12 ug/ml (R). Note: For treatment of meningitis, ceftriaxone MIC breakpoints are <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R). For treatment with oral penicillin, the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R). YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | ERYTHROMYCIN---------- =>1 R LEVOFLOXACIN---------- 1 S PENICILLIN G---------- 0.25 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S [**2169-10-23**] 12:49 am BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2169-10-23**]): <10 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS IN SHORT CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2169-10-25**]): Commensal Respiratory Flora Absent. STREPTOCOCCUS PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # 355-8839G [**2169-10-22**]. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2169-10-23**]): NEGATIVE for Pneumocystis jirovecii (carinii). HCV VIRAL LOAD (Final [**2169-10-24**]): 7,148,084 IU/mL. (Reference Range-Negative). CMV Viral Load (Final [**2169-10-27**]): CMV DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC PROCEDURES. This test has been validated by the Microbiology laboratory at [**Hospital1 18**]. HELICOBACTER PYLORI ANTIBODY TEST (Final [**2169-11-1**]): NEGATIVE BY EIA. [**10-31**] Blood Culture: Pending DISCHARGE LABS [**2169-11-1**] 07:32AM BLOOD WBC-12.6* RBC-3.15* Hgb-10.1* Hct-30.9* MCV-98 MCH-32.2* MCHC-32.8 RDW-12.6 Plt Ct-134* [**2169-10-31**] 07:41AM BLOOD Neuts-96.0* Lymphs-1.7* Monos-2.2 Eos-0.1 Baso-0.1 [**2169-11-1**] 07:32AM BLOOD Glucose-74 UreaN-24* Creat-1.5* Na-143 K-3.5 Cl-102 HCO3-36* AnGap-9 [**2169-11-1**] 07:32AM BLOOD ALT-39 AST-18 AlkPhos-75 TotBili-0.7 [**2169-11-1**] 07:32AM BLOOD Calcium-8.4 Phos-2.5*# Mg-1.6 [**2169-11-1**] 10:22AM BLOOD Type-ART pO2-73* pCO2-53* pH-7.43 calTCO2-36* Base XS-8 Brief Hospital Course: Brief Course: 64M with a hx of HIV and recent hospitilization for COPD exacerbation presented with nephew complaining of several days of worsening DOE, cough, and new AMS status. He was admitted to the ICU and intubated for hypercarbic respiratory failure secondary to COPD exacerbation. He was successfully extubated 2 days later and transferred to the [**Month/Day/Year **] floor. His total bilirubin was noted to be elevated, so a RUQ ultrasound was performed that showed a 1cm common bile duct stone. Patient underwent ERCP, but the stone had passed on its own. Active Issues: #COPD Exacerbation: Patient presented with shortness of breath and productive cough. He was found to be in hypercarbic respiratory failure and was intubated in the ICU. Likely precipitated by pneumonia given findings on chest xray and sputum and bronchoalveolar lavage growing strep pneumo. Treated with antibiotics as mentioned below. PCP was ruled out, especially in immunocompromised patient. Extubated on [**2169-10-24**] without difficulty. Started initially on Solumedrol IV and transitioned to PO Prednisone with taper. Treated with nebulizer treatments. Oxygen saturation was stable in the 90s on 3L nasal cannula (baseline requirement) on discharge. #Strep Pneumoniae Pneumonia: Possible precipitant of COPD exacerbation. Patient was treated initially with IV vancomycin in the ICU then transitioned to unasyn then to oral ampicillin. He completed the intended 5 day course, but was continued on ampicillin for 14 days total for UTI (see below). PCP and urine legionella negative. #Enterococcal UTI: Treated with IV vancomycin and transitioned to Unasyn for 3 more days of treatment prior to transfer to the floor. He was then transitioned to ampicillin based on culture sensitivities to complete 14 day total antibiotic course. Patient was asymptomatic. #Choledocolithiasis: 1cm CBD stone found on RUQ ultrasound after total bilirubin was noted to be elevated. Patient had mild epigastric tenderness. The patient's LFTs normalized and his pain resolved without intervention. However, gastroenterology had concern for future obstructions so patient underwent ERCP with sphincterotomy. No stone was found, no stent placed so it seemed that the stone passed on its own. A small duodenal ulcer was seen on ERCP, but H.pylori serology was negative and patient was asymptomatic so treatment was not initiated. #Altered mental status: Patient was initially confused and agitated. Most likely multifactorial with delirium, uremia, and tobacco, opioid withdrawal contributing. Also was likely secondary substance abuse. Ambien was also thought to be contributing to morning confusion so it was stopped. Required large amounts of haldol and benzos over a few days in the ICU. He was started on Seroquel standing along with an adjunct Precedex dose and improved. QT interval was monitored. Precedex was weaned off and seroquel was stopped. #Leuckocytosis: Peaked at 22.1 during hospital course. Likely secondary to steroid administration. Patient was afebrile, no localizing symptoms. C. diff negative, repeat UA negative, repeat blood cultures with no growth to date. No stones found on ERCP, LFTs normalized. #Hyperglycemia: No history of diabetes. Likely steroid induced. Improved as steroids were tapered. #[**Last Name (un) **] on CKD: Most likely secondary to ATN (possible post renal, had 1 L of urine on foley in ER) and appeared pt was self diuresing with increased urine output post ATN during his stay in the MICU. Medications were dosed renally and we followed lytes and repleted as needed. Renal was consulted. Patient's creatinine improved to baseline. #Drug Abuse: Patient reports using heroine, marijuana, valium, ativan which is consistent with his urine tox screen. He was initially placed on a CIWA scale when he was transferred to the floor, but he did not score. No signs of active withdrawal. Patient was counseled on cessation. Inactive Issues: # HIV: Last CD4 54 on [**2169-9-15**], continued on home meds at renally dosed regimens. Bactrim, PCP [**Name9 (PRE) **], was held for a few days in light of the [**Last Name (un) **], restarted once creatinine improved. # HCV: Unclear if he has been treated. No signs or symptoms of decompensated liver disease during his MICU admission. HCV viral load 7,148,084 IU/mL on this admission. # Chronic pain: Chronic knee and back pain on oxycontin 40 tid and oxycodone 5 qid prn breakthrough. Patient was continued to these pain medications. Transitional Issues: 1. Code Status: FULL 2. Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45417**] [**Telephone/Fax (1) 57600**] 3. Medication Changes: -START Ampicillin for 3 more days (last day= [**11-4**]) -STOP Ambien, we think think may be causing your confusion 4. Pending Studies: [**10-31**] Blood culture 5. Follow up: PCP, [**Name Initial (NameIs) **] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 2. Aspirin 325 mg PO DAILY 3. Atazanavir 300 mg PO DAILY 4. Diazepam 5 mg PO Q8H:PRN anxiety 5. Docusate Sodium 100 mg PO BID hold for oversedation or RR 6. [**Name Initial (NameIs) **] 200 mg PO EVERY OTHER DAY 7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 8. OxycoDONE (Immediate Release) 5 mg PO QID:PRN pain hold for oversedation 9. Ranitidine 150 mg PO BID 10. RiTONAvir 100 mg PO DAILY 11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 12. Tenofovir Disoproxil (Viread) 300 mg PO EVERY OTHER DAY 13. Senna 1 TAB PO BID:PRN constipation 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 15. Ensure Plus *NF* (food supplement, lactose-free) 0.05-1.5 gram-kcal/mL Oral TID 16. Tiotropium Bromide 1 CAP IH DAILY 17. Nicotine Patch 21 mg TD DAILY 18. Oxycodone SR (OxyconTIN) 40 mg PO Q12H 19. Zolpidem Tartrate 10 mg PO HS Discharge Medications: 1. Ampicillin 500 mg PO Q6H RX *ampicillin 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*14 Capsule Refills:*0 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 3. Atazanavir 300 mg PO DAILY 4. Diazepam 5 mg PO Q8H:PRN anxiety 5. [**Hospital1 **] 200 mg PO EVERY OTHER DAY 6. Nicotine Patch 21 mg TD DAILY 7. Oxycodone SR (OxyconTIN) 40 mg PO Q12H 8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 9. Tenofovir Disoproxil (Viread) 300 mg PO EVERY OTHER DAY 10. RiTONAvir 100 mg PO DAILY 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 12. Aspirin 325 mg PO DAILY 13. Docusate Sodium 100 mg PO BID hold for oversedation or RR 14. Senna 1 TAB PO BID:PRN constipation 15. Tiotropium Bromide 1 CAP IH DAILY 16. Ranitidine 150 mg PO BID 17. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 18. Ensure Plus *NF* (food supplement, lactose-free) 0.05-1.5 gram-kcal/mL Oral TID 19. OxycoDONE (Immediate Release) 5 mg PO QID:PRN pain hold for oversedation 20. PredniSONE 20 mg PO DAILY Slow taper: 20mg for 2 days ([**11-1**], [**11-2**]) then 10mg for 2 days ([**11-3**], [**11-4**]) then discontinue prednisone Tapered dose - DOWN RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 21. Home Oxygen Continue regular home oxygen (3 liters nasal cannula) Discharge Disposition: Home Discharge Diagnosis: Primary: COPD Exacerbation Strep Pneumoniae Pneumonia Entercoccus UTI Choledocolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 976**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted with shortness of breath and altered mental status. Your breathing was initially supported with a breathing machine in the ICU. You were treated with nebulizers and steroids for COPD exacerbation. Your were also found to have a pneumonia and urinary tract infection which we are treating with antibiotics. We also found a stone in your bile duct which has passed on its own. Your breathing and mental status was much improved. Please make the following changes to your medications: -START Ampicillin for 3 more days (last day= [**11-4**]) -STOP Ambien, we think think may be causing your confusion Followup Instructions: Please follow up with the following appointments: Department: PULMONARY FUNCTION LAB When: FRIDAY [**2169-11-10**] at 9:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2169-11-10**] at 10:00 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Wednesday [**2169-11-8**] at 12:00 PM Location: AMERICAN [**Hospital **] MEDICAL CENTER, PC Address: [**State **] [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 588**] Phone: [**Telephone/Fax (1) 30384**] Completed by:[**2169-11-2**]

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Discharge summary

report+addendum

Admission Date: [**2120-3-12**] Discharge Date: [**2120-3-17**] Date of Birth: [**2080-3-6**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: S/P FALL Major Surgical or Invasive Procedure: NONE History of Present Illness: 40M from [**Country **] who fell today. He says he was dizzy and fell and hit his head. There was no loss of consciousness but on arrival to the ER he was confused and agitated. However, he calmed down and was answering questions. His GCS was 15. He got a head CT that showed left frontal brain contusion, and tiny SDH. Past Medical History: NONE Social History: From [**Last Name (LF) 27654**],[**First Name3 (LF) 651**] Non smoker Social drinker Family History: unknown Physical Exam: ON ADMISSION: PHYSICAL EXAM: O: T:98.0 BP:115/80 HR:86 R 22 O2 97 RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:Reactive to light bilaterally. 4mm EOMs: Intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, affect is unusual. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-13**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2+ 2+ Left 2+ 2+ 2+ 2+ 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements. ON DISCHARGE: Neurologically intact / ambulatory Pertinent Results: HEAD CT [**2120-3-12**]: IMPRESSION: 1. Subdural hemorrhages along the vertex, anterior falx and left anterior cranial fossa. 2. Multiple foci of intraparenchymal left frontal lobe hemorrhage and foci of subarachnoid extension. No significant mass effect. 3. Nondepressed fracture of the right parietal bone. HEAD CT [**2120-3-13**]: IMPRESSION: 1. Stable appearance of vertex epidural hematoma, left-sided subdural hematomas and foci of subarachnoid hemorrhage, as detailed above. 2. Evolving hemorrhagic contusions in the left orbitofrontal region and anterior temporal lobe, without evidence of significant mass effect or shift of normally midline structures. PELVIC XRAY [**2120-3-12**]: No fracture. CT CSPINE [**2120-3-12**]: No fracture noted. Chronic DJD. CSPINE FLEXION/EXTENSION XRAY: IMPRESSION: No acute fracture is identified. No malalignment or instability. EKG [**2120-3-13**] and [**2120-3-14**]: Sinus bradycardia (55-56). Non-diagnostic Q waves inferiorly. Early repolarization. Carotid U/S [**2120-3-13**]: Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is no plaque seen in the ICA. On the left there is no plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 37/13, 42/16, 59/17, cm/sec. CCA peak systolic velocity is 59 cm/sec. ECA peak systolic velocity is 80 cm/sec. The ICA/CCA ratio is 1.0. These findings are consistent with no stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 32/12, 38/13, 41/12, cm/sec. CCA peak systolic velocity is 78 cm/sec. ECA peak systolic velocity is 75 cm/sec. The ICA/CCA ratio is .52. These findings are consistent with no stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. ECHO [**2120-3-14**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. [**2120-3-15**] 07:20AM BLOOD WBC-10.0 RBC-5.09 Hgb-15.7 Hct-42.3 MCV-83 MCH-30.8 MCHC-37.0* RDW-12.7 Plt Ct-271 [**2120-3-15**] 07:20AM BLOOD Plt Ct-271 [**2120-3-17**] 08:05AM BLOOD Na-128* K-3.7 Cl-92* [**2120-3-16**] 05:55AM BLOOD Glucose-131* UreaN-12 Creat-1.0 Na-130* K-3.4 Cl-92* HCO3-24 AnGap-17 [**2120-3-14**] 02:30PM BLOOD cTropnT-<0.01 [**2120-3-13**] 03:43PM BLOOD CK(CPK)-108 [**2120-3-16**] 05:55AM BLOOD Calcium-8.9 Phos-1.7* Mg-2.6 [**2120-3-12**] 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 40M admitted after a fall with a SDH and frontal contusion. He was admitted to the Trauma ICU For observation overnight. A repeat head CT was stable and the patient was transferred to the floor. Patient reported no neck pain with ROM or palpation and the collar was removed. On [**3-13**] he was transferred to the floor. A syncope work-up was started and by [**3-14**] most exams were completed and normal. On [**3-15**] his serum NA was 123 but patient remained asymptomatic and nonfocal. His sodium was followed and remained stable. He was ambulating in the hallway without assistance. He was voiding, toelrating po intake and his pain was well controlled. He was d/c'd home. Medications on Admission: NONE Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-11**] Tablets PO Q4H (every 4 hours) as needed for Headache. Disp:*30 Tablet(s)* Refills:*0* 3. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 2 days: this will complete your 7 days dosing . Disp:*6 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: SUBDURAL HEMATOMA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed / you will only be taking it for a total of 7 days (this includes your days in the hospital) Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 2 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. YOU HAD A COMPLETE SYNCOPE WORK UP WHICH WAS NEGATIVE. PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN. Completed by:[**2120-3-17**] Name: [**Known lastname 12396**],[**Known firstname **] Unit No: [**Numeric Identifier 14184**] Admission Date: [**2120-3-12**] Discharge Date: [**2120-3-17**] Date of Birth: [**2080-3-6**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 40**] Addendum: Patient had hyponatremia but remained asymptomatic, no intervention was required. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2120-3-27**]

[ "E885.9", "800.21", "780.2", "276.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8831, 8972

5385, 6071

314, 321

6686, 6686

2316, 5362

7581, 8808

818, 827

6126, 6595

6645, 6665

6097, 6103

6837, 7558

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2261, 2297

266, 276

349, 671

1394, 2247

856, 856

6701, 6813

693, 699

715, 802

27,346

109,910

53781

Discharge summary

report

Admission Date: [**2168-1-9**] Discharge Date: [**2168-1-14**] Date of Birth: [**2122-10-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 45 yo M with a PMH Of DMII, HTN, morbid obesity, and sleep apnea who presents with SOB. He states that he [**Doctor Last Name **] had worsening dyspnea on exertion for approximately one month. States he was previously able to walk up three flights of stairs, but can now only go up about 1.5 flights. This week he was unable to walk to the bathroom without SOB. Also notes increased orthopnea requiring [**3-19**] pillows, and prior to 9 months ago was able to sleep on his back. He also notes increasing LE edema and decreased urination over an unclear duration of time. He also notes edema in his back and increasing abdominal girth over the past month. Has seen PCP on this issue, and has his had lasix uptitrated recently to 120mg QAM and 80mg QPM. He states he is medically compliant. On ROS he denies cough, CP, rhonorrhea, leg pain, nausea, vomiting, diarrhea. He denies tobacco use but smokes marijuana daily. Has also been diagnosed with severe OSA, requiring him to quite his job [**1-16**] to daytime somnolence and an MVA while at work. . In the ED, his vitals were: 97.5, 201/117, 102, 22 and (?)67% on RA. He was noted to have LE edema. He was placed on CPAP and received NTG 0.3 SL tab x1, [**12-16**] inch of nitro paste, Albuterol/atrovent nebs, azithromycin 500 mg po x1, and CTX 1 gm IV x1. CXR was notable for assymetric pulmonary edema, cannot r/o infiltrate. His BNP was 856. He was placed on BIPAP with improved O2 sats. He refused A-line and they were unable to obtain an ABG. He had c/o mild chest discomfort (although he denies that he complained of this) but denies palpitations. Has started taking aspirin one week PTA, but denies ever being instructed to do so by a physician. [**Name10 (NameIs) **] leaving the ED, this O2 sat had improved to 96%/4L NC with these interventions. Past Medical History: -Hypertension -Morbid Obesity -Type 2 diabetes Mellitus --hgb A1c 6.9 in [**8-21**] -sleep apnea, mixed sleep disorder: per Dr.[**Name (NI) 935**] note from [**2167-12-25**]: "On [**2167-12-16**] he had a split study, which showed severe mixed sleep-disordered breathing. Sleep efficiency was decreased in the 50 percentage level at that time with also evidence of obstructive events as well as periodic breathing and the baseline oxygen saturation while awake was in the 80s, suggesting hypoventilation, although carbon dioxide level was not checked. He was subsequently evaluated on CPAP and BiPAP with BiPAP destabilizing him and an effective pressure of CPAP was not found. He had a AHI of 130, desaturation to 53%, CPAP and BiPAP failed in [**12-22**]; He was placed empirically on cpap auto with a pressure of 15cm and a flex of 2. O2at 2L/min ; the past six years, he has been having worsening symptoms of excessive daytime sleepiness, nocturnal awakenings along with even problems functioning at work. He also has on occasion fallen asleep or even just dozed off and most recently rear-ended vehicle in front of him at a stoplight." Social History: Denies tobacco, etOH, or drug use current or past Occ: previously employed driving trucks but now unable to due to health problems [**Name (NI) **]: lives with wife and kids in [**Location (un) 686**] Family History: Mother died of cancer Father died of unknown causes . Physical Exam: Physical Exam on MICU admission: VS: Temp: 97.8 BP: 173/97 HR: 91 RR: 22 O2sat 96/6L NC GEN: obese, pleasant, comfortable, NAD speaking in short sentences HEENT: PERRL, EOMI, anicteric, MMM, 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: distant heart sounds, RR, S1 and S2 wnl, no m/r/g ABD: obese, +b/s, soft, nt, cannot assess masses or hepatosplenomegaly [**1-16**] to body habitus EXT: 1+ peripheral edema to distal thigh, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Pertinent Results: ABG pH 7.38 / pCO 257 / pO2 67 / HCO3 35 . EKG: Sinus tachycardia = 100bpm, nml axis, frequent PVCs, no TW abnormalities . CXR: AP UPRIGHT RADIOGRAPH OF THE CHEST: The exam is extremely limited by poor penetration and technique. Increased interstitial marking of the pulmonary edema is visualized. The lungs are difficult to evaluate; however, patchy consolidation is noted at the right lower lobe which might represent asymmetric pulmonary edema or pneumonia/atelectasis. No pleural effusion or pneumothorax is noted. Cardiac silhouette is mildly enlarged. The hilar contours are prominent. The osseous structures of the thorax appear normal. IMPRESSION: Findings consistent with interstitial pulmonary edema. Focal consolidation at the right lung base cannot be excluded. This appearance is suggestive of asymmetric alveolar pulmonary edema or less likely pneumonia/atelectasis. Brief Hospital Course: The pt is a 45 yo AA male with a PMH significant for DMII, HTN, morbid obesity, and sleep apnea who presents with SOB and increased swelling in his LE. . # Hypoxia/Hypercarbia: Multifactorial. Most likely [**1-16**] CHF: BNP elevated and subsequent TTE showed LVEF of 35%. However, other etiologies likely contributed to hypoxia as well: hypoventilation and pulm HTN [**1-16**] severe OSA and obesity. ABG on admission was c/w chronic retention at 7.38/57/67. Ruled-out for MI with negative enzymes. PE and PNA unlikely given lack of clinical or laboratory signs. On the floor, pt diuresed well with lasix, and symptoms improved. The patient remained stable throughout the hospitalization and reported no SOB/CP/palpitations on day of discharge. . # CHF (acute on chronic systolic) - Although has had signs and symptoms of CHF dating back to [**2162**] in prior notes. There is no echo in our system. Echo done here showed EF of 35%. Serum studies were ordered to eval for secondary causes of CHF: Iron studies (hemochromatosis), CBC (anemia), TSH(hypothyroid) and returned within normal limits. A stress test was ordered to evalute for ischemia, however, given patient's weight it had to be a two day stress and patient could not stay in the hosptial. Most likely etiology of CHF is severe OSA however stress test should be done to rule out ischemia as a possible etiology as an outpatient. Patient discharged home on 160mg PO lasix [**Hospital1 **] and advised to f/u with PCP next week for chem 7 check. # Severe OSA: Recently found to have very severe mixed sleep apnea, AHI of 130, desaturation to 53%, CPAP and BiPAP failed. Patient states poorly tolerated mask at home. We gave noninvasive mechanical ventilation with CPAP at 15 at night, tolerated well. Pt was counseled to continue using CPAP at home and he is scheduled for an overnight sleep titration study with sleep lab. . # Lower extremity edema: Most likely [**1-16**] CHF and non-compliance with meds. Low suspicion for DVT given symmetry on exam, nontender & no history of prolonged recumbency. Improved with lasix during hospitalization, and was significantly improved by day of discharge. . # HTN: Hypertensive on admission to SBP > 200. Confirms mild CP, but denies HA or other symptoms of hypertensive urgency. Discontinued Norvasc due to CFH. Maintained BP with lasix, lisinopril, metoprolol, hydralzaine, while inpatient. The pt's BP improved significantly with these measures and was stable throughout this hospitalization. Stopped hydralazine on day of discharge and changed over to hydrochlorthiazide. Pt was instructed to follow up with PCP in next few days re: HTN management. . # DM: Per patient is on glipizide and metformin and ASA as an outpatient. While hospitalized, we held the pt's glipizide and metformin, and instead used an insulin sliding scale. Restarted glipizide and metformin on day of discharge. . # CRI: BL Cr 1.4. Cr and UO were monitored throughout hospitalization: pt remained at his baseline. . # ?BPH - Pt on Doxazosin 4 mg qhs as outpatient. Continued while inpatient. Medications on Admission: atenolol 100 mg daily glipizide 10 mg daily valsartan 320 mg daily lasix 120 mg in AM and 80 mg in PM lisinopril 40 mg daily metformin 1000 mg [**Hospital1 **] norvasc 10 mg daily Doxazosin 4 mg qhs . Allergies: NKDA Discharge Medications: 1. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO every twelve (12) hours. Disp:*180 Tablet(s)* Refills:*1* 5. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Contact your physician if you begin to experience muscle cramps, nausea, vomiting . Disp:*30 Tablet(s)* Refills:*11* 6. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*1* 7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*1* 9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Congestive Heart Failure Obstructive sleep apnea Hypertension Diabetes Mellitus Secondary: Chronic Kidney Disease Lower extremity edema Discharge Condition: Stable, improving. Discharge Instructions: You were admitted to the hospital with shortness of breath and were seen by the intensive care specialists and the medicine team. We gave you IV diuretics to take off some fluid. An Echo was done which showed 35% of ejection fraction. Please continue to take all medications as prescribed, and attend all of your appointments. If you have chest pain, shortness of breath, lightheadedness please return to the emergency room. Followup Instructions: You should follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11528**] [**Telephone/Fax (1) 7976**] in 2 weeks. You can also call [**Telephone/Fax (1) 250**] to setup an appointment with another PCP at Health [**Name9 (PRE) **] Associate. Please call Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at [**Telephone/Fax (1) 3512**] for an appointment in the heart failure clinic. You have the following upcoming appointments: -Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 9529**] & DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2168-2-12**] 4:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2168-1-16**]

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icd9cm

[ [ [] ] ]

[ "88.72" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report+addendum

Admission Date: [**2183-10-28**] Discharge Date: [**2183-11-5**] Date of Birth: [**2111-7-21**] Sex: M Service: VSU CHIEF COMPLAINT: Nonhealing foot ulceration. HISTORY OF PRESENT ILLNESS: This is a 72 year-old gentleman with known peripheral vascular disease who has had multiple lower extremity bypasses and he has recently underwent a left lower arteriogram which revealed focal stenosis of the distal superficial femoral artery and he had single vessel runoff via the peroneal with an occluded dorsalis pedis graft. The patient was admitted the night before for IV hydration and antibiotics for elective left femoral popliteal re-do bypass graft. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Diovan 160, Flomax 0.4 mg daily, Lasix 40 mg b.i.d., Lipitor 10 mg q.d., Lopressor 25 mg b.i.d., Coumadin 7.5 mg daily, calcium, multivitamin, vitamin C daily, aspirin daily. Insulin is NPH insulin 32 units q A.M. and 38 units q P.M. with 4 of regular insulin at lunch. ILLNESSES: Include a history of atrial fibrillation, anticoagulated, history of coronary artery disease, status post myocardial infarction. History of congestive heart failure, compensated. History of aortic stenosis. History of hypertension. History of type 2 diabetes. History of ankylosing spondylitis. History of left heel osteomyelitis. PAST SURGICAL HISTORY: Includes left below knee popliteal with dorsalis pedis with PTFE and multiple foot debridements. PHYSICAL EXAMINATION: Vital signs: 98.3, 98, 18, [**Year (4 digits) **] pressure 158/70, oxygen saturation 99%. Glucose 217. General appearance: An alert male in no acute distress. Heart is regular rate and rhythm. Lungs are clear to auscultation bilaterally. Pulse examination shows palpable femorals bilaterally 2+, popliteals are 1+ bilaterally. The dorsalis pedis are absent bilaterally and the posterior tibials are monophasic Dopplerable signals only bilaterally. ADMITTING LABORATORIES: Included white count of 10.1, hematocrit 35.4, BUN 25, creatinine 0.8, INR 1.2. Chest x-ray was unremarkable. Electrocardiogram was without acute changes and in normal sinus rhythm with left anterior hemiblock. Vein mappings were done the previous admission. HOSPITAL COURSE: The patient was prepared for surgery and underwent a left popliteal posterior tibial bypass with non- reverse lesser saphenous vein angioscopy and valve lysis on [**2183-10-29**]. He tolerated the procedure well and was transferred to the post anesthesia care unit in stable condition. The patient was transferred intubated. He had a triphasic graft pulse. Dressing was stained, saturated with [**Year (4 digits) **]. Patient remained in the post anesthesia care unit overnight. Plastic surgery was consulted regarding the patient's left heel and anticipated debridement and flap closure. Patient was extubated overnight and on postoperative day 1 remained afebrile. His graft was Dopplerable with a warm foot. Hematocrit was 30.3. His fluids were Hep-locked and diet was advanced as tolerated. He was placed on subcutaneous heparin for deep venous thrombosis prophylaxis. He was continued on Vancomycin, ciprofloxacin and Flagyl and transferred to the Vascular Intensive Care Unit for continued monitoring and care. Patient remained on bed rest. Patient on postoperative day 2 with low urinary output, was begun on Dopamine with improvement in his urinary output. Postoperative day 3 Dopamine was weaned. His T-max was 100 to 97.8. [**Year (4 digits) **] pressure 113/44. O2 saturations 97% on 3 liters. Physical examination was unremarkable. Patient's diet was advanced. He was ambulated and assessed by physical therapy who felt he would require rehabilitation. Patient's home medications were begun and anticoagulation was held in anticipation of plastic surgery. The patient underwent a left foot plantar ulcer debridement and left plantar flap closure of the wound on [**2183-11-3**]. Patient tolerated the procedure well an was transferred to the post anesthesia care unit in stable condition. He did have an episode in the post anesthesia care unit of supraventricular tachycardia by monitor. Electrocardiogram was without acute changes. Electrolytes were unremarkable. Patient continued to well and was transferred to the regular nursing floor for continued care. Patient's Vancomycin, levofloxacin and Flagyl were discontinued on [**2183-11-5**] and Augmentin 500 mg t.i.d. was begun. Initial dressing was removed on postoperative day # The remaining hospital course was unremarkable. Patient will be transferred to rehabilitation when bed is available. DISCHARGE DIAGNOSES: Left heel wound secondary to failed graft. Status post left popliteal to posterior tibial bypass with nonreverse saphenous vein, angioscopy and valve lysis. Status post left foot plantar ulcer debridement with plantar flap and wound closure on [**2183-11-3**]. Postoperative [**Year (4 digits) **] loss anemia transfused, corrected. Postoperative intravascular volume depletion with low urinary output, resolved, requiring Dopamine, resolved. History of peripheral vascular disease, status post left below knee popliteal to dorsalis pedis bypass, failed. History of hypertension, controlled. History of ischemic heart disease with a history of myocardial infarction, stable. History of congestive heart failure, compensated. History of aortic stenosis. History of ankylosis spondylitis with severe kyphosis. Type 2 diabetes, insulin dependent, controlled. History of tobacco use. FOLLOW UP: Patient should follow up with Dr. [**First Name (STitle) **] of the plastic service in 1 to 2 weeks post discharge. Call for an appointment at [**Telephone/Fax (1) 5343**]. Patient should also follow up at the time with Dr. [**Last Name (STitle) 1391**] and call for an appointment at [**Telephone/Fax (1) 13922**]. DISCHARGE MEDICATIONS: Flomax 0.4 mg q.h.s., ascorbic acid 500 mg daily, multivitamin tablet 1 daily, oxycodone/acetaminophen 5/325 pills, 1 to 2 q 4 to 6 hours p.r.n. for pain, calcium carbonate 250 mg q.d., Lopressor 25 mg tablets 1.5 tablets b.i.d., Colace 100 marginal branch b.i.d., amoxicillin clavulanate 500/125 q 8 hours for a total of 1 week, insulin of fixed and sliding scales as follows: NPH 32 units q breakfast and 38 units q dinner, Humalog sliding scale before meals as follows - Glucoses less than 120 no insulin; 121 to 160 3 units; 161 to 200 6 units; 201 to 240 9 units; 241 to 280 12 units; 281 to 320 15 units; 321 to 360 18 units; greater than 360 notify physician. [**Name10 (NameIs) **] sliding scales as follows: Glucoses less than 120 no insulin; 121 to 160 1 unit; 161 to 200 3 units; 201 to 240 5 units; 241 to 280 7 units; 281 to 320 9 units; 321 to 360 10 units, greater than 360 notify physician. OTHER DISCHARGE INSTRUCTIONS: Patient my ambulate essential distances nonweight bearing x1 week on the left foot. Dry sterile dressings to left heel changed daily. Patient should elevate the leg when sitting in the chair. No driving until seen in follow up. Take all medications as prescribed. Continue antibiotics until all pills are gone. Ace wrap foot to left knee to left leg when ambulating. Patient should take stool softeners while on narcotic pain medications. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2183-11-5**] 12:45:28 T: [**2183-11-5**] 13:54:49 Job#: [**Job Number 27100**] Name: [**Known lastname 4662**],[**Known firstname 651**] E. Unit No: [**Numeric Identifier 4663**] Admission Date: [**2183-10-28**] Discharge Date: [**2183-11-6**] Date of Birth: [**2111-7-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2183-11-6**] Patient's coumadin restarted at 7.5mgm qd 9 preadmission dose) for history of AF. Patient instructed to ;have INR Monitered by PCP upon discharge.patient's diovan 160mgm was restarted and lopressor dosing changed from 37.5mgm [**Hospital1 **] to 25mgm [**Hospital1 **]. Lipitor 10mgm ans ASA 325mgm restarted.Patient instructed continue preadmision insulin regime. d/c to rehab stable. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) 3876**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2183-11-6**]

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icd9cm

[ [ [] ] ]

[ "99.04", "86.72", "77.68", "00.17", "39.49" ]

icd9pcs

[ [ [] ] ]

8340, 8616

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1380, 1478

5537, 5854

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213, 714

46,904

154,626

30559

Discharge summary

report

Admission Date: [**2136-9-7**] Discharge Date: [**2136-9-12**] Date of Birth: [**2085-7-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3574**] Chief Complaint: fatigue, elevated INR, ?melena Major Surgical or Invasive Procedure: Endoscopy Colonoscopy History of Present Illness: 51 YO M w COP (cryptogenic organizing pneumonitis) on prednisone 30mg, HTN, HLD, CHF, PE on coumadin admitted to ICU with c/o 1 week of weakness and fatigue along with orthostasis and several episodes of "blacking out". He describes feeling very weak when walking and shaking uncontrollably. He also reports nausea and resultant loss of appetite although no vomiting or abdominal pain. On day of admission, he had one large black tarry bowel movement. . He had a routine INR drawn at [**Location (un) 945**] where he was visiting his daughter on [**9-5**] and was called due to elevated INR of 9. He was asked to go to [**Hospital3 **] Hospital. He went there on [**9-6**] and was going to be admitted but the patient left AMA and travelled to [**Hospital1 18**] for evaluation. He has never had a c-scope. . Upon arrival to the ED, his VS were: 97.7 85 98/57 22 99%. Exam was notable for a comfortable male in NAD with guaiac + brown stool. Labs were notable for hct 20.7 (baseline mid-30s), INR 4.9. EKG was unchanged from prior. GI was consulted and recommended CT to eval for RP bleed. CT was negative for hematoma or RP bleed. He was given 2u FFP, 2u pRBCs and an 18 and a 20g PIV were placed. NG lavage had return of stomache contents (no bile) but was negative for blood. . In the MICU, he received 4 more units PRBCs for a total of 6 units PRBCs and 4 units FFP. Coumadin was held. HCT subsequently remained stable at 30 and he remained HD stable. Last transfused 5pm on [**9-8**]. GI saw him and recommended possible scope on Tuesday since may need intubation and OR for scope. . Prior to transfer, he denies SOB, CP, LH, dizziness, furhter bleeding. He has not passed any further stool. . Review of sytems: (+) Per HPI; long history of LE edema, he reports his current edema is much improved from the past several months (-) Denies fever, chills, night sweats, recent weight loss or gain. Denied nausea, vomiting, diarrhea, or abdominal pain. No dysuria. Denied arthralgias or myalgias. Past Medical History: -Cryptogenic organizing pneumonia, dx via RML wedge resection [**2-/2136**], on chronic prednisone. -PEs, now on warfarin; subsegmental, d/x [**2136-6-7**]. -Fracture of L2 and multiple ribs after mechanical fall. -Crush injury to his legs after being involved in a [**Doctor Last Name 9808**] collapse in [**2116**], leading to right knee replacement and bilateral femoral pins. -Multiple gunshot wounds to legs/back/buttocks, complicated by osteomyelitis, in [**2106**] after being involved in an altercation with a neighbor. -Obesity - tracheobronchomalacia with difficult intubation -Severe obstructive sleep apnea -- restarted biPAP [**5-/2136**] -HTN -Hyperlipidemia -Diastolic CHF -Diabetes mellitus -- developed secondary to steroids -Depression and PTSD -Tobacco abuse -Alcohol abuse -Squamous cell carcinoma on dorsum of right hand s/p Mohs micrographic surgery -Back pain on narcotics contract -Questionable h/o pericarditis with pericarial effusion requiring drainage at [**Hospital1 **] (patient report) . Social History: Lives alone in [**Location (un) 5289**]. On disability, but formerly worked in construction doing wrecking. He was a certified asbestos remover and had significant asbestos exposure 20-30 years ago. - Tobacco history: Smoked 1.5 pk/day x30 years, quit ~3 months ago - ETOH: Last drink the weekend prior to admission. He used to drink about 4 beers/night and 3 shots of vodka/night. Reports occasionally drinking more than 20 beers at a sitting. Asserts that he drinks minimally now because of his health. - Illicit drugs: None. - Herbal/alternative therapy: None. - He is divorced, but close with his ex-wife. Two children, son died last year in [**Name (NI) 8751**]. Family History: - Brother with heart transplant for pericarditis - No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. - mother had melanoma and died of perforated peptic ulcer at 71 - father alive and well - 3 brothers and 3 sisters alive and well Physical Exam: Physical Exam on admission: Vitals: T: BP: 113/60 P: R: 18 O2: General: Alert, oriented, no acute distress, ruddy complexion, obese HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, reducible umbilical hernia, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 1+ bilateral pitting edema . Vitals: afeb, 97.0, 122/70 122-148/70-88 60 (60s-70s) 20 98% RA gluc 93, 142, 162, 173 got total 4R insulin and 10L shift I=npo, O=BRP+BM General: Alert but tired, oriented, no acute distress, ruddy complexion, obese habitus HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to appreciate given habitus, no LAD Lungs: Faint bibasilar rales but otherwise CTAB CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Distant likely due to body habitus Abdomen: +BS soft, obese, NTND, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 1+ bilateral pitting edema, bilateral erythema, no warmth . Pertinent Results: [**2136-9-12**] 06:18AM BLOOD WBC-10.9 RBC-3.35* Hgb-9.8* Hct-29.8* MCV-89 MCH-29.3 MCHC-33.0 RDW-16.1* Plt Ct-279 [**2136-9-11**] 01:00PM BLOOD WBC-14.8* RBC-3.53* Hgb-10.4* Hct-31.4* MCV-89 MCH-29.4 MCHC-33.1 RDW-16.4* Plt Ct-275 [**2136-9-11**] 05:05AM BLOOD WBC-13.8* RBC-3.62* Hgb-10.8* Hct-33.1* MCV-92 MCH-29.8 MCHC-32.6 RDW-16.7* Plt Ct-318 [**2136-9-10**] 05:00PM BLOOD WBC-13.8* RBC-3.47* Hgb-10.2* Hct-31.3* MCV-90 MCH-29.4 MCHC-32.6 RDW-16.7* Plt Ct-296 [**2136-9-10**] 06:35AM BLOOD WBC-13.2* RBC-3.55* Hgb-10.6* Hct-31.8* MCV-90 MCH-30.0 MCHC-33.4 RDW-16.8* Plt Ct-285 [**2136-9-9**] 02:39AM BLOOD WBC-10.5 RBC-3.36* Hgb-10.2* Hct-29.6* MCV-88 MCH-30.3 MCHC-34.4 RDW-16.8* Plt Ct-224 [**2136-9-8**] 06:22AM BLOOD WBC-10.6 RBC-2.95* Hgb-8.6* Hct-25.2* MCV-85 MCH-29.3 MCHC-34.3 RDW-17.3* Plt Ct-208 [**2136-9-7**] 11:41PM BLOOD WBC-11.6* RBC-2.65* Hgb-7.8* Hct-23.1* MCV-87 MCH-29.6 MCHC-34.0 RDW-17.8* Plt Ct-227 [**2136-9-7**] 01:50PM BLOOD WBC-10.9 RBC-2.42*# Hgb-7.0*# Hct-20.7*# MCV-85 MCH-28.9 MCHC-33.9 RDW-18.0* Plt Ct-259 [**2136-9-10**] 06:35AM BLOOD Neuts-81.5* Lymphs-14.0* Monos-3.7 Eos-0.4 Baso-0.5 [**2136-9-9**] 02:39AM BLOOD Neuts-82.7* Lymphs-12.1* Monos-3.7 Eos-1.1 Baso-0.3 [**2136-9-8**] 06:22AM BLOOD Neuts-76.7* Lymphs-18.9 Monos-3.2 Eos-1.0 Baso-0.2 [**2136-9-7**] 11:41PM BLOOD Neuts-82.7* Lymphs-14.1* Monos-2.8 Eos-0.3 Baso-0.1 [**2136-9-7**] 01:50PM BLOOD Neuts-92.2* Lymphs-5.9* Monos-1.7* Eos-0.2 Baso-0.1 [**2136-9-7**] 01:50PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-1+ Ovalocy-1+ Schisto-OCCASIONAL Burr-OCCASIONAL Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2136-9-12**] 06:18AM BLOOD Plt Ct-279 [**2136-9-12**] 06:18AM BLOOD PT-12.5 PTT-24.8 INR(PT)-1.1 [**2136-9-11**] 01:00PM BLOOD Plt Ct-275 [**2136-9-11**] 05:05AM BLOOD Plt Ct-318 [**2136-9-9**] 02:39AM BLOOD PT-15.9* PTT-24.5 INR(PT)-1.4* [**2136-9-8**] 11:32AM BLOOD PT-19.7* PTT-29.1 INR(PT)-1.8* [**2136-9-8**] 06:22AM BLOOD PT-21.2* PTT-27.1 INR(PT)-2.0* [**2136-9-7**] 11:41PM BLOOD PT-27.4* PTT-29.4 INR(PT)-2.7* [**2136-9-7**] 01:50PM BLOOD PT-45.6* PTT-33.9 INR(PT)-4.9* [**2136-9-12**] 06:18AM BLOOD Glucose-86 UreaN-13 Creat-0.8 Na-139 K-3.6 Cl-99 HCO3-34* AnGap-10 [**2136-9-11**] 05:05AM BLOOD Glucose-83 UreaN-18 Creat-0.9 Na-141 K-3.7 Cl-98 HCO3-33* AnGap-14 [**2136-9-10**] 06:35AM BLOOD Glucose-129* UreaN-25* Creat-1.0 Na-138 K-3.7 Cl-98 HCO3-33* AnGap-11 [**2136-9-9**] 02:39AM BLOOD Glucose-119* UreaN-19 Creat-0.7 Na-136 K-4.1 Cl-97 HCO3-31 AnGap-12 [**2136-9-8**] 06:22AM BLOOD Glucose-108* UreaN-29* Creat-0.9 Na-135 K-3.2* Cl-92* HCO3-36* AnGap-10 [**2136-9-7**] 01:50PM BLOOD Glucose-229* UreaN-38* Creat-0.8 Na-130* K-3.3 Cl-87* HCO3-33* AnGap-13 [**2136-9-7**] 01:50PM BLOOD LD(LDH)-164 [**2136-9-12**] 06:18AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3 [**2136-9-11**] 05:05AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.7* [**2136-9-10**] 06:35AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.3 [**2136-9-9**] 02:39AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.5 [**2136-9-8**] 06:22AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.2 [**2136-9-7**] 01:50PM BLOOD Hapto-214* [**2136-9-11**] 05:05AM BLOOD %HbA1c-6.4* eAG-137* [**2136-9-7**] 11:55PM BLOOD Lactate-2.0 [**2136-9-7**] 05:42PM BLOOD Hgb-7.3* calcHCT-22 [**2136-9-7**] 03:00PM URINE GR HOLD-HOLD [**2136-9-7**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2136-9-7**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG . ECG Study Date of [**2136-9-7**] 1:21:06 PM Sinus rhythm. Normal tracing. Compared to the previous tracing of [**2136-8-9**] no change. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 156 98 390/428 26 67 59 . CHEST (PA & LAT) Study Date of [**2136-9-7**] 2:59 PM AP AND LATERAL VIEWS OF THE CHEST: Cardiac, mediastinal, and hilar contours are stable. Redemonstrated are bilateral ill-defined airspace opacities, most pronounced in the upper lobes, but stable from prior, compatible within the patient's known history of cryptogenic organizing pneumonia. No new areas of focal consolidation are present. No pneumothorax or pleural effusion. Cervical spinal fusion hardware is partially imaged. IMPRESSION: Unchanged appearance of the chest with bilateral air-space opacities compatible with known diagnosis of cryptogenic organizing pneumonia. . CT PELVIS W/O CONTRAST Study Date of [**2136-9-7**] 3:17 PM CT ABDOMEN WITHOUT CONTRAST: The imaged portions of the lung bases are notable for small, tree-in-[**Male First Name (un) 239**] type opacities at the left lower lobe which are improved from the previous study as well as suture material in the right middle lobe which is stable. Note is also made of subpleural fat. Imaged portions of the heart, stomach, duodenum, spleen, adrenal glands, pancreas, kidneys, gallbladder, and liver are normal. There is no free gas or fluid in the abdomen. There is no retroperitoneal or mesenteric lymphadenopathy. Regional vascular structures reveal scattered atherosclerotic calcifications along the aorta. Note is made of fat-containing umbilical hernia. The left adrenal gland is notable for a small 15 x 13 mm nodule containing bulk fat, consistent with an adrenal myelolipoma. CT PELVIS WITHOUT CONTRAST: The urinary bladder, distal ureters, prostate, seminal vesicles, rectum, and colon are normal. There is no free gas or fluid in the pelvis. There is specifically no evidence of retroperitoneal or other hematoma. There is no pelvic fat or inguinal lymphadenopathy. OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion. A superior endplate compression deformity of the L2 vertebral body is unchanged. IMPRESSION: 1. No retroperitoneal or other hematoma. 2. Unchanged left adrenal myelolipoma. 3. Fat-containing umbilical hernia. . CT HEAD W/O CONTRAST Study Date of [**2136-9-7**] 7:37 PM FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or recent infarction. The ventricles and sulci are normal in size and appearance. No concerning osseous lesion is seen. The visualized paranasal sinuses are clear. There are calcifications of the bilateral carotid siphons. IMPRESSION: No evidence of acute intracranial process. . ECG Study Date of [**2136-9-8**] 9:44:40 AM Sinus rhythm. Normal tracing. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 190 104 430/447 59 60 54 . BILAT LOWER EXT VEINS Study Date of [**2136-9-10**] 9:13 AM COMPARISON: [**2136-7-10**]. BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler examination of the right and left common femoral, superficial femoral, and popliteal veins were performed and demonstrate normal compressibility, augmentability and respiratory variation in flow. No intraluminal thrombus is identified. IMPRESSION: No deep venous thrombosis involving the right or left lower extremity. . Colonoscopy [**2136-9-12**] Findings: Protruding Lesions A single 2 mm polyp of benign appearance was found in the rectum. Cold forceps biopsies were performed for histology at the rectum. Impression: Polyp in the rectum (biopsy) Otherwise normal colonoscopy to cecum Recommendations: Given poor prep, will need screening colonoscopy. Additional notes: The procedure was performed by the fellow and the attending. The attending was present for the entire procedure. The patient's reconciled home medication list is appended to this report. . EGD [**2136-9-12**] Findings: Esophagus: Other Esophagus with white plaques suggestive of candidiasis Stomach: Other Erythema of the antrum suggestive of gastritis Duodenum: Normal duodenum. Impression: Esophagus with white plaques suggestive of candidiasis Erythema of the antrum suggestive of gastritis Otherwise normal EGD to third part of the duodenum Recommendations: Treat likely [**Female First Name (un) 564**] Esophagitis with Fluconazole Brief Hospital Course: 51 YO M w COP, HTN, HLD, dCHF, PE on coumadin, recent elevated INR now presenting to the ED for orthostasis and malaise found to have acute anemia, elevated INR and guiac positive stool concerning for GI bleed; question of possible melena per pt. . # ACUTE BLOOD LOSS ANEMIA: The patient was admitted to the medical ICU given concern for active GI bleeding in the setting of low hematocrit with inappropriate response to transfusion in the setting of supratherapeutic INR. He was hemodynamically stable without evidence of active bleeding. He was transfused a total of 6 RBC. His INR was reversed with vitamin K and FFP. He was stable and transferred to the floor for further management. He underwent colonoscopy and endoscopy under MAC in the OR which showed a polyp in the rectum (biopsy) but otherwise otherwise normal colonoscopy to cecum (evaluation limited by prep). EGD showed esophagus with white plaques suggestive of candidiasis; erythema of the antrum suggestive of gastritis but otherwise normal EGD to third part of the duodenum. Pt was prescribed fluconazole for tx of [**Female First Name (un) **] and omeprazole for GI prophylaxis given evidence of gastritis and that pt taking chronic steroids for lung disease. . # Orthostasis, hyponatremia: This was likely related to blood loss although also likely a component of dehydration given that patient had decreased PO intake for several days as well. Home lasix, spironlactone and lisinopril were briefly held while pt stablized. Home medications were added back slowly on the floor as pt condition improved and pt was discharged on home medications. . # COP: Pt was continued on home prednisone along with bactrim ppx. He did not require oxygen once stablized. . #OBSTRUCTIVE SLEEP APNEA: The night of admission the patient destaturtated to 70s while asleep. He agreed to wear CPAP at night and improved to 90s. . #PULMONARY EMBOLISM: The coumadin was held and he was given FFP and vitamin K in the setting of presumed GI bleed. Lower extremity ultrasound showed no evidence of DVT. Pt had been on coumadin roughly 3months and per attending recommendations, it was felt that this was a sufficient course and coumadin was not restarted particularly given concern for other possible bleeding. . Pt was full code during this admission. . . . Medications on Admission: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 4. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID 6. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) application Topical every six (6) hours as needed for irritation. 7. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Hospital1 **] 8. Ergocalciferol (Vitamin D2) 50,000 unit weekly 9. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twelve (12) units Subcutaneous at bedtime. 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 11. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours): please do not drive or drink alcohol while taking this medication. 12. Oxycodone 15 mg Tablet Sig: 1-2 Tablets PO every four (4) hours: please do not drive or drink alcohol while taking this medication. 13. Prazosin 1 mg Capsule Sig: One (1) Capsule PO HS 14. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 15. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY 16. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY 17. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 18. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 19. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 20. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 21. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. . Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 4. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) topical application Ophthalmic every six (6) hours as needed for skin irritation. Disp:*1 tube* Refills:*2* 5. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. Disp:*4 Capsule(s)* Refills:*2* 7. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twelve (12) units Subcutaneous at bedtime: 12 units at bedtime adjust as instructed by your doctor . Disp:*30 pens* Refills:*2* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Oxycodone 15 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for pain for 3 days. Disp:*36 Tablet(s)* Refills:*0* 10. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every eight (8) hours for 3 days. Disp:*9 Tablet Sustained Release 12 hr(s)* Refills:*0* 11. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every eight (8) hours for 3 days. Disp:*9 Tablet Sustained Release 12 hr(s)* Refills:*0* 12. Clotrimazole 1 % Cream Sig: One (1) Topical twice a day: 1 Cream(s) twice a day Apply a thin film of cream to red scaly patches on legs and redness in groin folds twice daily . Disp:*1 tube* Refills:*2* 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: 1 Tablet(s) by mouth twice a day Take with the 80 mg tablet for total of 120 mg twice a day . Disp:*60 Tablet(s)* Refills:*2* 16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day: 1 Capsule(s) by mouth twice a day Please do not drive while taking this medication. Disp:*60 Capsule(s)* Refills:*2* 17. Prazosin 1 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:*30 Capsule(s)* Refills:*2* 18. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 19. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 20. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 21. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3 times a week Monday, Wednesday, and Friday . Disp:*12 Tablet(s)* Refills:*2* 22. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*2* 23. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 24. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 25. 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* 26. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day for 21 days. Disp:*21 Tablet(s)* Refills:*0* 27. Oxycodone 15 mg Tablet Sig: Two (2) Tablet PO every four (4) hours for 30 days. Disp:*360 Tablet(s)* Refills:*0* 28. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every eight (8) hours for 16 days. Disp:*48 Tablet Sustained Release 12 hr(s)* Refills:*0* 29. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every eight (8) hours for 16 days. Disp:*48 Tablet Sustained Release 12 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Acute anemia, due to unknown source of intestinal bleeding Secondary: Hyponatremia IDDM COP Severe OSA [**Female First Name (un) 564**] Infection of the esophagus Irritation of the lining of the stomach 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 you were found to have an INR of 9 and were having dark black bowel movements suggestive on bleeding in your intestine as well as feeling lightheaded, sweating, nausea and other symptoms suggestive of acute anemia (low red blood cell count). When you arrived at the hospital you were found to have a low red blood cell count. You were briefly admitted to the ICU you were you received blood to treat your acute anemia. You're vital signs stablized and you where transferred out of the ICU. A colonoscopy and upper endoscopy was performed to look at your gastrointestinal tract to determine if there was a possible source for the bleeding. They found some evidence of irritation of the lining of your stomach and a yeast infection in your esophagus. Unfortunately, the preparation for the colonoscopy was not very good; this was not your fault. We did not find a source of the bleeding. Now that your blood is not thinned, we believe that it is safe for you to go home. However, we advise that you follow-up with gastroenterology to complete the evalutation. You have an appointment to see Dr. [**Last Name (STitle) **] in the gastroenterology clinic. Gastroenterology evaluation will start with a capsule endoscopy (camera pill) which will be ordered and arranged for you to do as an outpatient. You were discharged home after you recovered from your colonscopy. The following changes were made to your medications: - Please START taking omeprazole 40mg daily - Please START taking fluconazole 100mg daily until you have taken all pills provided; this is to treat the yeast infection in your esophagus - Please STOP taking coumadin. - Please continue to take all of your other home medications as prescribed. Please be sure to take all medication as prescribed. Weigh yourself every morning, [**Name6 (MD) 138**] your MD if your weight goes up more than 3 lbs. Please be sure to keep all follow-up appointments with your PCP, [**Name10 (NameIs) **] and gastroentestinal doctors. It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your PCP, [**Name10 (NameIs) **] and gastroentestinal doctors. [**Hospital3 **] social work will call you with an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Licsw Department: [**Hospital3 249**] When: MONDAY [**2136-9-24**] at 3:50 PM With: [**Known firstname **] [**Last Name (NamePattern1) 24385**], MD [**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: PULMONARY FUNCTION LAB When: WEDNESDAY [**2136-9-26**] at 3:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: WEDNESDAY [**2136-9-26**] at 3:30 PM Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2136-9-26**] at 3:30 PM With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2136-10-3**] at 4:00 PM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Completed by:[**2136-9-19**]

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Discharge summary

report

Admission Date: [**2194-10-22**] Discharge Date: [**2194-10-29**] Date of Birth: [**2131-5-15**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4679**] Chief Complaint: dysphagia Major Surgical or Invasive Procedure: [**2194-10-22**] 1. Minimally-invasive esophagectomy. 2. Buttressing of intrathoracic anastomosis with pericardial fat pad History of Present Illness: 63-year-old male with EUS stage T3 N1, adenocarcinoma of the GE junction/distal esophagus who is s/p lap J-tube placement on [**2194-7-14**] for significant nausea and intolerance of adequate PO intake secondary to chemoradiation now returns for f/u. He has done well from the J-tube and is currently taking in ~1200-1300kcal daily from TF's. His nausea had resolved w/ the completion of the chemorads (total 2 cycles chemo, 28days of radiation; last chemotherapy cycle ~7weeks ago). He is currently tolerating a regular diet. He currently only c/o straining his abdominal muscle at L-sided J-tube exit site after playing golf ~2weeks ago. He denies any F, C, CP, SOB, dysphagia, odynophagia, hemoptysis. He is also regaining some of weight that he had lost during chemo - regained ~12 lbs of the 35 that he initially lost. He had a PET-scan on [**2194-9-23**] that demonstrated interval resolution of FDG avidity in the GE junction and in celiac axis lymph node noted on prior PET [**2194-6-12**] and there were no new or worsened focus of FDG avidity. Past Medical History: Adenocarcinoma of esophagus Kidney stones, status post multiple lithotripsies Social History: Smoking: 5 pack year history ETOH: 5 drinks/week Married Family History: Negative for history of cancers. Physical Exam: Weight: 148. Height: 68.5. BMI: 22.2. Pain Score: 0. Temperature: 97.3. BP: 132/84. Heart Rate: 74. Resp. Rate: 16. O2 Saturation%: 100RA. Gen: AAOx3, NAD Neck: No cervical/supraclacivular LAD Heart: RRR Lungs: CTAB Abd: J-tube intact, no erythema/induration, no drainage, no TTP, no masses palpated Pertinent Results: [**2194-10-22**] 05:14PM WBC-9.8# RBC-3.25* HGB-10.6* HCT-31.1* MCV-96 MCH-32.6* MCHC-34.1 RDW-12.6 [**2194-10-22**] 05:14PM PLT COUNT-163 [**2194-10-22**] 03:51PM GLUCOSE-227* LACTATE-3.6* NA+-136 K+-4.7 CL--104 [**2194-10-22**] 03:51PM HGB-11.1* calcHCT-33 [**2194-10-22**] 05:14PM GLUCOSE-185* UREA N-23* CREAT-1.0 SODIUM-139 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12 [**2194-10-28**] CXR : Status post chest tube removal without evidence of pneumothorax; trace left pleural effusion; central air-fluid level likely reflects the neoesophagus. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the hospital and taken to the Operating Room where he underwent a laparoscopic esophagogastrectomy. He had an epidural catheter placed prior to surgery for pain control. He tolerated the procedure well and returned to the ICU in stable condition. He maintained stable hemodynamics and his pain was controlled well enough for him to continue good pulmonary toilet. His J tube feedings began on post op day #1 and he was getting out of bed without difficulty. He maintained stable hemodynamics. Following transfer to the Surgical floor he continued to improve. He tolerated his cyclic feedings and had good pain relief with the epidural. The epidural catheter was removed on POD 6 and Roxicet was effective. He was voiding without difficulty and his port sites were dry. He had a barium swallow on [**2194-10-28**] which showed no evidence of a leak and subsequently his chest tube and JP drain was removed. He began a full liquid diet and tolerated it in modest amounts. He was instructed to stay on liquids for a few days then begin soft solids in small amounts as long as he feels like it. He will remain on full tube feedings for now and is comfortable with using the pump and starting the feedings. After an uncomplicated recovery he was discharged to home on [**2194-10-29**] and will follow up with Dr. [**First Name (STitle) **] in 2 weeks. Medications on Admission: none Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2 times a day). Disp:*250 mls* Refills:*2* 2. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-15 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*500 ML(s)* Refills:*0* 3. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every six (6) hours as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Health Alliance Home and Hospice Discharge Diagnosis: Esophageal cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr. [**Last Name (STitle) **] [**Name (STitle) **] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers greater than 101 or chills -Increased shortness of breath, cough or chest pain -Nausea, vomiting (take anti-nausea medication) -Increased abdominal pain -Incision develops drainage -Remove chest tube and j-tube site bandages Thursday and replace with a bandaid, changing daily until healed. Pain -Roxicet via J-tube or orally as needed for pain -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Diet: Tube feeds: Isosource 1.5 Full Strength 80 mL from 6pm to 9am Flush J-tube with water every 8 hours with 1 cup of water, before and after starting tube feeds and giving medications through tube Full liquid diet, may increase to soft solids over the next few days as tolerated. Eat small frequent meals. Sit up in chair for all meals and remain sitting for 30-45 minutes after meals Daily weights: keep a log bring with you to your appointment NO CARBONATED DRINKS Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2194-11-11**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please report to the [**Location (un) **] Radiology Dept. in the [**Hospital Ward Name 23**] Clinical Center 30 minutes before your appointment for a chest xray. Completed by:[**2194-10-29**]

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icd9cm

[ [ [] ] ]

[ "96.6", "43.99", "03.90" ]

icd9pcs

[ [ [] ] ]

4599, 4662

2701, 4106

322, 450

4725, 4725

2107, 2678

6175, 6680

1734, 1769

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4876, 6152

1784, 2088

273, 284

478, 1541

4740, 4852

1563, 1643

1659, 1718

46,809

109,529

2276

Discharge summary

report

Admission Date: [**2170-2-8**] Discharge Date: [**2170-2-14**] Date of Birth: [**2104-9-15**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Amiodarone Hcl Attending:[**First Name3 (LF) 1185**] Chief Complaint: anemia Major Surgical or Invasive Procedure: - EGD [**2-9**] - EGD [**2-13**] with APC of GAVE tissue History of Present Illness: 65 year old male w/ hx of CAD s/p MI, chronic cardiomyopathy (EF 30% IN [**2167**]), afib (on warfarin), vtach (s/p pacer/ICD), HTN and DMII presenting after a CBC blood draw by clinic that demonstrated a precipitous drop (last in 9/[**2164**]). Pt was seen by PC [**1-19**] with complaints of mild lightheadedness when standing. No syncope or feelings of pre-syncope. He was seen [**Location 11973**] yesterday and had blood drawn which revealed a Hct of 21. His previous hct was in [**8-/2165**] and was 40. He was advised to come to walk-in today by the on call doctor. Pt notes his stool over the past 3-4 days having specks of charcoal stool but mainly yellow.Upon questioning, pt hasn't taken any pepto-bismol, blueberries or iron supplementation. His stool are usually completely yellow. He denies chest pain, sob, abd pain. He denies use of pepto-bismol. He notes a slight nose bleed 2-3 days ago but denies any other symptoms of gross bleeding. . Patient is a non-drinker for 26 years and denies any NSAID usage. . In the ED inital vitals were, 98.2 63 110/50 18 97%. The patient had an NG lavage with red specks but no frank blood. Rectal exam demonstrated brown, guaiac negative stool. GI was consulted and will see in ICU. Pt was initiated on protonix bolus + gtt. Pt given Vitamin K 10 mg IV once. Pt is a Jehovah's witness and refuses blood products (patient was explicitly told that may die with refusal of blood). . On arrival to the ICU, vital signs are afebrile 82 15 124/77 100% 2L. Patient in no acute distress. Communicating clearly and coherently. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, 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. Myocardial infarction, coronary artery disease. 2. Chronic cardiomyopathy with LVEF of 30%. 3. Moderate mitral regurgitation. 4. Atrial fibrillation, on warfarin. 5. Nonsustained VT, status post ICD -- last device interrogation [**11/2169**], w/ e/o atrial tachycardia up to atrial rate of 300 6. Atrial tachycardia. 7. Diabetes. 8. Hypertension. 9. Gout. 10. Hyperlipidemia. 11. Anxiety. Social History: spanish speaker from [**Male First Name (un) 1056**], Jehova's Witness who will not have any blood products - Tobacco: none - Alcohol: none - Illicits: none Family History: No cancer. There is premature heart disease. . Physical Exam: ADMISSION PHYSICAL EXAM; Vitals: afebrile 82 15 124/77 100% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear (Mallampati 2) Neck: supple, JVP 7cm H2O, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE PHYSICAL EXAM 98.7, 106/58, 60, 20, 99RA FS 189 General: Alert, oriented, no acute distress, pale HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, NO JVP, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no edema Pertinent Results: . [**2170-2-7**] 05:07PM BLOOD WBC-6.9 RBC-2.74*# Hgb-6.9*# Hct-21.6*# MCV-79*# MCH-25.2*# MCHC-31.9 RDW-13.9 Plt Ct-257 [**2170-2-8**] 11:42AM BLOOD WBC-5.4 RBC-2.61* Hgb-6.6* Hct-20.4* MCV-78* MCH-25.2* MCHC-32.3 RDW-14.1 Plt Ct-240 [**2170-2-9**] 05:55AM BLOOD WBC-6.1 RBC-2.76* Hgb-7.0* Hct-21.0* MCV-76* MCH-25.3* MCHC-33.3 RDW-14.0 Plt Ct-245 [**2170-2-10**] 06:15AM BLOOD WBC-6.9 RBC-2.80* Hgb-7.1* Hct-21.6* MCV-77* MCH-25.2* MCHC-32.6 RDW-14.4 Plt Ct-258 [**2170-2-11**] 06:25AM BLOOD WBC-8.4 RBC-2.98* Hgb-7.3* Hct-22.6* MCV-76* MCH-24.4* MCHC-32.2 RDW-15.2 Plt Ct-261 [**2170-2-12**] 06:56AM BLOOD WBC-6.9 RBC-3.03* Hgb-7.5* Hct-23.2* MCV-77* MCH-24.8* MCHC-32.4 RDW-16.3* Plt Ct-234 [**2170-2-13**] 07:27AM BLOOD WBC-7.0 RBC-2.90* Hgb-7.3* Hct-22.1* MCV-76* MCH-25.1* MCHC-32.9 RDW-16.8* Plt Ct-240 [**2170-2-8**] 11:42AM BLOOD Neuts-56 Bands-0 Lymphs-29 Monos-10 Eos-3 Baso-1 Atyps-0 Metas-1* Myelos-0 [**2170-2-8**] 12:40PM BLOOD PT-33.0* PTT-35.3 INR(PT)-3.2* [**2170-2-8**] 11:07PM BLOOD PT-24.6* INR(PT)-2.4* [**2170-2-9**] 05:55AM BLOOD PT-19.7* PTT-26.9 INR(PT)-1.9* [**2170-2-10**] 06:15AM BLOOD PT-15.5* INR(PT)-1.5* [**2170-2-13**] 07:27AM BLOOD PT-13.6* PTT-24.9* INR(PT)-1.3* [**2170-2-7**] 05:07PM BLOOD UreaN-25* Creat-1.6* Na-132* K-5.2* Cl-101 HCO3-24 AnGap-12 [**2170-2-8**] 11:42AM BLOOD Glucose-145* UreaN-26* Creat-1.3* Na-132* K-4.6 Cl-99 HCO3-25 AnGap-13 [**2170-2-9**] 05:55AM BLOOD Glucose-137* UreaN-18 Creat-1.2 Na-135 K-4.4 Cl-102 HCO3-23 AnGap-14 [**2170-2-12**] 06:56AM BLOOD Glucose-133* UreaN-23* Creat-1.3* Na-136 K-4.6 Cl-104 HCO3-22 AnGap-15 [**2170-2-8**] 11:42AM BLOOD LD(LDH)-193 TotBili-0.3 [**2170-2-9**] 05:55AM BLOOD ALT-16 AST-20 LD(LDH)-181 AlkPhos-56 TotBili-0.5 [**2170-2-7**] 05:07PM BLOOD proBNP-1157* [**2170-2-9**] 05:55AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.0 Mg-1.8 [**2170-2-8**] 11:42AM BLOOD calTIBC-446 Hapto-122 Ferritn-7.6* TRF-343 [**2170-2-9**] 05:55AM BLOOD IgA-227 [**2170-2-9**] 05:55AM BLOOD tTG-IgA-4 . CXR ([**2170-2-8**]): A dual-lead pacemaker/ICD device appears unchanged with leads again terminating in the right atrium and ventricle, respectively. The heart is mildly enlarged. The mediastinal and hilar contours appear unchanged. A calcified nodule in the right upper lobe suggesting a granuloma appears unchanged. Otherwise, the lungs remain clear. There is no pleural effusion or pneumothorax. Small osteophytes are noted along the mid-to-lower thoracic spine. IMPRESSION: No evidence of acute disease. . ABDOMINAL ULTRASOUND: Normal abdominal ultrasound. Normal liver. . EGD ([**2-9**]): Findings: Esophagus: Normal esophagus. Stomach: Flat Lesions Many non-bleeding localized angioectasias were seen in the stomach antrum. The lesions were distributed in a watermelon-stomach pattern, consistent with GAVE. Duodenum: Normal duodenum. Impression: Angioectasias in the stomach antrum, watermelon stomach consistent with GAVE Otherwise normal EGD to third part of the duodenum Recommendations: The findings account for the symptoms. GAVE could not be treated during this endoscopy due to elevated INR. . EGD with APC ([**2-13**]): Normal mucosa in the esophagus Angioectasias in the antrum (thermal therapy) Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: Repeat endoscopy in [**3-30**] weeks for repeat APC. Additional recs by inpatient GI team. Brief Hospital Course: 65 yo M w/ CAD s/p MI, sCHF, AFIB, HTN and DMII presented with four days of dark stools and several weeks of progressive fatigue. Found to have marked iron-deficiency anemia likely secondary to chronic bleeding and GAVE treated with EGD/APC on [**2-13**]. . # Anemia / GI bleed: Hct ~ 20 at presentation. He refuses transfusion for religious reasons. His anemia is likely secondary to both acute bleeding (dark stools) and slow chronic loss (ferritin of 7). He has received two doses of IV iron during this admission and is discharged on PO BID iron to be continued until his iron stores are replete. GAVE tissue was successfully treated with EGD/APC (cautery) and he will have to follow-up in two weeks for repeat EGD/APC. As discussed with his PCP and GI, he will hold coumadin until at least after this procedure in two weeks. . # Chronic Systolic CHF Last EF 30% in [**2167**], followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at [**Hospital1 18**] who was notified at the time of admission. Continued home valsartan, lasix, spironolactone, carvedilol throughout his hospital stay and at discharge. He remained euvolemic during this admission. . # CAD: It is unclear why this diabetic gentleman is not on aspirin for CAD. Given that he has never been on this, I am hesitant to start it this soon after his gastric bleed. Would favor starting it along with coumadin when hae follows-up after the EGD/[**Last Name (un) **]. . # Atrial Fibrillation: CHADS2 score is 3. Given his refusal of blood, Hct of 20, and high risk for re-bleed as above, have advised him to hold coumadin until after the repeat APC and colonoscopy. . CHRONIC INACTIVE ISSUES: # DMII: Continued metformin. Pt's most recent HA1c = 7.3 ([**11-4**]). # Chronic Renal Insufficiency: Pt w/ Cr 1.6 --> 1.3 --> 1.2. Most recent Cr 1.4 in [**2169-10-24**]. # Gout: stable, continued colchicine # Anxiety: continued klonopin . Medications on Admission: AMMONIUM LACTATE - 12 % Cream - apply to feet twice a day ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth once a day for cholesterol BENZONATATE - 200 mg Capsule - 1 Capsule(s) by mouth four times a day as needed for cough CARVEDILOL - 25 mg Tablet - 1 (One) Tablet(s) by mouth twice a day CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 1 Tablet(s) by mouth one in am, one i pm and 2 qhs as needed for anxiety COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth as needed up to twice a day prn DOFETILIDE - 500 mcg Capsule - 1 Capsule(s) by mouth q 12 h ECONAZOLE - 1 % Cream - apply [**Hospital1 **] to rash on back and chest x 6 weeks disp at least 60gram tube FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 puff each nostril once a day for allergies/running nose FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a day for swelling and blood pressure METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day for diabetes (also called GLUCOPHAGE) PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day brand name only SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - Apply twice daily to affected areas for up to 2 weeks/month max twice a day as needed for AVOID face and folds VALSARTAN [DIOVAN] - 80 mg Tablet - 1 Tablet(s) by mouth twice a day WARFARIN - 2 mg Tablet - 1 Tablet(s) by mouth as directed blood thinner Medications - OTC BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - test twice a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day PEG 400-PROPYLENE GLYCOL [LUBRICANT EYE (PEG-PEG 400)] - 0.3 %-0.4 % Drops - 1 drop(s) each eye three times a day SENNOSIDES-DOCUSATE SODIUM - 8.6 mg-50 mg Tablet - 1 OR 2 Tablet(s) by mouth at bedtime as needed for constipation Discharge Medications: 1. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. benzonatate 200 mg Capsule Sig: One (1) Capsule PO four times a day as needed for cough. 3. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Klonopin 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day. 5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for gout. 6. dofetilide 500 mcg Capsule Sig: One (1) Capsule PO twice a day. 7. Flonase 50 mcg/actuation Spray, Suspension Sig: One (1) Nasal once a day. 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 12. valsartan 80 mg Tablet Sig: One (1) Tablet PO twice a day. 13. multivitamin Oral 14. peg 400-propylene glycol 0.4-0.3 % Drops Sig: One (1) Ophthalmic three times a day. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: - UPPER GI BLEED secondary to GAVE SYNDROME (Gastric Antral Vascular Ectasia) - IRON DEFICIENCY ANEMIA - CHRONIC SYSTOLIC HEART FAILURE - DIABETES TYPE 2 CONTROLLED, COMPLICATED - CORONARY ARTERY DISEASE 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 the hospital with severe anemia which seems to have been caused by abnormal tissue in your stomach which was treated with endoscopy and cautery. You were given intravenous iron to address your severe iron deficiency anemia. You have received a prescription for oral iron twice daily which you should take until your primary care doctor tells you to stop. Pantoprazole has been increased to 40mg twice daily--you have received a prescription for this. You should take this increased dose for at least 4-6 weeks and can discuss the ultimate duration with your PCP. You should continue to hold coumadin until your PCP tells you to restart it after your EGD/colonoscopy (which is scheduled in two weeks). As we discussed, you take coumadin to lower your risk of stroke from atrial fibrillation. The risk of anticoagulating you with the degree of anemia you already have and because we cannot transfuse you (for religious reasons) is too high currently. You should be on Aspirin for your coronary disease and diabetes. Now is not the time to start given the very recent bleeding, but you should discuss starting this eventually with your PCP. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. SUMMARY OF MEDICATION CHANGES: - STOP COUMADIN until Dr. [**Last Name (STitle) 8499**] tells you to re-start - INCREASE PANTOPRAZOLE TO TWICE DAILY - START IRON TWICE DAILY Followup Instructions: WE HAVE SCHEDULED THIS APPOINTMENT WITH YOUR PCP FOR YOU: Department: [**Hospital1 7975**] INTERNAL MEDICINE When: THURSDAY [**2170-2-22**] at 3:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site YOU HAVE A COMBINE EGD & COLONOSCOPY SCHEDULED FOR: WEDNESDAY [**2170-2-28**] with Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) 2161**] at 1:00pm in the [**Hospital1 18**] [**Hospital Ward Name **]. You will be contact[**Name (NI) **] regarding preparation for the procedure. [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2170-2-14**]

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icd9cm

[ [ [] ] ]

[ "45.13", "44.43" ]

icd9pcs

[ [ [] ] ]

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7561, 9237

298, 357

12923, 12923

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3025, 3075

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252, 260

385, 1961

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2848, 3009

14,988

115,138

25830

Discharge summary

report

Admission Date: [**2125-9-3**] Discharge Date: [**2125-9-4**] Date of Birth: [**2078-2-8**] Sex: M Service: MEDICINE Allergies: Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 2186**] Chief Complaint: flushing, periorbital edema, and hives during CT scan Major Surgical or Invasive Procedure: 1. ERCP History of Present Illness: 47 YO Caucasian male with Hx of chronic pancreatitis admitted following an anaphylactoid reaction in CT scan. Today, the patient went for ERCP to further evaluate his pancreatitis. The ventral pancreatic duct was normal in caliber. The pancreastic duct in the area of the head of the pancreas was very dilated, and contained multiple stones. There was no filling of the pancreatic duct beyond the head. There were no lesions amenable to endoscopic therapy. The patient went for a CTA pancreas to rule out pancreatic neoplasm b/c of elevated CEA and CA19-9. The patient received IV contrast and developed flushing, periorbital/facial edema and hives. Code Blue was called and the patient was given IV benadryl, solumedrol, and H2 blocker. The patient maintained his O2 sats >100% on a 100% NRB, and BP had MAP>60. The patient was able to speak without difficulty and was x-ferred to the [**Hospital Unit Name 153**] for monitoring. Past Medical History: 1. ? hypertriglyceridemia in the past, but reports triglycerides levels have been much lower in recent years 2. Chronic pancreatitis Mr. [**Known lastname 64313**] has never undergone any surgery. Social History: Mr. [**Known lastname 64313**] previously worked as a painting contractor but has not worked for the last 3 years. He is still drinking a few beers per week but did not quantify exactly his alcohol intake. He used to smoke 2 packs per day but currently smokes about 1 pack per day. He is divorced with 3 children ages 14, 12, and 11. Family History: Mr. [**Known lastname 64313**] has 3 children age 14, 12 and 11. They are healthy. There is no family history of pancreatic diseases. His mother has diabetes mellitus but no symptoms of chronic abdominal pain, steatorrhea, or pancreas problems. His father died of a myocardial infarction at age 49. Physical Exam: General: thin man appearing his stated age at times very uncomfortable with changes in position. Skin had no jaundice. HEENT: no scleral icterus, mucus membranes were moist. There was no oral thrush and no oropharyngeal erythema and no oropharyngeal exudates. His neck was supple without lymphadenopathy. The lungs were clear to auscultation, bilaterally. Cardiac regular rate and rhythm, normal S1 and S2 with no murmurs, gallops or rubs. The abdomen had normoactive bowel sounds, soft with tenderness in the right upper quadrant, right midabdomen and right lower quadrant with voluntary guarding but no rebound. There were focal mass. There was no hepatosplenomegaly. The extremities had 2+ distal pulses without edema. Pertinent Results: [**2125-9-3**] 05:54PM WBC-15.4*# RBC-4.27* HGB-14.0 HCT-40.6 MCV-95 MCH-32.7* MCHC-34.4 RDW-12.6 [**2125-9-3**] 05:54PM PLT COUNT-279 [**2125-9-3**] 05:54PM GLUCOSE-102 UREA N-9 CREAT-0.7 SODIUM-135 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16 [**2125-9-3**] 05:54PM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-1.6 [**2125-9-3**] 05:54PM ALT(SGPT)-17 AST(SGOT)-31 LD(LDH)-158 ALK PHOS-67 AMYLASE-59 TOT BILI-0.5 [**2125-9-3**] 05:54PM LIPASE-67* [**2125-9-3**] 05:54PM PT-13.7* PTT-27.1 INR(PT)-1.3 Abd CT: Area of atelectasis is seen in the right lung base. There is no pleural effusion. The liver and spleen are not enlarged. Ther is mild intrahepatic biliary duct dilatation. The CBD measures up to 10 mm. The gallbladder, kidneys, and both adrenals are unremarkable. There are multiple coarse calcifications throughout the head and body of the pancreas. Mild dilatation of the pancreatic main duct. In the head of the pancreas, there is a septated cystic region measuring 12 x 15 mm that could correspond with dilated side branches of the duct, or IPMT. This region doesn't enhance following the administration of the IV contrast. The pancreas appears irregular. There is no free fluid or free air within the abdomen. The aorta is normal in caliber. The bowel loops appear unremarkable. ERCP: 1. The distal pancreatic duct within the head and neck of the pancreas is markedly dilated with multiple filling defects consistent with stones. The pancreatic duct proximally within the body and tail of the pancreas cannot be opacified. 2. Normal-appearing ventral pancreatic duct. Brief Hospital Course: 1. Anaphylaxis: the pt had anaphylactoid reaction to IV contrast dye during CT as evidenced by acute onset of flushing, periorbital/facial edema, and hives. He was treated in the CT suite with IV benadryl, and was observed to maintain O2 sat 100% on NRB and had MAP>60 at all times. He was admitted to the ICU for ongoing care, and was treated with standing doses of IV benadryl, famotidine, and solumedrol overnight. The pt had stable respiratory status and BP throughout his admission. By HD#2, his facial edema and hives had resolved, and he was transferred to the medical [**Hospital1 **] for ongoing care. On the medical [**Hospital1 **], he was asymptomatic and tolerated regular diet for lunch well. After lunch, he was d/c home with instructions to take benadryl prn for itching or rash. The pt was instructed to present to the ED if he developed repeated hives, dyspnea, weakness, or confusion. . 2. Chronic pancreatitis: his pacreatitis has been long-standing, with evidence of pancreatic calcification on CT and ERCP consistent with pancreatic ductal stones. These stones were not amenable to removal by ERCP, and as they are contributing to inflammation and pain, the pt was referred for consultation with Dr. [**Last Name (STitle) 468**] for surgical treatment. During his admission, he was treated with pancreatic enzyme replacement before meals. His pain was controlled with IV dilaudid initially, and on the day of d/c the pt was transition to his usual regimen of oral morphine, with good results. He will follow-up with Dr. [**Last Name (STitle) 468**] for surgical consultation after d/c. . 3. Code status was FULL CODE during this admission. Medications on Admission: Protonix 40 mg before breakfast multivitamin 1 tablet per day thiamine 100 mg per day folate 1 mg per day Viokase 2 tablets with meals morphine sulfate 15 mg tablets (approximately 6 tablets per day) prn for abdominal pain Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for Headache. 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 4. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 5. Benadryl 50 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for allergy symptoms. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Anaphylaxis secondary to IV contrast dye 2. Chronic pancreatitis Discharge Condition: Stable to go home. Vital signs normal; no dyspnea, itching, or other evidence of active anaphylaxis. Discharge Instructions: You have been hospitalized after having an allergic reaction to IV contrast dye. Your vital signs and symptoms have all returned to [**Location 64314**]. Please take all medications as prescribed. Call your PCP or present to the ED if you develop fevers, chills, wheezing, shortness of breath, hives, swelling, uncontrolled itching, uncontrolled pain, or other concerning symptoms. Followup Instructions: Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 468**] in [**12-10**] weeks for evaluation of further treatment options for your chronic pancreatitis. Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-9**] weeks.

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Discharge summary

report+addendum

Admission Date: [**2158-9-12**] Discharge Date: [**2158-9-20**] Date of Birth: [**2106-2-18**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Intubated Central Line History of Present Illness: The patient is a 52 yo F with h/o ETOH and cocaine abuse who presented to an OSH from home after a drinking binge and ingestion of cocaine with symptoms of withdrawal, black diarrhea and abdominal pain. She states that she usually binge drinks around [**9-17**] which is her mother's birthday. She has had little po but ETOH for the past two days and reports a single ingestion of cocaine with her girlfreinds several days ago. She reports history of DTs but no history of seizures. Vitals on scene were BP 165/124, HR 1008, o2 97. Her glucose was 47. She was brought to [**Hospital1 **] [**Location (un) 620**] ED and her ABG there was 7.45/45/18. Her lactate was 10 and Hct 57. sodium and K 130, 2.5. Her CIWA WAS 36 and she was given ativan (total 1.5 mg iv). A central line was placed and she was given 7L IVF. She remained hypotensive to the 70s and norepinephrine was stared. She also received zofran 4mg iv x1, zosyn and k and mag repletion. Before transfer to ED here, ABG was 7.31/37/78 and lactate 2.7. On arrival to ED here, BP 128/57 HR 81 O2 96 on 2L NC. Her antibiotics were broadened to vancomycin/zosyn given her hypotension and given her OB positive stool and abdominal pain with elevated lactate, a CT was obtained which showed non-specific enteritis. Surgery was consulted and recommended admission to medicine with GI consult and CTA id persisetent concern for ischemic colitis. During her ED course she received valium 10 IV x 2, protonix 80mg IV x 1 and additional K repletion. He levophed was weaned and has been off since 0510 this am. . On arrival to ICU, she is complaining of abdominal pain. She states taht she has had nothing but etoh for 3 days. Her binge began 3 weeks ago. She drinks at least a gallon of dark rum per day. Other than when binging, she does not drink every day and can go "for weeks". She used cocaine only once and prior use before then was about a year. She reports that she began vomiting and having diarrhea on sunday. She did not have any ETOH to drink on Monday. On tuesday, she felt withdrawal symptoms and had six "nips" (airplane bottle size). Her sister called EMS that evening. She reports seeing maroon blood in her diarrhea, mioxed in. She has seen this before and has assumed that it is from her hemorhoids which falre whn she drinks. She denies seeing any blood or coffee grounds in her emesis. . Review of systems: see metavision. negative for cp. positive for exertional dyspnea. Past Medical History: hypothyroidism ETOH abuse depression with h/o suicide attempt by overdose in [**6-17**] fibromyalgia h/o ortho surgeries to right arm, left leg (MVA, fall) hypertension Social History: - Tobacco: 1ppd - Alcohol: daily - Illicits: cocaine Family History: Non Contributory to ischemic colitis Physical Exam: Exam on Transfer out of MICU to floor. General Appearance: No acute distress, Anxious Eyes / Conjunctiva: PERRL, Pupils dilated Head, Ears, Nose, Throat: Normocephalic, NG tube Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , Crackles : anterior) Abdominal: Soft, Bowel sounds present, Tender: diffuse but mostly in RUQ an LLQ Extremities: Right lower extremity edema: Absent, Left lower extremity edema: bsent, No(t) Cyanosis, No(t) Clubbing Skin: Not assessed, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed . Discharge Exam: AVSS Neck with site of CVL, no significant redness, site or prior sutures intact. Card: S1 S2 No MRG Lungs: Clear Abd: Soft Non-Tender BS+ Extr: No Edema Pertinent Results: Admission Labs: [**2158-9-12**] 01:29AM BLOOD WBC-11.0 RBC-3.49* Hgb-11.7* Hct-31.8* MCV-91 MCH-33.5* MCHC-36.7* RDW-15.4 Plt Ct-134* [**2158-9-12**] 01:29AM BLOOD Neuts-36* Bands-35* Lymphs-12* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-10* Myelos-0 [**2158-9-12**] 01:29AM BLOOD Glucose-100 UreaN-56* Creat-1.5* Na-137 K-2.9* Cl-100 HCO3-19* AnGap-21* [**2158-9-12**] 10:44AM BLOOD ALT-29 AST-62* LD(LDH)-301* CK(CPK)-295* AlkPhos-70 TotBili-0.5 [**2158-9-12**] 01:29AM BLOOD ALT-32 AST-72* AlkPhos-65 Amylase-52 TotBili-0.5 [**2158-9-12**] 10:44AM BLOOD Albumin-3.1* Calcium-6.4* Phos-3.7 Mg-2.6 Iron-PND [**2158-9-12**] 01:29AM BLOOD Calcium-6.1* Phos-3.6 Mg-2.4 [**2158-9-12**] 04:34AM BLOOD Lactate-2.0 [**2158-9-17**] 02:57AM BLOOD WBC-4.9 RBC-3.12* Hgb-10.3* Hct-30.3* MCV-97 MCH-32.9* MCHC-33.9 RDW-14.9 Plt Ct-84* [**2158-9-14**] 05:02AM BLOOD Neuts-79.1* Lymphs-15.9* Monos-4.5 Eos-0.4 Baso-0.1 [**2158-9-13**] 03:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-1+ [**2158-9-17**] 02:57AM BLOOD Plt Ct-84* [**2158-9-17**] 02:57AM BLOOD PT-13.3 PTT-25.5 INR(PT)-1.1 [**2158-9-17**] 02:57AM BLOOD Glucose-128* UreaN-8 Creat-0.7 Na-143 K-3.6 Cl-103 HCO3-33* AnGap-11 [**2158-9-13**] 03:20AM BLOOD ALT-24 AST-39 LD(LDH)-224 AlkPhos-68 TotBili-0.6 [**2158-9-12**] 10:44AM BLOOD ALT-29 AST-62* LD(LDH)-301* CK(CPK)-295* AlkPhos-70 TotBili-0.5 [**2158-9-17**] 02:57AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.7 Mg-1.7 [**2158-9-16**] 06:00PM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0\ TTE: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild hypokinesis of the basal to mid left ventricle. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2158-9-13**], the function of the basal to mid segments has improved and is nearly normal. The degree of mitral regurgitation has decreased. CXR: FINDINGS: As compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed. The bilateral parenchymal opacities are unchanged in extent. A minimal right-sided pleural effusion might have newly occurred. Unchanged size of the cardiac silhouette. No pneumothorax. Discharge Labs: [**2158-9-19**] 05:45AM BLOOD WBC-5.0 RBC-3.21* Hgb-10.6* Hct-31.6* MCV-98 MCH-33.1* MCHC-33.7 RDW-15.1 Plt Ct-161 Brief Hospital Course: Please see below: Ms. [**Known lastname 90842**] Hospital course was divded into an ICU (described by daily events below), and subsequently the general medical floor (divided by problem). . 52F with h/o ETOH and cocaine abuse, suicide attempt in [**Month (only) 596**] [**2158**] who presented to an OSH and transferred to the [**Hospital1 18**] ICU after a drinking binge and ingestion of cocaine with symptoms of withdrawal, black diarrhea and abdominal pain. . [**9-12**]: -per PCP [**Name Initial (PRE) 3726**]: HCT 41.8 in [**3-/2158**], 39.9 in [**10/2157**] -CT read: 1. Abnormal small bowel, with segmental areas of wall thickening and mild peripheral stranding which may be contiguous (or separated by a small amount of normal small bowel) from inflamed terminal ileum. This picture is compatible with enteritis, which could be inflammatory, infectious, or, less likely, ischemic 2. Probable colonic wall thickening and fatty infiltration consistent with chronic inflammatory changes in the proximal colon. 3. Fatty liver. 4. Right basal aspiration or atypical pulmonary infection. - [**Location (un) 620**] blood cultures still pending. need to f/u. - brother gave her methadone for her fibromyalgia. - GI consult: get KUB tonight (no free air), CT abdomen tomorrrow, consider TTE - HCT 31.8-> 28.3. . [**9-13**]: - opacicity right lung base ?aspiration -Liberal with valium/haldol, added physical restraints -CT abd held off for tomorrow; no new GI recs -[**Location (un) **] micro: NGTD - TTE read - LVEF 40% Moderate MR [**First Name (Titles) 151**] [**Last Name (Titles) 20691**] normal valve morphology. Normal left ventricular cavity size with mild global hypokinesis in a pattern suggesting a non-ischemic cardiomyopathy. - EKG QTc 432 earlier in evening, 480 @ 2:30am - she got some rest over night which is important - total valium > [**9-13**] ~240mg, [**9-14**] ~50mg - total haldol > [**9-13**] ~12.5mg, [**9-14**] ~10mg - gave 5mg olanzapine as well - RR ~50's > O2 Sat 92, CXR pending, ABG pH 7.52 pCO2 31 pO2 60 HCO3 26 , A-a gradient ~50. - called CVS in [**Location (un) **] to confirm meds [**Telephone/Fax (1) 90843**] ---cymbalta 120mg qhs - sack - 58-[**Telephone/Fax (1) 90844**] ---amitryptaline 150mg qhs ---hctz 25 daily ---clonazepam 2mg once [**Doctor Last Name **] ---cymbalta 30 mg daily twice daily gowda ---meloxicam ---acyclovir 400mg daily ---baclofen 20mg daily ---vicodin es 7.5/500 120/month, q 6 hour ---levoxyl 75mcg daily ---meloxicam 15 mg 1 qam .5 qpm ---prilosec 40 [**Hospital1 **] . [**9-14**]: -intubated for hypoxic respiratory failure. Now on PSV. Getting PRN fentanyl. -CXR shows satisfactory position of ET tube (4.5cm), NGT advanced, ? aspiration PNA -vancomycin added to zosyn to cover for HCAP -family ([**Doctor Last Name **]) updated -GI: no new recs -nutrition consult -> TF started -increased IV metoprolol to 5mg q6h . [**9-15**]: -during weaning of peep, PS she has become tachypnic up to 40s with tidal volumes of only ~200-250, RR improves to 16-18 after bolus of fentanyl, she past RSBI -tube feeds stopped: above EG junction, high residuals. -advanced NG tube. -dry - slightly hypernatremic; increased free water flushes to 250Q4 . [**9-16**]: -extubated -GI: cont supportive care -Got 1L D5W for hypernatremia. PM Na: 144 -restarted amitryptyline 50mg restarted hctz 50 (home dose) for am -d/c iv metoprolol (standing), can use prn - converted levothyroxine from IV to PO . [**9-17**]: - plan to continue abx for full 8 day course (2 more days starting tomorrow.) - social work consulted - GI signing off - called out to HMED, bed pending . MEDICAL FLOOR: ([**Date range (1) 9846**]) . # E.Coli Pneumonia: CXR evidence of evolving RLL pna. The patient continued to be treated HCAP PNA, potentially from aspiration PNA. The pt was treated initially with Vancomycin and Zosyn in the ICU, this was changed to Ceftriaxone on the floor. The patient received treatment through her date of discharge, at which time she had received 9 days of antibiotics. The patient was breathing comfortably on room air at discharge. . # ETOH withdrawal: h/o dts but no seizures. Pt was on CIWA while in ICU (see above), on floor, no valium was require. Outpatient follow-up recommended. . # Bloody diarrhea, Bowel wall thickening: Pt presented with symptoms. Per radiology intervening section of small bowel may be normal but does not contain oral contrast for it is difficult to evaluate. a skip lesion would change differential making inflammatory and infectious more likely than ischemic. area of bowel thickening is also large for watershed ischemia. the patient has been taking total of 20mg of meloxicam daily and reports compliance with this med even over past week. The CT findings could be NSAID induced enteritis. Concern also for ischemic enteritis secondary to cocaine induced vasospasm. KUB with no free air. Serial abdominal examinations unchanged. Infectious diarrhea was negative. . # Cardiomyopathy: Initial CV function depressed per echo. Some diastolic +/- systolic dysfunction. QTc prolongation may be due to ingestion of methadone; trending EKG esp given use of haldol / Cardiomyopathy. Intial TTE ([**9-13**]) showed LVEF 40% Moderate MR with [**Month/Day (4) 20691**] normal valve morphology. Normal left ventricular cavity size with mild global hypokinesis in a pattern suggesting a non-ischemic cardiomyopathy. A repeat TTE ([**9-17**]) was later performed that revealed EF 55% with mild hypokinesis of the basal to mid left ventricle. *Cardiology recommends outpatient follow-up and potential pMIBI, this has not yet been ordered* . #: Hypertension: Restarted on home meds on discharge. . # Depression, fibromyalgia: Restarted on home meds on discharge. Held while in house. . # Hypothyroid: Continued levothyroxine . # Chronic pain: Pt on vicodin as outpatient. No narcotics were provided to the patient on d/c. Medications on Admission: called CVS in [**Location (un) **] to confirm meds [**Telephone/Fax (1) 90843**] ---cymbalta 120mg qhs - sack - 58-[**Telephone/Fax (1) 90844**] ---amitryptaline 150mg qhs ---hctz 25 daily ---clonazepam 2mg once [**Doctor Last Name **] ---cymbalta 30 mg daily twice daily gowda ---meloxicam ---acyclovir 400mg daily ---baclofen 20mg daily ---vicodin es 7.5/500 120/month, q 6 hour ---levoxyl 75mcg daily ---meloxicam 15 mg 1 qam .5 qpm ---prilosec 40 [**Hospital1 **] Discharge Medications: 1. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day: Do not drive or operate heavy machinery while taking this medication. 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. amitriptyline 150 mg Tablet Sig: Two (2) Tablet PO at bedtime. 9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every 4-6 hours. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Alcohol Withdrawl - Aspiration Pneumonia - Stress inducted cardiomyopathy . Secondary Diagnosis - Depression 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 alcohol withdrawl and subsequently developed a pneumonia. You were evaluated by cardiology that would like to evaluate you as an outpaient. Followup Instructions: Name: GOWDA,SAVITHA Location: [**Hospital **] MEDICAL ASSOCIATES, P.C. Address: [**Street Address(2) 75807**], STES 3A, B, [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 54268**] Appt: [**9-29**] at 2pm Department: CARDIAC SERVICES When: FRIDAY [**2158-10-6**] at 10:20 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Known lastname 14329**],[**Known firstname 647**] Unit No: [**Numeric Identifier 14330**] Admission Date: [**2158-9-12**] Discharge Date: [**2158-9-20**] Date of Birth: [**2106-2-18**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12673**] Addendum: Spoke with patient 2 days post discharge. Pt states she redness at site of prior left CVL. She was instructed circle area with pen and monitor for expanding redness. Pt also was instructed to not over exert herself since she her mobility in the hospital was limited. Discharge Disposition: Home [**First Name11 (Name Pattern1) 1937**] [**Last Name (NamePattern4) 12674**] MD [**MD Number(2) 12675**] Completed by:[**2158-9-23**]

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Discharge summary

report

Admission Date: [**2101-10-5**] Discharge Date: [**2101-10-28**] Date of Birth: [**2059-9-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: EtOH cirrhosis/jaundice Major Surgical or Invasive Procedure: Multiple paracenteses . endoscopy History of Present Illness: 42y/o M w/ a PMH of only HTN who was transferred here after a 1month admission at an OSH for further management of his liver disease. He was in his USOH until approximately 1 month ago when, in the context of continued heavy drinking, he developed tremors of his hands and became unstable with walking. He also noticed, at this time, abdominal distention and diffuse abdominal pain. He presented to the the ED at [**Hospital3 **] where he found to be confused and jaundiced and was admitted for furhter management. . While in the OSH, he developed increasing somnolence and eventually required ICU level care for respiratory protection (although it does not appear he was ever intubated). He was noted to have ARF and hyponatremia as well as a ? PNA. His ARF was thought to be [**1-13**] renal hypoperfusion [**1-13**] diuretic therapy and poor PO intake but worsened despite IVF support. He was initially treated with CTX/azithromycin for the suspected PNA but these were later d/c for unclear reasons. UCX during this time grew multiple organisms including MRSA and he was treated with vancomycin by level. Taps of his abdomen were reported to be c/w SBP but no note of antibiotic therapy is made in the d/c summary and these results show <10 PMN per tap. He was eventually transfered her for further management of his medical conditions. . On arrival here, the patient complained only of abdominal tightness, mild abdominal pain, and decreased appetite but denied any CP, SOB, N/V, HA, rash, cough, URI symptoms, dysuria, diarrhea, or constipation. Past Medical History: HTN Social History: No tobacco/drug use. Married with infant child. Immigrated from [**Country 11150**]. Drank [**5-18**] glasses of hard liquor a day until his hospital admission (~1mo ago). Family History: No liver/kidney problems. Father w/ CAD s/p CABG. Physical Exam: 99.2, 121/80, 87, 22, 96%RA Gen: Jaundiced M lying in bed, slightly uncomfortable HEENT: + scleral icterus, MMM, O/P clear, no cervical LAD CV: RRR, 2/6 SEM at the USB w/out radiation Lungs: L basilar crackles Abd: Grossly distended and tense, easily appreciable fluid wave and shifting dullness, distant BS, HSM not able to be assessed, mild diffuse tenderness, + caput medusa Ext: 3+ LE pitting edema to the mid thigh, distal pulses difficult to assess Neuro: AAO x3, appropriate in conversation per interpreter, moving all his extremities spontaneously Skin: Jaundiced Pertinent Results: Admission labs: Na 131, K 4.1, Cl 104, bicarb 16, BUN 45, Cr 2.8, glu 115 Ca 8.1, Mg 3.9, Phos 2.4 tbili 34.1, alk phos 157, Ast 138, ALT 59, INR 1.8, alb 2.9 . Dispo Labs tbili 11; Na 141, K 3.7, Cr 1.4 Alb 3.9, INR 1.5 WBC 10, Hct 28.7, plt 177 . ferritin 619 . Ceruloplasmin wnl . HBV and HCV serologies negative . HAV Ab + . [**Doctor First Name **], AMA, ANCA negative . AFP 1.9 . OSH Cultures: [**9-26**] - Ascites: 52WBC (5% pmn) Cx negative [**9-28**] - Stool: Cdiff negative [**9-30**] - UCx: enterococcus (2sp) and s aureus - BCx: NGTD [**10-4**] - Ascites: 122WBC (3% pmn) Cx NGTD . [**9-30**] Renal US: 2 calculi, no obstruction [**9-16**] abd angiogram: no Portal or hepatic vein obstruction, recanulized umbilical vein suggestion varices. . [**10-6**] paracentesis: no SBP [**10-6**] RUQ US: normal portal/hepatic vein flow. [**10-6**] CXR Two PA and two lateral views of the chest show markedly elevated right hemidiaphragm and bilateral perihilar and left bibasilar atelectasis. Different technique compared to study from nine hours earlier makes exact comparison difficult, but consolidation may have progressed. Pneumonia remains a possibility, but the appearance could be entirely consistent with consolidation from atelectasis . [**10-7**] CXR:Lung volumes remain quite low, and the right hemidiaphragm is still markedly elevated, but less so compared to the prior study. Pulmonary vasculature is congested, but there is no edema or focal consolidation and no clear evidence of substantial pleural effusion. No pneumothorax. Heart size is difficult to assess because of displacement by the elevated hemidiaphragm, but probably top normal. . endoscopy: no varices. + esophageal candidiasis Brief Hospital Course: Mr [**Known lastname **] is a 42y/o M w/ EtOH cirrhosis and alcoholic hepatitis complicated by renal failure and massive fluid overload/ascites who was transferred to [**Hospital1 18**] after a 1mo OSH admission for further management. . #. Cirrhosis/alcoholic hepatits: Mr [**Known lastname **] presented with labs suggestive of alcoholic hepatitis superimposed upon his EtOH cirrhosis. He was admitted with a discriminant function of 62 and a MELD score of 35 with bili 34, Cr 2.7, INR.1.8, albumin 2.9. . He was shortly started on pentoxyphylline for his alcoholic hepatitis and completed over a 3 wk course in the hospital. Steroids were not administered b/c of concern over potential infection. Due to concern over very poor po intake (abt 300kcal/d) A post-pyloric dauboff feeding tube was placed and he was begun on continuous tube feeds with thiamine, folate, and multivitamin. He gradually improved with this therapy and his bilirubin declined from 34 on admission to 11 on discharge. His INR remained stable around 1.6. His feeding tube was discontinued after a trial at po with about 1300kcl and 40g protein daily intake. . Mr [**Known lastname **] did have an EGD which revealed no varices. He was placed on lactulose and rifaxamin due to hepatic encephalopathy which gradually cleared. He was moderately encephalopathic on admission with +asterixis and slowed speech, but was without asterixis and at his mental baseline as per family members. . Mr [**Known lastname **] also had significant pruritis presumed to be [**1-13**] bile acids (also with component of drug rash as below). He improved with cholestyramine and is dishcarged with this medicine. . With regards to further characterization of his cirrhosis/hepatitis: Clinical hisory and laboratory pattern (AST/ALT>2) are certainly consistant with alcoholic hepatitis. HCV and HBV serologies were negative, RUQ US showed patent flow in hepatic and portal veins, no stones. [**Doctor First Name **] was negative, and serum ceruloplasm was normal as was ferritin. AFP was 1.9 and US showed no signs of hepatoma. . Mr [**Known lastname **] will eventually need a liver transplantation and the patient is aware of this, although his true understanding may be limited. Multiple conversations took place through an interpreter with the patient and his health care proxy (cousin) regarding the seriousness of his condition and the need for alcohol abstinence. He will follow up in the liver clinic with Dr. [**Last Name (STitle) **] and then be seen in the liver transplant clinic with Dr. [**Last Name (STitle) 497**]. He will also be set up with the substance abuse counselors in the transplant center in order to document 6 mos sobriety. . #. Renal failure: Mr [**Known lastname **] Cr was 2.7 on transfer from OSH, which improved to 2.0 with 1L NS bolus. He was massively total-body fluid-overloaded with very diminished lung volumes and pulmonary edema, although oxygenating on room air. He was unable to be diuresed due to concern over his progressively rising creatinine. He was started on midodrine, octreotide, and IV albumin at maximum doses for treatment of presumed hepatorenal syndrome. At several points in his hospitalization paracentesis was performed with approx 3-4L off per procedure (8g albumin/L replaced) and his creatinine would subsuquently rise and then gradually fall. His highest Cr was 3.5. Renal was consulted on the patient and felt that he was in a likely pre-renal state with a component of ATN given his urine Na of 20 and a high urine output. Nevertheless, his renal failure gradually improved and he tolerated several large volume paracentesis and was then started on low-dose diuretics (lasix 20, aldactone 50) with large and persistant diuresis. He was taken off midodrine/octreotide/albumin several days prior to dishcarge with stable renal function with a cr at 1.2-1.4. He will continue lasix 20mg/aldactone 50mg daily after discharge. . #ID: Mr [**Known lastname **] was admitted with low-grade fevers to 100.7-8, leukocytosis to 18 (neutrophil predominant, no left shift). CXR was very difficult to interpret due to his large ascites, poor lung volumes, and fluid overload. Diagnostic paracentesis was persistantly negative (despite 1 contaminated specimen + for enterococcus w/o WBC that was repeated and was negative). Blood and urine cultures were also negative persistantly as was C diff. He was treated empirically for several days with CTX; his low-grade fevers and leukocytosis persisted. CTX was discontinued without clinical worsening. EGD during his hospital course revealed esophageal candidiasis and he was started on fluconazole. Within several days he began having high fevers up to 103 and was empirically started on CTX and flagyl to cover empirically for C-diff and SBP or pneumonia. He subsuquently developed a pruruitic rash and eosinophilia; with negative cultures and no sympoms to suggest infection all antibiotics were stopped and his leukocytosis, eosinohpilia, and fevers resolved prior to discharge. Of note, he did receive 9 days of fluconazole for [**Female First Name (un) **] esophagitis treatment and was also treated with continued nystatin. . #. Immunizations: He was immunized with the first series of HBV; he was + for HAV Ab; he also received a pneumovax and an influenza vaccine. . #. psychosocial: Mr. [**Known lastname **] seemed quite depressed through much of his stay with what appeared to be a lack of motivation and a very blunted affect. I was not in contact with his wife for much of the hospital stay. Dr. [**Last Name (STitle) **] of psychiatry was very helpful in evaluating the patient and in discussion issues of substance abuse. Dr. [**Last Name (STitle) **] felt that Mr. [**Known lastname **] did not meed criteria for major depression, but rather adjustment disorder. He was started on Mirtazipine 15mg qhs which seemed to help quite significantly with insomnia and seemed to improve Mr. [**Known lastname **] mood. He will continue with Mirtazipine 30mg qhs on discharge. Mr. [**Known lastname **] will follow with the substance abuse program throuth the liver transplantation center in the next few weeks. Medications on Admission: 1. Protonix 2. Vit B12 3. Folate 4. MVI 5. Diovan 60mg (at home; d/c at OSH) Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): titrate so that you have at least [**4-16**] bowel movements per day. Disp:*1800 ML(s)* Refills:*2* 2. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day) for 2 weeks: this medication can help with itching. Disp:*28 Packet(s)* Refills:*1* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*90 Cap(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). Disp:*1 bottle* Refills:*2* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Alcoholic hepatitis Alcoholic cirrhosis acute renal failure encephalopathy coagulopathy Discharge Condition: fair: Afebrile, VSS, bilirubin 12, Cr 1.2 Discharge Instructions: Please continue to take the medications we have prescribed for you. You should come back to [**Hospital1 18**] for an appointment in the liver clinic as listed below. You will also need to see substance abuse counselors. It is very important that you do not drink any alcohol at all. Your liver is very sick and cannot tolerate it. You should also avoid taking tylenol or any medications that you have not discussed with your doctor. . Please seek medical attention if you notice worsening confusion, shakiness, fevers, chills, abdominal pain, swelling, yellowness, or for anything that concerns you. . You must refrain from drinking all types of alcohol. You will likely need a liver transplant in the future. In order to qualify for this you must enroll in a substance abuse program. Followup Instructions: With Dr. [**Last Name (STitle) **] in the Liver Center on [**11-9**] at 2:10. [**Location (un) **] [**Hospital Unit Name **], [**Doctor First Name **]. ([**Telephone/Fax (1) 1582**]

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icd9cm

[ [ [] ] ]

[ "45.13", "96.6", "54.91" ]

icd9pcs

[ [ [] ] ]

12150, 12156

4583, 10789

339, 375

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10,725

147,534

43214

Discharge summary

report

Admission Date: [**2151-12-13**] Discharge Date: [**2151-12-23**] Date of Birth: [**2110-4-16**] Sex: F Service: CHIEF COMPLAINT: Fever, sore throat and confusion. HISTORY OF PRESENT ILLNESS: Briefly, this is a 41 year-old female with a history of diabetes mellitus type 1, coronary artery disease, chronic renal insufficiency, antiphospholipid syndrome, scleroderma, obstructive sleep apnea, hypertension, gastroesophageal reflux disease, hypothyroidism, and diastolic congestive heart failure initially presented to [**Hospital1 69**] for fever and change in mental status on [**2151-12-13**]. While on the medical floor the plan was to do a lumbar puncture, however, the patient was found to have a high INR so she needed to be transfused with 4 units of fresh frozen platelets prior to the lumbar puncture. After receiving the 4 units of fresh frozen platelets, the patient began having difficulty breathing secondary to pulmonary edema. Therefore on [**2151-12-14**] she was transferred to the Medical Intensive Care Unit for a BiPAP. While in the Intensive Care Unit the patient was diuresed and then weaned down to nasal cannula oxygen. The lumbar puncture was eventually performed, which was negative. A CT of the chest was done, revealing bilateral lower lobe opacity consistent with pneumonia and/or pulmonary edema. The patient was started on Levaquin. Infectious disease consult team then recommended Doxycycline for Ehrlichiosis. Vancomycin and Zosyn was also recommended for nasochromial pneumonia coverage. Her last fever was on [**2151-12-19**] morning with a temperature of 102 Fahrenheit. On [**2151-12-20**] the patient was then transferred back to the medical floor. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION ON [**2151-12-13**]: Lantus 65 units subQ q.h.s., Humalog sliding scale NPH 26 units subQ q.a.m., aspirin, Verapamil SR 120 mg po q day, Procardia 60 mg po q day, Lipitor 40 mg po q day, Neurontin 300 mg po q day, Synthroid 0.150 mg po q day, Betaxolol .10 mg po q day, Desipramine 50 mg po q day, Prilosec, Procrit, Lasix 80 mg po b.i.d., Coumadin 3 mg po q day, Cozaar 50 mg po q day, Hydrochlorothiazide 25 mg po q day. MEDICATIONS ON TRANSFER FROM THE INTENSIVE CARE UNIT TO THE MEDICAL FLOOR: Glargine 36 units subQ q.h.s., NPH 13 units subQ a.m., Humalog sliding scale, Reglan 10 mg po q.i.d., Zosyn 2.25 mg po q 6 hours, Vancomycin 1 gram intravenous q 24 hours, Lopressor 50 mg po b.i.d., Atrovent two puffs q.i.d., Epoetin 10,000 units subQ Saturday and Tuesday, Levaquin 250 mg po q day, Lipitor 40 mg po q day, aspirin, Albuterol two puffs q six hours, Protonix 40 mg po q day, Desipramine 75 mg po q day, Levothyroxine 125 micrograms po q day, Neurontin 300 mg po q.h.s. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1. 2. Hyperthyroidism. 3. Scleroderma/crest. 4. Antiphospholipid syndrome/pulmonary embolism. 5. Coronary artery disease status post myocardial infarction. 6. Congestive heart failure. 7. Hypertension. 8. Hypercholesterolemia. 9. Restrictive lung disease. 10. Gastroesophageal reflux disease. SOCIAL HISTORY: The patient denies smoking or alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON TRANSFER TO THE MEDICAL FLOOR FROM THE INTENSIVE CARE UNIT: Temperature 97.3. Blood pressure 138/78. Pulse 84. Respiratory rate 20. 96% on 3.5 liters O2. HEENT eyes are anicteric. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Mucous membranes are moist. There are some pustules on the hard palette. Neck is supple without lymphadenopathy. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs or thrills noted. Chest decreased breath sounds at the bases bilaterally. Abdomen soft, nontender, nondistended. Normoactive bowel sounds. Extremities no clubbing, cyanosis or edema noted. Neurologically, cranial nerves II through XII. Alert and oriented times three. LABORATORIES ON TRANSFER: White blood cell count 5.2, hematocrit 24.6, platelets 250, sodium 140, potassium 4.2, chloride 104, bicarb 23, BUN 70, creatinine 2.4, glucose 353, albumin 3, calcium 8.7, magnesium 2, PT 424.7, PTT 68.5, INR 4. Microbiology tests revealed Legionella and microplasm were negative. Urine culture on [**12-19**] is negative. Blood culture on [**12-19**] is pending. Throat culture shows no strep or gram C. HOSPITAL COURSE: 1. Cardiovascular: In regard to the patient's diastolic congestive heart failure she was continued on her treatment with beta blockers. As far as her coronary artery disease the patient was continued on secondary prevention with aspirin, beta blocker and a statin. Her blood pressure was well controlled in the 130s with Lopressor 50 mg po b.i.d. The patient did have an episode of feeling lightheaded with decreased blood pressures so her Cozaar and Hydrochlorothiazide were never restarted. 2. Infectious disease: The patient finished her seven day course of Doxycycline for possible Ehrlichiosis. As for her community and Nasochromial pneumonia, the patient was initially continued on the regimen of Vancomycin, Zosyn, and Flagyl. By day of discharge her Vancomycin and Flagyl were discontinued. It was felt that a two week course of Levaquin at 250 mg po q day and Augmentin 500 mg po b.i.d. would be enough to cover the pneumonia. Mycoplasma serum antibodies were checked and are pending. Attempts were made to do obtain a nasopharyngeal wash collection for viruses. However, given the fact that the patient recently had some nasal pluggings removed by ENT that was initially placed for a nose bleed, we were unable to obtain the nasopharyngeal washings. The patient did have diarrhea one day prior to discharge, so Clostridium difficile ASA was sent. The Clostridium difficile was negative. 3. Renal: The patient does have chronic renal insufficiency secondary to diabetes mellitus with a creatinine baseline at 2.1. Her creatinine during the hospital resumed back to baseline at 2 to 2.1. 4. Hematology: On transfer to the medical flor the patient was found to be anemic, so she was given 2 units of packed red blood cells. Her epoetin shots were restarted. Hematocrit was followed on a daily basis. Iron studies were sent, but are still pending upon discharge. 5. Endocrine: For management of the diabetes mellitus, the patient was continued on only half of her normal regimen given the fact that her po intake was not at her normal level. She was managed on Glargine 36 units at night and NPH 13 units in the morning, being covered by a Humalog sliding scale. The patient did have an event of hyperglycemia for refusal of taking her NPH dose in the morning. Her [**Last Name (un) **] doctors did [**Name5 (PTitle) **] by to consult and recommended that the patient should be taking the NPH despite the fact that the sugars may be within reasonable levels in the morning. 6. Rheumatology: The patient had a rash that may be associated with her scleroderma. She was encouraged to follow up with her rheumatologist Dr. [**Last Name (STitle) **] as needed. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Diabetes mellitus type 1. 3. Coronary artery disease. 4. Chronic renal insufficiency. 5. Scleroderma/crest. 6. Antiphospholipid syndrome. 7. Hypertension. 8. Hyperthyroidism. 9. Gastroesophageal reflux disease. 10. Diastolic congestive heart failure. DISCHARGE MEDICATIONS: Atrovent inhaler two puffs q.i.d., Metoprolol 50 mg po b.i.d., Albuterol inhaler two puffs q 6 hours, Metoclopramide 10 mg po q 6 hours prn nausea and aspirin 325 mg po q day, Atorvastatin 40 mg po q.h.s., Levofloxacin 250 mg po q day and on [**2152-1-2**]. Prilosec 20 mg o b.i.d., Lovenox 60 mg subQ b.i.d. to be discontinued when INR is 2.5 to 3.5. Gabapentin 300 mg po q.h.s., Desipramine 75 mg po q day, Levofloxacin 125 micrograms po q day, Epoeitin alpha 10,000 units subQ Saturday and Tuesday, Colace 100 mg po b.i.d., Augmentin 500 mg po b.i.d. and on [**2152-1-2**]. Coumadin 2 mg po q.h.s., Glargine 36 units subQ q.h.s., NPH 13 units subQ q.a.m. and a Humalog sliding scale. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 93102**] on the week of [**12-27**]. Follow up with Dr. [**Last Name (STitle) **] as needed at phone number [**Telephone/Fax (1) 2226**]. Follow up with the [**Hospital **] Clinic at [**Telephone/Fax (1) 2378**]. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Last Name (NamePattern1) 3796**] MEDQUIST36 D: [**2151-12-31**] 01:38 T: [**2152-1-4**] 08:47 JOB#: [**Job Number 93103**] cc:[**Last Name (NamePattern4) 93104**]

[ "286.9", "782.1", "584.5", "250.61", "250.51", "486", "428.33", "710.1", "250.41" ]

icd9cm

[ [ [] ] ]

[ "21.01", "03.31", "93.90" ]

icd9pcs

[ [ [] ] ]

8176, 8214

3201, 4426

7161, 7440

7464, 8154

4444, 7140

8226, 8835

147, 182

211, 2766

2789, 3123

3140, 3184

64,416

107,802

45661

Discharge summary

report

Admission Date: [**2149-9-24**] Discharge Date: [**2149-11-19**] Date of Birth: [**2086-9-12**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 943**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Diagnostic Paracentesis History of Present Illness: 62M with ETOH cirrhosis, recent prolonged hospitalization from [**Date range (1) 97340**] for right axillary hematoma requiring massive blood product resuscitation, readmission on [**9-4**] for continued right groin bleed which achieved hemostasis with DDAVP and aminocaproic acid, presenting one day after discharge with altered mental status. His sister reports picking him up from the hospital the evening of [**9-22**] and reports he had normal mental status. The following morning he appeared confused with decreased PO intake and not using bathroom. His symptoms of confusion progressed throughout the day and by evening he was awake but not verbal. He was thus brought by his sister to the [**Name (NI) **] for further evaluation. In ED vitals were 97.8 73 127/68 24 100% 2L. Paracentesis was performed which was negative. A RUQ-US showed gallbladder sludge and a patent portal vein. He received 200cc of NS and flagyl 500mg IV X1, and transferred to the ICU. On admission he had put our 300cc urine. Past Medical History: -ETOH cirrhosis with ESLD, ascites with possible fibrosis and steatohepatitis via Bx however patient denies hx of Bx. He is currently being evaluated for transplant at [**Hospital1 1774**]. -ETOH abuse - quiescent x 6 mo per pt with occasional relapse -Pancytopenia - admitted [**Month (only) **]-[**Month (only) **] to [**Hospital1 112**] with "severe anemia", given vit K, FFP, PRBCs. EGD and colonoscopy performed which showed few polyps -HTN -ARF -GERD Social History: [**Doctor Last Name **] professional NBA basketball player, then basketball coach at [**University/College **]. Worked with suicidal individuals. + ETOH - sober x 6 months except for few days of relapse with last drink on [**9-17**], denies hx of ETOH withdrawal symptoms No smoking. No drugs. Family History: Cardiac arrhythmia and stroke - mother Hypertension - sister Physical Exam: Admission Exam General: cachectic, awake, eyes open, somnolent, awakens to voice, not responding to qustions or name. HEENT: scleral icterus Neck: no LAD Lungs: CTA b/l CV: RRR, noi m/g/r Abdomen: large ascites, non-tender Ext: 3+ pitting edema, right groin without bruit. well healed scar of old puncture site over right groin Neuro: Awake, opens eyes when spojken to, not responding to name or questions. Pertinent Results: Admission Labs [**2149-9-24**] 02:00AM BLOOD WBC-7.5# RBC-2.99* Hgb-10.1* Hct-29.9* MCV-100* MCH-33.9* MCHC-33.9 RDW-18.9* Plt Ct-125* [**2149-9-24**] 02:00AM BLOOD Neuts-75.9* Lymphs-16.6* Monos-5.2 Eos-1.5 Baso-1.0 [**2149-9-24**] 02:00AM BLOOD PT-23.4* PTT-80.2* INR(PT)-2.2* [**2149-9-24**] 02:00AM BLOOD Glucose-115* UreaN-30* Creat-1.9* Na-137 K-3.8 Cl-106 HCO3-15* AnGap-20 [**2149-9-24**] 02:00AM BLOOD ALT-14 AST-53* CK(CPK)-108 AlkPhos-69 TotBili-10.8* [**2149-9-24**] 02:00AM BLOOD Lipase-82* [**2149-9-24**] 10:19AM BLOOD Calcium-9.8 Phos-3.0 Mg-1.6 [**2149-9-24**] 10:19AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2149-9-24**] 10:30AM BLOOD Type-[**Last Name (un) **] Temp-37.7 pO2-123* pCO2-37 pH-7.29* calTCO2-19* Base XS--7 Intubat-NOT INTUBA [**2149-9-24**] 03:47AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.008 [**2149-9-24**] 03:47AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG [**2149-9-24**] 09:24AM URINE Hours-RANDOM UreaN-497 Creat-108 Na-59 [**2149-9-24**] 09:24AM URINE Osmolal-372 [**2149-9-24**] 06:00AM ASCITES WBC-158* RBC-1185* Polys-3* Lymphs-18* Monos-77* Mesothe-2* [**2149-9-24**] 06:00AM ASCITES TotPro-3.4 Glucose-122 Albumin-1.6 Imaging: -[**2149-9-24**] CT Head: IMPRESSION: Study limited due to patient movement in the scanner due to altered mental status, however, no large acute hemorrhage is seen. No obvious fractures are seen. NOTE ON ATTENDING REVIEW: 1. There is expanded, slightly lobulated appearance to the medulla and ponto medullary and cervico-medullary junctions on the axial images. It is unclear if this is real/artifactual related to the motion/angulation. Repeat study when the pt. is co-operative and if persistent, MR [**Name13 (STitle) 430**] can be considered. 2. Degenerative changes are noted at the dens on the right side and a small osteoma in the right side of the frontal sinus. -[**2149-9-24**] Abdominal Ultrasound: 1. Coarsened liver in keeping with diagnosis of cirrhosis. Small hypoechoic round lesion at the dome of the liver, likely a small cyst. 2. Main portal vein is patent. 3. Ascites. 4. Sludge in the gallbladder. 5. Residual pleural effusion. -[**2149-9-24**] CXR: Basal consolidation is new since [**9-11**]. Since there is appreciable leftward mediastinal shift this could be collapsed. A lesser volume of abnormality is present in the infrahilar right lower lobe. Small bilateral pleural effusions could be present but not appreciated on conventional radiographs. Mild cardiomegaly is longstanding. Nasogastric tube ends in the region of the pylorus. Substantial intestinal distention is noted in the imaged portion of the upper abdomen. -[**2149-9-24**] KUB: NG tip within the stomach, with the sidehole above the GE junction and with minimal purchase in the stomach. Recommend advancement further into the stomach. This result was communicated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to the primary medical team. -[**2149-9-30**] CT Pelvis: 1. Colonic ileus with dilated loops of transverse colon. Contrast passes through the transverse colon into the descending colon and sigmoid. 2. Stable hepatic hypodenities and apparent new tiny hypodensity, too small to characterize, statically likely to be cysts. 3. Massive and increased ascites. 4. Right middle lobe pulmonary nodule. Consider chest CT followup in 12 months. 5. Findings consistent with cirrhotic liver. 6. Decreased pleural effusions and associated relaxation atelectasis. 7. Persistent right chest wall hematoma and associated probable right tenth rib fracture. -[**2149-10-3**] KUB: 1. Worsening colonic ileus. 2. Massive ascites. 3. Bilateral pleural effusions and airspace disease. -[**2149-10-4**] KUB: Compared to the prior study, there is a stable substantially air distended colon, but no evidence for progressive distention. Relative paucity of bowel gas distally is seen with thin rim of air consistent with the compressed sigmoid colon from the ascites as was demonstrated on the recent CT scan of [**2149-9-30**]. There is no free air or pneumatosis. -[**2149-10-7**] KUB: 1. Stable colonic ileus. 2. Ascites. -[**2149-10-9**] KUB: Isolated dilatation of large bowel, suggestive of colonic ileus. Low colonic obstruction is a less likely possibility, given temporal stability. -[**2149-10-10**] KUB: Severe colonic distention, the caliber of which is not significantly changed, most suggestive of ileus. -[**2149-10-11**] KUB: Severe distention of the colon, not significantly changed compared to prior examinations, most suggestive of ileus. -[**2149-10-11**] Lower extremity U/S: No evidence of DVT seen in either lower extremity -[**2149-10-13**] KUB: No definitive evidence of ileus or obstruction -[**2149-10-15**] Chest CT: 1. No change in size of a large right chest wall hematoma, however presence of high-attenuation areas within the collection indicates recent rebleeding. 2. Interval increase in bilateral pleural effusions. 3. Abnormal appearance of renal parenchyma, correlate with renal function, as this appearance can be seen in the setting of acute renal failure such as ATN. 4. Number of noncalcified pulmonary nodules, largest 5 mm solid nodule in the right middle lobe. In absence of risk factors, followup in one year is recommended to document stability. 5. Large abdominal ascites. -[**2149-10-15**] KUB: Overall no appreciable change in gaseous distention of large bowel loops. -[**2149-10-16**] Paracentesis Guided U/S: Ultrasound-guided diagnostic and therapeutic paracentesis yielding 2 liters of clear dark-yellow fluid. -[**2149-10-17**] KUB: Persistent gaseous distention of large bowel loops without appreciable change. -[**2149-10-18**] KUB: Two distended segments of colon are present in the mid abdomen. There is probably increased gaseous distention since the prior study. There is overall haziness and under-penetration of this film. -[**2149-10-19**] CT Abd/Pelvis: 1. Small hematoma of the abdominal wall muscles in the right lower quadrant. 2. Hematoma of right internal obturator muscle. 3. Large hematoma in the right lateral thorax and abdominal wall, stable compared to the previous exam. 4. A large amount of ascites. 5. Small to moderate amount of pleural effusion bilaterally. 6. Dilatation of the transverse colon up to 8.2 cm with fluid in its lumen and collapsed distal large bowel. -[**2149-10-20**] KUB: There is a stable marked distention of the ascending and transverse colon measuring up to 10 cm in maximal diameter. There is mild interval increase in gas distention of small bowel loops. Patient has known ascites -[**2149-10-24**] KUB: The new right-sided PICC line tip is satisfactory at the cavoatrial junction. Consolidation in the middle lobe is slightly worse than on the previous chest radiograph from [**2149-9-9**] and there is new left lower lobe atelectasis. The remaining lungs are clear with no pneumothorax or pleural effusion. Cardiomediastinal silhouette is unchanged and within normal limits. There is progressive distention of the large bowel without no obvious bowel wall thickening. -[**2149-10-26**] Chest CT: 1. Very minimal increase in the size of the large right chest wall hematoma as described above. The presence of high-attenuation areas within the collection indicates re-bleeding. 2. Stable bilateral pleural effusions and basal atelectasis. 3. Non-calcified pulmonary nodules, largest 5-mm nodule in the right middle lobe. In the absence of risk factors, followup in one year is recommended to document stability. 4. Cirrhotic liver and large abdominal ascites is stable -[**2149-10-27**] KUB: Again identified is marked distention of the ascending, transverse and descending colon, not significantly changed. Air-fluid levels are identified. Loops of bowel measuring up to 10 cm in maximal diameter, unchanged. -[**2149-10-27**] CXR: Left PICC transverses the midline and subsequently terminates in the right subclavian vein as communicated to [**First Name8 (NamePattern2) 8513**] [**Last Name (NamePattern1) **] on [**2149-10-27**]. Appearance of the chest is relatively unchanged compared to the recent radiograph except for slight worsening of left retrocardiac opacification. Within the abdomen, distended loops of bowel are incompletely imaged but probably slightly improved. -[**2149-10-28**] CXR: As compared to the previous examination, the position and course of the left PICC line is unchanged, the line placed over the left upper extremity crosses the midline and is located in the distal right brachiocephalic vein. There is no evidence of pneumothorax or other complications -[**2149-10-28**] Fluoro: Uncomplicated fluoroscopically guided PICC line exchange for a new 5-French double lumen PICC line. Final internal length is 46 cm, with the tip positioned in the SVC. The line is ready to use. -[**2149-10-30**] Right Upper Extrem U/S: No evidence of DVT of the right upper extremity -[**2149-10-30**] KUB: Persistent colonic dilatation without significant interval change. -[**2149-10-30**] CXR: Appropriate position of PICC line, no evidence of new acute pulmonary infection. -[**2149-10-31**] KUB: Unchanged colonic distention -[**2149-11-3**] CXR: Left PICC is again seen, now terminating at the brachiocephalic junction. Again noted are bibasilar opacities, left retrocardiac opacity is dense, and may represent atelectasis, however, superimposed infection may not be excluded. Again, marked elevation of both diaphragms is present, as well as significant air distention of the large bowel. BLOOD BANK: [**2149-10-19**]: Mr. [**Known lastname **] has a new diagnosis of Anti-E antibody. E-antigen is a member of the Rhesus blood group systems. Anti-E antibody is clinically significant and capable of causing a hemolytic transfusion reaction. In the future, Mr. [**Known lastname **] should receive E-antigen negative products for all red cell transfusions. Approximately 71% of ABO compatible blood will be E-antigen negative. A wallet card and a letter stating the above will be sent to the patient. Micro: -[**2149-9-24**] Ascites: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2149-9-27**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2149-9-30**]): NO GROWTH. -[**2149-9-24**] Blood x 2: No growth -[**2149-9-27**] Urine: No growth -[**2149-9-29**] Stool/C. Diff: Negative -[**2149-9-30**] Urine: YEAST 10,000-100,000 ORGANISMS/ML -[**2149-10-2**] Urine: YEAST >100,000 ORGANISMS/ML -[**2149-10-7**] Stool/C. Diff: Negative -[**2149-10-9**] Stool/C. Diff: Negative -[**2149-10-12**] URINE CULTURE: ENTEROCOCCUS SP 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML ENTEROCOCCUS SP. AMPICILLIN <=2 S NITROFURANTOIN <=16 S TETRACYCLINE =>16 R VANCOMYCIN <=1 S -[**2149-10-15**] Urine: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. -[**2149-10-16**] Ascites: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2149-10-19**]): NO GROWTH ANAEROBIC CULTURE (Final [**2149-10-22**]: NO GROWTH -[**2149-10-18**] Blood x 2: No growth -[**2149-10-27**] Blood: No growth -[**2149-10-30**] Blood: No growth -[**2149-10-31**] Blood: No growth -[**2149-11-2**] Stool/C. Diff: Negative -[**2149-11-2**] Urine: No growth -[**2149-11-4**] Blood x 2: ________ -[**2149-11-4**] Urine: No growth Brief Hospital Course: Mr. [**Known lastname **] is a 63 yo man with alcoholic cirrhosis, complicated by ascites, coagulopathy, and hepatic encephalopathy, who initialy presented with altered mental status and was admitted to the ICU. His mental status improved and he was transferred to the liver service for continued management. . # Altered Mental Status: Likely due to hepatic encephalopathy. At admission, a diagnostic paracentesis was performed by the ED which was not suggestive of infection. A RUQ US was also performed which did not show any acute biliary pathology. Serum and urine toxicologies were negative. In the ICU Lactulose and Rifaximin were started for likely hepatic encephalopathy. A CT head without contrast was performed but was substantially hampered by motion artifact. Stool output began to pick up on lactulose regimen and mental status substantially improved. Lactulose and rifaximin were continued with improvement of mental status back to baseline. Lactulose was then stopped because of concern regarding his colonic pseudoobstruction and his continued diarrhea. The patient had an acute decline in mental status on the morning of [**2149-10-18**], with physical exam findings suggestive of hepatic encephalopathy, including asterixis. Additionally, he had received two doses of morphine for pain and appeared oversedated. He received narcan IV x3, and became substantially more alert. He was restarted on lactulose, and then stopped after stabilization of his mental status. On [**2149-10-30**] the patient again had a change in mental status, this time consistent with delerium and felt to be secondary to underlying infection. The patient was started on Vanc/CTX [**10-30**] out of concern for possible RUE cellutitis and possible other occult infection. His mental status was then generally clear for several days, with occasional confusion or disorientation. With his liver and kidney functioning worsening daily, both encephalopathy and uremia became an etiologic factor in his altered mental status. Lactulose was not restarted, given the patient's regular bowel movements. He was continued on rifaximin through [**11-11**], when his code status had changed to Comfort Measures Only. The patient's mental status also waxed and waned in the setting of receiving opioid analgesia. The patient and family members showed good understanding that he may be increasingly somnolent with fewer and shorter lucid intervals, and he called his HCP and other family members to relay this message, in advance of starting more aggressive comfort measures on [**11-11**]. He was admitted to an inpatient hospice service and was given increasing doses of morphine. He was eventually started on a morphine drip, scopalomine patch, and atropine sublingual drops, when he developed large amounts of oropharyngeal and nasal secretions. He expired early in the morning of [**11-19**]. . # Acute Renal Failure: Initially, the patient presented with Cr 1.9 elevated from a baseline value of 0.8. On clinical exam the patient appeared itravascullary depleted supported by a lactate of 4.3 with decreased to 3.8 after initial fluid bolus. His UA in the ED was negative. Renal function was reponsive to initial fluid boluses suggesting that this was pre-renal in etiology. Creatinine continued to trend down with fluids reaching at nadir at his baseline of 0.9 on [**9-26**]. However, his renal function again began to decline and became unresponsive to fluid challenges. Initially, it was felt that there was a prerenal component to his ARF, because he had been intermittently NPO for procedures and bowel rest in relation to his ileus. However, renal function did not improve with several days of albumin administration, and it was felt to be due to hepatorenal syndrome. All diuretics were stopped, and the patient was initiated on treatment for HRS including octreotide, midodrine and daily albumin. Additionally, the differential for renal failure included abdominal compartment syndrome, given the patient's significant ascites and colonic distension. A bladder pressure was transduced at 14-17 mmHg; elevated but nondiagnostic for compartment syndrome. The patient was not considered a candidate for hemodialysis, given the frequent episodes of bleeding that he had demonstrated with even minor interventions. On [**11-5**], the decision was made to keep checking daily BUN and creatinine levels, to help the family know how much of the patient's mental status they could attribute to his uremia. It was clearly communicated to the patient and the family members that the patient's kidneys were failing and were likely to continue worsening daily. On [**11-11**], the patient was made CMO and all lab checks, including BUN and creatinine, were discontinued. # Diarrhea - On transfer from ICU, patient was noted to have dark, watery diarrhea. Initially attributed to lactulose, which was continued. TTG WNL and C. Diff was negative. Flexiseal was discontinued with some improvement in diarrhea. Diet was changed to lactose and gluten free despite negative results for celiac. On physical exam, concern for obstruction given high-pitched "tinkling" bowel sounds. CT A/P was consistent with large bowel ileus with megacolon (9 cm loops) that were filled with air (see pseudoobstruction below). Diarrhea was felt to be multifactorial, due to a combination of lactulose and non-obstructing ileus. The diarrhea remained throughout his hospital stay and was felt to be responsible for a chronic metabolic acidosis. # Colonic Ileus - Abdomen with tympany to percussion on exam and diarrhea concerning for obstruction. CT A/P with megacolon (9cm) with repeat KUBs stable with possible 14cm loop of bowel. Out of concern for partial obstruction, flex sigmoidoscopy was performed on [**10-6**]; the bowel was decompressed and reaccumulated air within several hours. Bowel rest and rectal tube decompression was also attempted, without success. He was closely monitored with serial abdominal exams and KUBs over several weeks, with no significant change in colonic distention. Additionally, he continued to have bowel movements. As his condition became increasingly terminal, he occasionally seemed to indicate abdominal discomfort, and was treated with increasingly aggressive comfort measures. # Traumatic foley placement: As above, abdominal compartment syndome was considered on the differential for renal failure. A foley catheter was placed, with trauma to the urethra because of difficulty advancing the catheter past the prostate. Urology placed a coude catheter, with a plan to leave the foley in place for at least one week to tamponade bleeding. Post procedure, the patient continued to bleed from the urethra, and required many units of PRBCs and FFP (see coagulopathy). He occasionally passed clots through his Foley catheter, manipulation of the Foley was kept to a minimum, given the aforementioned bleeding complications. His Foley was kept in place until he passed away. # Coagulopathy: Multifactorial from lupus anticoagulant and liver dysfunction. Large chest wall hematoma with CT suggesting component of rebleed. Also developed urethra bleed from traumatic foley placement (see above), as well as abdominal wall bleeding from para site which required several brief ICU stays for hemodynamic monitoring. During ICU stay from [**10-19**]/-[**10-21**] received FFP, DDAVP, thrombin dressing to paracentesis site with continued oozing, which resolved after stitch and pressure dressing by surgery. He was again sent to the MICU from [**Date range (1) 11301**] after appearing to have passed a large clot per rectum, and a 7 pt Hct drop. The patient was guaiac negative and subsequently had a formed brown stool so it is believed that the blood was actually pooled blood from his penis that had collected in his perineum. The patient subsequently had significant bleeding from his penis that lasted throughout the day and following night. He received FFP, PRBCs, Cryo and vitamin K. Urology was contact[**Name (NI) **] who recommended continuing his Foley and correcting his coagulopathy. Upon returning to the medicine floor, the patient continued to require daily transfusions of PRBCs and FFP. On [**2149-11-2**] he was also given DDAVP to treat for uremic platelets and Factor 7. His coagulation studies did not show any significant change, and his hematocrit did not stabilize. A subsequent blood transfusion caused low grade temperatures and increased work of breathing, and was stopped early. With increasing focus on the patient's comfort, it was decided to not give further transfusions. # UTI - yeast on urine culture. U/A from [**10-12**] now grew enterococcus and pt completed 7 day course of ceftriaxone from [**Date range (1) 1195**]. # ESLD: Complicated by ascites and encephalopathy. Presented with hepatic encephalopathy that improved with lactulose and rifaximin, and then declined again for unclear reasons; progression of liver disease versus infection versus stopping lactulose. Additionally, the patient underwent several diagnostic paracenteses, which showed no evidence of any infection. During his hospitalization, he was evaluated for liver transplantation and a decision was made that he was not a candidate of transplantation due to the severity of his coagulopathy. # Guaiac Positive Stools: Patient with history of Guaiac positive stools during prior hospitalization which was atributed to hemorrhoids. Initial HCT of 26.5 in ED which appears to be at baseline with prior levels. Pt placed on 5 day course of ceftriaxone for SBP prophylaxis in setting of GIB. Serial hematocrits were followed with a tendency to drift down and require periodic transfusions. He had one further episode BRBPR, which was self-limited and felt to be hemorrhoidal in origin. # Hypokalemia - Likely secondary to diuretics and diarrhea. Diruetics held intermittantly, potassium replaced prn. Hypokalemia resolved with improvement of diarrhea. In spite of his ESRD, his potassium remained borderline low when checked on [**11-10**]. Medications on Admission: 1. Folic Acid 1 mg DAILY 2. Pantoprazole 40 mg Tablet, Q24H 3. Thiamine HCl 100 mg once a day. 4. Lactulose Thirty (30) ML PO TID 5. Spironolactone 100 mg DAILY 6. Lasix 80 mg once a day 7. Aminocaproic Acid 1,000 mg Tablet One (1) Tablet PO every six (6) hours for 11 days Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Kidney injury [**2-10**] end-stage liver disease Discharge Condition: Expired

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Discharge summary

report

Admission Date: [**2178-12-12**] Discharge Date: [**2179-1-1**] Date of Birth: [**2103-8-7**] Sex: F Service: MEDICINE Allergies: Hydrochlorothiazide / Bactrim Attending:[**First Name3 (LF) 905**] Chief Complaint: GI bleeding at rehab Major Surgical or Invasive Procedure: PEG placement Upper endoscopy Colonoscopy central line placement History of Present Illness: Ms. [**Known lastname 105630**] is a 75 year old woman with a history of multiple medical problems including CAD, AFIB, colon ca s/p hemicolectomy/XRT, hypertension, CVA [**1-/2178**], gallstone pancreatitis [**6-/2178**] complicated by Klebsiella, MRSA, and [**Female First Name (un) 564**] bacteremia and most recently AAA repair w/ stent [**83**]/[**2178**]. She presented to [**Hospital1 18**] from [**Hospital1 **] after having maroon stools and lethargy. Her mental status slowly and progressively has been declining since [**Month (only) 116**]. She was initially thought to have a brisk upper gi bleed so she was admitted to the surgical ICU. Subsequent EGD was negative but colonscopy was equivocal with poor prep but diverticuli were considered to be the likely source of bleeding. Ultimately transfused 3u pRBC and 4u FFP While on the surgery service, they found her to be lethargic and consulted geriatrics. They felt she had predominantly medical issues so she is transferred to medicine for further management. Per family she has had a progressive decline since may. Her MS has been at its worst since [**Month (only) **]. At [**Location 105701**], they attempted to reduce the number of medications she was on, so being she was in normal sinus rhythm, her amiodarone was discontinued. Past Medical History: - Atrial Fibrillation (on amiodarone and on coumadin) - Heart murmur - TTE in [**2172**] showed LA mod dilated, LV mildly hypertrophied, aortic sclerosis, mild AI, mild MR. - Gallstones s/p ERCP in [**6-21**] for gallstone pancreatitis - Colon cancer dx'd in [**2159**], tx'd with hemicolectomy, XRT, chemo. CEA was in the 8 range (down from 9) [**Last Name (un) **] [**3-18**] showed sig tics and int hemorrhoids. - Lymphedema from XRT, takes a diuretic - Cataracts - Hypertension - Anxiety - Coronary artery disease - Left corona radiata stroke with right facial droop and dysathria [**1-/2178**] - scoliosis - rectus sheath hematoma - history of sacral ulcer status post z-plasty - ectopic pregnancy x2 Social History: Currently staying at [**Hospital **] rehab. Married, former secretary, waitress. + tobacco; 160py (40 years at 4ppd) quit 30 yrs ago. No alcohol or drug use. Family History: Mother with stroke at age 82. no early deaths. 2 daughters- healthy Physical Exam: VS: Tm 99.2 Tc 98.2 BP 120/72 RR 18 Sat 98% RA Gen: Pleasant dysarthric woman in no apparent distress, staring into space, gives one word answers. HEENT: PERRL, sclerae anicteric, dry MM. Neck: JVP elevated to angle of jaw, RIJ site healing CV: III/VI SEM at LSB, III/VI HSM at apex, regular, no heaves/thrills. Pul: CTA anteriorly. Abd: Distended, soft, tender LLQ, no rebound, no guarding. Ext: 2+ anasarca. RP 2+ left, RP 1+ right. Neuro: moves UE/RLE, cannot wiggle toes on LLE. Pertinent Results: ADMISSION LABS: [**2178-12-12**] 03:20PM WBC-18.3*# RBC-3.02* HGB-9.0* HCT-27.0* MCV-89 MCH-29.9 MCHC-33.5 RDW-17.4* [**2178-12-12**] 03:20PM PT-15.3* PTT-24.1 INR(PT)-1.6 [**2178-12-12**] 09:24PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-MOD [**2178-12-12**] 09:24PM URINE RBC-[**3-21**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 TRANS EPI-[**3-21**] [**2178-12-12**] 09:24PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 Studies: Bleeding scan [**12-12**]: No site of tracer extravasation into bowel is identified. Negative GI bleeding study. EKG [**12-12**]: Sinus rhythm. Early transition. Normal ECG. Compared to the previous tracing no significant change. EKG [**12-14**]: Atrial fibrillation with a rapid ventricular response. Right axis deviation. Prominent initial R wave in lead V1, although baseline artifact makes assessment difficult. Diffuse non-specific ST-T wave abnormalities. These findings suggest possible right ventricular overload or possible left posterior fascicular block. Clinical correlation is suggested. Since the previous tracing of [**2178-12-12**] atrial fibrillation, futher right axis deviation and ST-T wave abnormalities are now present. MRI Brain [**2178-12-21**]: 1. Limited study due to above-mentioned technical factors. In particular, the MRA provides no useful diagnostic information. 2. Two foci of slow diffusion at the left paramedian aspect of the mid pons, consistent with acute small vessel ischemic infarcts. 3. Multiple foci of increased susceptibility at the occipital lobe and right temporal lobe, ? chronic blood products, ? multiple cavernous angiomas v. amyloid angiopathy foci. A larger focus of increased susceptibility at the left occipital lobe with an adjacent prominent vessel may represent a cavernous angioma with an associated developmental venous anomaly. CT Abdomen/Pelvis [**2178-12-28**]: 1. No evidence of obstruction. 2. Status post PEG tube placement. Status post abdominal aortic aneurysm repair with stent graft placed. 3. Peribronchial thickening within right lung base. 4. Diveriticulosis. 5. Atherosclerosis. 6. Diffuse demineralization with degenerative changes. DISCHARGE LABS: Brief Hospital Course: Mrs. [**Known lastname 105630**] is a 75 year old woman with a history of multiple medical problems including CAD, AFIB, colon ca s/p hemicolectomy/XRT, hypertension, CVA [**1-/2178**], gallstone pancreatitis and AAA repair w/ stent [**10/2178**] presenting with resolved lower GI bleed. For her GI bleeding: The patient was initially admitted to the surgical service for workup of what was thought to be a brisk upper GI bleed given a blood-tinged NG lavage. Her anticoagulation was reversed with FFP and she was transfused packed red blood cells. A bleeding scan was performed and this was negative. GI performed an EGD and then a colonoscopy, which showed no obvious source of bleeding. Ultimately, it was felt the bleeding was most likely from a diverticulum. She remained hemodynamically stable for the remainder of her hospital stay. Regarding her heart, she had a history of coronary artery disease and atrial fibrillation. She was on amiodarone in the past, although this was recently discontinued at rehab. The anticoagulation was reversed due to her GI bleeding. Two EKG's were performed showing atrial fibrillation. While she was on the medicine service, telemtry was re-started and showed normal sinus rythym for four consecutive days. Given the resolution of her GI bleed, we restarted her Aspirin. Given the findings on MRI, she was not further anticoagulated and her coumadin should be held indefinitely. For her mental status, further history was first obtained from her family. See the HPI. When she was examined by the medical team, she was practically catatonic. TSH was checked, and this was normal. Ritalin was started, as was zoloft. Given her paroxsymal atrial fibrillation, and concern for frontal release signs, an MRI was checked. Despite sedation, the MRI was difficult to interpret, but did show a new left pontine ischemic infarction, ?amyloid angiopathy with blood products and ?cavernous angioma. Neurology was consulted with the question of re-starting anticoagulation. They felt that this would pose a very high risk to the patient. We discussed this with the family, and have elected to proceed with aspirin alone. A urinalysis was also performed and showed a likely urinary tract infection. The patient had elevated temperatures as well, so Ciprofloxacin was started. The urine culture demonstrated greater than 100k CFU of multi-drug resistent klebsiella. Her foley was changed. Imipenem was started, and the patient should complete a 14-21 day course, given the presence of a foley catheter. Within 24hrs of starting treatment for the UTI (as well as starting the ritalin), her mental status began to clear significantly. For her nutrition, after transfer from the surgical service, a speech and swallow eval was performed. The patient was able to swallow ground food with prethinned liquids. A nutrition consult was obtained. Unfortunately, she had difficulty feeding herself, and could not take enough by mouth to meet her nutritional requirements. A dobhoff nasogastric tube (NGT) was placed to . Tube feeds were started per their recomendations. Two days within starting the tube feeds, the patient pulled out the NGT. After discussion with the patient, her husband and her daughter, we re-consulted GI for PEG placement. After one to two days with the PEG, she was noted to have increased residuals. Tube feeds were held and a CT scan was obtained to rule out obstruction. The CT scan showed no obstruction and no signs of constipation. The patient was given a bowel regimen and started on reglan with good effect. For access, central lines were placed in the SICU and eventually a PICC was placed. This was used for blood draws and antibiotic infusions. Her code status is DNR. Communication was with her husband [**Name (NI) **] [**Name (NI) 105630**] [**Telephone/Fax (1) 105702**], and her daughter [**Name (NI) **]. Medications on Admission: Amiodarone 200mg po qd Coumadin 2mg po qd Lansoprazole 30 [**Hospital1 **] Sertraline 20mg po qd Lasix 20mg [**Hospital1 **] Aspirin 81mg qd Colace 100mg [**Hospital1 **] Senna Laculose Dulcolax (noted elsewhere: Reglan 5mg [**Hospital1 **], oxandrolone 2.5 [**Hospital1 **]) Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: each lumen QD and PRN. 11. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 14 days: Day 1=[**2178-12-22**] . Discharge Disposition: Extended Care Facility: [**Hospital **] Care Center - [**Location (un) **] Discharge Diagnosis: Multidrug resistant klebsiella urinary tract infection left pontine stroke lower gi bleeding acute mental status changes Discharge Condition: Stable, afebrile, with improvement in mental status Discharge Instructions: Please seek medical attention for fevers > 101.4, for change in mental status, or for anything else medically concering. Please take all of your medications as directed. You are not to receive any anticoagulation given the high risk of causing bleeding in you brain. Followup Instructions: Please make an appointment to see Dr. [**Last Name (STitle) **] 1-2 weeks after discharge from rehab. [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 4775**] 1) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2179-4-28**] 10:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "414.01", "599.0", "562.12", "401.9", "434.91", "041.3", "V09.81", "285.1", "V10.05", "427.31" ]

icd9cm

[ [ [] ] ]

[ "43.11", "99.15", "45.13", "45.23", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

10737, 10814

5510, 9427

309, 376

10979, 11033

3227, 3227

11350, 11783

2638, 2708

9754, 10714

10835, 10958

9453, 9731

11057, 11327

5487, 5487

2723, 3208

249, 271

404, 1715

3243, 5469

1737, 2446

2462, 2622

26,160

167,607

9853

Discharge summary

report

Admission Date: [**2179-11-9**] Discharge Date: [**2179-11-20**] Service: MEDICINE Allergies: Vancomycin / Flagyl Attending:[**First Name3 (LF) 759**] Chief Complaint: nausea, vomiting, dizziness Major Surgical or Invasive Procedure: none History of Present Illness: 84 year old male with multiple cardiac risk factors and problems including IDDM, CAD s/p CABG, ex-smoker, hypertension, hypercholesterolemia, atrial fibrillation, and peripheral vascular disease presents with nausea/vomiting, rhinorrhea, and tachycardia for 24 hours. The patient was in his usual state of health until yesterday evening when he began to experience a "horrible runny nose that wouldn't stop". This was followed by nausea and vomiting x2. He denied chest pain, palpitations, abdominal pain, radiating pain to arms/abdomen/jaw, lightheadedness, pre-syncope, syncope. He also denies orthopnea, PND, increase in abdominal girth or lower extremity swelling. On review of systems, the patient reports several episodes per week where he experiences dizziness, disorientation, and slight aphasia. The patient has not seen a neurologist for these symptoms and they have occurred over the last 4 years. Because of his history of cardiac disease, he decided to seek medical attention immediately for his nausea/vomiting. Past Medical History: * Bladder outlet obstruction. * BPH. * Peripheral vascular disease * Glaucoma. * Cataracts. * Insulin-dependent diabetes mellitus. * Hypertension. * Hypercholesterolemia. * Coronary artery disease. * Atrial fibrillation. * History of methicillin-resistant Staphylococcus aureus positive. _-_-_-_-_-_-_-_-_ SURGICAL HISTORY * s/p toe amputations * Coronary artery bypass graft 15 years ago of six vessels. * Glaucoma and cataracts. * Bladder stone removal. * Status post three toe amputation of left leg. Social History: Lives at home with his wife. Retired [**Name2 (NI) 5059**]. Smoked pipe for 40 years and quit 14 years ago. Rare alcohol use. No illicit drugs. Family History: unknown to the patient. Physical Exam: VS: Afebrile 142/80 76 18 99%RA GEN: pleasant, NAD, comfortable appearing male appearing his stated age, well-nourished HEENT: PERLL, EOMI, sclera anicteric, no conjuctival injection, mucous membranes slightly dry, no lymphadenopathy, no thryroid nodules or masses, no supraclavicular lymph nodes, no posterior lymphadenopathy, neck supple, full ROM, neck veins elevated to mid-ear, no carotid bruits [**Last Name (un) **]: CTA b/l COR: RRR, S1 and S2 wnl, no murmurs/rubs/gallops, no abd bruit, no femoral bruits ABD: non-distended with positive bowel sounds, non-tender,no guarding, no rebound or masses BACK: neg CVA tenderness EXT: no cyanosis, clubbing, edema NEURO: Alert and oriented x3. Some difficulty with word-finding and comprehension of terms consistent with the patient's occupation ("pulse", "anti-emetic", "anticoagulant"). CNII-XII are intact, and patient with 5/5 strength throughout, normal sensation throughout. No pronator drift. Pertinent Results: [**2179-11-9**] 12:11PM GLUCOSE-108* K+-4.0 [**2179-11-9**] 11:30AM GLUCOSE-102 UREA N-25* CREAT-1.2 SODIUM-141 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16 [**2179-11-9**] 11:30AM CK(CPK)-41 [**2179-11-9**] 11:30AM cTropnT-0.03* [**2179-11-9**] 11:30AM CK-MB-NotDone [**2179-11-9**] 11:30AM DIGOXIN-0.4* [**2179-11-9**] 11:30AM WBC-12.1* RBC-4.72# HGB-14.8# HCT-43.5# MCV-92 MCH-31.4 MCHC-34.1 RDW-15.1 [**2179-11-9**] 11:30AM NEUTS-79.1* LYMPHS-16.0* MONOS-4.2 EOS-0.4 BASOS-0.3 [**2179-11-9**] 11:30AM PLT COUNT-235 [**2179-11-9**] 11:30AM PT-14.6* PTT-30.3 INR(PT)-1.3 head CT [**2179-11-10**]: 1. No acute hemorrhage or mass effect. Maxillary sinusitis. 2. Low-attenuation focus in the right frontal lobe periventricular white matter, likely consistent with an infarct of indeterminant age. If there is clinical concern for acute stroke, a MRI with diffusion-weighted images is recommended. [**2179-11-10**] MRA: 1. Extremely faint visualization of flow in the right vertebral artery. 2. No evidence of stenosis in the right or left carotid arteries. [**2179-11-10**] MRI brain: IMPRESSION: No evidence of acute ischemia. Multiple chronic infarcts. [**2179-11-12**] GI tagged red cell scan: IMPRESSION: Uptake of tracer in the proximal small bowel, suggesting active bleed. EGD [**2179-11-12**]: Fresh red blood was noted to be oozing from the second part of the duodenum. Red blood tracked further down the duodenum, but was most concentrated in the second portion. Ulcer in the second part of the duodenum (thermal therapy, injection). Otherwise normal egd to third part of the duodenum. Brief Hospital Course: 1. nausea/vomiting - pt's symptoms initially thought to be secondary to myocardial ischemia versus viral gastritis versus cerebrovascular infarct. Since the patient also complained of significant rhinorrhea, a viral etiology was favored. There was an initial troponin leak of 0.03 but subsequent measurements were negative for myocardial infarct. This small leak was attributed to a component of CHF. Cardiac ECHO was performed which revealed an EF<20% and severe global biventricular systolic dysfunction consistent with a diffuse process (multivessel CAD, toxin, metabolic, etc.) There was also a dilated ascending aorta. Head CT was negative for acute hemorrhage or mass effect. There was maxillary sinusitis. Stroke and myocardial infarct were ruled out, and then pt's N/V was managed medically with resolution. 2. confusion/word finding difficulties - pt was somewhat confused on admission and had episodes of somnolence over the first couple of days. Head CT showed a low-attenuation focus in the right frontal lobe periventricular white matter, likely consistent with an infarct of indeterminant age. To follow up on that focus, MRI was performed which showed there was no intracranial mass or shift of normally midline structures. The ventricles and basal cisterns were patent and symmetric. There was no evidence of acute ischemic on diffusion weighted images. There was, however, an area of chronic ischemia in the right frontal white matter, with adjacent increased T2 signal consistent with gliosis. There were multiple other small foci of small-vessel ischemic disease in the periventricular white matter and in the right cerebellum. The visualized osseous structures and extracranial soft tissues appeared unremarkable. General impression was no evidence of acute ischemia, but there were multiple chronic infarcts. Pt was somewhat improved by the time of his transfer to the floor and was back to baseline per family. 3. upper gastrointestinal bleed - on the night of [**11-11**], pt was noted to have melena about 400cc+ x2, with an associated Hct drop from 38.3 to 28.0. INR was 2.1 at that time, pt was hemodynamically stable. He was given protonix and was scoped the following morning after a tagged red cell scan showed an active bleed. Pt was intubated for the EGD. There was an ulcer noted in the second part of the duodenum with fresh red blood oozing from that area, as well as a protruding vessel in the area, possibly being a Dieulafoy's lesion. H pylori serology was negative. Hemostasis was achieved. Surgery consult was also called - recommended close followup, no intubation at that time, and aggressive resuscitation. Pt had been transfused with 8 units PRBCs prior to EGD and did not require any further transfusions afterwards. Pt was extubated on [**11-13**] and transferred to the floor on [**11-14**]. His Hct remained stable around 30 for the remainder of his hospitalization. Aspirin will be held for 2 weeks, coumadin for 4 weeks, and pt will take [**Hospital1 **] PPI for 2 months, then daily PPI, all per GI recs. Pt also does not need to be scoped again, per GI. 4. atrial fibrillation - The patient reported that he has chronic atrial fibrillation and has been on coumadin. He admitted, however, that he has not seen a cardiologist in 5 years. He also does not take coumadin regularly or follow up at coumadin clinic to check his INR. At admission, INR was subtherapeutic and he was restarted on coumadin to a therapeutic INR. After his UGI bleed, pt's coumadin was held, and will be held for one month before being restarted. 5. congestive heart failure - EF was <20% on recent echo. On transfer to the floor, pt was volume overloaded, likely due to aggressive fluid resuscitation in the context of his upper GI bleed. Pt was diuresed with lasix, to which he responded well. His exam improved over the next few days, in that his crackles resolved, neck veins became flat; however, he still had some lower extremity edema on the day of discharge. He was sent out on a daily po dose of lasix. 6. diabetes - Pt's glucose was checked 4x/day on the floor, and pt had RISS in place as well as standing NPH doses. As his glucose remained somewhat high, his home dose was increased with good glucose control. 7. aspiration risk - Pt was noted to be aspirating on a bedside speech and swallow evaluation, but pt refused further workup. Pt has history of a few pneumonias, which might be due to aspiration. However, pt declined further evaluation or treatment. 8. hyperbilirubinemia - Pt's total bilirubin a few days before discharge was 2.2, with a fractionation of direct 1.2 and indirect 1.0. As he had no abdominal pain, it was decided with consultation of the GI fellow that this could be worked up as an outpatient. Pt will follow up with a new PCP, [**Name10 (NameIs) 6643**] was arranged for him while in the hospital, for further workup. Repeat bilirubin showed it to be stable, and not trending up, on discharge. 9. physical limitations - pt with limited physical capabilities. PT/OT was consulted, and pt refused to work with them initially. Evaluation showed that pt was likely not safe to live at home alone. Family discussions ensued, and pt did not want to go to a rehabilitation facility. Family refused to take responsibility for him; pt's wife has dementia, pt's son-in-law is the primary point person. Ultimately, pt was sent home with [**Name (NI) 269**], PT, and home health services. Daughter also offered to stay with patient. 10. primary care - an appointment was made for pt to see Dr. [**Last Name (STitle) **], in geriatrics, who will be his new PCP. [**Name10 (NameIs) **] was made by attending. Medications on Admission: * Pentoxifylline 400 mg thrice daily * Warfarin 5 mg daily * Glyburide 5 mg daily * Carvedilol 6.25 mg daily * Digoxin 0.125 mg daily * aspirin 325 mg daily Discharge Medications: 1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Name10 (NameIs) **]:*90 Tablet(s)* Refills:*0* 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): You should decrease to once a day dosing in 2 months . [**Name10 (NameIs) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. [**Name10 (NameIs) **]:*30 Tablet(s)* Refills:*2* 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. [**Name10 (NameIs) **]:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. insulin Please continue to take NPH insulin 5 units at breakfast and 5 units at dinner. Continue to check your glucose 4 times a day, discuss your diabetes regimen with your new primary care doctor. 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: discuss your lasix dose with your primary care physician. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO BID:PRN: for constipation, hold for loose bowel movements or diarrhea. [**Name Initial (NameIs) **]:*60 Capsule(s)* Refills:*2* 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day: take as directed. Tablet Sustained Release(s) 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: 1)Upper gastrointestinal bleed 2)Duodenal Ulcer 3)Congestive Heart Failure (systolic) 4)Anemia Discharge Condition: Fair Discharge Instructions: Please contact your primary care physician or return to the hospital if you have bloody emesis, dark, tarry stools, abdominal pain, shortness of breath or fever, or other symptoms that are concerning to you. You should resume the medications that you were taking prior to admission, with the following exceptions: 1) Do not take your aspirin or coumadin for now: -You should resume your aspirin in 2 weeks -You should resume your coumadin in 1 month. -You should also avoid NSAIDs (Motrin, Ibuprofen,e tc.) given the risk of bleeding. 2) You will need to take Protonix (pantoprazole is the generic name) twice a day for 2 months, then just once a day. 3) lisinopril 1 tablet per day Followup Instructions: 1)Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3940**], MD Where: LM [**Hospital Unit Name 1640**] Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2179-11-23**] 11:30 Your bilirubin was high (2.2, fractionation pending) for unknown reasons. You may need to have further workup if it continues to be high. This should be discussed further with your new PCP. [**Name10 (NameIs) 357**] bring your finger stick glucose log to the visit and discuss your diabetes regimen. You should also have your digoxin level checked. You were started on an ACE inhibitor. You will need to have your potassium and renal function checked. Your potassium was low in the hospital, so you were given a small dose of potassium to use daily at home for the next few days. Your potassium will be checked by the [**Name10 (NameIs) 269**] on Friday.

[ "272.0", "532.40", "250.00", "443.9", "425.4", "428.0", "427.31", "287.3", "782.4", "V12.59", "403.91", "276.8", "V45.81", "280.0", "276.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "44.43" ]

icd9pcs

[ [ [] ] ]

12178, 12255

4703, 10427

255, 261

12394, 12400

3050, 4680

13136, 13996

2031, 2056

10634, 12155

12276, 12373

10453, 10611

12424, 13113

2071, 3031

188, 217

289, 1323

1345, 1850

1866, 2015

28,930

152,649

25337+57445

Discharge summary

report+addendum

Admission Date: [**2151-7-18**] [**Month/Day/Year **] Date: [**2151-7-26**] Date of Birth: [**2089-2-17**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Demerol / Bacitracin / Ciprofloxacin Attending:[**First Name3 (LF) 6346**] Chief Complaint: Hypotension, abdominal pain and distension Major Surgical or Invasive Procedure: Exploratory laparotomy, extensive lysis of adhesions, abdominal colectomy, end ileostomy, Hartmann's pouch creation, transgastric jejunostomy feeding tube placement [**2151-7-18**]. History of Present Illness: Mrs. [**Known lastname 63375**] is a 62-year-old female with a history of adrenal insufficiency who had a fall at home with hypotension in the emergency room at an outside hospital. She had an elevated white blood cell count. She was evaluated with multiple imaging studies that showed a dilated colon. She was found to be tender to abdominal exam. She was fluid avid. She was in acute renal failure. She was transferred for surgical evaluation. Given her tenderness, hypotension and pressor requirement, she was offered exploratory laparotomy to determine etiology. Consent was reviewed and signed with the understanding that she might require an ostomy. Past Medical History: PMH: adrenocortical insufficiency/congenital adrenal hyperplasia history of Addisonian crisis x several episodes neurogenic bladder Hashimoto thyroiditis/hypothyroidism insomnia depression glaucoma [**Doctor Last Name 15532**] esophagus restless leg syndrome hypertension [**Doctor Last Name **]-Leventhal syndrome gangrenous cholecystitis rectal prolapse PSH: tonsillectomy remotely appendectomy, LOA, ?ileocecectomy for cecal volvulus [**2099**] vaginoplasty [**2111**] ovarian wedge resection [**2115**] R carpal tunnel release TAH-RSO [**2134**] (NWH) R TKA [**2136**] L TKA [**2140**] RYE GB [**2143**] ([**Location (un) 40029**]) NWH sigmoidectomy/rectopexy [**1-/2149**] ([**Doctor Last Name 1120**]) lap CCY [**2141**] lap->open L adrenalectomy [**9-/2150**] ([**Hospital1 112**]) Social History: Lives with husband, non-[**Name2 (NI) 1818**], no alcohol use Family History: Mother deceased at 77 of diabetic complications. Father deceased at 77 of lung cancer and strokes. No other changes. Physical Exam: On Admission: . GEN: elderly female, NAD, no icterus, appears comfortable at rest HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD on my exam, +R periorbital hematoma, 3cm laceration below R eye repaired COR: RRR without m/g/r, no JVD, no bruits LUNGS: CTA bilat. ABDOMEN: hypoactive BS, distended, tender at LLQ, RLQ, focal percussion tenderness at LLQ, no palpable hernias or masses EXTREM: cool feet, no edema, palpable pulses . At [**Name2 (NI) **]: . VS: T: 98.2, HR: 87, BP: 138/82, RR: 16, SaO2: 99% RA GEN: Well-appearing, elderly female in NAD. HEENT: Sclerae anicteric. O-P moist, intact. NECK: Supple. No lymphadenopathy. No JVD. COR: RRR; nl S1/S2 w/o m/c/r. LUNGS: CTA(B). ABDOMEN: Incision with staples OTA c/d/i. GJ-Tube patent, intact. Site w/o erythema. Ostomy reddish pink, intact, patent with liquid brown output. Appliance intact. BSx4. Soft/NT/ND. EXTREM: No c/c/e. NEURO: A+Ox3. Non-focal/grossly intact. Pertinent Results: [**2151-7-18**] 05:16PM TYPE-ART PO2-244* PCO2-39 PH-7.36 TOTAL CO2-23 BASE XS--2 [**2151-7-18**] 05:16PM LACTATE-1.7 [**2151-7-18**] 05:16PM freeCa-1.06* [**2151-7-18**] 05:13PM GLUCOSE-136* UREA N-28* CREAT-1.1 SODIUM-137 POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-19* ANION GAP-15 [**2151-7-18**] 05:13PM CALCIUM-7.7* PHOSPHATE-4.0 MAGNESIUM-2.1 [**2151-7-18**] 05:13PM TSH-0.77 [**2151-7-18**] 05:13PM WBC-7.3 RBC-2.30* HGB-8.0* HCT-23.4* MCV-102* MCH-34.8* MCHC-34.2 RDW-12.3 [**2151-7-18**] 05:13PM PLT COUNT-250 [**2151-7-18**] 05:13PM PT-16.3* PTT-40.8* INR(PT)-1.4* [**2151-7-18**] 05:13PM FIBRINOGE-165 [**2151-7-18**] 03:00PM PT-19.4* PTT-52.0* INR(PT)-1.8* [**2151-7-18**] 11:30AM cTropnT-0.16* [**2151-7-18**] 11:30AM CK-MB-118* MB INDX-5.6 [**2151-7-18**] 11:30AM TOT PROT-5.5* ALBUMIN-3.6 GLOBULIN-1.9* CALCIUM-8.2* PHOSPHATE-4.3# MAGNESIUM-2.6 [**2151-7-18**] 11:30AM OSMOLAL-286 [**2151-7-18**] 11:30AM NEUTS-85* BANDS-8* LYMPHS-0 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2151-7-18**] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2151-7-18**] 11:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-TR [**2151-7-18**] 11:30AM URINE RBC-[**4-1**]* WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0-2 TRANS EPI-<1 [**2151-7-18**] 11:30AM URINE GRANULAR-[**4-1**]* HYALINE-0-2 . [**2151-7-18**] Pathology: SPECIMEN SUBMITTED: abdominal colon, fecalith. DIAGNOSIS: Abdominal colectomy: 1. Focal markedly dilated colon with extensive ischemic necrosis of mucosa and focal necrosis of muscularis propria. 2. Fecalith. Clinical: Acute abdomen. Gross: The specimen is received fresh in two parts, both labeled with the patient's name, "[**Known firstname **] [**Known lastname **]" and the medical record number. Part 1 is additionally labeled "abdominal colon." It consists of a total colectomy specimen measuring 126 cm in length and ranges in diameter from 12 cm to the smallest area and measures 7.0 cm. The area of greatest dilation occurs approximately 17 cm from the distal resection margin. A portion of mesentery is attached to the colon measuring 126 cm x 5.0 cm. The proximal resection margin is not stapled and measures 4.0 cm. The distal resection margin is stapled and measures 2.3 cm. The mesentery appears unremarkable. The serosa of the bowel is erythematous, black and slightly green in appearance. The specimen is opened along the antimesenteric surface to reveal a lumen that is filled with fecal material. The mucosa is diffusely erythematous with multiple large black areas present throughout the entire colon. Black areas range in size from 15 x 7 to 2 x 2 cm. No masses or polyps are identified. The bowel wall varies in thickness. The area which is the thinnest measures 0.2 cm. The thickest measures 0.8 cm. No diverticula are identified. An appendix is present. The appendix measures 7.5 cm x 2.5 cm. The serosa of the appendix is diffusely erythematous and green in appearance. The specimen is opened to reveal fecal filled lumen. The mucosa appears erythematous. The specimen is represented as follows; A = proximal resection margin, B = distal resection margin, C-D = representative sections of necrotic bowel, E-F = representative sections of appendix. Part 2 is additionally labeled "fecalith." It consists of a portion of firm brown to black stool weighing 48 grams and measuring 5.5 x 3.5 x 3.0 cm. The outer surface of the stool has blood. The outer surface of the stool has blood on the surface. The specimen is for gross examination only and has been seen by Dr. [**Last Name (STitle) 174**]. . Cardiology Report ECG Study Date of [**2151-7-18**] 11:44:24 AM Sinus rhythm. Normal tracing. Compared to the previous tracing of [**2150-6-2**] no diagnostic interim change. Intervals Axes: Rate PR QRS QT/QTc P QRS T 85 162 78 398/441 58 -11 71 Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment of infarcted colon. On [**2151-7-18**], the patient underwent exploratory laparotomy, extensive lysis of adhesions, abdominal colectomy, end ileostomy, Hartmann's pouch creation, transgastric jejunostomy feeding tube placement, which went well. After recovering from anesthesia in the PACU, the patient was initially transferred to the SICU, and then to the inpatient floor on POD3. Neuro: The patient received Dilaudid PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. Psychotropic medications were restarted as soon as able, and the patient remained psychologically stable during hospitalization. CV: The patient was given LR and albumin POD2 for low CVP and low SBP. Also, transfused a total of 4 units PRBC for abrupt drop in hematocrit, responding well without further issue (see below). 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 spirrometry were encouraged throughout hospitalization. GI/FEN: Post-operatively, the patient was made NPO with IV fluids. Trophic tube feeds were started via the J-Tube after the patient tolerated G-Tube clamping on [**2151-7-21**]. By [**Date Range **] date, the patient was tolerating full strength tubefeeds at 25mL/Hr. On [**2151-7-22**], the patient was started on a clear diet, which was advanced when appropriate to a regular diet, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Ostomy remained intact and patent. The Ostomy Nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for care instructions and patient education; recommendations were appreciated and followed. The patient will follow-up with the Ostomy Nurse [**First Name (Titles) **] [**Last Name (Titles) **] from the Rehabilitation Facility. GU: A foley catheter to gravity drainage was placed [**2151-7-18**] peri-operatively, and was retained at [**Month/Day/Year **] due to the patient's history of neurogenic bladder. Foley will be discontinued at the rehabilitation facility with voiding trial. ID: The patient was started on IV Zosyn and Vancomycin post-operatively. Blood and urien cultures taked during hospitalization revealed no growth. A standard MRSA screen upon SICU admission was negative. The patient's white blood count and fever curves were closely watched for signs of infection. The surgical incision and GJ-Tube insertion site remained clean, intact without infection during the hospital stay. Antibiotics were discontinued on the [**Month/Day/Year **] date. Endocrine: Peri-operatively and during initial hospitalization, the patient received stress dosing of steroids given history of adrenal insuffiency. Endocrinology was [**Month/Day/Year 4221**] regarding steroid taper; their recommmendations were appreciated and followed. At the time of [**Month/Day/Year **], prednisone was tapered to 10mg PO daily. The patient's blood sugar was monitored throughout his stay; sliding scale insulin dosing was adjusted accordingly. The patient did not require exogenous insulin at the time of [**Month/Day/Year **]. Hematology: While in the SICU, the patient received a total of 4 units PRBCs for progressively declining hematocrit with a low of 15.4. After transfer to the floor, the patient's hematocrit remained stable with a hematocrit at [**Month/Day/Year **] of 25.5. Prophylactic heparin was held until hematocrit stable, and the patient monitored closely. Prophylaxis: The patient received subcutaneous heparin as above and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible with Physical Therapy. At the time of [**Month/Day/Year **] on [**2151-7-26**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet as well as tubefeeds via the J-Tube, ambulating with assistance, had a foley catheter to gravity drainage in place due to neurogenic bladder, ostomy was patent and functioning, and pain was well controlled. The patient was discharged to a rehabiliation facility. The patient received [**Date Range **] teaching and follow-up instructions with understanding verbalized and agreement with the [**Date Range **] plan. Issues to be addressed at follow-up with Dr. [**First Name (STitle) 2819**] include: (1) discontinuing or cycling tubefeeds, (2) staple removal, (3) routine post-op follow-up. Medications on Admission: Prednisone 5mg po qd, fludricortisone 0.1mg qam, Sanctura 20mg po qam, levothyroxine 175mcg po qd, clonazepam 0.5mg po tid:prn anxiety, olanzapine 20mg po qhs,lumigan od qhs, pantoprazole 40mg po qam, pramipexole 4mg po qam, diclofenac 150mg po bid, quinapril 20mg po qam, HCTZ 25mg po qam, tramadol 50mg po qid prn pain, cyclobenzaprine 10mg po tid:prn, hydroxychloroquine 200mg [**Hospital1 **]. [**Hospital1 **] Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB/cough/wheeze. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB/cough/wheeze. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fevers. 4. Olanzapine 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for spasm. 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO QTUESDAY & SATURDAY (). 10. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 12. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold tubefeeds 1 hour before and 1 hour after administration. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for pain. 17. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): Hold for SBP<100, HR<60 . 18. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays each nostril Nasal once a day as needed for allergy symptoms. 20. Solu-Cortef 100 mg Recon Soln Sig: One Hundred (100) mg Injection injected once for adrenal crisis; then proceed to ER. 21. Sanctura 20 mg Tablet Sig: One (1) Tablet PO once a day. 22. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 23. Mirapex 1 mg Tablet Sig: Two (2) Tablet PO twice a day. 24. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO Qmonth on the 12th. 25. Bimatoprost 0.03 % Drops Sig: One (1) 1 drop (R) eye Ophthalmic at bedtime. 26. Quinapril 20 mg Tablet Sig: One (1) Tablet PO once a day. 27. Vagifem 25 mcg Tablet Sig: One (1) tab Vaginal 1-2x/ per week as needed for vaginal dryness. [**Hospital1 **] Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] [**Location (un) **] Diagnosis: Primary: 1. Infarcted colon. Secondary: 1. Adrenal Insufficiency 2. HTN 3. Neurogenic Bladder 4. Depression/Anxiety [**Location (un) **] Condition: Stable [**Location (un) **] Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a [**Location (un) **]. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-6**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody [**Month/Year (2) **], warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. 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 call ([**Telephone/Fax (1) 11816**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) **] (PCP) in 2 weeks. Please call [**First Name4 (NamePattern1) 18758**] [**Last Name (NamePattern1) **], [**Name8 (MD) 30637**], RN, CWOCN (Ostomy Nurse) [**Telephone/Fax (1) 63376**] once discharged from rehabilitation for outpatient follow-up. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2151-8-4**] 9:45. Location: [**Location (un) 620**] Office. Completed by:[**2151-7-26**] Name: [**Known lastname 11308**],[**Known firstname **] Unit No: [**Numeric Identifier 11309**] Admission Date: [**2151-7-18**] Discharge Date: [**2151-7-26**] Date of Birth: [**2089-2-17**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Demerol / Bacitracin / Ciprofloxacin Attending:[**First Name3 (LF) 2674**] Addendum: Please note changes to discharge medications: Prednisone taper: 10mg daily x 10days 7.5mg daily x 10 days 5mg daily ongoing Fludricortisone 0.1mg QAM Discharge Disposition: Extended Care Facility: [**Location (un) 176**] Of [**Location (un) 407**] [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 2675**] MD [**MD Number(1) 2676**] Completed by:[**2151-7-26**]

[ "584.9", "V45.86", "401.9", "596.54", "333.94", "300.4", "557.0", "560.39", "V58.65", "568.0", "244.9" ]

icd9cm

[ [ [] ] ]

[ "44.39", "54.59", "45.82", "96.6", "46.23" ]

icd9pcs

[ [ [] ] ]

19683, 19920

7337, 12112

374, 557

3363, 7314

18530, 19530

2268, 2386

19554, 19660

12138, 12538

16853, 18507

2401, 2401

15177, 15296

292, 336

15328, 15337

15068, 15145

12568, 15038

15372, 16837

585, 1243

2415, 3344

1265, 2172

2188, 2252

5,381

161,703

26099

Discharge summary

report

Admission Date: [**2169-12-19**] Discharge Date: [**2170-1-30**] Date of Birth: [**2101-7-26**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Confusion, history of fall Major Surgical or Invasive Procedure: Right-sided craniotomy for evacuation of hematoma, adhesiolysis, duraplasty. Percutaneous endoscopic gastric tube placement History of Present Illness: Pt is a confused 68y/o F with a history of having fallen down the stairs at around 10pm on [**12-18**]. She appearently landed on the floor of her kitchen and may have remained there all night. Alternatively, she may have fallen when she got out of bed in the am [**12-19**] and crawled/fell down the stairs to the kitchen looking for help. When she was found on the floor on the morning of [**12-19**] EMS was called and they brought her to [**Location (un) 620**] ED. In the ED she was noted to have a large SDH and was transferred to [**Hospital1 18**] for further evaluation. Pt's PCP notes that in the past 9 months he has noticed a marked decline in her mental status which he characterizes as "in the last nine months she's aged 20 years." PCP also notes that her husband has had a similar decline over the same timecourse. Patient was transferred to the [**Hospital1 18**] for further evaluation and treatment. Past Medical History: Atrial fibrillation, Hypertension for over 30 yrs, Bilateral osteoarthritis of the knees, History of childhood measles. Social History: Retired school teacher of home economics Lives with husband Family History: Unknown Physical Exam: PE T96.9 HR110s BP 130/91 RR 29 saO2 98%on RA Gen: elderly lady with multiple psoriatic like lesions on her face and arms in NAD HEENT: PERRL, EOMI, anicteric, no racoon eyes, or battle sign, TMs clear b/l Pulm:LCTA b/l CV:irregluarly irregular NEURO: AAOX3, gives inconsistent answers to most questions, is unable to follow complex commands. Folstien 22/30, GCS 14, CN2-12 grossly intact, although pt gave inconsistant results in visualfield testing. Cerebellar: Impaired finger to nose b/l slightly worse on L side, with missed finger on R and past pushing on R. [**Doctor First Name **] impaired on Left (pt barely moves this hand) MOTOR: Grip WE WF [**Hospital1 **] Tri psoas [**Last Name (un) 938**] TA gastroc R 5 5 5 5 5 5 5 5 5 L 4 4 4 5 4 4 5 5 4 Reflexes [**Hospital1 **] BR patellar R 3 2 2 L 3 1 3 Sensation: subjectively dimished on the RLE to light touch in the L4 dermatome. Pertinent Results: [**2169-12-19**] 09:17PM O2 SAT-98 CARBOXYHB-1.0 MET HGB-0.6 [**2169-12-19**] 09:17PM freeCa-0.92* [**2169-12-19**] 03:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017 [**2169-12-19**] 03:45PM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2169-12-19**] 03:45PM URINE RBC-[**11-19**]* WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2169-12-28**] 04:17AM BLOOD WBC-13.4*# RBC-4.03* Hgb-12.4 Hct-36.9 MCV-92 MCH-30.7 MCHC-33.6 RDW-13.5 Plt Ct-424 [**2169-12-27**] 05:45AM BLOOD WBC-8.5 RBC-3.76* Hgb-11.1* Hct-33.7* MCV-90 MCH-29.5 MCHC-32.9 RDW-13.5 Plt Ct-294 [**2169-12-28**] 04:17AM BLOOD Neuts-81.1* Lymphs-11.7* Monos-4.9 Eos-1.5 Baso-0.9 [**2169-12-28**] 04:17AM BLOOD Plt Ct-424 [**2169-12-28**] 04:17AM BLOOD Glucose-104 UreaN-22* Creat-0.9 Na-139 K-5.0 Cl-107 HCO3-17* AnGap-20 [**2169-12-28**] 04:17AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.5* Mg-1.6 [**2169-12-19**] 03:15PM BLOOD VitB12-359 Folate-7.2 [**2169-12-19**] 03:15PM BLOOD TSH-1.2 [**2169-12-27**] 05:45AM BLOOD Digoxin-0.9 [**2169-12-28**] 04:17AM BLOOD Phenyto-6.3* [**2169-12-26**] 02:44PM CEREBROSPINAL FLUID (CSF) WBC-18 RBC-3420* Polys-44 Lymphs-51 Monos-4 Eos-1 [**2169-12-26**] 02:44PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-1551* Polys-44 Bands-1 Lymphs-46 Monos-8 NRBC-1 [**2169-12-26**] 02:44PM CEREBROSPINAL FLUID (CSF) TotProt-44 Glucose-67 RADIOLOGY IMAGING CT HEAD WITHOUT IV CONTRAST:[**2169-12-19**] Large right frontoparietal subdural hematoma. This likely represents a subacute/chronic hematoma with recent re-hemorrhage. There is associated mass effect, compression of the right lateral ventricle, and slight leftward subfalcine herniation.Small left frontal convexity chronic subdural fluid collection.No other foci of hemorrhage are identified. HEAD CT WITHOUT IV CONTRAST: [**2169-12-25**] Reason: seizure post craniotomy - is there a bleed? No significant interval change in the appearance of the right subdural hemorrhage with pneumocephalus. No new intracranial hemorrhage identified. [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2169-12-27**] Reason: r/o DVT [**Hospital 93**] MEDICAL CONDITION: 68 year old woman with low grade temp - prolonged Bedrest and Increase HR REASON FOR THIS EXAMINATION: r/o DVT INDICATION: History of low-grade temperature and prolonged bed rest and increased heart rate. Evaluate for DVT. BILATERAL LOWER EXTREMITY ULTRASOUNDS: Grayscale and color Doppler son[**Name (NI) 867**] was performed of the right and left common femoral, superficial femoral, popliteal veins. Normal compressibility, waveforms, augmentation, and flow demonstrated. No intraluminal thrombus is identified. IMPRESSION: No DVT is identified. Brief Hospital Course: Patient was transferred to the [**Hospital1 18**] from outside hospital. She was intubated in emergency department for cognitive decline and was transferred to the ICU in preparation for surgical decompression. She underwent a right-sided craniotomy for evacuation of hematoma, adhesiolysis, duraplasty (for further details please see dictated operative report dated [**2169-12-20**]). Post-operative management included dilantin and decadron, strict blood pressure control, blood sugar control, and hyperventilation. Vent was progressively weaned and patient was extubated on post-operative day 2 without sequele. As patient remained stable, she was transferred to the neurosurgery step-down unit on [**2169-12-24**]. The following day, patient developed a seizure (as described by RN) which lasted 1-2 minutes and had resolved by the time house officer arrived to examine the patient. Neuro exam was essentially unchanged after the described seizure and she remained hemodynamically stable with good oxygen saturation. She was administered ativan and transferred to the ICU for further observation. Dilantin dosing was increased per neurology recommendations. Patient's neurologic status improved and she continued to be without seizure activity. She was subsequently transferred to the step-down unit and continued to be free of seizures. Since patient was unable to successfuly pass a Speech and Swallow challenge, a percutaneous endoscopic gastric tube was placed on [**2169-12-27**] for nutritional support. Syncope work-up was also initiated. Post-operatively patient experienced tachycardia with heart rates reaching 140's. Cardiology service was consulted and patient was started on lopressor and digoxin. TEE was obtained and showed a left atrium that is mildly dilated, a moderately dilated right atrium, severe global left ventricular hypokinesis to akinesis with some preservation of basal inferior and basal lateral wall motion and a severely depressed left venttricular function, severe global. Mild to moderate ([**1-1**]+) mitral regurgitation is seen. On admission patient was found to have a urinary tract infection that was treated with levaquin. Patient failed speech and swallow evaluation and a percutaneous endoscopic gastric tube was placed on [**2169-12-28**] for nutritional support. On [**2170-1-3**] patient passed video swallow and was placed on a regular diet with no restrictions. Poor PO intake so tube feeds were continued cycled at night until pt pulled out her gtube on [**2170-1-20**]. PO intake alone has been encouraged since that time with supplements. On [**1-5**] cspine flex/ex films done. Cspine cleared clinically and collar was removed. Her digoxin level has been followed and dosages changed to maintain therapuetic levels. Her neuro exam has improved since admission/surgery but she remains confused and oriented to person only. She is agaitated at times. She walks independently in the halls. Her incision is well healed. Post operative CT scans have been stable. Medications on Admission: Per PCP: [**Name10 (NameIs) **], [**Name11 (NameIs) 64754**], nadolol, EC aspirin, lipitor Discharge Disposition: Extended Care Facility: [**Hospital 64755**] Rehab Discharge Diagnosis: Right craniotomy for right subdural hemorrhage Afib tachycardia UTI Discharge Condition: Good Discharge Instructions: Please call office or return to the emergency room for any change in mental status. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] and CT in 8 weeks, call [**Telephone/Fax (1) 2992**] for appt. Completed by:[**2170-1-30**]

[ "293.0", "272.4", "342.90", "715.36", "852.20", "780.39", "787.2", "428.0", "784.3", "294.8", "599.0", "696.1", "428.20", "401.9", "427.31", "311", "E880.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "01.39", "96.6", "96.71", "43.11", "99.06", "99.05", "03.31", "02.12", "99.07", "96.04", "02.91" ]

icd9pcs

[ [ [] ] ]

8619, 8672

5449, 8478

347, 474

8783, 8789

2682, 4837

8921, 9060

1659, 1668

4874, 4948

8693, 8762

8504, 8596

8813, 8898

1683, 2663

281, 309

4977, 5426

502, 1423

1445, 1566

1582, 1643

81,865

158,276

36908

Discharge summary

report

Admission Date: [**2193-6-8**] Discharge Date: [**2193-6-13**] Date of Birth: [**2145-4-30**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 898**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Femoral line placement; removed at discharge. History of Present Illness: Mr. [**Known lastname 69335**] is a 48 yo man with a history of mental retardation, DVT on coumadin, seizure disorder, and recent admission to [**Hospital1 18**] in [**5-7**] for seizure thought [**12-31**] bacterial meningitis, s/p completion of abx course at Rehab and discharged back to group home in early [**6-6**]. Seen by PCP for [**Name Initial (PRE) **]/u visit today and noted to have fever to 101.3 F and b/l upper extremity rash. He was referred to the [**Hospital3 **] ED where labs were notable for WBC of 8.2 with 58% neutrophils and 30% bands, Cr 1.9, mild transaminitis, and a mildly dirty U/A. Influenza A & B negative and CXR nl. His CT head was concerning for a small left inferior basal ganglia hypodensity. LP was unable to be done due to INR 2.4. Pt was transferred here for further Neuro evaluation. Prior to transfer, he developed hypotension to 66/38 with tachycardia and was thought to be septic. Cultures were drawn. Two EJs were placed, and he was given tylenol, decadron, 1.35 L NS and started on a dopamine gtt at 5 cc/h. He was also started on vancomycin and ceftriaxone as well as received a dose of dilantin. . In our ED, admit vitals: T 98.2, HR 103, BP 98/60, RR 18, O2sat 98. Pt interactive, neuro exam intact on ED and Neuro eval. Labs notable for WBC 9 with 94.3 neutrophils but no bands, Na 130, bicarb 14, Cr 1.5. U/A appeared dirty. CXR negative. OSH CT head reviewed by radiology and hypodensity thought to be small old lacunar infarct or a Virchow-[**Doctor First Name **] space. Neuro thought infarct unlikely, and silent if present. Recommended LP when INR reversed with broad abx coverage for meningitis in interim. Pt given ampicillin 2g IV, as well as vitamin K 10mg IV, and tylenol 1000mg. A right femoral line was placed with dosed prior given persistently low SBP despite 5 liters IV fluids, and dopamine was uptitrated to 15 cc/h. Pt also given one unit of FFP in anticipation of LP. On transfer, T 99.5, HR 102, BP 94/31, RR 23, O2sat 98%RA. . In the ICU, pt repeatedly saying "I'm a good boy." Reports feeling cold; otherwise without complaints. Denies dysuria or respiratory sx. Per mother, pt never complains about pain. . Review of sytems: (+) Per HPI (-) Denies fever. Denies headache, cough, shortness of breath. Denies chest pain or abdominal pain. Denies nausea. No dysuria. Denies arthralgias or myalgias. Denies pruritis. Past Medical History: -Seizure Disorder (last seizure [**12-6**]) -Deep Vein Thromboses *2 without history of pulmonary embolism -Lower extremity cellulitis (started on TMP-Sulfa [**Date range (1) 83313**]) -Mental Retardation -Obsessive Compulsive Disorder -Hypothyroidism -Urosepsis with hospitalization at [**Hospital3 **] in [**2191**]. Social History: He lives at a group home. No known smoking, alcohol, drugs. Family History: Non-contributory Physical Exam: Vitals: Afebrile, BP 140/85, P 90, R 16, O2 99% RA General: Alert, oriented to person and hospital, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, chronic venous changes over lower extremities with 1+ pitting pedal edema, 2+ pulses Skin: Fine, macular rash over distal upper extremities b/l, not affecting palms or soles; much improved from admission Neuro: AAO x 2, CN II-XII grossly intact, strength 5/5 when cooperative, sensation intact to light touch, DTR symmetric, toes downgoing on Babinski, gait not assessed. Pertinent Results: [**2193-6-13**] 08:39AM BLOOD WBC-5.0 RBC-3.59* Hgb-10.8* Hct-31.9* MCV-89 MCH-30.1 MCHC-34.0 RDW-13.7 Plt Ct-230 [**2193-6-13**] 08:39AM BLOOD PT-12.6 PTT-23.0 INR(PT)-1.1 [**2193-6-13**] 08:39AM BLOOD Glucose-110* UreaN-12 Creat-1.0 Na-142 K-3.8 Cl-105 HCO3-26 AnGap-15 [**2193-6-9**] 04:16AM BLOOD ALT-38 AST-27 AlkPhos-78 TotBili-0.2 [**2193-6-13**] 08:39AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.6 [**2193-6-8**]: Urine culture negative [**2193-6-13**]: Blood cultures negative to date . [**2193-6-7**] CXR: Prominent bilateral hila, unchanged with several radiographs. This may be due to bronchovascular crowding although underlying infection cannot be excluded. Dedicated PA and lateral may be obtained if clinically feasible or necessary. . [**2193-6-7**] OSH CT head: No acute intracranial process. Small focal hypodense area in the left basal ganglia, could be old small lacunar infarct, or Virchow-[**Doctor First Name **] space. Brief Hospital Course: 48 yo man with h/o mental retardation, seizure disorder, DVT on coumadin, and recent meningitis who presents with fever, rash, relative leukocytosis, and hypotension. . Hypotension/Sepsis: Presented with fever, rash, and relative leukocytosis ([**Doctor First Name 5348**] WBC [**1-31**]) with subsequent hypotension requiring pressors. Initially started on vanc, ceftriaxone, and ampicillin due to to concern for meningitis but thought less likely given [**Month/Day (1) 5348**] mental status, absence of nuchal rigidity, and no evidence of seizure activity. Pulmonary source unlikely given absence of respiratory symptoms and unremarkable CXR; influenza negative at OSH. Most likely sepsis [**12-31**] UTI given dirty U/A at OSH and here despite negative urine cultures at both OSH and here. All blood cultures NGTD. Given resolution of fevers on [**6-8**], hemodynamic stability off pressors, and negative micro data, antibiotics narrowed to PO cipro for planned 10-day course. Of note, anaphylactic shock was a concern at last hospitalization but med list without any recent medication changes and eos not elevated on diff. No findings to suggest cardiogenic shock. On floor he was afebrile and completed 7 days of cipro with prescription to complete 10day course. . Rash: Fine macular rash over b/l arms and thighs of unclear etiology. Rash improved over course of hospital course. . Acute renal failure: Cr 1.9 on presentation to OSH with [**Month/Year (2) 5348**] Cr 0.5. Medications were renally dosed and pt's Cr at discharge was 1.0. He was discharged on lovenox as his renal function had improved from admission. . H/o multiple DVTs: On coumadin with supratherapeutic INR on presentation. Coumadin held initially given possibility of LP and INR reversed for possible LP which was not performed. He was restarted on lovenox to bridge to Coumadin. At discharge, pt's INR was 1.1. He was given prescription for lovenox and coumadin. The outreach group set up through his PCP will draw his INR. VNA will come to administer lovenox daily. Group home has been notified that ativan prior to lovenox injections is helpful to prevent needle stick to VNA as pt is very scared of needles. . Hypertension: Home antihypertensives held initially in setting of shock. Given stabilization of BP of pressors, restarted gradually on beta blocker. Pt's SBP was stable on the floor in 140s-160s so BP meds were increased. Pt was discharged on atenolol dose of 37.5mg PO daily and his home clonidine dose. . OCD: Continued home sertraline 250mg, buspirone 30mg [**Hospital1 **], and risperidone 0.5mg [**Hospital1 **], as well as lorazepam 0.5-1mg po q4h prn anxiety. . Seizure disorder: Continued home phenytoin. Pt had no seizures in ICU or on floor. . Hypothyroidism: Continued home levothyroxine 250 mcg po daily . GERD: Continued home famotidine 20mg daily . Anemia: Stable at [**Hospital1 5348**]. . FEN: No IVF, replete electrolytes, regular diet . Prophylaxis: Pneumoboots, lovenox while bridging to coumadin . Code: Full (discussed with mother). . Communication: Patient. Mother ([**Telephone/Fax (1) 83314**]). Medications on Admission: Atenolol 25 mg po daily Neurontin 600 mg po tid Risperidone 0.5 mg po bid Lorazepam 0.5 mg 1-2 tabs po q4h prn anxiety Phenytoin 300 mg po bid Levothyroxine 250 mcg po daily Buspirone 30 mg po bid Famotidine 20mg po daily Sertraline 250 mg po daily Clonidine 0.1 mg po bid Acetaminophen 325 mg 1-2 tabs po q6h prn Docusate Sodium 100 mg po bid Bisacodyl 10 mg po prn constipation Senna 8.6 mg 1-2 tabs po bid prn constipation Warfarin 2 mg po qhs Discharge Medications: 1. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 2 weeks. Disp:*14 syringes* Refills:*0* 2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety: Please give 30 minutes prior to lovenox injections. Thank you. Disp:*30 Tablet(s)* Refills:*0* 3. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Phenytoin 125 mg/5 mL Suspension Sig: Three Hundred (300) mg PO twice a day. 5. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*45 Tablet(s)* Refills:*2* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 7. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day for 5 days: PLEASE HAVE INR CHECKED on MONDAY [**2193-6-17**] AND HAVE YOUR COUMADIN DOSE ADJUSTED ACCORDINGLY. RESPONSIBILITY FOR YOUR COUMADIN DOSING AND PRESCRIPTION WILL BE RESUMED BY YOUR PCP AND RN [**Name9 (PRE) **] AT THIS TIME. Disp:*10 Tablet(s)* Refills:*0* 8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Sertraline 100 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipatin. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Outpatient Lab Work Please have your INR checked within 3-4 days of discharge and every 3 days thereafter until your INR is therapeutic. (INR Range 2-3). Dates: Draw #1: Monday [**2193-6-17**] or Tuesday [**2193-6-18**] Draw #2: Thursday [**2193-6-20**] Draw #3: Friday [**2193-6-21**] or Monday [**2193-6-24**] Further Draws as directed by your primary care physician Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1. Hypotension/sepsis 2. DVTs 3. HTN 4. Acute renal failure Discharge Condition: Stable, SBP stable between 140-160, Afebrile, MS [**First Name (Titles) **] [**Last Name (Titles) 5348**] Discharge Instructions: You were admitted to the hospital because on [**2193-6-8**], you were seen by PCP and were noted to have fever to 101.3 F and a rash. You were taken to the [**Hospital3 **] ED where your labs were abnormal. You were transferred to [**Hospital3 **] for further evaluation. Prior to transfer, you developed hypotension to 66/38 with tachycardia and was thought to have a severe infection. You were started on antibiotics and your seizure medication. . In [**Hospital1 18**] ED: Your neurological exam was normal. You received fluids and a number of studies were done. . In the ICU, you did not have fevers and your blood pressure was stabilized. You were started on antibiotics and eventually treated for a urinary tract infection with ciprofloxacin. Your rash improved. You had developed kidney failure because of your low blood pressure and that resolved. We thought you might need a lumbar puncture to look for infection so your coagulation studies (INR) were reversed. Once your renal function returned to normal, you were started on lovenox to be bridged to coumadin to increase your INR again to a goal of [**1-1**]. We restarted you on your home blood pressure medications, but your blood pressure was high in the hospital so we increased your blood pressure metoprolol. . You were having some mouth pain, but we could not get a dental film in the hospital. Your doctors/dentist will follow up on this as an outpatient. Followup Instructions: Appointment #1 MD: DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Specialty: PRIMARY CARE Date and time: [**2193-6-24**] @ 7:30pm Location: 99 LONGWATER CIR [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier **] Phone number: [**Telephone/Fax (1) 18509**] . Appointment #2 MD: DR [**First Name (STitle) 161**] DAS Specialty: UROLOGY Date and time: [**2193-7-31**] @ 3:30pm Location: [**Hospital Ward Name **] CLINICAL CENTER [**Location (un) **] Phone number: [**Telephone/Fax (1) 921**] Special instructions if applicable: suppressive therapy to prevent urinary tract infections Please follow up with your dentist regarding getting panoramax films in the next 1-2 weeks.

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icd9cm

[ [ [] ] ]

[ "99.10", "38.93" ]

icd9pcs

[ [ [] ] ]

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1130

Discharge summary

report

Admission Date: [**2150-12-11**] Discharge Date: [**2150-12-16**] Date of Birth: [**2073-5-13**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old gentleman with a past medical history of ventricular peritoneal shunt placement in [**2150-9-28**] for normal pressure hydrocephalus. The patient had a 6-week course of rehabilitation and was doing well. He was recently having complaints of headaches. He had a routine follow-up appointment and head computed tomography which showed bilateral subdural hygromas with a subacute component on the left frontal area . The patient had a median pressure valve placed at the time of shunt placement. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. Hypercholesterolemia. 3. Right hip fracture. 4. Dementia. 5. Shunt placement. 6. Left leg cellulitis. 7. Renal insufficiency. MEDICATIONS ON ADMISSION: 1. Protonix. 2. Neurontin. 3. Sertraline. 4. Allopurinol. 5. Trazodone. 6. Lente insulin. 7. Lopressor. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient was awake, alerted to [**Hospital1 346**]. Speech was fluent. Naming was intact. The patient was following commands bilaterally. Pupils were equal, round, and reactive to light. Extraocular movements were full. Visual fields were full. He had a right facial droop which was baseline. Sensation was grossly intact. The tongue was midline. Strength examination revealed a bilateral pronator drift. Strength was [**6-1**] in all muscle groups. His toes were upgoing bilaterally. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Neurosurgery Service. He had ligation of his ventricular peritoneal shunt in the Surgical Intensive Care Unit. He tolerated the procedure well. He had a repeat head computed tomography on [**2150-12-12**] which showed a slight increase in the ventricles. His neurologic status remained stable, and he was transferred to the regular floor. On [**2150-12-15**] the patient again had a repeat head computed tomography which showed a stable appearance of the ventricles and the bilateral subdural hygromas. DISCHARGE DISPOSITION: The patient was transferred to rehabilitation with followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one month for a repeat head computed tomography for possible ventricular peritoneal shunt revision. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. MEDICATIONS ON DISCHARGE: (Medications on discharge included) 1. Lisinopril 10 mg by mouth once per day. 2. Toprol-XL 100 mg by mouth once per day. 3. Allopurinol 300 mg by mouth once per day. 4. Sertraline 50 mg by mouth once per day. 5. Terazosin 28 mg by mouth at hour of sleep. 6. Colace 100 mg by mouth twice per day. 7. Neurontin 600 mg by mouth twice per day. 8. Pantoprazole 40 mg by mouth q.24h. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up in one month for a repeat head computed tomography with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2150-12-15**] 15:15 T: [**2150-12-15**] 15:44 JOB#: [**Job Number 7246**]

[ "290.0", "593.9", "272.0", "432.1", "250.00", "V45.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2178, 2427

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899, 1583

2941, 3390

1612, 2154

2442, 2492

158, 685

707, 873

78,303

142,303

44336

Discharge summary

report

Admission Date: [**2173-2-14**] Discharge Date: [**2173-2-17**] Date of Birth: [**2086-6-12**] Sex: F Service: MEDICINE Allergies: Calcium Chloride / Augmentin / Unasyn Attending:[**First Name3 (LF) 2071**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: [**2173-2-15**]: Dual chamber PPM History of Present Illness: Ms. [**Known lastname 95055**] is an 86-year-old woman with history of coronary artery disease, peripheral vascular disease, hypothyroidism, hypertension, and high cholesterol who complains of syncope. . Pt with multiple syncopal events in last couple weeks. Noted to syncopize today while at grocery store with daughter. [**Name (NI) **] backwards and hit her head. bleeding and swelling of posterior head. Boarded and collared by EMS. The patient says that she lost conciousness very quickly, and does not remember falling. No chest pain or palpitations. She was not hypoglycemic. She has had intermitent lightheadedness and dizzyness over past month, and was seen recently by neurology, with a fairly unremarkable MRI. She does endorse several episodes of "fainting" this month where she gets a prodrome of "painful face squeezing" but that did not occur prior to this episode. She denied any bowel or bladder incontinence. In the [**Last Name (LF) **], [**First Name3 (LF) **] report she had sinus brady into the 40s, and felt lightheaded as such. She did not recieve any atropine. . In the ED, initial vitals were 97.2 70 137/62 16 100% RA. . Labs were notable for a stat lactate 2.1, Cr 1.4, and HCT 32.6. A CT of her head was perfomred, which showed no acute intracranial hemorrhage or fractures. Mild increase (since [**2166**]) in the left parietal meningioma, now [**Last Name (un) **] 2.2 cm , without significant mass effect. left parietal scalp hematoma. . Of note, the patient recently was discharged from [**Hospital1 18**] after a Right PT angioplasty . She also had a CT C-spine, which showed no acute C-spine fractures, but multilevel severe DJD. . A pelvis XR showed a high riding humeral head may be due to rotator disease, no acute fracture. . A L elbow film read was still pending, but by my read showed no acute fracture. . Vitals on transfer were 53, 139/74, 16, 97.8, 98 ra. . REVIEW OF SYSTEMS + for prior history fo DVT, and positive for peripheral vascular disease On review of systems, she denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle palpitations, syncope or presyncope. She does endorse intermittent lower extremity edema that is most notable when she has not urinated. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER MEDICAL ISSUES -Chronic diarrhea -Anxiety -Fibroids of the uterus -Coronary artery disease -Kidney stones -Back pain -Cervical myelopathy -S/p cholecystectomy -Meningioma Social History: Widowed, lives alone in subsidized housing, independent in all ADL's. Children live in [**Location (un) 86**] area. No tobacco. Minimal EtOH. Enjoys [**Location (un) 1131**] and learned English by [**Location (un) 1131**]. Has VNA at home. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission: VS: T 97.3 BP 166/73 HR 74 RR 22 100% RA GENERAL: elderly female in NAD. Oriented x3. HEENT: posterior eccymoses on the scale, TTP. Sclera anicteric. Dry MM. NECK: Supple without JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. 1/6 SEM, no S3 or S4 LUNGS: CTAB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Right heel ulcer is clean and dry, no surroudning erythema. Pulses: Warm extremities, difficult to palpate pulses manually On Discharge: VS: 98, 122/64, 80, 18, 100% on RA; [**2161**] in/1200 out GENERAL: Elderly female in NAD. Oriented x3. HEENT: posterior eccymoses on the scalp, mildly TTP. Sclera anicteric. Dry MM. NECK: Supple without JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. [**1-22**] soft systolic murmur best heard at RUSB, no S3 or S4, pacer insertion site clean, no ecchymoses or hematoma LUNGS: CTAB, good air movement ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Right heel ulcer is clean and dry, no surroudning erythema. Pulses: Warm extremities, good pulses Pertinent Results: Admission: [**2173-2-13**] 08:10PM BLOOD WBC-6.0 RBC-3.38* Hgb-11.1* Hct-32.6* MCV-96 MCH-32.7* MCHC-34.0 RDW-14.3 Plt Ct-159 [**2173-2-13**] 08:10PM BLOOD Neuts-63.1 Lymphs-27.8 Monos-4.0 Eos-4.1* Baso-0.9 [**2173-2-13**] 08:10PM BLOOD Glucose-102* UreaN-25* Creat-1.4* Na-140 K-6.1* Cl-107 HCO3-26 AnGap-13 [**2173-2-13**] 08:10PM BLOOD Calcium-10.1 Phos-4.1 Mg-1.9 [**2173-2-13**] 08:36PM BLOOD Glucose-99 Lactate-2.1* Na-143 K-4.8 Cl-107 Discharge: [**2173-2-17**] 07:10AM BLOOD WBC-5.2 RBC-3.03* Hgb-9.9* Hct-29.7* MCV-98 MCH-32.7* MCHC-33.3 RDW-14.1 Plt Ct-131* [**2173-2-17**] 07:10AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.7 Cardiac Enzymes: [**2173-2-13**] 08:10PM BLOOD CK(CPK)-160 CK-MB-4 cTropnT-<0.01 [**2173-2-14**] 02:00AM BLOOD CK-MB-3 cTropnT-<0.01 Portable AP CXR & PELVIS XR ([**2173-2-13**]) -CHEST: Supine portable view of the chest was obtained. The right costophrenic angle is not fully included on the image. Given this, no focal consolidation, large pleural effusion, or evidence of pneumothorax is seen. Cardiac and mediastinal silhouettes are stable and unremarkable. Degenerative changes are seen at the left shoulder joint with the humeral head appearing high-riding. -PELVIS: Supine AP portable view of the pelvis was obtained. The osseous structures are underpenetrated presumably due to patient's overlying soft tissue. There is popcorn type calcification in the pelvis most consistent with calcified fibroids. Grossly, no acute fracture or dislocation is seen. The pubic symphysis and sacroiliac joints are intact. Degenerative changes are likely present in the visualized lower lumbar spine. Bilateral iliac [**Doctor First Name 362**] and greater trochanter enthesopathy is seen. Vascular calcifications are seen. -IMPRESSION: 1. No acute intrathoracic process. High riding humeral head may be due to rotator cuff disease, although not optimally evaluated on this study. 2. Suboptimal pelvic radiograph due to underpenetration due to patient's overlying soft tissue. Given this, grossly no acute fracture is seen. However, if clinical concern is high, consider additional imaging. CT C-SPINE W/O CONTRAST ([**2173-2-13**]) No acute cervical spine fracture. Multi-level moderate to severe degenerative changes of the cervical spine. CT HEAD W/O CONTRAST ([**2173-2-13**]) 1. No acute intracranial hemorrhage or fractures. 2. Small left parietal scalp hematoma. 3. Mild interval increase in a partially calcified left parietal meningioma since [**2166**]. ELBOW (AP, LAT & OBLIQUE - [**2173-2-13**]) No acute fracture or dislocation is seen in the left elbow. There is no joint effusion. Minimal degenerative changes with spurring is seen at the articular margins of the ulna and distal humerus. Soft tissue are not adequately assessed in this study. An IV access tubing overlies the left elbow. PORTABLE CHEST ([**2173-2-14**]) Normal heart, lungs, hila, mediastinum and pleural surfaces. TTE : ([**2173-2-15**]) The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. No structural cardiac cause of syncope identified. CHEST: ([**2173-2-16**]) CHEST RADIOGRAPH TECHNIQUE: Single portable upright chest view was reviewed in comparison with prior chest radiograph from [**2173-2-14**]. FINDINGS: Patient received a new left pectoral pacemaker with each lead terminating into the right atrium and right ventricle respectively. There is no pneumothorax. Both lungs are clear. There are no lung opacities of concern. There is no pleural abnormality. Heart size, mediastinal and hilar contours are normal. Brief Hospital Course: 86F w/ CAD, PVD, HTN, HLD, hypothyroidism who presented with syncope, found to have SSS now s/p dual chamber St. [**Male First Name (un) 923**] pacemaker on [**2173-2-15**]. . . # Syncope s/p pacemaker: Pt had syncopal episode. Found to have SSS with multiple [**5-23**] sec pauses on telemetry. Dual chamber PPM placed. Pt subsequently had two episodes of vasodepressor episodes yesterday while using bathroom. Reverse hysteresis was turned on. The pacer was functioning well with A sensing and V sensing in the 60s-70s with A pacing and V pacing at 60bpm on discharge. The patient was continued on metoprolol after PPM placement. Orthostatics were negative. Echo demonstrated no structural abnormalities to account for syncope. . # PVD: Pt remained on Clopidogrel 75 mg daily and aspirin 325 mg daily for peripheral vascular disease s/p R PT angioplasty. . # Hypertension: - Continue HCTZ . # Dyslipidemia: - Continue simvastatin . # AOCKI: - Patient's Cr at baseline after IVF. . # Hypothyroidism: - Levothyroxine. . # Anemia: - Stable . # Left parietal scalp hematoma/lac: - Stable, CT head was negative . # Diabetes: - Held home meds and placed on ISS in-house. . CODE: Confirmed FULL EMERGENCY CONTACT: Daughter [**Name2 (NI) **] [**Telephone/Fax (1) 95056**] . Transitional: 1) F/u with [**Hospital **] clinic Medications on Admission: oxycodone-acetaminophen 5-325 mg Q4H prn pain Docusate sodium 100 mg [**Hospital1 **] Omeprazole 40 mg Daily Clopidogrel 75 mg Daily Aspirin 325 mg Daily Hydrochlorothiazide 25 mg Daily Metformin 1000 mg [**Hospital1 **] Meclizine 12.5 mg TID Allopurinol 200 mg Daily Simvastatin 10 mg Daily Levothyroxine 50 mcg Daily Glyburide 5 mg [**Hospital1 **] Metoprolol tartrate 25 mg TID Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 doses: Please give one dose on [**2-18**] then stop. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**] Discharge Diagnosis: Primary: Sick sinus syndrome s/p PPM, Syncope Secondary: PVD, HTN, HLD, hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 95055**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for an episode of syncope and were found to have significant pauses of your heart. A permanent pacemaker was placed to prevent episodes like this from recurring in the future. The following changes were made to your medications: STOP Omeprazole STOP Meclizine DECREASE Allopurinol 100mg daily Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2173-2-25**] at 9:10 AM With: [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**], MD. [**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 *This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: CARDIAC SERVICES When: THURSDAY [**2173-2-25**] at 10:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VASCULAR SURGERY When: THURSDAY [**2173-2-25**] at 1:10 PM [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: THURSDAY [**2173-2-25**] at 1:55 PM [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: THURSDAY [**2173-2-25**] at 2:30 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**] Completed by:[**2173-2-17**]

[ "285.9", "787.91", "272.0", "427.81", "414.01", "401.9", "244.9", "440.20", "300.00" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

12052, 12144

9248, 10575

306, 342

12275, 12275

4829, 5457

12862, 14639

3590, 3706

11006, 12029

12165, 12254

10601, 10983

12426, 12839

3721, 4205

3072, 3311

4219, 4810

5474, 9225

259, 268

370, 2964

12290, 12402

2986, 3052

3327, 3574

23,003

180,811

28562

Discharge summary

report

Admission Date: [**2146-8-1**] Discharge Date: [**2146-8-10**] Date of Birth: [**2083-12-4**] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Percocet Attending:[**First Name3 (LF) 165**] Chief Complaint: 62yoM presented to [**Hospital 1474**] Hospital with abdominal pain radiating to back, found to be in AFib and ruled in for MI by enzymes. Abdm Ct showed incidental AAA(3.2cm)and pt transferred to [**Hospital1 18**] for cardiac catheterization and ASA desensitzation. Major Surgical or Invasive Procedure: cabg x4 [**2146-8-5**] (LIMA to LAD, SVG to DIAG, SVG to PDA, SVG to OM1) cardiac cath [**2146-8-2**] History of Present Illness: Mr. [**Known lastname 1022**] is a 62 man with hx paroxysmal afib (previously treated at [**Hospital1 336**]) who developed sharp [**6-23**] abdominal pain yesterday evening 30 min following dinner. The pain lasted for several hours, was dull, and radiated to back, with profuse diaphoresis. He denies any chest pain, chest pressure, SOB. Per patient's wife, he has had several similar episodes in the past 6 months. He has gone to other ED, but no records. . He initially presented to [**Hospital1 1474**] ED, and EKG showed atrial fibrillation with RVR, but no ischemia. At [**Hospital1 1474**], CK 212, CK-MB 13.9, troponin I 0.8; 2nd set CK 476, CK-MB 47.4, troponin I 12.1. Abd CT 3.2 cm AAA non leaking and mild small bowel distension consistent with either partial SBO or focal ileus. Received Plavix 300 once, metoprolol 50 q6h for rate control, enoxaparin 80 mg SC q12 (last dose 5 AM, [**8-1**]). Transfered for to [**Hospital1 18**] for cath, and initially went to CCU for aspirin desensitization. . Following successful desensitization, he was transferred to the floor in preparation for cath. he currently denies any nausea, vomiting, CP, SOB, palpitations. He nots that his abd pain is now [**11-23**]. His last BM was yesterday morning, and no BRBPR, no melena, but stool has been very light brown/yellow colored for 2 weeks. ROS otherwise noncontributory. Past Medical History: 1. HTN 2. Paroxysmal Afib, not on any anti-coag/rate control 3. hypercholesterolemia 4. GERD 5. bleeding ulcer 4-5 years ago Social History: Patient and his wife immigrated from [**Country **] in [**2118**], now works in shipping and lifts packages. No smoking or alcohol history. Family History: Brother: MI age 65 Otherwise, no DM, stroke hx Physical Exam: Admission Ht66" Wt160lb VS: 97.2 102-126/59-88 60 18 98%RA GEN: NAD, pleasant, speaks some English HEENT: PERRL, EOM intact, MMM, OP clear PULM: CTAB COR: RRR, no M/R/G, nl S1, S2 ABD: soft, normoactive BS, slightly distended, very mildly tender to deep palpation, no organomegaly EXT: no pedal edema, +DP Discharge VS:T 97.6 HR 62 BP 135/73 RR 18 O2Sat 94% RA Wt 77.7K Gen: NAD Neuro: A&O, non focal exam Pulm: diminished @Rt base otherwise CTA CV: RRR, S1-S2, Sternum stable wound w/o erythema or drainage Abdm: soft, NT/ND/NABS Ext: Warm, 1+ pedal edema, Left EVH site w/steri strips-CDI Pertinent Results: [**2146-8-1**] WBC-8.5 RBC-5.07 Hgb-15.0 Hct-44.7 MCV-88 MCH-29.6 MCHC-33.6 RDW-13.6 Plt Ct-167 Glucose-99 UreaN-15 Creat-1.0 Na-139 K-4.2 Cl-103 HCO3-29 PT-12.1 PTT-33.0 INR(PT)-1.0 Calcium-9.3 Phos-2.8 Mg-2.2 . [**2146-8-1**] 01:40PM BLOOD CK(CPK)-624* CK-MB-85* MB Indx-13.6* cTropnT-1.31* . EKG: NSR, 67bpm, Q in III, TWI in III, AVF, nl axis, nl intervals . [**2146-8-9**] 08:35AM BLOOD WBC-8.3 RBC-3.58* Hgb-11.2* Hct-32.1* MCV-90 MCH-31.4 MCHC-35.0 RDW-14.3 Plt Ct-147* [**2146-8-9**] 08:35AM BLOOD Plt Ct-147* [**2146-8-9**] 08:35AM BLOOD Glucose-117* UreaN-28* Creat-1.3* Na-136 K-4.8 Cl-98 HCO3-32 AnGap-11 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 69173**] [**Hospital1 18**] [**Numeric Identifier 69174**] (Complete) Done [**2146-8-5**] at 9:08:06 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2083-12-4**] Age (years): 62 M Hgt (in): 66 BP (mm Hg): / Wgt (lb): 160 HR (bpm): BSA (m2): 1.82 m2 Indication: Left ventricular function. Mitral valve disease. Intra-op TEE for CABG, ? MV repair ICD-9 Codes: 402.90, 786.05, 440.0, 424.1, 424.0 Test Information Date/Time: [**2146-8-5**] at 09:08 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2006AW04-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.8 cm Left Ventricle - Fractional Shortening: *0.19 >= 0.29 Left Ventricle - Ejection Fraction: 45% >= 55% Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Arch: 2.9 cm <= 3.0 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 0.9 m/sec Findings 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. Mild-moderate regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. There are complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction in the Septal and inferior walls. Overall left ventricular systolic function is mildly depressed. An Asymmetric septal bulge is noted near the basal septum. No LVOT gradient or [**Male First Name (un) **] is seen at rest or with provocative maneuvres. 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The C-[**Month (only) **] distance is <2.5 cm and the [**Doctor Last Name **]/PL ratio is > 2. The vena contracta measures between 0.3 and 0.4 cm. The annulus is 3.2 cm in the commisural view. Drs. [**Last Name (STitle) 3318**] and [**Name5 (PTitle) 6507**] present during study 7. There is a trivial/physiologic pericardial effusion. POST-BYPASS: Pt is being A paced and is receiving an infusion of phenylephrine 1. LV systolic function is improved. RV function is preserved. 2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] 3. Aorta is intact post decannulation 4. Other findings are [**Last Name (Titles) 1506**] I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician FINAL REPORT INDICATION: Evaluate baseline abdominal aortic aneurysm and evaluate for any hepatobiliary or pancreatic disease. COMPLETE ABDOMINAL ULTRASOUND: Liver is of normal echotexture with a simple hepatic cyst seen within the dome of the right lobe of the liver, measuring 1.9 cm in diameter. The gallbladder is unremarkable. There is no evidence of intra- or extra-hepatic ductal dilatation. There is appropriate forward portal venous flow. The pancreas is not well visualized. The right kidney is lobulated and measures 10.4 cm. The left kidney is small measures 8.3 cm and contains a nonobstructive 5 mm stone. There is no evidence of hydronephrosis or stones. There is a small simple cyst within the mid pole of the right kidney measuring 6 mm in diameter. Within the distal aorta, there is aneurysmal dilatation measuring 3.4 x 3.1 cm in maximal diameter. There is a small amount of associated plaque formation. IMPRESSION: 1. Abdominal aortic aneurysm within the distal aorta measuring 3.4 x 3.1 cm in maximal diameter. 2. Simple hepatic cyst within the right lobe. 3. Small left kidney. Querying history of left renal artery stenosis. 4. Small left lower pole nonobstructive kidney stone, 5 mm. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: [**Doctor First Name **] [**2146-8-4**] 8:26 AM Procedure Date:[**2146-8-3**] Brief Hospital Course: A/P: 62 yo M w/ history of paroxysmal Afib presents to OSH w/ Abd pain, found to have Afib with RVR, NSTEMI, AAA and possible small bowel obstruction. Transfered to [**Hospital1 18**] for ASA desensitization and cardiac cath. An abdm CT to evaluate abdm pain showed incidental finding of 3.2 cm AAA. ASA desensitization done and had cath on [**8-2**] which revealed Ef 45-50%, no MR, 1+ AI, 80% right subclavian stenosis, LM 50%, LAD serial 80% lesions, 100% CX, RCA 100%. Referred to Dr. [**Last Name (STitle) **] for CABG. Preop w/u included Carotid US that showed no [**First Name8 (NamePattern2) 3098**] [**Last Name (un) 2435**]., right ICA < 40%.Dental consult completed and cleared for surgery on [**8-4**]. Underwent cabg x4 on [**8-5**] and transferred to the CSRU in stable condition on neo and propofol drips. Returned to the OR that evening for mediastinal exploration for bleeding.Postop Afib treated with amiodarone and beta blockade after which he converted to sinus rhythm. He was transferred to the floor on POD #2 to begin increasing his activity level. Chest tubes removed on POD #2. Pacing wires removed on POD #3. On the floor he had an uneventful post-operative course. He had no further episodes of AFib. On POD 5 He sucessfully completed the physical therapy guidelines and was cleared fro discharge to home with visiting nurses. Medications on Admission: Meds at Home: NONE Patient takes Cambodian herbal remedies, but no meds . Meds on transfer from CCU: 1. DiphenhydrAMINE HCl 50 mg PO Q6H:PRN [**8-1**] @ 1858 2. MED Heparin IV per Weight-Based Dosing Guidelines 3. MED Pantoprazole 40 mg PO Q24H [**8-1**] @ 1858 4. MED Atorvastatin 80 mg PO DAILY [**8-1**] @ 1858 5. MED Acetaminophen 325-650 mg PO Q4-6H:PRN [**8-1**] @ 1858 6. MED Metoprolol 25 mg PO BID please hold for sbp < 90, hr < 50 [**8-1**] @ 1858 7. MED Senna 1 TAB PO BID [**8-1**] @ 1858 8. MED Bisacodyl 10 mg PO DAILY:PRN [**8-1**] @ 1858 9. MED Nitroglycerin 0.05-0.2 mcg/kg/min IV DRIP TITRATE TO pain free or SBP <135 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: please take 400mg daily for 1 week and then decrease to 200mg daily and follow up with cardiologist. Disp:*35 Tablet(s)* Refills:*0* 12. Outpatient Lab Work Please have BUN/CR drawn in 1 week - results to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: s/p cabg x4(LIMA-LAD,SVG-Diag,SVG-OM1,SVG-PDA) PAFib HTN MI ileus/? partial SBO elev. chol. AAA ? renal artery stenosis Discharge Condition: good Discharge Instructions: may shower over incisions and pat dry no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 days call for fever greater than 101.5, redness or drainage Followup Instructions: see Dr. [**Last Name (STitle) **] in [**11-15**] weeks see Dr. [**Last Name (STitle) **] in [**12-17**] weeks see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2146-8-10**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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54,188

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29147+57626

Discharge summary

report+addendum

Admission Date: [**2141-2-2**] Discharge Date: [**2141-3-9**] Date of Birth: [**2079-10-25**] Sex: M Service: SURGERY Allergies: Mercaptopurine Attending:[**First Name3 (LF) 158**] Chief Complaint: bowel perforation Major Surgical or Invasive Procedure: [**2141-2-2**]: Exploratory laparotomy, resection of terminal ileum, end ileostomy and mucous fistula. . [**2141-2-4**]: Decompressive laparotomy, abdominal washout. . [**2141-2-15**]: Exploratory laparotomy, abdominal washout, closure with a VAC. . [**2141-2-17**]: Tracheostomy, abdominal washout, partial closure, maturing of the ileostomy and placement of VAC and drains. History of Present Illness: 61 M with a history of [**Hospital 70135**] from [**Hospital **] Hospital with Free air seen on xray. He was driving to dinner with his wife on the eveningof presentation and he had some mild abdominal discomfor. Then had all of a sudden abdominal pain. It has been diffuse, worse in epigastrium, nothing improves, worse with movement, has never has before. Past Medical History: PMH: -Crohn's disease x 25 years -Prostate cancer . PSH: -Inguinal Hernia Repair -Vasectomy -Exploratory laparotomy, resection of terminal ileum, end ileostomy and mucous fistula -Decompressive laparotomy, abdominal washout -Exploratory laparotomy, abdominal washout, closure with a VAC Social History: no tob, occasional ETOH, no drugs, supportive wife Family History: noncontributory Physical Exam: PE: 97.9 136 101/69 20 97% 3L RA AAOx3, distressed Tachycardic CTAB diffusely firm tender abdomen, tenderness worse at epigastrium no edema, extrem warm rectal - guaiac negative, no masses or external fistulas Pertinent Results: [**2141-3-8**] 03:28AM BLOOD WBC-5.7 RBC-3.34* Hgb-10.0* Hct-30.6* MCV-92 MCH-29.8 MCHC-32.6 RDW-15.4 Plt Ct-381 [**2141-2-2**] 09:25PM BLOOD WBC-2.5*# RBC-5.53 Hgb-16.1# Hct-49.6 MCV-90 MCH-29.1 MCHC-32.5 RDW-14.1 Plt Ct-399 [**2141-3-6**] 05:00AM BLOOD PT-18.0* PTT-31.9 INR(PT)-1.6* [**2141-2-2**] 09:25PM BLOOD PT-13.0 PTT-19.2* INR(PT)-1.1 [**2141-3-9**] 03:43AM BLOOD Glucose-121* UreaN-44* Creat-4.5* Na-134 K-3.5 Cl-96 HCO3-27 AnGap-15 [**2141-2-2**] 09:25PM BLOOD Glucose-146* UreaN-19 Creat-1.5* Na-142 K-3.8 Cl-105 HCO3-23 AnGap-18 [**2141-3-7**] 07:36PM BLOOD ALT-40 AST-45* AlkPhos-671* Amylase-45 TotBili-3.9* [**2141-3-1**] 05:06AM BLOOD ALT-47* AST-42* LD(LDH)-276* AlkPhos-645* TotBili-5.6* [**2141-2-2**] 09:25PM BLOOD ALT-19 AST-23 AlkPhos-76 TotBili-0.5 [**2141-3-7**] 07:36PM BLOOD Lipase-62* [**2141-2-2**] 09:25PM BLOOD Lipase-118* [**2141-3-9**] 03:43AM BLOOD Calcium-8.0* Phos-5.8*# Mg-2.2 [**2141-2-16**] 03:01AM BLOOD calTIBC-104* Ferritn-878* TRF-80* [**2141-2-3**] 03:08AM BLOOD Triglyc-82 . Culture Data: UCX [**2141-3-7**]: No growth BCX [**2141-3-7**]: No Growth Catheter tip CX [**2141-3-4**]: no growth Peritoneal fluid [**2141-3-1**]: enterococcus, [**Female First Name (un) **] Peritoneal Fluid [**2141-2-3**]: haemophilus (sparse), bacteroides fragilis . Path: [**2141-2-3**]: ileum: Crohn's ileitis . Imaging: CT Chest/Abd/Pelvis [**2141-2-10**]: 1. Status post small bowel resection with end ileostomy and distal terminal ileum connected to the lateral aspect stoma as a mucous fistula. 2. Catheter along the lateral stoma appears to follow the mucous fistula for a few centimeters before entering the peritoneum with the tip in the right lower quadrant. 3. Rectal contrast is seen within the peritoneum around the mucous fistula, tracking up to the open abdominal wound and down to the sigmoid. Please note that wound vacuum drainage also increased after rectal contrast administration. 4. 8 x 6 cm fluid collection inferior to the greater curvature of the stomach, location is not amenable to percutaneous radiology-guided access. . RUQ US [**2141-2-13**]: 1. Moderately distended gallbladder with wall edema. No gallstones. In the setting of a known low albumin, these findings are nonspecific, although it is not possible to exclude acalculous cholecystitis. Further evaluation could be obtained with HIDA. 2. Echogenic liver lesions consistent with hemangiomas as seen previously on MRI of [**2140-12-28**]. . CT Abd/Pel [**2141-2-22**]: Three small fluid collections within the abdomen: a) along the greater curvature of the stomach, b) in the right lower quadrant and c) along the left iliopsoas muscle. The small size and inaccessible locations makes these unsuitable for percutaneous drainage. . Duplex US Abdomen [**2141-2-28**]: 1. Scattered ill-defined hypodensities in the right and left lobes of the liver (segment II, II/III, V, VI) concerning for parenchymal infection/abscess given time course of appearance. No areas of drainable fluid are identified within the lesions at this time. 2. Stable left hepatic hemangioma. 3. Persistent gallbladder distention, wall thickening, and pericholecystic fluid, with interval development of sludge. In the setting of low albumin these findings are not specific but remain compatible with acalculous cholecystitis. Would recommend HIDA scan for further evaluation if clinically indicated. . Tunneled line placement [**2141-3-1**]-->removal [**2141-3-4**] Tunneled line placement [**2141-3-6**] Brief Hospital Course: Severe Crohn disease with chronic obstruction from ileosigmoid fistula with perforation and terminal ileum at the fistula site. On [**2141-2-2**] Mr [**Name13 (STitle) 70136**] was taken emergently to the operating room for acute onset of abdominal pain, nausea, vomiting secondary to his longstanding Crohn's disease. The patient underwent exploratory laparotomy, resection of terminal ileum, end ileostomy and mucous fistula for severe Crohn disease with chronic obstruction from ileosigmoid fistula with perforation and terminal ileum at the fistula site. Immediately postoperatively he was taken to the Surgical ICU in critical condition on 3 different pressors which were quickly weaned off. However, on the morning of [**2-4**] he developed increased pressor requirement, much more tense abdomen with a drop in urine output consistent with compartment syndrome. He then underwent a decompressive laparotomy with an abdominal washout. He also had bilateral chest tubes placed for effusions so large that there were causing cardiac compromise. Following the washout his events were as follows: [**2-4**]: had bedside ex-lap with esophageal balloon placement (concern for compartment syndrome. Pt required bilateral chest tubes for bilateral layering pleural effusions, with subsequent improvement. His hemodynamics improved over the next few days, but abdomen was left open. [**2-6**]: milrinone weaned off, started TPN [**2-7**]: weaning hydrocortisone, no acute vents. Hemodynamically stable. [**2-9**]: L chest tube removed originally placed on [**2-4**] for increasing pleural effsusions bilaterally. [**2-10**]: Also 8x6cm fluid collection inferior to the greater curvature of the stomach. [**2-11**]: started D5W at 75cc/h for 2.3L free water deficit. On [**2-12**] Renal was consulted for [**Last Name (un) **] and reccomended keeping I/Os net even. And thought due to his previous hemodynamic instability this was likely ATN, supportive measures were deemed most important and dialysis was going to be necessary.D5W was continued at 75cc/h to replace insensible free water losses. The patient was off of pressor support at this time with Vanco/Zosyn/flagyl/micafungin for antibiotic coverage. A thera-ab vac was in place for his open abdomen. At this time it was also noted that hoisbilirubin was increasing to Tbili of 2.5 and RUQ u/swas neg. This was thought to be TPN cholestasis. Both chest were now out. Trophic tube feeds were started on [**2-14**]. However,on [**2-15**] his vac was changed and an increase in intraperitoneal fluid c/w with either purulence or TF were found. He was then taken back to the operating room for abdominalwashout and it was found that this was pus and not tube feeds. 3 separate [**Doctor Last Name **] drains were placed in the pelvis and right and left paracolic gutter respectively. TF were restarted the next day. [**2-17**] pt underwent repeat washout and tracheostomy. [**2-19**] HD was begun Pt then tolerated trach collar well Over the course next few days his antibiotics were removed 1 at a time and JP culture returned as VRE for which he was placed on linezolid. We discontinuefd the flagyl on [**2-23**] but the next day his LFTs rose with alow grade temp prompting another U/S which showed hepatic abscesses flagyl was restarted. The pt was transferred to the floor on [**2-27**] with 2 drains to bulb suction. Left JP was pulled on [**2-28**] and pt had a passy-muir valve/ PICC line placed. Pt failed swallow study. A tunnelled HD line was placec on [**3-6**]. And vac changes (now with white [**Last Name (un) 41829**] over bowel and black sponge was being changed Q 2-3 days. A 19F [**Doctor Last Name **] drain was placed at the bedside on [**3-6**] in the left gutter as more fluid seemed to accumulate there on previous vac changes. [**3-7**] Zosyn was D/c'd leaving pt on Linezolid and flagyl. [**3-9**] Pt received rehab bed and was discharged to rehab in good stable condition Medications on Admission: BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Sust. Release 24 hr TID CHOLESTYRAMINE-ASPARTAME [CHOLESTYRAMINE LIGHT] - 4 gram Powder once a day CIPROFLOXACIN - 500 mg Tablet qday CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] FOLIC ACID - 1 mg Tablet - 3(Three) Tablet(s) by mouth once a day IRON SUCROSE [VENOFER] - Dosageuncertain ASPIRIN - 81 mg Tablet, DelayedRelease (E.C.) ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - Dosage uncertain Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**] Drops Ophthalmic PRN (as needed) as needed. 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. heparin (porcine) 1,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] units Injection PRN (as needed) as needed for line flush: Original Order: Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 7. linezolid 100 mg/5 mL Suspension for Reconstitution Sig: Six (6) ml PO Q12H (every 12 hours) for 14 days: To complete a 14 day course. Last day should be [**2141-3-20**]. 8. Famotidine 20 mg IV Q24H 9. Thiamine 100 mg IV DAILY 10. Labetalol 10 mg IV Q6H:PRN SBP>170 11. Methadone 5 mg IV Q8H 12. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 14 days: Please complete a 14 day course last [**2141-3-22**]. 13. 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. 14. 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. 15. HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain 16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for thick secretions. 17. Insulin Slinding Scale Insulin SC Fixed Dose Orders Breakfast Bedtime NPH 7 Units NPH 7 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 2 Units 160-199 mg/dL 4 Units 4 Units 4 Units 4 Units 200-239 mg/dL 6 Units 6 Units 6 Units 6 Units 240-279 mg/dL 8 Units 8 Units 8 Units 8 Units 280-319 mg/dL 10 Units 10 Units 10 Units 10 Units 320-359 mg/dL 12 Units 12 Units 12 Units 12 Units 360-399 mg/dL 14 Units 14 Units 14 Units 14 Units Instructons for NPO Patients: Evening Prior to Surgery/Procedure: If on glargine or detemir: give 80% of usual dose; If on NPH: give 100% usual dose. Morning of Surgery/Procedure: If on glargine or detemir: give 80% of usual dose; If on NPH: give 50% of usual dose; If on premix insulin (e.g. 70/30, 75/25): take total number of AM units ordered, divide by 3, and give that many units as NPH; If on sliding scale of short acting insulin: administer according to HS schedule. Hold all oral antidiabetic medications, and consider sliding scale coverage; If appropriate, give IVF with dextrose to prevent hypoglycemia. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Crohns Disease, perforation 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 bowel perforation which caused you to become very sick. You have been in the ICU and on the floor for quite some time. Your abdomen remains open to decompress the area and it wil granulate in with a VAC dressing. You have [**Location (un) **]-[**Location (un) **] drains in your abdomen as well which will stay in place after discharge to the rehabilitation hospital. You have a new ileostomy and it is important that the output is monitored. The output should be between 500cc-1500cc daily. It is important that you are monitored for signs and symptoms of dehydration and symptoms of constipation. You have a tracheostomy tube that is protecting your airway and the nurses at the rehabilitation hospital will care for this tube as their nursing protocol indicates. You have been doing well but you are still unable to pass your speech and swallow consult. You will need to be reevaluated by the speech and swallow team at the rehab hospital. You have tolerated the valve that allows you to talk well and should continue to use this. You will be sent to rehab to recieve very important care and help you recover. Followup Instructions: Please make a follow-up appointment to see Dr. [**Last Name (STitle) **] in 7 days, call [**Telephone/Fax (1) 160**] to make this appointment. . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **]/KALMYKOW PCC/UROLOGY PHONE VISITS Date/Time:[**2141-3-22**] 9:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **]/KALMYKOW PCC/UROLOGY PHONE VISITS Date/Time:[**2141-9-20**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**] Date/Time:[**2141-12-12**] 11:15 Name: [**Known lastname 11900**],[**Known firstname **] Unit No: [**Numeric Identifier 11901**] Admission Date: [**2141-2-2**] Discharge Date: [**2141-3-9**] Date of Birth: [**2079-10-25**] Sex: M Service: SURGERY Allergies: Mercaptopurine Attending:[**First Name3 (LF) 94**] Addendum: Bowel Perforation. Medications on Admission: Budesonide 3mg tid cholestyramine-aspartame 4g dailyl Ciprofloxacin 500mg daily Cyanocobalamin Folic acid 3mg Iron ASA 81mg daily Vit D2 Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**] Drops Ophthalmic PRN (as needed) as needed. 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. heparin (porcine) 1,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 5068**] units Injection PRN (as needed) as needed for line flush: Original Order: Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 5068**] UNIT DWELL PRN line flush Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 7. linezolid 100 mg/5 mL Suspension for Reconstitution Sig: Six (6) ml PO Q12H (every 12 hours) for 14 days: To complete a 14 day course. Last day should be [**2141-3-20**]. 8. Famotidine 20 mg IV Q24H 9. Thiamine 100 mg IV DAILY 10. Labetalol 10 mg IV Q6H:PRN SBP>170 11. Methadone 5 mg IV Q8H 12. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 14 days: Please complete a 14 day course last [**2141-3-22**]. 13. 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. 14. 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. 15. HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain 16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for thick secretions. 17. Insulin Slinding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70mg/dL Proceed with hypoglycemia protocol 71-119mg/dL 0 Units 0 Units 0 Units 0 Units 120-150mg/dL 2 Units 2 Units 2 Units 2 Units 160-199mg/dL 4 Units 4 Units 4 Units 4 Units 200-239mg/dL 6 Units 6 Units 6 Units 6 Units 240-279mg/dL 8 Units 8 Units 8 Units 8 Units 280-319mg/dL 10 Units 10 Units 10 Units 10 Units 320-359mg/dL 12 Units 12 Units 12 Units 12 Units 360-399mg/dL 14 Units 14 Units 14 Units 14 Units > 400 mg/dL Notify M.D. Notify M.D. Notify M.D. Notify M.D. Instructons for NPO Patients: Evening Prior to Surgery/Procedure: If on glargine or detemir: give 80% of usual dose; If on NPH: give 100% usual dose. Morning of Surgery/Procedure: If on glargine or detemir: give 80% of usual dose; If on NPH: give 50% of usual dose; If on premix insulin (e.g. 70/30, 75/25): take total number of AM units ordered, divide by 3, and give that many units as NPH; If on sliding scale of short acting insulin: administer according to HS schedule. Hold all oral antidiabetic medications, and consider sliding scale coverage; If appropriate, give IVF with dextrose to prevent hypoglycemia. 18. NPH insulin human recomb 100 unit/mL Suspension Sig: Seven (7) units Subcutaneous please see below: Please administer 7 units of NPH with breakfast and 7 units of NPH at bedtime. 19. insulin regular human 100 unit/mL Solution Sig: Please see sliding scale units Injection every six (6) hours: Please see sliding scale on page 1. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU Discharge Diagnosis: Crohns Disease, perforation 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 bowel perforation which caused you to become very sick. You have been in the ICU and on the floor for quite some time. Your abdomen remains open to decompress the area and it wil granulate in with a VAC dressing. You have [**Location (un) **]-[**Location (un) **] drains in your abdomen as well which will stay in place after discharge to the rehabilitation hospital. You have a new ileostomy and it is important that the output is monitored. The output should be between 500cc-1500cc daily. It is important that you are monitored for signs and symptoms of dehydration and symptoms of constipation. You have a tracheostomy tube that is protecting your airway and the nurses at the rehabilitation hospital will care for this tube as their nursing protocol indicates. You have been doing well but you are still unable to pass your speech and swallow consult. You will need to be reevaluated by the speech and swallow team at the rehab hospital. You have tolerated the valve that allows you to talk well and should continue to use this. You will be sent to rehab to recieve very important care and help you recover. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 97**], MD Phone:[**Telephone/Fax (1) 5721**] Date/Time:[**2141-3-23**] 8:45, Please make an appointment with the wound/ostomy nurses for this day as well, call [**Telephone/Fax (1) 11902**] to make this appointment. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7601**]/KALMYKOW PCC/UROLOGY PHONE VISITS Date/Time:[**2141-3-22**] 9:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7601**]/KALMYKOW PCC/UROLOGY PHONE VISITS Date/Time:[**2141-9-20**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11903**], MD Phone:[**Telephone/Fax (1) 11904**] Date/Time:[**2141-12-12**] 11:15 Please make a follow-up appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11905**], your GI doctor to discuss crohns medications. Call ([**Telephone/Fax (1) 11906**] to make this appointment. [**Name6 (MD) **] [**Last Name (NamePattern4) 97**] MD [**MD Number(2) 98**] Completed by:[**2141-3-9**]

[ "575.10", "038.0", "560.89", "569.83", "995.92", "785.52", "567.29", "584.5", "569.81", "185", "572.0", "E878.8", "729.73", "555.0", "518.81", "276.0", "276.2", "998.89", "511.9", "276.69" ]

icd9cm

[ [ [] ] ]

[ "46.41", "34.91", "54.91", "33.23", "33.24", "54.12", "45.62", "96.72", "46.10", "38.95", "39.95", "99.15", "46.21", "96.6", "54.25", "38.97", "31.1" ]

icd9pcs

[ [ [] ] ]

19159, 19225

5232, 9201

290, 668

19297, 19297

1716, 5209

20627, 21669

1453, 1470

15581, 19136

19246, 19276

15420, 15558

19448, 20604

1485, 1697

233, 252

696, 1057

19312, 19424

1079, 1368

1384, 1437

19,011

110,160

27101

Discharge summary

report

Admission Date: [**2187-2-26**] Discharge Date: [**2187-4-24**] Date of Birth: [**2128-11-24**] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 148**] Chief Complaint: pancreatic pseudocyst Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Washout and drainage of the abdomen. 3. External drainage of pancreatic pseudocyst. 4. Pancreatic necrosectomy. 5. Open cholecystectomy. 6. G tube placement. 7. J tube placement. History of Present Illness: Patient is a 56 year old gentleman who recently underwent an exploratory laparotomy and debriedment of abdominal wall abscess at [**Hospital3 3583**] in setting of prior subtotal gastrectomy and and partial colon resection in past. HIDA scan at [**Hospital1 3325**] was consistent with biliary leak. Patient complained of epigastric abdominal pain and was found to have pancreatits with amylase 1035, lipase 2280 and CT scan showing significant peripancreatic inflammatory changes consisitent with pancreatitis. He improved and was discharged home on [**2187-2-21**] from [**Hospital3 3583**] but returned on [**2-24**] with lower extremity edema. He was found to hava a R popliteal vein thrombosis extending to the superficial femoral vein. Repeat CT scan showed extensive perihepatic fluid collections consistent with pancreatic psuedocysts and pancreatic necrosis. Patient was subsequently transferred to the [**Hospital1 18**] for further management. Past Medical History: Atrial fibrilation Pancreatitis DM (recent) DVT (recent) HTN bilateral CEAs Social History: non-contributory Family History: non-contributory Physical Exam: NAD Tracheostomy capped Bibasilar crackles, good air entry abdomen soft, non-tender, healing midline open incision with overlying wound drain Pertinent Results: [**2187-4-22**] 8:25 pm STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT [**2187-4-23**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2187-4-23**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [**2187-4-2**] 7:07 am SWAB Source: Rectal swab. **FINAL REPORT [**2187-4-4**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2187-4-4**]): No VRE isolated. [**2187-3-22**] 09:28PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2187-3-22**] 09:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030 [**2187-4-21**] 07:25AM BLOOD WBC-9.7 RBC-2.83* Hgb-9.3* Hct-29.0* MCV-102* MCH-32.8* MCHC-32.0 RDW-24.4* Plt Ct-268 [**2187-4-17**] 06:00AM BLOOD WBC-6.5 RBC-2.62* Hgb-8.4* Hct-26.2* MCV-100* MCH-32.1* MCHC-32.1 RDW-22.9* Plt Ct-271 [**2187-3-11**] 07:05AM BLOOD Hct-23.7* [**2187-3-12**] 04:14AM BLOOD WBC-6.4 RBC-2.71* Hgb-8.6* Hct-25.1* MCV-93 MCH-31.7 MCHC-34.3 RDW-16.2* Plt Ct-130* Brief Hospital Course: 58-year-old gentleman admitted for treatment of a complex pancreatic pseudocyst situation secondary to gallstone pancreatitis. He had been at an outside hospital for 2 weeks prior to his transfer to us where he had evidence of a lower extremity DVT. Upon transfer to us, he had clear-cut pulmonary embolism identified and this was treated with anticoagulation. In the antrum we accessed the pancreas via CT and found it to be stable with a complex multi-loculated cystic architecture that appears to be growing slightly in size while here at [**Hospital1 18**]. We also recognized a bile duct stone on imaging and he had an ERCP performed prior to this procedure. He was doing well except from a respiratory standpoint where he had decompensation and evidence of an advancing pulmonary embolism. For this reason, a DVT filter was placed 3 to 4 days prior to this procedure. He continued to have respiratory distress but was doing well other than that. On the night prior to this operation, he had an acute decompensation and moved from an alkalotic state to an acidotic state. He required massive amounts of fluid resuscitation and had a progressive lactic acidosis. He had a tender tense abdomen as well.He was seen early in the morning of the [**5-11**] and felt that he had an acute abdominal catastrophe requiring emergent exploration. He went to the operating room on the morning of [**2187-3-13**] with the intent of performing exploratory laparotomy. The presumed diagnosis was ruptured pseudocyst with secondary diagnosis of dead bowel. Over the next three weeks patient remained in ICU for postop care. On [**2187-4-15**] patient was transfered to the floors for further care. remainder of hospital course was uneventful, he continued to be stable on TPN, tolerating regular diet. On POD 51/39 patient was cleared for discharge to rehabilitation center for further recovery. Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension [**Date Range **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 150 mg/15 mL Liquid [**Date Range **]: One (1) PO BID (2 times a day). 3. Amiodarone 200 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet [**Date Range **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Octreotide Acetate 100 mcg/mL Solution [**Date Range **]: One (1) Injection Q8H (every 8 hours). 6. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for dyspnea. 7. Trazodone 50 mg Tablet [**Date Range **]: 0.5 Tablet PO TID (3 times a day) as needed for Agitation. 8. Warfarin 5 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at bedtime). 9. Oxycodone-Acetaminophen 5-325 mg Tablet [**Date Range **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 12. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed for congestion. 13. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 15. Cephalexin 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours). 16. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 17. Acetazolamide 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours) for 5 days: d/c [**4-29**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: ruptured Pancreatic psuedocyst Discharge Condition: stable Discharge Instructions: Resume your regular medications. Take all new medications as directed. Do not drive while taking narcotics. You may shower. Allow water to run over the wound, and do not scrub. Pat the wound dry. Do not take a bath or swim until after follow-up appointment. No heavy lifting (> 10 lbs) for 6 weeks. Please call your doctor or return to the ER if you experience: -Fever (> 101.4) -Inability to eat/drink or persistant vomiting -Increased pain -Redness or discharge from your wound -Other symptoms concerning to you Followup Instructions: Please followup with Dr. [**Last Name (STitle) **] in [**3-24**] weeks call [**Numeric Identifier 66571**] to schedule an appointment Completed by:[**2187-4-24**]

[ "576.2", "401.9", "577.2", "287.4", "427.31", "453.8", "577.0", "E934.2", "575.0", "415.19", "250.00", "707.05", "518.81" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.04", "46.39", "00.14", "89.64", "43.19", "99.15", "96.6", "31.1", "93.90", "99.07", "51.85", "38.93", "51.22", "96.72", "52.22" ]

icd9pcs

[ [ [] ] ]

6791, 6863

2955, 4841

296, 507

6938, 6947

1839, 2932

7516, 7682

1644, 1662

4864, 6768

6884, 6917

6971, 7493

1677, 1820

235, 258

535, 1494

1516, 1594

1610, 1628

2,136

101,901

9678

Discharge summary

report

Admission Date: [**2168-8-10**] Discharge Date: [**2168-8-17**] Date of Birth: [**2100-11-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Tunnelled Catheter Placement History of Present Illness: 67m with htn, cad, afib, cva, esrd on hd presents with fevers and sepsis. He apparently was found to be febrile at HD so was transferred to the the ED. In ED, attempts at subclavian and IJ's failed and a femoral line was placed. A CT abdomen/pelvis was attempted, but contrast extravasated out into the abdominal wall, for which surgery was consulted. At the time of admission, the patient was able to anwer basic questions and follow commands, but seemed confused and was not cooperative with the interpreter. His daughter was [**Name (NI) 653**] who said that although normally fairly oriented, he generally becomes confused in the setting of fever. She also noted that she'd seen him the day prior to admission and that he had no complaints and was acting his normal self. She said he'd had no f/c, ha, neck pain, chest pain, sob, increased cough (has been coughing since recent admit for aspiration pneumonia), abd pain, n/v/d. He makes no urine. He was initially admitted to the MICU and transferred out to the floor after 24 hours. . Currently, he has had no positive blood cultures for 48 hours and is being maintained on vancomycin 1g QHD for MRSA sepsis. He has no complaints, denies weakness, pain, shortness of breath, chest pain, fevers, chills, nausea or vomiting. History taken through bedside phone translator for Haitian Creole. Past Medical History: 1) Left occipital lobe CVA [**2-22**] p/w change in MS [**First Name (Titles) **] [**Last Name (Titles) **], chronic CVAs now on coumadin for likely embolic nature 2) Paroxysmal Afib, rate controlled with tachy/brady, occas 2 sec pauses, best managed with metoprolol 75 tid per cards 3) Chronic eosinophilia unknown etiology, strongyloides sent in [**2-22**] for w/u as well as SPEP/UPEP 4) h/o GI Bleed in [**2167-7-20**] while on asa, plavix, IIb/IIIa post-cath--no EGD or C-scope performed in f/u yet 5) ESRD secondary to HTN, dialysis MWF- followed by Dr. [**First Name (STitle) 805**] 6) h/o bacteremia w/ MSSA (last bacteremia [**11-22**] with coag neg staph sensitive to oxacillin but resistent to PCN- treated w/vanco) 7) h/o pulling out groin lines 8) HTN, controlled 9) CAD s/p NSTEMIS, 2 LAD stents, CABG [**2164**]: last ECHO [**2167-8-27**], EF >55% 10) Hyperlipidemia 11) Diverticulosis 12) Severe Hyperparathyroidism, presumed adenoma, not on vitamin D for this concern 13) chronic anemia 14) chronic transudative pleural effusions 15) h/o neurocysticercosis calcified Social History: Lives in nursing home. No tobacco, etoh, illicit drug use. Transfer paper work from nursing home lists [**First Name4 (NamePattern1) **] [**Known lastname **] as the relative or guardian ([**Telephone/Fax (1) 32722**]. Family History: Mother with hypertension. No history of no strokes, seizures, or heart disease Physical Exam: t 96.7, bp 130/86, hr 88, rr 12, spo2 99% 2lNC gen- chronically-ill appearing male, pleasant, non-tox, NAD heent- anicteric but muddy, op clear with mmm neck- no jvd/lad cv- irreg irreg, II/VI midsystolic murmur at the RLSB. no r/g. PMI wnl. Lungs- no resp distress or acc muscle use, poor air movement, mild rales in bases l>r abd- soft, nt, nd, +BS. Ext- 1+ pitting edema LLE, none right, warm/dry nails- no clubbing, [**Doctor First Name 15569**] nails neuro- Knows name, knows at hospital, CN V, VII-XII in tact, although the patient squints his right eye (he is capable of opening both eyelids wide). EOM difficult to assess s/s compliance. No asterixis. DTR's in tact and equal bilaterally. Seems to be weaker on the left side. Pertinent Results: [**2168-8-10**] 11:00AM BLOOD WBC-14.3*# [**2168-8-10**] 05:00PM BLOOD WBC-27.4*# [**2168-8-10**] 07:00PM BLOOD WBC-21.5* [**2168-8-11**] 03:38AM BLOOD WBC-18.0* [**2168-8-12**] 02:00AM BLOOD WBC-11.6* [**2168-8-12**] 03:41PM BLOOD WBC-9.7 [**2168-8-14**] 05:00AM BLOOD WBC-7.0 . [**2168-8-14**] 05:00AM BLOOD PT-21.2* PTT-36.1* INR(PT)-2.1* [**2168-8-10**] 11:00AM BLOOD Glucose-68* UreaN-19 Creat-3.8* Na-139 K-3.6 Cl-96 HCO3-33* AnGap-14 . [**2168-8-10**] 11:00AM BLOOD cTropnT-0.14* [**2168-8-10**] 05:40PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2168-8-11**] 03:38AM BLOOD cTropnT-0.16* [**2168-8-13**] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.13* [**2168-8-14**] 12:15AM BLOOD CK-MB-NotDone cTropnT-0.12* [**2168-8-14**] 05:00AM BLOOD CK-MB-2 cTropnT-0.12* . [**2168-8-14**] 05:00AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.4 [**2168-8-11**] 03:48AM BLOOD Type-[**Last Name (un) **] Temp-36.2 Rates-2/ pO2-31* pCO2-52* pH-7.40 calTCO2-33* Base XS-5 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] . CXR: IMPRESSION: AP chest compared to most recent prior chest film [**2168-7-11**]: Consolidation in the lung bases has improved and small left pleural effusion has decreased. Small region of prior right apical consolidation has cleared. Moderate enlargement of the cardiac silhouette has decreased. There is no pneumothorax. No change in alignment of sternal wires including fracture of the most superior and the off-line configuration to the most inferior two. . CT Abd/Pelvis: IMPRESSION: 1. Complete extravasation of administered contrast into the patient's right lower quadrant in an extraperitoneal location. The likely explanation for this finding is that the right femoral CVL tip was positioned in the right inferior epigastric vein, which ruptured upon contrast administration. 2. Slightly limited exam due to the lack of intravenous contrast, but no definite acute intraabdominal abnormalities identified. . ECG Study Date of [**2168-8-10**] 10:25:58 AM Shaky baseline. Probable atrial fibrillation with rapid heart action and tachycardia. Inideterminate axis. Non-specific ST segment depression in leads V4-V6, either rate-related or ischemic. Compared to the previous tracing of [**2168-7-10**] atrial fibrillation was previously present with likely continuation to the present. Low voltage in the limb leads as before. ST segment depressions were previously present. . TTE: Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The ascending aorta is mildly dilated. 5. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 7. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 8. No evidence of endocarditis seen. 9. Compared with the prior study (images reviewed) of [**2168-5-31**], tricuspid regurgitation and pulmonary hypertension are worse. . Tunnelled Cath Report: IMPRESSION: Successful placement of a tunneled left groin hemodialysis catheter for a left temporary triple-lumen hemodialysis catheter. Brief Hospital Course: 67m with cad, afib, esrd here with fevers and elevated WBC found to have MRSA sepsis now on Vancomycin IV. . #MRSA Baceteremia -- Pt met SIRS criteria with fever, wbc, and occasional tachycardia. There was no evidence of severe sepsis or septic shock, with pt actually hypertensive and no other end-organ disease noted during MICU stay. Possible primary sources for MRSA sepsis would be his HD line which was removed and site replaced. WBC is now wnl. -D/w renal, do not feel it's necessary to pull L femoral catheter at this time (placed on [**8-11**]) even though 1 pos Blood cx on [**8-12**]. -Vanco for MRSA bacteremia administered during dialysis, s/p Gentamicin 80mg QHD X 2 doses with HD for synergy. - Decision made to defer TEE due to risk/benefit ratio in his case - he has a h/o a GI bleed that has not been worked-up and is at high risk for aspiration so would need to be intubated for the procedure. Will plan to treat empirically for endocarditis with 6 wks of Vanc (through [**2168-9-23**].) - Last positive blood cx [**8-12**], afebrile, hemodynamically stable . # Chest Pain - Has had intermittant episodes of CP. Unlikely to be cardiac in origin as without ECG changes, prior cycled enzymes neg (elevated trop but his trop is elevated at baseline). GI causes are also in the differential and after giving maalox, symptoms resolved. Possible that the patient is having gastritis. Ordered PPI and maalox/benadryl/lidocaine mix. Patient is no longer symptomatic. . #Contrast extravasation -- Felt to be due to superficial placement of CVL. Currently asymptomatic. NTD per surgery. . #CAD -- No active ischemia, con't asa, atorvastatin, metoprolol, lisinopril. patient ruled out for mi. . #Afib -- Con't metoprolol - decreased dose to 12.5mg [**Hospital1 **] due to episode of bradycardia to 30s (asymptomatic). Warfarin held for several days for the possibility of procedures but he was restarted on 3 mg po qd on [**8-16**]. . #ESRD -- Con't HD on MWF. Con't sevelamer, nephrocaps . #HTN -- Con't lisinopril, metoprolol, clonidine, amlodipine . # Anemia -- Microcytic, likely a mixed picture of iron-deficiency and ACD - added iron supplement . #FEN -- Renal diet; vol even . #PPx -- boots, aspiration precautions . #Code -- full, confirmed with family . # Dispo -- d/c to nursing home with 6 wks antibiotics - needs to have ongoing safety labs (CBC, Chem 10, LFTS, INR, Vanc trough) followed by Dr. [**Last Name (STitle) **] - PCP and ID [**Name9 (PRE) 32723**] scheduled . #Contact -- [**Doctor Last Name **], daughter, [**Telephone/Fax (1) 32724**]. [**Name (NI) **], wife, ([**Telephone/Fax (1) 32722**]. Medications on Admission: -Lisinopril 10mg daily -Folic Acid 1mg daily -Docusate 100mg [**Hospital1 **] -Nephrocaps -Sevelamer 800mg TID -Warfarin 3mg daily -Lactulose 30cc daily -Trazodone 50mg qHS -Cinacalcet 30mg daily -Aspirin 325mg daily -Clonidine 0.2mg TID -Amlodipine 5mg daily -Atorvastatin 80mg qHS -Metoprolol Tartrate 25mg [**Hospital1 **] -Calcium Carbonate 500mg [**Hospital1 **] Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Lactulose 10 g/15 mL Solution Sig: Thirty (30) cc PO once a day as needed for constipation. 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 months. 16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous QHD (each hemodialysis) for 6 weeks: through [**2168-9-23**]. 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: MRSA bacteremia Chest pain Atrial fibrilation ESRD on HD HTN Anemia Discharge Condition: Hemodynamically stable. Discharge Instructions: Please return to the hospital for fevers, chest pain, shortness of breath. . Please take all medications as prescribed. Followup Instructions: Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2168-9-1**] 10:40 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2168-9-20**] 9:00 Please have the following labs drawn weekly at dialysis and have them faxed to Dr.[**Name (NI) 32725**] office: ([**Telephone/Fax (1) 9190**] CBC with diff CHEM 10 AST, ALT, Alk phos, TBili, INR, Vancomycin level prior to dialysis . Continue to have dialysis Monday, Wednesday and Friday [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "562.10", "397.0", "272.4", "996.62", "V12.59", "585.6", "V58.61", "252.01", "038.11", "285.21", "424.0", "427.31", "995.91", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "99.07" ]

icd9pcs

[ [ [] ] ]

11807, 11843

7352, 9984

322, 353

11955, 11981

3939, 7329

12149, 12875

3088, 3170

10402, 11784

11864, 11934

10010, 10379

12005, 12126

3185, 3920

276, 284

381, 1727

1749, 2835

2851, 3072

16,810

133,106

8058

Discharge summary

report

Admission Date: [**2131-2-17**] Discharge Date: [**2131-3-4**] Date of Birth: [**2082-1-30**] Sex: F Service: CARDIOVASC CHIEF COMPLAINT: Aortic valve replacement. HISTORY OF PRESENT ILLNESS: This is a 48-year-old female with a history of right heart disease and status post a mitral valvuloplasty in [**2125**]. Patient has increasing symptoms and was referred for cardiac catheterization for preoperative mitral valve replacement. Patient is not interested in a repeat valvuloplasty. The cardiac catheterization revealed normal coronary arteries with a left ventricular ejection fraction of 56%. Cardiac echocardiogram revealed an ejection fraction of 60%, moderate to severe mitral valve stenosis, 1+ mitral valve regurgitation and 2+ aortic valve regurgitation. PREVIOUS MEDICAL HISTORY: 1. Right heart disease. 2. Mitral valve stenosis. 3. Status post mitral valve valvuloplasty in [**2125**]. MEDICATIONS ON ADMISSION: Coumadin. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Patient denies any seizures, syncope, CVA, transient ischemic attack. Pulmonary: No acute shortness of breath. Denies asthma. Denies sputum production. Denies diarrhea, constipation. Denies gastroesophageal reflux disease. Denies dysuria. PHYSICAL EXAMINATION: Patient was afebrile. Vital signs were stable. She was alert and oriented times three in no apparent distress. Lungs: She was breathing evenly and unlabored. She was clear to auscultation bilaterally. Cardiovascular exam: She had a 2/6 systolic ejection murmur, S1, S2 were noted. Abdomen was soft, nontender, nondistended. Neurological exam was grossly intact. Cranial nerves II through XII are intact. Her extremities were warm and well-perfused. No erythema or edema were noted. PERTINENT LABORATORIES ON ADMISSION: CBC: White blood cell count 13.8, hematocrit 37.2, platelets 248. Chem-7: Sodium 135, potassium 3.7, chloride 102, bicarbonate 25, BUN 14, creatinine 0.7, INR 1.2. BRIEF HOSPITAL COURSE: The patient was admitted on [**2131-2-17**] for preop of her mitral valve replacement. Following the preoperative, the patient was placed on a heparin drip and seen by Dental for a preoperative consult. Also during her preoperative period, the patient had an ultrasound of her carotid arteries which revealed no significant stenosis. On [**2131-2-20**], the patient underwent a mitral valve replacement with a 27 mm [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] valve and also had an aortic valve replacement with a 19 mm [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]. The procedure was done by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Known lastname **] [**Doctor Last Name **] and assisted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28802**]. The patient tolerated the procedure well. There were no complications during the surgery. Following a brief stay in the Post Anesthesia Care Unit, the patient was transferred to the Cardiac Surgery Recovery Unit on a propofol and Neo-Synephrine drip. On postoperative day number one, the patient failed her initial CPAP trial and remained intubated until mid afternoon. When the patient was extubated, she was placed on 50% face mask which maintained her saturations at 95%. From a cardiovascular standpoint, the patient was maintained on a nitroglycerin drip, and was experiencing episodes of tachycardia and becoming hypertensive. Following her hypertensive crisis, the patient would become hypotensive down to the 80s. The heart rate would drop into the 40s. The patient would need to be apaced up to 92 following which her blood pressure would elevate and she would have to be restarted on her nitroglycerin. The patient was unable to take po medications. The patient was given intravenous Lopressor, which had a dramatic effect by dropping her systolic blood pressure into the 70s. The patient was apaced again with only transient effect and patient was started on Neo-Synephrine. The patient was finally stabilized with a systolic blood pressure in the 110s with Neo-Synephrine running at 2.5 mcg. The patient was also placed on an insulin drip for one day, which was then switched over to a regular insulin sliding scale on postoperative day number one. On postoperative day number two, the patient remained on Neo-Synephrine for hypotension and was started on amiodarone for atrial fibrillation. Patient was also seen by a Physical Therapy Consult which determined that the patient would be able to be discharged to home following several days of inpatient treatment. The patient was seen by the Electrophysiology fellows on postoperative day number three. The patient at this time was in postoperative atrial fibrillation with intermittent atrial flutter and occasionally converting over the sinus rhythm. The patient needed to be apaced with a low systolic blood pressure. Recommendations at the time would be not place a pacemaker, but to maintain her current drug regimen. By postoperative day number four, the patient was off of her Neo-Synephrine and remained only on amiodarone drip. The patient was able to maintain her blood pressure adequately, but her systolic blood pressure normalized in the upper 70s to low 80s. The patient continued to have episodes of bradycardia down to the 40s following which her atrial wires would pacer up to 90. Patient was slightly symptomatic being diaphoretic and slightly dizzy. By postoperative day number five, the patient continued to be followed by Electrophysiology for her tachybrady symptoms. As the patient from a cardiovascular standpoint maintained sinus rhythm, it was determined that the pacemaker would not be needed at this time. The patient was restarted on her intravenous heparin for anticoagulation for her atrial fibrillation. By postoperative day number six, the patient was taken off her intravenous heparin and just maintained on amiodarone, Lopressor, and levofloxacin for a suspected urinary tract infection. On postoperative day number seven, the patient was well on the floor. The patient had an uneventful recovery. The patient continued to be up and ambulating with assistance of her family. The patient was also continued to be seen by Electrophysiology who noted that the patient did have brief episodes of atrial fibrillation, but maintained sinus rhythm for most of the time. Recommendation that the patient is switched from 400 mg b.i.d. to 200 t.i.d. of amiodarone and continuation of the beta-blockers for her cardiac disease. On postoperative day number eight, the patient complained of left hand weakness and a Neurology Consult was requested. The patient had a head CT and neurological checks q. 4 following this. The head CT revealed no mass shift, bleed, or abnormalities. On the next day, [**2131-3-1**], the patient was seen by the Neurology Stroke Team which recommended continuing the anticoagulation and also continuation of Physical Therapy and Occupational Therapy. Recommendations were to continue the anticoagulation for long-term. Following this, the patient was placed on Coumadin at 3 mg. Over the next couple of days, the patient was gently weaned off her heparin drip as she reached therapeutic levels, and her Coumadin was increased to 5 mg po q.d. She had no further complications during the remainder of her hospital stay. On [**2131-3-4**], it was determined by the Surgical Team and by the patient that she was well enough to be discharged to home. PHYSICAL EXAMINATION ON DISCHARGE: Patient was in no apparent distress, alert and oriented times three. Cardiovascularly, patient was in regular rate and normal sinus rhythm, S1, S2 were noted. Her surgical incision was clean, dry and intact. Lung exam was even, unlabored, clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended, no hepatosplenomegaly noted. Extremities: Erythema, no edema. PERTINENT LABORATORIES ON DISCHARGE: CBC: White blood cell count 14.7, hematocrit 29.8, platelets 546,000. PT 18.6, PTT 33.4, INR 2.3. Sodium 137, potassium 4.4, chloride 98, bicarbonate 28, BUN 14, creatinine 0.7, glucose 89, calcium 9.0, magnesium 2.1, phosphorus 4.6. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement with a 19 mm [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]. 2. Status post mitral valve replacement with a 21 mm [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]. 3. Right heart disease. 4. Mitral valve stenosis. 5. Status post mitral valvuloplasty in [**2125**]. DISCHARGE MEDICATIONS: 1. Lasix 20 mg po b.i.d. times seven days. 2. Potassium chloride 20 mEq po b.i.d. for seven days. 3. Colace 100 mg po b.i.d. 4. Aspirin 81 mg po q.d. 5. Percocet 1-2 mg po q. 4 prn pain. 6. Levofloxacin 500 mg po q. 24 hours times seven days. 7. Amiodarone 200 mg po t.i.d. for ten days, followed by 200 mg po b.i.d. for ten days, followed by 200 mg po q.d. for ten days, then discontinue. 8. Metoprolol 25 mg po t.i.d. 9. Coumadin 3-5 mg po q.d. to dose daily to maintain INR between 2.5 and 3.5. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2131-3-4**] 12:06 T: [**2131-3-4**] 13:35 JOB#: [**Job Number 28803**]

[ "396.1", "458.29", "530.81", "E878.1", "427.31", "790.92" ]

icd9cm

[ [ [] ] ]

[ "99.04", "35.22", "35.24", "39.61" ]

icd9pcs

[ [ [] ] ]

2018, 7588

8284, 8637

8660, 9414

955, 1004

1293, 1810

8025, 8263

1024, 1270

156, 183

212, 928

1825, 1994

30,699

105,206

48966

Discharge summary

report

Admission Date: [**2120-6-10**] Discharge Date: [**2120-6-15**] Date of Birth: [**2055-6-29**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 6021**] Chief Complaint: Fatigue, nausea and vomiting Major Surgical or Invasive Procedure: Cystoscopy with fulguration for bleeding points and evacuation of large volume clot from bladder. Bilateral nephrostomy tube placement History of Present Illness: The patient is a 64 yo F with metastatic breast Ca to brain, vertebrae and ribs, presenting for recent fatigue, nausea, and vomiting and found to have ARF. She noted hematuria associated with right flank pain for 2 days, during which she passed clots. She was seen today by her oncologist NP who noted abnormal labs consistant with ARF. In the ED her creatinine was noted to have risen [**Last Name (un) 834**] 1.0 to 6.1 in 10 days and her potassium was 6.1. An EKG was performed which showed peak Ts, but she denies palpitations, CP, and SOB. The pt has recently had MS [**First Name (Titles) 4245**] [**Last Name (Titles) 102819**]d with brain and spinal mets s/p XRT. She denies frequency and urgency, but has had mild dysuria. over the past few days. She denies fever, chills, and denies nausea currently. . In the ED, she received calcium gluconate 1 amp x1, bicarb 1 amp x 1, D5 1 amp IV x 1, and 7 units regular insulin. Repeat K was 5.9. . Past Medical History: 1.Breast cancer with metastases to the bone, pelvis, spine, and brain: Diagnosed in [**2112**] after a car accident when the lesion was noted on an MRI. - She was treated at that time with chemo and radiation including Adriamycin. - She was diagnosed with metastatic cancer to bone and her vertebrae and ribs in the back in [**2114**]. - Chemo therapy included Herceptin, Navelbine & Zometa.Also has had recent XRT (radiation to T12-L5). Had whole brain radiation earlier this month ([**Date range (1) 94270**]/07) for bilateral frontal masses. 2. Hypertension. 3. GERD. 4. Cataracts . PAST SURGICAL HISTORY: 1. Breast reduction in [**2102**]. 2. Breast cancer in [**2112**] status post meniscectomy. 3. Left hip replacement seven to eight years ago. 4. Multiple tendon releases and carpal tunnel release in bilateral hands over the years. Social History: - Works as an administrative assistant at the statehouse. She lives alone, has 3 children; her daughter and son-in-law live downstairs with two children and her son lives upstairs from her with children. - She is divorced for over 30 years. - She quit tobacco 32 years ago. She notes an occasional drink and denies any drugs. Family History: N/C Physical Exam: (Only post-procedure physical exam available below) Vitals - T97.8 HR 73 RR 12 BP 162/81 O2 100% on CMV 600x20, FiO2 100%, PEEP 5 General - intubated, sedated, not responsive to sternal rub HEENT - PERRL, ET tube in place Neck - JVD difficult to appreciate CV - RRR, no murmur, rub or gallop Lungs - clear to auscultation anteriorally Abd - soft, NT/ND, ++ BS; 3-way foley in place Ext - warm feet, 2+ DP pulses b/l, no edema Neuro: unresponsive to sternal rub Skin: scar over L breast Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2120-6-10**] 09:30AM 10.3 3.45* 10.9* 31.5* 91 31.5 34.5 17.9* 159 UREA N-118* CREAT-6.6*# SODIUM-132* POTASSIUM-6.1* CHLORIDE-99 TOTAL CO2-14* ANION GAP-25* ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-8.6*# MAGNESIUM-2.4 ALT(SGPT)-22 AST(SGOT)-26 LD(LDH)-362* ALK PHOS-66 TOT BILI-0.3 PT-10.9 PTT-28.4 INR(PT)-0.9 . URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.023 URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-<1 . IMAGING . CT abd/pelvis: 1. Lingular consolidation and ill-defined bibasilar nodularity that may be inflammatory in nature. A followup chest CT in three months is recommended to assess for stability. Small area of tree-in-[**Male First Name (un) 239**] configuration in the right lower lobe may reflect sequelae of aspiration. 2. Bilateral hydroureteronephrosis. High-density material in the distended urinary bladder suggestive of a hematoma which may potentially be the underlying cause of ureteral obstruction.No obstructing urinary tract calculi identified . 3. Diffuse sclerotic bony metastases. . Renal/bladder U/S: 1. Hydronephrosis, right greater than left. 2. Presumed hematoma within the bladder lumen. Please correlate with subsequently performed CT. Brief Hospital Course: 64 year old female with metastatic breast cancer admitted for acute renal failure and hyperkalemia, found to have b/l hydronephrosis and bladder hematoma. . # Acute Renal Failure: Pt found to have abdominal/pelvis mets, explaining compression of ureters. She went for cystoscopy with plan to place b/l stents. A 250cc old blood clot was removed. There was mild bleeding from the mass at the bladder neck which was cauterized. During this event, the ureteral orifices might have been cauterized which were difficult to identify because of her distorted anatomy. No stents could be placed due to her anatomy but a 22F three-way foley with continuous bladder irrigation which showed clearing after the procedure. She then had b/l percutaneous nephrostomy tubes placed by IR to solve the primary cause of her ARF. Nephrology also followed the patient for her post-obstructive ARF. Her creatinine dramatically improved after the procedures back down to its baseline. She remains with nephrostomy tubes. Foley was removed. Her hyperkalemia was managed and improved with improved renal function. Repeat renal ultrasound showed near complete resolution of hydronephrosis. . # Respiratory failure: Patient required re-inbuation after dropping O2 sats and being unresponsive post-cystoscopy. This reason is unclear as there was not excessive sedation during procedure per urology and extubation was uneventful post-OP. There were no signs of infection; her WBC is stable, and she has been afebrile throughout. CXR done in PACU did not show any acute findings compared to recent CXR VBG of 7.03/84/95 is suggested of acute hypercarbic respiratory failure. She was likely oversedated, especially in setting of ARF reducing clearance of sedating meds. She was extubated in the ICU and did very well following this, with excellent O2 sats on room air by the time of discharge. . # MS changes: She had CT head on [**6-11**] following decreased responsiveness after her procedure. Repeat CT was also performed the following day. There were hyperdensities in the frontal lobes, subarachnoid hemorrhage vs. hemorrhage into known frontal mets. Neurosurgery was consulted and did not feel that this was the cause of acute MS changes that prevented extubation. No neurosurgical interventions were done. The patient does have some baseline impaired MS. [**Name14 (STitle) **] and electrolyte derangements from ARF were the most likely contributors to her depressed mental status. Following treatment and transfer back to the floor, her mental status cleared back to baseline. . # Metastatic Breast Cancer (including brain metastases): Her Keppra was continued for seizure ppx. She should continue twice daily after discharge. No seizure occurred during this admission. . # Hypertension: Her anti-hypertensive meds were adjusted as needed. She will likely be discharged on metoprolol alone. . # Anemia: Hct baseline of 33, here has been trending down since admission. This was likely due to gross hematuria and the 250 cc blood clot found in the bladder. Hemolysis labs showed elevated LDH but low-normal total bilirubin. Retic count is low at 0.8. Anemia is likely due to marrow suppression and acute blood loss from bladder. She required one unit PRBC transfusion and responded appropriately. Medications on Admission: - Keppra 1000 mg twice daily - Amlodipine 10mg daily - Metoprolol 50mg [**Hospital1 **] - Protonix - Senna - Colace - Tylenol p.r.n. - Trazodone 25 q.h.s. insomnia. Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. 2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: Life Care Center at [**Location (un) 2199**] Discharge Diagnosis: Acute renal failure Bilateral hydronephrosis Breast cancer (metastatic) Respiratory failure Discharge Condition: Stable Discharge Instructions: You were admitted because of an obstruction that was blocking your urine flow. You had a procedure to help drain out your urine. Please keep all of your appointments with your doctors and take [**Name5 (PTitle) **] of your medications as prescribed. Return to the hospital if you note bloody or thick drainage from your nephrostomy tubes, if you have back or abdominal pain, if you have fevers, or if you notice any new symptoms that you are concerned about. The following medication changes were made while you were here: We stopped your amlodipine, and we decreased your dose of Metoprolol. Your doctors [**Name5 (PTitle) **] adjust these medications further in the future. Followup Instructions: You have the following upcoming appointments: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-6-17**] 10:10 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2120-6-17**] 3:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2120-6-20**] 8:45 Also, please make a followup appointment with urology in [**12-23**] weeks. Please call ([**Telephone/Fax (1) 4376**] to set up this appointment with Dr. [**Last Name (STitle) **].

[ "197.6", "584.9", "198.1", "198.3", "591", "V10.3", "530.81", "518.81", "276.7", "285.1", "V15.3", "401.9", "198.5", "599.7" ]

icd9cm

[ [ [] ] ]

[ "96.04", "57.0", "55.03", "57.49", "96.71" ]

icd9pcs

[ [ [] ] ]

8811, 8882

4580, 7870

297, 434

9017, 9025

3182, 4557

9754, 10414

2655, 2660

8086, 8788

8903, 8996

7896, 8063

9049, 9731

2053, 2289

2675, 3163

229, 259

462, 1414

1436, 2030

2305, 2639

6,718

132,192

44499

Discharge summary

report

Admission Date: [**2202-11-27**] Discharge Date: [**2202-12-10**] Date of Birth: [**2162-8-15**] Sex: M Service: MEDICINE Allergies: Betadine / Iodine; Iodine Containing / Compazine / Keflex / Zosyn / Heparin Agents Attending:[**First Name3 (LF) 348**] Chief Complaint: Transfer to MICU for sinus/atrial tachycardia and need for monitoring Major Surgical or Invasive Procedure: intubation suprapubic catheter placement History of Present Illness: 40y/o M well known to [**Hospital1 18**] with h/o c6 quadraplegia, autonomic dysreflexia, renal transplant, multiple sacral decubiti, anemia, chronic pain, and recurrent UTI with indwelling suprapubic catheter sent in to ED from his NH after awakening at 3AM c/o worsening HA and chest tightness, SOB, nausea and vomiting small amounts of bloody material with uncontrolled BP 175/90, 210/140 L arm, HR 90. He was given 1" nitropaste, lopressor 5mg IV x1, and BP decreased to 180/100 with continued vomiting. ECG revealed no significant STE despite wavy baseline. Pt referred to ED for further evaluation. . NH notes indicate recent dx with new UTI after UA 20-50 RBC, [**9-30**] WBC, many bacteria, urine Cx grew >100,000 mixed GNR; NH referral recommended treatment with tobramycin based on previous sensitivities ([**10-30**] pseudomonas sensitive to tobramycin and acinetobacter sensitive to bactrim. Given presumed hematemesis, guaiac revealed OB + brown stool, hemoccult of emesis not performed. . Upon arrival to ED, Vitals in ED [**Company 95359**] 97.6 BP 135/22 HR 91 RR 13 O2sat 99% on 2L; increased to T 100.7 at 1300, HR 128-163; given 500cc IVF total, with 1250cc urine output recorded; for tachycardia adenosine 6mg IV x 1 given without effect, then verapamil 2.5mg IV x1 and diltiazem 10mg IV x 2 without decrease in HR. Brief moment recorded wenckebach pattern. ECGs faxed to EP fellow on call with report of sinus tachycardia versus atrial tachycardia and recommendation to avoid nodal blockers and correct underlying causes. No formal consult received. Past Medical History: s/p MVA, c6 quadraplegia, autonomic dysreflexia, renal transplant, multiple chronic sacral decubiti, obesity wt 260lbs, depression, anemia, chronic pain, and recurrent UTI with indwelling suprapubic catheter, h/o HIT thrombosing port-a-cath, h/o anyphylaxis with iodine refractory to pretreatment with steroids, h/o cocaine-induced MI '[**88**], chronic osteomyelitis, s/p R BKA, s/p diverting colostomy, h/o adrenal insufficiency, h/o hypoventilation on opiates, s/p splenectomy, asthma, neurogenic bladder Social History: lives at [**Hospital3 672**] rehab, former tobacco use, Mom [**Name (NI) 622**] [**Name (NI) 11679**] is HCP [**0-0-**], denies etoh or illicits since cocaine in '[**88**] Family History: N/A Physical Exam: Vitals in ED [**Company 95359**] 97.6 BP 135/22 HR 91 RR 13 O2sat 99% on 2L; increased to T 100.7 at 1300, HR 128-163 until transfer to ICU In ICU 18:12pm T 102 BP 143/22, HR 134, RR 15 O2 sat 88% on 2L NC General: ill-appearing man, laying flat, towel on face, diaphoretic Heent: anicteric, dry mm, op clear Neck: supple no JVP elevation CV: tachy rate, nl s1/s2, can't appreciate split, left chest portacath Resp: basilar crackles, good air movement without wheezes Abd: protruberant, distended, no fluid wave appreciated, nontender, suprapubic catheter in place, ostomy with brown formed stool Back: sacral decub extensive with granulation tissue, no frank pus Extrem: right knee ulceration without erythema or induration, faint radial pulses palpable Neuro: spasticity of UE, CN grossly intact, A&O x 3 Pertinent Results: ECG: sinus tachycardia 160, reg, nl axis, nl intervals except long QTC in 480s, no ST/TW ischemic changes, RBBB pattern in ECG CXR: mild pulmonary edema, no distinct consolidation [**2202-11-27**] 05:15AM BLOOD WBC-8.9 RBC-3.79* Hgb-10.9* Hct-34.4* MCV-91 MCH-28.7 MCHC-31.6 RDW-16.0* Plt Ct-219 [**2202-11-28**] 02:37AM BLOOD WBC-15.1*# RBC-3.59* Hgb-10.5* Hct-32.2* MCV-90 MCH-29.3 MCHC-32.7 RDW-16.2* Plt Ct-193 [**2202-12-10**] 05:13AM BLOOD WBC-8.2 RBC-3.01* Hgb-8.6* Hct-26.6* MCV-89 MCH-28.4 MCHC-32.1 RDW-16.7* Plt Ct-318 [**2202-11-27**] 05:15AM BLOOD Glucose-134* UreaN-10 Creat-0.5 Na-144 K-4.5 Cl-101 HCO3-35* AnGap-13 [**2202-11-27**] 07:31PM BLOOD Glucose-102 UreaN-8 Creat-0.5 Na-146* K-4.0 Cl-103 HCO3-36* AnGap-11 [**2202-12-10**] 05:13AM BLOOD Glucose-75 UreaN-25* Creat-0.6 Na-140 K-4.6 Cl-103 HCO3-31 AnGap-11 [**2202-11-27**] 05:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2202-11-27**] 07:31PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2202-12-9**] 04:58AM BLOOD CK-MB-3 cTropnT-<0.01 [**2202-11-27**] 07:31PM BLOOD Calcium-8.8 Phos-2.9 Mg-1.3* [**2202-12-10**] 05:13AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.6 [**2202-12-8**] 05:30AM BLOOD calTIBC-181* Ferritn-134 TRF-139* [**2202-11-27**] 07:31PM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE [**2202-11-27**] 07:31PM BLOOD Cortsol-6.7 [**2202-11-27**] 01:15PM BLOOD Lactate-2.3* [**2202-12-3**] 07:35AM BLOOD Lactate-1.3 Brief Hospital Course: Ill-appearing 40y/o M with multiple medical concerns, presenting with likely urosepsis complicated by autonomic dysreflexia and respiratory failure. . # SIRS/SEPSIS: Pt has suprapubic catheter which was likely source of infection. Initially susceptible to tobramycin but subsequent studies showed resistance to all bacteria. Also considered possible source from chronic sacral wound although no frank signs or symptoms of infection were present. Treatment started on [**11-27**] based on results from previous cultures - given tobramycin, bactrim, and coverage w/ vancomycin for sacral wound. Per ID recs, recommended continuing on tobra until [**12-11**], changing catheter and repeat U/A soon thereafter (will need after discharge). Pt has been afebrile with normal WBC. . # Hypoxia: Initially thought to be from pulmonary edema due to fluid administration, less likely PE, and possibly due to hypoventilation secondary to opiates. Could not get dye load for CTA, and ECHO ruled out new WMA. He was intubated several days after admission for respiratory failure presumably from aspiration given multiple episodes of vomiting in the 24 hours prior to failure. His CXR also showed persistent LLL collapse. He was extubated on [**12-6**] and transferred out to the floor from the [**Hospital Unit Name 153**]. He was satting 97% on 37% shovel mask and was transitioned to 96% on 4L within a few days. He continues to complain of intermittent shortness of breath and chest tightening, but his vitals have been stable, cardiac enzymes negative and had no evidence of EKG changes during these episodes. He responds well to reassurance and nebulizer treatments. He should continue to be weaned from supplemental O2 as tolerated. . # Emesis ?hematemesis: [**Month (only) 116**] be in response to infection; he had no abdominal tenderness at admission. He has h/o chronic abdominal pain. NG lavage with coffee ground OB+ material did not clear entirely after 1 liter NS lavage. Now, emesis resolved and hct has remained stable in the mid to high 20s. . # Tachycardia: Pt presented w/ sinus tachycardia w/ inverted P in AVR, likely due to infection/SIRS and hypovolemia. Resolved w/ IVF and treatment of underlying causes. . # Long QT: likely due to hypokalemia given emesis. Resolved after repletion of lytes. . # Anemia: Iron deficiency documented; continued iron supplementation, hct stable in mid-20s. . # Metabolic Alkalosis: Likely secondary to volume contraction and emesis; resolved w/ NS IVF boluses and repletion of lytes. . #Sacral decubiti/chronic osteomyelitis: No acute signs/symptoms of infection; WBC normal and afebrile prior to hypoxic episode. Followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] from orthopedics. Continued Zn, MVI, and wound care. . # s/p renal transplant: stable. Continued immunosuppressive medications. Renal function normal despite renotoxic meds. Started prednisone 40 on [**12-9**] and plan to taper to previous outpatient dose of 5mg po qd. Random AM cortisol level was 6.7 suggesting adrenal insufficiency. . # Chronic pain: continued methadone, dilaudid prn . # Spasticity: continued baclofen . #Autonomic dysreflexia: Given supportive care and was not a significant issue during this admission . #Depression: continued lamotrigine, celexa . #FEN: regular diet #PPX: PPI qd, bowel regimen, pneumoboots #ACCESS: port-a-cath #Communicate with pt and HCP/mom [**Name (NI) 622**] [**Name (NI) 11679**] is HCP [**0-0-**] #CODE: full Medications on Admission: dilaudid, benadryl, nicorette gum, phenergen, tylenol, lamictal 25 daily, imuran 75 daily, methadone 5mg tid, folate, thorazine 10 tid, protonix 40 daily, feosol [**Hospital1 **], lioresal 20mg tid, paxil 10 daily, colace, lactulose, zinc, prednisone 5 daily, dulcolax, senna, lopressor 12.5mg [**Hospital1 **], albuterol prn, desenex prn Discharge Medications: 1. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Azathioprine 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Nicotine 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed. 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 15. Sodium Chloride 0.9 % Syringe Sig: One (1) ML Injection DAILY (Daily) as needed. 16. Tobramycin Sulfate 40 mg/mL Solution Sig: One (1) Injection Q24H (every 24 hours) for 2 days. 17. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 21. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 22. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 24. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 26. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO qd () for 2 doses. 27. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO qd () for 3 doses. 28. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 3 doses. 29. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 3 doses. 30. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please start after he completes 10mg doses. 31. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): Please refer to ISS. 32. Phenergan 12.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary: urinary tract infection - pseudomonas resistant to all abx aspiration pneumonia . Secondary: Paraplegia s/p MVA C6C7 Chronic sacral decubitus ulcer s/p renal tx [**2181**] h/o frequent recurrent UTIs w/ indwellling catheter s/p MI [**2188**] 2' to cocaine Chronic Osteomyelitis s/p R BKA, multiple amps of b/l distal fingers s/p diverting colostomy autonomic dysreflexia depression Discharge Condition: stable Discharge Instructions: Please return for further care if you have fever, chills, chest pain, shortness of breath, nausea, vomiting, lightheadedness or any other symptoms that are concerning to you. Followup Instructions: Please contact your physician if you need further care. Completed by:[**2202-12-10**]

[ "V44.3", "038.9", "337.3", "280.9", "041.3", "304.01", "401.9", "995.92", "730.18", "311", "707.03", "V42.0", "578.0", "V09.81", "507.0", "599.0", "V44.59", "907.2", "518.81", "V49.75", "344.1", "276.3", "255.4", "996.64", "276.52" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

11682, 11737

5045, 8558

414, 457

12172, 12181

3643, 5022

12404, 12492

2794, 2799

8949, 11659

11758, 12151

8585, 8926

12205, 12381

2814, 3624

305, 376

485, 2058

2080, 2589

2605, 2778

15,722

195,260

43559

Discharge summary

report

Admission Date: [**2134-1-11**] Discharge Date: [**2134-1-20**] Date of Birth: [**2066-6-1**] Sex: M Service: CARDIOTHORACIC Allergies: Biaxin / Vioxx / Morphine / Ibuprofen / Plavix / Ticlid / Tricor / Zetia / Crestor / Protonix / Ultram / Nexium Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2134-1-15**] Coronary Artery Bypass Graft x 3 (Left internal mammary artery to Left anterior descending, Saphenous vein graft to Obtuse marginal, Saphenous vein graft to Postrior descending artery) History of Present Illness: This 67 year old white male with extensive past medical history of coronary artery disease s/p multiple stent placement who underwent cardiac cath on [**1-5**] which revealed left main and right coronary artery disease. Patient was scheduled to have surgery in next few weeks but developed increasing chest pain at the end of [**Month (only) **] and was admitted for surgery early. Past Medical History: Coronary Artery Disease with Myocardial infarctions, s/p Multiple Stent placement, Chronic renal insufficeincy, Obesity, Anemia, Kidney stones s/p lithotripsy, Diverticulitis/Diverticulosis, Gastroesophageal reflux disease w/ Barrett's esophagus, Osteoarthritis, Polymalgia rheumatica, Degenerative joint disease, Chronic low back pain with left siatica, Lung nodules, s/p removal of basal cell skin cancer, h/o asbestos exposure, s/p Tonsillectomy, s/p Lipoma removal from neck Social History: Lives with wife. Quit smoking 20+ yrs ago, 20 pkyr history. No alcohol or other drug use. Family History: +family history of coronary artery disease Physical Exam: At discharge: VSS Gen: WDWNWM in NAD Skin: sternal wound and leg wounds C/D/I HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly Chest: Clear to A+P Heart: RRR without R/G/M Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext: 1+ bilat LE edema Neuro: nonfocal Pertinent Results: [**1-15**] Echo: Prebypass: 1. Small secundum atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 2. Right ventricular chamber size and free wall motion are normal. 3. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2134-1-15**] at 830am. Post bypass: Patient is in sinus rhythm and receiving an infusion of phenylephrine. 1. Biventricular systolic function is unchanged. 2. Aorta intact post decannulation. 3. Trivial mitral regurgitation present. [**Known lastname 10384**],[**Known firstname **] F [**Medical Record Number 93709**] M 67 [**2066-6-1**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2134-1-16**] 3:39 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2134-1-16**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 93710**] Reason: PTX/ileus Final Report CHEST SINGLE VIEW ON [**1-16**] HISTORY: Status post CABG, question pneumothorax. REFERENCE EXAM: [**1-15**]. There has been interval removal of the ET tube, right IJ, Swan-Ganz catheter. There is volume loss at both bases with dense consolidation and small bilateral pleural effusions. There is no pneumothorax. DR. [**First Name (STitle) **] [**Doctor Last Name **] Approved: SAT [**2134-1-16**] 7:56 PM [**2134-1-20**] 05:00AM BLOOD WBC-7.3 RBC-3.27* Hgb-8.7* Hct-26.0* MCV-80* MCH-26.5* MCHC-33.3 RDW-13.5 Plt Ct-264 [**2134-1-20**] 05:00AM BLOOD PT-14.0* INR(PT)-1.2* [**2134-1-19**] 06:40AM BLOOD Glucose-103 UreaN-30* Creat-1.4* Na-137 K-4.5 Cl-99 HCO3-28 AnGap-15 Brief Hospital Course: Mr. [**Known lastname **] was admitted prior to surgery and appropriately worked-up for his increasing angina. He was appropriately medically managed over several days and was brought to the operating room on [**1-15**] where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. His chest tubes were discontinued on POD 1 and he was transferred to the floor on POD 2. He had post op atrial fibrillation converted to sinus rhythm with Amiodorone. His epicardial pacing wires were discontinued on POD 3. He continued to progress with physical therapy and was discharged to home on POD 5 in stable condition. Dr.[**Name (NI) 29254**] office was called and they will follow his coumadin. Medications on Admission: Amlodipine 5mg qd, Lipitor 10mg qd, Nexium 40mg qd, HCTZ 12.5mg qd, Lisinopril 20mg qd, Lopressor 75mg [**Hospital1 **], Aspirin 325mg qd, Metamucil, Meclizine, Nitro prn, Vicoden prn, [**Doctor First Name **] Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Amiodarone instructions: Please take 2 pills (400mg) twice daily for one week, then starting [**2134-1-27**] take 2 pills once daily for one week, then starting [**2134-2-3**] take 1 pill (200mg) once daily until otherwise instructed. . Disp:*120 Tablet(s)* Refills:*0* 6. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily): Please take this daily dose until instructed to otherwise by your doctor's office. Disp:*150 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. Nexium 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:*0* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Take for 5 days then stop. Disp:*5 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days: Take with lasix and stop when lasix stopped. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Myocardial infarctions, s/p Multiple Stent placement, Chronic renal insufficeincy, Obesity, Anemia, Kidney stones s/p lithotripsy, Diverticulitis/Diverticulosis, Gastroesophageal reflux disease w/ Barrett's esophagus, Osteoarthritis, Polymalgia rheumatica, Degenerative joint disease, Chronic low back pain with left siatica, Lung nodules, s/p removal of basal cell skin cancer, h/o asbestos exposure, s/p Tonsillectomy, s/p Lipoma removal from neck Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**3-15**] weeks Dr. [**Last Name (STitle) **] in [**2-11**] weeks Completed by:[**2134-1-20**]

[ "414.01", "530.81", "997.1", "285.9", "V17.3", "411.1", "V45.82", "412", "278.00", "427.31", "725", "V13.01", "585.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6853, 6911

4082, 4905

388, 590

7470, 7476

2029, 4059

7987, 8158

1626, 1670

5165, 6830

6932, 7449

4931, 5142

7500, 7964

1685, 1685

1699, 2010

338, 350

618, 1001

1023, 1503

1519, 1610

10,304

143,601

5620+5621

Discharge summary

report+report

Admission Date: [**2160-2-28**] Discharge Date: [**2160-3-4**] Date of Birth: [**2110-7-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Alcohol abuse, abdominal pain, delirium. Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 46 year old homeless man with a past medical history significant for hepatitis C and alcoholic cirrhosis, who presented with two to three days of multiple complaints including abdominal pain, blurry vision, tremors and malaise. The patient reports that he has had vague epigastric abdominal pain for the past two to three days. This was associated with anorexia. No hematemesis, change in bowel habit, weight loss. nonproductive cough. He also admits to feeling depressed and hopeless and wishes to undergo alcohol detox and to speak with psychiatry re his depression and substance abuse. He apparently was delirious at one point and threatened to throw himself off a bridge. In ER, he received IVF, folic acid, thiamine and ativan. Past Medical History: (COLLATERAL HISTORY FROM CHART) 1.) History of hepatitis A. 2.)History of hepatitis B. 3.) History of hepatitis C. 4.)History of alcohol abuse with a history of delirium tremens. 5.) Cirrhosis 6.) History of spontaneous bacterial peritonitis. 7.) History of incarcerated inguinal hernia Social History: The patient is homeless. He is originally from the Bronx. He previously worked as a musician, playing piano and drums. He has been divorced 4 times. He tells me he does not have any living relatives. [**Name (NI) **] reports significant alcohol intake. The patient reports smoking one pack of cigarettes per day. The patient admits to using crystal meth, cocaine and heroin IV. The patient has a history of multiple admissions for detoxification as well as multiple sign-outs against medical advice. Family History: Non-contributory Physical Exam: Pulse 74 BP 112/59 Afebrile RR 16. Alert, oriented, co-operative. Unkempt. Hands - no clubbing. No flap. No evidence peripheral stigmata of infectious endocarditis. HEENT - no jaundice. Eyes are bloodshot. Mucous membranes dry. No lymphadenopathy. JVP - not elevated. Cardiac- regular rate and rhythm. No murmur/rub/gallop Chest - R > L basal crackles. [**Last Name (un) **] - tender RUQ and RLq. No masses. No hepatomegaly. +BS Legs - no edema/swelling/erythema Pertinent Results: GLUCOSE-84 UREA N-7 CREAT-0.7 SODIUM-145 POTASSIUM-3.1* CHLORIDE-106 TOTAL CO2-24 ANION GAP-18 ALT(SGPT)-159* AST(SGOT)-349* ALK PHOS-103 AMYLASE-45 TOT BILI-3.5* CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-1.4* WBC-5.8# RBC-4.34* HGB-14.4 HCT-39.1* MCV-90 MCH-33.2* MCHC-36.8* RDW-16.7* Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative Comments: 80 (These Units) = 0.08 (% By Weight) CATHETER Urine Benzos Pos Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative Brief Hospital Course: . Alcohol/Substance Abuse - The patient was admitted intoxicated. He was high risk for DT's given his recent admission at [**Hospital1 2177**] ([**12-24**]) with a prolonged ICU course with DT's. He was given 15mg Valium initially and put on a q2 hour Valium CIWA scale. He continued to have symptoms of anxiety/hallucinations and we continued to give high doses of Valium. He was switched over to 10mg Valium q4hrs. He was treated with thiamine 100mg po, MVI 1 qd, folic acid QD. His electrolytes were aggressively repleted in hopes of preventing arrhythmias including torsades given his slightly prolonged QTc. Because of concern for increased sedation with high doses of Valium, he was switched over to a Ativan CIWA scale and standing dose on [**2160-3-2**]. Eventually he was tapered off of Ativan. Patient expressed interest in being discharged to a rehab facility. Unfortunately, we could not find an [**Hospital 19586**] rehab for which he was eligible, given he had already detoxed. . Suicidal Ideations - The patient was followed by psych during his admission. During his detox he did expressed suicidal ideations and so he was maintained on a 1:1 sitter. When he was no longer withdrawing, he did not express any suicidality. He did report a history of depression and anxiety. He denied a history of suicide attempts in the past. Psychiatry was consulted and involved with his management. . Abdominal pain - The patient had slightly elevated LFT's from baseline. He is most likely having a flare of alcoholic hepatitis. His LFT's trended down during his admission and his abdominal pain decreased. He does not show any clinical evidence of decompensated liver disease. Given that he had Grade 3 varices on endoscopy in [**2156-6-17**], nadolol 20mg po qd was started. . Medications on Admission: None Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis ETOH withdrawal * Secondary diagnoses ETOH induced hepatitis Hep C Hep B depression Discharge Condition: good Discharge Instructions: Please take all your medications as prescribed. * Please continue to refrain from using alcohol. * Please call your doctor or return to the emergency room if you develop chest pain, shortness of breath, or any other symptoms that are concerning to you. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11435**] in one-two weeks. Admission Date: [**2160-3-5**] Discharge Date: [**2160-3-7**] Date of Birth: [**2110-7-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 49M with a past medical history significant for hepatitis C and alcoholic cirrhosis with continued alcohol use. He was d/c'd yesterday following admission with abdominal pain/ alcohol withdrawal and alcoholic hepatitis. He was seen by Psychiatry during recent admission, howevere did not qualify for inpatient detox because he completed an ativan taper in house and detox programs require that participants have had their last drink within approx 36 hours of admission. Thus, pt was discharged from [**Hospital1 18**] with a cab voucher to go to [**Street Address(1) 5904**] Inn. However, he reports that he stopped at the Berkeley College of Music to see a friend who gave him some vodka. He was found outside the Berkeley college of music unresponsive. He told EMS that he took a Xanax OD, however is currently denying this. He denies any preceding symptoms to his collapse. He c/o ankle and knee pain. He also c/o hearing voices and sounds that he thought were due to withdrawal. In ED given Banana Bag and Clindamycin and Levofloxacin for possible PnA. Past Medical History: History of hepatitis A. History of hepatitis B. (HBcAb positive) Hepatitis C. Alcohol abuse with a history of delirium tremens. Cirrhosis - grade 3 varices on endoscopy in past spontaneous bacterial peritonitis. Admission at [**Hospital1 2177**] this year with ?Ecoli sepsis and ?MRSA pneumonia Social History: homeless - prior to his last admission here he stayed at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] house and [**Hospital1 2177**] where he's been admitted with E.coli sepsis? , smoker one pack of cigarettes per day for thirty years.. Can drink a pint of Vodka per day History of heroin and marijuana use but denies any intravenous drug abuse. Family History: non-contributory Physical Exam: Pulse 70/min BP 120/70 Afebrile T: 97.6 RR 16 Pox: 99% on RA Smells strongly of alcohol Awake, Alert, oriented, co-operative. Unkempt. HEENT - no jaundice. No LAD Cardiac - regular rate and rhythm. No murmur/rub/gallop Chest - R > L basal crackles. [**Last Name (un) **] - ? Sl distended, Soft with slightly tender RUQ No hepatomegaly. +BS Ext: no edema/swelling/erythema Neuro: PEARL No focal deficit Pertinent Results: Non-contrast head CT ([**3-4**]): "No evidence of intracranial hemorrhage or mass effect" . CXR ([**3-4**]): Right lower lobe opacity is seen consistent with aspiration versus pneumonia. Brief Hospital Course: . # Altered mental status/ETOH intoxication - ETOH and benzos positive on tox screen. Suspect that altered mental status is [**12-20**] ETOH intoxication. Positive urine benzo's may be due to recent benzo's given during recent hospitalization. As patient at risk for DT's was placed on CIWA scale with Valium/Ativan. Social work and psychiatry were involved during his admission. He was also started on thiamine 100mg po, MVI 1 qd, and folic acid. His mental status improved during his stay. He was not accepted to any in-patient facilities as was sober and not at risk from withdrawal at the time of discharge. He was encouraged to abstain from ETOH use. . # Hypotension - patient admitted with intoxication, on hospital day # 2 became hypotensive with SBP 70-80s. Likely multifactorial - patient had received Ativan, nadolol and sublingual nitroglycerin also likely hypotensive from dehydration. Baseline BP only around SBP 115. Sepsis (secondary to PNA, SBP, cholangitis) was also considered. He was started empirically on Zosyn/vanco to cover for possible SBP and PNA and transferred to the ICU. He was in the ICU overnight. He was supported with fluid boluses. He did not require pressors and returned to the floor the following day. Blood and urine cultures were negative. Antibiotics were discontinued. . # Abdominal Pain - likely secondary to acute ETOH hepatitis. Improving since last admission. LFT's and T Bil down from last admission. Abdominal imaging - U/S and CT - were both negative. Abdominal pain had improved on discharge. He was tolerating po intake without difficulty. . # Chest pain - Had episode of chest pain - L sided chest pressure radiating to arm. Seems to have a pleuritic component so pain unlikely to cardiac in nature. BP 112/68, HR 86, T 98.4, sat 98% 2LNC - EKG done - no acute changes, given sl nitro x 1 - pain resolved. CE neg x 2. . # Cirrhosis - Most likely due to ETOH/HCV/HBV; likely with poor synthetic liver function (mildly elevated INR, low albumin - could also be poor nutrition. Continue Nadolol given Grade 3 varices on endoscopy in [**2156-6-17**]. Will need hepatology f/u as an out-patient. . # Pneumonia - ? RLL infiltrate on CXR, had recent admission at [**Hospital1 2177**] for PNA so this may be resolving. Received Levaquin and Clinda for possible aspiration in ED. Asymptomatic - no cough, afebrile, WBC WNL, lungs clear. Antibiotics were discontinued. . # Anxiety - Patient has a hisotry of anxiety. He reported that Buspar had worked well for his anxiety in the past, so he was restarted on Buspar during his admission. Medications on Admission: The following were prescribed to the patient on his discharge earlier on the day of admission: MVI T QDay Folic Acid 1mg Qday Nadolol 20mg Qday Mag. oxide 400mg [**Hospital1 **] Protonix 40mg Qday 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. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis ETOH intoxication * Secondary diagnoses alcoholism depression anxiety homelessness alcohol cirrhosis Grade 3 esophageal varices Discharge Condition: good Discharge Instructions: Please take all of your medications as prescribed. * Please try to abstain from alcohol use. * Please call your doctor or go to the emergency room if you feel short of breath, have chest pain, cannot eat, drink, or take your medications, or if you develop any other symptoms that are concerning to you. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11435**] ([**Telephone/Fax (1) 22549**]in [**11-19**] weeks. He will be able to titrate up your Buspar dose if necessary. * [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "304.20", "458.29", "E947.8", "303.01", "304.30", "456.21", "571.1", "571.2", "414.01", "486", "291.81", "V60.0", "E849.8" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

12467, 12473

8845, 11431

6356, 6362

12663, 12670

8632, 8822

13021, 13355

8176, 8194

11679, 12444

12494, 12642

11457, 11656

12694, 12998

8209, 8613

6298, 6318

6390, 7449

7471, 7770

7786, 8160

50,093

163,903

994

Discharge summary

report

Admission Date: [**2164-10-1**] Discharge Date: [**2164-10-4**] Date of Birth: [**2103-12-24**] Sex: M Service: MEDICINE Allergies: bupropion Attending:[**Doctor First Name 3290**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: [**2164-10-1**] endotracheal intubation, placement of right internal jugular central line History of Present Illness: 60 y/o Male with history of metastatic esophageal cancer s/p esophagectomy w/ recurrence as well as brain mets, multiple recurrent PNAs, recurrent VTE on lovenox, afib, presents with weakness, fatigue, cough, SOB, total body pain starting today. Patient was most recently hospitalized in mid [**Month (only) **] for pneumonia. Patient was in his usual health until earlier this morning when he complained of increased weakness and fatiuge, cough, SOB and chest pain with decreased appetite and total body pain. Triggered on arrival for HR of 180. . ED Course (labs, imaging, interventions, consults): - Initial Vitals/Trigger: 98.0 162 78/58 16 100% ra - EKG: afib at 171 with uncontrolled ventricular response [x] portalbe CXR - right sided PNA and pleural effusion - treated with cefepime/vanc/flagyl/levo [x] CBC - WBC of 31 with left shift [x] lactate 6.7 [x] CT head - no worsening process. stable l frontal craniotomy with persistent thoguh improved adjacent frontal lobe edema. known left cerebellar lesion not well seen. stable ventricles and sulci [x] CT torso - Migration of the esophageal stent cephalad, posterior, and to the right,likely eroded through the gastric pull through and freely communicating with the right pleural space/lung with resultant necrotic pneumonia of the right > added on micafungin lower lobe and hydropneumothorax > NO EVIDENCE OF Pulm Emb [x] chem 7 - K 5.6, gap of 21 (likely lactic acid), sugar 272 - stress dose steroids - patient was full code for now - baseline BP 80-90 per patient and wife - 4L IV fluids - bedside ultrasound - no evidence of pericardial effusion - 6U insulin IV for K 5.4 and gap with sugar of 272 (though gap is likely related to lactic acid) - R IJ placed [**1-26**] ?hypotensions > neosynephrine - intubated for unclear reasons perichest-tube placement [x] ONC - sent FYI page [x] thoracic surgery - placed chest tube, no surgical intervention at this time Past Medical History: ONCOLOGIC HISTORY: [**5-/2163**], s/p cisplatin/5FU/XRT, esophagectomy; brain mets [**12/2163**], s/p cyberknife [**1-/2164**] and [**2164-8-14**]. [**2163-5-30**]: EGD with large circumferential mass at GE junction. Biopsy showed adenocarcinoma. [**2163-5-31**]: CT abd/pelvis with distal esophageal mass and a 3cm partially necrotic lymph node in the hepatogastric ligament. [**2163-6-6**]: EUS staging Tx, N2, Mx. FNA of gastrohepatic node positive for adenocarcinoma. [**2163-6-8**]: PET with FDG avid left paratracheal lymph node immediately anterior to esophagus at level of aortic arch, 7 mm, SUV max 4.5, multiple small (2-6 mm) pulmonary nodules too small to fully characterize, and a large 2.9 cm lymph node in the gastrohepatic ligament with SUV max 11.4. The primary distal esophageal mass was also highly FDG avid. [**Date range (2) 6545**]: Chemoradiation with cisplatin (75 mg/m2, D1 and D29) and 5-FU (1000 mg/m2/day D1-4, D29-32). [**Date range (1) 6546**]/11: Admission for PE (RLL segmental) causing pleuritic chest pain; therapeutic enoxaparin initiated. [**Date range (3) 6547**]: Admission with new atrial fibrillation and acute right axillary DVT. CT showed improving PE. Cardioverted. Therapeutic enoxaparin continued. [**2163-8-26**] PET/CT: Gastrohepatic and left paratracheal lymph nodes now without FDG-avidity. [**2163-9-19**]: Dr. [**First Name (STitle) **] performed minimally invasive esophagectomy showing pathologic complete response including 15 negative nodes. [**2163-11-15**], [**2163-12-13**], [**2163-12-30**]: Esophageal stricture dilation. Port removed on [**2163-12-13**] and J-tube removed on [**2163-12-30**]. [**Date range (3) 6566**]: Admission with aphasia. Brain MRI showed solitary 1.9 cm left frontal lobe mass. CT torso with segmental LUL PE (new since [**2163-10-26**]), stable 9 mm right hilar lymph nodes and right upper lobe pulmonary nodules, no clear metastatic disease. Resection of brain mass on [**2164-1-20**] ([**Doctor Last Name **]) showed metastatic adenocarcinoma, CK7/CK20 positive, TTF-1 negative, consistent with upper GI origin. HER-2 positive by FISH. [**2164-2-7**]: Cyberknife to resection cavity. [**2164-3-7**]: Dilation of anastomotic stricture. [**2164-3-27**]: CT chest with 7 mm RUL subpleural nodule (previously 5mm) and new 7 mm LUL nodule, and increased right hilar and mediastinal adenopathy (may be reactive). [**2164-4-2**]: J-tube placement, dilation of stricture, biopsy of gastric conduit revealed adenocarcinoma. [**2164-4-3**]: Esophageal stent placed for possible fistula (fluid draining from esophagus seen on EGD [**2164-4-2**], but no tract found on EGD or bronchoscopy). [**2164-5-4**] MRI brain: Marked decrease in enhancement at left frontal resection site. No new lesion. [**2164-6-20**]: CT abd/pelvis: No metastatic disease seen. [**2164-7-13**]: CT chest: Improvement of bilateral lower lobe consolidations suggests resolving infectious/inflammatory process. New GGO in right upper lobe likely represents aspiration pneumonia. Stable 6 mm right upper lobe and 7 mm left upper lobe nodules. [**2164-7-31**]: MRI head with new 25 x 21 mm left cerebellar metastasis. [**2164-8-14**]: Cyberknife to left cerebellar lesion. . PAST MEDICAL HISTORY: 1) Severe rheumatoid arthritis, previously on enbrel and now on prednisone alone. History of multiple joint surgeries related to RA. 2) Atrial fibrillation s/p cardioversion [**2163-8-19**]. 3) RLL Pulm Emb in [**7-4**]. 4) Right axillary DVT [**2163-8-17**]. 5) LUL Pulm Emb in [**2164-1-17**] while on warfarin. Now on enoxaparin. Social History: - Tobacco: Quit in [**2161**], 30-35 years 1ppd. - Alcohol: [**12-26**] cocktails every few weeks. - Illicits: Negative. - Housing: lives with wife. - Employment: on disability for past 10 years related to RA, former manager of bottling plant and [**Location (un) 6350**] [**Location 6351**]. - Family: wife, four children. Family History: His mother and [**Name2 (NI) 1685**] sister have [**Name2 (NI) **]. There is no family history of cancer. No clotting disorders in the family. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.7 135 80/60 19 99% see resp setting CMV GENERAL: intubated, sedated HEENT: MMM. no LAD. no JVD. neck supple. HEART: RRR S1/S2 heard. no murmurs/gallops/rubs. LUNGS: rhonchorus breath sounds anteriorly on the right ABDOMEN: soft, no involuntary guarding EXT: warm, trace edema SKIN: dry, no rash DISCHARGE PHYSICAL EXAM: Expired. Pertinent Results: ADMISSION LABS [**2164-10-1**] 05:50PM [**Month/Day/Year 3143**] WBC-31.5*# RBC-4.55* Hgb-11.5* Hct-36.8* MCV-81* MCH-25.2* MCHC-31.1 RDW-17.2* Plt Ct-554*# [**2164-10-1**] 05:50PM [**Month/Day/Year 3143**] Neuts-86* Bands-10* Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2164-10-1**] 06:57PM [**Month/Day/Year 3143**] PT-13.7* PTT-28.7 INR(PT)-1.3* [**2164-10-1**] 05:00PM [**Month/Day/Year 3143**] Glucose-272* UreaN-30* Creat-0.9 Na-131* K-5.6* Cl-92* HCO3-21* AnGap-24* [**2164-10-1**] 05:00PM [**Month/Day/Year 3143**] ALT-13 AST-13 AlkPhos-131* TotBili-0.3 [**2164-10-1**] 05:00PM [**Month/Day/Year 3143**] Lipase-9 [**2164-10-1**] 05:00PM [**Month/Day/Year 3143**] cTropnT-<0.01 [**2164-10-1**] 05:00PM [**Month/Day/Year 3143**] Albumin-2.9* [**2164-10-2**] 02:32AM [**Month/Day/Year 3143**] Albumin-2.2* Calcium-7.9* Phos-4.4 Mg-1.6 [**2164-10-1**] 05:06PM [**Month/Day/Year 3143**] Type-[**Last Name (un) **] pO2-40* pCO2-40 pH-7.37 calTCO2-24 Base XS--1 [**2164-10-1**] 05:06PM [**Month/Day/Year 3143**] Lactate-6.7* [**2164-10-1**] 09:32PM [**Month/Day/Year 3143**] O2 Sat-99 [**2164-10-2**] 04:07AM [**Month/Day/Year 3143**] freeCa-1.13 [**2164-10-1**] 07:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022 [**2164-10-1**] 07:15PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-30 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2164-10-1**] 07:15PM URINE RBC-3* WBC-8* Bacteri-FEW Yeast-NONE Epi-0 TransE-1 [**2164-10-1**] 07:15PM URINE CastHy-59* IMAGING: [**2164-10-1**] CT CHEST/ABD/PELVIS: IMPRESSION: Migration of the esophageal stent cephalad, posteriorly, and to the right within the gastric pull-through, which has likely eroded through the posterior wall and is now freely communicating with the pleural space and lung with resultant large area of fluid and consolidation in the right lower lobe and hydropneumothorax. Brief Hospital Course: Mr. [**Known lastname 6352**] is a 60 yo male with history of metastatic esophageal cancer status post esophagectomy but with recurrence as well as brain metastasis, recurrent pneumonias and thromboemboli on lovenox who presented with esophageal stent migration into right lung and septic shock with afib RVR. His initial presentation of hypotension with elevated lactate and relative increased work of breathing was due to sepsis from the stent migration. His esophageal stent had likely eroded through the cancer since it had been seen to be quite necrotic on prior EGDs. Unfortunately, it eroded into his right lung and pleural space creating collapse of lung parenchyma on that side and hypoxemic respiratory distress. He was initially intubated for this and a chest tube was placed on the right side to suction. There was significant air leak (4+) on the chest tube, thought to be due to the open esophagus. He required vasopressors as well to maintain his [**Known lastname **] pressure and an esmolol drip for afib with RVR. Thoracic surgery was consulted about possible operative management of his stent and hydropneumothorax on the right. They did not feel that there would be any worthwhile outcome from surgery given the scope of the procedure it would require and the baseline metastatic cancer. A family meeting was held with members from thoracic surgery, ICU team, and the patient's primary oncology fellow. The family decided to make the patient CMO, understanding that he would pass away from hypoxia and sepsis. His antibiotics, vasopressors, esmolol, and mechanical ventilation were discontinued. Patient was transferred to the general medicine floor, where his care was focused on comfort. The patient expired peacefully on [**2164-10-4**] with his family at the bedside. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Amiodarone 200 mg PO DAILY 2. Codeine Sulfate 30 mg PO Q4H:PRN cough 3. Enoxaparin Sodium 90 mg SC DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Lorazepam 0.5 mg PO HS:PRN anxiety, insomnia 6. Metoprolol Tartrate 12.5 mg PO BID hold SBP < 85, HR < 50 7. Omeprazole 40 mg PO BID 8. PredniSONE 10 mg PO DAILY 9. Dexamethasone 4 mg PO BID Give at 8:00AM and 4:00PM. 10. Docusate Sodium 100 mg PO BID:PRN Constipation 11. Senna 1 TAB PO BID:PRN Constipation 12. Albuterol-Ipratropium [**12-26**] PUFF IH Q4H:PRN dyspnea 13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain 14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Continue to take as long as you are taking decadron or prednisone Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "714.0", "038.9", "150.9", "995.92", "276.7", "996.59", "E878.8", "785.52", "427.31", "198.3", "V12.51", "510.0", "V66.7", "511.89", "513.0", "V49.87", "V49.86", "518.81", "V12.55", "244.9", "530.89", "V58.65", "V44.4" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93", "96.71", "96.04", "34.04" ]

icd9pcs

[ [ [] ] ]

11447, 11456

8765, 10568

284, 375

11507, 11516

6844, 8742

11572, 11582

6294, 6438

11415, 11424

11477, 11486

10594, 11392

11540, 11549

6478, 6790

233, 246

403, 2330

5601, 5936

5952, 6278

6815, 6825

25,972

103,384

28664

Discharge summary

report

Admission Date: [**2186-8-24**] Discharge Date: [**2186-8-31**] Date of Birth: [**2115-10-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ICD/BiV pacer placement in L chest History of Present Illness: 70 M with CHF EF 10%, s/p ICD biv placement through L subclavian vein approach on [**8-24**] complicated by L hemothorax. Chest tube placed in OR-no evidence for active bleeding. Procedure today was complicated by hitting subclavian artery became hypotensive to 90s, Hct 30 to OR out of concern for subclavian artery stick. Inserted chest tube for L hemothorax and pleural effusion Hct 16. 400 cc out, stopped draining overnight to [**8-25**]. Intubated for 24 hrs, then extubated successfully. Aggressive diuresis once BP stabilizes. Went into AFIB, cardioverted in AM, chest tube pulled today. . SBP 150s by arterial line s/p 2L of fluid s/p 3 URBC . ROS: Pt denies fever or chills. No night sweats or recent weight loss or gain. Denied 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. No rash. Past Medical History: New biv icd- concerto [**Company **] CHF-ischemic cardiomyopathy EF %[**10-24**] (below) CAD s/p CABG AFIB s/p R arm surgery w rodding for congenital abnormality L CEA Multiple right ankle fractures arthritis DM Hyperlipidemia Social History: He has been happily married for 47 years. He has three adult children. He is retired. Prior to retiring he worked as an auto mechanic. He does not smoke or drink. He lives with his wife. Family History: He has a mother who died of complications of heart disease and diabetes. He has two brothers both of whom have heart disease and diabetes Physical Exam: Vitals: 97.2 / 77 / 14 / 105-143/48-64 / 98%-100% RA General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, sclera anicteric. MMM, OP without lesions Neck: supple, no JVD or carotid bruits appreciated Pulm: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G appreciated Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted. Ext: No edema b/t, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary, or inguinal LAD. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert & Oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength, and tone throughout. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. F->N and H->S WNL bilaterally. -DTRs: 2+ biceps, patellar and 1+ ankle jerks bilaterally. Downgoing Babinskis bilaterally Pertinent Results: EKG: BiV paced . [**2186-8-26**] CXR: [**Location (un) 1131**] pending . [**2186-8-25**] CXR: There is no pneumothorax. Mild cardiomegaly is stable. No pulmonary edema or appreciable pleural effusion is present. Endotracheal tube was removed between 9:20 and 10:35 a.m. Transvenous right atrial and ventricular pacer leads are unchanged in their positions. The tip of the ventricular lead projects over the mid portion of the right ventricle, and probably along the anterior wall. The tip of the left pleural tube has also repositioned more inferiorly, now at the level of the left hilus. . TTE [**8-24**]: EF 10-20%, [**1-9**]+ AR, 1+ MR [**Name13 (STitle) 650**] global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. LVEF< 20%. The right ventricular cavity is dilated. There is focal hypokinesis of the apical free wall of the right ventricle. Wires are visualized in the RA/RV/coronary sinus. There is a moderate left pleural effusion visualized with small loculations. The effusion mostly disappeared after chest tube drainage. . [**2186-8-24**] 11:23PM TYPE-ART TEMP-35.3 PO2-205* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2186-8-24**] 11:23PM O2 SAT-99 [**2186-8-24**] 09:57PM TYPE-ART TEMP-35.1 PO2-350* PCO2-33* PH-7.41 TOTAL CO2-22 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED [**2186-8-24**] 09:57PM GLUCOSE-147* LACTATE-0.8 NA+-138 K+-4.0 CL--109 [**2186-8-24**] 09:57PM O2 SAT-98 [**2186-8-24**] 09:57PM freeCa-1.16 [**2186-8-24**] 09:28PM GLUCOSE-153* UREA N-48* CREAT-1.1 SODIUM-139 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-20* ANION GAP-13 [**2186-8-24**] 09:28PM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-2.1 [**2186-8-24**] 09:28PM WBC-11.2* RBC-2.80* HGB-8.1* HCT-23.5* MCV-84 MCH-28.9 MCHC-34.5 RDW-16.3* [**2186-8-24**] 09:28PM PLT COUNT-159 [**2186-8-24**] 09:28PM PT-15.5* PTT-33.3 INR(PT)-1.4* [**2186-8-24**] 09:28PM FIBRINOGE-228 [**2186-8-24**] 08:27PM TYPE-ART PO2-305* PCO2-32* PH-7.42 TOTAL CO2-21 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED [**2186-8-24**] 08:27PM GLUCOSE-157* NA+-137 K+-3.8 [**2186-8-24**] 08:27PM HGB-6.8* calcHCT-20 [**2186-8-24**] 08:27PM freeCa-1.02* [**2186-8-24**] 08:02PM TYPE-ART PO2-348* PCO2-39 PH-7.33* TOTAL CO2-21 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED [**2186-8-24**] 08:03PM PLEURAL HCT-16* [**2186-8-24**] 08:02PM TYPE-ART PO2-348* PCO2-39 PH-7.33* TOTAL CO2-21 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED [**2186-8-24**] 08:02PM GLUCOSE-161* NA+-137 K+-4.4 [**2186-8-24**] 08:02PM O2 SAT-99 [**2186-8-24**] 08:02PM freeCa-1.02* [**2186-8-24**] 06:44PM GLUCOSE-186* UREA N-51* CREAT-1.2 SODIUM-137 POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2186-8-24**] 06:44PM WBC-13.4* RBC-3.47* HGB-9.8* HCT-29.3* MCV-85 MCH-28.2 MCHC-33.4 RDW-16.2* [**2186-8-24**] 06:44PM PLT COUNT-183 Brief Hospital Course: 70 M with CHF EF 10%, s/p BiV/ICD placement through L subclavian vein approach on [**8-24**] complicated by L hemothorax, now with L chest hematoma. . # L chest hemothorax: Patient has Class II-III CHF EF 10-20% and had a BiV/ICD pacer placed through the left subclavian vein. Patient developed L hemothorax and had a chest tube placed for one day for evacuation (chest tube pulled on [**8-26**]). He was also intubated and extubated after 1 day for airway protection. CXR showed good lead placement. His hematocrit dropped as low as 15 with SBP 90s, and he received 5 URBC to keep Hct above 30. Throughout, he was asymptomatic, with no chest pain, no shortness of breath. He was placed on ASA 325, plavix 75, carvedilol 6.25 [**Hospital1 **], Lisinopril 2.5 QD, Digoxin 0.125 QD, lasix 20 QD. He was given Vancomycin for 48 hrs s/p ICD placement. He was transferred to CCU stepdown, where he was placed on heparin for AFIB, and developed a 7x7 cm hematoma in his L chest. Pressure dressing was applied, and hematoma gradually diminished over the next 2 days. His pacemaker was checked inhouse by electrophysiology. He was discharged on coumadin 1.5 QD, to followup for Hematocrit and INR with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] as his cardiologist, and Device Clinic. . # AFIB: Patient was in AFIB and was cardioverted on [**8-26**] to NSR. He remained in NSR, and was placed on heparin and coumadin for anticoagulation. He is s/p BiV/ICD placement on [**8-24**], and is paced at 75. For rate control, patient is on carvedilol 6.25 [**Hospital1 **], digoxin 0.125 QD. He was given 1 dose of ibutilide, then was started on amiodarone 600 x1, then 400 x 10 days, then 200 QD thereafter. . # DM2: Metformin and glyburide were held inhouse for hypoglycemic episodes, and patient was on insulin ss. These meds were reinstated upon discharge. Medications on Admission: Medications: Carvedilol 6.25mg daily Lasix 20mg daily Magnesium Oxide 400mg twice daily Lisinopril 25mg daily Digoxin 0.125mg daily Plavix 75mg daily Potassium 40meq daily Zoloft 50mg daily Simvastatin 40mg daily Aspirin 325mg daily Glyburide 5 mg twice daily *Instructed patient to hold the morning of the procedure Metformin 500mg daily *Instructed patient to hold the morning of the procedure Captopril 12.5mg twice daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. Disp:*60 Tablet(s)* Refills:*0* 2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for 5 days. Disp:*15 Tablet(s)* Refills:*0* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please start taking after Amiodarone 400 QD x 9 days. Disp:*30 Tablet(s)* Refills:*2* 15. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO once a day: You will need to have your INR checked by a doctor when you are taking this medication. Disp:*45 Tablet(s)* Refills:*2* 16. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 17. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 18. Hematocrit and INR check Sig: One (1) check Q3 days: Please fax to: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] (cardiology) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology). Disp:*30 checks* Refills:*2* 19. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 9 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Facility: Meadowbrook - [**Location (un) 2624**] Discharge Diagnosis: Primary diagnosis: ICD/BiV pacer placement complicated by L hematoma in L chest Secondary diagnosis: AFIB cardioverted to NSR, CHF EF 10% Discharge Condition: VSS, good, moderate hematoma (5x5 cm) over L chest, ambulating Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all appointments with your physicians as written below. 3. Please come to the emergency room if you experience chest pain, fatigue, dizziness. Followup Instructions: 1. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2186-9-4**] 11:30 AM. You will have your hematocrit and INR checked. Please bring your prescription for hematocrit and INR check with you to this appointment. . 2. Please make an appointment to see Dr. [**Last Name (STitle) 7047**] ([**Telephone/Fax (1) 3183**]) within the next week. Dial this phone number, then press 0. Dr. [**Last Name (STitle) 7047**] is aware that you will be contacting him. Please bring your 'Hematocrit and INR check' prescription to this appointment. . 3. If you cannot get an appointment with Dr. [**Last Name (STitle) 7047**], please call [**Company 191**] outpatient clinic at [**Telephone/Fax (1) 250**], and state that you need a blood test performed (you need a hematocrit and INR check). Please bring your 'hematocrit and INR check' prescription to your appointment. . 3. If you get your hematocrit and INR checked by VNA nursing at home, please have the results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**]. . 4. **Changes in medication: a) DO NOT TAKE WARFARIN (COUMADIN) tonight (Thurs, [**8-31**]). b) Take Warfarin 1.5 mg by mouth once a day starting on Friday. c) Carvedilol 12.5 [**Hospital1 **] was changed to 6.25 [**Hospital1 **]. Completed by:[**2186-9-1**]

[ "V45.81", "414.8", "998.2", "427.31", "458.29", "998.12", "755.50", "511.8", "428.0", "250.00", "272.4", "285.9" ]

icd9cm

[ [ [] ] ]

[ "00.51", "89.49", "96.04", "99.04", "34.04", "96.71" ]

icd9pcs

[ [ [] ] ]

10657, 10726

5964, 7856

328, 365

10910, 10975

3049, 5941

11230, 12576

1911, 2050

8332, 10634

10747, 10747

7882, 8309

10999, 11207

2698, 3030

2065, 2601

278, 290

393, 1440

10850, 10889

10767, 10828

2616, 2681

1462, 1690

1706, 1895

48,736

195,525

47689

Discharge summary

report

Admission Date: [**2181-10-24**] Discharge Date: [**2181-10-27**] Date of Birth: [**2122-11-11**] Sex: F Service: NEUROSURGERY Allergies: Latex / Penicillins / lisinopril / hydrochlorothiazide / sulfa / Losartan / amlodipine Attending:[**First Name3 (LF) 1835**] Chief Complaint: "I have not felt well for over a year" Major Surgical or Invasive Procedure: [**2181-10-24**] Bifrontal craniotomy resection of mass History of Present Illness: This is a very pleasant 58 year old female who present to the office for second opinion regarding her bifrontal brain lesion. She reports that for over a 1 year she was complaining of dizziness, nausea and general fatigue. She was initially treated for HTN. Then she reported a fall due to her dizziness. As a result, a brain MRI was obtained which demonstrated a bifrontal enhancing lesion origination from olfactory groove meningioma. She was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] who recommended surgical intervention. She presents for second opinion. Past Medical History: HTN, Hashimotis thyroiditis, anxiety Social History: married, cosmetic sales, 1 child Family History: NC Physical Exam: O: 5'7", 147 lbs. Gen: WD/WN, comfortable, NAD. HEENT: normal, eyes clear, ears hearing intact, nasal passages patent, oropharynx pink without exudate,Pupils: PERRL EOMs full Neck: Supple. Lungs: CTA bilaterally, no w/c/r Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-25**] 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: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**3-29**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+ ---------- Left 2+ ----------- Toes downgoing bilaterally Handedness Right Discharge: Stable and intact. Bilateral facial edema and periorbital ecchymosis Pertinent Results: Brain MRI with and without contrast [**2181-8-10**]: large bifrontal enhancing lesion originating from olfactory groove without signficant edema. 60% of lesion lay on the left side. No compression on pituitary stalk. Question compression of opthalmic artery. [**2181-10-24**] CT head shows expected postop changes and a substantial amount of bifrontal pneumocephalus. [**2181-10-25**] MRI Brain: expected postop changes, improved pneumocephalus, no evidence of stroke Brief Hospital Course: Patient was admitted to Neurosurgery on [**2181-10-24**] and underwent the above stated procedure. Please review dictated operative report for details. Patient was extubated without incident and transferred to the ICU for Q1 hour neurochecks and systolic blood pressure control less than 140. Postop head CT was negative for hemorrhage but demostrated significant bifrontal pneumocephalus and thus the patient was placed on 100% oxygen via facemask for 24 hours. On POD 1 she was placed on double antiemetic therapy for pesistent nausea and vomiting. MRI on [**10-25**] demosntrated no evidence of stroke with good tumor resection and resolving pneumocephalus. She transferred to the regular floor in stable condition. She continued to have persistent nausea and vomiting and so she was maintained on IV Fluids fo hydration and electrolyte replacement. By [**10-27**] she was mobilizing well and tolerating adequate PO intake and stable for discharge. At the time of discharge she was ambulating without difficulty, tolerating a regular diet, afebrile with stable vital signs. Patient's pain is well-controlled. Pt's incision is clean, dry and inctact without evidence of infection. She is set for discharge home in stable condition and will follow-up accordingly. Medications on Admission: levoxyl 50mcg daily, xanax 0.5mg prn Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, HA, fever. 6. dexamethasone 1 mg Tablet Sig: Taper PO Taper: [**10-27**]: 3mg Q6hrs 12/4-5: 3mg Q8hrs 12/6-7: 2mg Q8hrs 12/8-9: 2mg [**Hospital1 **] [**2181-11-3**]: 2mg Daily [**11-5**]: stop. Disp:*48 Tablet(s)* Refills:*0* 7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: bifrontal cerebral mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Dressing may be removed on Day 2 after surgery. ?????? Your wound was closed with staples and ypou must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-3**] days(from your date of surgery) for removal of your staples and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in [**2-28**] weeks. ?????? You have an appointment in the Brain tumor Clinic on [**2181-12-3**] at 930am with Dr [**Last Name (STitle) 724**]. His office is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name 516**]. His office can be reached at [**Telephone/Fax (1) 1844**]. Completed by:[**2181-10-29**]

[ "348.4", "245.2", "225.2", "784.0", "787.01", "348.89", "401.9", "300.00", "530.81" ]

icd9cm

[ [ [] ] ]

[ "02.12", "01.51" ]

icd9pcs

[ [ [] ] ]

5739, 5745

3240, 4518

394, 452

5813, 5813

2742, 3217

7759, 8542

1235, 1239

4606, 5716

5766, 5792

4544, 4583

5964, 7736

1254, 1555

315, 356

480, 1107

1848, 2723

5828, 5940

1129, 1168

1184, 1219

66,095

136,545

48574

Discharge summary

report

Admission Date: [**2120-10-24**] Discharge Date: [**2120-11-2**] Date of Birth: [**2054-11-17**] Sex: F Service: MEDICINE Allergies: Augmentin Attending:[**First Name3 (LF) 1377**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Thoracentesis Pigtail catheter placement History of Present Illness: Ms. [**Known lastname **] is a 65 year old woman with alcoholic cirrhosis c/b hepatic encephalopathy, hyponatremia, presented to OSH with worsening dyspnea. Patient reports becoming more short of breath over past week, with notable DOE. Less than two days ago, patient developed pleurtic chest discomfort on both the left and right sides of her chest, "kicking" sensation, that progressed over the course of the day yesterday. Patient receives weekly paracenteses, and was scheduled to receive one today. Patient denies fever, did feel chills today. Did not measure temp. Endorses cough productive of clear sputum. No chest pain. No syncope. Denies hematochezia, BRBPR, or melena. Appetite has been okay, patient continues to take nutritional supplements. Reports [**1-25**] BMs daily. Has chronic nausea, episode of emesis yesterday, non-bloody, reflux of food. She also denies dysuria, headaches, and confusion. . Patient presented to OSH ED with above complaints, found sitting on bed in respiratory distress. vitals 139/56 HR 122, 96% on NRB. Received morphine 4 mg x 1. [**First Name8 (NamePattern2) **] [**Hospital1 **] ED, paracentesis performed, no documentation, unclear amount of fluid removed or tests obtained. . Following Med flight from [**Hospital1 **], initial [**Hospital1 18**] ED vs were: 99.1 BP 158/94 HR 128 RR 22 O2 92% on RA, 99% on NRB. Triggered on arrival in resp. distress with sinus tach, breathing to 30s and accessory muscles. received two units of FFP, now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] (3 liters removed), O2 requirement improved to 99% on RA, now breathing at 19 and not using accessory muscles. Patient also received albuterol nebulizer for wheezing and lorazepam 0.5 mg PO x 1. Transfer vitals: 105 128/74 19 97% RA . On the floor, patient reports resolution of pleurisy. Still feels slightly short of breath, also feels fatigued. No other complaints. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: - Alcoholic cirrhosis with stage 4 fibrosis c/b recurrent ascites, hepatic encephalopathy, and hyponatremia - Thrombocytopenia/anemia - Alcohol abuse - h/o Hypertension - Heterozygotic hemochromatosis (clinically silent genotype) - Depression Social History: Ms. [**Known lastname **] lives with her daughter, last EtOH use prior to first admission in [**Month (only) 359**] of this year; per patient, in [**Month (only) 216**]. No current or prior tobacco use. No other drug use. Family History: No history of DVT/PE. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 95.8 139/66 105 28 99% 3 liters n/c General: Alert, oriented, mildly increased work of breathing, otherwise comfortable HEENT: Sclera icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: rare rales left base, markedly dimished breath sounds [**12-27**] up left thorax CV: tachycardic, regular, hyperdynamic, normal S1 + S2, II/VI SEM, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2120-10-23**] 11:03PM BLOOD WBC-14.3* RBC-3.09* Hgb-10.6* Hct-30.6* MCV-99* MCH-34.2* MCHC-34.6 RDW-21.1* Plt Ct-176 [**2120-10-23**] 11:03PM BLOOD Neuts-83.1* Lymphs-9.9* Monos-5.3 Eos-1.5 Baso-0.2 [**2120-10-23**] 11:03PM BLOOD PT-22.7* PTT-40.1* INR(PT)-2.1* [**2120-10-23**] 11:03PM BLOOD Glucose-135* UreaN-16 Creat-0.7 Na-123* K-4.2 Cl-93* HCO3-20* AnGap-14 [**2120-10-23**] 11:03PM BLOOD TotProt-7.7 Albumin-3.5 Globuln-4.2* Calcium-8.7 Phos-3.7 Mg-1.4* [**2120-10-23**] 11:03PM BLOOD TSH-2.0 [**2120-10-24**] 08:30AM BLOOD Ethanol-NEG . Discharge Labs [**2120-11-2**] 04:15AM BLOOD WBC-8.3 RBC-2.45* Hgb-8.6* Hct-26.1* MCV-107* MCH-35.3* MCHC-33.1 RDW-20.5* Plt Ct-97* [**2120-11-2**] 02:05PM BLOOD Glucose-105* UreaN-18 Creat-1.0 Na-129* K-4.7 Cl-92* HCO3-28 AnGap-14 [**2120-11-2**] 04:15AM BLOOD ALT-22 AST-38 LD(LDH)-190 AlkPhos-118* TotBili-5.0* [**2120-11-2**] 04:15AM BLOOD Albumin-3.7 Calcium-9.7 Phos-3.5 Mg-1.4* . Pertinent Reports CXR ([**2120-10-23**]): The left lung shows minimal basilar opacification, but is otherwise clear with no pleural effusion or pneumothorax. There is complete opacification of the right lung concerning for pleural effusion. Mild leftward shift of the mediastinum and trachea is appreciated. . CXR ([**2120-10-24**]): In comparison with the earlier study of this date, there has been apparent reaccumulation of right pleural effusion. No evidence of pneumothorax. Prominence of interstitial markings is consistent with some elevation in pulmonary venous pressure. Relatively mild atelectatic changes seen at the left base. . CXR ([**2120-10-25**]): In comparison with study of [**10-24**], there has been removal of substantial pleural fluid from the right chest. No definite pneumothorax is appreciated. There is a structure simulating a pleural line, but this appears to be an extraneous tube on that side. . CXR ([**2120-10-26**]): In comparison with study of [**10-26**], there is further re-accumulation of the large right hydrothorax. Respiratory motion makes it difficult to determine whether there is true prominence of interstitial markings consistent with elevated pulmonary venous pressure. The left lung remains relatively clear. . CT chest ([**2120-10-28**]): 1. Extensive bronchocentric abnormality is either multifocal aspiration pneumonia or a primary pulmonary hemorrhage and right middle lobe pneumonia. 2. Small residual non-hemorrhagic right pleural effusion with no demonstrable pulmonary cause, since it preceded the multifocal pneumonia; basal pigtail catheter. . CXR ([**2120-10-31**]): 1. Decreased right pleural effusion since [**2120-10-28**]. 2. Faint left mid lung opacity corresponding to CT finding. Other consolidations seen on CT are not visible on the current radiograph. . TTE ([**2120-10-25**]): Normal RV cavity size. Normal global and regional biventricular systolic function. Moderate pulmonary hypertension . Liver US ([**2120-10-25**]): 1. Patent left and right portal veins with normal direction of flow. 2. Cirrhosis. 3. Right pleural effusion. Brief Hospital Course: 65 year old female with alcoholic cirrhosis presented with progressive dyspnea and pleurisy found to have massive right-sided pleural effusion likely due to hepatic hydrothorax. 1. Hepatic hydrothorax - Her initial thoracentesis fluid analysis showed pleural effusion:serum ratio of total protein to be 0.1 and LDH eff:serum ratio of 0.14, both consistent with transudative effusion. Patient has normal LVEF and diastolic function on TTE. Gram stain was negative, no organisms, no polys. Effusion recurred within 6 hours of her first thoracentesis in the ED (~3 liters removed). She was transferred to MICU on day #2 of her admission due to progressive shortness of breath due to her pleural effusion. She was diuresed in the ED with IV lasix and received thoracentesis x 2 with pig tail placement to drain the fluid after the second thoracentesis. Her pleural effusion did not recur after her pig tail catheter was removed. She continued to do well on room air. She was discharged on lasix 40 mg po qdaily, spironolactone 100 mg po qdaily and tolvapton 15 mg po qdaily 2. Hyponatremia: She was noted to have hyponatremia on admission which was thought to be due to nonosmolar vasopression related from her ESLD. Since she needed continued diuresis with lasix and spironolactone to help with her pleural effusion, tolvapton 15 mg po qdaily was started. It was discontinued while she was in the MICU as her sodium normalized. On the floor prior to discharge, she was noted to have hyponatremia again on her lasix/spirolactone dose so she was started on tolvapton 15 mg po qdaily again. 3. Pneumonia: She was noted to have early signs of pneumonia on CT chest. She was started on empiric vancomycin/cefepime which was eventually switched to levaquin/cefpodoxime once blood cultures showed no growth. 4. Alcoholic Cirrhosis- MELD of 19. Continued on her home lactulose and started on rifaximin 550 mg po BID and ursodiol 300 mg po TID (for her itching). Things to follow up on: 1. Sodium: She was started on tolvapton as inpatient to help with her hyponatremia. She will have blood drawn on Monday [**2120-11-4**], Wednesday [**2120-11-6**] and Friday ([**2120-11-8**]) and fax results to [**Telephone/Fax (1) 4400**]. Medications on Admission: saline nasal spray PRN acetaminophen 325 mg 1-2 tabs Q8H PRN pain thiamine 100 mg daily furosemide 40 mg daily omeprazole 20 mg daily promethazine 25 Q6H PRN KCl 20 mEq daily lactulose 15 cc PO TID PRN 3 BMs daily MVI one tab daily Folic acid 1 mg daily magnesium oxide 400 mg daily Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for titrate to [**1-26**] BMs daily. 7. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-25**] Sprays Nasal TID (3 times a day) as needed for dry nose. 12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: Take on [**2120-11-3**] and [**2120-11-4**]. Disp:*2 Tablet(s)* Refills:*0* 13. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours): Take on [**2120-11-2**], [**2120-11-3**] and [**2120-11-4**]. Disp:*5 Tablet(s)* Refills:*0* 14. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 15. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 16. tolvaptan 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. Outpatient Lab Work Please get electrolytes and creatinine (on Monday [**2120-11-4**], Wednesday [**2120-11-6**] and Friday ([**2120-11-8**]). Fax results to [**Telephone/Fax (1) 4400**] (Liver Center at [**Hospital1 771**]) with attention to Dr. [**Last Name (STitle) **]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Hepatic hydrothorax 2. Alcoholic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. On room air Discharge Instructions: You were admitted because you were found to be short of breath due to fluid in your lungs. Fluid was drained from you lungs with a procedure called thoracentesis and a drain was placed to remove the fluid. . One of the electrolytes in your body, sodium, was noted to be low. You were started on a medication called TOLVAPTAN to improved that electrolyte. . FOLLOWING CHANGES WERE MADE TO YOUR MEDICAL REGIMEN: START TOLVAPTAN 15 mg by mouth once a day for your salt levels START ALDACTONE 100 mg by mouth once a day to keep fluid off START RIFAXIMIN 550 mg by mouth twice a day to prevent confusion START LEVAQUIN 750 mg by mouth once a day for two more days (End date: [**2120-11-4**]) for your pneumonia START CEFPODOXIME 200 mg by mouth twice a day for two more days (End date: [**2120-11-4**]) for your pneumonia START URSODIOL 300 mg by mouth twice a day to prevent itching Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] R Address: [**Location (un) 102195**], [**Location (un) **],[**Numeric Identifier 102196**] Phone: [**Telephone/Fax (1) 75222**] *Someone from Dr. [**Last Name (STitle) 102197**] office will call you to schedule an appointment. If you dont hear back within 2 business days, call the number above. Department: LIVER CENTER When: TUESDAY [**2120-11-12**] at 4:00 PM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

[ [ [] ] ]

[ "34.91", "34.04" ]

icd9pcs

[ [ [] ] ]

11196, 11202

6750, 8986

280, 323

11310, 11310

3668, 3668

12377, 13196

3016, 3040

9320, 11173

11223, 11289

9012, 9297

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2298, 2493

233, 242

351, 2279

3684, 6727

11325, 11449

2515, 2760

2776, 3000

51,986

161,938

40951

Discharge summary

report

Admission Date: [**2171-5-1**] Discharge Date: [**2171-5-6**] Date of Birth: [**2099-8-6**] Sex: M Service: MEDICINE Allergies: amiodarone / flecanide / ryhinol / metoprolol / Quinolones / levoquin / Septra / trimethoprim / Sulfamethoxazole / Haldol / Lithium / Percocet / Multaq Attending:[**First Name3 (LF) 7333**] Chief Complaint: paroxysmal Afib presenting for elective PVI; pericardial effusion following PVI complicated by [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 11368**] Major Surgical or Invasive Procedure: attempted PVI pericardiocentesis w/ drain placement History of Present Illness: 71YOM with history of severe COPD, HTN, 4 years of paroxysmal atrial fibrillation, atrial tachycardia and right-sided cardiac hypertrophy presented for elective PVI that was performed under TEE guidance and intracardiac echo. The procedure was complicated by a perforation of his left atrium and a subsequent pericardial tamponade resulting in an episode of hypotension in his 40ies/50ies. Emergency pericardiocentesis yielded 500cc of blood, also causing injury to his right ventricle. A drainage was placed, the patient was intubated, heparin was stopped and protamine was given. Two repeat ECHOs showed no signs of reaccumulation of effusion, INR was 3.4, Hct had fallen from 46 on admission to 35. Patient was subsequently transfered to CCU with pressure in his 110s. . Here patient arrived still intubated and presented with another episode of hypotension in his 70ies. BP responded to a bolus of fluids and a follow-up ECHO confirmed that no fluids had reaccumulated. Next, muscle relaxants were antagonized and the patient was extubated. He was kept anticoagulated with coumadin. . With regard to history of pAF (as per chart) the patient is intolerant of or has failed all antiarrhythmics per Dr.[**Name (NI) 33490**] note of [**2171-2-18**]. Patient denies ever having a cardioversion. Patient was in sinus rhythm during his last office visit with Dr. [**Last Name (STitle) **] and felt well. An echo on [**2081-2-7**] showed a LVEF of 60-65%. The patient reports worsening symptoms during his episodes of atrial fibrillation over the past one and a half years. His symptoms include feeling tired, non-radiating left chest tightness, pounding in chest, and intermittent episodes of shortness of breath sometimes occurring at rest. He sleeps on 3 pillows and occasionally wakes at night gasping and "looking for air". He does not use oxygen at home. His shortness of breath variably limits his activity. Some days he is able to walk his dog 1 mile. Patient reports he is occasionally aware of his atrial fibrillation. He also describes episodes of postural lightheadedness. . REVIEW OF SYSTEMS (as per chart): He denies any prior history of stroke, TIA, claudication, 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 intermittend chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, and palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: pAF, atrial tachycardia 3. OTHER PAST MEDICAL HISTORY: - COPD and asthma - HTN - CIGS - BPH s/p TURP - IBS - anxiety/depression - GERD - arthritis - hard of hearing - s/p hernia repair - s/p hip surgery R 2x Social History: - Tobacco history: about 50 PY, currently 0.5 pack per day - ETOH: currently none - Lives with wife - Retired, worked in welding and hotel maintenance Family History: - No family history of cardiac disease. Physical Exam: ON admission to CCU: VS: T 96, BP 105/56, P 73, RR 19, Sat 100% GENERAL: unresponsive under sedation HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no JVD CARDIAC: PMI located around xiphoid region. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. bilateral wheezes, no crackles or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/e, mild clubbing. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . ON discharge: VS: AF 98.2 113/69-144/86 64-136 18 97% on RA GENERAL: awake, alert, NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, no JVD CARDIAC: PMI located around xiphoid region. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. bilateral wheezes, no crackles or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/e, mild clubbing. No femoral bruits. Pertinent Results: Labs on admission: . [**2171-5-1**] 07:00AM BLOOD WBC-10.0 RBC-4.76 Hgb-15.5 Hct-46.8 MCV-98 MCH-32.7* MCHC-33.2 RDW-14.0 Plt Ct-398 [**2171-5-1**] 07:00AM BLOOD PT-31.0* INR(PT)-3.0* [**2171-5-1**] 07:00AM BLOOD Glucose-70 UreaN-11 Creat-0.7 Na-142 K-4.5 Cl-103 HCO3-29 AnGap-15 [**2171-5-2**] 05:00AM BLOOD ALT-14 AST-24 LD(LDH)-186 AlkPhos-92 TotBili-0.4 . After 2U PRBC transfusion: [**2171-5-1**] 05:53PM BLOOD WBC-15.0* RBC-3.30*# Hgb-11.0*# Hct-32.6*# MCV-99* MCH-33.4* MCHC-33.9 RDW-13.9 Plt Ct-368 . [**5-1**] TTE: FOCUSED STUDY: The right atrium is dilated. The right ventricular cavity is dilated with mild global free wall hypokinesis. The tricuspid valve leaflets are mildly thickened. There is a large pericardial effusion. The effusion appears circumferential. No right ventricular diastolic collapse is seen. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Post-pericardiocentesis: There is resolution of the pericardial effusion. . [**5-2**] TTE: The right ventricular cavity is markedly dilated with mild global free wall hypokinesis. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2171-5-1**], the current study is more complete. The findings are similar. A small amount of pericardial fluid persists, particularly near the right atrium. There is fluid seen also near the inferolateral wall - this area was not visualized on the two post-tap studies yesterday. Brief Hospital Course: 71YOM with history of severe COPD, HTN and paroxysmal atrial fibrillation presented for elective PVI that was complicated by a perforation of his left atrium and a hemodynamically significant pericardial tamponade s/p emergency pericardiocentesis and drain placement. # Pericardial tamponade: Following perforation of LA during PVI; pericardiocentesis removed 500 cc of blood. Tamponade resolved after pericardiocentesis in the cath lab. Pericardial drain was left in overnight and was removed on [**5-2**] after drained only 100 cc's. Repeat Echo on [**2171-5-2**] confirmed there was no reaccumulation of fluid and no tamponade physiology. BP was stable ~ 90s-100s/40s. He received intermittent fentanyl for pericarditis. He was called out to the cardiology floor on [**5-3**]. # Hallucinations: He was noted to have hallucinations on [**5-2**] which he reports having had in the past. He was restarted on his home benzodiazepine and received intermittent Zyprexa for agitation. # Hypotension: Acute drop in blood pressure to 70's after transfer to the floor. Resolved with 1L IVF bolus and reduction in propofol dose. BP's were then measured in the 100's. Likely secondary to hypovolemia / dehydration and medication effect. # COPD: History of severe COPD on Albuterol / Ipratropium bromide nebs QID and Theophylline 200 mg 1 tbl [**Hospital1 **]. Bilateral wheezes across all lung fields. Home medications were continued. # pAFib: History of pAFib with symptoms of tiredness, non-radiating left chest tightness, pounding in chest, and intermittent episodes of shortness of breath sometimes occurring at rest. After attempted PVI failed, he was started on dofetilide. EKG was checked after each dose to ensure there was no significant increase in QT interval. Heart rate remained elevated on [**5-4**] - [**5-5**] and rose into the 160s (multifocal atach). Diltiazem was increased to 90 mg QID. Coumadin was restarted - dose was decreased to 2 mg per day from 2.5 mg per day at home. Dofetilide was stopped due to unable to maintain sinus rhythm. # Anemia: Due to blood loss given 14 point hct drop - though this may not reflect true hct as drawn after receiving 4L IVF. He received 2U PRBC and Hct stabilized ~ 33. # Leukocytosis: Probably due to stress response, as currently no clinical signs of infection. Also received one dose of steroids on admission to CCU. Blood cultures were negative. CXR showed mild pulmonary edema but no infiltrate. WBC improved and was 11.9 on discharge. # Arthritis: Treated at home with Tylenol as needed. # Anxiety / depression: continued home meds Alprazolam 0.5 mg 1 tbl TID and Sertraline 50 mg 1 tbl daily. # Delirium/agitation: On the evening of [**5-4**], the patient became increasingly agitated. Zyprexa 2.5 mg IM was given without effect. The patient required restraints overnight to prevent him from harming himself. Medications on Admission: - Verapamil 360 mg 1 tbl daily - Digoxin 250 mcg 1 tbl daily - Warfarin 5 mg 0.5 tbl daily - Aspirin 81 mg 1 tbl daily - Albuterol / Ipratropium bromide inhaler 2 puffs QID - Theophylline 200 mg 1 tbl [**Hospital1 **] - Tylenol as needed - Alprazolam 0.5 mg 1 tbl TID - Sertralin 50 mg 1 tbl daily Discharge Medications: 1. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization Sig: One (1) vial Inhalation four times a day. 3. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) vial Inhalation four times a day. 4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:*15 Tablet(s)* Refills:*2* 10. theophylline 200 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO BID (2 times a day). 11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 12. Outpatient Lab Work Please check INR on Wednesday [**5-8**] with results to Dr. [**Last Name (STitle) **] 13. Cartia XT 180 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO twice a day. Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Atrial fibrillation Chronic Obstructive Pulmonary Disease Delerium Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital following a pulmonary vein ablation to treat atrial fibrillation. Unfortunately, this procedure was complicated by bleeding around your heart and the procedure was not completed. To help control your heart rate, you were started on a medication called diltiazem. You will need come back to [**Hospital1 18**] for an ablation of your heart and will need a permanant pacemaker. The cardiology office will call you with a date and time and instructions in the next week. Please call [**Telephone/Fax (1) 62**] and ask to talk to a electrophysiology fellow on call if you are worried about your heart rate or blood pressure on these new medicines. . We made the following changes to your medications: We STOPPED Verapamil and Digoxin We STARTED Diltiazem long acting to lower your heart rate We CHANGED Coumadin to 2 mg per day, you should have your INR checked on Wednesday [**2171-5-8**] WE started a low dose of Atenolol to slow your heart rate . Your follow-up information is listed below. Please watch the swelling in your legs and keep your legs elevated as much as possible. You can also get compression stockings at the pharmacy to use to reduce the swelling. If the swelling worsens, please call Dr. [**Last Name (STitle) **]. Followup Instructions: Name: [**Last Name (LF) 89374**],[**First Name3 (LF) **] Location: [**Hospital **] [**Hospital **] HEALTH CENTER Address: [**Location (un) 10215**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 10216**] Appointment: Friday [**5-10**] at 8:30AM Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**] Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 18655**] Phone: [**Telephone/Fax (1) 8725**] Appointment: Friday [**5-10**] at 10:45AM

[ "427.32", "998.11", "E879.0", "600.00", "305.1", "423.3", "493.20", "458.29", "420.90", "401.9", "564.1", "998.2", "427.31", "276.51", "293.0", "E870.6" ]

icd9cm

[ [ [] ] ]

[ "37.0", "99.69", "37.27", "37.34", "37.28" ]

icd9pcs

[ [ [] ] ]

11417, 11480

6823, 9706

568, 621

11604, 11604

5027, 5032

13047, 13730

3755, 3796

10054, 11394

11501, 11583

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3811, 4529

3361, 3385

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370, 530

649, 3251

5046, 6800

11619, 11733

3416, 3570

3273, 3341

3586, 3739

6,217

179,921

3102

Discharge summary

report

Admission Date: [**2121-4-14**] Discharge Date: [**2121-5-9**] Date of Birth: [**2068-4-29**] Sex: F Service: MEDICINE Allergies: Percocet / Heparin Agents Attending:[**First Name3 (LF) 3619**] Chief Complaint: Pelvic Mass Major Surgical or Invasive Procedure: Exploratory laparotomy, TAH, Pelvic Lymph node dissection, repair of left renal vein defect. Colectomy with side to side reanastomosis Lysis of adhesions and loop transverse colostomy Central Line Placement Chemotherapy Blood product Transfusion History of Present Illness: The patient is a 52 year old female sent by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14727**] for consultation regarding an enlarged uterus. The patient presented recently with postmenapausal bleeding. She was noted to have multiple vaginal lesions on examination. Pelvic exam revealed an enlarged uterus. An ultrasound at [**Hospital3 **] on [**2121-4-1**] revealed a uterus measuring 13.1 cm in largest diameter. She recently underwent examination and D&C with Dr. [**Last Name (STitle) 14727**] which showed multiple vaginal tumors. A biopay of two of the vaginal lesions revealed squamous cell carcinoma. She also mentioned that she had an attempted colonoscopy, but this was unsuccessful due to difficulty in passing the colonoscope. Past Medical History: SVT x 2 Neg ECHO and EKG No CAD Surgical HX: Laprascopic BSO [**2117**] Social History: No smoking Drinks Occasionally Family History: Significant for a mother who died of ovarian CA at age 48, sister diagnosed with a stage II ovarian cancer at age 52, and a paternal aunt who developed breast cancer in her 60s Physical Exam: Gen: Well developed, well nourished HEENT: sclerae anicteric, lymph node survey is negative Lungs: clear to auscultation Heart: regulart without murmurs Breasts: without masses Abd: soft, nondistended. There was a palpable mass wxtending to the lower abdomen, particularly on the left side. This was nontender Ext: without edema. Pertinent Results: SPECIMEN SUBMITTED: UTERINE TUMOR (FS), LEFT EXTERNAL ILIAC, UTERUS AND CERVIX, RIGHT ILIAC LYMPH NODE, OBTURATOR, LYMPH NODE, COMMON ILIAC, PERI AORTIC LYMPH NODE, HIGH PERI AORTIC LYMPH NODE, LEFT PERI AORTIC LYMPH NODE, DISTAL SIGMOID, AND SIGMOID COLON (10). Procedure date Tissue received Report Date Diagnosed by [**2121-4-14**] [**2121-4-14**] [**2121-4-23**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12033**]/kg Previous biopsies: [**Numeric Identifier 14728**] EMC,POST/ANT WALL VAGINAL BX. [**-2/2301**] EMC, LEFT FALLOPIAN TUBE & OVARY, RIGHT FALLOPIAN TUBE & [**-1/2017**] ENDO BX/bq/wp. [**Numeric Identifier 14729**] ENDOMETRIAL POLYP + EMC/ga. (and more) DIAGNOSIS: 1. Uterine tumor, biopsy (A-F): Poorly differentiated carcinoma with extensive necrosis. 2. Left external ileac lymph nodes (G-J): Metastatic poorly differentiated carcinoma present in one of six ([**12-13**]) lymph nodes. 3. Uterus and cervix, total hysterectomy (K-Q): a. Metastatic poorly differentiated carcinoma extensively and diffusely involving serosa, myometrium, lymphatic- vascular spaces, and focally endometrial stroma (see note). b. Inactive endometrium. 4. Lymph nodes, right external iliac (R-T): Metastatic poorly differentiated carcinoma present in two of eleven ([**1-18**]) lymph nodes. 5. Lymph nodes, right obturator (U-W): Metastatic poorly differentiated carcinoma present in four of five ([**3-12**]) lymph nodes and blood vessels. 6. Lymph nodes, right common iliac (X-Y): Metastatic poorly differentiated carcinoma present in two of two ([**1-9**]) lymph nodes. 7. Lymph node, peri-aortic (Z): Metastatic poorly differentiated carcinoma present in one of one ([**12-8**]) lymph node. 8. Lymph node, high peri-aortic (AA): Metastatic poorly differentiated carcinoma present in one of one ([**12-8**]) lymph node. 9. Lymph nodes, left peri-aortic (BA-EA): Twelve lymph nodes, no carcinoma seen (0/12). 10. Distal colon, segmental resection (FA-HA): Segment of colon with focal endometriosis. No carcinoma seen. 11. Sigmoid colon, segmental resection (IA-NA): Metastatic poorly differentiated carcinoma involving serosa, subserosa, muscularis propria, focally submucosa, and present within large blood vessel. Note: No origin of this carcinoma is identified in the uterus, endometrium, and colon segments submitted. Immunohistochemical stains reveal tumor cells to be positive for CK7 and CEA, with no staining for CK20, S100, and MART1. The microscopic and immunophenotypical features are not specific as to origin, however favor Mullerian sites including possibly endometriosis. Primary peritoneal, breast, and lung carcinoma are also within the differential. Other mucosal sites are less likely, but not definitively excluded. Additional immunostains are being performed (ER, PR, and CDX-2) for further characterization, the results of which will be reported in an addendum. Sinus tachycardia, rate 117. Since the previous tracing of [**2121-4-11**] the heart rate is faster. Increased ST-T wave abnormalities are seen with diminished voltage over the mid to lateral precordium. Read by: [**Last Name (LF) **],[**First Name3 (LF) 1730**] Intervals Axes Rate PR QRS QT/QTc P QRS T 117 96 72 318/387.71 48 21 23 CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: please evaluate for PE Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 52 year old woman with metastatic endometiral CA, POD #3 from extensive case, now with tachycardia, o2 sat 94 REASON FOR THIS EXAMINATION: please evaluate for PE CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 52-year-old female now postop day 3 with tachycardia and hypoxia. TECHNIQUE: MDCT continuously acquired axial images of the chest were obtained, using a low-dose technique at end expiration without IV contrast followed by images after the administration of 100 mL of Optiray IV contrast as a rapid bolus per the pulmonary embolism protocol. Coronal and sagittal reformatted images were also obtained. CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There is no pathologic mediastinal, axillary or hilar lymphadenopathy. The heart and pericardium are unremarkable. There are new small bilateral pleural effusions with associated bibasilar atelectasis. The previously identified 9 mm subpleural lingular lesion is now less prominent and likely represented inflammatory change. The previously described probable esophageal duplication cyst is not well visualized. There has been no significant change in right paraspinal soft tissue nodules adjacent to T4 and T5. Limited evaluation of the abdomen demonstrates a new small amount of perihepatic ascites. The previously identified hepatic lesions are better seen on CT of [**2121-4-2**] due to differences in contrast timing. CT ANGIOGRAM OF THE CHEST: There are filling defects of the basal segmental arteries of the left lower lobe indicative of pulmonary embolism. There is subtle mosaic perfusion at the apices bilaterally which could be compatible with tiny emboli or less likely hypersensitivity due to a drug reaction. The heart opacifies well. The aorta is of normal caliber without evidence of aneurysm or dissection. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. Pulmonary emboli of the left lower lobe basal segmental arteries. 2. Small bilateral pleural effusions with associated bibasilar atelectasis. 3. No significant change in right paraspinal soft tissue nodules along T4 and T5. 4. New small amount of perihepatic ascites. 5. Hepatic metastases better seen on CT [**2121-4-2**] due to differences in timing of contrast. CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: EVAL FOR FLUID COLLECTION/ABSCESS, S/P HYSTERECTOMY, SURGICAL STAGING FOR PELVIC MASS, SPIKING TEMPS Field of view: 40 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 52 year old woman POD #21 s/p Hysterectomy, surgical staging for pelvic mass now spiking temps, cellulitis vs. intraabdominal abscess. REASON FOR THIS EXAMINATION: R/O fluid collection/abscess CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Post-op day #21, status post hysterectomy and pelvic mass. Cellulitis versus abscess. COMPARISON: [**2121-4-2**]. TECHNIQUE: Contrast-enhanced axial CT imaging of the chest, abdomen and pelvis with coronal and sagittal reformats was reviewed. CT CHEST WITH CONTRAST: Again identified in the chest are two paraspinal lesions (1.7 and 2.4 cm) that are concerning for metastases. Again seen is a fluid-containing structure adjacent to the esophagus, likely a duplication cyst. No lung nodules are identified. The heart and great vessels of the mediastinum are unremarkable. CT ABDOMEN WITH CONTRAST: Multiple hypodense lesions likely metastases are again identified in the liver. There is a new ascites throughout the abdomen and pelvis. The gallbladder, pancreas, spleen, adrenals, and kidneys are normal. Adjacent to the aorta near the left renal vein is a hypodense 3-cm mass, again likely metastatic disease. Small bowel loops are of normal caliber. Within the mid abdomen is a focal un-drainable fluid collection. This collection demonstrates no enhancement to suggest abscess, but continued followup may be helpful as this may represent an organizing collection. A similar collection is seen more inferiorly. Free flowing ascites present about the liver and runs along both paracolic gutters. There is a small amount of left perinephric fluid. CT PELVIS WITH CONTRAST: Bladder appears normal. There is a small free fluid in the pelvis. The rectum, sigmoid, and large bowel are normal-appearing. The patient is status post removal of a large uterine mass. BONE WINDOWS: No lytic or sclerotic lesions are identified. IMPRESSION: 1. New fluid fluid throughout abdomen and pelvis, though continued follow- up may be helpful if symptoms persist to exclude organizing collection. 3. Metastatic disease as described above. 4. Status post hysterectomy. CT ABDOMEN W/CONTRAST [**2121-4-26**] 2:55 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: Abd/Pelvis with contrast to assess for peritonitis, abscess, Field of view: 38 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 52 year old woman POD#12 s/p hyst/signmoid colectomy with reanastomosis with peritoneal cancer with spiking fevers and unknown source REASON FOR THIS EXAMINATION: Abd/Pelvis with contrast to assess for peritonitis, abscess, anastamotic leak CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 52-year-old woman post-operative day 12, status post hysterectomy and sigmoido-colectomy with re-anastomosis with peritoneal cancer, now spiking fevers of unknown source. Question peritonitis, abscess, anastomotic leak. Comparison is made to [**2121-4-25**]. TECHNIQUE: MDCT acquired axial images from the lung bases through the pubic symphysis were acquired with intravenous and oral contrast material and displayed with 5-mm slice thickness. Multiplanar reformations were performed. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is stable atelectasis and small pleural effusions at the lung bases. The amount of abdominal ascites has increased slightly compared to yesterday. Multiple hypoattenuating liver lesions appear unchanged. No evidence of cholelithiasis or cholecystitis is seen. Spleen, kidneys, adrenal glands, pancreas appear unchanged. There is contrast material throughout the small bowel.There is a single slightly dilated small bowel loop (3.6 cm). No small bowel wall thickening is seen. There is contrast material in the colon which presumably represents contrast from the prior study as it exhibits higher density values than the small bowel. The colonic loops appear unremarkable without wall thickening or pneumatosis. There are tiny amounts speckled contrast material layering on top of the bladder, in proximity of the anastomis, suggestive of anastomotic leak, although the exact location of the extravasation cannot be determined. Multiple pockets of ascites are scattered throughout the mesentery, which have not significantly changed compared to yesterday. The descending aorta and its major tributaries appear patent. There is stable 3- cm left retroperitoneal mass representing metastasis. Note is made of significantly increased free air within the anterior abdomen, around the porta hepatis, and in multiple locations in the mesentery, increasing the suspicion for leak/perforation. The appearance of the midline incision appears unchanged without evidence of new dehiscence. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The amount of pelvic ascites is approximately stable. The anastomotic site appears unchanged. There is a small amount of air in the bladder, presumably to recent catheterization. Small bowel loops in the pelvis appear unremarkable. IMPRESSION: 1. Significant increase in amount of free intra-abdominal air. There is a very small amount of extraluminal contrast layering on top of the bladder (Se2 Im 75) in proximity to the anastomosis. These findings are suggestive of a leak or bowel perforation, most likely an anstomotic leak. 2. Slight increase in amount of abdominal ascites. 3. Stable left retroperitoneal mass representing metastasis. Ther pertinent findings have been communicated to Dr. [**Last Name (STitle) 14730**] at 11.20 pm on [**2121-4-26**]. Brief Hospital Course: She was admitted to [**Hospital1 18**] on [**2121-4-14**] and went to the OR for a resection of a pelvic mass and sigmoid colectomy. Her surgery was complicated by injury to the left renal vein and approximately 2 liter blood loss. #Respiratory Failure She was intubated post-operatively with metabolic acidosis that improved on ventilation. She was extubated on POD 2. #Heme She was stable hemodynamically after receiving PRBC and multiple liters of crystalloid. There were no signs of active bleeding. She received several fluid boluses POD 2 for a low urine output. POD 12, thrombocytopenia was noted. At this point there was a concern for HIT due to low platelet count. On [**2121-4-27**], POD 13, she received FFP prior to going to the OR for an urgent exploratory laparotomy. Hematology recommended HIT antibodies ordered and subsequently she was started on Argatroban while awaiting a therapeutic INR with Coumadin. She also received RBC transfusions for a HCT of 24. Her PTT and INR were monitored daily and Coumadin was dosed accordingly. #CV POD 2 she had SVT at a rate of 190-205 and BP 150/100. She was treated with Adenosine 6mg x 1 dose that converted her to ST HR 115-117 with no ectopy. She has a history of SVT and was previously treated with Adenosine. Most likely the episode was due to increased catecholamine state and increased total circulating blood volume, possibly causing atrial stretch. She continued to have tachycardic episode with HR >130bpm. She was treated with Lopressor for tachy episodes and rate controlled. She was started on a Heparin drip for evidence of a Pulmonary Embolism as seen on a CTA on POD 4. #Pain She was started on a PCA after being extubated with good relief. She was transitioned to oral pain medications once taking PO's. #Wound OB/GYN recommendations were followed. The wound was healing well with staples in place. Erythema was noted several days post-operatively to the inferior aspect of the incision which improved. Her incision remained C,D,I. The staples were removed on [**2121-5-6**], POD 22/10. Her JP drain was pulled on POD 23/11 and a suture placed. #GI The patient was NPO awaiting return of bowel function. No flatus for several days. POD 7, she had + flatus and +BM and was tolerating fluids. She spike a temp to 101.7 on POD 10. Blood cultures later showed no growth. She was empirically started on Keflex, which was later changed to Augmentin. Augmentin was then changed to Levo/Clinda. She also was having RLQ abdominal pain and increased generalized pain with no N/V. A CT showed intraabdominal ascites and free air, but no evidence of a Pneumonia or pelvic abscess. A surgery consult was obtained on [**2121-4-27**] for evaluation of free air and a small amount of oral contrast in peritoneum and question of an anastomotic leak. She went to the OR for an Exploratory Laparotomy and loop colostomy to repair an anastomotic leak. There were no signs of sepsis. She was continued on Vanco/Levo/Flagyl. The Ostomy nurse, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10132**], instructed the patient on care of a new transverse colostomy. She was NPO post-operatively and receiving TPN nutrition. Her diet was advanced and the TPN weaned once she had return of bowel function. On [**2121-5-7**] she was tranfered to the OMED service to start chemo. Medications on Admission: Effexor [**Doctor First Name **] Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 4 weeks. Disp:*45 Tablet(s)* Refills:*0* 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 7 doses: Have INR checked by PCP and dose Coumadin accordingly. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Metastatic Pelvic Cancer Pulmonary Embolism Heparin-Induced Thrombocytopenia Free intraperitoneal air and anastomotic leak resulting in colostomy. Discharge Condition: Good, tolerating POs well, ambulating well, hemodynamically stable. Discharge Instructions: Please seek immediate medical attention if you have fever >101.4F, nausea or vomiting, shortness of breath, severe or persistent abdominal pain or bleeding, persistent redness around your surgical site, increased bruising or bleeding, new leg swelling, or any other worrisome symptoms. . Please take all medications as directed. You should not drive while taking pain medications. You should take a stool softener while taking pain medications. . You may shower normally but keep your surgical site clean and dry. No heavy lifting for 6 weeks. Continue to walk several times per day. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Date/Time:[**2121-5-15**] 11:00 Provider: [**Name10 (NameIs) 9977**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2121-5-20**] 11:00 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**] Date/Time:[**2121-5-20**] 2:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2121-5-29**] 10:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**] Completed by:[**2121-5-12**]

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Discharge summary

report

Admission Date: [**2192-10-23**] Discharge Date: [**2192-11-30**] Service: MEDICINE Allergies: Penicillins / Ciprofloxacin / Atenolol / Amiodarone / Diphenhydramine / Neosporin / Tetanus Toxoid,Adsorbed / Vancomycin / Bactrim Ds / Heparin Agents Attending:[**First Name3 (LF) 2181**] Chief Complaint: hypotension, altered mental status. Major Surgical or Invasive Procedure: None. History of Present Illness: 89F with multiple medical problems who presented to [**Hospital1 18**] on [**2192-10-23**] d/t hypotension from E. coli urosepsis in setting of poor PO intake, hypovolemia, and poor IV access/fluid administration. Briefly, the patient is s/p recent 1 month admission to [**Hospital3 **] for COPD exacerbation, complicated by AIN [**12-28**] Cipro, and hypernatremia, discharged to [**Hospital 100**] rehab. She was admitted to the MICU on [**10-23**] w/ urosepsis and hypotension, and required dopamine and dobutamine for septic shock with cardiogenic shock component and was given stress dose steroids for adrenal insufficiency. She was initially treated with Linezolid, meropenem, and gentamycin which was narrowed to ceftriaxone once E.coli identified (completed 10 day course). She was called out to floor on [**10-28**] and remained HD stable with tapering of steroids (finished [**11-14**]). On [**11-6**] the patient was hypothermic and blood cultures were drawn and demonstrated Stenotrophomonas bacteremia; she was started on Bactrim which was changed to ceftaz on [**11-13**] due to worsening renal failure with plan for 14 day course. 2 days after finishing Ceftaz she became hypothermic on the floor (temps to 91) and hypotensive. She was transferred to the MICU on [**11-22**] - where she responded to IVF/warming blanket. She was started on stress dose steroids. Stat Abd CT only showed left pleural fluid collection (although study inadequate due to lack of contrast). Blood cultures have remained negative since [**11-8**]. Urine has grown yeast, she is s/p one dose of fluconazole for yeast in her urine with continued yeast despite this dose. She had a renal US today to evaluate for possible abscess and received a second dose of fluconazole. . In regards to ARF, patient developed AIN at OSH d/t cipro and was prerenal d/t septicemia. Her renal function improved daily as HD's improved, with renal following. Developed exacerbation while on bactrim, which was stopped. Cr drifted down to a low of 1.0, but she has been intermittently diuresed d/t whole body anasarca, leading to worsening renal function again - lasix was stopped on [**11-21**]. Additionally, there was concern for HIT as PF4 was positive but SRA negative so no longer on treatment with argatroban for HIT. Also, patient has had significant whole body edema d/t RV failure and hypoalbuminemia and she was intermittently diuresed as above. . On review of systems, the patient denies any chest pain, shortness of breath, night sweats, fevers, chills, weight loss, night sweats, fatigue, headaches, dizziness, blurred vision, sore throat, nausea, vomiting, abdominal pain, any new rashes, denies dysuria, hematuria, increased urgency, diarrhea, constipation, hematochezia, melena, epistaxis. All other systems reviewed in detail and negative except for what has been mentioned above. Past Medical History: CAD s/p left circumflex stent in [**2182**] COPD CHF HTN Hyperlipidemia Sick sinus syndrome s/p pacemaker placement [**2188**] Syncope PAF GERD Diverticulosis of the sigmoid colon s/p colon resection [**12-28**] colonc cancer History of VRE in urine and stool Spinal stenosis Iron deficiency anemia Social History: From [**Hospital **] rehab. h/o smoking. Good family supports. Family History: Noncontributory. Physical Exam: ADMISSION EXAM VS: t: 96.1; BP: 104/36; HR: 75; RR: 16; O2: 99 5L Gen: Lethargic, though easily arousable. Words are slightly mumbled but in NAD HEENT: Left surgical pupil. R pupil ERRL; EOMI; sclera anicteric; conjunctiva slightly pale Neck: JVD to mandible. No LAD CV: RRR S1S2. No M/R? Lungs: Scattered crackles at bases, course sounds. Pt unable to take in deep breaths of me. Ext: 2+ pitting edema b/l. DP 1+ Neuro: Difficult to do exam. CN II-XII tested, intact. Can grip hands and moves all four limbs. Biceps, brachio, pattella [**11-27**]. Skin: Scattered diffuse erythematous, nonwarm rash throughout. On back blachable with few echhymotic areas. Scattered erythema on abdomen, extremities and face. No pustules or macules. Confluencing in areas. Pertinent Results: Hematology: [**2192-10-23**] 01:05PM PT-15.0* PTT-33.8 INR(PT)-1.3 [**2192-10-23**] 09:18AM WBC-4.9 RBC-3.31* HGB-10.1* HCT-30.5* MCV-92 MCH-30.5 MCHC-33.1 RDW-21.4* [**2192-10-23**] 09:18AM NEUTS-74* BANDS-14* LYMPHS-6* MONOS-1* EOS-4 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* . Chemistry: [**2192-10-23**] 09:18AM GLUCOSE-135* UREA N-62* CREAT-2.3* SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17 [**2192-10-23**] 09:18AM proBNP-6508* [**2192-10-23**] 09:18AM CALCIUM-8.4 PHOSPHATE-4.4 MAGNESIUM-2.3 [**2192-10-23**] 01:05PM FIBRINOGE-341 [**2192-10-23**] 09:18AM CORTISOL-11.2 [**2192-10-23**] 01:58PM TSH-1.6 [**2192-10-23**] 01:58PM CORTISOL-23.8* [**2192-10-23**] 01:05PM CORTISOL-21.2* [**2192-10-23**] 06:51AM LACTATE-1.0 [**2192-10-23**] 06:45AM CK(CPK)-21* [**2192-10-23**] 06:45AM CK-MB-NotDone cTropnT-0.06* [**2192-10-23**] 05:20AM PO2-36* PCO2-51* PH-7.35 TOTAL CO2-29 BASE XS-0 [**2192-10-23**] 12:50AM ALT(SGPT)-31 AST(SGOT)-34 CK(CPK)-25* ALK PHOS-255* AMYLASE-42 TOT BILI-0.7 [**2192-10-23**] 12:50AM LIPASE-63* . Other Data: [**2192-11-26**]: C.diff negative [**2192-11-25**]: Urine culture: YEAST. >100,000 ORGANISMS/ML. 2ND ISOLATE. <10,000 organisms/ml. [**2192-11-23**]: Blood culture x 2 pending [**2192-11-8**]: Blood culture STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. ANAEROBIC BOTTLE (Final [**2192-11-15**]): PORPHYROMONAS SPECIES. BETA LACTAMASE NEGATIVE. . [**10-23**] CXR IMPRESSION: Interval increase in size in the cardiac silhouette that may represent increasing heart size, or perhaps a pericardial effusion. There is no evidence of failure. . [**10-23**] Head CT: A hypodense focus in the right lentiform nucleus, which could represent subacute infarction. Please note sensitivity of MR is much higher than the present CT in detecting acute brain ischemia. . [**10-24**] Echo: Conclusions: 1. The left atrium is moderately dilated. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.The right ventricular cavity is mildly dilated. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] 4.The ascending aorta is mildly dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-27**]+) mitral regurgitation is seen. 7.Severe [4+] tricuspid regurgitation is seen. 8.There is moderate pulmonary artery systolic hypertension. 9.There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2189-6-11**], the RV is now mild to moderately dilated with severe TR. . [**10-25**] Renal US: Evidence of some bilateral renal cortical atrophy. No signs of obstruction. Small left effusion noted . [**10-29**] KUB: Moderate amount of air and stool throughout the colon. No dilated bowel. . [**10-23**] CXR IMPRESSION: Interval increase in size in the cardiac silhouette that may represent increasing heart size, or perhaps a pericardial effusion. There is no evidence of failure. . [**10-23**] Head CT: A hypodense focus in the right lentiform nucleus, which could represent subacute infarction. Please note sensitivity of MR is much higher than the present CT in detecting acute brain ischemia. . [**10-24**] Echo: Conclusions: 1. The left atrium is moderately dilated. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.The right ventricular cavity is mildly dilated. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] 4.The ascending aorta is mildly dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-27**]+) mitral regurgitation is seen. 7.Severe [4+] tricuspid regurgitation is seen. 8.There is moderate pulmonary artery systolic hypertension. 9.There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2189-6-11**], the RV is now mild to moderately dilated with severe TR. . [**10-25**] Renal US: Evidence of some bilateral renal cortical atrophy. No signs of obstruction. Small left effusion noted . [**10-29**] KUB: Moderate amount of air and stool throughout the colon. No dilated bowel. . [**11-22**]: CT Abdomen/Pelvis 1. Limited examination due to lack of intravenous contrast and large amount of streak artifact within the pelvis due to patient body habitus. Given these limitations, no definite evidence of colitis or diverticulitis identified. 2. Moderate-sized left side pleural fusion and asymettric soft tissue swelling of left chest wall. 3. Extensive degenerative changes of the thoracic and lumbar spine with compression fractures of T8 and T9 vertebral bodies of uncertain chronicity. 4. Midline omental containing hernia. No evidence of infarction or bowel obstruction. Large amount of stool in rectal vault. . [**11-23**]: CT Chest 1. Limited study due to the lack of intravenous contrast [**Doctor Last Name 360**] and motion artifact. 2. Cardiomegaly, pericardial effusion, and moderate pleural effusion on the left and small pleural effusion on the right with associated atelectasis. The evaluation of the underlying cause of effusion is limited due to the lack of intravenous contrast [**Doctor Last Name 360**]. 3. Enlarged left thyroid gland with 2-cm nodule. 4. Findings suggestive of tracheobronchomalacia with mucous secretion in the right main bronchus and bronchus intermedius and lower lobe bronchi. 5. Small amount of ascites and gallstone. Evaluation of the upper abdomen is limited. 6. Left upper lobe opacity. Follow-up to comfirm resolution. . [**11-27**]: Renal US: The right kidney measures 10.1 cm. The left kidney measures 10.4 cm. There are no stones, hydronephrosis, or perinephric fluid collection bilaterally. Again seen is evidence of cortical atrophy. There is mild-to-moderate amount of ascites. . [**11-29**]: Thyroid US: Study is limited by patient respiratory motion. Right thyroid gland measures 2.5 x 2.1 x 3.7 cm, and the left thyroid gland measures 2.8 x 2.8 x 3.3 cm. Both lobes are heterogeneous with multiple masses. The largest nodule is within the left mid/lower pole of the thyroid gland and measures 2.4 x 1.3 x 2.2 cm. This nodule corresponds to the nodule noted on recent CT, and is likely stable dating back to [**2189-5-26**] when a chest radiograph demonstrated fullness of the left superior mediastinum. IMPRESSION: Multinodular goiter Brief Hospital Course: 89F w/ multiple medical problems admitted initially to MICU with E. coli urosepsis, now resolved, complicarted by ARF, stenotrophomonas bactermia, hypotension, adrenal insufficiency, GI bleeding, HIT type 2, hospital-acquired pneumonia. . # Adrenal insufficiency: She has had cortisol levels in the past, both in the setting of sepsis and while completing a steroid taper, which have been consistent with both relative and absolute adrenal insufficiency, respectively. She had a normal cosynotropin stim test on [**11-23**], however cortisol level was <19 in setting of hypotension so started on stress-dose steroids. After receiving two days of stress dose steroids, she was transitioned to prednisone 10mg and tapered to 5mg at discharge which she should continue for 2 days. She will followup with endocrine as an outpatient. . # Hypotension: Initially likely [**12-28**] hypovolemia and ?adrenal insufficiency and responded well to IVFs and steroids. The patient is chronically low temperatures, raising concern for infectious source but blood cx neg since [**11-8**] and no leukocytosis. Urine culture since E.coli with only yeast (see below). . # Altered mental status: Delirium on transfer to MICU, which improved with treatment of hypotension and hypothermia. All sedating meds were briefly held until mental status improved. A&Ox3 at discharge. . #. ID: The patient was admitted with a E coli UTI and likely urosepsis (hypotensive and hypothermic, though no positive blood cultures). She was admitted to the ICU and initially required 2 pressors to maintain her blood pressure. She improved with Ceftriaxone and stress dose steroids, and was sent to the medical floor on day 4, where she remained hemodynamically stable, afebrile and with negative cultures. She completed a 10 day course of Ceftriaxone. Her steroids were slowly tapered. . However, on [**11-6**] the patient became lethargic and hypothermic; blood cultures grew Stenotrophomonas. She was initally started on Cefepime, which was changed to Bactrim when the speciation was performed. She was then changed to ceftaz on [**11-13**] due to rising creatinine from the bactrim; she completed a full course of ceftaz on [**2192-11-22**]. On [**11-23**], the patient again became hypotensive, workup significant only for urine culture with yeast likely [**12-28**] foley/antibiotics, which was treated with a two doses of fluconazole. Renal U/S revealed no evidence of abscess or fluid collection. Repeat urine culture [**11-28**] with 10-100K yeast but patient asymptomatic. Last positive blood culture was [**11-8**]. . A worsening retrocardiac opacity was noted on her CXR, she was started on empiric meropenem and linezolid for hospital acquired pneumonia. Without a confirmed organism, linezolid was stopped after 4 days and she will complete a 10 day course of meropenem (started [**11-23**]; will complete [**12-2**]). Aspiration precautions. Good SaO2, afebrile, and comfortable at discharge. . # HIT Type 2: 1. The patient's platelets fell from 132 on admission to 71 on [**10-29**]. HIT antibody was positive; therefore the patient was started on argatroban and all heparin products were discontinued. Her platelets trended up, and coumadin was added when her platelets were >100. However, as the pretest probability of HIT was low, a serotonin releasing antibody was sent as well; this result returned negative. Hematology was [**Month/Day (4) 4221**] and recommended heparin be still listed as allergy as possible HIT. She will be discharged on coumadin for both possible HIT and afib. . #. GI bleed/ANEMIA: The patient has a chronic anemia with a baseline Hct of 29-30, and is on epo as an outpatient. Her stool was persistantly heme + throughout her admission, though without frank blood. The patient has a history of colon CA s/p resection. GI was [**Month/Day (4) 4221**]; however the patient has had numerous EGD's and colonoscopies in the past 2 years for this chronic problem, therefore GI recommended continuing anticoagulation for HIT type 2 as above and pursuing a capsule endoscopy as an outpatient (scheduled to followup with Dr. [**First Name (STitle) 572**]. Epo was discontinued prior to discharge as her Hct was 33 and stable. She was given Iron supplements given her ongoing GI blood loss and started on a PPI [**Hospital1 **]. She did require PRBC transfusion while her INR was supertherapeutic; presumably the anticoagulation accelerated her chronic slow GI blood losses. Hct remained stable at discharge (~30). She will need repeat Hct checks with her INR's to ensure no increasing blood loss and outpatient GI workup as above. . # RENAL/ELECTROLYTES: 1. ARF: The patient had an episode of AIN at the OSH during her recent admission [**12-28**] Cipro. She was admitted with an elevated Cr likely due to prerenal ARF secondary to septicemia coupled with resolving AIN. Renal was [**Month/Day (2) 4221**]. The patient's renal function improved daily as the patient became hemodynamically stable, and returned to her baseline (1.0) while on the floor. Nephrotoxic meds were avoided. The patient again developed ARF when started on Bactrim; her creatinine peaked at 2.0; renal was reconsulted. Her creatinine improved with discontinuation of bactrim. Her lasix was held as her renal function recovered, and now that her creatinine has trended down to 1.3, she is being gently diuresed for total body volume overload on her home lasix dose of 40mg [**Hospital1 **]. . 2. HYPERNATREMIA- The patient developed hypernatremia with a free water deficit as high as 4.5 L despite being 8L positive for length of stay. The hypernatremia resolved with gentle fluids (D5w), encouragement of PO free water intake, and tapering of her stress dose steroids. . 3. Hypokalemia- The patient had hypokalemia on admission which resolved with repletion over the first few days of her stay. . # CV: Ischemia: CAD s/p left circumflex stent in [**2182**], hyperlipidemia, HTN. Restarted statin, BB when hypotension resolved and aspirin when no significant GI bleed. Will defer starting imdur, ACEi to PCP as outpatient given patients multiple medication allergies, poor tolerance of new agents, and GI bleeding. Rhythm: PAF, sick sinus s/p pacer. On Coumadin as outpatient for afib, d/c'd at OSH during previous admission for heme positive stool. She was anticoagulated with argatroban upon diagnosis of HIT, and then bridged to coumadin during her admission. Continued on BB for rate control. Pump- preserved EF, however, h/o R sided /diastolic failure and presented with severe anasarca. Lasix 40 PO BID was started after the patient became hemodynamically stable and her kidney function had returned to baseline. She should continue to be diuresed slowly with goal I/O -0.5 to 1 liter per day. She was continued on her home dose beta blocker. ACE-I was held given recent ARF; will defer adding ACE to PCP as outpatient. . # COPD / trachebronchomalacia: Continued on scheduled/prn nebs. ?tracheobronchomalacia on [**11-23**] chest CT. IP [**Month/Year (2) 4221**] who reviewed films and recommended outpatient pulm followup with possible treatment after maximizing COPD regimen. She is scheduled to be evaluated in Pulmonary clinic. . # Thyroid nodule: A 2cm left lobe nodule was noted incidentally on CT chest. Thyroid US revealed multinodular goiter. TSH was 3.9 on [**11-24**]; free T4 was sent and is pending. Outpatient endocrine followup as above. . # SKIN- 1. The patient recently developed a severe drug reaction to Cipro at OSH; and presented with a dermatitis with open sores. The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**]. She was initially treated with fexodenadine and pepcid; these were discontinued as her rash improved. Her skin was treated with silvadene cream-->open areas; hydrocortisone cream; sarna PRN per the wound care nurse. 2. The patient developed perirectal skin irritation and breakdown due to diarrhea (c diff negative, likely medication induced). A rectal tube was inserted and meticulous skin care re: the wound care RN was performed with improvement. . # Nutrition: A Dobhoff feeding tube was placed for nutrition while her mental status was decreased, but now that MS has improved, she was able to resume a regular po diet (low Na, cardiac, [**Doctor First Name **]). The Dobhoff tube was discontinued. A recent swallow study did not show any aspiration risk. . A flu shot was administered. Medications on Admission: Tylenol 650 mg q6 prn Bisacodyl 10 mg qday MOM Atarax 10 mg po q6 prn Ferrous sulfate 325 mg [**Hospital1 **] Pepcid 20 mg [**Hospital1 **] Lasix 40 mg po q8am, q2 pm Combivent inhalers- three times a day Darbepoetin alpha 60 mcg qc qweek Colace 100 mg [**Hospital1 **] Fexodenadine 60 mg qday Fluticasone/salmeterol 500/50 1 puff [**Hospital1 **] Guafenisin 1200 mg [**Hospital1 **] Isosorbide mononitrate 60 mg qday Toprol XL 25 mg qday Pantoprazole 40 mg [**Hospital1 **] Potassium chloride 20 mEq qday Silvadene cream to rash/eroded areas of neck, chest, arms, legs and back Hydrocortisone cream to body rash [**Hospital1 **] Discharge Medications: 1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 6. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-27**] Drops Ophthalmic PRN (as needed). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous ASDIR (AS DIRECTED). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 17. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane QID (4 times a day) as needed. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 20. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. 21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 22. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 23. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 2 days. 24. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 25. Hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 26. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. 27. Combivent 103-18 mcg/Actuation Aerosol Sig: [**11-27**] Inhalation three times a day. 28. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day. 29. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 30. Guaifenesin 1,200 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: E coli UTI with urosepsis Stenotrophomonas bacteremia HIT type 2 Acute blood loss anemia [**Hospital **] Hospital-acquired pneumonia CHF . Secondary: CAD s/p left circumflex stent in [**2182**] COPD HTN Hyperlipidemia Sick sinus syndrome s/p pacemaker placement [**2188**] Syncope PAF GERD Diverticulosis of the sigmoid colon s/p colon resection [**12-28**] colon cancer Spinal stenosis Iron deficiency anemia Discharge Condition: Good. Discharge Instructions: During this admission you have been treated for a severe urinary tract infection, bacteremia (a blood infection), acute renal failure as well as a platelet disorder called Heparin-Induced Thrombocytopenia type 2. . Please continue to take all medications as prescribed. 2gm sodium diet; fluid restriction 1.2L Measure weights daily, call your doctor if increase > 3 pounds . New medications: coumadin, meropenem, metoprolol, prednisone, atorvastatin, aspirin Discontinued medications: toprol XL, erythropoeitin, imdur, potassium . Please call your doctor or come to the emergency room immediately if you develop fevers, chills, confusion, chest pain, shortness of breath, incontinence, black or bloody stools, or any other concerning symptoms. Followup Instructions: Follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 14943**]. . Gastroenterology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Date/Time:[**2192-12-6**] 2:15. Please discuss your guaiac positive stools and possibly obtaining a capsule endoscopy. . Pulmonary: DR. [**First Name8 (NamePattern2) 5445**] [**Last Name (NamePattern1) 1843**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2192-12-17**] 2:30. [**Hospital1 18**], [**Hospital Ward Name 23**] building [**Location (un) 436**]. Please discuss management of your COPD and possible further evaluation for tracheobronchomalacia. . Endocrinology: [**Name6 (MD) 21503**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2193-1-8**] 2:00. [**Hospital1 18**], [**Hospital Ward Name 23**] building [**Location (un) 436**]. Please discuss further evaluation of your multinodule goiter and prior diagnosis of adrenal insufficiency.

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icd9cm

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Discharge summary

report+addendum

Admission Date: [**2114-9-30**] Discharge Date: [**2114-10-10**] Date of Birth: [**2031-11-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Aortic Valve replacement(23mm [**Doctor Last Name **] pericardial) [**10-1**] History of Present Illness: The patient is an 82 year old male with a history of aortic stenosis who has been experiencing dyspnea on exertion and moderate to severe aortic stenosis by echo. Cardiac catheterization reveals normal coronary arteries. He is referred for surgical management. Past Medical History: hypertension aortic stenosis h/o urosepsis congestive heart failure (chronic systolic) chronic atrial fibrillation hyperlipidemia benign prostatic hypertrophy s/p tonsillectomy s/p permanent pacemaker implant s/p cholecystectomy gout coronary artery disease- s/p myocardial infarction hearing loss Social History: works as a manufacturing engineer smoked cigars for 47 years, quit 20 yrs ago lives with wife [**Name (NI) **] quit 20 yrs ago Family History: father died of MI at age 72 Physical Exam: Admission VS 66 bpm RR 20 BP 122/71 5'[**15**]" 190lbs Gen: no acute distress Skin: unremarkable HEENT: unremarkable Neck: supple Chest: lungs clear to auscultation bilaterally Heart: Irregular. III/VI murmur Abdomen: soft, nontender with normoactive bowel sounds Extremities: warm, well perfused with 2+ edema to ankles Neuro: grossly intact Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80270**] (Complete) Done [**2114-10-1**] at 12:46:12 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2031-11-24**] Age (years): 82 M Hgt (in): 71 BP (mm Hg): 100/70 Wgt (lb): 190 HR (bpm): 60 BSA (m2): 2.07 m2 Indication: Aortic stenosis. ICD-9 Codes: 424.1, 424.0, 424.2, 440.0 Test Information Date/Time: [**2114-10-1**] at 12:46 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW04-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 20% to 30% >= 55% Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: *3.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *42 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 24 mm Hg Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate symmetric LVH. Mildly dilated LV cavity. No LV aneurysm. Moderate-severe global left ventricular hypokinesis. Severely 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. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Mild to moderate ([**11-22**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**11-22**]+) MR. TRICUSPID VALVE: Mild to moderate [[**11-22**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient is in a ventricularly paced rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. No left ventricular aneurysm is seen. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Overall left ventricular systolic function is severely depressed (LVEF= 30 %). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([**11-22**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-22**]+) mitral regurgitation is seen. There is no pericardial effusion. Post Bypass: The patient is V-paced and on an infusion of epinephrine and phenylephrine. Left and right ventricular function is preserved. An aortic valve bioprosthesis is well seated with good leaflet motion. There is no AI. The mean gradient across the aortic valve is approximately 10 mmHg. The aorta is intact without evidence of dissection. The remainder of the study is unchanged. Dr. [**Last Name (STitle) **] was notified in person of the results on Mr.[**Known firstname **] [**Last Name (NamePattern1) **] at 11AM POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including XXXX. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2114-10-2**] 14:25 ?????? [**2108**] CareGroup IS. All rights reserved. Brief Hospital Course: The patient is an 82 year old gentleman with a history of aortic stenosis. On echo he was found to have moderate to severe AS with an aortic valve area of 0.6cm2, mean gradient 37mmHg, and peak gradient 67mmHg. Coronary arteries were clean on angiography. He was brought to the operating room on [**2114-10-1**], where he underwent aortic valve replacement with a 23mm [**Doctor Last Name **] pericardial bioprosthesis. For further details, please see operative report. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for observation and recovery. At this time he was on milrinone and epinephrine to maintain adequate hemodynamics. By POD 1 the patient was extubated, alert and oriented and breathing comfortably. Drips were weaned as tolerated. He did develop some post-operative confusion, for which narcotics were discontinued. Zyprexa and haldol were given as needed. Permanent pacemaker was interrogated and temporary pacing wires were discontinued. Chest tubes were removed without complication. The patient was transferred to the step down unit on POD 7. The same day he passed speech and swallow and diet was advanced. He was screened and was discharged to rehab on POD 9. Medications on Admission: Coumadin7.5mg S/S/M/W/F Coumadin 5mg T/TH Allopurinol 300mg/D Flomax 0.4mg/D Coreg 3.125mgBID Lasix 20mg/D Diazepam 5mg prn tricor 145mg/D Discharge Medications: 1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*0* 8. 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* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: 7.5 mg every day except Tuesday and Thursday, on which days he should receive 5mg for an INR goal of [**12-23**].5 for afib. Disp:*0 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: aortic stenosis chronic atrial fibrillation gout benign prostatic hypertrophy s/p permanent dual chamber pacemaker insertion s/p tonsillectomy s/p cholecystectomy hearing loss hyperlipidemia coronary artery disease- s/p myocardial infarction Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any drainage from incisions or redness report any fever greater than 100.5 report any weight gain more than 2 pounds a day or 5 pounds a week shower daily, no baths or swimming no lotions, creams or powders to incisions take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) [**Hospital 409**] clinic in 2 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25693**] in [**11-22**] weeks ([**Telephone/Fax (1) 25694**]) Please call for appointments Completed by:[**2114-10-10**] Name: [**Known lastname 183**],[**Known firstname 422**] Unit No: [**Numeric Identifier 12901**] Admission Date: [**2114-9-30**] Discharge Date: [**2114-10-10**] Date of Birth: [**2031-11-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Added to diagnoses should be the following; s/p post-operative CVA Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2114-10-10**]

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icd9cm

[ [ [] ] ]

[ "39.61", "96.6", "35.21" ]

icd9pcs

[ [ [] ] ]

11298, 11517

6988, 8257

343, 423

10113, 10120

1611, 6965

10517, 11275

1197, 1226

8446, 9708

9849, 10092

8283, 8423

10144, 10494

1241, 1590

284, 305

451, 715

737, 1036

1052, 1181

3,866

127,467

48700

Discharge summary

report

Admission Date: [**2135-4-14**] Discharge Date: [**2135-4-28**] Date of Birth: [**2084-5-28**] Sex: M Service: MEDICINE Allergies: Codeine / Enalapril Attending:[**First Name3 (LF) 1042**] Chief Complaint: chest pain, hemoptysis Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 50 yo M with ESRD secondary to amyloidosis on HD, h/o pulmonary aspergillosis (mycetoma), and multiple other medical problems p/w CP during hemodialysis. He had [**9-11**] SSCP, 1.5L into HD session, lasting 15 minutes, resolved spontaneously. He reported SOB and diaphoresis. Of note patient was recently admitted ([**2135-4-3**]) for CP, hypotension and epistaxis/hemoptysis. . In the ED his VS were 97.9, 106, 104/67, 16, 100%RA. He was given aspirin 325mg. He was seen by the renal fellow. He then began coughing up frank blood. IP was contact[**Name (NI) **] and recommended a chest CT which was done. He was admitted to the MICU. Past Medical History: ESRD secondary to amyloidosis -failed LRRT in [**7-5**] now on HD- R groin line IVC stent Sarcoidosis Pulmonary aspergillosis DM (diet controlled) Chronic HCV Hypertension Sinusitis, Paroxysmal atrial fibrillation, C. difficile [**3-8**] MRSA line sepsis Renal osteodystrophy Adrenal insufficiency Upper extremity DVT ([**2132**]) Pancreatitis Bilateral BKA Right index and fifth finger amputations Social History: Smoked 1 ppd X 30 years but quit one year ago. No alcohol. Previous drug use (IVDU). Girlfriend is involved in his care. Family History: Mother, brother with diabetes. Physical Exam: VS: 98.3, HR: 100, 128/71, 25, 93-96% on RA Gen: NAD. Answering all questions appropriately. HEENT: PERRL, aniceric, dried blood on lips, no frank blood in OP. Neck: Supple, no LAD. Lungs: Few bibasilar crackles. No wheezes. Heart: RRR, II/VI systolic murmur throughout, loudest at LLSB. Abd: +BS. Soft, NT/ND. Extrem: s/p b/l BKA. No edema. R femoral HD catheter, C/D/I, no drainage, redness, or fluctuance. Left groin with pressure dressing. Pertinent Results: [**2135-4-14**] 04:15PM WBC-12.4* RBC-3.54* HGB-10.8* HCT-34.5* MCV-98 MCH-30.6 MCHC-31.4 RDW-18.8* [**2135-4-14**] 04:15PM PLT SMR-NORMAL PLT COUNT-253 [**2135-4-14**] 04:15PM GLUCOSE-261* UREA N-33* CREAT-6.9* SODIUM-138 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-22* Cardiac enzymes negative . Chest CT: New, multifocal ground-glass opacification, both lungs, left greater than right, largely dependent suggesting this is aspiration neither of blood or esophageal contents. Interstitial pneumonia, particularly pneumocystis should be considered, but not fungal infection. Drug reaction is also in the differential diagnosis as is pulmonary hemorrhage. 2. Although the intracavitary nodule at the upper margin of the chronic left apical consolidation and atelectasis is new since [**2134-6-1**], there has been a suggestion of a cavity or bronchiectatic saccule in that location since [**2133-5-27**]; whether the lesion is a mycetoma contained in a pre-existing space, or semi- invasive aspergillosis is open to question. . Follow Chest CT [**4-26**] IMPRESSION: 1. Near complete resolution of multifocal ground-glass opacification within both lungs. 2. Cavitary lesion at the upper margin of chronic left apical consolidation is likely unchanged. Brief Hospital Course: 50M with ESRD secondary to amyloidosis on HD, h/o pulmonary aspergillosis here with hemoptysis, epistaxis complicated by melena. . # Hemoptysis: Patient presented with one episode of hemoptysis. Bronchoscopy showed no revealing lesion, but blood tinged mucus on left side, and patient had the single episode of hemoptysis without any recurrence. Likely source of bleeding was thought to be left upper lobe at the fungal infection site. ID has recommended to continue voriconazole. Thoracic surgery was consulted and recommended no surgical intervention as he was a high-risk patient. Hemoptysis resolved in house and pt will follow up with ID as an outpatient. Initial CT showed multi-focal ground glass opacities thought possibly due to aspiration/hemoptysis. CXR on [**4-26**] reported possible RLL infiltrate suggestive of aspiration and pt was started on broad spectrum ABx. Follow up CT on [**4-27**] revealed resolution of ground glass opacities and pt was clinically improved with clear lungs & sating well on RA. Abx were stopped on [**4-28**]. . #Acute blood loss: On [**4-17**] patient developed epistaxis and melenic streaks in his stools. Both the epistaxis and melenic stools worsened on [**4-19**], with at times profuse nose bleed and multiple bowel movements with dark maroon liquid stools. SBP was in the 80s but came back to 110s with IVF. Hct dropped to 24 from 32 within a few hours. Patient got an 18-gauge peripheral IV placed with ultrasound. Labs were drawn from the femoral dialysis line. Patient was initially clinically stable but slowly became somnolent and transferred to MICU. GI was consulted and believed the melena was directly related to the epistaxis. He received 2uPRBC and HCT stabilized. No further intervention needed. ENT was also consulted for epistaxis and packed his nose. He has received Keflex for prophylaxis with packing. Packing was removed successfully and there was no recurrence of epistaxis in house. Hct was stable & pt was recommended to follow up with ENT in 4-6wks. . # Chest pain: CP resolved at admission, it had been right sided and sharp. CE were negative x 3 and pt was effectively ruled out for MI. There was no recurrence of CP during admission. . # PAF: Pt is not anticoagulated because of known bleeding tendency. Pt was continued on metoprolol and had good rate control . # Diarrhea: Pt developped loose stools on [**4-27**]. He had a c.diff checked but was started on empiric flagyl. Plan is to continue a course of empiric flagyl. His loose stools were resolving at time of discharge. Pt had received 2 doses of empiric antibiotics (vanc/[**Last Name (un) 2830**]) for aspiration seen on cxr [**4-25**] with associated shortness of breath. Subsequent CT scan was negative for infiltrate and demonstrated overall resolution of the changes seen at admission and antibiotics were discontinued. Pt should continue Flagyl 500mg TID for an additional 8 days for empiric coverage of C. Diff given his relative [**Name (NI) 102398**] state. . # End-Stage Renal Disease on Hemodialysis: HD per regular outpatient schedule T/H/Sa . # DM: Continued on insulin sliding scale with decent BS control . # MRSA/endocarditis/osteomyelitis: Recently transitioned to TMP/SMX suppressive therapy from vanco per ID/PCP. [**Name10 (NameIs) **] by ID and pt was continued on TMP/SMX 4 tabs given after HD. . # Adrenal insufficiency: continued on home low-dose Prednisone. . # Code: FULL CODE Medications on Admission: Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. B Complex Vitamins Capsule Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. Megestrol 40 mg/mL Suspension Sig: One (1) 10ml PO twice a day. ****Patient cannot confirm that he is taking this**** 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four (4) Tablet PO QHD (each hemodialysis). 16. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous ASDIR (AS DIRECTED). Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four (4) Tablet PO QHD (each hemodialysis): please give after HD. 10. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) unit Injection TID (3 times a day). 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) unit Subcutaneous at bedtime. 15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. 17. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day) as needed for irritation / pain. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare-[**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Hemoptysis Epistaxis Secondary diagnoses: ESRD secondary to amyloidosis s/p LRRT (failed) [**7-5**] Diabetes History of recurrent MRSA bacteremia Endocarditis of the mitral valve Hepatitis C infection Pulmonary Aspergillosis, now on voriconazole, previously on itra until [**10-9**] Left common iliac stent [**3-9**] Sarcoidosis Hypertension Sinusitis Paroxysmal atrial fibrillation C. difficile [**3-8**] Renal osteodystrophy Adrenal insufficiency Upper extremity DVT ([**2132**]) Pancreatitis Bilateral BKA Right [**3-9**], Left [**5-8**] Right index and fifth finger amputations Discharge Condition: Stable Discharge Instructions: You presented to [**Hospital1 18**] with low blood pressure and coughing blood. The source of the hemoptysis was likely from your fungal infection in the lung which is essentially stable on CT scan. The hemoptysis has improved. You also developed what appeared to be blood in your stool, but this was found to be due to a severe nosebleed. You were seen by ENT who packed your nose and recommended follow up in 4-6wks. . Please take all your medications as instructed. Please resume your outpatient hemodialysis schedule. . If you develop recurrent coughing up blood, chest pain, shortness of breath, or any other concerning symptoms, please go to the nearest Emergency Room. Followup Instructions: You have a follow up appointment with ENT on Tuesday [**6-9**] at 2pm in the [**Hospital **] medical building on the [**Location (un) **], suite 6E . Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] for an appointment within 2 weeks. . Please keep the follow-up appointments: PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2135-4-25**] 7:40 [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2135-4-25**] 8:00 . [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. (Infectious Diseases) [**Hospital Unit Name **], [**Hospital1 18**] Date/Time:[**2135-5-2**] 11:00

[ "117.3", "784.7", "786.3", "585.6", "V49.75", "135", "583.81", "277.39", "427.31", "255.41", "070.54", "403.91", "787.91" ]

icd9cm

[ [ [] ] ]

[ "39.95", "21.01", "33.22", "99.07" ]

icd9pcs

[ [ [] ] ]

9768, 9844

3363, 6817

303, 318

10490, 10498

2073, 3340

11230, 11593

1561, 1593

8227, 9745

9865, 9865

6844, 8204

10522, 11207

1608, 2054

9927, 10469

11617, 12054

241, 265

346, 984

9884, 9906

1006, 1406

1422, 1545

314

155,540

50679

Discharge summary

report

Admission Date: [**2181-9-18**] Discharge Date: [**2181-9-24**] Date of Birth: [**2141-5-22**] Sex: F Service: MEDICINE Very briefly, this is a 40-year-old female with a history of HIV, CD4 account around 1, and self-reported high viral load presently with hepatitis B and hepatitis C, asthma, history of bacterial endocarditis, and active polysubstance abuse including alcohol, smoking crack, and shooting up with heroin. She is homeless and lives occasionally at her sister's place. According to patient her primary care physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 7474**] at the [**Hospital1 756**] Home, whom she last saw on [**5-/2181**], but Dr. [**Last Name (STitle) 7474**] had left. She was admitted to [**Hospital6 1760**] Intensive Care Unit on [**2181-9-18**] after she presented to [**Last Name (un) 33912**] Detox Facility and was found to have a low blood pressure. In brief, she was found to have endocarditis and CMV viremia. She was treated appropriately with improvement of her symptoms. She was transferred out of the ICU onto the floor on [**2181-9-23**] when the General Medicine team became involved in her care. We continued her on IV Oxacillin via her peripherally inserted central catheter line as well as other medicines. She looked well. The 24 to 36 hours she spent on 5 South were marked with complaints about wanting to leave and smoke. Despite the staff's best attempts at watching her, she was noticed missing on several occasions. When she returned she was asked repeatedly to stay on the floor and not to leave without permission or notification of the nurse. She was noted missing from her room last seen at approximately 2:40 p.m. on [**2181-9-24**]. The hospital security was notified, and her family was called, but no one answered. The nurses were instructed to contact Security if patient should return; however, patient did not return and, hence, left the hospital against medical advice. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 105446**] MEDQUIST36 D: [**2181-11-3**] 17:18 T: [**2181-11-5**] 17:08 JOB#: [**Job Number 105447**]

[ "042", "276.2", "070.54", "421.0", "070.32", "305.91", "292.0", "078.5", "493.90" ]

icd9cm

[ [ [] ] ]

[ "94.65", "38.93" ]

icd9pcs

[ [ [] ] ]

60,295

187,626

41735

Discharge summary

report

Admission Date: [**2201-5-6**] Discharge Date: [**2201-5-28**] Date of Birth: [**2160-11-28**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / morphine Attending:[**First Name3 (LF) 5790**] Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: [**2201-5-8**] Cervical tracheal resection, reconstruction with anterior cricoid split, flexible bronchoscopy with bronchoalveolar lavage, and suprahyoid release. [**2201-5-11**] bronchoalveolar lavage [**2201-5-14**] Direct laryngoscopy with operating telescope, flexible bronchoscopy with bronchoalveolar lavage [**2201-5-18**] Flexible bronchoscopy with bronchoalveolar lavage [**2201-5-18**] Direct laryngoscopy with operating telescope, diagnostic History of Present Illness: Mrs. [**Known lastname **] is a 40 year-old female with multiple cormobidities, including CAD s/p NSTEMI s/p CABGx5 ([**6-/2200**]) with course complicated by necrotizing tracheitis s/p tracheostomy who has required multiple interventions including balloon dilation, stoma revision, and several attempts with CO2 laser excision, most recently in 04/[**2200**]. She is closely followed by Pulmonology, ENT and her cardiologist. She was most recently admitted to the Medicine service on in [**3-/2201**] after another re-attempt at laser excision of this area of tracheal stenosis, which on previous imaging is approximately 4cm. Her hospital course was complicated by hypotension and somnolence likely secondary to excessive pain medication requiring observation in the ICU with no additional airway interventions. She was stabilized and transferred back to the floor without sequelae. She was pre-operatively evaluated by cardiology with recommendations to continue her current regimen of metoprolol, aspirin, plavix and lipitor without the need for additional testing. She was discharged home in good condition. In the interim, she has followed up with Dr. [**Last Name (STitle) **] and Pulmonology for anticipated surgery. She currently denied any worsening shortness of breath or chest pain; she denied any fevers or chills. She notes an intermittent cough with secretions through her tracheostomy which are easily suctioned. She also notes dyspnea on walking, which is approximately her baseline and has not exacerbated in the past month. Past Medical History: CAD with h/o STEMI s/p CABG x 5 [**2200-7-8**] (LIMA->LAD, SVG->OM, RCA, sequential SVG to rPDA, R post LV branch) CHF EF 20-30% Diabetes HTN Hyperlipidemia Asthma Fibromyalgia Obesity Tracheal stenosis Crohn's disease h/o MRSA pneumonia s/p appendectomy s/p ventral hernia repair [**5-11**] s/p cholecystectomy s/p C-section with tubal ligation Social History: -tobacco: former smoker -EtOH: none -Drugs: none Family History: non-contributory Physical Exam: Physical Exam: VS: T 98.5, BP 134/66, HR 91 GENERAL: NAD NECK: Trach tube in place. HEART: RRR, no MRG, nl S1-S2. TTP over sternotomy site LUNGS: mild inspiratory crackles bilaterally. Resp unlabored ABDOMEN: soft, NT, ND. +BS EXTREMITIES: WWP, no c/c/e SKIN: Multiple tattoos, no rashes or lesions Pertinent Results: [**2201-5-20**] Video swallow : Penetration with all administered consistencies and likely aspiration with nectar and honey consistencies. High risk of aspiration. Please see speech and swallow note in OMR for further details [**2201-5-25**] Video swallow : Penetration with all consistencies of barium and aspiration with thin and nectar thick barium. [**2201-5-26**] CXR : No acute intrathoracic process Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the hospital and taken to the Operating Room where she underwent a cervical tracheal resection, reconstruction with anterior cricoid split, flexible bronchoscopy with bronchoalveolar lavage, and suprahyoid release. She tolerated the procedure well and returned to the SICU in stable condition. She remained intubated and maintained stable hemodynamics. Plans were for her to remain intubated until some of her supraglottic edema decreased. She returned to the Operating Room on [**2201-5-11**] for a bronchoscopy with potential extubation but her edema persisted. At that point she began tube feedings to maintain her calorie requirements and she continued to be vigorously diuresed. On [**2201-5-18**] she returned to the Operating Room for another bronchoscopy which showed decreased edema and a healthy anastomosis. The ENT service also did a direct laryngoscopy and agreed the edema was much less. Her cords could not be evaluated as she was sedated. She was then extubated successfully. As she continued to improve from a respiratory standpoint, she underwent a bedside swallow to assess her swallowing capacity but unfortunately she had overt symptoms of aspiration and therefore remained NPO. She refused placement of a feeding tube which made it difficult boost her nutrition and maintain her pre op medications. She was re evaluated with a video swallow and aspiration was confirmed. Unfortunately some of her psych medications had to be withheld for a period of time and she developed what appeared to be delirium with impulsive behavior, poor concentration and poor judgement. The Psychiatric service was consulted and made medication adjustments and at the same time her swallowing was improving so she was able to resume all of her prior medications. After a few days she was much more reasonable, engaged in conversation and had better judgement. The Physical Therapy and Occupational Therapy service evaluated her on multiple occasions and noted her daily improvement in balance and mobility. The Speech and swallow therapist recommended pureed solids and honey thick liquids after her video swallow on [**2201-5-25**]. Mrs. [**Known lastname **] was reluctant to always adhere to this diet as she felt that her swallowing was normal. I spoke with Dr.[**Name (NI) 90677**] assistant who will arrange for her to have a speech and swallow evaluation in [**Location (un) **], NH, closer to home, within the next week or two. After a long hospital stay, she was discharged to home on [**2201-5-28**] and will follow up in the Thoracic Clinic in 3 weeks as well as with Dr. [**Last Name (STitle) 65534**], next week. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Pantoprazole 40 mg PO Q24H 2. esomeprazole magnesium *NF* 40 mg Oral qd 3. Paroxetine 40 mg PO DAILY 4. Glargine 38 Units Bedtime 5. Acetaminophen 650 mg PO Q6H:PRN pain 6. Benzonatate 100 mg PO TID 7. Aspirin 325 mg PO DAILY 8. Ipratropium Bromide Neb 1 NEB IH Q6H with albuteral 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 10. Gabapentin 400 mg PO TID 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. Lidocaine 5% Patch 1 PTCH TD DAILY 13. Quetiapine extended-release 150 mg PO DAILY 14. Atorvastatin 40 mg PO DAILY 15. Clopidogrel 75 mg PO DAILY 16. Metoprolol Tartrate 25 mg PO BID 17. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 18. Cyanocobalamin 100 mcg PO DAILY 19. Mesalamine DR 400 mg PO BID 20. Vitamin D 5000 UNIT PO DAILY 21. Clonazepam 1 mg PO BID 22. Miconazole 2% Cream 1 Appl TP [**Hospital1 **] 23. Mucinex *NF* (guaiFENesin) 1,200 mg Oral [**Hospital1 **] 24. Insulin Lispro Desensitization Protocol 0 UNIT SUBCUT ASDIR Follow Insulin Lispro Desensitization Protocol Discharge Medications: 1. Fentanyl Patch 50 mcg/hr TP Q72H RX *Duragesic 50 mcg/hour 1 patch every 72 hours Disp #*10 Packet Refills:*3 2. Miconazole Powder 2% 1 Appl TP TID:PRN fungal RX *Anti-Fungal 2 % apply to both groins and under breasts twice a day Disp #*1 Tube Refills:*0 3. Quetiapine Fumarate 25 mg PO TID RX *quetiapine 25 mg 1 Tablet(s) by mouth three times a day Disp #*100 Tablet Refills:*1 4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 Tablet(s) by mouth three times a day Disp #*40 Tablet Refills:*1 5. Acetaminophen 650 mg PO Q6H:PRN pain 6. Vitamin D 5000 UNIT PO DAILY 7. Insulin Lispro Desensitization Protocol 0 UNIT SUBCUT ASDIR Follow Insulin Lispro Desensitization Protocol 8. Cyanocobalamin 100 mcg PO DAILY 9. Mucinex *NF* (guaiFENesin) 1,200 mg Oral [**Hospital1 **] 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 11. Aspirin 325 mg PO DAILY 12. Atorvastatin 40 mg PO DAILY 13. Clonazepam 1 mg PO BID 14. Gabapentin 800 mg PO Q8H 15. Metoprolol Tartrate 25 mg PO BID 16. Pantoprazole 40 mg PO Q24H 17. Glargine 15 Units Q12H Insulin SC Sliding Scale using REG Insulin 18. Paroxetine 40 mg PO DAILY 19. Docusate Sodium 100 mg PO BID Discharge Disposition: Home With Service Facility: [**Location (un) **] visiting nurses Discharge Diagnosis: Complex tracheal stenosis Delerium 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 airway surgery and you've had a long recovery but are now doing well medically. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Make sure that you continue to follow the instructions given by [**Last Name (un) 51796**] from speech and swallow to help you eat safely. You will have follow up in [**Location (un) **] as Dr. [**Last Name (STitle) 65534**] is arranging this for you. * 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, chest pain or any other symptoms that concern you. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2201-6-23**] at 9:30 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 [**Location (un) 40900**] for a chest xray. * You have an appointment with Dr. [**Last Name (STitle) 65534**] on Friday [**2201-6-5**] at 2:15PM * You will need a repeat swallow study and Dr. [**Last Name (STitle) 65534**] is arranging that for you. * Call your psychiatris to arrange an appointment to review your recent hospitalization and medications. Completed by:[**2201-5-28**]

[ "V58.67", "V14.0", "250.92", "272.4", "V85.32", "428.22", "493.90", "V15.82", "V55.0", "478.6", "293.0", "729.1", "V11.8", "V45.81", "414.01", "555.9", "428.0", "519.02", "412", "278.00", "401.9", "519.19", "V64.2", "458.29", "V14.5", "E932.0" ]

icd9cm

[ [ [] ] ]

[ "38.91", "31.79", "96.72", "33.24", "31.42", "96.04", "31.5", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

8592, 8659

3572, 6265

300, 759

8738, 8738

3138, 3549

9931, 10785

2785, 2803

7409, 8569

8680, 8717

6291, 7386

8889, 9908

2833, 3119

250, 262

787, 2333

8753, 8865

2355, 2702

2718, 2769

76,327

117,931

33460

Discharge summary

report

Admission Date: [**2148-9-4**] Discharge Date: [**2148-9-12**] Date of Birth: [**2106-1-28**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Adhesive Bandage / Dicloxacillin / Linezolid Attending:[**Male First Name (un) 5282**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: This is 41 yo m w/ hx cirrhosis secondary to EtOH + HCV, OSA, PAH and hypothyroidism, w/ recurrent episodes of severe enceophalopathy and ascites well-known to the MICU who was transferred from the Liver service for encephalopathy. . Mr. [**Known lastname 19420**] has been at rehab since discharge from [**Hospital1 18**] on [**2148-8-21**]. Per his mother he has been having more frequent encephalopathic episodes this month. Over the past few days she reports that [**Known firstname **] has been in good health without fevers, night sweats, n/v, or abdominal pain. Over the last few days he has been having ~6BMs/day. Notably, she reports the rehab would not increase the lactulose frequency from Q4hr which [**Known firstname **] often requires when he is becoming encephalopathic. . Notably, patient's most recent admission [**Date range (1) 77611**] was also for changes in mental status. He was found to have a Klebsiella bacteremia and UTI treated with 3 weeks of ceftriaxone ([**2148-8-5**], to complete on [**2148-8-26**]). Neurologic work-up demonstrated that he has a comunicating hydrocephalus, etiology of which remains unclear. . In the ED Vitals: 78 98/63 18 99% RA. He received 30mL of PO lactulose as well as Vanc/Cipro/Flagyl for question of infection.He received 2L NS. CXR with mild atelectasis. Duplex U/S showed flow in L portal vein, pt combative and this could not be completed. . In the ICU, patient able to follow directions though continued to have agitated outbursts. Denied any pain or discomfort. Past Medical History: - End Stage Liver Disease [**1-22**] alcohol and hepatitis C. Currently on the [**Month/Day (2) **] list. Course complicated by recurrent ascites, SBP, pulmonary hypertension. Currently on the [**Month/Day (2) **] list (s/p aborted liver [**Month/Day (2) **] given elevated pulmonary pressures in OR [**2148-2-28**]) - Sepsis w/ Enterococcus Avium and Group B Step, recent discharge on [**2148-7-5**] - Spontaneous bacterial peritonitis early [**7-27**] on Cipro prophylaxis - Grade II esophageal varices - Recurrent hepatic encephalopathy on vegetarian diet - Pulmonary hypertension - Hypothyroidism - Anxiety disorder - History of alcohol and IVDU - Osteoporosis of hip and spine per pt - Anemia with history of guaiac positive stool Social History: He lives with his mother. Remote history of smoking [**12-23**] ppd. Quit drinking 11 years ago. Prior history of IVDU as a teenager. Family History: Mother with diabetes and hypertension. Father with rheumatic heart disease. Physical Exam: In MICU: Gen: Awake, alert, agitated intermittently HEENT: dry MM, + scleral icterus Pulm: lungs clear bilaterally, no wheezes or rhonchi CV: S1 & S2 regular without murmur Abd: +BS, soft, non-tender, mildly-distended Ext: no lower extremity edema Neuro: Alert, unable to comply with neuro exam Pertinent Results: [**2148-9-4**] 11:07PM GLUCOSE-100 UREA N-39* CREAT-1.2 SODIUM-154* POTASSIUM-3.7 CHLORIDE-122* TOTAL CO2-25 ANION GAP-11 [**2148-9-4**] 11:07PM ALT(SGPT)-20 AST(SGOT)-47* LD(LDH)-208 ALK PHOS-120* TOT BILI-7.8* [**2148-9-4**] 11:07PM ALBUMIN-3.3* CALCIUM-9.8 PHOSPHATE-2.8 MAGNESIUM-1.7 [**2148-9-4**] 11:07PM WBC-3.7* RBC-2.17* HGB-6.7* HCT-22.7* MCV-104* MCH-31.0 MCHC-29.7* RDW-21.5* [**2148-9-4**] 11:07PM NEUTS-76.5* LYMPHS-13.9* MONOS-6.7 EOS-2.7 BASOS-0.2 [**2148-9-4**] 11:07PM PLT COUNT-32* [**2148-9-4**] 11:07PM PT-28.4* PTT-53.0* INR(PT)-2.8* [**2148-9-4**] 05:09PM LACTATE-1.3 [**2148-9-4**] 05:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2148-9-4**] 05:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 Imaging/Studies: CXR: Left and right mid lung subsegmental atelectasis. No focal consolidation or pulmonary edema. . ABD U/S: 1. Cirrhosis, ascites, splenomegaly. 2. Limited doppler exam without evaluation of the main portal vein. If there is high clinical concern for vascular thrombosis, a CT is suggested. 3. Cholelithiasis. . ABD US [**8-13**] 1. Flow within the main portal vein, now demonstrates a hepatofugal (reversed) directionality (as demonstrated on a prior study from [**2148-1-21**]) although patent. Flow within the left portal vein could not be obtained no doppler evaluation either secondary to occlusion or very slow flow in this uncooperative patient. 2. Shrunken cirrhotic liver consistent with known cirrhosis. Cholelithiasis with gallbladder wall edema/thickening unchanged over multiple comparisons likely secondary to third spacing from decompensated liver disease rather than acute cholecystitis. 3. Large amount of intra-abdominal ascites. . Head CT [**8-15**]: No interval change in moderate ventriculomegaly. No evidence of intracranial hemorrhage. . MRI Head [**7-23**]: 1. Prominent lateral ventricles with evidence for transependymal CSF flow suggestive of communicating hydrocephalus; also prominence of the sulci suggestive of atrophy. 2. No acute intracranial process. Unchanged diffuse hydrocephalus since [**2148-7-15**] (new since [**2148-1-21**]) with mild transependymal CSF flow. . CSF Fluid: neg cryptococcal, fungal WBC 0-2, Polys 0, Lymphs 0-56 Brief Hospital Course: 41 year old man with cirrhosis secondary to EtOH and HCV, complicated by recurrent ascites, history of SBP and esophageal varices, who has been hospital w/ recurrent episodes of encephalopathy presents with an episode of encephalopathy. . # Recurrent encephalopathy: Presentation secondary to inadequate bowel regimen while at rehab facility. Work up negative for infection (stool, blood, urine), GI bleed, and U/S failed to show significant ascites. A CT of abdomen was done to evaluate questionable poor flow through the portal vein seen on US. The CT was sig for patent portal vein. Patient was treated with rifaximin and Q2hr lactulose and produced ~4L of stools per day. Mental status improved to baseline on discharge. Cipro was continued for SBP prophylaxis. He was also continued on his vegetarian diet. A decision was made to discharge patient home w/ services as mother felt that she could provide better care at home. Physical therapy was consulted who agreed that the patient could be discharged home. . # Hypernatremia: Secondary to reduced access to free water in the setting of encephalopathy and high stool output. Resolved with free water replacement. . # ESLD. Secondary EtOH and HCV. Patient initially presented with improved ascites and edema. An ultrasound of the abdomen showed poor flow through the portal vein, and CT of the abdomen was done for further assessment. The CT demonstrated patent portal vein. Patient was continued on his lactulose and rifaximin as above. He was also continued on cipro for SBP ppx, his home diuretics and ppi. Octreotide and midodrine were discontinued while in the ICU. The patient's creatine remained stable off treatments. Patient was ultimately disharged to home (see above). . # H/o HRS: Octreotide and midodrine discontinued while in the ICU and were held throughout his hospital course. Creatinine stable off octreotide and midodrine. . # Anemia: Initial hct of 23 lower than baseline of 25-28. Patient hcts were followed throughout hospitalization and were stable. . # Thrombocytopenia: Stable and secondary to liver disease. . # Hypothyroidism: Stable, patient was continued on home levothyroxine. . # Pulmonary HTN: There were no active issues during his hospitalization and the patient was continued iloprost. . # Osteoporosis: Patient was continued on his home regimen of Vit D and Calcium Medications on Admission: Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane 5X/DAY (5 Times a Day). Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for candidiasis. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig:PO DAILY Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID Octreotide Acetate 100 mcg/mL Solution Sig:Q8H Iloprost 10 mcg/mL Solution for Nebulization Sig:Inhalation 6x/day Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY Midodrine 10 mg Tablet Sig: TID Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Discharge Medications: 1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day): No script given. Disp:*0 Troche(s)* Refills:*0* 2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)): No script given. Disp:*0 Capsule(s)* Refills:*0* 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): No script given. Disp:*0 bottle* Refills:*0* 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): No script given. Disp:*0 Tablet(s)* Refills:*0* 5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): No script given. Disp:*0 Tablet(s)* Refills:*0* 6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): No script given. Disp:*0 Capsule(s)* Refills:*0* 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating: No script given. Disp:*0 Tablet, Chewable(s)* Refills:*0* 8. Iloprost 10 mcg/mL Solution for Nebulization Sig: One (1) ML Inhalation q4hr (): No script given. Disp:*0 ML(s)* Refills:*0* 9. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO Q2H (every 2 hours) as needed for encephalopathy: For [**2-22**] Bowel Movements per day. Disp:*0 ML(s)* Refills:*0* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): No script given. Disp:*0 Tablet(s)* Refills:*0* 11. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO once a day: No script given. Disp:*0 Tablet(s)* Refills:*0* 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: No script given. Disp:*0 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 13. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 14. Tubefeeding Tubefeeding: Nutren 2.0 Full strength Rate: 35 ml/hr; Do not advance rate Goal rate: 35 ml/hr Flush w/ 250 ml water q2H 15. Outpatient Physical Therapy To continue with home physical therapy Discharge Disposition: Home With Service Facility: vna of southeastern mass Discharge Diagnosis: Primary: Hepatic Encephalopathy Secondary: history of SBP, Grade II esophageal varices, Pulmonary hypertension, Hypothyroidism, Osteoporosis, Anemia Discharge Condition: Stable Discharge Instructions: You were seen in the hospital for your confusion. This was because of your liver disease and we treated you with lactulose. We did an ultrasound of your abdomen that did not show worsening ascites but showed poor flow through the portal vein. CT of your abdomen however showed a patent portal vein. While you were in the hospital, we replaced your feeding tube. Your mental status improved to baseline on discharge. We have made the changes to your home medications: 1. You do not need to take lasix, midodrine and octreotide 2. Please continue the rest of your home medications. Please return to the emergency room if you should experience further confusion, severe abdominal pain, fevers > 101, or any concerning symptoms. Followup Instructions: Please follow up with Gastroenterology: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-9-16**] 9:00 Completed by:[**2148-9-13**]

[ "V49.83", "416.8", "789.59", "285.9", "287.5", "244.9", "331.3", "733.00", "327.23", "571.2", "303.93", "276.0", "300.00", "070.71", "518.0" ]

icd9cm

[ [ [] ] ]

[ "96.07" ]

icd9pcs

[ [ [] ] ]

10997, 11052

5576, 7950

344, 350

11245, 11254

3246, 5553

12033, 12224

2838, 2915

9023, 10974

11073, 11224

7976, 9000

11278, 11732

2930, 3227

11750, 12010

283, 306

378, 1909

1931, 2669

2685, 2822

10,207

118,574

7447

Discharge summary

report

Admission Date: [**2144-12-1**] Discharge Date: [**2144-12-12**] Date of Birth: [**2062-9-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5827**] Chief Complaint: Shortness of Breath, Hypoxia Major Surgical or Invasive Procedure: Intubation PEG replacement History of Present Illness: HPI: This is an 82 yo M with a past medical history of vascular dementia, s/p CVA with aphasia and dysphagia requiring G-tube [**12-26**] chronic aspiration, recurrent aspiration pneumonias, and h/o hemoptysis, was brought to [**Hospital1 18**] after having worsened shortness of breath and hypoxia at his NH. Apparently there is some concern he was hypoxic for a while until his NH brought him in. On the day of admission, he was noted at the NH to be short of breath with sats in the 70's on room air. He was started on O2, and was watched during the morning, but his status continued to worsen and was transferred to our ED for further work up. . In the ED, he was placed on a NRB and sats came up to 98% but respiratory rates continued in the 30's. He was noted to have abdominal distention as well, and an NGT was placed with a lot of air output. His breathing seemed to improve after decompression. He was taken for chest and abdominal films which seemed to be concerning for a right lower lobe infiltrate, and he was given doses of cefepime, flagyl and levofloxacin. His labs were significant for a normal wbc with 4 bands on diff without a left shift, and a lactate of 1.6. His vitals before transfer were temp of 101.6, RR 32, sats high 90's on NRB. Without ABG's, the decision was made to intubate the patient prior to transfer, out of concern that he was tiring out. Post intubation he had a transient episode of bradycardia to the 40's. He was hemodynamically stable throughout. No post-intubation ABG performed. . Past Medical History: Renal/GU: 1. Nephrolithiasis/Uretolithiasis/Urosepsis a.Proteus urosepsis secondary to obstructing uretal stone, relieved by percutaneous nephrostomy tube, complicated by perinephric hematoma. Hospitalized [**2141-3-29**] x14d. b.Hematuria from nephrostomy secondary to renal stone. Hospitalized [**2141-4-16**] x5d. c.Tube dislodged [**2141-5-25**] and was replaced d.Klebsiella urosepsis secondary to uretrolithiasis. Hospitalized [**2141-8-7**] x2d e.Uretal stone was passed during hospitalization [**2141-8-7**]. f. Percutaneous nephrostomy tube removed CV: 1.Hypertension. 2.Descending thoracic aortic aneurysm. GI: 1.G tube placement 2.Dysphagia secondary to CVA, plus aspiration pneumonia status/precautions 3.Cholelithiasis 4. History of elevated liver function tests. PULM: 1.Aspiration pneumonia. Hospitalized [**6-/2136**] MSK: 1.S/p Proteus abscess. Hospitalized [**7-27**]. Status post incision and drainage. Neuro/Psych: 1.Cerebrovascular accident leading to dementia and aphasia. Nonverbal. 2.Depression 3.Atypical Psychosis FEN: 1.H/o of hypernatremia Social History: The patient is not verbal. He lives at [**Hospital3 2558**]. His family is involved in his care. Family History: N/C Physical Exam: VS: Temp: 98 ax BP: 143/88 HR: 105 RR: 14 O2sat: 96% on A/C 550 x 14 FiO2 1.0, peep 5 GEN: intubated and sedated, NAD HEENT: PERRL, anicteric, MM dry, op without lesions. poor dentition. NGT in place draining yellow fluid. NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with moderate air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: distended, +b/s, soft, no masses, g-tube in place, site is c/d/i. Flushes without resistance. Asymmetric distention, very tympanitic to percussion. EXT: no c/c/e, warm, good pulses (hands cool). Contractures present SKIN: no rashes/no jaundice NEURO: unable to conduct adequate exam at this time. Could not obtain DTR's. Increased tone. Mild peripheral wasting. RECTAL: guaiac negative, [**Male First Name (un) 1658**] colored stool Pertinent Results: [**2144-12-1**] 11:24PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2144-12-1**] 11:24PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [**2144-12-1**] 11:24PM URINE RBC-70* WBC-26* BACTERIA-NONE YEAST-NONE EPI-0 [**2144-12-1**] 11:24PM URINE MUCOUS-RARE [**2144-12-1**] 10:08PM GLUCOSE-149* UREA N-27* CREAT-1.2 SODIUM-141 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15 [**2144-12-1**] 10:08PM ALT(SGPT)-14 AST(SGOT)-27 LD(LDH)-246 ALK PHOS-68 AMYLASE-76 TOT BILI-0.9 [**2144-12-1**] 10:08PM LIPASE-22 [**2144-12-1**] 10:08PM ALBUMIN-4.2 PHOSPHATE-3.8 MAGNESIUM-2.6 [**2144-12-1**] 10:08PM TSH-0.57 [**2144-12-1**] 10:08PM WBC-9.2 RBC-5.01 HGB-15.1 HCT-43.3 MCV-87 MCH-30.1 MCHC-34.8 RDW-14.0 [**2144-12-1**] 10:08PM PLT COUNT-158 [**2144-12-1**] 10:08PM PT-13.5* PTT-26.5 INR(PT)-1.2* [**2144-12-1**] 09:44PM TYPE-ART PO2-244* PCO2-56* PH-7.34* TOTAL CO2-32* BASE XS-3 [**2144-12-1**] 05:14PM LACTATE-1.6 [**2144-12-1**] 05:00PM GLUCOSE-159* UREA N-28* CREAT-1.3* SODIUM-139 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-30 ANION GAP-14 [**2144-12-1**] 05:00PM estGFR-Using this [**2144-12-1**] 05:00PM proBNP-168 [**2144-12-1**] 05:00PM WBC-8.3 RBC-5.00 HGB-15.0# HCT-42.7# MCV-85# MCH-30.0 MCHC-35.2* RDW-14.3 [**2144-12-1**] 05:00PM NEUTS-59 BANDS-4 LYMPHS-19 MONOS-11 EOS-2 BASOS-0 ATYPS-5* METAS-0 MYELOS-0 [**2144-12-1**] 05:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2144-12-1**] 05:00PM PLT SMR-NORMAL PLT COUNT-176 [**2144-12-1**] 05:00PM PT-12.9 PTT-27.3 INR(PT)-1.1 ,,,,,,,,,,,,,,,,,,,,,,,,,,, CT ABDOMEN PELVIS CHEST [**2144-12-2**] . CT OF THE CHEST: There is an endotracheal tube in place with its tip approximately 3 cm above the carina. The nasogastric tube is seen with its tip in the stomach. The heart is mildly enlarged. Coronary artery calcifications are noted. Evaluation of the pulmonary arteries demonstrates several filling defects within the segmental and subsegmental branches of the left upper lobe pulmonary artery consistent with pulmonary emboli. There is also increase in caliber in the main left pulmonary artery that measures approximately 3.1 cm. Pulmonary arteries, branches of the right pulmonary artery and left lower lobe pulmonary artery are unremarkable. The tracheobronchial tree is patent. There is a mildly prominent right hilar lymph node that measures 1.3 x 1.6 cm. There is an aneurysm with an extensive partially calcified thrombus involving the descending thoracic aorta that measures approximately 4.7 x 3.5 cm. This is stable when compared with the prior examination of [**2142-2-5**]. Evaluation of lung windows demonstrates bibasilar atelectasis. There is diffuse mild emphysema. There is no pneumothorax and no pleural effusions. CT OF THE ABDOMEN: The liver is unremarkable. There is no intrahepatic or extrahepatic biliary dilatation. Multiple calcified gallstones are seen within the gallbladder. There is no gallbladder wall thickening or pericholecystic fluid. The pancreas demonstrates normal diffuse homogeneous enhancement. A 3-mm fat-containing lesion is seen in the tail of the pancreas that is unchanged since the prior CT of the abdomen from [**2140**] and likely represents a small lipoma. The spleen is normal in size and contour. The left adrenal gland is unremarkable in size and demonstrates several calcifications that are stable since the prior study. There is diffuse enlargement of both medial and lateral limbs of the right adrenal gland _____ have a lobular appearance. This is also stable when compared with the prior CT of the abdomen from [**2140**]. The kidneys enhance symmetrically. There is no hydronephrosis. A very small subcapsular fluid collection is seen along the posterior cortex of the right kidney likely reflecting residual fluid from the previous hematoma that was seen on the prior study. Multiple renal cysts are present. There is also an indeterminate lesion measuring approximately 1.1 cm in the medial aspect of the left kidney (hypoenhancing) that is unchanged since the prior study from [**2140**]. Multiple areas of scarring and calcifications are seen in both renal cortices. No pathologically enlarged intra-abdominal lymph nodes are identified. The small bowel is normal in caliber. Large amount of stool is seen in the rectum compatible with rectal impaction. There is gaseous distention of the proximal rectum and distal descending colon. The proximal descending colon, transverse colon and the right colon are unremarkable. There is no evidence of free air or bowel pneumatosis. The small bowel is normal in caliber. The abdominal aorta is normal in caliber and demonstrates diffuse atherosclerotic calcifications. The celiac and superior mesenteric arteries are patent. CT OF THE PELVIS: There are bilateral fat-containing inguinal hernias. There is a Foley catheter in place. The urinary bladder is collapsed which limits its evaluation. There is no significant free pelvic fluid. No pelvic masses or pathologically enlarged pelvic lymph nodes are identified. Rectal impaction is present as above. Extensive bony productive changes are seen in the region of the left ischium that are unchanged since the prior study. Incidental note is made of a central filling defect in the right common femoral vein (series 5, image 102) that may possibly represent a deep venous thrombosis. Correlation with Doppler ultrasound is recommended for further evaluation. BONE WINDOWS: There is a compression fracture of superior endplate of L1 that is unchanged since the prior study. No suspicious lytic or sclerotic lesions are identified. There are degenerative changes at L5-S1 level with disc space narrowing and subchondral sclerosis. IMPRESSION: 1. Pulmonary emboli involving segmental and subsegmental branches of the left upper lobe pulmonary artery. 2. Emphysema. 3. Cardiomegaly and coronary artery calcifications. 4. Cholelithiasis. 5. Rectal impaction with likely secondary gaseous distention of the proximal rectum and distal descending colon. 6. Probable deep venous thrombosis involving the right common femoral vein. Further evaluation with Doppler ultrasound is recommended for further evaluation if clinically indicated. . [**12-3**] CT NECK WITHOUT CONTRAST . HISTORY: Hypoxic respiratory failure, evaluate for laryngeal edema. An endotracheal tube is seen in place and there is collapse of the larynx surrounding the endotracheal tube. As such, evaluation of the laryngeal structures is not possible in an intubated state. There does appear to be mild edema of the subglottis which could be related to the process of intubation. There is bilateral maxillary and ethmoid opacification. Small maxillary sinus fluid levels are seen. The study is limited for evaluation of lymphadenopathy although no large masses are identified. Evaluation of the brain parenchyma demonstrates volume loss. There is bilateral pleural fluid/thickening. IMPRESSION: Endotracheal and NG tube are seen in situ and it is difficult to assess for edema of the larynx in an intubated state. . [**12-3**] ECHOCARDIOGRAM. . LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Aortic valve not well seen. No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Prolonged (>250ms) transmitral E-wave decel time. LV inflow pattern c/w impaired relaxation. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Suboptimal image quality - ventilator. Conclusions Technically suboptimal study. The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) 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 valve is not well seen. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. Due to the technically suboptimal nature of this study, a cardiac source of embolus cannot be excluded with certainty. . [**12-7**] CT HEAD WITHOUT CONTRAST . CT HEAD WITHOUT INTRAVENOUS CONTRAST: The study is slightly limited by patient movement. Allowing for this limitation, there is no evidence of intra-or extra-axial hemorrhage, shift of normally midline structures, mass effect or hydrocephalus. There is prominence of the ventricles and sulci consistent with moderate atrophy. Periventricular and subcortical white matter hypodensity presumably represents chronic microvascular ischemic change. No fractures are identified. There is confluent opacification of the left frontal sinus, multiple ethmoid air cells and the sphenoid sinus. There is moderate circumferential thickening within the maxillary sinuses, left greater than right. A nasogastric tube is noted in place. The mastoid air cells are diminutive and opacified with soft tissue/fluid density. IMPRESSION: 1. Study limited by patient movement. No definite evidence for intracranial hemorrhage or edema. 2. Moderate-to-severe confluent paranasal sinus opacification as described above. 3. Significant brain atrophy with changes of chronic microvascular ischemia . . CONVERT G TO GJ, ALL INCL. [**2144-12-7**] 8:12 AM . OPERATORS: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] performed the procedure. Dr. [**Last Name (STitle) **], attending radiologist, was present throughout the procedure. PROCEDURE AND FINDINGS: After the risks, benefits and alternatives of the procedure were explained to the patient's wife written informed consent was obtained. A prepocedure timeout was performed to confirm the patient's identifying information. The patient was placed supine on the angiographic table and the abdomen and Foley catheter were prepped and draped in standard sterile fashion. A 0.035 [**Doctor Last Name **] wire was advanced through the Foley catheter into the duodenum under fluoroscopic guidance. The indwelling Foley was removed over the wire and exchanged for a 18-French peel-away sheath was advanced into the stomach. The wire was exchanged for a 0.035 Amplatz stiff wire which was advanced to the jejunum using a 5 French Kumpe catheter. The Kumpe catheter was exchanged for a 16 French MIC gastrojejunostomy tube which was advanced over the wire with the tip in the distal duodenum under fluoroscopic guidance. Injection of a small amount of contrast confirmed positioning. The balloon was inflated with 10 cc of fluid to secure the catheter. A sterile dressing was applied. The patient tolerated the procedure well and there are no immediate procedure complications. Total fluoroscopy time : 7 minutes. A total of 20 cc of 60% Optiray contrast was used. IMPRESSION: Successful exchange of a Foley catheter for a 16 French MIC gastrojejunostomy feeding tube. The tip is in the distal duodenum. The tube is ready to use. . EKG [**12-7**] . Baseline artifact. Sinus rhythm. Late R wave progression. Compared to the previous tracing of [**2144-12-4**] probably no significant change. Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 90 160 86 356/408 55 19 40 . CXR [**2144-12-8**] . [**Hospital 93**] MEDICAL CONDITION: 82 year old man with SOB, dysphagia, secretions, sounds wet REASON FOR THIS EXAMINATION: pulmonary edema HISTORY: Shortness of breath with dysphagia and secretions. FINDINGS: In comparison with the study of [**12-7**], allowing for the slightly lower lung volumes, there is probably little overall change. Mild atelectatic streaks are seen at the right base and probably in the retrocardiac area as well. Tubes remain in place. Brief Hospital Course: 1)Pulmonary Embolus: The patient came to the ED very tachypneic and hypoxic, as well as bloated. He was decompressed with an NG tube. A CTA showed an embolism, and the patient was started on anticoagulation with a heparin drip and bridged to warfarin. Through the hospital course, he was intubated for persistent hypoxia and tachypnea. An attempt at extubation was unsuccessful because there was no cuff leak. There was concern for an upper airway obstruction. CT of the neck showed only mild subglottic edema. The patient has dysphagia post CVA and could not handle his secretions. This, coupled with his lung congestion and productive cough, made management of his secretions challenging. He required constant deep suctioning by respiratory therapy in order to prevent desat and keep him comfortable. A scopolamine patch was used to control his oral secretions. . 2)Aspiration pneumonia - for which he was started on vancomycin and meropenem based on his prior cultures (he had been given cefepime and levaquin previously in the ED, as well as flagyl). All his blood and urine cultures remained negative. Stool cultures were negative. C difficile was negative x 2. 3 days prior to discharge, his IV antibiotics were stopped and he was started on cefpodoxime, last day [**12-13**] as detailed in the discharge paperwork. . 3). DYSPHAGIA: He came with his PEG dislodged. This was pulled and a Foley temporarily placed to maintain viability of the tract. The patient then underwent successful PEG replacement by IR. A previous consult by GI and images of the tract with contrast revealed no problems, however GI recommended that the procedure be done by IR due to the special kit required for the tube's size. Prior to that exchange, the patient had been receiving tube feeds via his NGT after decompression of his bloated abdomen. Subsequently, the patient has been receiving tube feeds via his PEG at 70 cc/hour and been followed by nutrition. He needs to be propped up at all times when being fed. . 4). COMFORT CARE: The patient was admitted with fecal impaction, contractures, and numerous pressure sores, as well as with hypoxia, infection, and a malpositioned feeding tube. All of these were addressed. The contractures seemed old but still he had PT for stretching and evaluation. This raised questions about the type of care he had been receiving, and case management was informed for an investigation. . Prior to discharge, the patient is at baseline, on room air. We have been restarting his blood pressure medications and introduced few changes. These will need to be managed according to his hemodynamics. He will need frequent lyte checks (he is on hctz and potassium) as well as INR checks. Please see medication list below. . The patient remains Full Code Medications on Admission: potassium 20meq daily MVI prilosec 20 daily artificial tears baclofen 10mg q6h albuterol MDI valium 1mg Qam, 2mg QHS lactulose 30cc daily lasix 20mg daily HCTZ 12.5mg daily lisinopril 20mg daily tubefeeds Discharge Medications: 1. Baclofen 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QID (4 times a day). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] Q24H (every 24 hours). 3. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours). 6. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 8. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3 times a day). 9. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr Transdermal Q 72 HOURS (). 10. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 11. Polyvinyl Alcohol 1.4 % Drops [**Last Name (STitle) **]: 1-2 Drops Ophthalmic Q4H (every 4 hours). 12. Hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 13. Potassium Chloride 10 mEq Capsule, Sustained Release [**Last Name (STitle) **]: One (1) Capsule, Sustained Release PO DAILY (Daily). 14. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY16 (Once Daily at 16). 15. Cefpodoxime 100 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H (every 12 hours) for 2 days: Last dose [**2144-12-13**] pm. 16. 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. 17. Morphine 2 mg/mL Syringe [**Month/Day/Year **]: Two (2) mg Injection every [**2-28**] hours as needed for pain, air hunger. 18. heparin drip to PTT 60-90 until INR 2 19. Valium 5 mg/mL Solution [**Month/Day (3) **]: One (1) mg Injection once a day: In the morning. 20. Valium 5 mg/mL Solution [**Month/Day (3) **]: Two (2) mg Injection at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Pulmonary Embolism Pneumonia Dysphagia Dementia Fecal Impaction Pressure sores (multiple) Dehydration Discharge Condition: Stable. At baseline dementia and respiratory. Normal bowel movements. No infection. Discharge Instructions: Admitted with shortness of breath and hypoxia and found to have a pulmonary embolism, being treated with anticoagulation. His PEG was malpositioned and it was replaced. . He also came impacted and had to be disimpacted manually. With contractures and pressure sores. All of these issues are being addressed. He is now at his baseline, on room air, comfortable, but with deep dementia and requiring assistance for all his ADLs. . It is important that the patient be turned in bed every two hours, that he wears appropriate protection at his bony joints, that he has his ulcers taken care of. He also needs daily stretching of his limbs by PT. He is on tube feeds by PEG and needs at least semi weekly labs/Chem 10 to ensure adequate hydration. He also needs an adequate bowel program for him to have a bowel movement at the very least every other day. He needs his INR checked frequently until it is stabilized, and his coumadin adjusted accordingly. He needs suctioning at an adequate frequency because he cannot handle his secretions. He needs to be propped up in bed at all times. He needs mouth care and cannot have any nutrition or hydration PO. His mouth must be swabed and hydrated at least every 4 hours. . Please return to the ED for any concerns. Followup Instructions: With facility doctor daily Completed by:[**2144-12-12**]

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icd9cm

[ [ [] ] ]

[ "44.32", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

21856, 21926

16539, 19313

345, 374

22072, 22158

4055, 16046

23462, 23521

3154, 3159

19569, 21833

16083, 16143

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22182, 23439

3174, 4036

277, 307

16172, 16516

402, 1931

1953, 3022

3038, 3138

21,686

171,796

43946

Discharge summary

report

Admission Date: [**2110-1-6**] Discharge Date: [**2110-1-10**] Date of Birth: [**2033-7-30**] Sex: M Service: UROLOGY Allergies: Percocet Attending:[**First Name3 (LF) 6157**] Chief Complaint: Left mid ureteral tumor Major Surgical or Invasive Procedure: Laparoscopic left nephrectomy and distal ureterectomy with resection of the bladder cuff. History of Present Illness: The patient is a 76-year-old gentleman with a longstanding history of bladder carcinoma. He has been worked up at the [**Location 1268**] VA and found to have a mid, left ureteral tumor. He has evaluated his options and has decided to undergo a laparoscopic left nephrectomy and distal ureterectomy. Past Medical History: He has an extensive past medical history with history of diabetes, hypertension, COPD, emphysema, and coronary artery disease. He has had angioplasties for his coronary artery disease. Social History: He is a retired salesman. He smokes 1 pack of cigarettes per day for the past 50 years and he drinks three caffeinated products per day. He does not consume any alcoholic beverages. Family History: There is no family history of prostate cancer Physical Exam: Blood pressure 124/70, pulse 77, and respirations 20. Head and neck exam does not reveal any supraclavicular lymphadenopathy. Chest is clear to auscultation bilaterally. He has change of air in both lungs equally and there is no evidence of wheezes on today's evaluation. Heart is regular in rate and rhythm. Abdomen is soft and nontender. There is no flank tenderness. He has well-healed bilateral inguinal hernia scars. Genitourinary exam reveals a normal scrotum, epididymides, and testes without any inguinal hernias. Rectal exam reveals a normal tone. His prostate is 50 g in size, and there is no nodularity. Pertinent Results: [**2110-1-7**] 04:09AM BLOOD WBC-9.0 RBC-4.25* Hgb-12.6* Hct-37.6* MCV-88 MCH-29.6 MCHC-33.5 RDW-13.6 Plt Ct-202 [**2110-1-6**] 03:22PM BLOOD WBC-14.8*# RBC-4.62 Hgb-14.0 Hct-40.7 MCV-88 MCH-30.2 MCHC-34.3 RDW-13.4 Plt Ct-230 [**2110-1-7**] 04:09AM BLOOD Glucose-119* UreaN-28* Creat-1.3* Na-139 K-4.4 Cl-110* HCO3-22 AnGap-11 [**2110-1-6**] 03:22PM BLOOD Glucose-132* UreaN-28* Creat-1.3* Na-138 K-4.6 Cl-109* HCO3-22 AnGap-12 [**2110-1-7**] 04:09AM BLOOD Calcium-8.0* Mg-2.0 [**2110-1-6**] 01:55PM BLOOD Type-ART pO2-141* pCO2-43 pH-7.34* calTCO2-24 Base XS--2 Intubat-INTUBATED Vent-CONTROLLED [**2110-1-6**] 09:22AM BLOOD Type-ART pO2-190* pCO2-47* pH-7.32* calTCO2-25 Base XS--2 Intubat-INTUBATED Vent-CONTROLLED [**2110-1-6**] 01:55PM BLOOD Glucose-145* Lactate-1.2 Na-136 K-4.6 Cl-108 [**2110-1-6**] 09:22AM BLOOD Glucose-141* Lactate-1.2 Na-136 K-4.7 Cl-111 Brief Hospital Course: The patient was admitted on [**2110-1-6**] for his surgery. The procedure went well. Due to the patients comorbities he spent the night in the PACU. A PCA was used for pain control and a foley catheter was in place. The patient did well in the PACU and was transferred to the floor on POD1. The patients cardiologist saw him and recomended resuming his home meds especially his Beta Blocker. This was done. On POD1 his diet was advanced to sips. On POD2 his diet was advanced to clears which he tolerated. On POD3 the patient diet was advanced to regular. His PCA was discontinued and he was switched to PO pain medication. A JP creatinine was sent and the patient's JP was discontinued. He was given leg bag teaching. He was discharged to home with VNA services on POD4 tolerating a regular diet. Medications on Admission: atenolol 50 qd, albuterol prn, asa, topiramate 25mg pqd, atrovent [**Hospital1 **], flomax, lisinopril 10 qd, flunisolide [**Hospital1 **] Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: please start the day before your follow up appointment. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Left mid ureteral tumor. Discharge Condition: stable Discharge Instructions: Please follow the directions given to you on your discharge sheet. You will be sent home with VNA services to help you at home with your catheter care. You will be given pain medication. This can make you drowsy- please do not drive while on medication. You will be given an antibiotic. Please start taking the day before your follow up appointment. You may restart your home medications unless otherwise told. If you have a fever>101, nausea, vomitting, increased abdominal pain, lack of urine, large amount of blood in your urine or any other concerns please call the Doctor. Followup Instructions: Please call Dr[**Name (NI) 13919**] office for your follow up appointment. ([**Telephone/Fax (1) 4230**] Completed by:[**2110-1-10**]

[ "250.00", "492.8", "414.01", "189.2", "V45.82", "412", "V10.51", "401.9" ]

icd9cm

[ [ [] ] ]

[ "55.51" ]

icd9pcs

[ [ [] ] ]

4160, 4218

2738, 3537

291, 383

4287, 4296

1848, 2715

4923, 5060

1141, 1188

3726, 4137

4239, 4266

3563, 3703

4320, 4900

1203, 1829

228, 253

411, 713

735, 923

939, 1125

63,792

179,248

42760

Discharge summary

report

Admission Date: [**2150-12-21**] Discharge Date: [**2150-12-29**] Date of Birth: [**2086-7-25**] 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: [**2150-12-24**]: Coronary artery bypass x2 with blood with left internal thoracic artery to left anterior descending and a reverse saphenous vein graft to the obtuse marginal branch. History of Present Illness: 64 year old male who presented to OSH for exertional chest pain on/off since [**Month (only) 359**]. His chest pain is squeezing in nature, located in the xiphoid area, and radiates to the left chest and arm, brought on by exertion. It is occasionally associated with shortness of breath, and has worsened such that it now occurs with fairly minimal activity. He presented to [**Hospital3 **] on [**12-21**] as these episodes were becoming more frequent. Cardiology was consulted at OSH and thought this was consistant with unstable angina, and recommended transfer to [**Hospital1 18**] for cardiac catheterization. He was found to have left main disease and is now being referred to cardiac surgery for revascularization. Cardiac Catheterization: Date:[**2150-12-22**] Place:[**Hospital1 18**] LMCA: 80% LCX: minimal luminal irregularities LAD: minimal luminal irregularities RCA: dominant but no single PDA Past Medical History: Dyslipidemia ? Hypertension (undiagnosed, but was hypertensive at OSH) Current smoker Perpherial vascular disease s/p stenting in Left leg 8 years ago BPH s/p TURP Past Surgical History: Perpherial vascular disease s/p stenting in left leg 8 years ago Social History: Race:Caucasian Last Dental Exam:1 month ago Lives with: wife Contact:[**Name (NI) 19313**] Phone #H [**Telephone/Fax (1) 92395**], C [**Telephone/Fax (1) 92396**] Occupation:retired. Used to work in maintenance Cigarettes: Smoked no [] yes [x] last cigarette [**12-21**] Hx:1 pack per day x45 years Other Tobacco use:denies ETOH: < 1 drink/week [] [**2-2**] drinks/week [x] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- Mother died of a heart attack at age 81. His brother died suddenly at age 58, unknown circumstances Physical Exam: Pulse:61 resp:13 O2 sat:99/RA B/P Right:138/79 Left:140/72 Height:5'5" Weight:175 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2 Left:2 DP Right: 1 Left:1 PT [**Name (NI) 167**]: 2 Left:1 Radial Right: 2 Left:2 Discharge Exam: VS: T: 98.1 HR: 88-92 SR BP: 117/68 Sats: 94% RA WT: 81.8 Kg General: 64 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur Resp: clear breath sounds through out. No wheezes or crackles GI: benign Extr: warm no edema Incision: sternal mild erythema superiorly no discharge, sternum stable no click Neuro: awake, alert oriented, MAE Pertinent Results: [**2150-12-29**] WBC-7.5 RBC-3.06* Hgb-9.6* Hct-28.1* MCV-92 MCH-31.3 MCHC-34.0 RDW-13.2 Plt Ct-297 [**2150-12-28**] Hct-27.7* [**2150-12-27**] WBC-12.7* RBC-3.13* Hgb-9.8* Hct-28.8* MCV-92 MCH-31.3 MCHC-34.0 RDW-13.2 Plt Ct-205 [**2150-12-26**] WBC-13.7* RBC-3.03* Hgb-9.5* Hct-27.7* MCV-91 MCH-31.5 MCHC-34.5 RDW-13.0 Plt Ct-181 [**2150-12-25**] WBC-15.4* RBC-3.28* Hgb-10.3* Hct-30.1* MCV-92 MCH-31.4 MCHC-34.2 RDW-13.0 Plt Ct-194 [**2150-12-24**] WBC-16.9* RBC-4.03*# Hgb-12.6*# Hct-36.5*# MCV-91 MCH-31.4 MCHC-34.6 RDW-12.9 Plt Ct-186 [**2150-12-29**] Glucose-130* UreaN-15 Creat-0.8 Na-137 K-4.1 Cl-100 HCO3-28 [**2150-12-28**] UreaN-16 Creat-0.8 Na-137 K-4.4 Cl-98 HCO3-30 AnGap-13 [**2150-12-27**] Glucose-138* UreaN-16 Creat-0.7 Na-138 K-3.8 Cl-101 HCO3-29 [**2150-12-26**] Glucose-118* UreaN-17 Creat-0.9 Na-140 K-3.8 Cl-104 HCO3-31 TTE [**2150-12-24**] LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Moderately depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Filamentous strands on the aortic leaflets c/with Lambl's excresences (normal variant). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is moderately, globally depressed (LVEF= 35-40 %). The right ventricle displays mild global free wall hypokinesis. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST BYPASS There is normal right ventricular systolic function. Global left ventricular systolic function is improved - now mild global hypokinesis with an ejection fraction of 45%. The mitral regurgitation may be slightly worsened and borders on being mild to moderate. The thoracic aorta is intact after decannulation. CXR: [**2149-12-27**]: The lungs are hyperinflated, suggesting background COPD. The patient is status post sternotomy, with mild-to-moderate cardiomegaly, unchanged compared with [**2150-12-26**] at 11:33 a.m. There is mild relatively diffuse prominence of the interstitial markings, however, CHF findings are considerably improved compared with the earlier film. There is patchy opacity in the retrocardiac region, also somewhat improved. Minimal blunting of the posterior costophrenic angles is seen, but no gross effusion identified. Brief Hospital Course: The patient was brought to the operating room on [**2150-12-24**] where the patient underwent Coronary artery bypass x2 with blood with left internal thoracic artery to left anterior descending and a reverse saphenous vein graft to the obtuse marginal branch. CARDIOPULMONARY BYPASS: 57 minutes. CROSS-CLAMP TIME: 43 minutes. 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. His Foley was removed and he failed a voiding trial. He was given Flomax and Foley was removed again and he voided initially 120 cc. He subsequently was bladder scanned for 1 Liter. Foley was reinserted and patient was discharged home with a leg bag and follow up appointment with outpatient urologist was arranged. Preop Plavix was restarted for PVD. He was started on Kefzol for upper sternal pole erythema and tenderness - sternum was without drainage and stable. He was afebrile and WBC was 7.5. He was continued on a 7 day course of Kefzol at the time of discharge for sternal erythema. 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 POD5 the patient was ambulating freely, the wound was healing, he was 92% on Room air and pain was controlled with oral analgesics. He was given a nicotine patch and smoking cessesation teaching. The patient was discharged in good condition with appropriate follow up instructions. Medications on Admission: HOME MEDS - Atorvastatin 40mg PO daily - Plavix 75mg PO daily - Aspirin 81mg PO daily . MEDS ON TRANSFER - plavix 75mg PO daily - ASA 81mg PO daily - ASA 325mg PO once - lipitor 80 - lovenox 60 today 10:30am - Magnesium hydroxide 10mL daily PRN constipation - Nitroglycerin 0.4mg SL Q5M PRN chest pain Discharge Medications: 1. nicotine (polacrilex) 2 mg Gum Sig: One (1) gum Buccal every 1-2 hours as needed for nicotine cravings. Disp:*100 * Refills:*2* 2. nicotine 21-14-7 mg/24 hr Patch, TD Daily, Sequential Sig: One (1) patch Transdermal once a day: 6 week total course. Disp:*42 * Refills:*2* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-28**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 9. cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 7 days. Disp:*28 Tablet(s)* Refills:*0* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while taking narcotics. 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) scoop PO DAILY (Daily). 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 13. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 5 days. Disp:*5 Capsule, Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease Dyslipidemia Hypertension (undiagnosed, but was hypertensive at OSH) Current smoker Peripherial vascular disease s/p stenting in Left leg 8 years ago BPH s/p TURP Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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 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**] Date/Time:[**2151-1-5**] 10:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on Date/Time:[**2151-2-3**] 1:15 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] PCP Dr [**Last Name (STitle) 29247**] - office to arrange appt [**Telephone/Fax (1) 29248**] Urologist: Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] on Tues [**1-5**] at 1:45 PM Needs cardiologist referral from PCP **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:[**2150-12-29**]

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43294

Discharge summary

report

Admission Date: [**2148-10-4**] Discharge Date: [**2148-10-23**] Date of Birth: [**2085-7-5**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Trileptal / Dilantin Attending:[**First Name3 (LF) 8388**] Chief Complaint: Hypotension, tachycardia Major Surgical or Invasive Procedure: Diagnostic Paracentesis Therapeutic Paracentesis History of Present Illness: Ms. [**Known lastname 92802**] is a 63 year old lady with a history of polycystic kidney disease and resulting nephrectomies and end stage liver disease. She presented to the ED today at the request of her nephrologist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**]) after an episode of hypotension to the 60s systolic yesterday at dialysis. The patient reports consistently low blood pressures in ths 60s-100s systolic. Of note, the patient was found to have a clot in her RUE fistula yesterday morning and had temporary HD access placed yesterday evening without complication. In the ED, initial vs were: 97.9 120 60/p 22. A diagnostic paracentesis was performed. The patient received a 250mL bolus of NS for SBP in the 60s which did correct her to the 80s. She also received Vancomycin and Ceftriaxone (1g each) and 10mg of Decadron as a stress dose given her chronic steroid use. Transfer vitals: VS: 120 72/48 22 100%RA On arrival to the MICU, the patient appears quite comfortable. She complains of some abdominal discomfort (therapeutic paracentesis scheduled for today independently) and otherwise denies chest pain, dyspnea greater than baseline, changes in her chronically loose stools, or any symptoms of viral illness. Per initial Nephrology notes, the patient is normally hypotensive but has not been tachycardic in the past which prompted their concern. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Medical History (Per OMR, confirmed with patient): - [**Last Name (NamePattern1) 93249**] (autosomal dominant w renal/liver involvement, c/b [**Doctor Last Name **] aneurysmal bleed and ESRD) - multiple liver cysts - ESRD [**1-1**] [**Month/Day (2) 18048**] now s/p bilateral nephrectomies - subarachnoid hemorrhage 2/2 L MCA [**Doctor Last Name **] aneurysm s/p surgical clipping c/b peri-operative hemorrhagic stroke resulting in right hemiparesis([**2136**]) - HTN - secondary hyperparathyroidism - anemia - acidosis - nephrolithiasis - stress fracture of the right ankle. - seizure disorder Social History: Lives w husband in [**Name (NI) 86**]. Ambulates w cane. Worked as a city planner. Smoking: denies EtOH: 1 glass of wine/day Drugs: denies Family History: Father and son with [**Name (NI) 18048**]. F - died in his 80s, [**Name (NI) 18048**] and prostate cancer M - died at [**Age over 90 **] yrs of old age Sister w [**Name (NI) 11398**]. Physical Exam: Vitals: T: 99.9 BP: 84/56 P: 119 R: 17 O2: 100% 2LNC General: Alert, oriented, some discomfort on deep breathes HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, lying flat, could not easily evaluate JVP, no LAD Lungs: Clear to auscultation anteriorly, difficulty with deep inspiration, unable to sit patient up for sufficient exam CV: S1 & S2 fast without murmur. Abdomen: Distended, tense with signs of previous paracentesis. Bowel sounds present. Prominent spleen and liver. Ext: R Subclavian/IJ HD line in place, no peripheral edema. Pertinent Results: Admission labs: [**2148-10-4**] 11:50AM PLT COUNT-380 [**2148-10-4**] 11:50AM NEUTS-89.6* LYMPHS-4.7* MONOS-5.4 EOS-0.1 BASOS-0.2 [**2148-10-4**] 11:50AM WBC-8.9 RBC-3.55* HGB-9.8* HCT-34.1* MCV-96 MCH-27.6 MCHC-28.7* RDW-16.5* [**2148-10-4**] 11:50AM CK-MB-NotDone [**2148-10-4**] 11:50AM cTropnT-0.90* [**2148-10-4**] 11:50AM LIPASE-27 [**2148-10-4**] 11:50AM ALT(SGPT)-18 AST(SGOT)-20 CK(CPK)-39 ALK PHOS-168* TOT BILI-1.3 [**2148-10-4**] 11:50AM estGFR-Using this [**2148-10-4**] 11:50AM GLUCOSE-111* UREA N-40* CREAT-3.6* SODIUM-139 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-29 ANION GAP-19 [**2148-10-4**] 12:02PM LACTATE-3.6* [**2148-10-4**] 12:02PM COMMENTS-GREEN TOP [**2148-10-4**] 01:06PM PT-15.6* PTT-33.2 INR(PT)-1.4* [**2148-10-4**] 01:20PM ASCITES WBC-9000* RBC-1100* POLYS-80* LYMPHS-1* MONOS-0 MACROPHAG-19* [**2148-10-4**] 01:20PM ASCITES TOT PROT-2.7 GLUCOSE-71 LD(LDH)-171 ALBUMIN-1.5 [**2148-10-4**] 07:59PM PT-17.3* PTT-33.3 INR(PT)-1.6* [**2148-10-4**] 07:59PM PLT COUNT-309 [**2148-10-4**] 07:59PM WBC-7.2 RBC-2.69* HGB-7.6* HCT-25.3*# MCV-94 MCH-28.4 MCHC-30.1* RDW-17.8* [**2148-10-4**] 07:59PM ALBUMIN-4.9* CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-2.2 [**2148-10-4**] 07:59PM CK-MB-4 cTropnT-0.62* [**2148-10-4**] 07:59PM GLUCOSE-125* UREA N-46* CREAT-3.9* SODIUM-138 POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-26 ANION GAP-24* [**2148-10-4**] 10:55PM HCT-25.8* = = = = = ================================================================ DISCHARGE LABS PITUITARY TSH [**2148-10-22**] 07:20AM 26* TSH ADDED 10;40AM THYROID Free T4 [**2148-10-22**] 07:20AM 1.1 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2148-10-23**] 07:00AM 14.7* 2.54* 7.1* 23.1* 91 27.9 30.7* 18.0* 379 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2148-10-23**] 07:00AM 108* 56* 4.1* 136 5.2* 95* 28 18 MICRO: [**2148-10-4**] Blood culture: STAPH AUREUS COAG +. LINEZOLID :PENDING. DAPTOMYCIN : PENDING. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [**2148-10-5**]): GRAM POSITIVE COCCI IN CLUSTERS. -[**2148-10-4**] Peritoneal Fluid Culture: GRAM STAIN (Final [**2148-10-4**]): 3+ PMNs. No microorganisms seen. FLUID CULTURE (Final [**2148-10-7**]): STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2148-10-8**]): NO ANAEROBES ISOLATED. -[**2148-10-9**] Peritoneal Fluid: GRAM STAIN (Final [**2148-10-9**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. FLUID CULTURE (Final [**2148-10-12**]): STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 284-9889S [**2148-10-4**]. ANAEROBIC CULTURE (Final [**2148-10-13**]): NO ANAEROBES ISOLATED. -[**2148-10-10**] Peritoneal Fluid: GRAM STAIN (Final [**2148-10-10**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. FLUID CULTURE (Final [**2148-10-13**]): STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 284-9889S [**2148-10-4**]. ANAEROBIC CULTURE (Final [**2148-10-14**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. -[**2148-10-10**] Mycolytic Blood Culture: BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. -[**2148-10-13**] Peritoneal Fluid: GRAM STAIN (Final [**2148-10-13**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS IN CLUSTERS. FLUID CULTURE (Final [**2148-10-16**]): STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 285-6101S [**2148-10-14**]. ANAEROBIC CULTURE (Final [**2148-10-17**]): NO ANAEROBES ISOLATED -[**2148-10-14**] Peritoneal Fluid: GRAM STAIN (Final [**2148-10-14**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. FLUID CULTURE (Final [**2148-10-17**]): STAPH AUREUS COAG +. RARE GROWTH. DAPTOMYCIN 0.5 MCG/ML = SENSITIVE BY E-TEST. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2148-10-20**]): NO ANAEROBES ISOLATED. -[**2148-10-20**] Peritoneal Fluid: GRAM STAIN (Final [**2148-10-20**]): 1+ PMNs (<1 per 1000X FIELD). NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. -[**10-12**], [**10-13**], [**10-14**] C. Diff toxins: Negative = = = = = = = = = ================================================================ Imaging: -[**2148-10-4**] CXR: No acute intrathoracic process. -[**2148-10-7**] TTE : The left atrium and right atrium are normal in cavity size. There is mild asymmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the third of the ventricle with a small apical aneurysm. The remaining segments are hyperdynamic (LVEF = 50-55 %). No intraventricualr thrombus is seen. There is valvular [**Male First Name (un) **] with a severe (?>60mmHg) resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. The mitral valve leaflets are not well seen. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2148-8-2**], regional left ventricular systolic dysfunction is now present c/w ischemia. The heart rate is also much faster -[**2148-10-9**] Upper Extremity Doppler U/S:Thrombosis of the right upper extremity AV fistula, extending into the brachial vein. No fluid collection. -[**2148-10-14**] CT Abd/Pelvis w/o contrast: 1. Increasing large amount of ascites with generalized anasarca. 2. Innumerable hepatic cysts nearly completely replacing the hepatic parenchyma and causing significant hepatic enlargement and architectural distortion. Overall, study limited due to absence of IV contrast. 3. Interval reduction in the size of nephrectomy bed collections, which are suboptimally seen due to lack of IV contrast. -[**2148-10-17**] WBC Scan: INTERPRETATION: Following the injection of autologous white blood cells labeled with In-111, images of the whole body were obtained. There is normal intense splenic uptake. Tracer activity between the proximal lower extremities are probably contamination. Uniform symmetric mild increase in tracer uptake is seen in proximal upper and lower extremities, consistent with expanded bone marrow in an activated reticuloendothelial system. SPECT image of the segment of abdomen encompassing the liver demonstrates markedly distorted and irregular uptake in a polycystic liver, generally with increased tracer activities corresponding to hepatic parenchyma and not the innumerable cysts. Within the liver parenchyma there is heterogeneous uptake with some regions showing more intense uptake than others. The reason for this heterogeneity is not apparent. Again seen is intense physiologic splenic uptake. Moderate ascites is present. IMPRESSION: No definite evidence of infected hepatic abscess Brief Hospital Course: A 63 year old lady with a history of bilateral nephrectomies from polycystic kidney disease, end stage liver disease and baseline hypotension presented with staph bacteremia and peritonitis. #. Staph bacteremia/peritonitis & sepsis: The patient was found to have positive blood and peritoneal cultures fo Staph aureus. She was treated with Vanc and Ceftriaxone and Albumin per hepatology and infectious disease recommendations. Her initially low blood pressures responded to fluids and albumin. The patient remained tachycardic due to under rescussitation given her renal status. She was continued on home florinef and midodrine. A TTE revealed outflow tract obstruction and wall motion abnormalities that were consistent with ischemia. She remained tachycardic throughout admission. [**Hospital Ward Name 121**] 10 Course: The patient was called out to the Hepatorenal service on [**10-6**]. She was generally stable. She underwent hemodialysis on [**10-7**], but ended up having a positive net fluid balance. On [**10-8**], she went to the hemodialysis unit, where she was found to be hypotensive with systolic BP in the 60's, and tachycardic into the 120's. Cardiac enzymes included a flat CK (MB not performed), and troponin of 0.35. EKG was unrevealing for ischemic changes. She remained hypotensive in spite of IV fluid boluses, and she was transferred to the MICU on [**10-8**]. As before, she did not require vasopressors or mechanical ventilation, and she was called back out to the floor on [**10-10**]. Back on the floor, the patient continued to have a peripheral leukocytosis, the in the setting of known MRSA bacteremia and peritoneal fluid infection. Her blood cultures were negative as of [**10-7**], and her peritoneal fluid was negative for SBP and cultures had no growth as of [**10-20**]. Per ID recommendations, the patient was to continue taking vancomycin for four weeks following her first negative peritoneal fluid culture. She also was started on Bactrim DS per ID recs, to be given on dialysis days, immediately after HD. She was instructed to follow up in Infectious Disease clinic two weeks and four weeks after discharge. TTE performed on [**10-7**] revealed aneurysmal apical akinesis which was not seen on a prior echo. In the setting of her admission EKG changes and cardiac enzymes, it was believed that the patient may have had an ischemic event prior to admission. She was started on aspirin and atorvastatin. Beta blockers were not given, since the patient seemed to require persistent tachycardia to maintain her borderline low blood pressures. She was discharged with instructions to continue taking the aspirin and atorvastatin daily. The patient's liver disease featured MELD scores in the high 20s. Her LFTs were generally stable. Her ascites reaccumulated regularly, and she required several large-volume paracenteses. She was never encephalopathic and did not experience any upper or lower GI bleeding. Her ESRD was managed with 3X/week dialysis, which she generally tolerated well, but which was not always successful in removing excess fluid, given the patient's consistently tenuous hemodynamics. She was discharged with instructions to continue her Tues/Thurs/Sat HD schedule. Her TSH was found to be greatly elevated on [**10-22**]. Her diarrhea was ruled out for C. Diff infection and she was given loperamide, which may have had some modest benefit. It was also believed that the frequent bowel movements may have been related to side effects from her prolonged antibiotic use, as well as her known intermittent rectal prolapse. Moments before discharge, the patient was found to be febrile to 101.4. She denied fever, chills or any other symptoms. A physical exam was negative for any localizing symptoms. Her line looked good. The patient was told that we recommend that she stay for a work up. She insisted that she be allowed to go. We discharged her on 2 gm of Ceftriaxone IV daily. ************** ************** TO FOLLOW UP 1) One febrile temperature prior to discharge with blood cultures drawn and ceftriaxone started 2) TACHYCARDIA and ISCHEMIC SEQUELAE 3) Persistent Leukocytosis without Fever or source 4) Elevated TSH and Normal Free T4 ************** ************** Medications on Admission: Levothyroxine 112 mcg PO DAILY Midodrine 5 mg PO BID Fludrocortisone 0.1 mg PO DAILY Clotrimazole 10 mg Troche 5X/DAY Nephrocaps 1 mg PO Daily Sevelamer HCl 800 mg PO TIDAC Metoclopramide 5 mg PO TIDAC (three Omeprazole 20 mg PO Daily Nutren Renal 0.08 2kcal/mL liquid, 1 Can TID Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take PRIOR to dialysis, on dialysis days. 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA): Take on the days you have dialysis, AFTER dialysis is complete. Disp:*30 Tablet(s)* Refills:*0* 5. Midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Take PRIOR to dialysis, on dialysis days. Tablet(s) 6. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane five times a day. 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 11. Loperamide 2 mg Capsule Sig: [**12-1**] Capsules PO QID (4 times a day) as needed for Diarrhea. Disp:*60 Capsule(s)* Refills:*0* 12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Dose Intravenous 3X/WEEK, with Dialysis for 4 weeks: You should receive this medication with dialysis, and the dose will be based on your blood vancomycin levels. 13. Outpatient Lab Work [**10-27**], [**11-3**], [**11-10**], [**11-17**] Please draw at Dialysis: ALT, AST, Alkaline Phosphatase, Vanc Level, esr and crp All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] 14. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a day. 15. Ceftriaxone 2 gram Recon Soln Sig: One (1) unit Intravenous once a day for 7 days: start on [**10-23**], pm. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Polycystic liver disease Polycystic kidney disease/End Stage Renal Disease Gram Positive Sepsis . Secondary hyperparathyroidism Anemia Seizure disorder Right upper extremity hemiparesis Discharge Condition: Medically stable for discharge to rehabilitation facility Discharge Instructions: Mrs [**Known lastname 92802**], You were admitted to the hospital for low blood pressures and high heart rate while undergoing hemodialysis. You had two stays in the intensive care unit, for closer monitoring. You also underwent several paracenteses to remove fluid from your abdomen. This fluid was initially found to be infected, and you had a blood infection as well; both infections were treated with intravenous antibiotics, and you will have to complete a six week course of vancomycin. You will also need to take another antibiotic (Bactrim) with dialysis sessions. . You were evalutated by our physical therapists, who felt that you would benefit from a brief stay in a rehabilitation facility. . While hospitalized, you had an echocardiogram performed to visualize your heart function. It showed areas of your heart that were not pumping as effectively as your last echocardiogram showed, in [**Month (only) **]. This was concerning for a possible episode of interrupted blood flow to your heart muscle. For this reason you were started on aspirin and atorvastatin, to protect your heart. You should discuss this with your primary care physician at your next visit, and also discuss the possibility of being referred to a cardiologist. . We made the following changes to your medication regimen: -Added ASPIRIN 81 mg by mouth, daily -Added ATORVASTATIN 40 mg by mouth, daily -Added SULFAMETHAZOLE-TRIMETHOPRIM Double Strength, 2 tabs to be given on the days you have hemodialysis, AFTER your dialysis sessions are complete -Added VANCOMYCIN. You will continue receiving this with dialysis through [**2148-11-17**]. The particular dose of vancomycin that you receive on any will be based on your blood vancomycin levels, as determined by blood tests. - Added CEFTRIAXONE - new antibiotic . Please call your providers or return to the hospital immediately if you experience any severe abdominal pain, nausea, vomiting, fevers > 101 degrees, severe chest pain, shortness of breath, lightheadedness, or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-10-29**] 2:20 INFECTIOUS DISEASE CLINIC: Please call ([**Telephone/Fax (1) 4170**] to schedule an appointment. You should be seen there two weeks after, and four weeks after discharge, to follow-up on the infection you had in your blood and abdominal fluid. PRIMARY CARE PHYSICIAN: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) 639**],[**First Name3 (LF) 640**] N. Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 93255**] Fax: [**Telephone/Fax (1) 93256**] Completed by:[**2148-10-24**]

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icd9cm

[ [ [] ] ]

[ "96.6", "39.95", "54.91" ]

icd9pcs

[ [ [] ] ]

18928, 19007

12327, 16570

334, 384

19237, 19297

3747, 3747

21385, 22070

2975, 3161

16900, 18905

19028, 19216

16596, 16877

19321, 21362

3176, 3728

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270, 296

1822, 2176

412, 1804

3764, 7721

9367, 12304

2198, 2802

2818, 2959

9320, 9331

72,094

101,151

35613

Discharge summary

report

Admission Date: [**2114-5-4**] Discharge Date: [**2114-5-11**] Date of Birth: [**2094-8-30**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Bactrim Attending:[**First Name3 (LF) 348**] Chief Complaint: left flank pain Major Surgical or Invasive Procedure: left percutaneous nephrostomy tube, [**2114-5-4**] History of Present Illness: 19F with past medical history significant for recent ruptured ovarian cyst presented to ED this morning with acute onset left flank pain. Pt had had dysuria for past 5-7 days, did home UA which was positive, had no insurance so did not seek treatment. 3 days prior to presentation noted subjective fevers and left work early. Has had intermittent fevers/chills. This morning noted severe left flank pain as well as some low abdominal discomfort and distention with associated polyuria, urgency and dysuria. Has had UTIs in the past but no history of flank pain or more complicated infection. Was seen [**4-13**] in ED for abd pain, dx with ruptured ovarian cyst. Was GC/Chla negative at that time. Upon arrival to ED patient was tachycardic to 110 but afebrile with other VS stable. She had a UA which was positive, otherwise labs unremarkable. Had an abdominal CT which showed a 9mm obstructing left ureteral stone and mild hydronephrosis. She was seen by urology who recommended upper tract decompression with percutaneous nephrostomy by IR, antibiotics and ICU admission due to concern for impending septic shock. The patient was given 1g ceftriaxone, zofran, morphine, ketorolac, benadryl and ondansetron. She remained persistently tachycardic throughout her ED stay, and received 4L IVF NS. She was taken to IR for placement of a L percutaneous nephrostomy tube which she tolerated well, urine was sent for microbiology. The stone was left in place to be removed by IR once infection treated. Upon return to the ED she complained of L flank pain that was pleuritic, radiating to the shoulder. She had a CXR to r/u free air under the diaphragm or PTX which was negative. Urology was called due to concern for possible subcapsular hematoma, recommendation made to watch drain output and [**Hospital1 **] hematocrits to monitor for bleeding. At time of transfer from the ED, VS Afebrile, 120 111/44 22 100% RA . Upon arrival to the floor the patient was complaining of left flank pain and spasm radiating to shoulder and abdomen as well as diffuse abdominal distention. She was also complaining of severe anxiety. Otherwise complaining of poor PO intake x months with estimated 10lb weight loss due to "nerves" and abdominal discomfort from her ovarian cysts. Also with occasional constipation. ROS as above, otherwise essentially negative. Past Medical History: Anxiety Ruptured ovarian cysts UTIs Social History: Lives with boyfriend, [**Name (NI) **], whom she identifies as emergency contact, and 2 cats. Just started work in factory in [**Location (un) **]. Sexually active. Denies EtOH, tobacco or drugs. Family History: Sister and aunts with history of [**Name (NI) 11011**]. Mom with CAD. Physical Exam: Vitals: T:99.7 BP:106/55 P:127 R:18 SaO2: 99% RA General: Anxious young woman, uncomfortable. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry. Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales, tattoo on left shoulder. Cardiac: Tachycardic and regular, no murmurs. Abdomen: Soft, hypoactive bowel sounds, tender to palpation lower quandrants, voluntary guarding, no rebound. L percutaneous nephrostomy tube in place left flank, dressing c/d/i, draining pink urine. Exquisitely tender around site. Extremities: trace non-pitting edema bilaterally. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. No nystagmus, dysarthria, intention or action tremor. Very anxious. Pertinent Results: [**2114-5-4**] 07:05AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019 [**2114-5-4**] 07:05AM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [**2114-5-4**] 07:05AM URINE RBC-[**6-13**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**3-8**] . [**2114-5-4**] 07:12AM WBC-4.0# RBC-4.56 HGB-13.8 HCT-39.2 MCV-86 MCH-30.2 MCHC-35.2* RDW-12.9 [**2114-5-4**] 07:12AM PLT COUNT-264 [**2114-5-4**] 07:12AM NEUTS-64.2 LYMPHS-26.3 MONOS-5.8 EOS-2.6 BASOS-1.1 [**2114-5-4**] 07:12AM GLUCOSE-95 UREA N-9 CREAT-0.7 SODIUM-143 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15 [**2114-5-4**] 07:16AM LACTATE-1.4 . Urine culture ([**2114-5-4**]) (standard sample) [**2114-5-4**] 7:05 am URINE Site: CLEAN CATCH **FINAL REPORT [**2114-5-6**]** URINE CULTURE (Final [**2114-5-6**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Pt's a 19 yo F treated for pyelonephritis, hydronephrosis status post percutaneous nephrostomy tube placement, C. difficile infection, and anxiety. Pyelonephritis: Her pan-sensitive E. coli infection was treated with intravenous ceftriaxone; this was switched to cefuroxime, to complete a two week course of antibiotics. She notes a cipro/bactrim allergy. She will pick up her antibiotic from the Freecare Pharmacy. Hydronephrosis: She was found to have a left ureteral stone with hydronephrosis. She was seen by the urology team and underwent percutaneous nephrostomy tube placement. This tube remains in place; she will follow-up with the urology team as noted, and will undergo laser lithotripsy after her urology follow-up. C. Difficile infection: Her treatment was complicated by C. difficile infection. She was treated with flagyl, with improvement in her diarrhea. She will continue to take flagyl while she is on the cefpodoxime, and will complete an additional two weeks of therapy after the course of cefpodoxime has been completed. Anxiety: She has significant panic disorder, and has not previously been treated. During her hospitalization, she had frequent episodes where she felt lightheadedness, dizziness, chest/throat tightness, and impending doom; these resolved spontaneously. She was seen by the psychiatry consult team; we offered Paxil, but the patient declined to initiate a new medication at this time. She reported hallucinations with ativan; as such, her episodes were managed with benadryl. She will follow-up next week with Dr. [**Last Name (STitle) 10166**] to initiate outpatient follow-up. She was discharged to home in stable condition. She has applied for FreeCare, and will pick up her medications from the FreeCare Pharmacy. She will follow-up as noted. Medications on Admission: none Discharge Medications: 1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*28 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 21 days. Disp:*63 Tablet(s)* Refills:*0* 3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Diphenhydramine HCl 25 mg Capsule Sig: [**1-5**] Capsules PO Q6H (every 6 hours) as needed for allergies, anxiety: Do not drive while taking this medication. Disp:*40 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pyelonephritis/urinary tract infection Nephrolithiasis/hydronephrosis Anxiety Discharge Condition: Stable Discharge Instructions: Nephrostomy care as noted. If your symptoms of pain worsen, you develop blood in your nephrostomy bag, or any other concerning symptom - please call your doctor and/or return to the hospital. Do not drive while taking Benadryl. Followup Instructions: Primary care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2114-5-16**] 2:00 Psychiatry: [**Last Name (NamePattern4) 81042**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2114-5-18**] 2:30 Urology: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2114-5-21**] 11:00

[ "300.01", "590.10", "008.45", "275.2", "041.4", "591", "276.8", "592.1" ]

icd9cm

[ [ [] ] ]

[ "55.03" ]

icd9pcs

[ [ [] ] ]

8421, 8427

6001, 7812

298, 350

8549, 8558

4166, 5978

8836, 9265

3021, 3093

7867, 8398

8448, 8528

7838, 7844

8582, 8813

3108, 4147

243, 260

378, 2732

2754, 2791

2807, 3005

11,558

125,520

27852

Discharge summary

report

Admission Date: [**2152-8-24**] Discharge Date: [**2152-8-30**] Date of Birth: [**2098-8-6**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3127**] Chief Complaint: Hep C cirrhosis/HCC here for liver transplant Major Surgical or Invasive Procedure: Liver transplant History of Present Illness: 54 y/o male with Hep C cirrhosis/HCC. Has felt reasonably well in the recent few weeks with no known exposure to infections, no fever or chills. Deemed appropriate for OLT on [**2152-8-24**] Past Medical History: ESLD secondary to Hep C cirrhosis/HCC HTN DMII Social History: Married Known IVDA in the past No tobacco use Family History: Non contributory Physical Exam: On Admission: VS: 98.1, 70, 127/83, 16, 96% NAD, A+O x 3 Lungs CTA bilaterally Card: RRR Abd: Mild distension, soft, NT. Mild fluid wave. Well healed subcostal scar RUQ. No hernias Extr: No C/C/E Pertinent Results: Labs on Admission [**2152-8-24**] 05:00AM GLUCOSE-107* UREA N-20 CREAT-0.8 SODIUM-141 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [**2152-8-24**] 05:00AM ALT(SGPT)-43* AST(SGOT)-91* ALK PHOS-88 TOT BILI-0.7 [**2152-8-24**] 05:00AM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-1.7 [**2152-8-24**] 05:00AM WBC-4.0 RBC-3.94* HGB-13.4* HCT-36.3* MCV-92 MCH-34.0* MCHC-37.0* RDW-14.4 [**2152-8-24**] 05:00AM PLT COUNT-62* [**2152-8-24**] 05:00AM PT-13.4* PTT-35.6* INR(PT)-1.2* [**2152-8-24**] 05:00AM FIBRINOGE-283 Brief Hospital Course: 54 y/o male admitted for liver transplant secondary to Hep C cirrhosis/HCC. Piggyback type liver transplant with portal vein to portal vein anastomosis. Celiac axis to proper hepatic artery anastomosis and bile duct to bile duct anastomosis. Surgery uneventful, stable on admission to SICU. Extubated on POD 1, required some fluid resuscitation and had high insulin requirements. Duplex showed patent vasculature. Transferred to the surgical floor on POD 3 after having some increased O2 requirements that resolved. Pt did have bilateral lower extr edema and was started on Lasix for the short term. Lasix will be re-evaluated in clinic Immunosuppression as per protocol, Prograf dosing increased to a final discharge dose of 5 [**Hospital1 **]. Initially liver enzymes decreased until POD 4 when Enzymes increased, bili remained stable. Liver US was repeated showing normal, patent hepatic vasculature. Continued monitoring of enzymes showed all values to decrease again. Chem 7 WNL. The last day of hospitalization the K was slightly low on the Lasix regimen, PO KCL given and patient counseled by dietitian to foods high in K. Labs will be followed on outpt basis as well. Patient continued to do well both physically and emotionally. Return demonstrated ability to manage glucose meter and insulin teaching. VS stable and afebrile throughout the post op period. Atenolol was increased from home dose of 50 [**Hospital1 **] to 75 [**Hospital1 **]. All tubes and drains were removed during the hospital course. Patient to have follow up clinic visit and labs per outpt protocol. D/Cd home in the care of his wife, no services. Medications on Admission: atenolol 50'', benicar 20', prevacid 30', zoloft 50', darvocet prn Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Ten (10) ML PO DAILY (Daily). 3. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day. 4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO twice a day. 10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. dressings Please dispense 4x4 gauze pads and drain sponges (20 each) 12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day. Advised to restart Zoloft Discharge Disposition: Home Discharge Diagnosis: s/p liver transplant, doing well Discharge Condition: Good Discharge Instructions: Call [**Telephone/Fax (1) 673**] if you experience any of the following symptoms: fever,chills, nausea, vomiting, diarrhea, pain over the incision site or liver, jaundice, an increase in abdominal girth or any other symptoms concerning to you. Have labs drawn every Monday and Thursday and have them faxed to [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST,ALT, Alk Phos, Albumin, T Bili and trough Prograf Level You are going home on Lasix, which is a "water" pill. It also depletes your body of postassium, please make sure you eat the higher potassium foods the dietitian recommended to you. Bananas and [**Location (un) 2452**] juice are always good choices. Make sure you drink enough to stay hydrated during the heat wave!! Followup Instructions: Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2152-9-7**] 10:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2152-9-7**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2152-9-14**] 1:10 Completed by:[**2152-8-30**]

[ "070.70", "401.9", "155.0", "571.5", "287.5", "250.00", "285.22" ]

icd9cm

[ [ [] ] ]

[ "99.05", "50.59", "00.93", "38.93" ]

icd9pcs

[ [ [] ] ]

4413, 4419

1504, 3134

316, 335

4496, 4503

955, 1481

5280, 5717

705, 723

3252, 4390

4440, 4475

3160, 3229

4527, 5257

738, 738

231, 278

363, 555

752, 936

577, 626

642, 689

75,326

107,058

14906

Discharge summary

report

Admission Date: [**2178-3-12**] Discharge Date: [**2178-3-12**] Date of Birth: [**2109-1-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: neck, throat swelling Major Surgical or Invasive Procedure: none History of Present Illness: 69 year-old man with a h/o DM2, CAD, CHF, GERD, chronic sinusitis, asthma, s/p esophageal dilatation who presents with uvular swelling. Pt reports that he was walking to the bathroom at midnight when he noted the onset of a swelling sensation in his throat with difficulty and mild pain on swallowing. He also notes mild lip swelling. No urticaria, flushing, pruritis, or lightheadedness. No fevers, cough, swollen lymph nodes, sore throat, or purulent sputum. He has stable rhinorrhea worst at night from chronic sinusitis. He denies any difficulty handling his secretions or dysphagia; these sx are dissimilar from those leading to his esophageal dilatation several years ago. The patient does recall one similar prior episode a few years ago after eating a [**Location (un) 6002**]. At an OSH ED, he was given some medications and the swelling resolved after several hours; this was attributed to mayonnaise. He has tolerated this fine since and denies mayonnaise or other new foods recently. He reports being on lisinopril for 2-3 years; he believes he was taking it at the time of this previous episode. His only new medication is ferrous sulfate, started yesterday AM. He has not taken ASA or NSAIDs in at least 4 months due to his renal failure. No insect stings or chemical exposures. No chronic abdominal pain or family history of angioedema. . In the ED, initial vs were: T 98, P 82, BP 161/66, RR 22, O2sat 100. Pt was without stridor or wheezing with minimal tongue and lip swelling but +uvular hydrops. He was given diphenhydramine 50mg IV, famotidine 20mg IV, and methylprednisolone 125mg IV. Pt stable but given absence of improvement, he is being admitted to the ICU. VS on transfer: T 98.0, P 83, BP 151/79, RR 14, O2sat 100% 2L. . On the floor, pt currently reports slight improvement in his swelling. No difficulty handling secretions. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, stably fluctuating weights due to CHF. Denies headache. Chronic sinus tenderness, rhinorrhea, and congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, abdominal pain. 1 episode of diarrhea yesterday; none since. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Diabetes mellitus 2 Hypertension Hyperlipidemia CAD with "mild MI" in the past per patient CHF (EF 51% on [**2178-2-19**] stress MIBI) ESRD undergoing work-up for PD and transplant Chronic sinusitis H/o asthma (last exacerbation in [**2152**]) GERD Prostate cancer (new dx on [**2-19**] prostatic bx - [**Doctor Last Name **] score 6 (3+3), small focus involving less than 5% of the core tissue) S/p esophageal dilatation several years ago S/p removal of benign cyst under tongue at age 15 Social History: Lives with wife and daughters and granddaughters. Retired, used to work for a cleaning company. - Tobacco: Quit tobacco 20 yrs ago - Alcohol: Denies - Illicits: Denies Family History: Strong family history of DM and CAD Physical Exam: T 96.9, P 90, BP 165/73, RR 14, O2sat 100% 2L General: Alert, oriented, no acute distress, stridor, or wheezing HEENT: Sclera anicteric, MMM, lips and tongue not noticeably swollen, uvular hydrops without exudates, no erythema, no parotitis Neck: Supple, JVP not elevated, no LAD, nontender Lungs: Minimal crackles at bilateral bases, otherwise clear without wheezes. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, obese but non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No flushing or rash Neuro: AAO x 3, nonfocal Pertinent Results: [**2178-3-11**] 10:36AM BLOOD WBC-6.8 RBC-3.92* Hgb-11.0* Hct-33.3* MCV-85 MCH-28.0 MCHC-32.9 RDW-13.5 Plt Ct-405 [**2178-3-11**] 10:36AM BLOOD UreaN-58* Creat-5.9* Na-140 K-4.7 Cl-100 HCO3-27 AnGap-18 [**2178-3-11**] 10:36AM BLOOD Calcium-7.9* Phos-4.5 [**2178-3-11**] 10:36AM BLOOD PTH-527* [**2178-3-12**] 12:35PM BLOOD C4-39 Brief Hospital Course: 69 yo man with DM, CAD, GERD, chronic sinusitis, asthma, s/p esophageal dilatation p/w angioedema. . # Angioedema: C/w angioedema. Most commonly associated with ACE-I. Does have a history of similar episode; acquired C1 inhibitor deficiency possible - familial less likely given age and absence of family hx. Did just start iron supplement and allergy to a component is possible, but time course not as consistent and more likely kinin-mediated rather than mast cell given absence of urticaria, prurutis. No inhalant abuse; not taking ASA or NSAIDS due to renal failure. Pharyngitis can cause uvular swelling but no fever, exudates, or sore throat to suggest acute infectious etiology. Lisinopril was held on admission and the patient was instructed not to resume this medication. Complement levels were checked. His angioedema resolved completely by the end of the day and he was discharged. . # HTN: He was restarted on home blood pressure medications except for lisinopril. Blood pressure was controlled and he was discharged with instructions to f/u with his PCP. . # DM: He reports episodes of hypoglycemia at home in the 50s and Lantus was recently lowered. His Glyburide was stopped on admission due to his end stage renal disease. He will continue to monitor his blood sugars regularly at home. . # ESRD: In work-up for PD and transplant. Sevelamer and calcitriol continued. . # CAD: Stable: Simvastatin and b-blocker continued. . # CHF: Euvolemic: Home lasix dose continued. . . # Prostate cancer: New dx, [**Doctor Last Name **] score 6 - Outpt f/u with Dr. [**Last Name (STitle) 770**] on [**2178-3-19**] Medications on Admission: ALBUTEROL SULFATE (not taking) CALCITRIOL 0.25 mcg daily FUROSEMIDE 80 mg [**Hospital1 **] GLYBURIDE 5 mg daily INSULIN GLARGINE [LANTUS] 8 units daily LISINOPRIL 40 mg [**Hospital1 **] METOPROLOL TARTRATE 25 mg [**Hospital1 **] NIFEDIPINE SR 90 mg daily SEVELAMER CARBONATE [RENVELA] 1600 mg tid w/ meals SIMVASTATIN 80 mg daily IRON 325 mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous once a day. 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three times a day. 7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Angioedema Secondary Diagnosis: 2. Diabetes Mellitus 3. End-Stage Renal Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a reaction called angioedema. We think that this was due to your Lisinopril dosing. It may have been related to your iron as well. You should not take Lisinipril ever or this may cause a life-threatening reaction. The following changes were made to your medications: STOP Lisinopril STOP glyburide You should follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You should monitor your blood pressure at home and call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] values over 160 systolic. You should check your blood sugars regularly and call your primary care doctor for values over 200 or less than 70. Followup Instructions: Scheduled Appointments: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-3-16**] 3:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**] Date/Time:[**2178-3-19**] 4:00 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-3-26**] 8:30 Please see your primary care doctor within 2 weeks of discharge.

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icd9cm

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icd9pcs

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7155, 7161

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14323

Discharge summary

report

Admission Date: [**2129-8-20**] Discharge Date: [**2129-9-7**] Date of Birth: [**2052-10-24**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 9454**] Chief Complaint: foot pain, fevers, sepsis, cardiogenic shock Major Surgical or Invasive Procedure: none History of Present Illness: Chief complaint: Transferred from [**Hospital3 417**] for management of acute on chronic congestive heart failure. . History of present illness: Mrs. [**Known lastname 19688**] is a 76 year-old Portuguese-speaking woman with insulin dependent diabetes, hyperlipidemia, cerebrovascular disease (with stroke), COPD, depression, GERD, heart failure (LVEF 20%) and chronic renal failure presenting to [**Hospital3 417**] Hospital with generalized weakness, possible abdominal pain, and leg and right foot pain. Today she is transferred to [**Hospital1 18**] for management of fluid overload. . The discharge summary from [**Hospital3 417**] mentions that she was suffering from gout with treatment begun in the nursing home, abdominal CT to assess ?abdominal pain, and generalized weakness. She had also presented with a creatinine of 2.2 and it appears that fluid resuscitation was commenced that has now reduced her creatinine but worsened her heart failure. In her summary, lower extremity pain was attributed to vascular disease and possibly in need of vascular studies and intervention. She is also to be worked-up for acute causes of heart failure. CT scan of the right kidney is suggestive of pyelonephritis that has so far been treated with Levaquin (renal dosing). While in-house at [**Hospital3 **]. one blood culture bottle was positive for staphlococcus but this was atributed to contamination. Another set from [**2129-8-17**] was negative at the time of transfer. CXR was suspicious for infiltration of the lower lobes. . Per the patient: There was no joint tap to diagnose gout. OSH records state that she was given allopurinol two weeks ago in the nursing home for suspected gout along with colchicine (unclear if renally dosed). She is mostly concerned for the pain in her right foot which is the reason she gave for her admission to [**Hospital3 417**]. She says that it had become painful in the nursing home and that she could no longer stand on it. She has trouble walking due to her left hemiparesis, and now with foot and bilateral leg pain. Past Medical History: .Chronic Congestive Heart Failure (LVEF ~ 20%) .NSTEMI .Coronary Artery Disease - s/p multiple RCA stents .Mitral Regurgitation .IDDM .Hypercholesterolemia .Cerebrovascular Disease - s/p CVA (left hemiparesis) .Known Carotid Disease .Right Subclavian Stenosis, Peripheral Vascular Disease .History of Humeral Fracture .GERD .Depression .Prior Bladder Surgery .Fem-[**Doctor Last Name **] bypass complicated by infection .Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension Social History: Lives in [**Hospital 1475**] Nursing Home and is retired. Denies tobacco, ETOH and recreational drugs. Ambulates with a walker at baseline. Lives with her daughter. Denies tobacco, ETOH and recreational drugs. Family History: Denies premature coronary disease. Physical Exam: VS - T 99.2 BP 117/54 HR 91 RR 22 SatO2 100% 2L glucose 310 pain 0/10 Gen: Resting awake and comfortably. Very pleasant and grateful. Some poverty of spontaneous speech and movement. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP to the angle of the mandible at 60 degrees. CV: RRR with occasional ectopy, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities. Resp were unlabored, no accessory muscle use. Crackles worse on the right base. No wheezes or rhonchi. Patient could not sit so listened to posterolateral lung. Patient had some difficulty following instructions for breathing during examination. Abd: Soft, NTND. No HSM or tenderness. Ext: [**1-11**]+ edema of the extremities. No clubbing. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Edema was severe limiting examination. Neurological: Left hemiparesis of leg, arm, face, with an upper motor neuron pattern of weakness. Speech was not dysarthric, slightly slowed, little spontaneous expression or speech. Possibly some limitation of comprehension but English is second to Portuguese. Sensation intact at extremities, forearm and lower legs. Some degree of pain asymbolia possible - said touching feet very painful but seemed blase. Reflexes not tested. Unable to walk. Pertinent Results: IMAGING: . [**2129-9-7**] CXR: IMPRESSION: Minimal pulmonary edema in the presence of mild cardiomegaly. No new consolidation. . [**2129-9-5**] Echo: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). The right ventricular cavity is dilated with depressed free wall contractility. 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 masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: No evidence of vegetation or abscess. Severe global LV hypokinesis. The lateral wall has relatively better function. The ventricle appears dyssynchronous. Moderate mitral, aortic and tricuspid regurgitation (all may be UNDERestimated due to acoustic shadowing from widespread calcification). Moderate pulmonary artery systolic hypertension. . Compared with the prior study (images reviewed) of [**2129-8-22**], overall ejection fraction is probably slightly less. Degree of aortic regurgitation has increased, degrees of mitral and tricuspid regurgitation probably similar. Estimated pulmonary artery systolic pressures are higher. . [**2129-9-3**] CT chest/abdomen/pelvis: CHEST: Trace pleural fluid is present bilaterally with minimal dependent bibasilar atelectasis. Images are somewhat degraded due to respiratory motion artifact; however, there is no consolidation. Small amount of fluid is present in the dependent portion of the central trachea. Cardiomegaly and heavy coronary arterial calcifications and atherosclerotic calcification of the thoracic aorta is unchanged. There is no mediastinal or axillary lymphadenopathy. Median sternotomy wires are in place. . ABDOMEN: The liver, spleen, adrenals, and kidneys are within normal limits. Numerous surgical clips in the gallbladder fossa and at the posterior aspect of the right hepatic lobe from previous cholecystectomy are again seen. There is no biliary ductal dilatation. The pancreas is within normal limits. There is diffuse atherosclerotic calcification of the abdominal aorta, aortic branches, and intrarenal vascular calcifications are noted. Right femoropopliteal arterial graft is again noted. There are no peritoneal fluid collections. There is a large amount of stool in the rectum, descending colon, and distal transverse colon. There is no small- bowel obstruction. A normal appendix is noted. There is no bowel wall thickening or pneumatosis. . PELVIS: The urinary bladder is collapsed about a Foley catheter balloon. Focus of air in the nondependent portion of the bladder is likely related to Foley catheter placement. Again seen is a calcified uterine fibroid. There are no adnexal masses. There are no pelvic fluid collections. . ABDOMINAL WALL: Numerous areas of infiltration of the subcutaneous fat in the anterior abdominal wall, few foci of subcutaneous air are likely related to injection sites. . BONES: Multilevel degenerative changes of the thoracic and lumbar spine are unchanged. Compression deformity of the superior endplate of L1 is unchanged. Right glenohumeral joint degenerative change and mild bilateral hip osteoarthritis is noted. . IMPRESSION: 1. No pneumonia, as questioned. 2. No abdominal or pelvic collections. No findings suggestive of ischemic colitis. . [**2129-9-3**] CT head: FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally midline structures, or edema. The ventricles and cerebral sulci remain prominent, compatible with age-related involutional change. Periventricular regions of hypodensity are unchanged, consistent with small vessel ischemic change. Bilateral basal ganglia calcifications are again noted. The [**Doctor Last Name 352**]-white matter differentiation remains normal. Chronic left basal ganglia, thalamic and left frontal infarcts are unchanged. Mastoid air cells are hypoplastic. The paranasal sinuses are otherwise well aerated. . IMPRESSION: No intracranial hemorrhage. . [**2129-8-26**] CTA lower extremities IMPRESSION: 1. Occluded left superficial femoral artery with reconstitution at the popliteal. Complete occlusion of the left posterior tibial artery with severely diseased, but patent anterior tibial and peroneal arteries. 2. Patent fem-[**Doctor Last Name **] bypass graft on the right with stable severe narrowing at the insertion of the bypass graft into the popliteal artery. Occluded native superficial femoral artery on the right. Evaluation for the runoff to the lower right leg is limited as the entire lower leg is not visualized on this study. However, it does appear that the posterior tibial artery is occluded on this side. . MICRO: . [**9-6**], [**9-3**] C. diff: neg Blood cx: [**9-6**], [**9-3**], [**9-2**] x2: NGTD Blood cx: [**8-26**], [**8-23**], [**8-20**] x2: NEGATIVE Urine cx: [**9-2**]: yeast, [**8-23**]: NEGATIVE . LABS ON ADMISSION: [**2129-8-20**] 08:10PM BLOOD WBC-14.9*# RBC-4.01*# Hgb-12.7# Hct-40.0# MCV-100* MCH-31.7 MCHC-31.7 RDW-15.7* Plt Ct-146*# [**2129-8-20**] 08:10PM BLOOD Neuts-89* Bands-0 Lymphs-10* Monos-0 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2129-8-20**] 08:10PM BLOOD PT-19.3* PTT-29.2 INR(PT)-1.8* [**2129-8-20**] 08:10PM BLOOD Glucose-303* UreaN-63* Creat-1.6* Na-131* K-4.6 Cl-96 HCO3-26 AnGap-14 [**2129-8-20**] 08:10PM BLOOD ALT-378* AST-177* CK(CPK)-41 AlkPhos-76 TotBili-0.6 [**2129-8-20**] 08:10PM BLOOD CK-MB-NotDone cTropnT-1.67* [**2129-8-20**] 08:10PM BLOOD Albumin-2.9* Calcium-8.4 Phos-2.3* Mg-2.8* [**2129-8-29**] 05:28PM BLOOD Lactate-1.4 . LABS ON DISCHARGE: [**2129-9-7**] 05:50AM BLOOD WBC-23.4*# RBC-3.96* Hgb-12.6 Hct-40.9 MCV-103* MCH-31.8 MCHC-30.9* RDW-17.5* Plt Ct-232 [**2129-9-7**] 05:50AM BLOOD Neuts-90.9* Lymphs-6.8* Monos-1.9* Eos-0.2 Baso-0.2 [**2129-9-7**] 10:00AM BLOOD PT-23.8* PTT-34.5 INR(PT)-2.3* [**2129-9-7**] 10:00AM BLOOD Glucose-307* UreaN-129* Creat-2.3* Na-143 K-5.7* Cl-108 HCO3-17* AnGap-24* [**2129-9-4**] 04:24AM BLOOD ALT-80* AST-96* LD(LDH)-303* AlkPhos-40 TotBili-1.3 [**2129-9-7**] 10:42AM BLOOD Type-[**Last Name (un) **] pO2-63* pCO2-35 pH-7.29* calTCO2-18* Base XS--8 [**2129-9-7**] 10:42AM BLOOD Lactate-6.3* Brief Hospital Course: 76 yo F with MMP including CHF and PAD, initially admitted for foot pain, transferred to [**Hospital1 18**] and felt to be in acute on chronic CHF (EF 20%), s/p aggressive diuresis, now presenting with intermittent fevers without source, progressive altered mental status, noted to be in oliguric acute renal failure, and in early sepsis. . BRIEF HOSPITAL COURSE: In brief, 76 yo F with MMP, admitted [**2129-8-20**] to [**Hospital3 **] Hospital for foot pain. She was empirically started on colchicine and allopurinol, despite lack of gout hx or joint tap. She was noted to be in ARF (Cr 2.2, baseline 1.2 in [**2127**]). Some concern for pyelo, despite normal U/A. Transferred to [**Hospital1 18**] for heart failure. Admitted to [**Hospital1 1516**] service, where she was aggressively diuresed total of 10L over next several days. Cr started to rise and 1.6-1.8. Pt spiked on [**2129-8-23**] and WBC 11. Left leg appeared red. Neg LENI's. Started on vanco and cipro for cellulitis. Switched to vanc and ceftriaxone given hx of cipro resistant E.coli at the site of her fem-[**Doctor Last Name **] bypass in the past. On [**8-26**], underwent CTA with contrast, seen by vascular, and planned for angio procedure, given concern for ischemia in leg. On [**9-21**], triggered for ?encephalopathy and AMS. On [**8-30**], CT head negative for hemorrhage. NGT placed for concern for inability to take in PO. On [**9-3**], triggered again, this time unresponsive and tachycardic. Concern for SIRS/sepsis given BP 90/50, HR 130, and transferred to MICU. Given fluid boluses, started on vanco/cefepime/flagyl. CT chest/abd/pelvis without consolidation or fluid collections. Echo neg for vegetations. Pancultured without source. On [**9-4**], given fluid boluses for low UOP. On [**9-5**], had neg TTE study again, given concern for intermittent temp spikes. After discussion with ICU team, patient DNR/DNI. On [**9-7**], spiked again and WBC to 23, with lactate rising (now 4.5). Discussion with family re: goals of care, and family wished to pursue comfort measures. . DETAILED HOSPITAL COURSE: . [**Hospital1 **] COURSE: # Acute on chronic heart failure/fluid overload: felt to be significantly fluid overloaded from aggressive hydration in OSH and perhaps earlier, given her poor systolic heart function. Physical exam significant for basilar crackles, raised JVP, significant edema throughout. CXR imaging noting pulmonary edema, without signs of infection. Other acute causes of pump dysfunction were considered including myocardial ischemia/infarction, medication error, colchicine, thyroid disease, anemia, atrial fibrillation. Patient initially started on sodium restriction, fluid restriction, lasix drip 15 mg/hr, metolazone (5 mg PO BID). EKG, cardiac enzymes, and TSH were non-revealing. Echo was performed showing, "severe global left ventricular hypokinesis with relative preservation of the basal anterior septum and inferolateral walls. The remaining segments are severely hypokinetic (LVEF = 25 %). Mild to moderate ([**12-10**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, anteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. Moderate tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension." Patient diuresed approximately 10L. . ## Lower and right foot pain: Possible etiologies felt to include arterial insufficency, DVT, severe edema secondary to acute on chronic renal and heart failure as well as hypoalbuminemia, possibly with neuropathic contribution. Gout is possible, but the appearance of the feet and distribution of pain are not consistent with monoarticular or oligoarticular gout, particularly not the great toe. DVT is possible but seen as less likely given bilateral symmetry and given the the degree of edema is somewhat in keeping with that of her hand and other signs such as crackles, raised JVP. Arterial insufficiency is also possible as is diabetic neuropathy. Initial workup consisted of LENI's (negative for DVT), and treatment for cellultis (started on vanco and cipro, switched to vanc and ceftriaxone given hx of cipro resistant E.coli at the site of her fem-[**Doctor Last Name **] bypass in the past). CTA lower extremities performed showing occluded left superficial femoral artery with reconstitution at the popliteal. Complete occlusion of the left posterior tibial artery with severely diseased, but patent anterior tibial and peroneal arteries. Patent fem-[**Doctor Last Name **] bypass graft on the right with stable severe narrowing at the insertion of the bypass graft into the popliteal artery. Occluded native superficial femoral artery on the right. Evaluation for the runoff to the lower right leg is limited as the entire lower leg is not visualized on this study. However, it does appear that the posterior tibial artery is occluded on this side. It was felt that patient's leg pain was largely from PAD/PVD/lower extremity ischemia, and vascular was consulted. However, angiogram was not performed, given co-morbidities and remainder of hospital course. . ## Renal failure: multifactorial, and likely from medications, impaired forward flow from heart failure, being physiologically pre-renal despite fluid overload, contrast nephropathy and possibly ATN. . ## Confusion/altered mental status: unclear but felt to be toxic metabolic in setting of elevated BUN. Head CT negative for CVA/ICH. Diuresis was held at this point. . MICU COURSE: Ms. [**Known lastname 19688**] is a 76 yo female w/ multiple medical problems, transferred to MICU for further management of presumed sepsis. . # Sepsis: Patient re-developed fevers on [**9-2**] on a regimen of vancomycin / ceftriaxone. Patient had no previous positive cultures since [**2129-8-20**]. Initial concern for infectious etiologies included the following: *** Intra-abdominal: given pain on palpation, and fevers while on broad spectrum gram positive coverage with somewhat limited gram negative/anaerobic coverage. Initial differential included C. diff colitis, mesenteric ischemia (given multiple vasculopathies, elevated lactate), abscess. However, CT torso was negative and pain resolved with disimpaction and bowel regimen. Patient was intermittently started on flagyl which was discontinued after the negative imaging. *** Urine: there was initial concern for renal abscess given prior history of pyelonephritis; however, CT was negative. *** Graft site infection of right fem-[**Doctor Last Name **] graft site: given right foot pain and history of resistant E. coli/ MRSA at the wound site. In ICU, antibiotics were initially broadened for gram negative coverage to cefepime to cover pseudomonas. Infectious disease was consulted who. Drug induced fever was considered. . # Volume status/Chronic systolic HF: as evidenced by her ABGs and electrolyte profile, she may have been over-diuresed at time of admission to MICU. Diuresis was held and the patient was provided fluids. Her ACE was also held given hypotension. . # Peripheral arterial disease: will follow up vascular surgery recs re: need for angio once hemodynamically stable. . # Insulin dependent diabetes: continued ISS with fingersticks # Hypertension: held antihypertensives while managing sepsis . # Peripheral arterial disease: s/p recent right fem-[**Doctor Last Name **] bypass graft c/b wound infections with MRSA/E. coli requiring prolonged courses of vanc/cefazolin/aztreonam-->linezolid/cephpodoxime (for cipro resistant E. coli). Then minocycline for MRSA suppression lifelong. . GENERAL WARDS: # Altered mental status: after discussion with family and extensive chart review, markedly off baseline. At baseline, patient alert, oriented, and conversant. Now has had progressive decline in mental status to the point that she is no longer verbal. Has had trigger for same event for unresponsiveness. DDX includes toxic metabolic (uremia) vs. infectious (though culture negative to date) vs. CVA/ICH (CT negative). Most likely etiology felt to be toxic metabolic. Nephrology was consulted, but given other co-morbidities, goals of care were discussed in parallel with potential dialysis. . # Oliguric acute renal failure: likely multifactorial in the setting of sepsis, cardiorenal syndrome (at baseline with poor EF), contrast/dye load (given [**2129-8-26**]), overdiuresis ([**Date range (1) 42498**]), and then decreased PO intake ([**Date range (1) 26417**]). Baseline Cr 1.2, then has been progressively increasing. Now holding diuresis. Currently BUN 118, Cr 2.1. Renal consulted, and goals of care discussed. . # SIRS/early sepsis: patient with intermittent fevers without source throughout hospital stay. On morning of [**9-7**], lactate 4.4, patient tachycardic and tachypnic, and low grade fevers. Repeat lactate > 6. With regard to source, suspect overt infection as opposed to occult infection, given jump in WBC from 13.5 to 23.4. Suspect Cdiff or bacteremia despite previous negative blood cultures/negative micro. Started on PO flagyl (in addition to previous IV vanco and cefepime). Goals of care discussed with family and HCP. Family and HCP elected to make patient [**Name (NI) 3225**]. Palliative care and pastoral care services offered. Family at bedside when patient passed. Medications on Admission: Medications on Transfer: SSI Phytonadione 2 mg PO DAILY Duration: 3 Days Acetaminophen 325-650 mg PO Q6H:PRN fever >100 Lactulose 30 mL PO TID Senna 1 TAB PO BID Docusate Sodium 100 mg PO BID Heparin 5000 UNIT SC TID CefePIME 1 g IV Q24H Vancomycin 1000 mg IV Q48H DAY Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: PRIMARY: septic shock cardiogenic shock Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2129-9-8**]

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icd9cm

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Discharge summary

report

Admission Date: [**2196-4-2**] Discharge Date: [**2196-4-22**] Date of Birth: [**2113-4-20**] Sex: M Service: MEDICINE Allergies: Insulin Zinc / Penicillins Attending:[**First Name3 (LF) 1711**] Chief Complaint: Bradycardia Major Surgical or Invasive Procedure: Temporary pacing wire Nuclear stress test Endotracheal intubaction Peripherally inserted central catheter Central venous line Intraosseous catheter History of Present Illness: 82M DM, CAD s/p CABG, CVA, HL, HTN presented with a two day history of weakness and nausea to [**Hospital3 6592**]. He was mottled on presentation and noted to be in high grade AV block. He was externally paced at 70. Presenting mental status was not clearly documented. Initial labs were significant for troponin T of 4.61 and pBNP of [**Numeric Identifier 97824**] with pending CK-MB. Chemistry panel showed Na 140, K 5.5, Cl 98, HCO3 21, Glucose 50, BUN 58, Cr 3.3 (unknown baseline). LFTs were ALT 633, AST 1151. VS at [**Hospital1 **] were variable including SBP readings x 3 of 57-78 with HR in 30s. Patient was intubated with 7.5 ETT 24 cm at lip prior to arrival to [**Hospital1 18**] - uncertain if was in frank respiratory failure or for airway protection. Initial ventilator settings were RR 16, Vt 500, FiO2 100 %, PEEP 8. He was sedated with fentanyl and midazolam. He was trancutaneously paced at 100 bpm. On arrival to ER, initial VS were BP 89/46, MAP 50. Access was lost. BP dropped to 60/37 and paced rate was increased to 100 to help maintain blood pressure. Dopamine infusion had been started at some juncture during transport and was increased. An IO was placed for pressor infusion in the left tibia. Blood pressure responded with resultant SBP 120-130s. A RIJ was placed with transvenous pacing started (25 mAmp @ 110 with good capture). Patient also had right femoral line. Dopamine was titrated down to 13 before transfer to CCU. All lines were placed in sterile fashion. Admission Vitals: 110 (paced), 114/74, 92% vent (FiO2 50, PEEP 8, rate 20) drips: fentanyl, versed, dopa 13 mcg/kg/min On arrival to CCU, repeat ABG showed pH 7.30 pCO2 41 pO2 58 HCO3 21 and lactate 8 --> 5 --> 3.6. PEEP was increased from 8--> 12, FiO2 50 % --> 70% with improvement of pO2 to 87. CXR showed frank pulmonary edema with proper placement of support structures. Dopamine was weaned further from 15 to 7. Pacing HR was decreased from 110 to 90. Patient had about 175 cc of urine output since arrival. Central venous sat was 68. Arterial line was placed for hemodynamic monitoring and frequent ABG draws. ROS unable to be obtained given intubated/sedation Past Medical History: - CAD s/p CABG [**2193-4-3**] - DM - CVA x3 - Hyperlipidemia - gout - HTN - on home 2L O2 at night PSH: CABG x4 LIMA --> first diagnoal; three reversed saphenous vein bypass grafts placed to the second diagonal (proximal anastomosis off obtuse marginal), to the obtuse marginal, and to the right anterior acute marginal Social History: Lives with son. [**Name (NI) **] health aide for ADLs. His wife lives in [**Name (NI) 1501**], and he visits daily. Drives. Tobacco: 50 years, 1-2 packs per day. Quit 7 years ago. EtOH: none Drugs: none Family History: N/a Physical Exam: Admission- General Appearance: No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL, pinpoint bilaterally Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal tube, OG tube Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Diminished: ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace Skin: Warm, No(t) Rash: Neurologic: Responds to: Unresponsive, Movement: No spontaneous movement, Sedated, Tone: Normal Discharge- Vitals - Tm/Tc: 99.6/98.4 HR: 109-114 BP: 87-119/63-70 RR:18-20 02 sat: 95% 2L GENERAL: 83 yo M in no acute distress HEENT: no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, unable to assess JVD CHEST: CTABL no wheezes, no rales, no rhonchi, [**Month (only) **] BL CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, obese, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs 2+. NEURO: 3/5 strength in U/L extremities. SKIN: perianal and coccyx area redness, no breakdown PSYCH: alert, oriented, no anxiety. Pertinent Results: Admission- [**2196-4-2**] 12:21AM BLOOD WBC-9.1 RBC-4.12* Hgb-12.3* Hct-40.7 MCV-99* MCH-29.9 MCHC-30.3* RDW-14.7 Plt Ct-278 [**2196-4-2**] 02:43AM BLOOD Neuts-86.5* Lymphs-8.2* Monos-5.2 Eos-0 Baso-0.1 [**2196-4-2**] 12:21AM BLOOD PT-19.9* PTT-30.7 INR(PT)-1.9* [**2196-4-2**] 02:43AM BLOOD Glucose-145* UreaN-63* Creat-3.2* Na-142 K-5.2* Cl-98 HCO3-19* AnGap-30* [**2196-4-2**] 02:43AM BLOOD ALT-673* AST-1341* CK(CPK)-445* AlkPhos-105 TotBili-1.0 [**2196-4-2**] 02:43AM BLOOD Albumin-3.6 Calcium-8.4 Phos-9.6* Mg-1.8 Discharge- [**2196-4-22**] 06:55AM BLOOD WBC-6.4 RBC-3.42* Hgb-9.5* Hct-31.3* MCV-92 MCH-27.8 MCHC-30.3* RDW-14.7 Plt Ct-559* [**2196-4-19**] 04:27AM BLOOD PT-12.0 PTT-27.8 INR(PT)-1.1 [**2196-4-22**] 06:55AM BLOOD Glucose-100 UreaN-31* Creat-1.1 Na-140 K-4.3 Cl-96 HCO3-37* AnGap-11 [**2196-4-21**] 06:55AM BLOOD ALT-26 AST-37 AlkPhos-165* TotBili-0.4 TTE ([**2196-4-2**]) The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to marked pacing-induced mechanical dyssynchrony and probable contractile dyfunction as well. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ([**2196-4-6**]) Mild mucosal thickening and sinus opacification as described above. This may be related to infection or inflammation or intubated state. No large air-fluid levels. CT CHEST, ABD, & PELVIS WITH CONTRAST ([**2196-4-6**]) -Mild nonspecific inflammatory changes in the sigmoid mesentery. Although a few colonic diverticula are noted in the sigmoid colon, the inflammatory changes are not seen contiguous with these diverticula. Diverticulitis however remains a consideration a consideration. -Small bilateral pleural effusions with adjacent atelectasis. Centrilobular pulmonary emphysema in the upper lobes. -Atherosclerotic vascular disease with infrarenal and common iliac artery aneurysms. -ETT ends 1.8 cm above the carina and needs to be retracted. TTE ([**2196-4-8**]) There is severe regional left ventricular systolic dysfunction with akinesis of the inferolateral, basal inferior, mid- and distal septal walls and hypokinesis of the distal anterior wall and apex. There is mild hypokinesis of the remaining segments (LVEF = 25-30%). The right ventricular cavity is mildly dilated with focal hypokinesis of the apical free wall. There is no aortic valve stenosis. Trace aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w multivessel CAD. Moderate mitral and tricuspid regurgitation. Moderate pulmonary hypertension. Brief Hospital Course: 83 yo M with CAD, CVA, HTN and DM presented with high grade AV block, sepsis, and respiratory failure. . # Shock The patient presented with hypotension requiring blood pressure support. Original hemodynamics were suggestive of a cardiogenic etiology, however he began to have elements suggestive of an overlying septic etiology. He was initially diuresed and started on broadspectrum antibiotics. He gradually recovered and he no longer required pressor support. His antibiotics were gradually scaled back until he again began to experience fevers with a opacity noted on CXR which was c/w a possible ventilator associated PNA. As below, he was then treated with an eight day course of meropenum and vancomycin for VAP. # High grade AV Block Upon arrival to the OSH, the patient was noted to be in a high grade AV block with hemodynamic compromise. He was temporarily paced, although over time his block improved to NSR with first degree AV block. The temporary wire was removed without incident. # Hypoxic Respiratory Failure He was brought to [**Hospital1 18**] intubated and sedated due to hypoxia and resuscitative efforts. His vent settings were weaned and he was extubated after a few days. He only lasted for about 12 hours, and was reintubated due to fatigue and an inability to handle his secretions. He was aggressively diuresed and then successfully extubated. # Acute on Chronic Systolic CHF: EF 25-30%. The patient was noted to be significantly fluid overloaded with peripheral edema and crackles on exam. His hypoxia required intubation, and he was aggressively diuresed after a failed extubation. His length of stay was about 15L negative, and on discharge he had no oxygen requirement during the day. (He has home O2 for nighttime oxygen use). He was gradually started on an ACE-I, beta blocker, and torsemide. He will require a repeat TTE as an outpatient and would likely benefit from spironolactone therapy. # VAP There was concern for a ventilator associated pneumonia, and he was treated with 8 days of vancomycin and meropenem. Currently he is afebrile with no cough. # CAD: He has a history of CABG. There is a question of ischemia causing his initial bradycardic arrest. He was sent for stress mibi prior to discharge, but this could not be performed due to hypotension and tachycardia. The decision was made to postpone the stress test until later on. He needs to have an appt with his cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] scheduled as the office was closed on day of discharge. # Transaminitis. Patient presented with significantly elevated LFTs (2:1 AST/ALT). Likely hypotension related. These improved spontaneously. # DM [**Last Name (un) **] consulted for difficulty controlling blood sugars. Required an intermittent insulin drip, then transitioned to subcutaneous insulin. At discharge, blood sugars have been well controlled. Metformin restarted. . # History of CVA restarted aggrenox . Transitional issues: 1. Make appt with cardiologist in [**2-5**] weeks. 2. Assess blood sugars on new sliding scale 3. Check Chem-7 and CBC on Monday [**2196-4-25**] 4. Consider spironolactone once pt is stable for systolic CHF 5. Increase metoprolol as needed, he is on [**2-5**] of the dose that he was on at home and is mildly tachycardic. Medications on Admission: - Aggrenox 25 mg/200 mg PO BID - Metformin 500 mg PO qAM and 1000 mg PO qPM - Metoprolol tartrate 100 mg Po TID - Insulin Determir (levelmir) 20 units SC HS - Insulin Aspart (Novolog) SSI 130-150 2 units, 151-175 4 units - Furosemide 80 mg PO BID - lovastatin 40 mg PO qHS - multivitamin PO qAM - lisinopril 10 mg PO qAM - Allopurinol 300 mg PO qD Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day): d/c once pt is mobile. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipatation. 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as needed for wheeze. 4. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap PO BID (2 times a day). 5. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day: 2 tabs at HS. 6. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day): Hold SBP < 100, HR < 60. 7. lovastatin 40 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. Multiple Vitamin Essential Tablet Sig: One (1) Tablet PO once a day. 9. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 10. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day. 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold SBP < 100. 13. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 14. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. 15. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 16. insulin aspart 100 unit/mL Solution Sig: 0-16 units Subcutaneous four times a day: see attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Hospital3 **] ([**Hospital **] Hospital of [**Location (un) **] and Islands) Discharge Diagnosis: Ventilator associated pneumonia Demand Ischemia Transaminitis Cardiogenic shock High grade AV block Acute on Chronic Systolic CHF Normocytic anemia Delerium 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 had a low blood pressure and heart rate and was transferred to [**Hospital1 18**] for treatment. You were treated for a pneumonia with antibiotics and needed to be placed on a breathing machine several times for low oxygen levels. You also needed medicine to keep your blood pressure up. Your heart is still weak and you will need to watch for signs of fluid retention such as increasing swelling in your legs, trouble breathing or a new cough. Weigh yourself every morning, call Dr. [**Last Name (STitle) 174**] if weight goes up more than 3 lbs in 1 day or 5 pound sin 3 days. . We made the following changes to your medicines: 1. Start senna and miralax to prevent constipation 2. Start heparin injections to prevent a blood clot 3. Start albuterol and Ipratroprium nebs for wheezing as needed 4. Decrease metoprolol to 100 mg twice daily 5. Change furosemide to torsemide Followup Instructions: Name: BROWN,[**First Name7 (NamePattern1) 569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Department: Cardiology Address: [**Location (un) 110567**], [**Location (un) 10068**],[**Numeric Identifier 39453**] Phone: [**Telephone/Fax (1) 110568**] *Please call your cardiologist on Monday [**4-25**] to book an appointment for your hospitalization. You need to be seen within 2 weeks of discharge.

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icd9cm

[ [ [] ] ]

[ "96.6", "37.78", "96.72" ]

icd9pcs

[ [ [] ] ]

13266, 13393

7891, 10876

298, 447

13594, 13594

4572, 7868

14675, 15095

3224, 3229

11618, 13243

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11246, 11595

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142,053

49788

Discharge summary

report

Admission Date: [**2115-5-16**] Discharge Date: [**2115-5-25**] Date of Birth: [**2036-5-13**] Sex: M Service: MEDICINE Allergies: Amiodarone / Quinidine / Radiation Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Placement of temporary hemodialysis line History of Present Illness: 79 year old male with history of CHF (predominantly diastolic failure, EF 40-45%, multiple admissions for CHF excacerbations), ESRD (not on dialysis), pulmonary hypertension, sick sinus syndrome (s/p dual chamber pacer), paroxysmal atrial fibrillation (on coumadin), and recently diagnosed poorly differentiated adenocarcinoma with possible mediastinal metastases who presents with shortness of breath for the last 3 months, worse in the past day. Reports that he is chronically dyspneic but typically can lay flat at night. However, in the last several days he has not been able to lie flat or use his home CPAP due to the dyspnea. He has not felt his home diuretic have provided any relief. He endorses orthopnea and PND, but denies worsening peripheral edema and states that he has lost 40 pounds in the last 1.5 years. Denies chest pain. . He also complains of severe LLE and left "sacroiliac" pain over the last few days. He had a fall a few weeks ago and injured his left hip, although his current pain symptoms didn't start until a few days ago. The pain is in his hip joint and radiates down the back of his leg. Denies bowel or bladder incontinence. . In the ED, initial VS: T97.7, HR69, BP109/56, RR20, O2 sat 96% 4L, [**4-18**] left leg pain. Labs were notable for K 3.2, Creatinine 3.0, BNP 926 with troponin 0.06, stable anemia (Hct 34.4) and therapeutic INR (2.4). Blood cultures were drawn and sent. Urinalysis was negative. T spine, hip/pelvis films were negative for fracture. CXR showed pulmonary edema with bilateral effusions as well as atelectasis. On exam, the patient had right basilar crackles and ecchymotic left hip. Vitals on transfer 98.1 70 14 108/50. . REVIEW OF SYSTEMS: Denies [**Month/Year (2) **], chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Diabetes c/b LE neuropathy - Dyslipidemia - Hypertension - CAD s/p CABG (LIMA to the LAD, LIMA to the RCA, SVG to the OM) in [**2089**]. DES to proximal saphenous venous graft to OM in 10/[**2106**]. - Chronic systolic/diastolic heart failure, EF 40-45% - Sick sinus syndrome s/p [**Company 1543**] pacemaker DDR mode [**8-/2107**] - Paroxysmal atrial fibrillation s/p multiple direct current cardioversion - Atrial flutter s/p ablation - Pulmonary vein isolation in [**2109-5-9**] - Stage III or IV chronic kidney disease, baseline creatinine 2.7 to 3.0, most recently 3.3. - Anemia - History of CVA with bilateral lacunar infarcts in [**2100**], with residual left paresthesias and gait dysfunction. - OSA on CPAP - History of GI bleed on Plavix now off aspirin/Plavix - History of scarlet [**Year (4 digits) **] - History of inflammatory bowel disease - Gout - Obesity - Fatty liver - Left ear deafness - Moderate pulmonary hypertension Social History: Lives with wife. Formerly worked at dialysis medical device company. 80 pack year history of tobacco use, none currently. Denies EtOH use. Denies drug use. Family History: Multiple family members with diabetes. No family history of early MI, arrhythmia, cardiomyopathy or sudden cardiac death: otherwise noncontributory. Physical Exam: ADMISSION EXAM: VS: 112/62 70 18 94%3L GENERAL - Alert, interactive, but chronically ill-appearing, NAD HEENT - EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, JVP elevated to mid neck when sitting up at 90 degrees HEART - PMI non-displaced, RRR with II/VI systolic murmur LUNGS - Crackles at bilateral bases, left>right ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, 1+ nonpitting edema. Difficulty abducting left hip due to pain. Pain on palpation of sacroiliac joint. Pertinent Results: ADMISSION LABS: [**2115-5-16**] 01:50AM BLOOD WBC-8.8 RBC-3.45* Hgb-11.8* Hct-34.8* MCV-101* MCH-34.2* MCHC-33.9 RDW-17.8* Plt Ct-197 [**2115-5-16**] 01:50AM BLOOD Neuts-89.1* Lymphs-5.1* Monos-4.3 Eos-1.1 Baso-0.4 [**2115-5-16**] 01:50AM BLOOD PT-25.5* PTT-40.7* INR(PT)-2.4* [**2115-5-16**] 01:50AM BLOOD Glucose-246* UreaN-165* Creat-3.0* Na-133 K-3.2* Cl-89* HCO3-26 AnGap-21* [**2115-5-16**] 01:50AM BLOOD ALT-19 AST-20 AlkPhos-87 TotBili-0.4 [**2115-5-16**] 01:50AM BLOOD CK-MB-6 cTropnT-0.06* proBNP-926* [**2115-5-16**] 09:30AM BLOOD CK-MB-6 cTropnT-0.06* [**2115-5-16**] 02:00PM BLOOD CK-MB-6 cTropnT-0.05* [**2115-5-16**] 09:30AM BLOOD Calcium-9.8 Phos-6.3* Mg-2.3 [**2115-5-16**] 03:50AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2115-5-16**] 03:50AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2115-5-16**] 03:50AM URINE RBC-2 WBC-5 Bacteri-NONE Yeast-NONE Epi-0 . MICROBIOLOGY: [**2115-5-16**] Blood culture: no growth [**2115-5-20**] Urine culture: mixed flora [**2115-5-22**] Sputum culture: contaminated [**2115-5-23**] Urine culture: no growth [**2115-5-24**] Sputum culture: culture pending . IMAGING: [**2115-5-16**] CXR: There is moderate pulmonary edema, similar to [**4-15**], [**2114**], but with increased, now moderate bilateral pleural effusions. A left retrocardiac opacity might represent collapse or postobstructive pneumonia. The cardiomediastinal shilouette and hila demonstrate known lymphadenopathy. There is no pneumothorax. . [**2115-5-16**] X-ray of T spine: The height of the vertebral bodies of the T-spine is preserved. There is no compression fracture. Sternotomy wires, pacemaker leads and surgical clips are seen in the mediastinum. . [**2115-5-16**] X-ray of left hip/pelvis: Vascular calcifications are seen at the common femoral arteries. There is no fracture of the pelvis or proximal femurs. There are no significant degenerative changes at the hip joints. . [**2115-5-18**] X-ray left femur: Single AP view of the left femur shows an intact femur without definite fractures or dislocations. There is no cortical destruction or focal lytic or blastic lesions. However, if there is high concern for a marrow replacing lesion, an MRI or perhaps bone scan would be helpful. There are extensive vascular calcifications. . [**2115-5-19**] CXR: There is cardiomegaly which is stable. There is left-sided pacemaker which is unchanged. There are disconnected leads inferiorly which are unchanged. There are pleural effusions, left greater than right. There is a persistent left retrocardiac opacity. There is some atelectasis at the right base. Overall, the findings are relatively stable allowing for differences in technique and positioning. There is moderate pulmonary edema. . [**2115-5-21**] left leg LENI: No evidence of deep vein thrombosis in the left leg. . [**2115-5-21**] CT head w/o con: Head CT very limited by patient motion, with no gross acute intracranial abnormality. . [**2115-5-22**] CT head w/ and w/o con: No hemorrhage, major vascular territory infarction, edema, mass, or shift of the midline structures is present. Moderate periventricular and subcortical white matter hyperdensities are the likely sequela of small vessel ischemic changes. Prominence of the ventricles and sulci suggest cortical atrophy. A small lacune or dilated perivascular spaces is noted in the left posterior limb of the internal capsule. [**Doctor Last Name **]-white matter differentiation is preserved. No abnormal delayed enhancement is noted. Visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No acute intracranial process. . [**2115-5-22**] CT torso: 1. New left psoas hematoma and slight hematoma of the left upper thigh. 2. No significant interval change in extensive mediastinal and hilar lymphadenopathy. Continued peribronchovascular thickening and pulmonary consolidation in the left upper lobe may reflect post-obstructive consolidation and/or lymphangitic spread of tumor. There is progressive collapse and consolidation of the left lower lobe. 3. Stable retroperitoneal lymphadenopathy. 4. No change in two heterogeneously dense right renal masses concerning for malignancy. Stable left renal hypodensity too small to characterize. 5. Right flank lipoma, partially calcified. Brief Hospital Course: 79 year old man with a history of chronic systlic and diastolic CHF, ESRD, pulmonary hypertension, paroxysmal atrial fibrillation, and recently diagnosed poorly differentiated adenocarcinoma who presented with worsening shortness of breath. Hospital course complicated by respiratory distress requiring MICU admission, and severe left hip/leg pain. Patient was eventually transitioned to comfort care and expired on [**2115-5-25**]. . # Respiratory distress: Initially attributed to a CHF exacerbation. Patient was admitted to the cardiology service and was diuresed. He had insufficient urine output so renal was consulted, a temporary HD line was placed, and he was started on dialysis. He was also found to have a moderate-sized left pleural effusion and plan was to perform a thoracentesis with placement of a pleurex catheter which was initially deferred due to patient's discomfort. He was called out to the medicine floor. He had known mediastinal lymphadenopathy and known adnocarcinoma of unkown primary (see oncology section below) so he was scheduled for a CT head and torso to evaluate his malignancy. The patient had severe left hip/thigh pain (see discussion below) so he was pre-medicated with tylenol, ibuprofen, lidocaine patch, and IV dilaudid prior to the CT. The study was performed on [**2115-5-22**] and afterward he was noted to be apneic. A code blue was called and he was administered an amp of narcan, after which he woke up with increased respirations and improvement in his oxygenation on a non-rebreather. He was transferred to the ICU for further evaluation. This event was felt to be due to over-sedation from the dilaudid. The plan was for thoracic surgery to do the thoracentesis and place a pleurex, however the patient declined this and the decision was made to focus on comfort. . # Left hip/thigh pain: Patient reported severe pain in his left hip and thigh throughout this admission. He did sustain a fall in the shower prior to admission, and had been on coumadin. CT revealed a left psoas bleed with extension into the thigh. We were reluctant to administer too many narcotics given his episode of apnea. The pain service was consulted and performed a femoral nerve block on [**2115-5-24**]. He has immediate pain relief, however the catheter became dislodged and he again reported excrutiating pain. His pain was managed with IV dilaudid and a ketamine drip. The pain service offered to perform an epidural however the patient declined. After a goals of care discussion with Mr. [**Name13 (STitle) 14077**] and his wife and son, the decision was made to focus on comfort care. He was started on a morphine drip and expired the morning of [**2115-5-25**]. . # Malignancy: Patient with supraclavicular, mediastinal, hilar, and retroperitoneal lymphadenopathy, as well as right renal masses which are concerning for metastatic malignancy. A biopsy of an RP lymph node revealed adenocarcinoma, but unclear primary. After discussion with oncology, the plan was to perform a thoracentesis and send the pleural fluid for cytology, and to try and obtain another tissue biopsy for further diagnostic information. However, his respiratory status declined and his pain control became the prominent issue. See above. . # ESRD on HD: Presumed secondary to DM, HTN, and CHF. A temporary HD catheter was placed and he was started on HD. He was continued on calcitriol, calcium carbonate, sevelamer, nephrocaps, and vitamin D. . # Hyponatremia: Sodium continued to drop throughout the admission. Was felt likely secondary to SIADH from his underlying malignancy. . # CHF: H/o of both systolic and diastolic dysfunction with LVEF 40-45%. As noted above, he was initially on the cardiology service and diuresed for suspected CHF exacerbation. We continued metoprolol. . # Atrial fibrillation: CHADS2 score is 6 so very high stroke risk. Metoprolol was continued. Coumadin was held given the left psoas bleed. . # CAD s/p CABG and PCI: Aspirin and plavix were held. We continued metoprolol, Imdur, and rosuvastatin. . # Diabetes: Continued glargine and insulin sliding scale. . # Hypertension: Continued metoprolol and Imdur. . # Hyperlipidemia: Continued rosuvastatin. . # Gout: Continued allopurinol. . # GERD: Continued omeprazole. Medications on Admission: Allopurinol 300mg daily Betamethasone 0.05% cream twice daily PRN Calcitriol 0.5mcg daily Gabapentin 200mg qHS Novolog (per OMR: 20 units at noon, 25 units at dinner, [**11-28**] units at bedtime, per patient, 28 units with each meal) Glargine 20 units in morning, 40 units at bedtime Isosorbide mononitrate ER 30mg daily Metolazone 2.5mg three times/week (T/Th/Sat) Metoprolol succinate 50mg qAM, 25mg qPM Nitroglycerin 0.4mg SL PRN Omeprazole 40mg daily Rosuvastatin 20mg daily Spironolactone 25mg daily Tamsulosin 0.4mg ER daily Torsemide 80mg qAM Coumadin - baseline dose is 1.25mg on M,F, 2.5mg other days but has been on 2.5mg daily recently as he had previously held coumadin for procedure) Calcium carbonate-Vitamin D3 dose uncertain Cholecalciferol dose uncertain Ferrous sulfate 325mg daily Glucosamine-Chondroitin-Vitamin C-Mn dose uncertain Multivitamin daily Omega-3 fatty acids-vitamin E [Fish Oil] dose uncertain Zinc dose uncertain Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Adenocarcinoma of unknown primary Congestive heart failure End stage renal disease Left psoas muscle hematoma with extention into thigh Discharge Condition: Expired Discharge Instructions: Patient expired. Followup Instructions: None Completed by:[**2115-5-25**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "04.81" ]

icd9pcs

[ [ [] ] ]

13832, 13841

8546, 12804

310, 353

14021, 14031

4177, 4177

14096, 14132

3480, 3631

13803, 13809

13862, 14000

12830, 13780

14055, 14073

3646, 4158

2083, 2326

263, 272

381, 2064

4193, 8523

2348, 3291

3307, 3464

14,263

100,597

51502

Discharge summary

report

Admission Date: [**2177-7-24**] Discharge Date: [**2177-7-29**] Date of Birth: [**2135-5-20**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7262**] is a 42-year-old HIV, hepatitis C positive man currently under evaluation for liver transplantation in [**Location (un) 19061**] for liver failure. Over the past four months or so he has noted some exertional chest discomfort. He describes this as a pressure sensation that occurs in his mid chest when walking quickly or going up any incline. This is occasionally associated with dizziness, shortness of breath and diaphoresis, resolving quickly with rest. He has never taken any Nitroglycerin. He was also having significant dyspnea on exertion at the time of admission. A Persantine stress test on [**2177-6-24**] was notable for ischemia in the distribution of the right coronary artery with a normal ejection fraction at 67%. The patient denies claudication, orthopnea, PND or lightheadedness. He does state that he has intermittent lower extremity edema, and he also states that he has ascites. PHYSICAL EXAMINATION: The patient was afebrile with stable vital signs upon presentation to the hospital. Neck, no JVD, 2+ carotid pulses without bruits. Heart, normal S1 and S2, regular rate and rhythm, grade 2/6 systolic ejection murmur at the right upper sternal border. Lungs, clear to auscultation bilaterally. Abdomen, soft, distended, nontender, normoactive bowel sounds. Extremities, trace ankle edema bilaterally. HOSPITAL COURSE: The patient was therefore admitted to [**Hospital1 1444**] on [**7-24**] for an elective coronary catheterization during which time a stent was placed in the right coronary artery. As per standard catheterization protocol, the patient received 2,000 units of Heparin during the procedure. He was also placed on Aspirin and Plavix following the procedure in order to maintain patency of the new stent. On [**2177-7-25**] (the first day following the procedure), the patient developed hematemesis. It should be noted that the patient has a baseline coagulopathy; in addition the patient has had periods of hematemesis in the past and has a known past medical history significant for esophageal varices which have been banded. An EGD was done at this time, and it revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear at the GE junction. Ulcers in the antrum, varices at the lower third of the esophagus and an otherwise normal EGD to the third part of the duodenum. Subsequent to this, the patient was taken off of Aspirin and Plavix due to the risk of repeated bleeds and was transfused with two units of packed red cells as well as FFP and platelets. Subsequent to this, his hematocrit stabilized and the patient was clinically stable. On the day prior to discharge the patient did experience some right upper quadrant pain; as a result an abdominal ultrasound was performed which was negative. In addition, a KUB was done which was negative and an EKG was done which showed no change from prior studies. The patient's hematocrit remained stable and he was therefore discharged to home on [**2177-7-29**]. DISCHARGE DIAGNOSIS: 1. Human immunodeficiency virus. 2. Hepatitis C virus with cirrhosis. 3. Esophageal varices. 4. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear. 5. Multiple ulcers of the gastric antrum. 6. Ascites. 7. Upper GI bleed while in the hospital. 8. Prior history of spontaneous bacterial peritonitis. 9. Coronary disease, now status post stenting of the right coronary artery. DR. [**First Name (STitle) **] [**Name8 (MD) **] m.d. [**MD Number(2) **] Dictated By:[**Name8 (MD) 106782**] MEDQUIST36 D: [**2177-7-29**] 17:00 T: [**2177-7-29**] 17:23 JOB#: [**Job Number **] cc:[**CC Contact Info 106783**]

[ "571.5", "789.5", "414.01", "287.5", "578.0", "456.0", "413.9", "530.7", "070.54" ]

icd9cm

[ [ [] ] ]

[ "45.13", "88.53", "36.06", "37.22", "36.01" ]

icd9pcs

[ [ [] ] ]

3240, 3909

1548, 3219

1123, 1530

160, 1100

9,003

124,359

50682

Discharge summary

report

Admission Date: [**2189-11-26**] Discharge Date: [**2189-12-1**] Service: MEDICINE Allergies: Antihistamines Attending:[**First Name3 (LF) 689**] Chief Complaint: hypotension/ MS changes, diarrhea . PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**] Major Surgical or Invasive Procedure: Central Line History of Present Illness: 86 year old man with PMHx of CAD presented to the PCPs office on [**11-26**] with MS changes and 2 days of fevers/edema. He also endorsed diarrhea for last 2-3 weeks. Patient presented from home. He was found to be hypotensive to 80/40 during the office visit and was subsequently sent to the ED. . On admission [**2189-11-26**], patient also reported intermittent abdominal pain in the lower quadrants x 2 weeks. The pain was not present there upon rest, but only upon palpation. He was having diarrhea x [**2106-1-26**] hours, loose, non bloody. No dysuria/hematuria. No f/c, has chronic dizziness/lightheadedness, slightly worse x 2 months; did report nl po, including compliance with medication. No sob, no cp, no n/v, no diaphoresis. has chronic R flank pain. Of note patient recently admited to [**Hospital1 112**] in early [**Month (only) 1096**] where he was given a 7 day course of ceftriaxone for PNA. He also had elevated INR at that time. . In ED, patient received 2 L IVF, he was started on peripheral dopamine. He had a R IJ placed after several failed attempts b/l with a stick to the carotid (it was not cannulated). Patient was subsequently found to have an INR of 12 and patient was given 10 mg Vitamin K SQ. Patient also underwent CT head, CT neck that showed no evidence of bleed or hematoma. Patient also had a CXR that did not reveal in infiltrate. A foley was placed. UA was negative. Lactate was 1.8. He was started on vanco/zosyn for broad empirice coverage and on flagyl for C. Diff. No recent abx. Patient was not tachycardic in ED - 80s, sating 96% on 3L upon transfer. . In the MICU, pt remained on pressors (levophed) for approximately 24 hours. The hypotension was attributed to diarrhea likely [**12-26**] C Diff versus sepsis, though pt remained afebrile, WBC was elevated to 21. His coagulopathy was reversed and may have been [**12-26**] vit K loss with diarrhea. His repeat KUB was unchanged and rate of diarreha decreased. . On transfer, the patient reports some diarrhea and denies n/v or abdominal pain. He denies [**Month/Day (2) **] or chills, denies dizzyness. He has new-onset bilat intesnse pain in his hands that he attributes to gout. Otherwise he denies cough, chest pain, sob. He does report some weakness with walking. He denies any back pain, which is significant as outpatient. Past Medical History: 1. CAD s/p inferior MI unknown date and no records here. He states that he had a stent placed in the past. - Dr. [**Last Name (STitle) **] 2. CVA in the left putamen [**2183**] with ongoing right sided weakness on coumadin. 3. Hypothyroidism 4. Depression 5. Chronic Back Pain 6. Atrial fibrillation - on coumadin 7. Inguinal hernia x4 8. SCIATICA 9. SPINAL STENOSIS- S/P SURGERY X2, DR. [**Last Name (STitle) **] 10. SLEEP APNEA . Social History: Lives at home with a day care nurse [**First Name (Titles) 1023**] [**Last Name (Titles) 31486**] the meds. Born in [**Location (un) 86**]. Italian in origin. No tobacco or etoh currently. Has sons who are very involved in his care Family History: NC Physical Exam: MICU PE ON PRESENTATION: Vs: 97.1 71 Afib 97/65 on Levophed CVP 12-22 15 98% 2L RIJ Gen: pleasant elder, pale male, NAD, AxOx2, not alert to the date, but fully aware of his diagnosis and the reason he is here HEENT: expanding R neck hematoma, no JVD CV: irregular, no extra HS Lungs: CTAB/L, no focal rhonchi appreciate Abd: + BS, soft, nondistended, mild guarding in b/l lower quadrants, no rebound, Back: no cva Ext: + 2 pitting edema, no cyanosis, + 1 dp bl, mild erythema/chronic . FLOOR TRANSFER PE: VS: T 95.4 BP109/79 HR80 97% RA GEN: comfortable, NAD, falls asleep at times HEENT: NC/AT, small mucous thread R eye, conjunctivae slightly pale, sclera anicteric, OP clear, MMM NECK: tender R neck at prior IJ site, some fluctuance but no clear hematoma LN: no cervical or supraclavicluar LN CVS: NR/RR, +S1/S2, no clear murmurs PUL: CTAB, no wheezes/[**First Name9 (NamePattern2) **] [**Last Name (un) **]: obese, +BS, soft, non-tender, no rebound, no masses EXT: [**11-25**]+ edema to shins, DP pulses difficult to palpate SKIN: venous stasis changes and erythema over bilat shins NEURO: slightly sleepy, oriented to name, place, year, season, current events, moves all four extremities Pertinent Results: admission labs: lactate 2.8--> 1.0 . Cr 2.6 . WBC 22.7 Hct 32.3 PLT 481 N 84%, no bands . INR 12.3 . LABS ON TRANSFER: cbc: 10.1 > 29.2 < 332 BL Hct 35-38 . 142 111 42 ==============< 95 3.7 23 1.7 . INR: 1.9 . uric acid 8.1 . [**Last Name (un) **] XR [**2189-11-26**]: FINDINGS: Two views of the abdomen are compared to CT abdomen and pelvis [**2188-5-27**]. Right IJV catheter terminates at the cavoatrial junction. Transverse colon is distended measuring up to 6.7 cm. Bowel gas pattern is nonspecific. No definite free air present. There is S-shaped scoliosis, with levoscoliosis at thoracolumbar junction and dextroscoliosis at lower lumbar levels. The patient is status post laminectomy. There is severe degenerative change of the right humeral head with superior migration compatible chronic rotator cuff tear. IMPRESSION: Transverse colon distention, with nonspecific bowel gas [**Doctor Last Name 5926**]. . CT HEAD: 1. No acute intracranial abnormality is detected. 2. Encephalomalacia and volume loss related to old left MCA territorial infarct. . EKG [**2189-11-26**] offical read: Baseline artifact. Sinus rhythm with significant atrial ectopy. Occasional ventricular premature beats. Left axis deviation. Right bundle-branch block. Old inferolateral myocardial infaction. ST-T wave abnormalities. Compared to the previous tracing of [**2188-5-28**] there is probably no significant diagnostic change and multiple abnormalities persist. Clinical correlation is suggested. . CT Neck: Soft tissue swelling and stranding in the bilateral neck without organized hematoma detected. . MICROBIOLOGY: STOOL: c diff neg x 2 BLOOD: NGTD Brief Hospital Course: 86 y.o. M with h/o CAD, Afib on coumadin, spinal stenosis and chronic pain, who presents to PCP with diarrhea, dehydration and hypotension attributed to likely C Diff infection after recent hospitalization for PNA and treatment with Ceftriaxone. His stool cultures were negative x2 but suspicion was still high and his symptoms improved quickly with cipro and flagyl antibiotic therapy. His leukocytosis to a peak of 22 trended down to 10.1. He will finish a 2-week course. . The patient also presented with Acute Renal failure with a peak creatinine at 3.0, BL < 1.0. Likely prerenal in setting of hypotension and diarrhea. Creatinine trended down and was 1.3 on discharge. His UOP remained slightly low and he received NS IVF boluses (gentle at 250cc) and patient was encouraged to take plenty of PO fluids which was difficult for him secondary to his hand stiffness from an acute gout flare. He will follow up with his primary care physician. . On admission the patient was hypotensive in setting of acute infection and diarrhea and was placed on levophed in MICU for 24 hours, now stable. Patient did not have cardiac symptoms to suggest cardiac etiology, minimal oxygenation. No neurological symptoms were identified to suggest neurological compromise. Patient has a h/o stroke with slurred speech and slight weakness but this was unchanged from his baseleine. His antihypertensives were held and he is instructed to restart them under the guidance of his PCP as an outpatient. . The patient had an elevated INR to 12 while on coumadin for a-fib. Incr INR appears to be recurrent, may be [**12-26**] colitis/infection and subsequent vit K deficiency. LFTs WNL, INR trended down s/p vitamin K. He sustained a hematoma at the R IJ puncture site (arterial) but the hematoma did not increase in size. He did have persistent anemia but did not require transfusions. His stool guaiacs were negative. His coumadin was restarted adn he will need to have his INR checked as an outpatient. . The patient developed bilateral hand pain which he attributed to gout, Uric acid 8. With normalized pressures, patient was restarted on his outpatient doses of morphine. Prednisone was not started given current infection. He was started on colchicine daily and NSAIDs while in the MICU which were held given potential for bleeding and GI distress. His pain was greatly improved on discharge and he was able to use his hands. . For his chronic low back pain/sciatica s/p laminectomy, outpatient doeses of morphine SR 30mg [**Hospital1 **] were restarted once his blood pressure normalized. Pt does have h/o withdrawal after abrupt stopping of opioids and has [**Hospital1 **]/sweats/diarrhea and family was concerned he was not receiving in-house. He also takes gabapentin [**Hospital1 **]. . During his hospitalization the patient and family voiced interest in home care and possible "do not hospitalize" status. A social worker will visit the family to discuss this. The patient is DNR/DNI. He will receive home PT and [**Hospital1 269**] on discharge. . # Communication - [**Doctor First Name **] is HCP [**Telephone/Fax (1) 73661**]; other son [**Name (NI) **] [**Telephone/Fax (1) 105449**] (laboratory hematologist in NH); there is family discussion re change of HCP but [**Name (NI) **] was not part of discussion; daughter [**Name2 (NI) 17486**] works with [**Name (NI) 269**]/Hospice and would like to be contact for long-term care plans [**Telephone/Fax (1) 105450**]; [**Telephone/Fax (1) 105451**] (home); [**Telephone/Fax (1) 105452**] (work) Medications on Admission: MEDICATIONS ON ADMISSION: atenolol 12.5mg daily ranitidine 150mg [**Hospital1 **] levothyroxine 175mcg daily coumadin 3mg daily Imdur 30mg daily vitamin b12 1000mcg daily morphine sulfate CR 30mg po BID colace nitroglycerin PRN lasix 20-40mg daily hydroxyzine 50mg QPM norvasc 2.5mg [**Hospital1 **] gabapentin 300mg TID senna percocet MEDICATIONS ON TRANSFER: Morphine IV PRN (1mg) bisacodyl cipro 500mg daily levothyroxine Magnesium oxide x 1 Flagyl 500mg TID Protonix Senna Coumadin 2mg HS Hep SubQ Colchicine 0.6mg daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days. Disp:*33 Tablet(s)* Refills:*0* 5. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 11 days. Disp:*22 Tablet(s)* Refills:*0* 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 10. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 12. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at bedtime)). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: PRIMARY: Diarrhea likely secondary to C. Diff colitis Sepsis SECONDARY: Coronary Artery Disease Stroke Hypothyroidism Depression Chronic Back Pain Atrial fibrillation - on coumadin Sciatica and low back pain Sleep Apnea Discharge Condition: Good Discharge Instructions: You were admitted with low blood pressure and diarrhea thought to be all related to a likely infection by C. Diff which can be a complication from antibiotic use. Your diarrhea resolved and you will finish a 2 week course of antibiotics. . Your blood pressure medications were held during this hospitalization. Please discuss with Dr. [**Last Name (STitle) 58**] at your next visit if you should restart the norvasc (amlodipine), atenolol, imdur, and lasix. . Your coumadin levels (INR) were very high and it is unclear if this was secondary to your infection. You were restarted on a lower dose of your coumadin at 2mg at bedtime. You will have your blood work done by the visiting nurse and your coumadin dose adjusted as needed . You were started on colchicine 0.6 mg daily for your gout flair. Please discuss with Dr. [**Last Name (STitle) 58**] if you should continue this. . Your kidney function was slightly impaired on admission, likely secondary to dehydration from your diarrhea. It returned to closer to your baseline on discharge. . If you develop any concerning symptoms please contact your physician or proceed to the emergency room. Followup Instructions: Please call your primary care physician to schedule [**Name Initial (PRE) **] follow-up appointment in [**11-25**] weeks: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**] . You had an appointment scheduled previously with Neurology. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2189-12-24**] 1:30

[ "285.9", "414.01", "311", "724.2", "008.45", "276.51", "V58.61", "427.31", "780.57", "244.9", "038.9", "584.9", "458.9", "274.9", "286.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11731, 11802

6338, 9893

324, 339

12066, 12073

4657, 4657

13275, 13705

3421, 3425

10470, 11708

11823, 12045

9945, 10256

12097, 13252

3440, 4638

183, 286

367, 2700

5596, 6315

4673, 5587

10281, 10447

2722, 3156

3172, 3405

23,891

191,187

18859+18860

Discharge summary

report+report

Admission Date: [**2106-7-9**] Discharge Date: [**2106-7-25**] Date of Birth: Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old woman with a 4-day history/complaint of a headache. The patient was complaining of a throbbing frontal headache approximately four days prior to arrival. There has been some mild nausea. There has been no vomiting. There has been no blurred vision, no photophobia, and no numbness. She has not had a fever and denies that this is the worst headache she has ever had. The patient is without any known history of trauma. PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital signs were stable. Her blood pressure was 135/71, her heart rate was 61, her respiratory rate was 16, and her temperature was 99.7 orally. In general, she was alert and cooperative. Head, eyes, ears, nose, and throat examination revealed atraumatic without temporal scalp tenderness. Eyes revealed the pupils were equal, round, and reactive to light. Extraocular movements were full. No discharge or injection. Tympanic membranes were without perforation, injection, or bulging. External canals were clear without exudate. Mouth examination revealed the mucous membranes were moist and without lesions. Throat examination revealed oropharynx without injection, exudative tonsilar hypertrophy. The airway was patent. The neck was supple. The lungs were clear to auscultation. Cardiovascular examination revealed a regular rate and rhythm without murmurs, ectopy, or gallops. The abdomen was soft and nontender. Good bowel sounds. No hepatosplenomegaly, rebound, or guarding. Skin examination was normal. Neurologic examination revealed the patient was awake, alert, and cooperative. Sensory and motor examinations were grossly intact. PERTINENT RADIOLOGY/IMAGING: The patient had a computed tomography which showed a subarachnoid hemorrhage and anterior cerebral artery aneurysm. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Neurosurgery Intensive Care Unit and underwent a cerebral angiogram on [**2106-7-9**] which showed this anterior cerebral artery aneurysm. The patient showed evidence of an ACOM aneurysm which was not amenable to endovascular treatment. Therefore, the patient was taken to the operating room on [**2106-7-10**] for left frontal/temporal craniotomy for clipping of ACOM aneurysm without intraoperative complications. The patient tolerated the procedure well and was in the Intensive Care Unit postoperatively. The patient was following commands, awake, alert, and oriented times three. Pupils were equal, round, and reactive to light. Extraocular movements were full. Her muscle strength was [**4-5**] in all muscle groups. Her sensation was intact to light touch. She was following commands times four. The patient remained in the Intensive Care Unit on triple H therapy from [**2106-7-10**] until [**2106-7-22**]. Her vent drain that was placed at the time of the original surgery on [**2106-7-10**] was discontinued on [**2106-7-20**]. She was transferred to the regular floor on [**2106-7-22**]. She was in stable condition and neurologically intact. She was following commands. She was moving all four extremities with good strength. Extraocular movements were full. Pupils were equal, round, and reactive to light. She was seen by Physical Therapy and Occupational Therapy and found to be safe for discharge to home. DISCHARGE STATUS: The patient was discharged to home on [**2106-7-25**]. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] in two weeks' time. CONDITION AT DISCHARGE: Her incision was clean, dry, and intact. Her staples were removed on [**2106-7-22**]. The patient's condition was stable at the time of discharge. MEDICATIONS ON DISCHARGE: (Her medications at the time of discharge included) 1. Percocet one to two tablets by mouth q.4h. as needed (for pain). 2. Protonix 40 mg by mouth q.24h. 3. Amlodipine 30 mg by mouth q.4h. (for 21 days total). [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2106-7-23**] 14:16 T: [**2106-7-27**] 07:52 JOB#: [**Job Number 51625**] Admission Date: [**2106-7-9**] Discharge Date: [**2106-7-26**] Date of Birth: [**2051-7-9**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 54 year old woman with a four day history of complaints of headache. She complained of throbbing frontal headache for approximately four days prior to admission. She had mild nausea with no vomiting. No blurry vision, no photophobia, no numbness, no fever. Denies that this is the worst headache of her life. The patient had a head CT which showed an ACA aneurysm with subarachnoid hemorrhage. She was transferred from an outside hospital to [**Hospital1 69**] for further management. PHYSICAL EXAMINATION: Blood pressure was 135/71, heart rate 61, respiratory rate 16, temperature 99.7. She was alert and cooperative. HEENT atraumatic without temporal or scalp tenderness. Pupils equal, round, reactive to light. EOMs full. No discharge or injection. Neck was supple, nontender, no lymphadenopathy. Lungs clear to auscultation. Breath sounds equal. Heart regular rate and rhythm, no murmurs, gallops or rubs. Abdomen soft, nontender, good bowel sounds. Extremities normal, no cyanosis, clubbing or edema. Neurologically alert and cooperative. Sensory and motor were grossly intact. Cranial nerves II-XII were intact. HOSPITAL COURSE: The patient had an arteriogram that showed an ACA aneurysm, but was not amenable to coiling. Patient was taken to the O.R. on [**2106-7-10**] for left frontotemporal craniotomy for clipping of ACA aneurysm and had a drain placed at that time. Post-op the patient was awake, alert and oriented times three, following commands. Pupils equal, round, reactive to light. Motor strength was [**4-5**] in all muscle groups. Sensation was intact to light touch. She remained in the ICU until [**2106-7-22**], receiving triple H therapy to prevent vasospasm. Patient's neurologic status remained stable throughout her ICU stay. Her vent drain was removed on [**2106-7-21**]. The patient went back for arteriogram on [**2106-7-21**] which showed good clipping of the aneurysm, minimal vasospasm. Patient was transferred to the regular floor on [**7-22**]. She remained neurologically intact with IV fluids being weaned off. She remained neurologically stable and was discharged to home on [**2106-7-26**] with Nimodipine 30 mg p.o. q.four hours until [**7-30**] and Percocet two tabs p.o. p.r.n. for pain. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2106-7-26**] 08:36 T: [**2106-7-28**] 16:12 JOB#: [**Job Number 51626**]

[ "430", "518.0", "997.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "02.2", "88.41", "39.51", "03.31" ]

icd9pcs

[ [ [] ] ]

3912, 4521

5724, 6833

3592, 3720

2012, 3558

5081, 5706

3735, 3885

4550, 5058

6858, 7124

20,309

150,431

46230+58887

Discharge summary

report+addendum

Admission Date: [**2131-9-27**] Discharge Date: [**2131-10-10**] Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 317**] Chief Complaint: Pneumonia, malfunctioning pacemaker Major Surgical or Invasive Procedure: Pacemaker replacement Subclavian line placement History of Present Illness: Pt is an 88 [**Hospital **] nursing home resident female who presents today at the request of Dr. [**Last Name (STitle) **] for a malfunctioning pacemaker as well as a left lower lobe pneumonia. The patient reports that she has had an increasing cough over the past several days (pt has difficulty with specifics), and has increasing shortness of breath. The patient reports that she has a hard time lying flat, but does not know if this is worse than usual for her. She does not report increased swelling in her ankles, but does report that her legs hurt. The patient currently denies any fevers/chills, nausea/vomiting, chest pain/shortness of breath, or pain with urination. The patient reports frequent problems with constipation. Past Medical History: 1. CHF s/p [**Company 1543**] Prodigy 7865U pacer placement 2. Syncope 3. RBBB, history of wenkebach, 2:1 AV block 4. Recurrent falls 5. Vascular Dementia, refuses pills frequently 6. ACom aneurysm 7. Diverticulitis 8. Breast cancer L s/p lumpectomy 9. Arthritis 10. COPD requiring constant O2 11. Frequent PNA 12. History of gastric ulcer 13. Multiple fractures Social History: Nursing home resident Daughter is health care proxy Family History: Non-Contributory Physical Exam: GEN: thin elderly F in NAD. Variably responsive to questions. Seems overall pleasant. HEENT: pink conjunctivae, anicteric. PERRLA, EOMI. NECK: supple, no LAD, no JVD detected, no bruits CHEST: coarse BS and rhonchi throughout L lung field, transmitted to right. Frequent hacking cough. COR: RRR, normal S1S2, no G/R/M ABD: soft, NT, ND. Mildly diffusely tender to palpation. EXT: no edema. W/wp. Legs tender to palpation. DP pulses symmetric. NEURO: AA&Ox1. CN II-XII intact. Pt was not ambulated, but MAEx4. Pertinent Results: Labs on admission [**2131-9-27**]: WBC 7.6, Hct 39.6, Plt 228, MCV 83 PT 13.9, PTT 26.4, INR 1.3 Na 142, K 3.7, Cl 96, HCO3 34, BUN 8, Cr 0.7, Glu 101 Lactate 1.7, K 3.8 . Lactate 1.7 -> 1.1 . ABG [**10-2**]: pH 7.35/51/132/29 . free Ca [**10-3**]: 1.23 . [**10-4**]: urine osm 593, Una 20, Ucr 75; serum osm 295 . TSH 5.2 -> 2.3 ([**10-1**]) free T4 1.0 ([**10-1**]) cortisol 19.3 ([**10-2**]) . Cardiac enzymes ([**10-2**]): CK 17 -> 19 -> 27 CK-MB not done -> 2 -> not done trop <0.01 x3 . LFTs [**10-2**]: ALT 2, AST 12, LDH 139, alk phos 93, tbili 0.4 . Micro: blood cx [**10-3**] - NGTD sputum cx [**10-2**] - GRAM STAIN (Final [**2131-10-3**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2131-10-5**]): SPARSE GROWTH OROPHARYNGEAL FLORA. urine cx [**10-2**] - no growth (final) blood cx [**10-1**] - no growth (final) sputum cx [**10-1**] - GRAM STAIN (Final [**2131-10-2**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2131-10-4**]): SPARSE GROWTH OROPHARYNGEAL FLORA blood cx [**9-27**] - no growth (final) . CXR [**9-26**]: 1. New left lower lobe consolidation, suspicious for pneumonia. 2. Small bilateral pleural effusions. 3. Stable asymmetrical pleural and parenchymal scarring, more prominent in the right apex than the left. . CXR [**9-27**]: Rapidly improving left basilar consolidation. Although possibly due to improving pneumonia, the rapid improvement favors at least a component of aspiration. . CT chest [**9-27**]: 1. Tiny right middle lobe pulmonary artery filling defect, likely representing chronic pulmonary embolus. 2. Enlarged left axillary lymph node. 3. Left 7th rib lytic lesion. In the setting of history of breast cancer, bone scan is recommended for further evaluation. 4. Consolidation within the left lower lobe and additional bilateral centrilobular nodular opacities consistent with superimposed infectious process. 4. Pneumobilia. Clinical correlation is recommended. 5. Left lobe thyroid nodule may be further evaluated with ultrasound. . EKG [**9-27**]: A-V dissociation with ventricular paced rhythm. Compared to the previous tracing of [**2130-10-4**] atrial sensed ventricular paced rhythm has been replaced by the A-V dissociation with ventricular pacing. . ECHO [**9-28**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF 80%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Thyroid U/S [**9-28**]: Scans through the right surgical bed of the thyroid shows no evidence of residual thyroid tissue, masses or lymphadenopathy. The left lobe of the thyroid is virtually completely replaced by a large solid and cystic mass, which is moderately vascular in the solid portions. This measures 4.5 x 3.6x 3.7 cm and extends into the superior mediastinum. CONCLUSION: Status post right thyroidectomy. Large solid and cystic mass in the left thyroid corresponding to the lesion on CT scan. . CXR [**10-2**]: The shape of the chest and relative hyperlucency of the lungs suggests COPD. Region of infrahilar opacity in the left lower lung is more pronounced today after showing substantial clearing between [**9-26**] and 20th. This could be pneumonia, but was probably due previously to aspiration or atelectasis. Lungs are otherwise clear of any focal abnormalities. The heart is normal size. Tiny left pleural effusion or pleural scarring is unchanged. Intended right atrial and ventricular pacer leads follow their expected courses, continuous from the left pectoral pacemaker. . CXR [**10-2**]: 1. Satisfactory position of subclavian introducer sheath. However, the central portion is kinked and may need to be repositioned for optimal flow. 2. Slightly worsening interstitial edema. . ECHO [**10-2**]: 1. The left ventricular cavity size is normal. Overall left ventricular systolic function cannot be reliably assessed. 2. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 3. The mitral valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. 4. There is moderate pulmonary artery systolic hypertension. 5. Compared with the findings of the prior study of [**2131-9-28**], there has been no significant change . Labs on discharge [**10-10**]: WBC 5.5, Hct 31.4, Plt 170, MCV 86 Na 146, K 4.2, Cl 96, HCO3 39, BUN 5, Cr 0.4, Glu 82 CA 7.6, Mg 1.8, Ph 3.5 PT 13.0, PTT 136.9, INR 1.1 Brief Hospital Course: #. CARDIAC: a. PERFUSION: Patient was chest pain free throughout her admission. She became hypotensive for several days and her cardiac enzymes remained negative x3 following that episode. No evidence for ongoing ischemia. She was monitored on telemetry for her bradycardia which resolved with the replacement of her pacemaker. She was on a beta-blocker, furosemide and an ACE-I on admission, but those were held once she became hypotensive. Her BP remained in the high 90s-110s for the remainder of her hospital course so her antihypertensives were not yet restarted. She was given Lasix 10mg PO BID to aid in her diuresis and her BP was well controlled on that medication. . b. PUMP: Ms. [**Known lastname 98288**] has a history of frequent CHF exacerbations. She never developed CHF during this admission and it was felt that her SOB and cough was due to pneumonia rather than failure. . c. RHYTHM: On admission, she was ventricular-paced with a regular rate. However, she then became bradycardic and hypotensive, with the pacer in what appeared to be VVI mode, and it was felt that her symptoms were likely due to pacemaker syndrome. Once her pneumonia had improved with antibiotics, the pacemaker was replaced. She did well post-procedure. She had some mild bruising around the pacemaker site, but otherwise did well. . #. HYPOTENSION: Ms. [**Known lastname 98288**] developed persistent, refractory hypotension on the evening of [**10-1**] with her systolics in the 70s. She received 6L of NS without any improvement. Peripheral dopamine was started with good effect and she was transferred to the MICU for closer monitoring. She received another 7L of IVF, was started on hydrocortisone and fluorinef for possible adrenal insufficiency and her antibiotics were broadened for possible sepsis. She was also started on pressors, but was able to be weaned off of pressors after 36 hours. The most likely etiology was felt to be pacemaker syndrome. Once she was stabilized and her pneumonia was improved, she was taken for replacement of her pacemaker which she tolerated well. She was able to maintain normal BP on the floor without any problems and began to autodiurese. Her broad spectrum antibiotics were discontinued after 12 days of levofloxacin and 7 days of metronidazole and vancomycin. Her fluorinef was discontinued and her hydrocortisone was changed to a prednisone taper to be completed as an outpatient (last day [**10-11**]). . #. LOW UOP: Ms. [**Known lastname 98288**] initially had low UOP after her fluid resuscitation. Her urine electrolytes were checked and the FeNa was 0.1, but in the setting of fluorinef usage, they were uninterpretable. Fluorinef was discontinued and her urine output picked up. She was restarted on low doses of lasix, 10mg PO BID, to aid in her diuresis. . #. THYROID LESION: On CT scan, a lesion was found in her thyroid. On ultrasound, it was found to be a solid and cystic lesion in L lobe thyroid, concerning for malignancy. Dr. [**Last Name (STitle) 13059**] saw Ms. [**Known lastname 98288**] as an inpatient and recommended FNA as an outpatient and yearly TFTs. TFTs were checked here and were within normal limits. . #. PNEUMONIA: On admission, her CXR and physical exam were consistent with focal pneumonia involving the LLL. She was originally treated with levaquin as it was felt that its etiology could be either aspiration, community-acquired, or nosocomial (as the patient lives in [**Location **]). However, once she became hypotensive, there was concern that she might have become septic so antibiotic coverage was broadened and she was also given metronidazole and vancomycin. She completed 12 days of levaquin and 7 days of both metronidazole and vancomycin. Her cough improved, she remained afebrile, and never developed an elevated WBC. Her sputum cultures were negative for anything other than oral flora. Blood cx and urine cx also remained negative. . #. DEMENTIA: Ms. [**Known lastname 98288**] has fairly severe vascular dementia. As a result, she frequently refuses her medications. Her medications were consequently crushed and given in apple sauce in order to improve her compliance. She was continued on aricept (except during her period of hypotension) and mirtazapine. . #. COPD: She had albuterol nebulizers available prn for her COPD. She was continued on 2L of O2 by NC per her home routine. . #. PE by CT CHEST: On admission, a CTA was done and she appears to have a "tiny" chronic PE on the right side. Given the reported history of upper GI bleed after her hip surgery, as well as her history of what sounds like an A-COM aneurysm, it was felt that the risks of anticoagulation outweighed the benefits in this case. Her oxygenation was frequently monitored and remained stable throughout her hospital course. . #. F/E/N: Ground diet, nectar thick liquids. Aspiration precautions. High protein, low sodium, heart healthy diet. Her electrolytes were checked daily and were repleted daily, to the goal of keeping K > 4 and Mg > 2. . #. PPX: She was kept on fall and aspiration precautions. She was continued on a PPI for GI prophylaxis and SQ heparin for DVT prophylaxis. She was given senna, milk of magnesia and lactulose for a bowel regimen. PT and OT were consulted. . #. ACCESS: Right subclavian line placed [**10-2**] and removed on [**10-10**]. . #. CODE: FULL, verified with both daughter and attending. . #. DISPO: To rehab. Medications on Admission: Tylenol prn Natural tears to OU QD Dulcolax Milk of magnesia Mylanta prn Protonix Aricept 10mg PO QD Senna Atenolol 12.5mg PO QD Lasix 40mg PO QD Potassium 40mg PO QD Lisinopril 5mg PO QD Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) for 4 days. 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 1 doses: To be given on [**10-11**]. 12. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO once a day. 13. Calcium 600 + D(3) 600-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) 14991**] - [**Location (un) 1411**] Discharge Diagnosis: Primary diagnosis: Pacemaker dysfunction Pneumonia . Secondary diagnosis: CAD CHF Thyroid lesion Hypotension Discharge Condition: Stable. T 97.2, BP 114/54, HR 66, RR 18, sats 96% on 2L. UOP 4600 in last 24 hours. Discharge Instructions: 1. Please call your PCP or go to the ER if you develop any of the following symptoms: chest pain, chest pressure, shortness of breath, difficulty breathing, cough, pain or swelling in either of your shoulders, worsening swelling in your arms or legs, low urine output, nausea, vomiting, diarrhea, or any other worrisome symptoms. . 2. Please take all medications as prescribed. . 3. Please make sure to attend all of your follow-up appointments. . 4. Please transmit your pacemaker parameters to Dr.[**Name (NI) 9920**] office every two months, starting in [**Month (only) 1096**]. You can use the transmitter you already have to call in to his office at [**Telephone/Fax (1) 10012**]. Followup Instructions: 1. Please follow-up in the pacemaker device clinic on [**2131-10-15**] at 2:30pm. The clinic is located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building at [**Hospital1 18**]. Please call the clinic at [**Telephone/Fax (1) 59**] if you need to cancel or reschedule this appointment. 2. Please call Dr.[**Name (NI) 9920**] office to arrange for a follow-up appointment. His number is [**Telephone/Fax (1) 10012**]. 3. Please call Dr.[**Name (NI) 98289**] office to arrange a follow-up appointment for your thyroid mass. You will need to have a fine needle aspiration performed on the mass in your thyroid gland. You can reach her office by calling [**Telephone/Fax (1) 6468**]. Name: [**Known lastname 15680**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 15681**] Admission Date: [**2131-9-27**] Discharge Date: [**2131-10-10**] Date of Birth: [**2043-2-19**] Sex: F Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 15682**] Addendum: Patient was given an influenza vaccine prior to discharge. Per her daughter, she received the pneumovax last year. Discharge Disposition: Extended Care Facility: [**Last Name (un) 3637**] - [**Location (un) 1502**] [**Name6 (MD) **] [**Last Name (NamePattern4) 8732**] MD [**MD Number(1) 8733**] Completed by:[**2131-10-10**]

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