ChanBeDu/relevant_section_length · Datasets at Hugging Face

71,461

158,571

41373

Discharge summary

report

Admission Date: [**2112-9-6**] Discharge Date: [**2112-10-3**] Date of Birth: [**2038-8-24**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: seizure and abdominal distention Major Surgical or Invasive Procedure: [**2112-9-6**] Repair of left inguinal hernia. [**2112-9-11**] Exploratory laparotomy, small bowel resection [**2112-9-15**] Right AC PICC History of Present Illness: 74yo M w/ h/o seizure d/o presented to ED s/p seizure with coffee ground emesis followed by feculent emesis. Pt reports abdominal pain and nausea but has limited ability to report accurate history [**2-17**] baseline dementia. Per the patient's niece, he has had increasing abdominal distention for past month with increasing constipation and increasing urinary frequency. Pt transferred from nursing home after having a seizure. Past Medical History: Past Medical History: seizure d/o dementia hyponatremia gout EtOH abuse Past Surgical History: None per family Social History: Lives in [**Hospital1 1501**], Distant h/o EtOH abuse, distant tob use Family History: non contributory Physical Exam: Temp 98.2 HR:114 BP:152/99 RR:18 100%RA GEN: A&O to person only, NAD HEENT: No scleral icterus, mucus membranes moist CV: tachycardic, regular rhythm PULM: CTAB ABD: Firm, hypoactive BS, distended, palpable L incarcerated hernia, no apparent tenderness except in area of hernia where he has significant TTP Ext: palpable pulses, no edema Pertinent Results: [**2112-9-6**] 01:29PM WBC-8.3# RBC-5.65# HGB-15.5 HCT-45.2# MCV-80* MCH-27.4 MCHC-34.3 RDW-13.7 [**2112-9-6**] 01:29PM NEUTS-88* BANDS-0 LYMPHS-5* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2112-9-6**] 01:29PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2112-9-6**] 01:29PM PLT SMR-NORMAL PLT COUNT-291 [**2112-9-6**] 01:29PM PT-11.8 PTT-20.5* INR(PT)-1.0 [**2112-9-6**] 01:29PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2112-9-6**] 01:29PM ALT(SGPT)-13 AST(SGOT)-18 TOT BILI-0.4 [**2112-9-6**] 01:29PM LIPASE-22 [**2112-9-6**] 01:29PM GLUCOSE-155* UREA N-14 CREAT-0.9 SODIUM-128* POTASSIUM-4.5 CHLORIDE-90* TOTAL CO2-24 ANION GAP-19 [**2112-9-6**] 01:46PM LACTATE-2.6* [**2112-9-6**] CT Abd/pelvis : 1. High-grade small bowel obstruction with dilated loops of fluid-filled small bowel measuring up to 3.7 cm. The cause of the obstruction is a left inguinal herniated loop of bowel. There is concern for a closed loop obstruction. Additionally, there is free fluid around this closed loop, which along with hyperenhancement of the walls raises suspicion for possible ischemia. There is no evidence of free air throughout the abdomen. 2. Bibasilar patchy ground-glass opacities raise suspicion for aspiration. [**2112-9-8**] CT Abd/pelvis : 1. Findings consistent with a high-grade small-bowel obstruction with transition point in the left lower quadrant. Some free fluid surrounds the obstructed loops of bowel, although there is no evidence of pneumatosis. 2. Postsurgical changes of left inguinal hernia repair are noted without evidence of recurrent bowel-containing hernia. 3. A 13-mm fluid collection in the prostate gland to the left of midline, the appearance of which could represent a prostate abscess. Clinical correlation is recommended. 4. Gallstones. 5. Hypodense hepatic and renal lesions, too small to characterize. Hepatic and splenic granulomas and calcified right hilar lymph nodes consistent with prior granulomatous disease. 6. Suggest advancement of a nasogastric tube, with sidehole currently located at the gastroesophageal junction. Brief Hospital Course: Mr. [**Known lastname **] was evaluated by the Acute Care team in the Emergency Room and based on his physical exam and abdominal CT he was taken to the Operating Room emergently for a left inguinal hernia repair. He tolerated the procedure well and returned to the SICU in stable condition. He maintained stable hemodynamics and his pain was adequately controlled. He was slowly extubated from the respirator on [**2112-9-7**] and remained in the ICU for pulmonary toilet. Unfortunately his abdomen became increasingly distended and an abdominal CT revealed a high grade small bowel obstruction with a transition point in the left lower quadrant. His nasogastric tube was replaced and serial exams showed no significant change. After 3 days of bowel rest and gastric decompression his exam remained the same and he was taken back to the Operating Room on [**2112-9-11**] for an exploratory laparotomy and small bowel resection. Again he tolerated the procedure well and returned to the SICU intubated. He was easily extubated and maintained stable hemodynamics. His nasogastric tube remained in placed for a prolonged period of time due to large output. He was placed on a bowel regime and given time to open up. He also developed an enterococcal UTI and was fully treated. Following transfer to the Surgical floor on [**2112-9-14**] he was working with Physical Therapy on a regular basis with the hope that increasing his activity would increase his bowel function. That did not happen and he eventually required PICC line placement for TPN. His abdomen was less distended and over time her nasogastric tube drainage decreased. His NG tube was finally removed on [**2112-9-21**] and he was cautiously started on sips of liquids. His diet was slowly advanced over 5-6 days and his abdomen remained soft. After tolerating a regular diet his TPN was weaned off and he was given nutritional supplements at each meal. His abdomen remains distended but is soft and non tender. He is having bowel movements with the help of multiple stool softeners, laxatives and fiber. His hematocrit has been stable in the 23-25 range and it is intended for him to start an iron supplement in a few weeks, once we are assured that constipation is not an issue. The Neurology service was consulted as his initial presentation was due to a seizure. He had been on Keppra and Tegretol prior to admission and they suspected that poor GI absorption was the cause of his breakthrough seizures. His trough levels were checked and were normal. He had no seizures during this admission and he remains on the same doses of Keppra and Tegretol. After a long, complicated course he was discharged back to his nursing home on [**2112-10-2**] and will continue with Physical Therapy and close monitoring of his nutritional status. His PICC line was removed prior to discharge. Medications on Admission: Keppra 1000 mg [**Hospital1 **] Tegretol XR 600mg PO BID Folic Acid 1mg PO QD Tylenol 500mg PO QD Caltrate 600mg/400Unit tab [**Hospital1 **] Senna 17.2mg PO BID ASA 81mg PO QD Polyethylene Glycol 17g QD Aricept 5mg QHS Colace 100mg PO BID Valium 5mg IM QD PRN seizures Milk of magnesia 30mL PO at 8pm if no BM for 3days Dulcolax 10mg supp if failure of MoM [**Name (NI) 20342**] Enema 1 PR if failure of supp Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. carbamazepine 200 mg/10 mL Suspension Sig: Thirty (30) mls PO BID (2 times a day). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 4. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) mls PO Q6H (every 6 hours) as needed for pain or temp >101.4. 5. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2 times a day). 10. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Caltrate 600 + D 600 mg(1,500mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Incarcerated left inguinal hernia. Prolonged post op ileus Enterococcus UTI . 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 due to abdominal pain from a hernia which required an operation to repair it. * You developed fevers and more abdominal pain post op due to a small bowel obstruction which again, required an operation to repair. * After the surgery your bowels were very slow to wake up and for a period of time you needed to get your nutrition from high calorie intravenous fluids. * Currently as time has passed and your bowel function has returned, you are able to tolerate a regular diet. * You must keep well hydrated and continue to eat well so that you can heal your wounds. * You will need to take medication to keep your bowels moving and hydration and high fiber will also help. * If you develop any increased abdominal distention, abdominal pain, nausea or vomiting or any other symptoms that concern you please return to the Emergency Room. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**2-18**] weeks. Completed by:[**2112-10-3**]

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Discharge summary

report

Admission Date: [**2182-6-22**] Discharge Date: [**2182-6-26**] Date of Birth: [**2110-2-2**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 72 year old male with a past medical history significant for gastrointestinal bleed, status post gastrectomy and +/- Billroth II procedure, who was admitted to the Medical Intensive Care Unit initially after two days of melena. The patient was previously taking Aspirin, however, he knew to stop this medication once the patient started to notice that he had several episodes of melanotic stools. The patient was last admitted to [**Hospital6 1708**] in [**2182-1-29**], where an esophagogastroduodenoscopy showed questionable scar rupture or Dieulafoy's lesion causing the patient's gastrointestinal bleed. During this admission to [**Hospital1 188**], the patient had an esophagogastroduodenoscopy which showed no active bleeding ulcers and they recommended increasing the patient's dose of Protonix. In the Intensive Care Unit, the patient required a total of four units of packed red blood cells. The patient's hematocrit on admission was 26.4 and subsequently went up to 33.4 after the four units. The patient remained hemodynamically stable throughout the brief Intensive Care Unit stay and did not require any pressors. The patient was not hypotensive at any point, nor did he require intravenous fluid boluses. However, on hospital day two, the patient's hematocrit continued to fall, eventually down to 26.0. However, on recheck, it was 29.1. There was no evidence of any acute bleeding going on and it was felt that the patient would continue to have some mild melanotic stools given the history of gastrointestinal bleed. The patient also spiked a temperature to 101.2 during the Intensive Care Unit stay. Urinalysis, chest x-ray and blood cultures were done. The urinalysis was negative and blood cultures were negative. Chest x-ray showed patchy opacities in both the right mid and left lung zones. Since there was no prior chest x-ray for comparison, it was not known if these were new or old, however, it was felt that there was no need for any antibiotics at this time. The patient defervesced on his own without any intervention. It was the feeling of the Intensive Care Unit team that the fever may just have been from postprocedure. The patient was transferred to the floor in stable condition for further management of his upper gastrointestinal bleed. PAST MEDICAL HISTORY: 1. History of gastrointestinal bleed times two, status post Billroth II gastrectomy in [**Male First Name (un) 1056**] forty years ago. 2. History of Dieulafoy's lesion. 3. Noninsulin dependent diabetes mellitus, followed at [**Last Name (un) **] by Dr. [**Last Name (STitle) **]. 4. Hypertension. 5. History of heart murmur. 6. Stress test at [**Hospital6 1708**] in [**2180-3-29**], showed no perfusion defects. 7. History of BCG vaccine and positive PPD in the past. ALLERGIES: Codeine. MEDICATIONS ON ADMISSION: 1. Glyburide 5 mg p.o. b.i.d. 2. Atenolol 50 mg p.o. q.d. 3. Zocor 20 mg p.o. q.d. 4. Aspirin which had been held. 5. Prevacid 30 mg p.o. b.i.d. 6. Metformin 500 mg p.o. b.i.d. 7. Sublingual Nitroglycerin 0.4 mg p.r.n. chest pain. MEDICATIONS ON TRANSFER: 1. Regular insulin sliding scale. 2. Protonix 40 mg p.o. b.i.d. 3. Metoprolol 25 mg p.o. b.i.d. 4. Sucralfate one gram q.i.d. FAMILY HISTORY: The patient's mother had a history of diabetes mellitus as well as congestive heart failure. Father died in a motor vehicle accident. SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] has been in the United States for thirty years, was originally fro [**Male First Name (un) 1056**]. He socially drinks alcohol and denies tobacco use. He works as a hospital inspector. PHYSICAL EXAMINATION: Vital signs on admission revealed temperature 98.9, blood pressure 140/90, pulse 110, oxygen saturation 100% in room air, respiratory rate 20. In general, the patient was an elderly Hispanic male in no apparent distress. Head, eyes, ears, nose and throat - mucous membranes moist. The oropharynx was clear. There was no jugular venous distention. No lymphadenopathy. The neck was supple. There were no bruits. The chest was clear to auscultation bilaterally, no wheezes or crackles were appreciated. Good air entry. The heart revealed regular rate and rhythm, II/VI systolic murmur at the apex radiating to the axilla, no rubs or gallops were appreciated. The abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities showed 1+ edema bilaterally and 2+ pulses bilaterally. No clubbing or cyanosis. Neurologically, the patient was awake, alert and oriented times three. LABORATORY DATA: On admission, white blood cell count 8.0, hematocrit 29.1, platelets 147,000, MCV 85. Sodium 140, potassium 2.7, chloride 105, bicarbonate 28, blood urea nitrogen 18, creatinine 0.6, calcium 7.7, magnesium 1.5, phosphorus 3.2. Blood cultures times two was negative. Urinalysis was positive for ketone, otherwise no leukocytes, negative for nitrites. HOSPITAL COURSE: 1. Gastrointestinal - The patient remained hemodynamically stable. He was transfused an additional two units of packed red blood cells with an appropriate bump in his hematocrit to 32.6 prior to discharge. The patient continued to have episodes of melena. The gastroenterology service thought that the patient would continue to have episodes of melena given his history of upper gastrointestinal bleed for approximately one week. The patient's Protonix was continued at 40 mg p.o. b.i.d. The patient was subsequently restarted on his Atenolol given the fact that the patient's blood pressure had remained stable and the patient was not hypotensive at any point. The patient tolerated p.o. diet well without any nausea or vomiting. 2. Endocrine - The patient had a history of diabetes mellitus. Initially, the patient was just on regular insulin sliding scale, however, once the patient tolerated clears as well as regular p.o. diet, he was restarted on his usual oral hypoglycemics that he was on as an outpatient and tolerated those just fine. 3. Pulmonary - Given the patient's patchy pulmonary opacities in the left mid lung and right base, a chest CT was done. Chest CT showed nonspecific ground glass opacities in the left upper lobe in the perihilar region. The differential included early or resolving infectious process, asymmetric pulmonary edema, pulmonary hemorrhage or aspiration event. Multiple calcified mediastinal and hilar lymph nodes. Calcified pulmonary granulomas and splenic and hepatic granulomas likely representing previous granulomatous infection and enlargement of the pulmonary artery suggestive of pulmonary hypertension. Small foreign body in the right upper lobe. Given these findings on chest CT, it was felt that another PPD should be planted. PPD was planted in the right forearm and was checked two days after placement. Since the patient was eventually readmitted after discharge, PPD was found to be 3.0 centimeters positive for induration. After discussion with infectious disease service, it was felt that given the patient's history of positive PPD in the past and lack of current symptoms including fever, chills, hemoptysis, that no treatment would be warranted given his advanced age and increased risk from INH toxicity. However, the patient should have a follow-up chest CT in a few months to follow-up those lesions. 4. Infectious disease - The patient was not given any antibiotics, did not have any more fevers. Blood cultures were negative. The patient had a RPR drawn at some point which was negative. The patient's white count remained stable. The patient was discharged to home with follow-up with follow-up at [**Company 191**] for [**Location (un) 1131**] of his PPD , however, the patient was readmitted. Apparently the patient has a primary care physician at [**Hospital1 **] and is followed by Dr. [**Last Name (STitle) 30281**] at [**Last Name (un) **]. He is looking for a new primary care physician. [**Name10 (NameIs) **] will be decided after discharge. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Noninsulin dependent diabetes mellitus. 3. Hypertension. 4. History of heart murmur. 5. Negative stress test. 6. History of PPD positive. 7. Chest CT with calcified granulomas. DISCHARGE STATUS: Stable. MEDICATIONS ON DISCHARGE: 1. Glyburide 5 mg p.o. b.i.d. 2. Atenolol 50 mg p.o. q.d. 3. Zocor 20 mg p.o. q.d. 4. Protonix 40 mg p.o. b.i.d. 5. Metformin 500 mg p.o. b.i.d. 6. Captopril 12.5 mg p.o. t.i.d. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**] Dictated By:[**Name8 (MD) 9784**] MEDQUIST36 D: [**2182-6-28**] 16:38 T: [**2182-6-29**] 18:31 JOB#: [**Job Number 30282**]

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icd9cm

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Discharge summary

report

Admission Date: [**2185-12-16**] Discharge Date: [**2185-12-22**] Service: MEDICINE Allergies: Iodine / Fosamax / Gadolinium-Containing Agents / Hydrochlorothiazide / Vasotec / Etodolac Attending:[**First Name3 (LF) 1115**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo woman with h/o CAD, CHF (baseline EF 45%), breast CA, DVT, AFib on Coumadin, who presents with hypotension. She has a home health aide who lives with her 24/7 and thought that the patient seemed altered this morning. Her speech was slurred and her BP was in the 70s. She also has a lot of bruising on her arms and face, so there's a concern for elder abuse (from PCP). . In the ED, her initial vs were: T 97.3, P 85, BP 80/46, R 16, O2 95% on RA. She triggered for hypotension and was given 1L of IVF, to which her BP increased to 88/46. Per review of OMR, her BP typically ranges from 80-90. She had a CXR, which demonstrated a ? right-sided PNA. She was given Ceftriaxone, Levaquin, and Vanc. The resident in the ED spoke with both of her daughters about her code status, and she is DNR/DNI with non-invasive measures only (no central line). She was ordered for a CT-neck, abdomen, pelvis, given the concern for elder abuse, but she had not yet received them in the ED. Trop 0.37, EKG showed AFib with RBBB, ST depressions in V2 and V3 that are new and no ST elevations. She got an ASA in the ED. Her VS at the time of transfer were T 97.2, 88/46, 80, 14, 98% on 2L. . On the floor, pt is drowsy but arousable. Denies CP, SOB, abd pain, recent fevers/chills. . Review of systems: unable to obtain due to pt mental status Past Medical History: Breast cancer s/p bilateral mastectomy, XRT [**2144**] Skin cancer Squamous cell cancer of the left ear canal - followed by Dr. [**First Name (STitle) **] of ENT Anemia CAD s/p MI, c/b re-stenosis of bare metal stents; last cath [**4-23**] with 3VD, moderated diastolic ventricular dysfunction, s/p PCI of the LMCA/LAD/LCX with kissing drug-eluting stents. Congestive heart failure (EF 40-45%) Aortic stenosis (4 m/s peak; moderate to severe [**5-26**] echo) Aortic regurgitation (mild-moderate [**5-26**] echo) Mitral regurgitation (mild-moderate [**5-26**] echo) Paroxysmal atrial fibrillation SVT [**1-19**] Carotid stenoses - 40% bilateral ([**11-22**]) Hypertension Hypercholesterolemia Multiple mechanical falls leading to subarachnoid hemorrhage Hysterectomy ([**2137**]) Colonic polyps (adenoma [**4-24**]) Chronic sternal infection w/actinomyces - followed by [**Doctor Last Name 1352**] at [**Hospital1 112**]. Hypothyroid Depression GIB secondary to peptic ulcer/angioectasia ([**3-23**]) CRI baseline Cr 1.4-1.8 Social History: Pt lives alone with a [**Hospital 2241**] home health aides. She requires assistance with dressing, walking (unsteady on a [**Hospital **]), preparing meals. Able to feed herself. She previously worked in the development office of [**Hospital **] Hospital for 47 years. No tobacco or EtOH. NOK: Eldest daughter - [**Name (NI) **] [**Name (NI) **] - [**Telephone/Fax (1) 94693**], daughter from [**Location (un) 5131**] [**Name (NI) **] - [**Telephone/Fax (1) 94694**]. Family History: Non-contributory. Physical Exam: Admission exam: Vitals: T:97.5 BP:87/47 P:81 R:18 O2:98% on 2L NC General: somwhat drowsy but opens eyes to commands, AOx2 ([**Hospital1 **], could not give month/date/year) HEENT: Sclera anicteric, mucous membranes very dry. Small bruise on left eyelid, pt unable to tell me how she got it, does not remember any trauma Neck: supple, difficult to evaluate JVP as pt does not cooperate w/ exam Lungs: poor inspiratory effort CV: Regular rate and rhythm, normal S1 + S2, 4/6 systolic murmur Chest: open wound on the chest, 4cm long, several cm deep. No evidence of active infection. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses. LUE swollen compared to right. Some bruising on R arm, +skin tear. Discharge Exam: VS: 96.5 134/62 90 22 95% 3L GENERAL: sleeping but arousable, oriented to person and place only, NAD HEENT: sclera anicteric, slightly dry mucous membranes, neck supple CHEST: dressing over chest wound intact, dry, intact CV: RRR, 3/6 systolic murmur at RUSB radiating to carotids, [**1-22**] holosystolic murmur heard at apex radiating to axilla RESP: bilateral crackles, R>L ABD: soft, non-tender, non-distended EXT: warm, well perfused, DPs 2+, LUE swelling unchanged, [**11-20**]+ pitting edema of feet, right knee mildly tender to palpation but without warmth, erythema or edema Pertinent Results: Admission Labs: [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] WBC-25.2*# RBC-3.60* Hgb-8.8* Hct-28.5* MCV-79* MCH-24.5* MCHC-31.0 RDW-16.3* Plt Ct-352 [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] Neuts-95.5* Lymphs-2.0* Monos-2.2 Eos-0.1 Baso-0.2 [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] PT-37.0* PTT-37.1* INR(PT)-3.8* [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] Glucose-125* UreaN-50* Creat-2.5* Na-140 K-5.3* Cl-107 HCO3-23 AnGap-15 [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] ALT-41* AST-64* AlkPhos-73 TotBili-0.6 [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] cTropnT-0.37* [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] Albumin-2.8* Calcium-8.1* Phos-5.4*# Mg-2.5 [**2185-12-16**] 01:20PM [**Month/Day/Year 3143**] Lactate-2.3* . Other Notable Labs: [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] Lipase-15 [**2185-12-16**] 01:10PM [**Month/Day/Year 3143**] cTropnT-0.37* [**2185-12-16**] 09:40PM [**Month/Day/Year 3143**] CK-MB-12* MB Indx-2.3 cTropnT-0.36* [**2185-12-17**] 05:01AM [**Month/Day/Year 3143**] CK-MB-9 cTropnT-0.35* [**2185-12-17**] 03:56PM [**Month/Day/Year 3143**] CK-MB-6 cTropnT-0.34* [**2185-12-17**] 03:56PM [**Month/Day/Year 3143**] ALT-40 AST-47* LD(LDH)-293* CK(CPK)-233* AlkPhos-65 TotBili-0.2 . Discharge Labs: [**2185-12-22**] 06:00AM [**Year/Month/Day 3143**] WBC-10.3 RBC-3.17* Hgb-8.0* Hct-25.2* MCV-79* MCH-25.3* MCHC-31.8 RDW-17.8* Plt Ct-313 [**2185-12-22**] 06:00AM [**Year/Month/Day 3143**] PT-26.2* PTT-38.7* INR(PT)-2.5* [**2185-12-22**] 06:00AM [**Year/Month/Day 3143**] Glucose-98 UreaN-36* Creat-1.4* Na-144 K-4.2 Cl-113* HCO3-22 AnGap-13 . Micro: [**Year/Month/Day **] cultures [**2185-12-16**] x2: negative Urine cultures [**2185-12-16**] x2: negative . Sternal wound culture [**2185-12-17**]: -Gram stain: 2+ polys, 4+ gram positive rods, 2+ GPCs in pairs and clusters, 1+ GNRs -Wound culture: ENTEROCOCCUS SP.. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S CIPROFLOXACIN--------- =>8 R LEVOFLOXACIN---------- =>8 R PENICILLIN G---------- 2 S VANCOMYCIN------------ <=0.5 S -Anaerobic culture (prelim): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. . Influenza DFA [**2185-12-17**]: negative for influenza A, B . Imaging: CXR [**12-16**]: Increased interstitial markings bilaterally are suggestive of interstitial edema. Superimposed infectious process cannot be excluded. . LUE U/S [**12-16**]: No evidence of left upper extremity DVT. Left cephalic and basilic veins not visualized. . CT Head [**2185-12-16**]: No acute intracranial abnormalities. CT C-spine [**2185-12-16**]: No fracture or change in alignment. If there is clinical concern for ligamentous or cord injury, MRI is more sensitive for this. . CT Abd/pelvis [**2185-12-16**]: 1. No evidence of retroperitoneal hematoma. 2. Redemonstration of pleural effusions and bibasilar atelectasis. inflammatory change on prior study has resolved. 3. Cholelithiasis, with no evidence of cholecystitis. 4. Sigmoid diverticula with no evidence of diverticulitis. 5. Diffuse vascular calcifications. 6. Diffuse spinal degenerative change. . [**2185-12-17**] Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8cm2). Mild to moderate ([**11-20**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. 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. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD. Severe aortic valve stenosis. Mild-moderate aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. . Bilateral Knee X-rays [**2185-12-17**]: 1. No evidence of acute fracture or dislocation of the left knee. Left knee chondrocalcinosis. 2. Suboptimal evaluation of the right knee as only a lateral view was obtained. The patella appears slightly low lying. No obvious fracture is seen, although evaluation is suboptimal. If clinical concern for right knee fracture persists, suggest attempt at repeat imaging or cross-sectional imaging. . CXR (PA & Lat) [**2185-12-19**]: The most significant abnormality in the chest developing over the past three days has been increased in moderate right pleural effusion and the development of new consolidation in a region of scarring in the right upper lobe. The latter could be pneumonia, or alternatively edema developing in a region of previous injury by radiation. A region of lesser consolidation at the left apex looks more like scarring and others at both lung bases are probably atelectasis. The slightly smaller left pleural effusion has also increased. Severe cardiomegaly is chronic. The extremely dilated upper esophagus is responsible for a central lucency in the neck and upper mediastinum. The patient has a history of extensive bone metastases and destruction of the sternum with soft tissue infection that can be evaluated by conventional radiographs. Thoracic aorta is heavily calcified, tortuous and unchanged recently. No pneumothorax. . Right Knee X-ray [**2185-12-19**]: There is chondrocalcinosis. There is no knee joint effusion. There is generalized demineralization which limits evaluation for subtle fractures; however no definite fractures are seen. No focal lytic or blastic lesions are present. If there is high clinical concern for nondisplaced fracture or acute intra-articular pathology, MRI could be performed. . CXR [**2185-12-22**] (prelim read): Worsening of right upper lobe and right lower lobe consolidation concerning for pneumonia. Stable small right greater than left pleural effusions. Brief Hospital Course: [**Age over 90 **] yo woman with h/o CAD, CHF (baseline EF 45%), breast CA, DVT, AFib on Coumadin, who presented with hypotension in the setting of possible acute on chronic sternal wound infection/osteomyelitis and pneumonia. . ACTIVE ISSUES: . #. Hypotension: Patient's hypotension was felt to be most likely secondary to sepsis, from worsening of sternal wound infection vs. pneumonia. Hypotension was also likely related to decreased fluid intake at home. Her BP responded to IVF administration in the ED, and she was initially admitted to the ICU for further evaluation. Per patient/family wishes, she did not have a central line placed for pressor support, given goals of care and wish for non-invasive measures. She was started on broad spectrum antibiotics, with subsequent downward trend in leukocytosis. [**Age over 90 **] cultures were negative. ID consulted, and followed closely (see below). Her home BP meds were initially held, but lasix and spironolactone were restarted prior to discharge (see below). BP stabilized, and SBP remained stable generally in the 100s-110s leading up to discharge. . #. Acute on Chronic Osteomyelitis/sternal wound: Patient was on avelox at home for suppressive therapy, and it was felt her hypotension and leukocytosis on admission may be secondary to acute on chronic osteomyelitis. Wound swab culture demonstrated polymicrobial infection, including enterococcus and corynebacterium species. The patient was followed closely by the Infectious Disease team, and continued on vanc/cefepime for broad spectrum antibiotic coverage until time of discharge. She was discharged on moxifloxacin 400mg PO daily, given goals of care and desire for oral regimen. Wound care was also consulted for recommendations about daily dressing changes. While the definitive treatment for this wound is surgical, the patient and family have declined surgical repair. . #. Pneumonia: Patient initially started on broad spectrum antibiotics with vanc/ceftriaxone/azithro given concern for PNA on presentation. Her antibiotics were later switched to vanc/cefepime as above. While evidence of pneumonia was not clearly demonstrated on initial CXR, subsequent CXR demonstrated worsening RUL pneumonia. The patient had a speech and swallow evaluation during this admission, which revealed she is intermittently aspirating. Given increased cough, rales on lung exam, and rising leukocytosis at time of worsening radiographic evidence of PNA, the patient was also started on flagyl as there was concern for aspiration PNA. The patient and her family are aware of the risks of continued aspiration should she continue to eat/drink, but they did not want to make her NPO or pursue alternate nutrition. She was discharged home to hospice care and will continue to take moxifloxacin as above, but was not discharged on any additional antibiotics. The patient's O2 requirement ranged from 2-3L NC during this admission, and the patient will be set up with home oxygen. It is also likely that worsening pleural effusions (see below) were contributing to oxygen requirement. . #. CHF: Patient's most recent echo in our system from [**2182**] showed EF 40-45%. Repeat echo this admission showed LVEF of 40% and severe aortic stenosis, similar findings compared to TTE in [**2182**]. The patient's lasix, spironolactone, carvedilol were initially held in setting of hypotension. Serial CXRs demonstrated increasing pleural effusions after diuretics were held, and the patient also developed lower extremity edema. Given concern that increased fluid was contributing to cough, SOB, and hypoxia, the patient was restarted on Lasix at half the home dose, and spironolactone at full dose prior to discharge. She will have home oxygen. . #. Acute on chronic renal failure: Patient's Cr was elevated from baseline of 1.5 to 2.5 on admission, likely secondary to pre-renal etiology in the setting of hypotension and dehydration. Her Cr improved throughout her hospital course, and was back to baseline at 1.4 on day of discharge. . #. CAD: The patient has a history of MI, last cath [**4-23**] with 3VD, s/p PCI of the LMCA/LAD/LCX with DES. Trop elevated to 0.37 on admission, EKG showed new ST depressions in V2 and V3; concerning for NSTEMI vs demand ischemia in the setting of hypotension. Cards consulted, repeat EKG improved, likely lead placement on the first EKG. Repeat trop stable. She was given aspirin and continued on a statin. Echo showed LVEF of 40% and severe aortic stenosis which is similar findings compared to TTE in [**2182**]. Of note, aspirin and statin stopped on discharge, given goals of care. . #. ? Elder abuse: PCP had concern about abuse due to bruises on face/arms, possibly from home care nurse. The patient had a CT head, c-spine, and abd/pelvis, which were all negative for any acute process. To be safe, the family will have a new home care provider. [**Name10 (NameIs) 7355**] work followed along closely. Of note, it is also possible that increased bruising was secondary to warfarin use, and INR was supratherapeutic at time of admission. . #. AFib and h/o DVT: Patient's INR was supratherapeutic on admission, and warfarin was initially held. She did receive several doses of warfarin during this admission, but warfarin will not be continued on discharge given goals of care. PCP aware of this decision, and in agreement. . #. Knee Pain: Patient complained of intermittent knee pain during the admission, likely secondary to arthritis. X-rays did not show evidence of acute fracture. The patient was started on standing tylenol for pain relief. . #. LFT elevation: ALT has been elevated in the past, AST slightly more elevated. The patient did not complain of abdominal pain or tenderness, and CT abdomen showed gallstones but no acute process. . #. HTN: Patient's carvedilol, lasix, and spironolactone were initially held in the setting of hypotension. Lasix and spironolactone were restarted prior to discharge as above, but carvedilol was not restarted. . INACTIVE ISSUES: . #. Hypercholesterolemia: Continued home simvastatin, but this was stopped at time of discharge given goals of care. . #. Hypothyroidism: Continued home levothyroxine. . #. Depression: Continued home citalopram, ropinirole. PENDING AT TIME OF DISCHARGE: Official read of [**2185-12-22**] portable CXR . TRANSITIONAL ISSUES: -She should continue to have daily dressing changes for her sternal wound. -She is at risk for aspiration, and should be monitored closely with all meals. To reduce the risk of aspiration, a diet of soft pureed foods and nectar pre-thickened liquids is best. The patient and her family are aware of the risks of aspiration, should she continue to eat/drink. -Patient's code status was DNR/DNI during this admission, and patient/family do not wish for aggressive measures. -Patient discharged home with hospice care. Medications on Admission: Coumadin 2 mg PO daily (MTWThF) Lorazepam 0.5mg PO daily Lasix 40 mg [**Hospital1 **] Folic Acid 1 mg daily spironolactone 25mg PO daily Citalopram 60 mg daily avelox ABC Pack 400mg tab PO carvedilol 3.125 mg daily Vitamin D 1,000 U PO daily Ferrous Sulfate 300 mg daily Levothyroxine 100 mcg daily omeprazole 40mg delayed release daily ropinirole 0.25mg QHS simvastatin 80mg QHS lactobacillus daily Discharge Medications: 1. Oxyfast [**Hospital1 **]: 1-20 mg Q1H as needed for difficulty breathing or pain: 20 mg/mL solution. Disp:*30 mL* Refills:*2* 2. Home Oxygen continuous oxygen via nasal canula at 2-4 lpm 3. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 4. furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. spironolactone 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. citalopram 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: 2.5 Tablets PO DAILY (Daily). 9. levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. ropinirole 0.25 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime. 12. acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 13. moxifloxacin 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Hospice Good [**Last Name (un) 3952**] Discharge Diagnosis: Primary Diagnoses: Chronic osteomyelitis, pneumonia, acute on chronic renal disease, chronic congestive heart failure Secondary Diagnoses: Coronary artery disease, osteoarthritis, hypothyroidism, depression Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure taking care of you during your stay at [**Hospital1 1535**]. You were admitted to the hospital with some confusion and low [**Hospital1 **] pressures, likely due to an infection in your sternal wound and a pneumonia. We treated you with fluids and antibiotics, and you improved. You required oxygen, and you will be set up with oxygen at home to help with your breathing. A speech and swallow evaluation showed you are aspirating small amounts of food/drink into your lungs while you are eating, which may contribute to pneumonia. You were continued on a diet of soft foods and thick liquids to minimize this from happening, but there is still a chance you may develop another pneumonia. We made the following changes to your medications: 1. STOPPED coumadin 2. DECREASED lasix to 40mg once daily 3. STOPPED carvediolol 4. STOPPED ferrous sulfate 5. STOPPED simvastatin 6. STARTED tylenol 1000mg three times per day 7. STARTED oxyfast as needed for pain or shortness of breath You should continue on moxifloxacin 400mg daily for your wound. Please continue to take all other medications as you have been doing. Your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] is aware you are being discharged from the hospital, and you may contact her if you have any questions about your medications. Followup Instructions: Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], as needed. The clinic number is [**Telephone/Fax (1) 40745**].

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

19931, 20000

11385, 11614

312, 318

20252, 20252

4718, 4718

21879, 22101

3260, 3279

18739, 19908

20021, 20140

18315, 18716

20432, 21194

6010, 11362

3294, 4098

20161, 20231

4114, 4699

17770, 18289

21223, 21856

1663, 1705

261, 274

11629, 17427

346, 1643

17444, 17749

4734, 5994

20267, 20408

1727, 2752

2768, 3244

703

168,914

46150

Discharge summary

report

Admission Date: [**2104-7-15**] Discharge Date: [**2104-7-21**] Date of Birth: [**2032-3-8**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male with history of coronary artery disease, hypertension, hypercholesterolemia who presented with a 12-hour history of left-sided chest pain radiating to the back and shoulder. The patient's pain was rated [**9-14**] and the patient had concomitant nausea, but denied having shortness of breath or palpitations. The patient also noted similar pain on a [**2104-6-5**] admission which required two sublingual nitroglycerin to alleviate. The patient denies a history of bright red blood per rectum, melena, dysuria, diarrhea, fevers, chills, or cough. Most recently the patient was admitted on [**2104-6-24**] with a stress MIBI which lasted approximately nine minutes on modified [**Doctor First Name **] protocol with achievement of 57% of maximum heart rate. The patient also was noted to have a new mild reversible defect in the inferolateral region although no EKG changes were noted and the patient's blood pressure decreased inappropriately to exercise. At this time the patient underwent a cardiac catheterization at [**Hospital1 190**] which revealed 20% left main coronary artery disease, left anterior descending coronary artery with hazy eccentric 70% and 50% mid, left circumflex normal, right coronary artery completely occluded, and saphenous vein graft to right coronary artery with 60-70% mid disease. Given these findings, cardiothoracic surgical evaluation was obtained. PAST MEDICAL HISTORY: 1. Coronary artery disease status post saphenous vein graft to right coronary artery bypass in [**2080**]. [**2103-6-6**] catheterization showed patent graft, 50% left anterior descending coronary artery. [**2103-9-6**] stress, ejection fraction 68% with no free wall motion abnormality. 2. Gallstones with common bile duct dilatation status post ERCP and sphincterotomy. 3. Gastroesophageal reflux disease. 4. Hypertension. 5. Hypercholesterolemia. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Mevacor 40 mg p.o. b.i.d. 3. Nadolol 80 mg p.o. q.d. 4. Vasotec 40 mg p.o. q.d. 5. Hydrochlorothiazide 25 mg p.o. q.d. 6. Ambien p.r.n. 7. Melatonin. 8. Multivitamins. SOCIAL HISTORY: The patient currently lives with his wife, has a history of former ethanol abuse and quit tobacco in [**2091**]. FAMILY HISTORY: No history of coronary artery disease, no diabetes, no cerebrovascular accidents and a positive history in the mother for hypertension. PHYSICAL EXAMINATION: Vital signs were temperature 99.4, pulse 66, sinus, blood pressure 113/50, respiratory rate 16 and 93% saturation on room air. The patient was a well-developed, well-nourished male in no apparent distress. HEENT: Sclerae anicteric, cranial nerves II-XII were intact. Mucous membranes were moist, no evidence of oral ulcers. Neck: No evidence of cervical lymphadenopathy noted. Chest: Sternotomy site without any drainage, no evidence of click and no evidence of erythema. Clear to auscultation bilaterally. Heart: Regular rhythm and rate, no evidence of murmur. Abdomen: Soft, nondistended, nontender with positive bowel sounds. No hepatosplenomegaly and no evidence of inguinal lymphadenopathy. Extremities: No evidence of rash and +1 lower extremity symmetric edema. LABORATORY DATA: Laboratory studies as of [**2104-7-21**] showed a white blood cell count of 8.3, hematocrit 26.4, platelet count 148, sodium 138, potassium 4.3, chloride 104, bicarbonate 24, BUN 16, creatinine 0.9, calcium 7.9, magnesium 2.0, phosphorous 3.0. HOSPITAL COURSE: Mr. [**Known lastname **] is a 73-year-old male status post coronary artery bypass grafting in [**2080**] (SVG to RCA) who presents with cardiac catheterization which revealed occluded right coronary artery, saphenous vein graft to right coronary artery with 60-70% mid disease, left anterior descending coronary artery with hazy eccentric 70% disease and 50% mid disease. Following the successful preoperative evaluation, the patient was taken to the operating room on [**2104-7-17**] and underwent an uncomplicated redo coronary artery bypass grafting x 2 (LIMA to LAD, SVG to PDA). Postoperatively the patient was taken to the cardiac surgery recovery unit for close observation. The patient was immediately extubated and was noted to have labile blood pressure which improved within several hours. During this time the patient maintained sinus rhythm with occasional premature ventricular contractions and was breathing spontaneously on four liters nasal cannula with good saturations at 97%. By postoperative day number two the patient was transferred to the floor in good condition and initiated on metoprolol while pacing wires were intact. No evidence of bradycardia occurred and pacing wires were removed on the following day. By postoperative day number three the patient cleared level five physical therapy requirement for discharge to home, however the decision was made to discharge the patient on the following day to further monitor the patient's improvement. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Status post redo coronary artery bypass grafting x 2. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Lasix 20 mg p.o. b.i.d. 3. Metoprolol 12.5 mg p.o. b.i.d. 4. Atorvastatin. 5. Potassium 20 mg p.o. b.i.d. The Lasix and potassium are to be discontinued approximately two weeks after discharge. FOLLOW-UP PLANS: 1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in six weeks after discharge. 2. The patient was also instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in seven to 10 days. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 11079**] MEDQUIST36 D: [**2104-7-21**] 09:29 T: [**2104-7-21**] 10:32 JOB#: [**Job Number 98159**] cc:[**Last Name (NamePattern1) 98160**]

[ "530.81", "401.9", "414.01", "411.1", "272.0", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.53", "36.15", "37.22", "88.55", "36.11" ]

icd9pcs

[ [ [] ] ]

2508, 2645

5297, 5352

5375, 5602

3731, 5214

2668, 3713

5619, 6309

183, 1609

1632, 2360

2377, 2491

5239, 5275

69,328

139,290

41127+58421

Discharge summary

report+addendum

Admission Date: [**2163-3-22**] Discharge Date: [**2163-4-11**] Date of Birth: [**2078-7-12**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Dilantin Attending:[**First Name3 (LF) 78**] Chief Complaint: nausea with vomiting Major Surgical or Invasive Procedure: [**2163-3-22**]: EVD placement [**2163-3-23**] angiogram with coiling History of Present Illness: Mr. [**Known lastname **] is a 84 year old rigth handed man with HTN who had a sudden and severe nausea with vomiting plus confusion at 5pm the day of admissionwhile operating a bulldozer. His son was not with him initially but responded to his call for help. He reports that the patient was vomiting and appeared very [**Known lastname **]. When the patient was not getting off the bulldozer, 911 was called and the patient was helped out of the bulldozer per his son and the [**Name (NI) 9168**]. Patient reports that the father [**Name (NI) 89612**] "[**Name2 (NI) **]" but was speaking clearly and walking with minimal support. He was initially taken to [**Hospital **] Hospital where his initial BP was elevated to 192/98 which was treated with labetalol 20mg IV. A head CT revealed extensive, bilateral SAH hence and he was given 1g of fosphenytoin then transferred to [**Hospital1 18**] for further care. En route, his mental status deteriorated and upon arrival, he was minimally responsive (opening eyes to sternal rub) although spontaneously moving all four extremities. Additionally, his BP was 85/44 upon arrival to [**Hospital1 18**] hence dopamine drip was started and given the poor mental status, he was intubated for airway protection. He underwent repeat head CT which did not show significant change from the initial CT at [**Hospital1 **] but CTA appeared to show AComm aneurysm. Given the increased lethargy prior to any sedation, increased ICP was suspected and EVD was placed at bedside per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**] while in the ED after obtaining consent from family in person. Past Medical History: 1. HTN 2. CAD - s/p triple bypass in [**2158**] 3. Vertigo 4. BPH s/p TURP in [**2152**] 5. Low back surgery to remove a synovial cyst in [**2154**] Social History: Social Hx: Lives at home with wife. Completely independent in all ADL's including instrumental ADL's. Remote smoking history. Full code and next of [**Doctor First Name **] is his wife, [**Name (NI) **] [**Name (NI) **]. Contact information includes [**Telephone/Fax (1) 89613**]. Family History: Vertigo - no FH of aneurysms or ICH. Physical Exam: On Admission: PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 3 O: T:96.9 BP: 85/44 HR:58 R: 17 O2Sats: 100% face mask Gen: Intubated and sedated. HEENT: Pupils: 5->3mm Lungs: Clear. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Dorsalis pedis palpable and no edema. Neuro: Mental status: Intubated and sedated - reportedly opened eyes to noxious stim prior to sedation per ED. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5 to 3mm bilaterally. III, IV, VI: Passes midline to doll's eye maneuver V, VII: Face appears symmetric. Motor: Normal bulk and tone bilaterally. No abnormal movements. Spontaneously moves all four limbs without asymmetry with resistance but unable to assess individual muscle groups. Sensation: Intact to pain. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 Toes upgoing bilaterally At Discharge: AO x 2, disoriented to time, follows simple commands. Motor is full, sensory is intact. Face is symmetric Gen: pleasant and cooperative HEENT: Pupils: 5->3mm Lungs: Clear. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Dorsalis pedis palpable and no edema. Pertinent Results: CT/CTA [**2163-3-22**]: Bilateral SAH but no evidence of IPH or IVH. Likely AComm aneurysm. [**3-23**] CT Head - Interval placement of a right transfrontal ventriculostomy drain, terminating in the atrium of the right lateral ventricle. No evidence of worsening hydrocephalus. Similar amount of moderate bilateral subarachnoid hemorrhage. Small intraventricular hemorrhagic extension, unchanged. CTA/CTP [**2163-3-26**]: IMPRESSION: The patient is status post coiling of an anterior communicating aneurysm, interval placement of ventriculostomy, unchanged intraventricular hemorrhage, interval decrease in the pattern of subarachnoid hemorrhage. Areas of low attenuation are demonstrated in the occipital and left parietal lobe, likely indicating edema, the possibility of PRES or early ischemic changes are considerations, if there is no clinical contraindication, correlation with MRI of the head is recommended. LENIS [**2163-3-27**]: IMPRESSION: 1. No left upper extremity DVT. 2. Mild subcutaneous edema. MRI/MRA Brain [**2163-3-28**]: IMPRESSION: 1. Subacute infarcts involving the bilateral occipital lobes amd right caudate head. Small foci of restricted diffusion in the cerebellar hemispheres may represent infarcts or blood products. 2. Extensive subarachnoid hemorrhage with intraventricular extension. A ventriculostomy catheter is in place. The ventricles are unchanged in size. 3. Regions of mild to moderate luminal narrowing within the cerebral vasculature, similar to the initial examination, likely reflecting underlying atherosclerosis. No definite evidence of vasospasm. 4. Status post coiling of acomm aneurysm. CT Head [**2163-3-30**]: IMPRESSION: 1. Subarachnoid hemorrhage, status post coiling of ACom aneurysm. 2. Hypodensities in the bilateral occipital lobes and right caudate head consistent with evolving infarctions. They correspond to the foci of restricted diffusion demonstrated on the MRI [**2163-3-28**]. There is no definite CT correlate to the small foci of restricted diffusion seen in the left cerebral hemisphere. CTA/P [**2163-3-31**]: CTA HEAD: The major branches of the carotid and vertebral arteries are of normal caliber without aneurysm, stenosis, obstruction or vasospasm. Anterior communicating artery aneurysm coils are seen. CT PERFUSION: There is a tiny focus of increased mean transit time and decreased blood volume in the left occipital lobe, corresponding to the known infarction. There is no other region of ischemia or large territorial infarction seen on CT perfusion. IMPRESSION: 1. Subarachnoid hemorrhage status post coiling of ACOM aneurysm. Minimal residual subarachnoid and intraventricular blood. 2. No evidence of vasospasm. 3. No evidence of acute ischemia on perfusion imaging. CXR [**2163-3-31**] The Dobbhoff tube tip is in the stomach. The heart size is top normal, stable, unchanged since the prior study obtained the same day earlier. The patient is in interstitial pulmonary edema, moderate in severity, accompanied by bilateral pleural effusions and bibasal atelectasis. CT head [**2163-4-2**] 1. Status post coiling of ACom aneurysm, and placement of right ventricular drain, with no change in ventricular size to suggest development of hydrocephalus. 2. Decreased conspicuity of subarachnoid blood at the vertex bilaterally, as well as intraventricular blood in the bilateral occipital horns, compatible with expected evolution of blood products. No new hemorrhage is identified. 3. Hypodensity in the bilateral occipital lobes and right caudate head, compatible with evolving infarcts. No acute territorial infarct is identified. CT head [**2163-4-4**] 1. Stable ventricular size following EVD clamping. 2. ACOM coil pack and diffuse subarachnoid hemorrhage. 3. Old bilateral parietal watershed infarcts. 4. Paranasal sinus disease. Brief Hospital Course: Mr. [**Known lastname **] was was admitted to the ICU on the neurosurgery service on [**2163-3-22**] by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. A right EVD was place without incident. Post procedure CT head demonstrated good placement and was left at 15cmH2O. He was brought to angiogram and underwent coling of Anterior communicating artery coiling. On [**3-23**], he was extubated without incident. He tolerated the angiogram without complication. Please review dictated operative report for details. He was transferred to SICU for further management. He became more lethargic on [**3-26**] a CTA no spasm or profusion mismatch was noted however with bilateral cerebellar infarcts. Initial TCDs for [**Date range (1) 21390**] were normal. On [**3-27**] he was noted to have a diffuse rash on back. Therefore, keppra was started and then the dilantin was stopped after the second dose. On [**3-28**] and [**3-29**] he remained quite lethargic but was following simple commands with much probing. Tubes feeding have been started. A CT on [**3-30**] showed no evidence of vasospasm. On [**4-19**] the patient underwent another CTA and transcranial dopplers that were negative for spasm. Fluid hydration in addition to tube feeds was discontinued. A downward trend in HCT was noted. He had been tranfused 2 units over two days. Stool guiacs were noted to be positive. Serial HCT checks were initiated. Hct was 28 on [**4-2**]. On [**4-2**] his EVD drain was clamped but needed to be reopened. A second attempt was made on [**4-3**], which he appeared to tolerate, and his CT was stable. On [**4-5**] his EVD was clamped. CSF was sent for panel, this showed no growth. There was no drainage at his EVD site on [**4-6**] and CT head was stable. EVD was removed at the bedside. He had a video swallow exam. He had a slow intake, but no aspiration. Calorie counts were initiated and the dobhoff was left for nutrition. He was advanced to thin liquids and soft solids. His hematocrits were followed as there was a drop to 23 on [**4-7**] then returned to 29 on [**4-18**] iron had been started. Neurologically he was making slow progress each day, slightly more interactive able to follow two step commands. Medications on Admission: None Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or T>100.4. 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours). 4. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: SAH ACOMM Aneurysm Discharge Condition: Mental Status: Confused - sometimes. Hard of hearing on the Left Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. 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, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? 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 [**7-3**] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 6 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2163-4-11**] Name: [**Known lastname 12459**],[**Known firstname **] Unit No: [**Numeric Identifier 14191**] Admission Date: [**2163-3-22**] Discharge Date: [**2163-4-11**] Date of Birth: [**2078-7-12**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Dilantin Attending:[**First Name3 (LF) 40**] Addendum: See amended areas. Follow up and d/c instruction updated. Meds updated Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or T>100.4. 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: SAH ACOMM Aneurysm Anemia requiring transfusion Post-op Delirium Dysphagia Malnutrition Hydrocephalus Discharge Condition: Mental Status: Confused - sometimes. Hard of hearing on the Left Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. 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 shower ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 1702**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need MRI/MRA of the brain with and without gadolinium contrast. [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2163-4-11**]

[ "V45.81", "401.9", "584.9", "430", "285.1", "293.9", "331.4", "263.9", "434.91", "414.00" ]

icd9cm

[ [ [] ] ]

[ "02.39", "96.04", "96.6", "96.71", "39.75", "88.41" ]

icd9pcs

[ [ [] ] ]

15105, 15148

7634, 9865

306, 378

15294, 15294

3780, 7611

16830, 17217

2551, 2589

14213, 15082

15169, 15273

9891, 9898

15500, 16807

2633, 2894

3501, 3761

246, 268

406, 2062

3015, 3486

2618, 2618

15309, 15476

2084, 2234

2250, 2535

24,042

172,576

49363

Discharge summary

report

Admission Date: [**2198-3-16**] Discharge Date: [**2198-3-21**] Service: C-MEDICINE HISTORY OF PRESENT ILLNESS: This is an 82 year old female with a history of coronary artery disease, status post coronary artery bypass graft who presented with on and off chest pain radiating to the back times two weeks. She had been getting relief with sublingual Nitroglycerin up to the date of admission. The chest pain lasted for five minutes at rest or with activity. The patient denied any nausea, vomiting,diaphoresis or shortness of breath. Chest pain is not similar to her prior chest pain when she had coronary artery bypass graft. In the Emergency Department, the patient was hypertensive to 210/100. CK and troponin were both flat. The patient received Aspirin, Lopressor 5 mg intravenously times two and Heparin and became chest pain free. Electrocardiogram showed normal sinus rhythm with new 1.0 to 2.0 millimeter ST segment elevation in V1 and V2, T wave inversion in leads I and aVL and there is a question of 1.[**Street Address(2) 2811**] depression in leads II, III and aVF. Chest x-ray was done and shows no cardiopulmonary process. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft in [**2184**], after failed left anterior descending percutaneous transluminal coronary angioplasty with dissection. 2. Renal carcinoma, status post partial nephrectomy in [**2191**]. 3. Colon polyp. 4. Hyperlipidemia. 5. Diabetes mellitus. 6. Mitral regurgitation 2+ in [**2197-5-21**], on echocardiogram. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient quit smoking fourteen years ago and no use of alcohol. The patient lives alone. Rarely needs to [**Known lastname **] with a cane. PHYSICAL EXAMINATION: On admission, the patient is afebrile, heart rate 75, blood pressure 140/80, respiratory rate 20, oxygen saturation 97% in room air. The patient is a pleasant elderly lady lying in bed, breathing comfortably, in no apparent distress. Sclera anicteric. Mucous membranes are moist. The oropharynx is clear. The neck is supple with no lymphadenopathy. No jugular venous distention. No thyromegaly. The lungs are clear to auscultation bilaterally. The heart is regular rate and rhythm, S1 and S2, no murmurs. The belly is soft, obese, nontender, nondistended with positive bowel sounds. Extremities have no cyanosis, clubbing or edema. The patient is alert and oriented. Cranial nerves II through XII are intact. The patient has full muscle strength throughout the upper and lower extremities. Sensory is intact to light touch. HOSPITAL COURSE: 1. Labile blood pressure - On the day of admission, the patient was placed on Nitroglycerin drip and her blood pressure consistently elevated and only slightly dropped to 180s. The patient was also given Hydralazine every four hours as needed. On the night of admission, the patient had episode of hypotension. Her blood pressure dropped down to 70s and Nitroglycerin drip was discontinued. The patient was placed on Lopressor. The patient's blood pressure remained stable on the day after admission, however, by noon, the patient's blood pressure was elevated again and we had to restart Nitroglycerin drip on her and also increase her Lopressor dose. The patient's blood pressure plummeted again to 70s and she became hypoxic. The patient was placed on nonrebreather oxygen and the patient's oxygen saturation only returned to 80s. Arterial blood gas was drawn showing pH of 7.21, CO2 of 60 and O2 of 90. The patient was transferred to the CCU. While in the CCU, the patient received 80 mg intravenous Lasix and Nitroglycerin drip and also had a head CT for having some change in mental status and delirium. CT was negative and Heparin was stopped. The patient was intubated for hypercarbia and hypoxia on [**2198-3-17**]. The patient was also treated with Dopamine for hypotension episode while on Nitroglycerin drip. The patient had another episode of hypotension and was briefly treated with intravenous Nitride. The patient was extubated on [**2198-3-18**], and was started on beta blocker and ace inhibitor. The patient was also started on Levofloxacin for question of pneumonia in the right middle lobe and also she spiked fever to 101.8. The patient had good response to intravenous Lasix on [**2198-3-18**], and was transferred back to the floor on [**2198-3-19**], after her blood pressure became more stable. The patient was continued on both beta blocker and ace inhibitor and her blood pressure remained stable until the time of discharge. 2. Coronary artery disease - Most likely she had subendocardial ischemia with possible saphenous vein graft/posterior descending artery region. The patient had stress MIBI done that showed there is a severe fixed apical perfusion defect unchanged from prior study. Ejection fraction was 37%. The patient was ruled out for myocardial infarction by enzymes. We continued the patient on Aspirin, beta blocker, Univasc and increased the Lipitor to 40 mg once daily. 3. Chest pain - Originally, the patient reported chest pain radiating to the back. Original concern was for dissection but the patient had negative CTA done and also a negative transesophageal echocardiogram. Her chest pain is most likely consistent with ischemia in the setting of severe hypertension. With resolution of her hypertension, the patient remained chest pain free throughout the rest of her hospital stay. 4. Diabetes mellitus - The patient's blood sugar remained stable throughout her hospital stay. We held Metformin given that she had CTA and we continued her with Glyburide and covered her with regular insulin sliding scale. DISCHARGE STATUS: To home with VNA services. CONDITION ON DISCHARGE: Stable, taking p.o., afebrile, blood pressure well controlled. DISCHARGE DIAGNOSES: 1. Hypertension. 2. Coronary artery disease. 3. Hypotension. 4. Diabetes mellitus. MEDICATIONS ON DISCHARGE: 1. Levothyroxine 25 mcg take 0.5 tablet p.o. once daily. 2. Aspirin 325 mg p.o. once daily. 3. Lipitor 40 mg p.o. once daily. 4. Glyburide 10 mg p.o. twice a day. 5. Atenolol 50 mg p.o. once daily. 6. Univasc 15 mg p.o. once daily. 7. Glucophage 1000 mg p.o. twice a day. FOLLOW-UP PLANS: The patient will follow-up with Dr. [**First Name (STitle) 572**] [**2198-3-29**], at 10:30 a.m. The patient will also be following up with gastroenterologist [**2198-3-29**], at 10:30 a.m. The patient will follow-up with Dr. [**First Name (STitle) **], her cardiologist, on [**2198-4-27**], at 11:40 a.m. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-269 Dictated By:[**Name8 (MD) 18513**] MEDQUIST36 D: [**2198-3-22**] 15:44 T: [**2198-3-24**] 08:12 JOB#: [**Job Number 103393**]

[ "411.89", "428.30", "428.0", "518.81", "401.0", "514", "458.29", "250.00", "E942.6" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "88.72" ]

icd9pcs

[ [ [] ] ]

5894, 5982

6008, 6288

2646, 5784

1789, 2629

6306, 6831

123, 1160

1182, 1603

1620, 1766

5809, 5873

67,877

106,665

6895

Discharge summary

report

Admission Date: [**2128-9-25**] Discharge Date: [**2128-10-2**] Date of Birth: [**2074-9-9**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 4393**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation lumbar puncture bronchoscopy History of Present Illness: Mr. [**Known lastname 25996**] is a 54M who presented to [**Hospital1 18**] overnight on [**2128-9-25**] w/4d of increasing confusion. [**Name (NI) 1094**] mother reported he was seen by PCP 2d prior to admission for new cough and sore throat and was given a z-pack (bronchitis vs COPD flare). The following day he reportedly was found unconsious after hitting his head on a table and his roommate sent him to [**Hospital3 **]. There, he was found to have RLL PNA, ARF w/Cr 2.0 from 0.8, hyperkalemia to 6.9 without EKG changes. Etoh level negative, but tricyclics, benzos, opiates +. He received levafloxacin, but then left AMA (no kayexelate given). Roommate and mother thought he was still very confused at home and he also complained of suprapubic pain and diarrhea, they and convinced him to come to [**Hospital1 18**] (where he is seen in the liver center by Dr. [**Last Name (STitle) 497**]. . Of note, he last saw Dr. [**Last Name (STitle) 497**] about 3 weeks ago. At that time he was considered to be sufficiently stable as to be under consideration for HCV eradication therapy with interferon, ribavirin and a protease inhibitor. He did report some BRBPR but no hematemesis, melena, abd pain or distension; grade I esophageal varices on EGD in [**2128-7-7**]. He had a palpable nontender liver and no ascites, no asterixis. His mental health counselor reported to Dr. [**Last Name (STitle) 497**] that he was clean, no alcohol or drug use. However, acording to family, the patient has been drinking cough syrup and using pills: non-prescription oxycontin, valium and depakote as well as a "koolaid concoction" that roommate suspects is methadone bc it "smells like bubblegum." No alcohol use witnessed heroin use was also suspected. . When he arrived in the [**Hospital1 18**] ED [**9-25**] he was found to be confused and lethargic with asterixis and icteric sclera. Belly was soft mildly distended with diffuse pain on palpation. Lungs had crackles and wheezes throughout. VS were T 98.8 HR 97 BP 126/74 RR 16 O2 98/RA. He had WBC 14.1 with a left shift. AST was 1358 and ALT 527. He was given 1 dose levaquin, 500 cc NS bolus and nebs. RUQ US showed nephrolithiasis without obstruction, no ascites, no concerning liver parenchymal changes and a patent portal vein. Could not assess kidneys [**3-10**] patient's lack of cooperation. CXR showed "increased interstitial edema-like pattern, volume overload (noncardiogenic edema) favored, although atypical infection may result in a similar appearance." Right hemidiaphragm was elevated compared to prior in [**Month (only) 116**]. Head CT showed unchanged left thalamic lacunar infarct. . On the floor, the patient was hydrated and put on CIWA [**Doctor Last Name **] 8 to 23. He was given ativan 0.5 mg IV x 2 and 3 doses of diazepam 2.5 mg, 3 doses of lactulose, and his rifaximan. . The afternoon of [**9-26**], the patient was noted to be more tachypneic, breathing 24-28 resp per minute, satting 98% on RA, and he was not oriented. He was minimally able to follow commands and appeared diaphoretic and tachycardic. ABG was performed on 2 L nc 7.55/23/59/21. Given his nongap respiratory alkalosis, Toxicology was called, who did not think he had aspirin toxicity. MICU was called for eval given tachypnea. Past Medical History: 1. Hepatitis C (Genotype 1) c/b Cirrhosis 2. Cirrhosis (Alcohol and HCV) 3. COPD (believes he was diagnosed approximately in [**2126**]) 4. s/p Right Shoulder Surgery (patient unsure of exact cause) Family History: Father died from alcohol cirrhosis. No other family history of liver disorders. Physical Exam: ADMISSION EXAM: ADMISSION EXAM LIMITED BY PATIENT AGITATION VS: 97.6 152/79 108 22 96/RA GEN: thrashing around in bed naked, sitting in feces, in soft wrist restraints, flushed, does not make eye contact, answers questions yes or no, ++fetor hepaticus HEENT: NCAT PERRL EOMI ABD: soft and nondistended EXT: no edema NEURO: nonverbal except yes/no, moves all 4 extremities spontaneously, EOMI . ICU DISCHARGE EXAM: VS: 97.7 115/64 70 20 96%RA GENERAL: Chronically ill-appearing man in NAD, comfortable, tearful at times. No asterixis. HEENT: NC/AT, R PRRL, L pupil non-reactive, EOMI, mild icterus, MM dry, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding, no fluid shift. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. Multiple tattoos. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-10**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric. . DISCHARGE EXAM: VS: 98.1 114/67 82 20 99/RA GENERAL: chronically ill-appearing NAD dressed and ready to leave HEENT: NC/AT, R PRRL, L pupil non-reactive, EOMI, mild icterus, MM dry, OP clear. No cervical LAD. NECK: Supple no JVD HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat no r/r/w. ABDOMEN: Soft/NT/ND, no HSM, no rebound/guarding, no fluid shift. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses, R upper arm no swelling but firm nontender palpable cord SKIN: Multiple tattoos, spider angiomata NEURO: Awake, A&Ox3, cannot spell WORLD forward or backward, CNs II-XII grossly intact, muscle strength 5/5 throughout, gait normal, no asterixis. Pertinent Results: ADMISSION LABS: [**2128-9-25**] 12:35PM BLOOD WBC-14.1*# RBC-4.08* Hgb-14.2 Hct-39.6* MCV-97 MCH-34.8* MCHC-35.8* RDW-15.6* Plt Ct-78* [**2128-9-25**] 12:35PM BLOOD Neuts-81* Bands-0 Lymphs-11* Monos-5 Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2128-9-25**] 12:35PM BLOOD PT-15.8* PTT-34.4 INR(PT)-1.4* [**2128-9-25**] 12:35PM BLOOD Glucose-108* UreaN-64* Creat-2.0*# Na-135 K-5.1 Cl-103 HCO3-22 AnGap-15 [**2128-9-25**] 12:35PM BLOOD ALT-527* AST-1368* AlkPhos-106 TotBili-4.0* DirBili-2.9* IndBili-1.1 [**2128-9-25**] 12:35PM BLOOD Lipase-45 [**2128-9-25**] 12:35PM BLOOD Albumin-3.4* Calcium-8.9 Phos-2.5* Mg-2.1 [**2128-9-25**] 12:35PM BLOOD Ammonia-27 [**2128-9-26**] 02:50PM BLOOD TSH-3.1 [**2128-9-26**] 02:50PM BLOOD Valproa-<3* [**2128-9-26**] 02:50PM BLOOD CK-MB-22* MB Indx-0.7 cTropnT-0.05* proBNP-5217* [**2128-9-25**] 12:48PM BLOOD Lactate-2.1* K-5.0 . [**Month/Day/Year **] SCREENS: [**2128-9-25**] 12:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2128-9-25**] 02:56PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG . SERIAL ABG: [**2128-9-26**] 01:21PM BLOOD Type-[**Last Name (un) **] pH-7.53* Comment-PERIPHERAL [**2128-9-26**] 03:09PM BLOOD Type-ART pO2-59* pCO2-23* pH-7.55* calTCO2-21 Base XS-0 [**2128-9-26**] 07:44PM BLOOD Type-ART pO2-67* pCO2-23* pH-7.54* calTCO2-20* Base XS-0 [**2128-9-27**] 02:22AM BLOOD Type-ART Rates-14/6 Tidal V-500 PEEP-5 FiO2-50 pO2-119* pCO2-31* pH-7.46* calTCO2-23 Base XS-0 -ASSIST/CON INTUBATED [**2128-9-26**] 11:07PM BAL FLUID Polys-58* Lymphs-1* Monos-2* Macro-1* Other-38* . URINALYSIS [**2128-9-25**] 01:45PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2128-9-25**] 01:45PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 [**2128-9-25**] 03:08PM URINE Hours-RANDOM UreaN-1297 Creat-134 Na-<10 K-38 Cl-11 . CSF ANALYSIS [**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-5240* Polys-91 Lymphs-9 Monos-0 [**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-2745* Polys-55 Lymphs-45 Monos-0 [**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-76 [**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) HSV PCR-NEGATIVE . DISCHARGE LABS: [**2128-10-2**] 05:40AM BLOOD WBC-4.5 RBC-3.32* Hgb-12.0* Hct-34.4* MCV-104* MCH-36.2* MCHC-35.0 RDW-15.2 Plt Ct-57* [**2128-10-2**] 01:10PM BLOOD PT-15.3* PTT-36.8* INR(PT)-1.3* [**2128-10-2**] 05:40AM BLOOD Glucose-180* UreaN-19 Creat-1.0 Na-137 K-3.5 Cl-110* HCO3-21* AnGap-10 [**2128-10-2**] 05:40AM BLOOD ALT-136* AST-140* AlkPhos-127 TotBili-1.7* [**2128-10-2**] 05:40AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.1 Mg-1.6 [**2128-10-2**] 05:40AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.1 Mg-1.6 . MICRO: CMV IGG NEG IGM NEG MYCOPLASMA IGG POS IGM NEG LEGIONELLA NEG RESPIRATORY VIRAL SCREEN NEG BAL CULTURE NEG URINE CULTURE NEG BLOOD CULTURES:1 OF 8 BOTTLES COAG-NEG STAPH (LIKELY CONTAMINANT) CSF CRYPTOCOCCAL ANTIGEN NEG CSF GRAM STAIN, CULTURES NEG (INCLUDING NEG FUNGAL CX) STOOL CDIFF NEG MRSA SWAB NEG VRE SWAB NEG . IMAGING: ADMISSION CXR: FINDINGS: There are low lung volumes, and there is elevation of the right hemidiaphragm. There is increased opacity in the bilateral lungs with a somewhat reticular pattern. The heart size is normal, and the mediastinal contours are unremarkable. There is no effusion or pneumothorax. IMPRESSION: Increased interstitial edema-like pattern. Volume overload (noncardiogenic edema) favored, although atypical infection may result [**Female First Name (un) **] similar appearance. . ADMISSION CT HEAD: FINDINGS: While somewhat limited by motion artifact, there is no evidence of hemorrhage. There is no edema or mass effect. The [**Doctor Last Name 352**]-white matter differentiation is preserved, although an old left thalamic lacunar infarct is unchanged from prior study. The ventricles and sulci appear unremarkable in size. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No acute intracranial process. 2. Unchanged left thalamic lacunar infarct. . ADMISSION RUQ US: FINDINGS: The liver demonstrates no focal lesion or intrahepatic biliary dilatation. The portal vein is patent with directionally appropriate flow. The gallbladder is distended with layering echogenic material compatible sludge but no pericholecystic fluid or wall edema. The common bile duct measures 6 mm in caliber. The right kidney measures 10.5 cm in its long axis and shows no hydronephrosis. The aorta is of normal caliber along its course. Views of the pancreatic head and body show no abnormality, but the tail is obscured by overlying bowel gas. No ascites was seen. . ECHO: LEFT ATRIUM: Normal LA and RA cavity sizes. RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated. Cannot assess RA pressure. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC [**Doctor Last Name **]: Normal aortic [**Doctor Last Name **] leaflets (3). No AS. No AR. MITRAL [**Doctor Last Name **]: Mildly thickened mitral [**Doctor Last Name **] leaflets. No MVP. Mild mitral annular calcification. Trivial MR. [**First Name (Titles) 24998**] [**Last Name (Titles) **]: Normal [**Last Name (Titles) **] [**Last Name (Titles) **] leaflets with trivial TR. Mild PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic [**Last Name (Titles) **] leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral [**Last Name (Titles) **] leaflets are mildly thickened. There is no mitral [**Last Name (Titles) **] prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild pulmonary artery systolic hypertension. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. . LUE LENI: One of the two brachial veins does not compress and no vascular flow is identified within this vessel on color Doppler imaging. Normal flow, compression, and augmentation is seen in the remainder of the vessels of the left arm. IMPRESSION: Deep vein thrombosis seen within one of the two brachial veins in the left upper arm. Brief Hospital Course: 54M with ETOH/HCV cirrhosis, recent cough and progressively declining mental status in setting of suspected hepatic encephalopathy and toxin/drug ingestion transfered from liver service to MICU on HD1 for worsening tachypnea after receiving benzos for presumed ETOH/benzo withdrawal. . #Hepatic encephalopathy. On arrival, the patient was started on standing lactulose 30 mg QID + rifaximin 550 [**Hospital1 **] for presumed hepatic encephalopathy. On the floor and in the ICU he received standing lactulose 30 ml QID and rifaximin 550 [**Hospital1 **] and had frequent BMs with slow symptomatic improvement. However, hepatic encephalopathy was thought to be only part of the explanation for his dramatically altered mental status on presentation, and the underlying reason for acute HE remained undetermined despite thorough workup. RUQ ultrasound showed no obstruction or biliary inflammation. Stools were guaiac negative and Hct was stable. Infection workup was negative. At time of transfer out of the ICU on HD6, he was hypoactive but oriented and appropriate. On the floor his mental status further cleared with additional doses of lactulose. He was discharged on lactulose (a new medication for him) and rifaximin (as before). . # Suspected drug ingestion: Pt presented to hospital with significantly altered mental status. He was non-verbal, naked, and not redirectable. Drug ingestion was suspected because the patient's roommate reported recent use of unknown substances; this was later corroborated by a close friend/neighbor. Initial [**Name2 (NI) **] screen positive for benzos, opiates, and tricyclics. Patient initially received benzodiazepines per CIWA for suspected benzodiazepine withdrawal. On HD2 he became progressively more agitated and tachypneic, so he was transferred to the ICU. In the ICU his benzodiazepine regimen was increased in dose and frequency with acute worsening of his encephalopathy. Benzos were stopped, & pt was given 5 mg IV haldol with no response followed by 10 mg IV haldol which caused sedation. Toxicology was consulted because patient's pre-admission drug history was cryptic, primary respiratory alkalosis was difficult to explain, and agitated delirium continued despite lactulose for hepatic encephalopathy. Patient later denied any ingestions beyond the valium and seroquel he is prescribed. In addition, it should be noted that his ETOH level was negative on admission. Patient does have a history of alcohol and substance abuse but had been clean as recently as 1 month ago per therapist report to Dr. [**Last Name (STitle) 497**] (see OMR note). Will require further outpatient follow-up. . # Occult infection/intubation: In the ICU, in the context of unexplained worsening mental status and respiratory alkalosis, infectious workup was pursued. The patient did have atypical infiltrates on CXR that could have been atypical pneumonia versus interstitial edema. He was intubated in order to perform LP and bronchoscopy with BAL. Started on Levofloxacin/Ceftriaxone to cover community acquired atypical pneumonia and acyclovir to cover HSV encephalitis. His BAL did not grow any organisms and his CSF was negative for HSV or bacterial infection so antibiotics were narrowed to levofloxacin. His vent settings remained minimal with good O2 saturations and ventilation. He was started on dexmetomidine and the following day was successfully extubated and transferred to the floor. On the floor he completed a 7-day course antibiotics. Blood cultures sent from the ICU only grew 1 bottle + for staph, suspected to be a contaminant. . # Tachypnea: Patient became tachypneic prior to ICU transfer. Differential diagnosis included agitation/withdrawal vs SIRS/infection vs pain vs splinting. However, the patient became worse with administration of benzodiazepines, making withdrawal less likely. CMV serologies, legionella antigen, BAL gram stain and culture and mycoplasma antibodies were negative. BNP was elevated and a source of infection was never isolated, making the pulmonary edema more likely. He was intubated not for hypoxia, but rather for altered mental status and the need to obtain studies for infectious workup (LP, BAL). Noted to have a elevated right hemidiaphragm, but this was not thought to be contributing to his tachypnea as he was not noted to be hypercarbic on ABG (decreased ventilation). The presumed reason for his tachypnea was toxin ingestion, as above. Respiratory status returned to [**Location 213**] after ICU discharge -- he was breathing comfortably with O2 sat >95 while walking around the floor. . # Elevated CK: Elevated on admission, unclear etiology. Pt reportedly had been complaining of leg pain prior to admission. Also had recent fall. Cardiac enzymes were slightly elevated with trop 0.05 and CK MB 22, but the cardiac index was not elevated at 0.7. His enzymes trended down with IV fluids in the ICU. . #Acute-on-chronic liver failure: The patients LFTs were noted to be elevated from one month prior. RUQ US showed no obstruction, a patent portal vein & no ascites. Tylenol and ETOH levels negative. He was continued on rifaximin and lactulose as above. . #Acute renal failure: On admision, Cr 2.0 from baseline 0.8. FeNa <1%, prerenal. Cr improved with IVF. . # Depression: Once patient extubated, he noted he did not wish to pursue treatment for his hepatitis C and wanted to "be with his daughter" (who had passed away several years earlier from a genetic disorder). Psychiatry evaluated the patient (in the context of capacity evaluation, below) and deemed him not to be depressed but to be suffering from prolonged (non-pathologic) grief. He does see an outpatient therapist and psychopharmacologist and should continue to meet with them as an outpatient. . #LUE DVT. The patient reported L arm pain and swelling ON HD5. LUE US showed a brachial vein DVT. Anticoagulated on a heparin gtt while inpatient. At time of discharge, after a careful evaluation of the risks and benefits of anticoagulation, we felt that the combination of fall risk, poor adherence to outpatient care, and concominant drug use given positive urinary opiates on admission and past indiscretions were contraindications to continuing outpatient anticoagulation for the patient's brachial vein DVT with either lovenox or coumadin. This has been communicated to the patient's primary hepatology team and they can consider further evaluation with repeat ultrasound or consider initiating therapy as indicated. . # Capacity: Given the patient's altered mental status throughout this hospitalization and worsening symptoms with benzodiazepines in the ICU, benzodiazepimes and opiates were avoided. On HD7 the patient tried to leave AMA because he did not understand why he was refused valium, opiates and seroquel, which he takes at home. He did not agree or understand when explained that these were held due to concern over very recent, incompletely-explained mental status changes. He threatened to leave AMA. Psych eval was obtained. They felt the patient was still too encephalopathic to understand his medical needs but felt it was safe to give him seroquel to promote sleep (he hadn't slept for 72 hours); he agreed to stay one more day for further treatment of his medical issues as long as he could have seroquel and sleep. He was discharged the following day with instructions to stop taking valium at home. . # Code status: The patient's code status was unclear. His recent discharge paperwork from [**6-16**] documented he was full code but did not "want to be a vegetable." He had not wanted to identify a health care proxy at that time, but made explicit instructions that his mother should not be his HCP. During this admission, the patient's sister told the team she was his HCP and that pt was DNI. Per discussions with the sister, she had previously been the patient's HCP, however this changed multiple times over the years. She called patient's lawyer who notified ICU team that the patient in fact did not have a HCP in writing. Per discussion with the patient's Primary care doctor, the patient requested his medical information not be shared with the sister. SW consulted and team instructed to proceed with patient being full code (per most recent documentation). . Medications on Admission: ALBUTEROL 90 1-2 PUFFS q6H prn sob DIAZEPAM 2.5 MG QD FLUTICASONE/SALMETEROL 250-50 inh x1 QD QUETIAPINE 50 MG QHS RIFAXIMIN 550 MG [**Hospital1 **] Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Please take as needed for goal [**4-9**] bowel movements/day. Disp:*1 Liter bottle* Refills:*2* 3. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day) as needed for agitation, insomnia. Disp:*60 Tablet(s)* Refills:*0* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-8**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) inhalation Inhalation once a day. Discharge Disposition: Home Discharge Diagnosis: Hepatic Encephalopathy Discharge Condition: Mental Status: A&O x 3. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname 25996**] it was a pleasure taking care of you. You were admitted due to concern for confusion and infection. You were treated with antibiotics as well as medications to treat your confusion from worsening liver disease. While hospitalized you were found to have a large blood clot (DVT) in your left arm. You were treated with heparin, a medication that stops the clot from spreading. At time of discharge the clot was stable and it was decided to discontinue your medications given your risk for falling when leaving the hospital. At the time you left the hospital we thought your thinking was back to baseline - you were no longer confused. We thought you would be safe to go home, and to make good decisions about staying away from alcohol and drugs. It is critically important for you to continue seeing your therapist at [**Hospital1 **] as well as to continue to abstain from substance use/drugs and alcohol. . Changes to your medications: . TO TREAT YOUR ANXIETY AND INSOMNIA: 1. STOP TAKING VALIUM - THIS MEDICATION [**Month (only) **] MAKE YOU CONFUSED 2. TAKE SEROQUEL AT A DOSE OF 50 mg UP TO 4 TIMES PER DAY AS NEEDED FOR ANXIETY AND INSOMNIA. . TO TREAT CONFUSION THAT IS CAUSED BY LIVER DISEASE: 1. CONTINUE TAKING Rifaximin 550mg. One tablet twice daily every day. 2. START TAKING Lactulose 30ml FOUR TIMES PER DAY. CALL YOUR DOCTOR AND TAKE MORE LACTULOSE IF YOU HAVE < 3 BOWEL MOVEMENTS A DAY. . To treat blood clot: 1. No medications needed, you will follow up with Dr. [**Last Name (STitle) 497**] in two weeks. . Again it was a pleasure taking care of you. Please contact the liver center or your primary care doctor with any questions or concerns. Followup Instructions: Please follow-up in the Liver Center with Dr [**Last Name (STitle) 497**] in [**3-11**] weeks. Contact the Liver Clinic to set up an appointment: . [**Hospital1 18**] LIVER CENTER [**Hospital Unit Name **] [**Location (un) **] [**Doctor First Name **], [**Location (un) **] [**Telephone/Fax (1) 2422**] . Please also see your therapist at [**Hospital1 **] within the next week. Call him to set up an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

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icd9cm

[ [ [] ] ]

[ "03.31", "96.04", "33.24", "96.71" ]

icd9pcs

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21658, 21664

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290, 331

21731, 21731

5763, 5763

23593, 24118

3884, 3965

20966, 21635

21685, 21710

20793, 20943

21871, 22817

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228, 252

359, 3645

9358, 12468

5779, 7994

21746, 21847

3667, 3868

28,666

151,351

19467+57053

Discharge summary

report+addendum

Admission Date: [**2129-11-1**] Discharge Date: [**2129-11-23**] Date of Birth: [**2078-11-10**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7141**] Chief Complaint: probable ovarian carcinoma, pancreatic pseudocyst Major Surgical or Invasive Procedure: For procedures completed from the dates of [**11-1**] to [**2129-11-21**], refer to Dr. [**First Name (STitle) 1022**] of Gynecologic Oncology and Dr. [**Last Name (STitle) 52874**] [**Name (STitle) **] of Pulmonary Medicine; No major surgical or invasive procedures were done while I was responsible for her care ([**2129-11-21**] to [**2129-11-23**]) History of Present Illness: As written on admission by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: The patient is a 50-year-old G1, P1, who was recently admitted three times to [**Hospital1 18**] with increasing abdominal distention, early satiety, and shortness of breath. She had a CT on [**2129-10-24**], which revealed a large amount of ascites. There was omental caking. There were low attenuation capsular lesions along the right lobe of the liver consistent with liver surface implants. There was a large cystic lesion with some internal septations in the region of the pancreas consistent with a large pancreatic pseudocyst, measuring 13.9 cm in largest dimension. Gastric varices were identified. There were multiple soft tissue masses or calcifications within the uterus consistent with fibroids. The right adnexa had an 8 cm soft tissue mass. There was no evidence of bowel obstruction. These findings were felt to be most consistent with ovarian carcinoma. She had a CA-125, which was 160 and a CEA, which was 6.5. The patient was discharged after initial evaluation, but has been readmitted twice with increased symptomatic ascites, and ahs undergone two therapeutic paracenteses with good effect. She states that she has been tolerating a regular diet and having bowel movements and urinating without difficulty. Past Medical History: ObHx: -Preterm vaginal delivery twins GynHx: -LMP [**2129-10-8**]. Has h/o menorrhagia secondary to uterine fibroids. Normal paps per pt. -Uterine fibroids. [**2125**] U/S showed multiple large uterine fibroids, largest 11.5 x 10.5 x 10 cm. Ovaries were not visualized. s/p uterine artery embolization [**2127**] @ [**Hospital1 112**]. PMH: -Pancreatic pseudocyst. Traumatic in origin per pt after a fall. Pt thinks she had drainage of fluid 2 years ago @[**Hospital1 2025**] which excluded malignancy. PSH: -Uterine artery embolization [**2127**] Social History: Pt is originally from [**Hospital1 46**]. Has lived in the States for approx 20+ years. Has two daughters. [**Name (NI) **] t/e/d. Family History: Mother-80s, alive and well, had TAH/BSO for fibroids. Father-age 85, alive and well. No FH of breast, ovarian, uterine, cervical, colon CA. Physical Exam: Admission H and P as written by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: Preoperative physical examination: GENERAL APPEARANCE: Well developed, well nourished, and in no acute distress. HEENT: Sclerae are anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. BREASTS: Without masses. ABDOMEN: Severely distended with obvious ascites. Large palpable mass in left upper quadrant. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was normal. Bimanual and rectovaginal examination was limited by the abdominal distention. However, there was a firm mass palpable in the cul-de-sac. The cervix was normal to palpation. The rectum was intrinsically normal. Pertinent Results: [**2129-10-31**] 09:45AM PT-11.8 PTT-28.1 INR(PT)-1.0 [**2129-10-31**] 09:45AM PLT COUNT-687* [**2129-10-31**] 09:45AM WBC-13.8* RBC-4.34 HGB-9.5* HCT-32.4* MCV-75* MCH-21.9* MCHC-29.3* RDW-14.5 [**2129-10-31**] 09:45AM TOT PROT-6.2* ALBUMIN-3.0* GLOBULIN-3.2 CALCIUM-8.4 PHOSPHATE-4.7* MAGNESIUM-2.0 [**2129-10-31**] 09:45AM ALT(SGPT)-12 AST(SGOT)-21 ALK PHOS-70 TOT BILI-0.3 [**2129-10-31**] 09:45AM GLUCOSE-118* UREA N-25* CREAT-0.9 SODIUM-133 POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-25 ANION GAP-17 [**2129-11-1**] 02:30PM freeCa-1.01* [**2129-11-1**] 02:30PM HGB-8.8* calcHCT-26 [**2129-11-1**] 02:30PM GLUCOSE-102 LACTATE-2.2* NA+-130* K+-4.7 CL--100 [**2129-11-1**] 02:30PM TYPE-ART PO2-154* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED [**2129-11-1**] 04:10PM HGB-9.9* calcHCT-30 [**2129-11-1**] 04:10PM HGB-9.9* calcHCT-30 [**2129-11-1**] 04:10PM TYPE-ART PO2-140* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0 [**2129-11-1**] 05:46PM PLT COUNT-488* [**2129-11-1**] 05:46PM WBC-14.7* RBC-4.52 HGB-11.5* HCT-34.7* MCV-77* MCH-25.4*# MCHC-33.1# RDW-15.9* [**2129-11-1**] 05:46PM CALCIUM-7.0* PHOSPHATE-4.1 MAGNESIUM-1.4* [**2129-11-1**] 05:46PM estGFR-Using this [**2129-11-1**] 05:46PM GLUCOSE-148* UREA N-17 CREAT-0.6 SODIUM-132* POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-25 ANION GAP-11 [**2129-11-1**] 09:28PM PLT COUNT-416 [**2129-11-1**] 09:28PM WBC-15.6* RBC-4.38 HGB-10.8* HCT-33.8* MCV-77* MCH-24.7* MCHC-32.0 RDW-16.2* [**2129-11-1**] 09:28PM CALCIUM-6.9* PHOSPHATE-4.3 MAGNESIUM-1.2* [**2129-11-1**] 09:28PM GLUCOSE-118* UREA N-19 CREAT-0.7 SODIUM-133 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-10 Brief Hospital Course: * I was involved in this patient's care only from the dates of [**2129-11-21**] to [**2129-11-23**]. * The following is a summary of the care that I provided: Summary of care provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from [**2129-11-21**] until [**2129-11-23**]: Ms. [**Known lastname 52872**] was transfered out of the medical ICU to my service overnight [**Date range (1) 52875**]. I met her on the AM of [**2129-11-22**]. She was suffering from multi-organ system failure due to end-stage, metastatic ovarian cancer and was actively dying with obtundation, and cheynes-[**Doctor Last Name 6056**] respirations. Per her family's wishes she was "Comfort Measures Only", and was being palliated with an ongoing Dilaudid intravenous drip. Her family remained at her bedside. No changes to her medication regimen were made, with the exception of the addition of a scopolamine patch to dry oral secretions that were noted to be causing some occlusion of her upper airway; this was done for palliation of dyspnea. The palliative care team was following along. She died peacefully early in the am of [**12-3**] at approximately one in the morning. The family declined post-mortem examination. For the details of her hospitalization prior to this time, please refer to DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] of Gynecology Oncology and Dr. [**Last Name (STitle) 52874**] [**Name (STitle) **] of Pulmonary Medicine for her care on the Gynecology Oncology Service and in the Medical Intensive Care Unit, respectively. * The following represents the care provided by the Gynecology Oncology Service from the dates of [**2129-11-1**] until [**2129-11-4**] * The patient was admitted to the gynecologic oncology service on [**2129-11-1**] and underwent an uncomplicated exploratory laparotomy; the details of her surgical procedure are dictated elsewhere. Postoperative course was notbale for the following issues: #) Oliguria: The patient had notable postoperative oliguria thought to be due to intravascular depletion and third-spacing. She received 4L of fluid boluses to maintain adequate urine output on POD#0-1. Hct was stable, and FeNa indicated increased sodium avidity consistent with intravascular volume depletion. On POD#2 her urine output improved and she began to diurese spontaneously. Her Foley catheter was discontinued. #) Hyperkalemia: The patient's potassium was noted to be elevated on POD#[**12-21**]. She was asymptomatic, and her ECG revealed no peaked T waves. The hyperkalemia was presumed due to renal hypoperfusion. It resolved spontaneously. #) Pulmonary emboli: The patient was initially placed on subcutaneous heparin in prophylactic doses, and had both [**Male First Name (un) **] stockings and pneumoboots in place. On POD#[**12-21**], she was noted to undergo an acute oxygen desaturation to the 80s with minimal response to oxygen supplementation. An ABG confirmed hypoxemia. A CTA revealed two pulmonary emboli. The patient was started on a heparin drip. Her oxygen saturation improved, and she remained asymptomatic. #) Fluid overload: The patient received large quantities of IV fluid to maintain end-organ perfusion after her surgery. Her ascited reaccumulated, and she was notably symptomatic on POD#3. She received a single dose of IV Lasix and diuresed appropriately. #) GI: The patient was transferred out of the OR with an NGT in place, with a plan to leave it until POD#4 to decompress her stomach and the pseudocyst. She self-D/C'd the NGT on POD#[**12-21**], and refused to have it replaced. After consultation with general surgery, the NGT was not replaced due to concern about trauma at the suture line. She remained NPO until POD#4. Medications on Admission: Refer to the admission History and Physical from the Gynecology Oncology Service under Dr. [**First Name (STitle) 1022**]. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Metastatic ovarian cancer Discharge Condition: Expired Discharge Instructions: Patient expired Followup Instructions: None Name: [**Known lastname 9830**],[**Known firstname 9831**] Unit No: [**Numeric Identifier 9832**] Admission Date: [**2129-11-1**] Discharge Date: [**2129-11-23**] Date of Birth: [**2078-11-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1015**] Addendum: [**Hospital Unit Name 1863**] Course [**Date range (1) 9833**]: 51 yo F with end stage metastatic ovarian cancer and pancreatic pseudocyst s/p debulking and cyst-gastrostomy, transferred to the ICU with worsening renal function and persistent leukocytosis. Pt was initially treated with fluid boluses and blood transfusions in attempt to maintain intravascular volume and urine output. However, the patient's renal function and overall performance status continued to decline despite best efforts. Further fluids were eventually discontinued in the setting of massive ascites and third spacing with no improvement in her renal function from this intervention. For her leukocytosis, no definite source was ever identified, though there was radiographic evidence of a possible left lower lobe pneumonia. She was treated with broad coverage including vancomycin, levaquin and flagyl. Patient received multiple therapeutic paracentesis in an effort to achieve greater comfort. Patient did receive one dose of palliative chemotherapy, Carboplatin, at her request. In the setting of end-stage ovarian cancer with multi-system organ failure the patient decided to be made comfort measure only and was transferred to the floor for further care. . #:Direction of Care: After discussing with patient her prognosis and options, the patient has decided it best to be made comfort measures only. She was be treated with dilaudid and morphine for pain, and dyspnea, respectively. . # Sepsis/leucocytosis - Afebrile since [**11-9**] however has had elevation in WBC upto 32, now trending down. Patient had been on vanc/levo/flagyl. Large fluid-filled collections in liver not felt to be infectious per radiology consistent with mucinous mets. Left lower lobe infiltrate noted on abd CT concerning for pneumonia. Ascitic fluid gram stain negative. However, did have elevated WBC count to 350 concerning for culture negative neutrocyctic ascities v. spontaneous bacterial peritonitis, both, however, are treated with the same broad spectrum antibiotics. CDiff could not be ruled out in the setting of an ileus. Antibiotics eventually discontinued when patient made CMO. . # Renal Failure - Has been oliguric since [**11-11**] and was been temporarily responsive to IVF boluses. Last set of urine lytes with Feurea 4.4% and urine Na of 14 consistent with prerenal etiology. Renal ultrasound neg for post renal causes. Bladder pressure 17. Worsening Cr despite fluid resuscitation and pRBC transfusion. Because of overwhelming ascites and third-spacing of fluids and the fact that patient continued to make urine at a constant, however minimal rate, fluid boluses were discontinued. Albumin infusions were also administered q6hours for a 24 hour period in an attempt to minimize third spacing of fluid but discontinued when the patient was made CMO. . #: Acute Hematocrit drop - Patient received 2 units pRBC for downward trending HCT. Downward trending HCT suggested that she was losing blood somewhere, likely source being her abdomen given her high RBC count in her paracentesis. Further intervention besides transfusions were not felt to be possible. . # Pulmonary Embolism - Had an upper GI bleed on heparin so gtt discontinued and IVC filter placed on [**11-8**], LENI's negative on that day. Continued SC heparin for prophylaxis for repeat PE. . # Ileus/Vomiting - Likely multifactorial contributed from recent surgery (pseudocyst marsupilization) and narcotics. Also concerning for small bowel obstruction, however, abd CT and KUB did not demonstarte onstruction. Followed clinically with abdominal exam and gyn/gen surgery input. Patient had an NG tube in place for the majority if her stay. However, as she transitioned to CMO, she requested that it be removed, Patient expressed full awareness of consequences and stated that she would still like tube out. Have was started on octreotide to try to limit pancreatic secretions and GI fluid accumulation in hope that she will have less nausea once the tube was pulled. The tube was removed on [**11-20**]. She continued to receive octreotide, zofran and phenergan for control of her nausea. . # Upper GI Bleed: Thought to be secondary to recent surgery and supratherapeutic PTT. Thought to be too high risk for EGD. Followed hematocrit daily, transfused as needed. Continued empiric IV PPI [**Hospital1 **]. . # Hyperbilirubinemia: Followed but no intervention was thought to be possible in setting of massive ascites and liver metastases. . # ONC: followed by GYN ONC. Patient expressed strong desire to explore any options that might be open to her to prolong her life. An inter-disciplinary team meeting was held and the patient requested further treatment. She received one dose of palliative Carboplatin [**11-18**]. Palliative care involved Therapeutic paracentesis were performed for abdominal ascites. . # FEN/GI: - NPO, octreotide, IV PPI [**Hospital1 **]. Patient received TPN until made CMO # Pain: Dilaudid PCA # Code: DNR/DNI CMO Discharge Disposition: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**] Completed by:[**2129-11-23**]

[ "584.9", "183.0", "997.4", "998.11", "276.1", "280.0", "415.11", "198.82", "577.2", "997.5", "560.1", "197.6" ]

icd9cm

[ [ [] ] ]

[ "99.15", "68.39", "54.4", "38.7", "52.4", "65.61", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

15061, 15228

5509, 9280

380, 736

9561, 9571

3819, 5486

9635, 15038

2850, 2992

9453, 9459

9512, 9540

9306, 9430

9595, 9612

3007, 3124

3146, 3800

291, 342

764, 2102

2124, 2682

2698, 2834

54,817

113,965

8924

Discharge summary

report

Admission Date: [**2118-9-19**] Discharge Date: [**2118-9-30**] Date of Birth: [**2057-11-22**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Aortic valve replacement with 19mm St. [**Male First Name (un) 923**] Mechanical valve, mitral valve ring with a 26mm ring, tricuspid valve ring with a 26mm ring, coronary artery bypass grafting times one (saphenous vein graft to posterior descending artery) [**2118-9-20**] History of Present Illness: 60 year old female with complex past medical history who has developed progressive and worsening dyspnea and fatigue. Workup revealed single vessel coronary artery disease, moderate to severe mitral regurgitation, moderate tricuspid regurgitation and mild to moderate aortic insufficiency. A nuclear stress test was performed which did not reveal any perfusion defects or myocardial ischemia. Originally it was planned to manage her medically however she has been severely limited by dyspnea with minimal to no exertion and fatigue which classifies her as a grade [**2-4**] heart failure. Additionally, cardiac cath reveals single vessel Coronary Artery Disease. Given the severity of her symptoms and extent of her disease, she has been referred to Dr. [**Last Name (STitle) **] for surgical management. Past Medical History: - Coronary artery disease - Mitral,aortic and tricuspid regurgitation - Likely rheumatic heart disease - Peripheral vascular disease - Atrial fibrillation on dabigatran/Coumadin. Both stopped [**2118-8-10**] - Hypertension - Diabetes mellitus - Hyperlipidemia - IgA nephropathy s/p DCD kidney transplant in [**2111**], with subsequent CKD - Osteoporosis - Breast CA ~ [**2106**]. No radiation. - Hearing Impaired - Varicose veins with history of venous ulcer - Asthma - Kidney Transplant [**2111**] - Appendectomy - Right thumb surgery - Right Mastectomy Social History: Ms. [**Known lastname 31001**] [**Last Name (Titles) **] tobacco, alcohol or illicit drug use. Family History: Ms. [**Known lastname 31002**] mother died at 71 from myocardial infarction, her father died at 71 from myocardial infarction, and her brother died at 62 from myocardial infarction. Physical Exam: Pulse: 80 AF Resp: 18 O2 sat: 100% B/P Right: R Mastectomy Left: 102/58 Height: 60" Weight: 122 General: WDWN in NAD Skin: Warm, Dry and intact. Well healed RLQ/Flank scar. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, Neck: Mild JVD, Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: Irregular rate and rhythm, III/VI systolic and I/VI diastolic rumble Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Mild hepatomegally. No frank ascites appreciated. Extremities: Warm [X], well-perfused [X] trace Edema Varicosities: Legs grossly varicosed posteriorly. Vein stripped from left leg below knee. Varicosities noted below knee in both legs and upper groin region. Right thigh appears best area for vein. Neuro: Grossly intact [X] Pulses: Femoral Right:1 Left:1 DP Right:Tr Left:Tr PT [**Name (NI) 167**]:Tr Left:Tr Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit R>L Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 31003**] (Complete) Done [**2118-9-20**] at 10:12:45 AM 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: [**2057-11-22**] Age (years): 60 F Hgt (in): 60 BP (mm Hg): 110/45 Wgt (lb): 110 HR (bpm): 70 BSA (m2): 1.45 m2 Indication: Atrial fibrillation. Coronary artery disease. Mitral valve disease. Valvular heart disease. ICD-9 Codes: 427.31, 786.51, 395.1, 424.1, 396.9, 424.0 Test Information Date/Time: [**2118-9-20**] at 10:12 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW-:2 Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Ascending: 2.2 cm <= 3.4 cm Aorta - Arch: 2.1 cm <= 3.0 cm Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. Dilated coronary sinus (diameter >15mm). LEFT VENTRICLE: Normal LV wall thickness and cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Minimal AS. Moderate to severe (3+) AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PREBYPASS: Normal LV systolic function with LVEF >55%, with no segmental wall motion abnormalities. The left atrium is moderately dilated. The coronary sinus is dilated (diameter >15mm) and left arm contrast is seen entering coronary sinus prior to entering RA confirming persistent left svc. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is a minimally increased gradient consistent with minimal aortic valve stenosis but this is in the setting of decreased LV antegrade stroke volume with severe MR . Moderate to severe (3+) aortic regurgitation is seen. AI jet height/LVOT diameter > 65%, AI vena contracta > 0.6 cm. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. Severe (4+) mitral regurgitation is seen due type 3a [**Last Name (un) 3843**] leaflet motion (restricton in both systole and diastole). Moderate to severe [3+] tricuspid regurgitation is seen. Initially the TR was moderate but this changed to severe during the exam (holosystolic hepatic venous flow reversal was initially not present, but this developed during the exam and the vena contracta increased to > 0.7 cm). There is no pericardial effusion. POSTBYPASS: Post Aortic Valve replacement, Mitral Valve repair, Tricuspid Valve repair single vessel CABG on Epi and Milrinone. AV mechanical st-[**Male First Name (un) **] valve with good function. TV repair with good result, trace to mild TR with no Tricuspic stenosis. MV with moderate to severe MR following mitral valve annuloplasty ring. No aortic dissection seen after cannula removed. Normal LV systolic function. Normal RV funciton initially post pump, but there was mild RV dysfunction at the end of the exam. Results discussed with the surgical team. [**2118-9-30**] 05:40AM BLOOD WBC-8.2 RBC-3.63* Hgb-12.0 Hct-36.5 MCV-101* MCH-33.0* MCHC-32.8 RDW-18.7* Plt Ct-478* [**2118-9-29**] 04:48AM BLOOD WBC-8.2 RBC-3.50* Hgb-11.2* Hct-34.1* MCV-98 MCH-32.0 MCHC-32.8 RDW-17.8* Plt Ct-472* [**2118-9-30**] 05:40AM BLOOD PT-29.9* INR(PT)-2.9* [**2118-9-29**] 10:52AM BLOOD PT-26.2* INR(PT)-2.5* [**2118-9-28**] 02:05AM BLOOD PT-23.9* PTT-40.5* INR(PT)-2.2* [**2118-9-27**] 02:16AM BLOOD PT-31.3* PTT-45.6* INR(PT)-3.1* [**2118-9-26**] 04:06AM BLOOD PT-57.8* PTT-45.8* INR(PT)-6.3* [**2118-9-26**] 02:31AM BLOOD PT-52.1* PTT-46.0* INR(PT)-5.6* [**2118-9-25**] 05:34AM BLOOD PT-43.8* PTT-43.1* INR(PT)-4.6* [**2118-9-24**] 07:43PM BLOOD PT-29.2* PTT-41.6* INR(PT)-2.8* [**2118-9-24**] 10:54AM BLOOD PT-65.1* PTT-55.1* INR(PT)-7.2* [**2118-9-24**] 09:09AM BLOOD PT-59.0* PTT-52.5* INR(PT)-6.4* [**2118-9-23**] 03:22AM BLOOD PT-16.7* PTT-32.3 INR(PT)-1.5* [**2118-9-22**] 01:35AM BLOOD PT-13.2 PTT-27.4 INR(PT)-1.1 [**2118-9-30**] 05:40AM BLOOD Glucose-125* UreaN-150* Creat-4.7* Na-130* K-4.9 Cl-90* HCO3-24 AnGap-21* [**2118-9-29**] 04:48AM BLOOD Glucose-97 UreaN-151* Creat-5.5* Na-136 K-4.5 Cl-94* HCO3-23 AnGap-24* [**2118-9-28**] 02:05AM BLOOD Glucose-76 UreaN-148* Creat-5.5* Na-135 K-4.5 Cl-96 HCO3-24 AnGap-20 Brief Hospital Course: The patient underwent the routine pre-operative work-up. She was found to have a positive urinalysis and was started on Cipro. The patient was brought to the Operating Room on [**2118-9-20**] where the patient underwent AVR (19mm mechanical), MVr (26mm ring), TVr (26mm ring), CABG x 1 (SVG-PDA) with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Anti-coagulation was started with coumadin and Heparin bridge for the mechanical valve. Renal followed for her history of renal transplant. Anti-rejection drugs were resumed. Bactrim was discontinued per the renal team. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. She did develop tachypnea and was transferred to the ICU for Lasix drip. Echo showed small pericardial effusion without evidence of tamponade. She improved with diuresis and was transferred back to the floor. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 10 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital 31004**] Care Center of [**Location (un) 1468**] in good condition with appropriate follow up instructions. Of note- lung nodule was found on pre-op chest CT and 1 year follow-up is recommended. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day AZATHIOPRINE - 50 mg Tablet - one Tablet(s) by mouth once a day DABIGATRAN ETEXILATE [PRADAXA] - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth twice a day LD friday (ON HOLD since [**2118-8-10**]) DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) weekly- wednesdays FENOFIBRATE - 54 mg Tablet - 1 Tablet(s) by mouth once a day INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - 15 units daily before dinner INSULIN GLARGINE [LANTUS SOLOSTAR] - (Prescribed by Other Provider) - 100 unit/mL (3 mL) Insulin Pen - 30 units qhs CARVEDILOL 50 MG TWICE DAILY LASIX 40 MG DAILY PREDNISONE - (Prescribed by Other Provider) - 1 mg Tablet - 2 Tablet(s) by mouth once a day SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth daily TACROLIMUS [PROGRAF] - (Prescribed by Other Provider) - 0.5 mg Capsule - 1.5 Capsule(s) by mouth twice a day Medications - OTC FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg Elemental Iron) Tablet - 1 Tablet(s) by mouth once a day FISH OIL-DHA-EPA [FISH OIL] - (Prescribed by Other Provider) - 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth twice a day Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication Mechanical AVR Goal INR 2.5-3.0 First draw [**2118-10-1**] 2. tramadol 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 4. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Dose to change daily for goal INR 2.5-3.0. 13. aluminum hydroxide gel 600 mg/5 mL Suspension Sig: Five (5) ML PO Q 8H (Every 8 Hours) for 3 days. 14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchy skin. 17. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO daily (). 18. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 19. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-5**] Sprays Nasal QID (4 times a day) as needed for dry nares . 20. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Outpatient Lab Work check BUN, Cr on [**2118-10-6**] Results to Dr. [**Last Name (STitle) **] Fax: [**Telephone/Fax (1) 21335**] 22. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): per attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital 3137**] Care Center - [**Location (un) 1468**] Discharge Diagnosis: Moderate to severe mitral regurgitation. Mild mitral stenosis. Mild to moderate aortic regurgitation. Moderate tricuspid regurgitation. Simple aortic atheroma. Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2118-10-26**] 1:15 Cardiologist: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2118-11-14**] 11:30 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2118-10-14**] 10:20 Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) **],[**Location (un) 9655**] S. [**Telephone/Fax (1) 12071**] in [**3-8**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Mechanical AVR Goal INR 2.5-3.0 First draw [**2118-10-1**] ***4mm nodule noted on Chest CT- recommend f/u in 1 year*** Completed by:[**2118-9-30**]

[ "427.31", "250.00", "V10.3", "584.9", "585.9", "E878.2", "733.00", "423.9", "428.0", "440.0", "286.9", "397.0", "493.90", "793.11", "396.8", "272.4", "599.0", "428.33", "428.32", "414.01", "V42.0", "998.11" ]

icd9cm

[ [ [] ] ]

[ "36.11", "35.33", "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

14480, 14565

9126, 10968

319, 596

14769, 14917

3327, 5743

15841, 16792

2139, 2322

12383, 14457

14586, 14748

10994, 12360

14941, 15818

5787, 9103

2337, 3308

272, 281

624, 1431

1453, 2010

2026, 2123

81,750

134,946

12480

Discharge summary

report

Admission Date: [**2196-2-15**] Discharge Date: [**2196-2-25**] Date of Birth: [**2150-10-23**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: 45 yo male w/known CAD presents to cardiologist w/increased frequency angina Major Surgical or Invasive Procedure: coronary artery bypass grafting x 4 with left internal mammary to left anterior descending artery, reverse saphenous vein graft to ramus, reverse saphenous vein graft to obtuse marginal artery and reverse saphenous vein graft to posterior descending artery History of Present Illness: 45 year old man with known coronary artery disease s/p multiple stents with increasing angina at rest. Referred for cardiac catheterization which showed three vessel disease. He was then referred for cardiac surgery. Past Medical History: coronary artery disease s/p stents '[**94**] Cypher DES x2; BMS to prox LAD '[**95**]; POBA Lcx '[**95**] Gastric esopheageal reflux disease HTN Syncope peptic ulcer disease obesity diastolic dysfunction s/p cholecystectomy s/p bilateral arm surgery Social History: unemployed lives with wife and mother quit smoking [**2194-8-3**] denies EtOH Family History: mom s/p CABG @75yo dad s/p CABG in his 50s Physical Exam: Admission VS T HR 78 BP 106/64 RR 18 O2sat Gen A&O, obese Neuro grossly intact Pulm Lungs CTAB CV RRR, no murmur, rub or gallop Abdm soft, non-distended, non-tender, +BS, no masses Ext warm, well-perfused, no edema Discharge VS T 97.8 HR 88 BP 107/52 RR 18 O2sat 94% on 2 liters Gen Neuro alert and oriented x3 Pulm : CTA bilat CV: RRR S1, S2. sternum stable. incision C/D/I. no redness, no drainage. Abd: soft, round, NT, ND, +BS Ext: Trace upper and lower extrem edema. ankle incision : no erythema but small amt serosang drainage. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2196-2-24**] 06:55AM 9.2 3.26*# 9.9*# 28.5* 87 30.4 34.8 15.1 368# [**2196-2-24**] 01:45AM 26.4* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2196-2-15**] 04:30PM 58.4 33.8 4.4 2.8 0.6 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2196-2-24**] 06:55AM 368# BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2196-2-19**] 04:26PM 225 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2196-2-24**] 06:55AM 108* 11 1.0 139 3.9 99 30 14 ESTIMATED GFR (MDRD CALCULATION) estGFR [**2196-2-24**] 06:55AM Using this1 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2196-2-15**] 04:30PM 38 28 66 0.4 0.1 0.3 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2196-2-24**] 06:55AM 2.2 HEMATOLOGIC VitB12 [**2196-2-15**] 04:30PM 914* DIABETES MONITORING %HbA1c [**2196-2-15**] 04:30PM 6.0*1 [**Doctor First Name **] RECOMMENDATIONS:; <7% GOAL OF THERAPY; >8% WARRANTS THERAPEUTIC ACTION ============================================================ [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 38730**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 38731**] (Complete) Done [**2196-2-19**] at 2:30:39 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2150-10-23**] Age (years): 45 M Hgt (in): 72 BP (mm Hg): 145/78 Wgt (lb): 340 HR (bpm): 79 BSA (m2): 2.67 m2 Indication: Chest pain. Coronary artery disease. Left ventricular function. Right ventricular function. Valvular heart disease. Intraoperative TEE for CABG procedure. ICD-9 Codes: 786.51, 440.0, 414.8 Test Information Date/Time: [**2196-2-19**] at 14:30 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD Doppler: Limited Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW4-: Machine: [**Doctor Last Name **] 3d Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal mitral valve supporting structures. No MS. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) 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 appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. There is no aortic stenosis. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. There is no pericardial effusion. 8. Unable to obtain transgastric images due to difficulty in advancing probe beyond 40 cms. POST BYPASS 1. Patient is in sinus rhythm and receiving an infusion of phenylephrine. 2. Biventricular systolic function is unchanged. 3. Aorta is intact post decannulation. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2196-2-19**] 17:13 Brief Hospital Course: The patient was admitted to the medicine service on [**2196-2-15**] with increased frequency of anginal symptoms. He underwent cardiac catheterization and coronary angiography on [**2-15**] which revealed severe 3 vessel disease. After a four day Plavix washout, the patient was brought to the operating room on [**2-19**] where he underwent coronary artery bypass grafting x 4. Please see operative note for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for further monitoring. He left the operating room on neosynephrine. This was weaned and the patient was transferred to the floor on POD 1. Chest tubes and pacing wires were discontinued without complication. Plavix was resumed per cardiology for drug eluting stents. The patient was screened for MRSA on admission, and found to be positive. He was therefore placed in isolation with contact precautions. Bactroban ointment was administered to the nares. The patient was treated post operatively with betablockers and diuretics. The patient was transfused two units of packed red blood cells for a hematocrit of 21% with an appropropriate response. By post-operative day six he was seen by physical therapy and was cleared for discharge to home with visiting nursing services. Medications on Admission: Plavix 75' ASA 325' Metoprolol XL 200' Norvasc 5' Lasix 40' Triemterene 37.5/25' KCL 20' Ranexa 500" Imdur 90' Fiorocet 1/TID-prn Zetia 10' Zocor 80' Celexa 20' Flexeril 10/TID-prn Ultram-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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Lasix 40 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 Q12H (every 12 hours). 11. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day. 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for chest pain. Disp:*45 Tablet(s)* Refills:*0* 14. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary artery disease, s/p Coronary artery bypass grafting x4 +MRSA colonization PMH: hypertension hyperlipidemia gastric esophogeal reflux disease peptic ulcer disease syncope obesity diastolic dysfunction s/p cholecystectomy s/p bilateral arm surgery Discharge Condition: good Discharge Instructions: No driving for 4 weeks and off narcotic pain medication no lifting more than 10 pounds for 10 weeks Keep wounds clean and dry. No lotions, creams or powders. Shower daily, no bathing or swimming x 6 weeks. Take all medications as prescribed. Call for any fever, redness or drainage from wounds. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-8**] weeks Dr [**Last Name (STitle) 7772**] in 4 weeks please call for appointments [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2196-2-25**]

[ "530.81", "401.9", "278.01", "V45.82", "414.01", "599.0", "411.1", "V17.3", "V02.54" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9683, 9738

6545, 7881

355, 614

10037, 10044

1872, 6522

10387, 10735

1244, 1288

8123, 9660

9759, 10016

7907, 8100

10068, 10364

1303, 1851

239, 317

642, 860

882, 1133

1149, 1228

11,424

102,178

16888

Discharge summary

report

Admission Date: [**2101-11-19**] Discharge Date: [**2101-11-23**] Date of Birth: [**2047-7-25**] Sex: F Service: CCU CHIEF COMPLAINT: Chest pain radiating to the left shoulder. HISTORY OF PRESENT ILLNESS: The patient is non-English speaking. The history was obtained from the chart as well as from the patient's son. The patient reportedly awoke on the morning of admission around 1 a.m. with the sudden onset of chest pain and epigastric rated [**7-30**] radiating to the left shoulder. The pain was associated with nausea, vomiting, and diaphoresis. She also complained of bilateral arm numbness; and according to her son she experienced similar symptoms two days prior to this admission. 911 was called. Emergency Medical Service responded and performed an electrocardiogram at home which revealed ST elevations in leads II, III, and aVF with right-sided leads showing an ST elevation in V4. The patient was treated with aspirin and morphine and brought to the [**Hospital1 188**] Emergency Department. In the Emergency Room, the patient's pain was then [**2-27**]. Electrocardiogram done again revealed a sinus rhythm at 55 beats per minute with a normal axis and intervals with persistent 1-mm to 2-mm ST elevations in leads II, III, and aVF along with 1-mm ST depression in aVL. Q waves were seen in II, III, and aVF as well. Right-sided electrocardiogram leads showed persistent 1-mm ST elevation in V4. Further history obtained from the patient's son at that time revealed decreased exercise tolerance over the past few weeks to one month, a history of claudication over the last couple of months as well, and constipation. The patient was taken directly from the Emergency Department to the catheterization where right heart catheterization revealed a cardiac output of 2.73 and with a cardiac index of 1.46 by Fick method, a wedge pressure of 23, right atrial pressure of 21, pulmonary artery pressure of 39/23, with a mean of 28, and right ventricular pressure of 39/17. Coronary angiography revealed a right-dominant system with a normal left main. The left anterior descending artery had diffuse disease of less than 50% with an 80% proximal stenosis prior to the second diagonal sub-branch. The left circumflex had a 50% proximal lesion as well as diffuse minor disease. The right coronary artery had a total occlusion of the medial portion with poor collaterals coming from the left coronary artery. The right coronary artery occlusion was treated with Angio-Jet thrombectomy and stenting times two. There were recurrent episodes of slow flow; however, treated with multiple doses of intracoronary diltiazem with improvement. The final result was TIMI-II fast flow with no residual stenosis. The hemodynamics reported above were consistent with right ventricular infarction with the elevated wedge pressure of 23 mm. Temporary pacing required for periods of marked sinus slowing with decreased blood pressure and loss of atrial synchrony. For these reasons, an intra-aortic balloon pump was placed due to the markedly reduced cardiac index and the above hemodynamics. The patient was then admitted to the Coronary Care Unit for further management. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Osteoporosis. 3. Osteoarthritis. 4. Lichen planus. 5. Cervical spine disk herniation. 6. Chronic low back pain. MEDICATIONS ON ADMISSION: 1. Lipitor 20 mg p.o. q.d. 2. Ibuprofen. 3. Hormone replacement therapy. 4. Calcium. 5. Zoloft. 6. Valium. ALLERGIES: No known drug allergies. FAMILY HISTORY: Family history negative for coronary artery disease. SOCIAL HISTORY: The patient is married and has four children. She smokes six to ten cigarettes per day. CARDIAC RISK FACTORS: Cardiac risk factors included tobacco, age, and high cholesterol. PHYSICAL EXAMINATION ON PRESENTATION: Examination on admission to the Coronary Care Unit revealed the patient was afebrile, heart rate ranged from 57 to 61, blood pressure ranged from 136 to 148/76 to 96 (with mean arterial pressure of 108), oxygen saturation was 99% on 3 liters. In general, she appeared comfortable. She denied chest pain at the time of admission to the Coronary Care Unit status post catheterization. Pertinent physical findings revealed no jugular venous distention on examination of the neck. Her lungs were clear to auscultation bilaterally without crackles. Her heart rate was 60 with a normal first heart sound and second heart sound. No murmur was audible. Her abdomen was protuberant and obese but nontender with normal active bowel sounds. Her extremities revealed trace pedal edema. She had 2+ pulses bilaterally with the balloon pump in place. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed white blood cell count was 9.8, hematocrit was 35.5, and platelets were 253. Coagulations were normal. Chemistry-7 was unremarkable. First cardiac enzymes revealed creatine kinase was 1395, with a MB of 278, and a MB index of 19.9. Troponin was read as greater than 50. Liver function tests revealed elevation of ALT at 43, AST was 146, and alkaline phosphatase was 77. Amylase and lipase were normal as was total bilirubin. HOSPITAL COURSE: 1. CARDIOVASCULAR SYSTEM: Following catheterization, the patient was continued on Integrilin, heparin drip, and Plavix. On the night status post catheterization, the patient did experience some episodes of neck pain, back pain, and arm pain without electrocardiogram changes. However, creatine kinases continued to climb, reaching 6148 on the first hospital day with improved hemodynamics. The patient's balloon pump discontinued later on the first hospital day with a small amount of oozing groin site which was stopped with pressure. The patient's hematocrit did fall from 32 to 29; although, no transfusion of packed red blood cells was necessary. As mentioned above, the creatine kinase peaked and fell quickly thereafter. As heart rate and blood pressure tolerated, the patient was initiated on Lopressor and low-dose captopril at 6.25 mg t.i.d. She had no further complaints of chest pain, neck, or back pain. An echocardiogram was performed on hospital day two which revealed a normal left atrium. Left ventricular wall thickness was normal. Overall left ventricular systolic function was mildly depressed with an ejection fraction of 40% to 45%. Resting regional wall motion abnormalities included basal and medial inferolateral, inferoseptal, and inferior hypokinesis. Ascending aorta was mildly dilated. There was 1+ mitral regurgitation, and no pericardial effusion. On [**2101-11-23**], the patient underwent a Persantine MIBI stress test to evaluate for any further reversible defect. She elevated her heart rate to 77 (which was 46% of her maximum heart rate). She had no chest discomfort or ischemic changes. The nuclear report revealed moderate partially reversible perfusion defect of the inferior wall with an ejection fraction of 38%. There was global hypokinesis which was most pronounced in the inferior wall. The patient's medications were changed to once daily medications, including atenolol and lisinopril. She remained hemodynamically stable and was called out to the floor. She was discharged later that day in good condition. The patient was discharged back home to [**Country 6607**] with a copy of her cardiac catheterization on CD-ROM to show to her doctors at [**Name5 (PTitle) **]. 2. HEMATOLOGIC ISSUES: On admission, the patient's hematocrit was noted to be 35.5; reaching a nadir of 29.1 on [**2101-11-20**] following removal of the balloon pump. As stated above, she was transfused one unit of packed red blood cells for this drop in hematocrit to which she responded appropriately; bringing her hematocrit up to 33.5. On the day of discharge her hematocrit was 34.3. 3. ANXIETY ISSUES: The patient was continued on her outpatient doses of Zoloft as well as given Valium on a as needed basis. 4. GASTROINTESTINAL SYSTEM: For her presenting complaint on review of systems of constipation, she was given a bowel regimen of Colace, Senna, and Dulcolax with good effect. DISCHARGE DIAGNOSES: 1. Inferior and right ventricular myocardial infarctions. 2. Status post thrombectomy and right coronary artery stent times two. MEDICATIONS ON DISCHARGE: 1. Atenolol 12.5 mg p.o. q.d. 2. Lisinopril 25 mg p.o. q.d. 3. Atorvastatin 20 mg p.o. q.d. 4. Sertraline 50 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Milk of Magnesia. 8. Senna. 9. Lactulose. 10. Ibuprofen as needed. CONDITION AT DISCHARGE: Condition on discharge was good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**] Dictated By:[**Name8 (MD) 3491**] MEDQUIST36 D: [**2102-1-16**] 13:33 T: [**2102-1-17**] 09:12 JOB#: [**Job Number 42051**]

[ "272.0", "692.9", "V15.82", "410.41", "414.01", "410.81" ]

icd9cm

[ [ [] ] ]

[ "37.64", "36.01", "37.78", "37.61", "36.06", "99.20", "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

3569, 3623

8197, 8329

8356, 8631

3400, 3552

5238, 8176

8646, 8941

152, 196

225, 3205

3227, 3374

3640, 5220

26,884

123,835

32236

Discharge summary

report

Admission Date: [**2152-2-17**] Discharge Date: [**2152-2-23**] Date of Birth: [**2067-1-31**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Aspirin Attending:[**First Name3 (LF) 4588**] Chief Complaint: right lower leg swelling, DVT Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: History per records and son. Pt unable to give any history directly due to language barrier and dementia. Essentially, this is a 85 year old Russian speaking female with CAD, CHF, CKD with multiple recent admissions for GI bleeding who prsents 10 days after her most recent discharge with a swollen right lower extremity. Apparently, the patient was noted to have asymmetry with a larger right lower extremity and was sent from [**Hospital 100**] Rehab to get an ultrasound, which showed a large right lower extremity thrombus. Therefore, the patient was brought to the ED for further evaluation. In the ED VS T 98, P 80, BP 126/70, RR 18, O2 100% on RA. She had palpable pulses bilaterally. Rectal exam with guiac+ brown stool Given recent history of GIB and guiac + stool, anticoaulation was not considered safe and was deferred. Vascular was called and ruled the patient out for mechanical thrombectomy as this also requires large doses of anticoagulation. The patient is being admitted to medicine for further work-up. Through her son the patient acknowledges discomfort in the right lower extremity. Otherwise denies chest pain, SOB, palpitations, or presyncope. REVIEW OF SYSTEMS: Positive per HPI. Through son pt denied chest pain or SOB. Past Medical History: * Coronary artery disease s/p MI ([**2132**]) with wall motion abnormalities on ECHO in [**2149-3-1**], NSTEMI/CHF exacerbation at [**Hospital1 882**] ([**7-/2151**]) * Congestive Heart Failure (EF45% in [**2149-3-1**]) felt due to ichemia, with poor nutritional status and compensated hypertension * Moderate pulmonary artery systolic hypertension * Mild-moderate tricuspid regurgiation * Carotid stenosis (<40% stenosis within bilateral carotids, right vertebral artery with no color flow on Doppler compatible with occlusion, [**3-/2149**]) * Hypertension * Hyperlipidemia * Dementia (A&OX2 at [**Year (4 digits) 5348**]) * Chronic renal insufficiency, stage III * Iron deficiency anemia with h/o heme positive stools * Osteoporosis * Anxiety * GERD * Constipation * Macular degeneration * s/p fall in [**2149-3-1**] with SAH, SDH, right temporal intraparenchymal hemorrhage plus minimally displaced right superior ramus fracture, left radial fracture * h/o left hip fracture with replacement ([**2148**]) * h/p right hip fracture with repair [**12/2151**] * h/o lower GI bleed * h/o pneumonias including aspiration PNA ([**4-/2149**]) * h/o UTIs, Staph Aureus * Left breast lumpectomy Social History: Denies tobacco/alcohol/illicit drugs. Retired teacher of Russian and [**Doctor First Name 533**], resides at [**Hospital1 100**] Senior Life in [**Location (un) 2312**], Russian unit since [**2148**]. Widowed, has two sons [**Name (NI) 2855**] and [**Name2 (NI) 59911**] [**Name (NI) 75363**] who are actively involved in her care. She is able to use a walker with assistance. She is incontinent of urine and stool. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: On admission: VS: T 96.9, BP 116/74, P 79, RR 20, O2 97% on RA Gen: Thin, elderly woman lying in bed in NAD HEENT: Normocephalic, anicteric, OP benign, MMM CV: RRR, no M/R/G; there is no jugular venous distension appreciated Pulm: Expansion equal bilaterally, CTAB Abd: Soft, NT, ND, BS+, no organomegaly or masses appreciated Extrem: Warm and well perfused, 1+ edema on right, none on left, palpable DP's bilaterally Neuro: Alert and responsive, intermittently appears anxious with nursing interventions On Discharge: exam was able to be performed with her son at her bedside VS: T 98, BP 125/75, P 74, RR 20, O2 98% on RA Gen: Thin, elderly woman lying in bed in NAD HEENT: Normocephalic, anicteric, OP benign, MMM CV: RRR, no JVD Pulm: CTAB, no murmurs Abd: Soft, NT, ND, BS+, no masses appreciated Extrem: Warm and well perfused, 1+ edema on right, none on left, palpable DP's bilaterally Neuro: Alert and responsive Pertinent Results: LABS: [**2152-2-17**] 02:47PM BLOOD WBC-9.0 RBC-3.02* Hgb-10.3* Hct-29.9* MCV-99* MCH-34.0* MCHC-34.5 RDW-14.8 Plt Ct-296 [**2152-2-17**] 02:47PM BLOOD Neuts-75.3* Lymphs-19.3 Monos-4.2 Eos-0.9 Baso-0.3 [**2152-2-17**] 05:45PM BLOOD WBC-9.4 RBC-2.96* Hgb-9.8* Hct-28.8* MCV-97 MCH-33.1* MCHC-34.0 RDW-14.8 Plt Ct-302 [**2152-2-18**] 11:50AM BLOOD WBC-8.0 RBC-2.84* Hgb-9.6* Hct-28.0* MCV-98 MCH-33.8* MCHC-34.4 RDW-14.8 Plt Ct-323 [**2152-2-19**] 06:10AM BLOOD WBC-9.3 RBC-3.14* Hgb-10.4* Hct-31.3* MCV-100* MCH-33.2* MCHC-33.3 RDW-14.9 Plt Ct-294 [**2152-2-20**] 12:55PM BLOOD WBC-8.6 RBC-3.45* Hgb-11.4* Hct-33.7* MCV-98 MCH-33.1* MCHC-33.8 RDW-14.8 Plt Ct-381 [**2152-2-21**] 11:05AM BLOOD WBC-7.1 RBC-3.21* Hgb-11.0* Hct-31.6* MCV-98 MCH-34.3* MCHC-34.9 RDW-14.7 Plt Ct-356 [**2152-2-22**] 06:15AM BLOOD WBC-7.1 RBC-3.30* Hgb-11.2* Hct-32.9* MCV-100* MCH-33.8* MCHC-34.0 RDW-15.0 Plt Ct-324 . [**2152-2-17**] 02:47PM BLOOD PT-12.1 PTT-22.5 INR(PT)-1.0 . [**2152-2-17**] 02:47PM BLOOD Glucose-129* UreaN-19 Creat-1.0 Na-139 K-3.6 Cl-108 HCO3-21* AnGap-14 [**2152-2-18**] 11:50AM BLOOD Glucose-100 UreaN-23* Creat-0.9 Na-139 K-3.7 Cl-109* HCO3-22 AnGap-12 [**2152-2-19**] 06:10AM BLOOD Glucose-97 UreaN-22* Creat-0.8 Na-138 K-4.1 Cl-107 HCO3-21* AnGap-14 [**2152-2-20**] 12:55PM BLOOD Glucose-143* UreaN-21* Creat-0.8 Na-137 K-3.6 Cl-106 HCO3-20* AnGap-15 [**2152-2-21**] 11:05AM BLOOD Glucose-118* UreaN-25* Creat-0.9 Na-135 K-3.8 Cl-105 HCO3-23 AnGap-11 [**2152-2-22**] 06:15AM BLOOD Glucose-153* UreaN-26* Creat-0.9 Na-135 K-4.4 Cl-107 HCO3-20* AnGap-12 . [**2152-2-18**] 11:50AM BLOOD Calcium-8.4 Phos-1.5* Mg-2.0 [**2152-2-19**] 06:10AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.0 [**2152-2-20**] 12:55PM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 [**2152-2-21**] 11:05AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1 [**2152-2-22**] 06:15AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1 STUDIES: LE U/S [**2-18**]: Deep venous thrombosis involving the right common and superficial femoral veins. The left common and superficial femoral veins appear patent. The popliteal and calf veins could not be evaluated. At the time of discharge: her urine culture was pending. Brief Hospital Course: 85 y.o. Russian speaking female with multiple medical problems including CAD, CHF, and dementia presenting with large right lower extremity DVT. #RLE DVT: The patient presented with swelling and tenderness unilaterally consistent with DVT seen on ultrasound prior to admission. This finding was confirmed on ultrasound after admission. The most likely risk factor for DVT is immobility but she may also be at somewhat increased risk due to megestrol dosing. The patient was hemodynamically stable and demonstrated no sign of embolization. She was evlauated by vascular surgery who did not feel she was a candidate for thrombectomy. The patient is at high risk for GIB given her history including a recent significant bleed attributed to esophageal erosions caused by GERD vs. [**Doctor First Name **]-[**Doctor Last Name **] tears. The risks and benefits of treatment options were discussed with patient's son/HCP. It was explained that anticoagulation is not an option now until the patient has had more time to heal from GIB and as she she is currently guaiac positive, and that anticoagulation may never be a viable option. We explained the role of an IVC filter to decrease the risk of life threatening embolic events including PE. The patient's sons were reluctant to have her undergo any procedure and were particularly nervous about reactions to contrast dye, which she has had in the past (anaphylaxis). Filter placement without dye is not possible, but vascular would be prepared to place if pt premedicated prior to dye administration with steroids and anti-histamines. The patient was followed on telemetry. After thorough discussion regarding the risks and benefits, pt's son (her health care proxy) elected to have the placement of IVC filter. Pt was premedicated prior to the procedure with solumedrol, zantac, and benadryl. The procedure was uncomplicated and she tolerated it well. Please see the vascular surgeon's operative note for details. #CAD: No signs of acute CHF or ACS. EKG stable. The patient was continued on her home medications including a beta blocker and a nitrate. #Chronic systolic CHF: Appeared euvolemic to slightly dry on admission. Oral fluid intake was encouraged and furosemide was held during her hospital course. #GI Bleed: At the time of admission the patient was less than 10 days out from hospitalization for a GI bleed thought to be due to gastritis and possible [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear. She was found to have guaiac positive brown stool. The patient was continued on sucralfate and a PPI. She was monitored with daily CBCs and her hct remained stable. #Dementia/Delirium: The patient has a history of agitation and refusing care/meds in the hospital. The is likely attributable to a combination of language barrier, delirium, and dementia with agitiation. We continued trazodone 50mg PO QHS for insomnia. It was useful to redirect frequently and call her sons as needed as she is much calmer and more cooperative with her sons present or speaking to her by phone. Non-pharmacologic measures such as lights/on blinds up during day, lights off/blinds down at night, and minimizing tethers were also used. #Chronic nausea: The patient has a history of chronic nausea and is on antiemetics including Zofran and prochlorperazine at [**Last Name (NamePattern1) 5348**] which were continued. This was not an active issue for her during this hospitalization. #CODE: DNR but okay to intubate confirmed with son. Medications on Admission: 1. sucralfate 1 gramPO QID 2. trazodone 50 mg PO HS 3. [**Last Name (NamePattern1) **] 8.6 mg One Tablet PO BID 4. polyethylene glycol 3350 17 gram/dose One PO Daily. 5. megestrol 400 mg PO BID 6. bisacodyl 10 mg PO DAILY PRN constipation 7. acetaminophen 650 mg PO TID 8. isosorbide mononitrate 15 mg Sustained Release Q 24 hr 9. metoprolol succinate 50 mg PO DAILY 10. lorazepam 0.5 mg PO TID. 11. Lansoprazole 30 mg PO Q12H 123. ondansetron 4 mg PO Q8hr : PRN nausea: 14. prochlorperazine 25 mg Suppository Q12H : PRN nausea 15. torsemide 20 mg PO DAILY Discharge Medications: 1. prochlorperazine 25 mg Suppository [**Last Name (NamePattern1) **]: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. 2. acetaminophen 325 mg Tablet [**Last Name (NamePattern1) **]: Two (2) Tablet PO every eight (8) hours as needed for pain. 3. docusate sodium 100 mg Capsule [**Last Name (NamePattern1) **]: One (1) Capsule PO BID (2 times a day). 4. [**Last Name (NamePattern1) 10687**] Lax 8.6 mg Tablet [**Last Name (NamePattern1) **]: Two (2) Tablet PO HS (at bedtime). 5. sucralfate 1 gram Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO QID (4 times a day). 6. trazodone 50 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (NamePattern1) **]: One (1) PO DAILY (Daily) as needed for constipation. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (NamePattern1) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr [**Last Name (NamePattern1) **]: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 10. lorazepam 0.5 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO TID (3 times a day). 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Last Name (NamePattern1) **]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (NamePattern1) **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 13. metoprolol tartrate 25 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: right lower extremity deep vein thrombosis Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - sometimes. Discharge Instructions: Ms. [**Last Name (Titles) 75369**], It was a pleasure caring for your at [**Hospital1 827**]. You were admitted after being found to have a blood clot in your right leg that was causing swelling. This clot was evaluated by ultrasound. The usual treatment for blood clots is anticoagulation. Because you have a history of bleeding in your gastrointestinal tract anticoagulation would be dangerous for you. The options of anticoagulation, the placement of an IVF filter to stop blood clots from reaching your heart and lungs and supportive measures were all discussed with you and your sons. Your son who is your health care proxy made the decision to proceed with IVF filter. You had the procedure done by vascular surgeons on [**2152-2-22**]. You tolerated the procedure well. We did not make any changes to your medications: Please take your medications as prescribed. Please keep your follow up appointments as scheduled. Followup Instructions: 1)Please arrange appt with primary care physician [**Name Initial (PRE) 176**] 1 week or as needed. 2)Department: CARDIAC SERVICES When: WEDNESDAY [**2152-8-2**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please follow up with your primary care physician as needed. Completed by:[**2152-2-23**]

[ "787.02", "424.2", "294.8", "453.51", "416.8", "414.01", "585.3", "428.22", "403.90", "733.00", "428.0", "272.4", "280.9" ]

icd9cm

[ [ [] ] ]

[ "38.7", "88.51" ]

icd9pcs

[ [ [] ] ]

12316, 12381

6491, 10006

325, 348

12468, 12583

4331, 6468

13597, 14083

3290, 3372

10613, 12293

12402, 12447

10032, 10590

12646, 13445

3387, 3387

3907, 4312

13475, 13574

1567, 1627

256, 287

376, 1548

3401, 3893

12598, 12622

1649, 2840

2856, 3274

5,272

193,548

18388

Discharge summary

report

Admission Date: [**2171-12-2**] Discharge Date: [**2171-12-10**] Service: #58 HISTORY OF PRESENT ILLNESS: This is an 81-year-old white male from the [**Location (un) **] area who was visiting his family in the Whorster area. He had been having chest pain two days prior to admission but felt it was indigestion. The pain radiated to his shoulders and jaw and increased in intensity. He presented to [**Hospital 1558**] Medical Center where he underwent cardiac catheterization which revealed left main and three-vessel coronary artery disease with an ejection fraction of 40-45%. He also had a positive troponin. He had intermittent chest pain throughout the day on intravenous Nitroglycerin, Heparin and Integrilin, and was transferred here for further treatment. He was still in pain upon admission to the CSRU. PAST MEDICAL HISTORY: Seizures. Prostate carcinoma status post chemotherapy and radiation therapy. Status post gastric resection. Status post vagotomy. Status post bezoar removal. MEDICATIONS ON ADMISSION: Phenytoin 100 mg p.o. t.i.d., Fosamax 0.4 mg p.o. q.h.s. MEDICATIONS ON TRANSFER: Nitroglycerin drip, Heparin 1000, Integrilin, Lopressor 12.5 mg p.o. b.i.d., Aspirin 325 mg p.o. q.d., Fosamax 0.4 mg p.o. q.d., Phenytoin 100 mg p.o. t.i.d., Lipitor 10 mg p.o. q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: He is a retired orthopedic surgeon. He quit smoking 40 years ago. He drinks 2-3 drinks per day. FAMILY HISTORY: Significant for coronary artery disease. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: General: He was a well-developed, well-nourished, elderly, white male who was pale looking with ongoing angina. Vital signs: Pulse 70, blood pressure 104/60, respirations 18, oxygen saturation 96% 2 L nasal cannula. HEENT: Normocephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck: Supple. Full range of motion. No lymphadenopathy. No thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs: Clear to auscultation and percussion bilaterally. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Abdomen: Soft and nontender. Positive bowel sounds. No masses or hepatosplenomegaly. He had a well-healed midline and transverse scar. Extremities: Without clubbing, cyanosis, or edema. Pulses: Exam showed 2+ pulses and equal bilaterally with the exception of the dorsalis pedis and posterior tibial which were 1+ and equal bilaterally. Neurological: Nonfocal. HOSPITAL COURSE: He was admitted to the CSRU and continued to have chest pain despite increasing his Nitroglycerin drip. He had an intra-aortic balloon pump placed. He still continued to have some intermittent chest pain even with the balloon. On [**12-3**] he underwent a coronary artery bypass grafting times three with LIMA to left anterior descending, and reversed saphenous vein graft to the obtuse marginal 1 and 2. He was transferred to the CSRU in stable condition. He was seen that night by Neurology, as he had a seizure on induction in the OR. They felt he should stay sedated on Propofol over night. On postoperative day #1, he was extubated. He was somewhat agitated. His intra-aortic balloon pump was discontinued. He remained delirious, and he was continued to be by Neurology. He looked a little bit more clear on postoperative day #2. On postoperative day #3, he had his chest tubes discontinued, and his pacing wires were discontinued. He also had a swallowing evaluation which he passed. On postoperative day #4, he was transferred to the floor. He was seen by Neurology again, and they felt that he had some left-sided neglect. He received a head CT which revealed a subacute right PCA infarct. He continued to improve with his ambulation but still had slight intermittent confusion but was much clearer. On postoperative day #7, he was discharged to rehabilitation in stable condition. DISCHARGE LABORATORY DATA: Hematocrit 26.2, white count 7,400; sodium 139, potassium 3.7, chloride 104, CO2 29, BUN 18, creatinine 1.0, blood sugar 97. DISCHARGE MEDICATIONS: Potassium 20 mEq p.o. b.i.d. x 7 days, Aspirin 325 mg p.o. q.d., Acetaminophen 2 tab p.o. q.4 hours p.r.n., Phenytoin 100 mg p.o. t.i.d., Lipitor 10 mg p.o. q.d., Lasix 20 mg p.o. b.i.d. for 7 days, Lopressor 50 mg p.o. b.i.d., Ibuprofen 400 mg p.o. q.8 hours p.r.n., Fosamax 0.4 mg p.o. q.h.s., Iron 325 mg p.o. q.d., Vitamin C 500 mg p.o. q.d. FOLLOW-UP: He will follow-up with Dr. [**Last Name (STitle) **] in four weeks and with Dr. [**Last Name (STitle) 911**] in two weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2171-12-10**] 11:27 T: [**2171-12-10**] 11:25 JOB#: [**Job Number 50637**]

[ "410.81", "780.39", "997.02", "293.9", "780.57", "414.01", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "99.20", "37.61", "36.12" ]

icd9pcs

[ [ [] ] ]

1485, 1527

4142, 4907

1046, 1104

2557, 4118

1585, 2539

1547, 1562

119, 834

1130, 1352

857, 1019

1369, 1468

82,010

199,190

26908

Discharge summary

report

Admission Date: [**2136-5-30**] Discharge Date: [**2136-6-14**] Date of Birth: [**2083-3-23**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 922**] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: [**2136-5-30**] Coronary bypass grafting x2: Left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to distal right coronary artery. Full left and right-sided maze procedure with a [**Company 1543**] Gemini X Irrigated Bipolar device, as well as the cryo catheter. History of Present Illness: 53 year old male who developed atrial flutter in [**2127**]. He underwent an atrial fibrillation ablation in [**3-/2131**]; however, had recurrence shortly thereafter. He then underwent pulmonary vein isolation in 12/[**2130**]. He had been doing well until [**5-22**] when he presented to [**Hospital1 18**] with two hours of left lower extremity pain and pallor and was diagnosed with left leg arterial clot. He was taken to the OR and underwent left iliac and left femoral popliteal thrombectomy and placement of a left common iliac stent. He also had left lower extremity four compartment fasciotomies and evacuation and drainage of a left medial calf hematoma. He was started on Coumadin and heparin. Of note, the patient has a history of brain aneurysm in [**2117**] and [**2127**] and had a subdural hematoma in [**2131**]. After the subdural hematoma, he stopped Coumadin and remains off anticoagulation. The patient is very reluctant to be on anticoagulation long term given his past medical history but was on it short term after recent left leg arterial clot. He currently reports episodes of palpitations occurring two to three times per week. They come on without apparent trigger and resolve spontaneously. The episodes last approximately 5-10 minutes in total. Similar frequency to prior. He has no associated chest pain, shortness of breath, lightheadedness, dizziness, syncope or presyncope. He recently had cardiac monitoring which showed primarily sinus rhythm and sinus bradycardia with rates ranging form 49 to 68bpm. There were several short episodes of Atrial Fibrillation with the longest 1 minute in duration. There were also PAC, and PAC pairs as well as 1 PVC couplet. Given his palpitations, concern with anticoagulation and recent cardiac study with documented atrial fibrillation, he has been referred for consideration of MAZE and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] removal. Past Medical History: - Atrial fibrillation s/p AF ablation and PVI [**2130**] - History of Cerebral Aneurysms - Subdural hematoma s/p MVA in [**2131**] - Chronic renal insufficiency, Polycystic Kidney Disease - History of LLE Embolism - Hypertension - GERD - Depression Past Surgical History - s/p Subdural Hematoma Evacuation [**2131**] - s/p Intracranial aneurysm clipping x 2 ([**2117**], [**2127**]) - s/p Left iliac and left femoral popliteal thrombectomy, left common iliac stent placement and lower extremity four compartment fasciotomies and evacuation and drainage of a left medial calf hematoma - s/p Bilateral wrist surgery - s/p Bilateral shoulder surgery - s/p Right knee arthroscopy - s/p Right hand Social History: Lives with: Wife Occupation: Retired police officer in [**2131**] Tobacco: smokes [**12-11**] ppd, approx 30 PYH ETOH: Quit 27 years ago Family History: Significant for grandfather who died of MI at 76 and mother had MI times two in her 70s Physical Exam: Pulse: 65 Resp: 16 O2 sat: 99% room air B/P Right: 133/87 Left: 137/91 General: Middle aged male in no acute distress Skin: Dry [X] intact [X] - no signficiant rash noted HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur - soft systolic 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: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: - Carotid Bruit Right: none Left: none Pertinent Results: [**2136-5-31**] 03:15AM BLOOD WBC-13.8* RBC-3.70* Hgb-11.8* Hct-35.7* MCV-97 MCH-31.8 MCHC-32.9 RDW-14.2 Plt Ct-146* [**2136-5-31**] 03:15AM BLOOD Glucose-138* UreaN-34* Creat-2.1* Na-141 K-5.1 Cl-112* HCO3-19* AnGap-15 [**2136-5-30**] TEE Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. 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 pericardial effusion. 3D echo reviewed the left atrial appendage prfe-procedure. Post-CPB: The patient is AV-Paced, on no inotropes. Preserved biventricular systolic fxn. No MR, no AI. Aorta intact. LAA successfully ligated. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2136-5-30**] where the patient underwent a coronary bypass grafting x2: Left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to distal right coronary artery and full left and right-sided maze procedure with a [**Company 1543**] Gemini X Irrigated Bipolar device, as well as the cryo catheter. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. The patient was extubated on post operative day 1 with hypoxia after extubation requiring noninvasive ventilation. He was hemodynamically stable on no inotropic or vasopressor support on POD 1. His chest tubes and temporary pacing wires were removed per protocol. He was diuresed aggressively but his respiratory status did not improve and he was reintubated. Attempts to decrease sedation and wean from ventialtor resulted in agitation which was managed with haldol. He developed a medication induced ATN which improved when diuretics and other nephrotoxic agents were d/c'd until renal function recovered. A leukocytosis developed and was pan cultured and started on Cipro. Sputum eventually grew out staph coag positive and cirpto was d/c'd and he was started on IV Vanco. He was once again extubated successfully. His mental status continued to improve over the course of his hospital stay. He developed post-operative afib and was started on betablockers for but developed a junctional rhythm. EP service was consulted and amiodarone was started. When his rhythm recovered betablocker was resumed. He was also maintained on a statin. He was anticoagulated with coumadin for afib and was sensitive to coumadin dosing. He was evaluated by physical therapy for strength and conditoning. The wound was healing and pain was controlled with oral analgesics. The patient was discharged home on POD# 15 in good condition with appropriate follow up instructions. Medications on Admission: Celexa 20 mg daily Metoprolol tartrate 50 mg TID Pramipexole 0.25 mg daily Omeprazole 20 mg daily Propafenone 150 mg twice daily Allergies: Codeine( GI upset) and midazolam (altered mental status) Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 mdi* Refills:*2* 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. pramipexole 0.125 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: Based on INR for AFIB Goal INR 2.0-2.5. Disp:*90 Tablet(s)* Refills:*2* 17. Outpatient Lab Work Check INR on [**2136-6-15**] and call results to Dr. [**Last Name (STitle) 27542**] [**Telephone/Fax (1) 27541**] Check INR daily until off bactrim athen 3 times per week until INR stable INR daily Goal 2.0-2.5 please check bun/creat next week Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Coronary Artery Disease Atrial fibrillation s/p AF ablation and PVI [**2130**] History of Cerebral Aneurysms Subdural hematoma s/p MVA in [**2131**] Chronic renal insufficiency, Polycystic Kidney Disease History of LLE Embolism, Hypertension, GERD, Depression, s/p Subdural Hematoma Evacuation [**2131**] s/p Intracranial aneurysm clipping x 2 ([**2117**], [**2127**]) s/p Left iliac and left femoral popliteal thrombectomy, left common iliac stent placement and lower extremity four compartment fasciotomies and evacuation and drainage of a left medial calf hematoma s/p Bilateral wrist surgery, s/p Bilateral shoulder surgery s/p, Right knee arthroscopy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema - none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] on [**6-26**] at 3:30pm [**Telephone/Fax (1) 170**] in the [**Hospital **] Medical office building [**Hospital Unit Name **] Cardiology: Dr. [**Last Name (STitle) **] on [**7-4**] at 12:40pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 27542**] in [**3-13**] weeks [**Telephone/Fax (1) 27541**] Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [**2136-6-15**] then daily until on a stable dose of coumadin given bactrim interaction Results to Dr. [**Last Name (STitle) 27542**] phone: [**Telephone/Fax (1) 27541**] fax: [**Telephone/Fax (1) 34527**] **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:[**2136-6-14**]

[ "427.81", "753.12", "585.4", "997.31", "427.31", "799.02", "V17.49", "311", "041.12", "327.23", "V58.61", "276.69", "V12.51", "403.90", "414.01", "584.5", "518.5", "530.81", "305.1", "348.31", "276.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "37.36", "33.24", "39.61", "36.11", "37.33", "36.15" ]

icd9pcs

[ [ [] ] ]

9615, 9683

5259, 7355

287, 614

10384, 10619

4271, 5236

11460, 12367

3467, 3557

7604, 9592

9704, 10363

7381, 7581

10643, 11437

3572, 4252

234, 249

642, 2578

2600, 3296

3312, 3451

8,179

118,699

8397+8398+55936+55940+55941

Discharge summary

report+report+addendum+addendum+addendum

Admission Date: [**2107-5-15**] Discharge Date: [**2107-6-9**] Service: CSU CHIEF COMPLAINT: Eighty-four-year-old gentleman with aortic insufficiency with dilated aorta, ascending thoracic aorta for repair. HISTORY OF PRESENT ILLNESS: His is an 84-year-old gentleman admitted preoperatively for replacement of his aortic valve after being admitted in [**Month (only) 958**] with atrial fibrillation and hypertension, and the finding of a dilated ascending aorta which we know to have existed back in [**2100**]. Cardiac catheterization was done preoperatively, which revealed no evidence of coronary artery disease and [**3-4**]+ AI in the setting of a 5.6-cm ascending thoracic aneurysm. In the interval between his medical diagnosis, and workup, and his admission, he underwent maximum medical therapy for his hypertension. His left ventricular ejection fraction was 40% by echocardiogram. A chest CT also done preoperatively showed a maximum diameter of his ascending aortic aneurysm of 5.6 cm which is correlated with the cardiac catheterization data. ALLERGIES: He has a questionable allergy to erythromycin. PAST MEDICAL HISTORY: His past medical history was significant for hypercholesterolemia, hypertension, PAF, depression, glaucoma, hearing aid, right-sided rib fractures, and cataracts, as well as placement of a permanent pacemaker for tachy-brady syndrome, and appendectomy. MEDICATIONS: His medications on admission include amiodarone 400 mg once a day, Coumadin 5 and 7.5 alternating which were held preoperatively on his admission for surgery, Toprol 100 mg XL, Lipitor 40 mg once a day, Paxil 10 mg once a day, timolol 0.25% both eyes once a day, Xalatan 0.005%, Reminyl 4 mg b.i.d., Lasix 40 mg once a day, potassium 20 mEq once a day. FAMILY HISTORY: His mom died of an abdominal aortic aneurysm. SOCIAL HISTORY: He lives with his wife, and he is retired. He is an ex-smoker, not currently smoking. He enjoys alcohol only socially and does not abuse it. PHYSICAL EXAMINATION: On vital signs on admission were temperature of 97.4, heart rate of 78, blood pressure 141/81, respiratory rate of 18, and 97% on room air. He was in no acute distress. His heart was regular rate and rhythm. He is anicteric. He had no JVD, no bruits. His chest was clear. His abdomen was soft and benign with well-healed incisions and no evidence of hernia. His extremities were warm with palpable 2+ DPs bilaterally with no evidence of embolism or acute ischemia. The patient was made NPO. EKG was obtained. He was typed and crossed. Consent was obtained and dental clearance was obtained and sent to Dr.[**Name (NI) 29645**] office. Mr. [**Known lastname **] was evaluated on the morning of [**5-16**] just prior to the operation by EP service to evaluate his pacemaker to make sure it was functioning correctly, and that afternoon underwent an AVR [**26**] mm C-E PERIMOUNT Pericardial Bioprosthesis valve. Basically, it was electively not to operate on the ascending aorta at that time. Please see the operative note for full details in regards to that. He was then transferred to the CSRU intubated and volume resuscitated with tight blood pressure control. HOSPITAL COURSE: Neurologically: The patient was weaned off sedation and moved towards extubation, and it was noted on [**2107-5-18**] on postoperative day #2 that he was not moving all of his extremities properly, and was very slow to wake up. A CAT scan was then obtained, which showed hypoattenuation and suggestive of chronic microvascular ischemia. Neurology was consulted immediately with regards to workup. Based on their evaluation, they felt the patient most likely did have a small watershed infarct intraoperatively, which resulted in this weakness. Even though the CT scan was not conclusive for such. Additional workup was then carried out including a carotid ultrasound which revealed no evidence of plaque that was significant. Based on neurology recommendations, we had his mean arterial pressure increased over 110, though cautiously because of his aneurysm as well. He did eventually regain all his function with minimal to no residua and did in fact move all his extremities at towards the end of discharge. He did not, however, recover a good gag reflex after his prolonged respiratory course which will be detailed below and required a PEG. On discharge, he is not having any acute neurological issues, and he is walking with PT with no evidence of significant neurological deficit or residua. Cardiovascularly: The patient was hemodynamically stable requiring pressors/vasodilators in the postop course to maintain a good blood pressure. In the immediate postop period, it was elected to keep his pressure on the low side due to his aneurysm. However, the further we got from the immediate postop period, the blood pressure was allowed to climb upwards to maximize perfusion to his brain, which had was previously outlined. Neurological event of which there was no sequelae. He had a few bouts of atrial fibrillation which were controlled well with amiodarone and beta-blockade. However, it was noted he was in a 1st degree AV block at the end of his hospital stay and was elected to minimize his beta- blockade and rate control, and just putting him on 12.5 of b.i.d. Lopressor to excellent effect. He has remained upon now and 24 hours of sinus rhythm and indeed for the most of the last week. In light of this, it has been elected not to continue his anticoagulation at this point due to the risks of anticoagulation in this elderly gentleman with a nonmechanical valve. Respiratory: The patient's respiratory course was somewhat complex. The patient was slow to wake up and remained intubated from the immediate postop period until [**2107-5-24**] more than a week from his operation. The reasons for this was mainly, he was slow to wake up and protect his airway, and 2) bouts of desaturations as well as pulmonary edema. Additionally, his chest x-ray was suggestive of pneumonia and sputum cultures which were sent off returned oropharyngeal flora for the most part, but did return corynebacterium as well. This was presumed to be a pneumonia, and he was treated with a course of Levaquin as well as Zosyn during the course of his hospital stay to good effect and upon that, his white count had normalized. Was discharged and he had no acute respiratory issues. With regards to his airway, he failed extubation, which was carried out on the 24th as outlined, and he remained in a tenuous position with regards to that finally being reintubated 2 days later on [**5-26**] after he demonstrated the inability to adequately protect his airways and continued to have a decline in his respiratory status. After this, a tracheostomy was elected to be carried out through the percutaneous fashion and this was done on [**2107-6-1**]. After this, we were able to do several tracheostomy collar trials and eventually weaned him on the ventilator. Upon discharge, he is off the ventilator for greater than 48 hours requiring routine tracheostomy care. GI and abdomen: The patient was initially NPO due to his inability to wake up. However, feeding tube was inserted, and he was given tube feeds. Several swallow evaluations were carried out during the course of the hospital stay, which the patient, unfortunately, floridly failed. It was then elected to perform a percutaneous endoscopic gastrostomy which was conducted on the patient on [**2107-6-7**] with no undo events. He continued his tube feeds the next day and upon discharge, he is tolerating those without any ill effect. Hematology: Patient required several units of blood for anemia of chronic disease as well as in the immediate postoperative period for operative-related anemia. His coags were within normal limits upon discharge, and as I said, with discussion with the ICU team as well as the attending, no anticoagulation is being carried out upon discharge. Patient has no acute hematological issues. ID: The patient received full courses of antibiotics for presumptive pneumonia and is currently afebrile with no white count. Endocrine: The patient does not have any endocrinology issues at this time. During the hospital stay, he received insulin for tight blood sugar control, which he should be discharged to rehab on. FEN, GU, and renal: Upon discharge, the patient has a normal BUN and creatinine. Is making excellent urine and is not requiring any aggressive diuresis, and is saturating very well. He had an episode of pulmonary edema early in his hospital course, the 1st week postoperative, which was treated with aggressive diuresis to which the patient responded and is currently doing well. He came in with some degree of renal insufficiency with a creatinine in the mid 1 range, and upon [**2107-6-7**], he has returned to what is his normal creatinine of 1.4, within his normal range. His electrolytes are in balance. DISCHARGE DIAGNOSES: 1. Aortic insufficiency status post repair. 2. Ascending thoracic aneurysm, 3. Ventilator-dependent respiratory failure now off the ventilator. 4. Tracheostomy placement for airway protection as well as respiratory support. 5. Insertion of gastric tube for failure to swallow. 6. Anemia of chronic disease. 7. Stroke without residua as well as his pre-existing diagnoses which include paroxysmal atrial fibrillation, hypertension, hypercholesterolemia, glaucoma. DISCHARGE MEDICATIONS: Aspirin 81 mg via the PEG once a day, Tylenol p.r.n. via the PEG, Lipitor 40 mg once a day, Reminyl 4 mg via the PEG b.i.d., Flovent 110 mcg 2 puffs b.i.d., timolol maleate 0.25% 1 drop both eyes b.i.d., latanoprost 0.005% solution 1 drop both eyes at bedtime, nystatin oral suspension 5 cc p.o. q.i.d., albuterol nebulizer inhaler q.4., ipratropium nebulizer inhaler q.4., Prevacid 30 mg via the PEG daily in a solution, iron 325 mg via the PEG daily, vitamin C 500 mg via the PEG b.i.d., heparin 5,000 units SC t.i.d. until ambulating very well, and Lopressor 12.5 mg per the PEG b.i.d. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Doctor Last Name 29646**] MEDQUIST36 D: [**2107-6-8**] 10:36:51 T: [**2107-6-8**] 11:24:50 Job#: [**Job Number 29647**] Admission Date: [**2107-5-15**] Discharge Date: [**2107-6-9**] Service: CSU ADDENDUM: Patient should go home on Coumadin as well for a goal INR of 2.0 to be monitored by his primary care physician as well as the doctors [**First Name (Titles) **] [**Last Name (Titles) **] and his warfarin dosed appropriately. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Doctor Last Name 29646**] MEDQUIST36 D: [**2107-6-8**] 10:59:27 T: [**2107-6-8**] 11:11:04 Job#: [**Job Number 29648**] Name: [**Known lastname 5171**],[**Known firstname **] Unit No: [**Numeric Identifier 5172**] Admission Date: [**2107-5-15**] Discharge Date: [**2107-6-9**] Date of Birth: [**2022-10-28**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base Attending:[**First Name3 (LF) 674**] Addendum: Pt. had inappropriate pacer spikes detected on [**6-8**]. He was evaluated by EP and has a faulty atrial lead. He needs to be seen by Dr. [**Last Name (STitle) **] in 4 weeks. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 3542**] [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2107-6-9**] Name: [**Known lastname 5171**],[**Known firstname **] Unit No: [**Numeric Identifier 5172**] Admission Date: [**2107-5-15**] Discharge Date: [**2107-6-9**] Date of Birth: [**2022-10-28**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base Attending:[**First Name3 (LF) 674**] Addendum: The pt. has an ALA pacer. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 3542**] [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2107-6-9**] Name: [**Known lastname 5171**],[**Known firstname **] Unit No: [**Numeric Identifier 5172**] Admission Date: [**2107-5-15**] Discharge Date: [**2107-6-9**] Date of Birth: [**2022-10-28**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base Attending:[**First Name3 (LF) 674**] Addendum: There was not a contraindication to giving this patient coumadin. The anticoagulation was held for trach and PEG placement. His coumadin was restarted and he was discharged on Amiodorone 200 mg qd for PAF. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 3542**] [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2107-6-9**]

[ "E878.1", "441.2", "280.0", "263.9", "997.3", "518.5", "427.31", "401.9", "486", "272.0", "997.02", "424.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "35.21", "39.61", "96.6", "31.1", "43.11", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

12825, 13034

1795, 1842

8947, 9424

9448, 11392

3209, 8926

2024, 3191

106, 221

250, 1133

1156, 1778

1859, 2001

78,222

199,580

1252

Discharge summary

report

Admission Date: [**2151-9-1**] Discharge Date: [**2151-9-18**] Date of Birth: [**2084-4-24**] Sex: F Service: MEDICINE Allergies: Zocor / Flagyl Attending:[**First Name3 (LF) 12**] Chief Complaint: Low blood pressure, diarrhea Major Surgical or Invasive Procedure: Central line placement Nephrostomy tube History of Present Illness: Pt is a 67 yo W with PMH of Stage III NSCLC and metastatic cervical cancer who presents with 3 days of diarrhea, as well as increase in malaise and weakness. Pt reports profuse diarrhea per day with one bloody stool several days ago. No n/v/abdominal pain. Last XRT treatment 2 weeks ago. Last chemo tx in 7/[**2150**]. In the ED: VS: T 95.6 HR 45 BP 75/30 RR 17 98% RA. Labs notable for WBC count of 26(chronic), HCT 26, Cr 4.9, lactate 4.1. Stool guaiac +. She received 4L IVFs with no improvement in BP. RIJ line was placed. CVP was 17 after fluids. She received cipro 400mg IV x 1, Vanco 1g, ceftriaxone 1g, protonix, 2 amps calcium gluconate and 2 U PRBCs. Non contrast CT abd/pelvis unrevealing. Pt transferred to [**Hospital Unit Name 153**] for further management. Past Medical History: PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, diabetes, diabetic retinopathy, and diabetic nephropathy. PAST SURGICAL HISTORY: Laser surgery for retinal hemorrhage. OB HISTORY: Vaginal delivery x2. GYN HISTORY: Last Pap smear as above. Last mammogram was in [**2148**] and normal. Social History: The patient has smoked one-half pack per day off and on for many years. She does not drink. She is a customer service supervisor. She has been married for 47 years and has 2 daughters as well as several grandchildren who all live close. Family History: Negative for malignancies. Physical Exam: VS: T BP 90/44 HR 53 RR 14 Sats GEN: Chronically ill appearing in NAD HEENT: EOMI, PERRL, anicteric NECK: Supple, RIJ line in place: C/D/I, Elevated JVP CHEST: CTABL, no w/r/r CV: Bradycardic, Regular, S1S2, III/VI systolic murmur at LLSB ABD: Soft/NT/ND, hypoactive BS EXT: no c/c/e SKIN: no rashes NEURO: AAOx3 however thought nurse was son in law and appeared to be having visual hallucinations; otherwise CN ii-Xii intact, strength in b/l lower extremities: 5-/5 (Right) 4+/5 Left toes: upgoing bilaterally Pertinent Results: [**2151-9-1**] 01:21PM HGB-9.4* calcHCT-28 GLUCOSE-124* LACTATE-4.1* NA+-130* K+-8.5* CL--98* TCO2-15* [**Name (NI) 7802**] TOP PT-16.1* PTT-32.7 INR(PT)-1.4* PLT COUNT-174 NEUTS-96.0* LYMPHS-1.8* MONOS-1.3* EOS-0.9 BASOS-0 WBC-26.0* RBC-2.65* HGB-8.0* HCT-25.8* MCV-97 MCH-30.0 MCHC-30.8* RDW-17.3* [**2151-9-1**] 01:44PM ALBUMIN-2.7* [**2151-9-1**] 01:44PM CK-MB-19* MB INDX-5.1 cTropnT-0.07* [**2151-9-1**] 01:44PM LIPASE-12 [**2151-9-1**] 01:44PM ALT(SGPT)-35 AST(SGOT)-38 CK(CPK)-369* ALK PHOS-278* TOT BILI-0.5 [**2151-9-1**] 01:44PM estGFR-Using this [**2151-9-1**] 01:44PM UREA N-138* CREAT-4.9*# SODIUM-130* POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-14* ANION GAP-27* [**2151-9-1**] 01:46PM K+-5.6* [**2151-9-1**] 01:46PM COMMENTS-GREEN TOP . [**2151-9-1**] 01:44PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016 RBC-[**5-18**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**10-28**] TRANS EPI-0-2 BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR . [**2151-9-1**] 10:01PM PLT COUNT-195 [**2151-9-1**] 10:01PM WBC-35.1* RBC-3.20* HGB-9.9* HCT-30.3* MCV-95 MCH-30.9 MCHC-32.6 RDW-17.3* [**2151-9-1**] 10:06PM HGB-10.7* calcHCT-32 LACTATE-1.2 TYPE-ART TEMP-36.1 PO2-148* PCO2-35 PH-7.18* TOTAL CO2-14* BASE XS--14 INTUBATED-NOT INTUBA CORTISOL-39.9* CALCIUM-7.2* PHOSPHATE-7.6*# MAGNESIUM-1.7 CK-MB-17* MB INDX-4.4 cTropnT-0.05* CK(CPK)-384* GLUCOSE-150* UREA N-123* CREAT-4.1* SODIUM-133 POTASSIUM-6.0* CHLORIDE-104 TOTAL CO2-11* ANION GAP-24* . [**2151-9-1**] 11:06PM URINE HOURS-RANDOM UREA N-410 CREAT-105 SODIUM-21 . Cardiology Report ECG Study Date of [**2151-9-1**] 12:59:30 PM Sinus bradycardia. Low voltage in the limb leads. Baseline artifact. Compared to the previous tracing of [**2151-1-7**] QRS voltage is decreased, bradycardia is present. . Radiology Report CT PELVIS W/O CONTRAST Study Date of [**2151-9-1**] 4:06 PM IMPRESSION: 1. Relatively stable appearance of the large presacral soft tissue mass with destruction of the left sacrum. The involvement of the colon with the tumor is impossible to assess in absence of oral or IV contrast. 2. Interval increase in size and number of multiple pulmonary nodules, consistent with worsening of metastatic disease. . TTE Done [**2151-9-2**] at 9:36:56 AM IMPRESSION: Normal left ventricular size and function. Right ventricle is dilated, mildly hypokinetic, and has elevated estimated pulmonary artery pressure. Moderate to severe tricuspid regurgitation. . Radiology Report LUNG SCAN Study Date of [**2151-9-3**] IMPRESSION: Low likelihood ration for recent pulmonary embolism. . Radiology Report UNILAT LOWER EXT VEINS LEFT Study Date of [**2151-9-7**] 7:59 AM IMPRESSION: Localized non-occluding thrombus in superior portion of superficial femoral vein probably old. . Radiology Report [**Numeric Identifier 7803**] ANTEGRADE UROGRAPHY Study Date of [**2151-9-7**] 2:47 PM IMPRESSION: 1. Mild-to-moderate hydronephrosis and hydroureter. No contrast is seen passing into the bladder from the distal left ureter. 2. 8 French nephrostomy tube placed. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2151-9-10**] 7:53 AM IMPRESSION: 1) Slight interval increase in right pleural effusion and right basilar atelectasis. 2) Slight interval improvement in vascular congestion. . Brief Hospital Course: 67 yo W with PMH of Stage III NSCLC and metastatic cervical cancer admitted for shock/hypotension, bradycardia, diarrhea, and acute renal failure. Hypotension/Shock: The patient was admitted to the ICU for management of hypotension, the cause of which was felt to be multifactorial, including hypovolemia, possible urosepsis vs. atenolol overdose in setting of renal failure. Pressure was not responsive to fluids and 2U PRBCs. She initially received glucagon drip for possible beta blocker toxicity but bradycardia did not improve. Pain medications were held. She was on max dose levophed with MAPS of 55-60. VQ scan was obtained which showed no evidence of PE and no evidence of tamponade on echo. Patient was slowly weaned off pressors, although blood pressures never returned to her hypertensive baseline. The patient was transferred from the ICU on HD 5. Home hypertensives were held. She continued to have SBPs in the 80's which were initially responsive to fluid boluses but the patient gradually became persistently hypotensive, especially in the setting of receiving pain medications. . Acute Renal Failure: The patient had chronic kidney disease due to hypertension, with a baseline creatinine of 1.5-2 since [**6-15**]. Urine studies gave evidence of ATN with muddy brown casts. Renal ultrasound demonstrated left sided hydronephrosis and this was ultimately felt to be due to a left sided pelvic mass. The Urology and nephrology services were consulted. A nephrostomy tube was placed [**9-7**] and the patients Cr slowly improved over the course of a week. The last creatinine was documented as 1.7 . E.Coli UTI - Treated with ceftriaxone for 14 days. Repeat urine cultures were negative. . Diarrhea: The patient had a history of c. Diff colitis requiring PO Flagyl. However, all c dipf testing was negative. It was felt that recent XRT and may have caused radiation colitis. The patient did not have further episodes of diarrhea following admission. . Leukocytosis: Pt was noted to have a chronically elevated WBC count since [**Month (only) 216**]. It was unclear whether this was secondary to infection or malignancy. Blood smear showed toxic granulations, but only evidence of infection was UTI. CT ABD/pelvis (w/o contrast) did not show evidence of inflammation/abscess. UTI was treated as above. There was some concern for C.dif, and po vanco was started for several days with an initial response (WBC 45-->25). However, the WBC returned to 30 despite continued treatment. This leukocytosis remained through admission and was last documented at 30 on [**9-14**], after which labs were discontinued. . Thrombocytopenia/LLE - The patient was noted to have an acute decrease in platelet count over a few days of hospitalization. Concern was raised for HIT, but HIT antibody was negative. There were no sx of bleeding. The patients platelet count did not recover. The patient was noted to have significant edema of the left lower extremity and LENIs were positive for an old DVT, there did not appear to be active clot. No further interventions were made. . Pain Control/Goals of care/End of Life: The patient had extensive bony metastases from her cervical cancer and she had an established pain control regimen as an outpatient. However, this was discontinued on admission most likely due to concerns for her blood pressure. On transfer from the ICU, the patient reported [**9-17**] left lower extremity pain and her home pain regimen was reinstated. However, the patient responded with hypotension and somnolence. A family meeting was held on Friday [**9-10**] which addressed the patient's goals of care. The goal was initially for a transition to home hospice. On [**9-11**] the patient was granted temporary leave to attend her grandson's homecoming football game. In the days following this event, the patient continued to experience exquisite pain. The pain and palliative care service was consulted for assistance managing the balance between mental clarity, pain control and blood pressure. On [**9-14**], discussions with the family identified that pain management was their highest priority and the patient was subsequently transitioned to CMO care. She died peacefully with her family by her side the afternoon of [**9-18**]. Medications on Admission: Lipitor 10mg daily lisinopril 15mg daily atenolol 100mg daily hydrochlorothiazide 25mg daily Oxycodone Fentanyl Klonopin Discharge Disposition: Expired Discharge Diagnosis: Metastatic cervical cancer Discharge Condition: Expired Completed by:[**2151-9-20**]

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icd9cm

[ [ [] ] ]

[ "34.91", "38.93", "55.03" ]

icd9pcs

[ [ [] ] ]

10149, 10158

5695, 9978

301, 343

10229, 10267

2337, 5672

1761, 1789

10179, 10208

10004, 10126

1327, 1487

1804, 2318

233, 263

371, 1147

1192, 1303

1503, 1745

49,382

174,526

32980

Discharge summary

report

Admission Date: [**2194-12-11**] Discharge Date: [**2194-12-17**] Date of Birth: [**2171-6-8**] Sex: F Service: MEDICINE Allergies: Egg [**Location (un) 76704**] Dust Attending:[**First Name3 (LF) 4095**] Chief Complaint: "DOE with dry cough and n/v." Major Surgical or Invasive Procedure: 1. CT-guided lung biopsy of the 1.9cm lesion in the RUL. History of Present Illness: 23 year old homeless female presents to the ED with temp 100.3, dyspnea on exertion and dry cough. . Patient has had intermittent dry cough since [**2194-7-24**]. At the end of [**Month (only) **] she was treated with azithromycin x 5 days for an atypical pneumonia. Patient was subsequently hospitalized at [**Hospital1 18**] from [**2194-10-25**] - [**2194-10-28**] with persistent cough, nightsweats and chills. Her CXR showed a RUL infiltrate which was thought to be an old pneumonia, not treated with any antibiotics. Initial concern for active TB, she had two negative AFB sputums however samples were noted to be concentrated with upper respiratory secretions. PPD was negative. Follow-up chest film on [**2194-12-4**] showed progression of lung lesion, now identified as two discrete lung lesions, in right upper vs lower lobe and lingula. Differential includes fungus, mycobacterial and nocardia infection. Patient was referred to pulmonary, per phone note from [**2194-12-8**], and scheduled for a CT chest without contrast tomorrow ([**2194-12-12**]). Patient complained of worsening chest tightness, sob and nightsweats. She was advised to go to the ED if symptoms persisted. . Patient reports Temp to 100.3 several days ago. She reports that she had been feeling better until Sunday when she had a episode of nausea and NB NB vomitting. She also reports worsening NS, chills and decreased activity tolerance. She reports that she is usually able to go for 15 minute walks without difficulty. Now she gets sob with about 5 minutes of walking. She says that she had infections fairly frequently in the past, but unsure of exact duration or location. She has a h/o pna at age 12 yo but no other pulmonary issues. Her ROS is also positive for vaginal discharge that she feels is from an untreated BV infection. She denies CP per say but says she has occasional parathesias in her chest. ROS is otherwise negative. . Had a negative HIV test in [**Month (only) 359**]. Attempting to relocate to a new shelter, reports high levels of mold. . ED: 98.6 108 120/60 16 100% RA; CTA Chest: neg for pe, multifocal nodules in both lungs, cavitation in 2 nodules, ddx includes multifocal infection, fungal vs septic emboli; patient given unasyn, nafcillin, gent and ambisome - to cover endocarditis and fungal etiologies . ROS:negative. Past Medical History: -Fibromyalgia and chronic pain -Iron deficiency -Depression, anxiety, PTSD -Gonorrhea/chlamydia [**2188**] and Gonorrhea [**6-/2194**] -Abnormal Pap in [**2187**] -Bed bug bites -h/o PNA Social History: -Living in a shelter with her 3 year old son. -Recently spent some time at grandparents house because she had bed bug bites from the shelter. -5 py hx of smoking, quit 1 month PTA. -No known TB exposure. -denies IVDU -denies ETOH -on depo for birth control, has unprotected sex with father of child Family History: No family h/o lung pathology. Son with asthma. Physical Exam: Exam on admission: VS: 98.2 117/69 94 18 100 RA General: AAOX3 in NAD HEENT: CN 2-12 grossly intact, MMM, oropharynx clear Endo/Lymph: no obvious thyroid nodules, no LAd CV: RRR, no RMG Lungs: mild bibasilar crackles, left greater then right, equal lung expansion Abdomen: flat, not TTP, no HSM, active BS Extremities: UE: WWP, pulses equal, sensation intact, strength wnl LE: WWP, pulses euqal, sensation intact, strenght wnl Derm: no obvious rashes, no stigmata of IE Psych: mood and affect wnl Exam at discharge: T 97.6 BP 112/60 P 70s-80s RR 16 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [**11-28**] blowing systolic murmur best heard at LUSB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: Labs upon admission: [**2194-12-11**] 02:58AM LACTATE-1.3 [**2194-12-11**] 02:43AM GLUCOSE-116* UREA N-14 CREAT-0.6 SODIUM-140 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12 [**2194-12-11**] 02:43AM WBC-6.7 RBC-4.05* HGB-13.3 HCT-38.2 MCV-95 MCH-32.8* MCHC-34.7 RDW-12.6 [**2194-12-11**] 02:43AM NEUTS-41.9* LYMPHS-45.7* MONOS-7.2 EOS-4.1* BASOS-1.2 [**2194-12-11**] 02:43AM PLT COUNT-208 [**2194-12-11**] 02:20AM URINE HOURS-RANDOM [**2194-12-11**] 02:20AM URINE UCG-NEGATIVE [**2194-12-11**] 02:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2194-12-11**] 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [**2194-12-11**] 02:20AM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE EPI-1 [**2194-12-11**] 02:20AM URINE MUCOUS-RARE Pregnancy test negative Labs prior to discharge: [**2194-12-12**] 06:35AM BLOOD ESR-7 [**2194-12-12**] 06:00PM BLOOD PT-15.7* PTT-32.8 INR(PT)-1.5* [**2194-12-13**] 03:05AM BLOOD PT-14.5* PTT-29.0 INR(PT)-1.4* [**2194-12-12**] 06:00PM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.5 Mg-2.1 [**2194-12-11**] 02:43AM BLOOD RheuFac-5 [**2194-12-11**] 02:43AM BLOOD [**Doctor First Name **]-NEGATIVE [**2194-12-12**] 06:35AM BLOOD CRP-2.0 [**2194-12-11**] 02:43AM BLOOD ANCA-NEGATIVE B Aspergillus Galactomannin: Negative Beta Glucan: Negative ACE, serum: Negative Micro: Blood culture x4 negative, included fungal and AFB culture . Cryptococcal antigen: negative . TISSUE RUL NODULE. GRAM STAIN (Final [**2194-12-12**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2194-12-15**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2194-12-18**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2194-12-15**]): NO FUNGAL ELEMENTS SEEN. ACID FAST SMEAR (Final [**2194-12-13**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2194-12-14**]): NEGATIVE for Pneumocystis jirovecii (carinii).. . AFB smear x3 negative . Reports: [**2194-12-11**] CTA Chest: 1. No evidence of acute pulmonary embolism or thoracic aortic pathology. 2. Multiple nodules in both lungs, with suggestion of cavitation in a single nodule. The differential considerations include multifocal infections, with etiologies including fungal and Nocardia infection and malignancy such as lymphoma. Septic emboli is considered unlikely given the time course of progression. Recommended biopsy for further evaluation. [**2194-12-11**] CXR: Three nodules in the right upper lobe and left mid lung, are concerning for an infectious process including fungal and nocardia infection. Malignancy is also in the differential. Please refer to the CT chest performed on the same day for further evaluation. Biopsy results from Right lung lesion: Lung nodule, needle core biopsy: Pulmonary parenchyma with non-necrotizing granulomatous inflammation, see note. Note: AFB and GMS (fungal) stains are negative for organisms. No polarizable material seen. The differential diagnosis includes an infectious process and other causes of granulomatous lung disease (sarcoidosis, etc...). . Cytology of right lung lesion: NEGATIVE FOR MALIGNANT CELLS. Bronchial cells, abundant macrophages, and structures suggestive of granulomas. . [**12-12**] TTE: The left atrium is normal in size. 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%). 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 stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: 23 year old woman with history of pneumonia and bronchitis as a child, recent history of presumed right upper lobe pneumonia treated with subsequent improvement but persistence of symptoms (dry cough, fatigue, night sweats, chills, shortness of breath on exertion), found to have progressive pulmonary nodules (increasing in size and number), now s/p CT guided biopsy with significant hemoptysis transferred to ICU for monitoring. . # Hemoptysis: [**1-25**] cups of hemoptysis acutely during CT guided biopsy of the right lung. Patient remained hemodynamically stable, transferred to the [**Hospital Unit Name 153**] with continued intermittent scant hemoptysis. 2 large PIVs were maintained and patient was T&S'd. Hct stable at 39, satting 100% on RA. Patient was kept on her right side (the side of the biopsy) and kept NPO. IP and IR were consulted and requested her transfer to the [**Hospital Ward Name **] for monitoring, should she need intervention. Repeat CXR showed new right pleural effusion, right upper nodule now hazier, consistent with post-biopsy state, no pneumothorax identified. Patient was trasnferred west for further monitoring. She was hemodynamically stable throughout the rest of her hospital course with resolution of hemoptysis. . # Non-necrotizing granulomatous lung nodules: No fever or leukocytosis. Biopsy and cytology results revealed non-necrotizing granulomatous disease. Tissue culture was negative, Staining for fungi and AFB were negative, serum fungal markers negative, AFBx3 negative, Normal ESR, CRP, and Rheumatoid factor, and [**Doctor First Name **] and ANCA negative. Based on these findings in conjunction with imaging studies, infectious etiologies, connective tissue disease/vasculidities, and lymphoma were considered highly unlikely. The exact disease is unclear at this time, but consideration was given to nodular sarcoid, which although typically presents with hilar lymphadenopathy and interstitial infiltrates can also present as nodular lesions with minimal hilar lymphadenopathy. . # Pain: Patient is having post procedural pain which was controlled initially with IV fentanyl, however was transtioned to IV morphine and then oxycodone with good control. . # Anxiety: Managed with ativan prn. . # Fibromyalgia and chronic pain: Patient does not appear to be managed with an SSRI at home. . # Iron deficiency anemia: not on iron supplements at home, no evidence of iron deficiency on OMR. MCV is 95-98. . # Depression, anxiety, PTSD: not on outpatient meds. . . Code: Full TRANSITIONAL: Follow up on lesions. Given worsening of symptoms at homeless shelter likely some component of allergies and reactive airway disease. Recommend consideration of allergy testing. Medications on Admission: MEDROXYPROGESTERONE PNV WITH CA,NO.71-IRON-FA [NATALCARE PLUS] - 27 mg-1 mg Tablet daily ACETAMINOPHEN - 325 mg Tablet - 2 Tablet(s) by mouth q6h prn pain NICOTINE - 14 mg/24 hour Patch 24 hr - apply 1 patch daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 3. Depo-Provera Intramuscular 4. cyanocobalamin (vitamin B-12) 50 mcg Tablet Sig: One (1) Tablet PO once a day. 5. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*14 Patch 24 hr(s)* Refills:*0* 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO twice a day. 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. fluticasone 250 mcg/Actuation Disk with Device Sig: One (1) Inhalation twice a day. Disp:*1 disk* Refills:*1* 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Non-necrotizing granulmatous pneumonitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [**Known lastname 51795**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for worsening of your dry cough, shortness of breath, fever, and nightsweats. You had imaging of your lungs done which demonstrated progression of your lung nodules including cavitation in one of them. Because it was unclear what was causing these lesions to progress, a biopsy was performed of a right upper lobe nodule. This caused you to cough up significant amounts of blood due to injury of a lung vessel. As a result, you went to the intensive care unit. Your coughing up blood resolved. Your sputums revealed no evidence of active tuberculosis and results of the biopsy showed no evidence of cancer, tuberculosis, or fungal infection. You did have a significant amount of inflammation on your biopsy in which certain cells have "walled off" a harmful substance that your immune system cannot clear; however, at this time, it is unclear what is causing this. The following changes were made to your medication: Increase dose of fluticasone Started oxycodone for chest pain just for the next few days Followup Instructions: Department: PULMONARY FUNCTION LAB When: THURSDAY [**2194-12-18**] at 2:10 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: THURSDAY [**2194-12-18**] at 2:30 PM Department: MEDICAL SPECIALTIES When: THURSDAY [**2194-12-18**] at 2:30 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 Completed by:[**2194-12-18**]

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Discharge summary

report

Admission Date: [**2192-11-30**] Discharge Date: [**2192-12-21**] Date of Birth: [**2132-11-12**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: headache Major Surgical or Invasive Procedure: [**2192-11-30**] external ventricular drain placement [**2192-11-30**] craniotomy for frontal IPH Multiple cerebral angiograms [**2192-12-18**] PEG PLACEMENT [**2192-12-18**] TRACHEOSTOMY PLACMENT History of Present Illness: The patient is a 60 year old man from [**Country 2784**] h/o HTN who had a headache last night, took aspirin and went to bed. The patient came into the ER after seizing, vomiting. He required intubation because he could not protect his airway. The patient was withdrawing all extremities to pain according to the ER resident. Currently the patient is on propofol. Neurosurgery was called because there was a large IVH seen on CT scan. Past Medical History: HTN Social History: Social Hx: is from [**Country 2784**] and is visiting friends in [**Name (NI) 86**] Family History: Family Hx:unknown Physical Exam: PHYSICAL EXAM: T: 99.8 131/65 HR:97 R17 O2Sats: 100% Gen: intubated opens eyes to stimuli HEENT: Pupils: 4mmto 2mm bil mm bilaterally Neck: in cervical collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: intubated and sedated Cranial Nerves: I: Not tested II: Pupils pinpoint III-XII: unable to test Motor: withdraws left Upper and Bil. lower extremities to noxious stimuli. Does not move the right UE to noxious. Toes downgoing bilaterally ON DISCHARGE ******************** Pertinent Results: [**Known lastname 81925**]-[**Known lastname 81926**],[**Known firstname 81927**] [**Medical Record Number 81928**] M 60 [**2132-11-12**] Cardiology Report ECG Study Date of [**2192-11-30**] 11:00:24 AM Sinus rhythm. Left ventricular hypertrophy. Non-specific septal ST-T wave changes. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D. Intervals Axes Rate PR QRS QT/QTc P QRS T 74 140 114 404/428 79 63 74 ([**Numeric Identifier 81929**]) [**Known lastname 81925**]-[**Known lastname 81926**],[**Known firstname 81927**] [**Medical Record Number 81928**] M 60 [**2132-11-12**] Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2192-11-30**] 11:16 AM [**Last Name (LF) 14311**],[**First Name3 (LF) **] EU [**2192-11-30**] SCHED CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 81930**] Reason: eval for cspine fx [**Hospital 93**] MEDICAL CONDITION: 60 year old man with HTN p/w acute ALOC w/ HA and ? Sz, obtunded, + Fall no signs of sig head trauma REASON FOR THIS EXAMINATION: eval for cspine fx CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: ENYa [**First Name9 (NamePattern2) **] [**2192-11-30**] 12:26 PM No acute cervical fracture or dislocation. No significant prevertebral soft tissue swelling. Small posterior osteophyte at C5/C6. Final Report HISTORY: 60-year-old man with hypertension, presenting with acute loss of consciousness with headache and questionable seizure. Possible fall but no signs of acute trauma. Evaluate for possible cervical spine fracture. TECHNIQUE: Helical MDCT images were acquired from the skull base to the cervicothoracic junction. Multiplanar reformatted images were acquired. COMPARISON: No comparison is available. FINDINGS: There is no evidence of acute cervical fracture or subluxation. There is no prevertebral soft tissue swelling. The normal cervical lordosis is preserved. There is normal atlanto-axial alignment. There are multilevel chronic degenerative changes, most prominent at C5-6 with posterior osteophyte, causing mild spinal canal stenosis. In the visualized lung apices, there are mild paraseptal emphysematous changes and bilateral dependent atelectasis. There are an endotracheal tube and a nasogastric tube. There is secretion pooling in the dependent position of the posterior pharynx. IMPRESSION: 1. No acute cervical fracture or subluxation. 2. Prominent posterior osteophytosis at level C5/C6, which increases risk of spinal cord injury even in minor trauma. Recommend MRI if clinically concerned for cord trauma. [**Known lastname 81925**]-[**Known lastname 81926**],[**Known firstname 81927**] [**Medical Record Number 81928**] M 60 [**2132-11-12**] Neurophysiology Report EEG Study Date of [**2192-12-6**] OBJECT: EVALUATE FOR BRAIN ACTIVITY. THIS IS A DIGITAL EEG MONITORING WITH EKG AND VIDEO [**12-5**] - [**2192-12-6**]. THERE WERE NO PUSHBUTTON ACTIVATIONS. ROUTINE SAMPLING AND SPIKE AND SEIZURE DETECTION PROGRAMS WERE UTILIZED. REFERRING DOCTOR: DR. [**First Name (STitle) **] L. [**Doctor Last Name **] FINDINGS: ROUTINE SAMPLINGS: Showed a general suppression of the background with bursts of either generalized or left or right activity seen with a frequency of between 8 and 12 seconds. There were no epileptiform features seen. SLEEP: There were no normal sleep features seen. CARDIAC MONITOR: Showed a generally regular rhythm. SPIKE DETECTION PROGRAMS: Showed occasional sharp and slow wave complexes in the left frontal region. SEIZURE DETECTION PROGRAMS: There were 12 entries in this file. Showed no epielptiform features. PUSHBUTTON ACTIVATIONS: There were no pushbutton activations in this file. IMPRESSION: This telemetry captured no ongoing seizure activity. The background activity was suggestive of a burst-suppression pattern and occasional sharp and slow wave complexes were seen in the left frontal region. INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] L. (09-0137F) [**Known lastname 81925**]-[**Known lastname 81926**],[**Known firstname 81927**] [**Medical Record Number 81928**] M 60 [**2132-11-12**] Radiology Report UNILAT UP EXT VEINS US LEFT PORT Study Date of [**2192-12-7**] 8:23 AM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-B [**2192-12-7**] SCHED UNILAT UP EXT VEINS US LEFT PO Clip # [**Clip Number (Radiology) 81931**] Reason: BRAIN HAEMORRHAGE ASSESS FOR DVT [**Hospital 93**] MEDICAL CONDITION: 60 year old man with REASON FOR THIS EXAMINATION: r/o DVT Final Report HISTORY: 60-year-old male. Rule out DVT. COMPARISON: None available. FINDINGS: Grayscale and color son[**Name (NI) 493**] imaging of the left internal jugular, subclavian, axillary, basilic, and brachial veins was performed. The right subclavian vein was interrogated for comparison purposes. There is a dampened waveform appreciated in the left subclavian vein compared to the right, suggestive of central obstruction. In the remainder of the vessels; however, there is normal flow, compressibility, and augmentation. There is no intraluminal thrombus identified. IMPRESSION: 1. Nonvisualization of the left internal jugular vein. This could be secondary to prior occlusion or aplasia. 2. Dampened waveforms in the left subclavian vein compared to the right. This of uncertain clinical significance. If there is clinical concern for an SVC syndrome, further evaluation with MRV could be considered. 3. No evidence for deep venous thrombosis in the left upper extremity. These findings were communicated to the referring physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 81932**] at 2:30 p.m. on [**2192-12-7**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Known lastname 81925**]-[**Known lastname 81926**],[**Known firstname 81927**] [**Medical Record Number 81928**] M 60 [**2132-11-12**] Radiology Report BILAT LOWER EXT VEINS PORT Study Date of [**2192-12-7**] 10:27 AM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-B [**2192-12-7**] SCHED BILAT LOWER EXT VEINS PORT Clip # [**Clip Number (Radiology) 81933**] Reason: BRAIN HAEMORRHAGE ASSESS FOR DVT [**Hospital 93**] MEDICAL CONDITION: 60 year old man with REASON FOR THIS EXAMINATION: r/o dvt Provisional Findings Impression: AJy [**First Name9 (NamePattern2) **] [**2192-12-7**] 6:59 PM PFI: No lower extremity DVT. Final Report HISTORY: 60-year-old male to rule out DVT. COMPARISON: None available. FINDINGS: Grayscale and color son[**Name (NI) 493**] imaging of the bilateral common femoral, femoral, popliteal and calf veins was performed. There is normal compressibility, flow, and augmentation. No intraluminal thrombus was identified. IMPRESSION: No evidence for DVT in the bilateral lower extremities. The study and the report were reviewed by the staff radiologist. [**Known lastname 81925**]-[**Known lastname 81926**],[**Known firstname 81927**] [**Medical Record Number 81928**] M 60 [**2132-11-12**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2192-12-15**] 3:35 PM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-B [**2192-12-15**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 81934**] Reason: re-eval ETT position [**Hospital 93**] MEDICAL CONDITION: 60 year old man with SAH REASON FOR THIS EXAMINATION: re-eval ETT position Final Report HISTORY: For ET tube position. FINDINGS: In comparison with the study of [**12-14**], the tip of the endotracheal tube now measures approximately 6.7 cm. No evidence of acute cardiopulmonary disease. Nasogastric tube and central catheter remain in place. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: SAT [**2192-12-15**] 4:45 PM Imaging Lab Brief Hospital Course: Pt was admitted to the hospital through the emergency department for SAH with IVH. Pt was brought to the angio suite and ACA aneurysm was coiled. He then had and EVD placed on Right side. He was then brought to the operating room for evacuation of left frontal IPH. He was transferred to the ICU. Nimodipine, Abx, and anti-seizure medications were initiated. The pt recieved 1-2 doses of intrathecal TPA for assistance in keeping the external ventricular drain catheter clear. His exam was followed closely and on [**2192-12-2**] he had a CTA/CTP which did not demonstrate any vasospsm. Later that same day his ICP spiked to 50's. Mannitol was given and the pt was placed on a cooling blanket. [**2192-12-4**] pt underwent cerebral angiogram which demonstrated mild vasospasm. ICP's remained difficult to control and the pt was ultimately placed in a pentobarb coma / this lasted for one full week and then was discontinued. A bolt was placed to confirm ICP's on [**2192-12-7**]. This was discontinued on the 19th. [**2192-12-11**] pt had CTA/P which demonstrated distal A1 A2 mild vaspasm a cerebral angiogram was ordered for the following am. His exam has remained unchanged till this point. He underwent a trial of external ventricular drain clamping and the drain was removed on [**2191-12-16**]. His blood cultures grew out gram negative rods and he was started on zosyn for this. CTA on the 25th of Janueary did not demonstrate any vasopsasm. Triple H therapy was discontued. Trach and peg were performed on [**12-18**] without complications. A famiily meeting took place on [**12-19**]. He does not need ICU level of care at this point in time. Therefore it is felt that rehabilitation could start now via an in pt facility whether within the U.S. or [**Country 2784**]. The screening process has begun and will continue until a match for the patients and families needs is found. He remains stable and cleared by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for transport to inpt rehabilitative care. Medications on Admission: MVI Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO PRN (as needed). 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for fever. 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection four times a day: FSBS check ac and hs cover with sliding scale reg. insulin prn. 14. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours). 15. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q6H (every 6 hours) as needed for hr>95 or sbp >220. 17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for MAP > 120. 18. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML Injection Q8H (every 8 hours) as needed for line flush. 19. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 11 more days days: Total of 14 days. Last doses [**2193-1-1**]. Discharge Disposition: Extended Care Discharge Diagnosis: ACOMM ANEURYSM RUPTURE WITH COIL OF ANEURYSM SUBARACHNOID HEMORRHAGE INTRAVENTRICULAR HEMORRHAGE OPHTHALMIC ARTERY ANEURYSM / NOT TREATED LEFT INTERNAL CAROTID ARTERY ANEURYSM / NOT TREATED CEREBRAL VASOSPASM RESPIRATORY FAILURE DYSPHAGIA TRANSIENT THROMBOCYTOSIS Discharge Condition: Neurologically stable at present Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. If you are being discharged to an inpatient facility, the staff should be evaluating your wound daily. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**5-31**] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. [**Name10 (NameIs) **] you are discharged to an inpatient facility, the [**Hospital 81935**] medical staff can also discontinue the sutures or staples. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain with / without contrast for this appointment. Completed by:[**2192-12-21**]

[ "331.4", "996.2", "E878.1", "305.1", "238.71", "430", "437.3", "E849.7", "401.9", "518.81", "493.90", "996.75" ]

icd9cm

[ [ [] ] ]

[ "96.72", "88.41", "89.14", "38.93", "01.10", "99.10", "39.72", "31.1", "43.11", "02.2", "96.04", "01.31", "03.31" ]

icd9pcs

[ [ [] ] ]

13762, 13777

9726, 11767

329, 528

14085, 14120

1766, 2674

16178, 16987

1139, 1159

11822, 13739

9183, 9208

13798, 14064

11793, 11799

14144, 16155

1189, 1456

281, 291

9240, 9703

556, 993

1510, 1747

1471, 1494

1015, 1021

1037, 1123

65,481

133,758

44199

Discharge summary

report

Admission Date: [**2101-5-21**] Discharge Date: [**2101-5-22**] Date of Birth: [**2057-11-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Amoxicillin / E-Mycin / Latex / Ondansetron / Vancomycin / Levofloxacin / Zofran / Phenergan / Dilaudid / Ceftriaxone / Sulfamethoxazole/Trimethoprim / Voriconazole / Fluconazole / Caspofungin / Doxycycline / Propranolol / Neurontin / Azithromycin / Xopenex Hfa / Optiray 300 / Ketorolac Attending:[**First Name3 (LF) 5893**] Chief Complaint: Doxycycline desensitization Major Surgical or Invasive Procedure: None History of Present Illness: [**Known firstname **] [**Known lastname 94828**] is a 43 yo female with a history of multiple drug allergies who presented to her PCP's office on [**5-9**] with diffuse joint aches and a history of a recent bull's eye rash. She reported that she had a rash on her left anterior shin for about 6 days prior to her visit with her PCP. [**Name10 (NameIs) **] took a picture of a rash and it was consistent with erythema migrans. She had had some exposure to the [**Doctor Last Name 6641**] prior to the rash developing, but does not recall a tick bite. Her PCP has not started treatment due to concern about her doxycycline allergy. She consulted with the patient's allergist at [**Hospital1 112**] who recommended doxycycline desensitization and outlined a protocol. The patient's treatment has been delayed by lack of ICU beds. She reports mild joint aches in her knees and elbows. Her joint pain was quite severe earlier but has lessened over the past week. She describes some low-grade fevers, but no chills. Denies joint swelling. Of note, the patient recently was treated for pyelonephritis with gentamycin. . Review of sytems: (+) Per HPI and for night sweats r/t menopausal sx, intermittent headache and chronic constipation. (-) Denies fever, chills, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: # Multiple drug allergies including likely [**Initials (NamePattern4) 22721**] [**Last Name (NamePattern4) **] Syndrome associated with fluconazole desensitization. Also, severe phlebitis with PICCs, milder phlebitis with conventional IV catheters if left indwelling # CVID - monthly IVIG # History of recurrent pyelonephritis # autonomic neuropathy - on IVIG primarily for neuropathy but also CVID. # esophageal dysmotility # oral/genital ulcers ? Behcet's # colonic inertia s/p subtotal colectomy at [**Hospital3 14659**] in [**2093**] # atrophic vaginitis with recurrent yeast infections # sleep disorder characterized by non-REM narcolepsy, restless leg syndrome, and periodic leg movements Social History: The patient was [**Name Initial (MD) **] GI NP at [**Hospital1 18**]. She has been on disability for 2 years. She lives alone in the [**Hospital3 4414**]. No tobacoo, alcohol and illict drugs. Family History: Mother with ovarian cancer and history of DVT. Physical Exam: General: Alert, oriented, no acute distress, very pleasant. 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, + midline abdominal scar, 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, no joint erythema or swelling. Skin: no rashes Pertinent Results: [**2101-5-21**] 08:29PM BLOOD WBC-4.0 RBC-3.89* Hgb-12.1 Hct-35.6* MCV-92 MCH-31.0 MCHC-33.9 RDW-12.1 Plt Ct-206 [**2101-5-21**] 08:29PM BLOOD PT-11.7 PTT-22.7 INR(PT)-1.0 [**2101-5-21**] 08:29PM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-138 K-4.0 Cl-102 HCO3-31 AnGap-9 [**2101-5-21**] 08:29PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0 Brief Hospital Course: 43 yo female with a history of CVID, multiple drug allergies, recurrent pyelonephritis, colonic inertia s/p colectomy, recurrent yeast vaginitis who presents for doxcycline desensitization after recent diagnosis of early lyme disease. She received pre-treatment with benadryl 25mg IV (over 30min) and famotidine 20mg IV. She successfully underwent the doxycycline infusion per desensitization protocol. She completed the infusion at 5am. She did not have any adverse reactions. She will start doxycycle as an outpatient at 5pm. The prescription has been provided to her already by her PCP. [**Name10 (NameIs) **] was instructed that the efficacy of her desensitization depends on maintaining a serum concentration of doxycycline and that if she misses a dose she is likely to get an allergic reaction. She was instructed to contact her PCP if she misses a dose. . She was continued on her home medications. Of note, she has had a history of phlebitic reactions previously to IV catheters left in place for longer than a day. Her IV was removed promptly. Medications on Admission: # Epinephrine [EpiPen] 0.3 mg/0.3 mL (1:1,000) Pen Injector # Esomeprazole Magnesium [Nexium] 40 mg PO BID # Ferumoxytol [Feraheme] 510 mg/17 mL (30 mg/mL) Solution Infuse over one minute weekly for 2 weeks Have patient stay in observation for 30 minutes after first dose - none recently # Fexofenadine 60 mg Tablet PO TID - not using currently # Lorazepam [Ativan] 0.5 mg Tablet PO Q6hr PRN anxiety # Methylphenidate [Concerta] 18 mg Tablet Extended Rel 24 hr 2 Tab(s) by mouth once a day [**2101-4-25**] # Sucralfate 1 gram Tablet crushed and used topically four times a day compound and diluted to 4% into an ointment please make dye and fragrance free PRN. Discharge Medications: 1. Concerta 36 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO daily (). 2. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection Intramuscular as needed as needed for anaphylaxis. 3. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a day: Crush tablet and use topically (diluted to 4% in an ointment). 6. Doxycycline Monohydrate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. 7. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO three times a day as needed for allergy symptoms. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Lyme Disease Doxycycline Allergy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital for desensitization of doxycycline. Your outpatient physicians feel that you have Lyme disease. Therefore, it was important to give you doxycycline to treat this infection. You were exposed to doxycycline to help prevent an allergic reaction from taking place. You were monitored very closely in the ICU and did not have any adverse reactions. We made no changes to your medications. Please start taking doxycycline at home tonight at 5pm. Please do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]. If you miss a dose, you are at risk of developing an allergic reaction. Please contact your primary care doctor if you miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] of the doxycycline. Followup Instructions: You have the following appointments scheduled: Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. Date/Time:[**2101-5-23**] 11:20 Provider: [**Name10 (NameIs) 1248**],CHAIR TWO [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2101-5-27**] 10:15 Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2101-6-6**] 3:30 Completed by:[**2101-5-22**]

[ "333.94", "088.81", "V14.1", "V07.1", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6663, 6669

4108, 5171

590, 597

6764, 6764

3758, 4085

7756, 8174

3131, 3179

5883, 6640

6690, 6743

5197, 5860

6915, 7733

3194, 3739

523, 552

1757, 2185

625, 1739

6779, 6891

2207, 2905

2921, 3115

54,728

119,634

18454

Discharge summary

report

Admission Date: [**2156-11-3**] Discharge Date: [**2156-11-7**] Date of Birth: [**2119-1-13**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Vancomycin / Lamictal / Levofloxacin / Benadryl Attending:[**First Name3 (LF) 1854**] Chief Complaint: Intractable Epilepsy Major Surgical or Invasive Procedure: Redo Right Temporal Lobectomy-Dr. [**Last Name (STitle) **], neurosurgery Right Cranioplasty-Dr. [**First Name (STitle) **], plastic surgery History of Present Illness: This is a 37 y/o who underwent a temporal lobectomy for intractable epilepsy. She continued to have seizures. She has been monitored with depth electrodes. A redo temporal lobectomy was recommended. Past Medical History: Infantile febrile seizures Right anterior temporal lobectomy. Post-operative infection requiring bone flap removal and replacement with an acrylic pad. 2.3 mm aneurysm versus tortuosity at the level of the right MCA bifurcation. catamenial seizures and ovarian cysts migraines Prior seizure medications have included phenobarbital, Tegretol, Depakote, Diamox, Tranxene, Topamax, and Felbatol, Keppra. Social History: Works for [**University/College 14925**]as a program coordinator, and works as a staff person in a group home for disabled individuals. She has been having difficultiues with Family History: Mom has high cholesterol, thyroid problems and anxiety. Dad has diabetes. Half sister has thyroid problems and anxiety. Maternal grandmother has bipolar disorder and was treated with lithium. Paternal grandmother and her sister had [**Name (NI) 2481**] disease. Paternal great grandmother had [**Name (NI) 5895**] disease. There is a family history of alcoholism. No family history of epilepsy. Physical Exam: [**2156-11-2**] elective admit for procedure. On the day of admission the patient had a non- focal neurological exam. She was alert and oriented x 3, with full strength and sensation. [**2156-11-7**] On the day of discharge the patient was alert and oriented x 3. The patient exhibited full strength. Brief Hospital Course: Ms. [**Known lastname 50759**] was admitted to [**Hospital1 18**] on [**2156-11-3**]. She underwent a redo Right temporal lobectomy and a cranioplasty with Dr. [**First Name (STitle) **] of PRS. She was extubated and transitioned to the SICU post-operatively. She was on Decadron and her anticonvulsants. She had some pain issues and required a morphine PCA overnight. She also had some intermittent nausea. She was receiving Scopolamine and Zofran. Her post operative CT showed some midline shift and expected post-op changes. On POD#1, she was transitioned to PO pain meds. She has some right facial numbness to the anterior perioral area but this was improving with time. She also had some diplopia with down gaze. She has had this in the past associated with sleep deprivation. She was neurologically intact and was transferred to the SDU for Q2 hr neuro checks. Her headaches were controlled with codeine. Her decadron taper was initiated and tapered to off prior to discharge. She remained without seizure activity and was discharged to home on [**11-7**].On the day of discharge, the patient was alert and oriented x3, with full strength and full ambulatory. She has some continued complaints of diplopia in the right eye and mild headache located behind the right eye controlled with codiene. The patient also has continued complains of mild numbness sensation in the anterior perioral area. Medications on Admission: clariton/carbatrol-own rx.Advair Diskus [**Hospital1 **] Ativan Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/t/HA. 2. Loratadine 10 mg Tablet Sig: One (1) Tablet PO QD (). 3. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QAM (once a day (in the morning)). 4. Carbamazepine 100 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QPM (once a day (in the evening)). 5. Carbamazepine 300 mg Capsule, Sust. Release 12 hr Sig: One (1) Capsule, Sust. Release 12 hr PO TID (3 times a day): Carbamazepine XR 300 mg PO DAILY Pt to take own med. this is afternoon dose -as you take at home. 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as needed for seizure for 1 doses. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. Carbamazepine 200 mg Capsule, Sust. Release 12 hr Sig: Two (2) Capsule, Sust. Release 12 hr PO QAM (once a day (in the morning)). 11. Carbamazepine 200 mg Capsule, Sust. Release 12 hr Sig: 2.5 Capsule, Sust. Release 12 hrs PO QPM (once a day (in the evening)). 12. Carbamazepine 100 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO once a day: afternoon dose.as you have already been taking at home-resume home medication dosing. 13. Loratadine 10 mg Tablet Sig: One (1) Tablet PO QD (): as you take at home. 14. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): as you take at home. 15. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO q4 hours PRN as needed for pain: do not take if you are lethargic, only take if you are experiencing pain, do not drive while taking this medication. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Intractible Epilepsy Cranial defect Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? 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. General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? 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 see Plastic Surgery, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for an appointment to be seen in 1 week and have your sutures removed in [**9-8**] days. ([**Telephone/Fax (1) 2868**] ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 6 weeks. Completed by:[**2156-11-10**]

[ "368.2", "V58.69", "345.81", "437.3", "738.19", "346.90", "782.0" ]

icd9cm

[ [ [] ] ]

[ "02.05", "01.53", "02.03", "38.91" ]

icd9pcs

[ [ [] ] ]

5702, 5708

2092, 3495

347, 490

5788, 5788

8613, 9036

1352, 1748

3610, 5679

5729, 5767

3521, 3587

5933, 8590

1763, 2069

287, 309

518, 718

5802, 5909

740, 1143

1159, 1336

30,507

198,526

25780

Discharge summary

report

Admission Date: [**2160-7-19**] Discharge Date: [**2160-7-26**] Date of Birth: [**2089-5-18**] Sex: F Service: SURGERY Allergies: Chlorhexidine Gluconate/Brush Attending:[**First Name3 (LF) 473**] Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: s/p transcutaneous liver biopsy History of Present Illness: 71F s/p R hemicolectomy on [**7-10**] for adenoCA (T3N1) returns with 9/10 abd pain and R shoulder pain. The pain is worse with movement. She was able to tolerate breakfast,lunch, and dinner yesterday. She reports an explosive, formed bm yesterday morning and then little flatus since then. She had one episode of dry heaves but no actual emesis. No fever or chills. No sob/chest pain. Past Medical History: PXE, diagnosed at age 42 c/b retinal hemorrhage OU, legally blind PVD, s/p bilateral SFA stenting Hypertension Hyperlipidemia (patient denies) Diastolic heart failure Mitral regurgitation, MVP Atrial fibrillation Polymalgia rheumatica Endometrial cancer, s/p TAHBSO Left carpal tunnel release Eczema Osteoporosis S/P fungal infection of right toes . Cardiac History: CABG: none Percutaneous coronary intervention: none Pacemaker/ICD placed: none . PMH: 1. PXE (pseudoxanthoma elasticum) a rare hereditary connective tissue disorder: legally blind 2. A fib (has been holding Coumadin for ~1 month starting with colonoscopy) 3. Eczema -Last mammogram [**7-25**]: normal -Colonoscopy [**2-24**]: normal OB/GYN HISTORY: She has had NSVD x2. She reports regular menstrual cycles until her ? early 50s. She denies history of abnormal Pap smears, STDs, cysts, or fibroids. Social History: She is married with two adult children. She does not smoke or drink alcohol. She is a homemaker. Family History: No family history of CAD. Physical Exam: NAD breathing comfortably, heart regular rate and rhythm soft abdomen, minimal RUQ tenderness, non-distended, no rebound or guarding LE with trace peripheral edema and dopplerable pulses Pertinent Results: [**2160-7-19**] 10:00AM BLOOD WBC-25.6*# RBC-3.04* Hgb-9.5* Hct-28.9* MCV-95 MCH-31.3 MCHC-32.9 RDW-14.1 Plt Ct-362 [**2160-7-20**] 06:15AM BLOOD WBC-30.2* RBC-2.99* Hgb-9.3* Hct-28.5* MCV-95 MCH-31.3 MCHC-32.8 RDW-13.9 Plt Ct-361 [**2160-7-21**] 05:50AM BLOOD WBC-27.2* RBC-2.68* Hgb-8.4* Hct-25.9* MCV-97 MCH-31.2 MCHC-32.3 RDW-13.9 Plt Ct-398 [**2160-7-22**] 12:18AM BLOOD WBC-22.7* RBC-2.65* Hgb-8.3* Hct-24.8* MCV-94 MCH-31.4 MCHC-33.5 RDW-13.8 Plt Ct-394 [**2160-7-23**] 02:45AM BLOOD WBC-16.5* RBC-2.73* Hgb-8.6* Hct-25.4* MCV-93 MCH-31.4 MCHC-33.7 RDW-14.0 Plt Ct-446* [**2160-7-24**] 05:55AM BLOOD WBC-14.7* RBC-2.71* Hgb-8.4* Hct-26.0* MCV-96 MCH-31.1 MCHC-32.5 RDW-13.8 Plt Ct-442* [**2160-7-25**] 03:06AM BLOOD WBC-14.3* RBC-2.72* Hgb-8.3* Hct-25.6* MCV-94 MCH-30.5 MCHC-32.4 RDW-13.6 Plt Ct-413 [**2160-7-26**] 06:15AM BLOOD PT-19.3* PTT-85.1* INR(PT)-1.8* [**2160-7-22**] 12:18AM BLOOD CEA-<1.0\ BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEED Clip # [**Clip Number (Radiology) 64219**] Reason: please biopsy liver lesion for diagnosis [**Hospital 93**] MEDICAL CONDITION: 71F colon ca s/p resection, now RUQ tenderness, new liver lesions ?mets. REASON FOR THIS EXAMINATION: please biopsy liver lesion for diagnosis Final Report HISTORY: Colon cancer, now with suspicious hepatic masses on MRI, for biopsy. TECHNIQUE: Written and oral consent was obtained prior to the procedure. Timeout was checked x2. Preliminary son[**Name (NI) 493**] interrogation demonstrates visualization of a somewhat subtle, heterogeneous lesion at the inferior right hepatic lobe which corresponds to the MRI findings. The overlying skin was prepped and draped in the usual sterile fashion. Local anesthesia was achieved with a buffered 1% lidocaine solution. Pain relief was achieved with 50 mg of Demerol. Under son[**Name (NI) 493**] guidance, an 18-gauge Bard biopsy system was advanced to the lesion within the inferior right hepatic lobe, and a single core sample was obtained. Pathology was present, and the sample demonstrated clusters of atypical cells. Following the first biopsy, there was decreased visualization of the lesion, and therefore a second biopsy was not performed. The patient tolerated the procedure well. There were no immediate complications. The patient was returned to her inpatient bed in good condition. Dr. [**First Name (STitle) **] was present for the entire procedure. IMPRESSION: Successful ultrasound-guided biopsy of an inferior right lobe hepatic mass previously seen on MRI. --------- Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 64220**],[**Known firstname 420**] M [**2089-5-18**] 71 Female [**-6/3370**] [**Numeric Identifier 64221**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **]. BROWN, [**Last Name (un) 48203**],[**Doctor First Name **]/mtd SPECIMEN SUBMITTED: CORE BX LIVER, 1 JAR. Procedure date Tissue received Report Date Diagnosed by [**2160-7-23**] [**2160-7-23**] [**2160-7-25**] DR. [**Last Name (STitle) **]. BROWN/mb???????????? Previous biopsies: [**-6/3223**] Right Colon. [**-6/2930**] PROX. ASCEND. COLON...1 JAR. [**-4/2041**] UTERUS (CERVIX/RT. TUBE/OVARY/LT. TUBES OVARY FS). DIAGNOSIS: Liver, core needle biopsy: 1. Minute distorted focus of poorly differentiated carcinoma (see RC L1). The histology is consistent with that of the patient's previously resected colon tumor (S08-[**Numeric Identifier **]). 2. Focal mild portal and lobular mixed inflammation. 3. Focal bile ductule proliferation associated with neutrophils. Note: Slides reviewed with Dr. [**Last Name (STitle) **]. Brief Hospital Course: Admitted to surgery with RUQ pain and leukocytosis.She was placed on IV antibiotics, made NPO and IVF. Anticoagulation was reversed with vitamin K. CT and MRI done to evaluate hepatic lesions, which were determined to be metastatic in appearance. The night of HD2, the pt trigger twice for hypotension. She responded initally to fluid boluses, but then required transfer to the SICU for monitoring on HD3. In the SICU, pt pressures were monitored through her a-line, and a central line was avoided, because she was on aspirin and plavix. She was started on broad spectrum antibiotics after an ID consult. In the SICU, MAPs remained in 60s without further boluses. On HD5, liver biopsy was done to confirm diagnosis of metastatic colon cancer. Pt was transferred to the floor and seen by physical therapy. Post procedure, she tolerated regular food with minimal RUQ pain. Antibiotics were discontinued after 2 sets of blood cultures and C.diff toxin study was negative and WBCs continued to trend down on discharge. Pt remained afebrile. She was discharged on HD8 to rehab, after arranging an appointment with Dr. [**Last Name (STitle) **] in oncology. Medications on Admission: asa 81', atenolol 25', caltrate 1 tab', diovan 160/12.5', ferrous sulfate 325', fosamax 70', lasix 80', ativan 0.5 prn, mvi, omeprazole SR 20', prednisone 4'', plavix 75', simvastatin 20', tylenol pm, coumadin 2.5 ttss 5 mwf. Discharge Medications: all home medications were continued. coumadin 5mg MWF, 2.5mg TuThSaSu lovenox 80mg sc bid (until INR is [**12-23**]) Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Rehab and Nursing Center Discharge Diagnosis: colon cancer with metastases to liver Discharge Condition: good Discharge Instructions: If you develop fever, chills, nausea, vomiting, diarrhea, blood in stool, chest pain, shortness of breath or any other symptoms concerning to you please call [**Hospital1 18**] or return to the emergency department for evaluation. You had a biopsy of your liver during this admission. The results of the biopsy were discussed with you and your family. For your heart disease, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs and adhere to 2 gm sodium diet. If you develop fever, chills, nausea, vomiting, diarrhea, blood in stool, chest pain, shortness of breath or any other symptoms concerning to you please call [**Hospital1 18**] or return to the emergency department for evaluation. You had a biopsy of your liver during this admission. The results of the biopsy were discussed with you and your family. For your heart disease, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs and adhere to 2 gm sodium diet. Followup Instructions: An appointment has been arranged for you to see Dr. [**Last Name (STitle) **] in Oncology in [**12-23**] weeks. Please call ([**Telephone/Fax (1) 5562**] to confirm the date and time of this appointment. If you have any questions, please call Dr.[**Name (NI) 9886**] office at ([**Telephone/Fax (1) 9058**].

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icd9cm

[ [ [] ] ]

[ "50.11" ]

icd9pcs

[ [ [] ] ]

7409, 7481

5828, 6991

297, 331

7563, 7570

2026, 3095

8586, 8899

1777, 1804

7268, 7386

3135, 3208

7502, 7542

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7594, 8563

1819, 2007

249, 259

3240, 5805

359, 748

770, 1646

1662, 1761

25,481

180,064

7319

Discharge summary

report

Admission Date: [**2111-1-23**] Discharge Date: [**2111-2-2**] Date of Birth: [**2042-8-14**] Sex: F Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 4162**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Intubation PICC line placement History of Present Illness: The pt. is a 68 year-old right-handed woman with recently diagnosed carcinoma of the lung with metastases to the brain who presented with seizure. Per the pt's family, she was in her usual state of health this morning. At approximtely 2:30 this afternoon, she was found lying on the ground by her grandchildren with shaking movements of her limbs, apparently having a seizure. 911 was immediately called. It is not known how long she was down prior to being discovered by her grandchildren, she was last seen "a few minutes" prior to being found. EMS arrived approximately 10 minutes after the seizure began. EMS found the pt to have clonic activity of her right upper and lower extremities and with forced eye deviation to the right. She was given 6mg of IV ativan by EMS en route to the ED. She received an additional 4mg of IV ativan in the ED (total dose 10mg). The seizure activity ceased in the ED, roughly 35 minutes from onset. After cessation of seizure activity, she was intubated and placed on mechanical ventilation. She received 1.5 grams of intravenous dilantin when her level was discovered to be subtherapeutic (1.5). A CT scan of the head was performed. Past Medical History: -non-small cell carcinoma of the lung with multiple hemorrhagic metastases to brain in both frontal lobes and right temporal lobe -renal cell carcinoma: resected in [**2103**] with a left nephrectomy -thyroid cancer, papillary type, with insularfeatures diagnosed in [**2102**] that was removed surgically in [**2105**] with extracapsular extension, and vascular invasion. She underwent postoperative RAI followed by radiation therapy. In [**2108-8-24**], a persistently elevated thyroglobulin prompted retreatment with radioactive iodine. -h/o C7-T1 paraspinal lesion, s/p C7-T1 laminectomy on [**2110-11-1**]. -HTN -type II diabetes mellitus c peripheral neuropathy -hypothyroidism -Hx of positive PPD, (exposure to pt w/Tb when working as nurse's aide), s/p rx w/INH. -PVD- Fem-ant/tib bypass on L in [**2099**] on coumadin since then presumably for low flow state; no hx dvt's or pe's, no hx afib -CRI (ARF as inpt recently) baseline 1.0-1.5 upto 2.0 in past Social History: Pt lives with her husband, has 6 children. Previous 40 pack year smoking history, quit 10 years ago. No ETOH, no illict drug use Family History: Children healthy, aunt with lung cancer, no other known fam hx Physical Exam: IN ER AS PER NEURO ADMISSION: . Vitals: T: NR P: 78 R: 13 BP: 126/32 SaO2: 100% NRB General: Lying on stretcher with eyes closed. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: supple, no nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -mental status: Lying in bed with eyes closed. Does not respond to voice. -cranial nerves: PERRL 1.5 to 1mm. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. EOMI to oculocephalic maneuver. Facial musculature appears symmetric. Corneal reflex present bilaterally. Gag reflex present. -motor: Normal bulk throughout. Tone slightly decreased throughout. No adventitious movements noted. The pt did not move her right upper or lower extremity to noxious stimuli but did localize to pain on the left. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 1 1 R 1 1 1 1 1 Plantar response was flexor on the left, extensor on the right. Pertinent Results: [**2111-2-2**] 05:48AM BLOOD WBC-39.5* RBC-3.01* Hgb-8.9* Hct-27.2* MCV-90 MCH-29.4 MCHC-32.6 RDW-19.0* Plt Ct-252 [**2111-1-23**] 03:30PM BLOOD WBC-26.5* RBC-3.61* Hgb-10.7* Hct-32.7* MCV-90 MCH-29.6 MCHC-32.7 RDW-18.2* Plt Ct-267 [**2111-1-30**] 08:35AM BLOOD Neuts-73* Bands-1 Lymphs-10* Monos-1* Eos-13* Baso-1 Atyps-0 Metas-1* Myelos-0 NRBC-1* [**2111-1-23**] 03:30PM BLOOD Neuts-83.1* Bands-0 Lymphs-4.0* Monos-2.0 Eos-10.6* Baso-0.4 [**2111-1-30**] 08:35AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-1+ [**2111-2-2**] 05:48AM BLOOD Plt Ct-252 [**2111-1-30**] 08:35AM BLOOD PT-12.9 PTT-25.4 INR(PT)-1.1 [**2111-1-24**] 02:39AM BLOOD PT-19.9* PTT-26.1 INR(PT)-2.8 [**2111-1-23**] 03:30PM BLOOD Plt Smr-NORMAL Plt Ct-267 [**2111-1-25**] 06:12AM BLOOD Fibrino-388 [**2111-2-2**] 05:48AM BLOOD Glucose-139* UreaN-28* Creat-0.8 Na-138 K-4.2 Cl-107 HCO3-25 AnGap-10 [**2111-1-23**] 03:30PM BLOOD Glucose-246* UreaN-28* Creat-1.2* Na-132* K-5.9* Cl-97 HCO3-24 AnGap-17 [**2111-1-25**] 03:12AM BLOOD ALT-18 AST-18 AlkPhos-222* Amylase-5 TotBili-0.5 [**2111-2-2**] 05:48AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.6 [**2111-1-24**] 02:39AM BLOOD Albumin-2.8* Calcium-8.6 Phos-2.0*# Mg-1.6 [**2111-1-27**] 04:33AM BLOOD TSH-19* [**2111-1-28**] 05:12AM BLOOD Free T4-0.6* [**2111-1-29**] 06:21AM BLOOD Vanco-15.1* [**2111-1-30**] 08:35AM BLOOD Phenyto-5.3* [**2111-1-22**] 10:43AM BLOOD Phenyto-3.5* . [**1-22**] CT HEAD FINDINGS: Again seen are multiple hemorrhagic foci in both frontal lobes as well as the right temporal lobe. Overall, they are less prominent than on the prior exam. No new foci of hemorrhage are identified. Note is made of slightly increased hypodensity adjacent to the anterior most right frontal hemorrhage compared to the head CT of [**2111-1-3**]. However, this difference may be secondary to volume averaging and no new hemorrhage is identified in this area. There is no new mass effect, hydrocephalus, or shift of normally midline structures. A calcified right frontal meningioma is again noted near the vertex. Surrounding osseous and soft tissue structures are remarkable only for a small amount of aerosolized secretions in the sphenoid sinus.. . [**1-22**] CXR: PA AND LATERAL CHEST RADIOGRAPHS: Again seen is small left lung volume with diffuse nodular thickening of the pleura compatible with the patient's known metastatic disease. Elevation of the left hemidiaphragm has slightly increased compared to the prior examination and may represent increasing subpulmonic or subdiaphragmatic fluid collection/mass. The right lung is clear. Heart size is normal. Note is again made of surgical clips in the left mid abdomen. Note is again made of laminectomy defects of the cervicothoracic junction. Brief Hospital Course: Briefly, 68 yo woman c renal cell CA, invasive papillary thyroid, NSCLC c brain mets admit [**1-23**] for status epilepticus responsive to IV benzos. . Noted to be subtherapeutic on dilantin prior to admission. Intubated. In ICU developed Klebsiella bacteremia thought [**2-26**] urinary source, MRSA PNA. Started on vanco/meropenem and switched to vanco/ceftriaxone. Also kept on dilantin while keppra titrated up. Developed urinary retention following removal of Foley catheter; Foley reinserted and 1 L urine drained. Urology consulted. Noted to have low free T4 on [**2111-1-29**] labs. . 1. Infections - Likey etiology of Klebsiella bacteremia is UTI. MRSA PNA probably related to intubation. HD stable. WBC elevated though likely leukocytosis [**2-26**] present dexamethasone use. Uctx [**1-29**] c 1000 col probably enterococcus; abx not changed in response to this finding. - Vancomycin since [**2111-1-25**] (for 14 day course) - Ceftriaxone since [**2111-1-27**] (for 14 day course) - f/u urine culture sensitivities from [**1-29**] . 2. Seizures - Plan to receive full dose keppra and then d/c phenytoin with gradual taper. For brain mets, pt. on dexamethosone - 1250 [**Hospital1 **] * 3 d of keppra until [**2111-2-1**] then 1500 [**Hospital1 **] continous keppra. - [**2111-2-1**] dilantin decreased to 100 mg [**Hospital1 **] (plan to decrease by 100mg q 3d) - plan to reduce steroids by [**1-26**] q 3d (2 mg IV q12 was started [**1-29**]) - Should be dexamethasone until [**2-24**] neuro-onc appointment when this will be readdressed. . 3. Urinary retention - Urologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 27027**] aware. Foley reinserted. Will be pulled in one week after f/u in urologist office. . 4. Chronic pain - - oxycontin 10 [**Hospital1 **] - morphine IV 2 mg q4h . 5. Low free T4 - low suspicion for ICU-related hypothyroidism. Concern re: proper administration of synthroid as outpt at home. Discussed c attg --> plan to maintain regular out pt synthroid dose and recheck thyroid levels after stable regimen of synthroid - continued synthroid . 6. HTN - well controlled on lopressor, lisinopril. . 7. DM - On Lantus 40u qhs with improving FSG; likely will require decrease in dosing if not on steroids. . 8. Sacral decubitus ulcer: Duoderm dressing applied to sacral ulcer. Medications on Admission: -COSOPT 0.5-2%--One drop into both eyes twice a day -FLONASE 50MCG--2 sprays to each nostril every morning -HUMULIN R 100 U/ML--12 u sq every morning -INSULIN NPH HUMAN RECOM 100 U/ML--30 u sq qam, 24 sq every evening -LEVOXYL 200MCG--One by mouth every day -LORATADINE 10MG--One tablet every day for allergies -NEURONTIN 300MG--One tablet every morning; one tablet in afternoon; 2 tabs at bedtime -PROTONIX 40MG--One tablet every day -ZESTRIL 10MG--One by mouth every day -metoprolol 37.5 mg TID -dilantin 400 mg po QDay -oxycontin 10 mg po BID -decadron 4mg po bid, began [**1-22**], plan was for taper over 9 days. Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-26**] Drops Ophthalmic PRN (as needed). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day) as needed for twice a day. 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Insulin Glargine 100 unit/mL Solution Sig: 40 units Subcutaneous at bedtime. 15. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale doses Injection four times a day: Sliding scale: 51-150 - 0 units 151-200 - 3 units 201-250 - 5 units 251-300 - 7 units 301-350 - 9 units 251-400 - 11 units. 16. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 17. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 18. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 5 days. 19. PICC double lumen PICC line maintenance as per usual protocol 20. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 21. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 5 days. 22. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours). 23. Phenytoin Sodium 50 mg/mL Solution Sig: Two (2) Intravenous Q12H (every 12 hours) for 6 days: Dose should be tapered to 100 mg qd on [**2-4**]. On [**12-8**], phenytoin should be stopped. 24. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: One (1) mg Injection Q12H (every 12 hours): taper to 1 mg qd on [**2-4**]. Keep on 1 mg qd until f/u with neurooncologist, Dr. [**Last Name (STitle) 4253**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Primary 1. Seizure 2. Bacteremia 3. Pneumonia Secondary 1. Non-small cell lung Cancer 2. Brain Metastases Discharge Condition: Fair Discharge Instructions: You should return to the ER or contact Dr. [**Last Name (STitle) **] if you have any further fevers, shakes, chills, chest pain, shortness of breath, vomiting, abdominal pain, or bony pain. You should take all your medications as directed and care for your PICC line as directed. Followup Instructions: 1. You have to follow up with Dr. [**Last Name (STitle) 27027**], your urologist, in 1 week to have the Foley catheter removed. His phone number is: [**Telephone/Fax (1) 2906**]. 2. You also need to have another swallow evaluation done once your secretions clear up. Your NG tube should be left in place until then. 3. You need to finish 5 more days of IV antibiotics. 4. You have to follow up with Dr. [**Last Name (STitle) 4253**], the neuro-oncologist on [**2-24**]. Her phone number is: ([**Telephone/Fax (1) 6574**] You also have the following appointments listed below. Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2111-2-16**] 3:00 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-2-21**] 11:45 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-2-21**] 12:30

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12297, 12370

6771, 9113

274, 307

12520, 12527

3997, 6748

12856, 13837

2671, 2735

9782, 12274

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2750, 3280

227, 236

335, 1517

3295, 3354

1539, 2506

2522, 2655

22,996

143,324

30630

Discharge summary

report

Admission Date: [**2183-4-27**] Discharge Date: [**2183-4-29**] Date of Birth: [**2164-4-3**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Acetominophen Toxicity Major Surgical or Invasive Procedure: Intracranial pressure monitor implantation - Neurosurgical Service History of Present Illness: This is a 19 y/o female with self-reported history of Bulimia and [**Hospital **] transferred to [**Hospital1 18**] from an outside hospital after overdosing on 72 tablets of Tylenol in a suicide attempt. Patient currently in acute liver failure, tachycardic, hyperkalemic and is being assessed for possible liver transplant. Patient reports she has been suffering from Depression since [**Month (only) **] '[**82**], but over the past week she has felt increasingly anxious, overwhelmed and anhedonic. This past Saturday AM she went to the kitchen, took two bottles of Tylenol 500 mg and counted 72 pills thinking this number would be enough to 'end it all'. She took all of them then went to sleep. She does not remember what happened all day until she was found by her sister in her car in her church parking lot. Past Medical History: Bulemia Depression Social History: lives at home, assistant manager at Subway Patient reports drinking alcohol socially, 1-2 drinks every other week. Denies use of illicit substances. Smokes [**1-7**] cigarettes a week socially. Family History: non contributory Physical Exam: Patient Deceased Pertinent Results: [**2183-4-29**] 11:27AM BLOOD WBC-4.8 RBC-2.70* Hgb-8.8* Hct-25.2* MCV-93 MCH-32.5* MCHC-34.8 RDW-13.8 Plt Ct-93* [**2183-4-29**] 08:00AM BLOOD WBC-9.4 RBC-2.81* Hgb-9.3* Hct-27.3* MCV-97 MCH-33.1* MCHC-34.0 RDW-13.6 Plt Ct-110* [**2183-4-29**] 02:01AM BLOOD WBC-11.1* RBC-2.87* Hgb-9.3* Hct-28.3* MCV-99*# MCH-32.6* MCHC-33.0 RDW-13.7 Plt Ct-121* [**2183-4-28**] 05:07PM BLOOD WBC-13.0* RBC-2.92* Hgb-9.3* Hct-25.8* MCV-88 MCH-31.8 MCHC-36.1* RDW-13.8 Plt Ct-151 [**2183-4-28**] 12:56PM BLOOD WBC-13.5* RBC-2.96* Hgb-9.6* Hct-26.2* MCV-89 MCH-32.4* MCHC-36.6* RDW-13.9 Plt Ct-147* [**2183-4-28**] 09:11AM BLOOD WBC-17.1* RBC-3.24* Hgb-10.0* Hct-29.5* MCV-91 MCH-31.0 MCHC-34.1 RDW-13.7 Plt Ct-162 [**2183-4-28**] 07:08AM BLOOD WBC-16.2* RBC-3.25* Hgb-10.4* Hct-29.2* MCV-90 MCH-31.9 MCHC-35.5* RDW-13.9 Plt Ct-171 [**2183-4-28**] 03:03AM BLOOD WBC-17.1* RBC-3.42* Hgb-10.9* Hct-30.7* MCV-90 MCH-31.8 MCHC-35.4* RDW-13.8 Plt Ct-168 [**2183-4-27**] 08:53PM BLOOD WBC-19.3* RBC-3.80* Hgb-12.1 Hct-33.7* MCV-89 MCH-31.7 MCHC-35.9* RDW-13.7 Plt Ct-172 [**2183-4-27**] 03:02PM BLOOD WBC-19.3* RBC-4.34 Hgb-13.1 Hct-39.1 MCV-90 MCH-30.3 MCHC-33.6 RDW-13.5 Plt Ct-201 [**2183-4-27**] 07:39AM BLOOD WBC-19.4* RBC-4.78 Hgb-14.4 Hct-44.1 MCV-92 MCH-30.1 MCHC-32.7 RDW-13.4 Plt Ct-261 [**2183-4-27**] 05:10AM BLOOD WBC-21.2* RBC-5.17 Hgb-16.2* Hct-48.6* MCV-94 MCH-31.3 MCHC-33.3 RDW-13.4 Plt Ct-298 [**2183-4-28**] 05:07PM BLOOD Neuts-82.2* Bands-0 Lymphs-16.4* Monos-0.5* Eos-0.8 Baso-0.1 [**2183-4-28**] 07:08AM BLOOD Neuts-95.6* Bands-0 Lymphs-3.5* Monos-0.4* Eos-0.2 Baso-0.4 [**2183-4-27**] 05:10AM BLOOD Neuts-90.9* Bands-0 Lymphs-7.4* Monos-1.5* Eos-0.2 Baso-0 [**2183-4-28**] 07:08AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ [**2183-4-29**] 11:27AM BLOOD Plt Smr-LOW Plt Ct-93* [**2183-4-29**] 11:27AM BLOOD PT-29.2* PTT-50.6* INR(PT)-3.1* [**2183-4-29**] 08:00AM BLOOD Plt Ct-110* [**2183-4-29**] 08:00AM BLOOD PT-29.8* PTT-51.4* INR(PT)-3.1* [**2183-4-29**] 05:01AM BLOOD Plt Ct-117* [**2183-4-29**] 05:01AM BLOOD PT-28.5* PTT-48.2* INR(PT)-3.0* [**2183-4-29**] 11:27AM BLOOD ALT-7910* AST-7065* AlkPhos-140* Amylase-641* TotBili-5.2* [**2183-4-29**] 08:00AM BLOOD ALT-8020* AST-8045* AlkPhos-136* Amylase-694* TotBili-4.9* [**2183-4-29**] 02:01AM BLOOD ALT-8610* AST-[**Numeric Identifier 72635**]* LD(LDH)-4490* AlkPhos-122* Amylase-720* TotBili-4.1* [**2183-4-28**] 08:12PM BLOOD ALT-9240* AST-[**Numeric Identifier 16217**]* AlkPhos-111 Amylase-826* TotBili-3.5* [**2183-4-28**] 05:07PM BLOOD ALT-8870* AST-[**Numeric Identifier 50858**]* TotBili-3.4* [**2183-4-28**] 03:11PM BLOOD ALT-9400* AST-[**Numeric Identifier 72636**]* TotBili-3.2* [**2183-4-28**] 12:56PM BLOOD ALT-9685* AST-[**Numeric Identifier 72637**]* TotBili-3.4* [**2183-4-28**] 09:11AM BLOOD ALT-[**Numeric Identifier 72638**]* AST-[**Numeric Identifier 72639**]* AlkPhos-98 TotBili-3.2* [**2183-4-29**] 11:27AM BLOOD Lipase-849* [**2183-4-29**] 08:00AM BLOOD Lipase-839* [**2183-4-29**] 02:01AM BLOOD Lipase-711* [**2183-4-28**] 08:12PM BLOOD Lipase-627* [**2183-4-28**] 03:03AM BLOOD Lipase-617* [**2183-4-27**] 08:53PM BLOOD Lipase-694* [**2183-4-27**] 07:39AM BLOOD Lipase-239* [**2183-4-27**] 05:10AM BLOOD Lipase-122* Brief Hospital Course: Patient Admitted to MICU on [**2183-4-27**] for acetominophen overdose and acute liver failure. Her intial laboratory values were significant for AST: 8610 ALT: [**Numeric Identifier 72635**] ALP: 122 LDH: 4490 Amylase: 720 Lipase: 711 and Total Bilirubin 4.1. She was acidemic with an initial pH of 7.21 and base excessof -17. She was also oligurinc while in the MICU and was resuscitated accordingly. She was initally placed on IV drip of N-acetylcysteine but due to time course charcoal was no intiated. She was also begun on IV Vancomycin and Zosyn as well as given FFP for her liver failure. Transplant Surgery was consulted and agreed with the current management and a transpant workup was intiated. The patient was placed on the Transplant list immediately, and patient was kept under close monitoring while in the MICU. While there she was seen by Hepatology, Psychiatry and Social Work. Over the course of the next 24 hours, patient showed signs of renal failure, became septic with a WBC >20 and became somnolent. She was intubated for Stage III coma on [**4-28**] and was given factor VIIa by transfusion medicine for eventual Intracranial pressure monitor implantation, performed [**4-28**] by Neurosurgical staff. Her acidemia continued to worsen in the setting of Fulminant Hepatic Failure. She was kept intubated and on pressors while in the ICU. Her other labarotory values (as seen in results section) were consistent with multiple organ failure in the setting of fulminant hepatic failure. On [**4-29**] she was declared unsuitable for transplant and after discussion with her family was made CMO at 15:40 on the evening of [**4-29**]. She died at 16:08 on [**4-29**]. Medications on Admission: Prozac 20 mg PO QDaily Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Multiple Organ Failure Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

[ "584.5", "348.30", "958.4", "276.2", "296.20", "276.3", "570", "965.4", "E950.0", "286.9", "785.0", "348.5", "307.51", "276.7" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.71", "01.18", "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

6668, 6677

4862, 6562

336, 404

6743, 6753

1596, 4839

6810, 6821

1526, 1544

6635, 6645

6698, 6722

6588, 6612

6777, 6787

1559, 1577

274, 298

432, 1256

1278, 1298

1314, 1510

67,651

172,963

36460+36461

Discharge summary

report+report

Admission Date: [**2182-5-6**] Discharge Date: [**2182-5-25**] Date of Birth: [**2154-11-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: Left Leg / Hip Pain Major Surgical or Invasive Procedure: - left quadriceps I&D with wound vac placement ([**2182-5-7**]) - left quadriceps I&D with wound vac change ([**2182-5-10**]) - left quadriceps I&D with wound vac change ([**2182-5-12**]) - CT-guided arthrocentesis of left hip ([**2182-5-13**]) - left quadriceps I&D with washout of left hip joint and wound vac change ([**2182-5-14**]) - left quadriceps I&D with debridement of necrotic muscle ([**2182-5-17**]) - left quadriceps I&D with biopsy of proximal femur History of Present Illness: Mr. [**Known lastname **] is a 27 y/oM with a history of IVDU (more in the past, most recently admitted to 2 weeks ago) who developed non-specific fatigue within the last 2 weeks, and six days of left sided groin/hip pain after lifting a heavy object. Four days ago he began to develop fevers, ranging from 100 to 102-3. This was accompanied by nausea, but no emesis, and no rashes. He presented to Bon Secour ([**Location (un) 7661**], MA) and was treated conservatively for the pain. Fevers persisted and his family brought him to the [**Hospital1 18**] ED for further workup and management. He functionally has been unable to walk well, or lift his left leg secondary to pain in the groin/proxleg and back of knee. In the last day he felt that some pain was spreading to his right leg. He has had constipation (reports no BM in 2 weeks) but no urinary hesitancy, overflow incontinence, or reduction in urine output. He had a prolonged ED course. Neurology was consulted, and L spine MR attempted but technically difficult. He spiked in the ED and was cultured and given vanc and zosyn each x1. CT scan of the thigh showed abscess in left proximal quads, the area where pain was concentrated. Past Medical History: prior alcohol abuse (quit 3 yrs ago) IV cocaine abuse (last use 3 wks prior to admission) anxiety Social History: Occupation: Metal Worker Drugs: IVDU (cocaine) last approx 2 weeks ago after period of sustained sobriety Tobacco: [**12-21**] ppd Alcohol: none presently; former alcohol abuse, sober for 3 years per report Family History: CAD in Father, Diabetes. Hemochromatosis in father Physical Exam: Vitals: T: 97.8 P: 88 R: 16 BP: 117/68 SaO2: 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: rosacea on face. Pertinent Results: Studies: ECG ([**2182-5-7**]): Sinus rhythm at 122 bpm, normal axis, normal intervals, 1 mm Q waves in inferior leads and V4-V6, no ST segment/T wave changes. . TTE ([**2182-5-7**]): The left atrium is normal in size. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Left LENI ([**2182-5-9**]): Grayscale and Doppler son[**Name (NI) 1417**] of the left common femoral, superficial femoral, and popliteal veins were performed. There is normal compressibility, flow, and augmentation. MRI L-spine with/without contrast ([**2182-5-10**]): There was no sign for the presence of a disc or vertebral abnormality to suggest either an inflammatory process or other pathologic entity. On the sagittal post-contrast images, there is questionable, very slight enhancement of a few rootlets of the cauda equina. If real, this finding could be inflammatory in nature. There is no other intrathecal abnormality seen. No overt paraspinal pathology is identified either. CONCLUSION: Very limited study due to poor pain control. CT Abdomen/Pelvis/Thighs ([**2182-5-12**]): The visualized part of the liver, gallbladder, adrenal glands, right kidneys, and pancreas has normal appearance. There is a simple cyst in the upper pole of the left kidney measuring 46 x 46 mm. Stomach and duodenal loops of small bowel and large bowel appear unremarkable. CT OF THE PELVIS: Urinary bladder contains a Foley catheter. The rectum, sigmoid colon, prostate, and seminal vesicles appear unremarkable. There is new rim-enhancing fluid collection lateral and medial to the left iliac bone, which is concerning for an abscess collection. UPPER THIGHS: There is interval development of new enhancing fluid collection of the left hip joint. Enhancing fluid collection is also abutting the left proximal femoral shaft. Multiple foci of rim-enhancing fluid collection are noted within the left quadriceps femoris muscle. Moderate-to- severe degree of swelling of the left upper thigh is noted. Small amount of gas bubbles are noted deep to the subcutaneous tissue in the superficial fascia that are most likely related to the recent surgical procedure. BONE WINDOWS: No concerning lytic or sclerotic lesions are identified. No signs of epidural abscess are noted within the lumbar spine. MRI Thigh ([**2182-5-19**] - prelim): There is edema and enhancement in the proximal left femur compatible with osteomyelitis. There are small intramuscular abscesses and edema surrounding the proximal left femur. There is a large soft tissue defect extending from the skin to the left femur. [**2182-5-6**] 11:00AM WBC-11.7* RBC-4.57* HGB-14.1 HCT-41.4 MCV-91 MCH-30.9 MCHC-34.2 RDW-13.3 [**2182-5-6**] 11:00AM NEUTS-89.6* LYMPHS-6.4* MONOS-3.5 EOS-0.4 BASOS-0.1 [**2182-5-6**] 11:00AM GLUCOSE-115* UREA N-21* CREAT-0.9 SODIUM-135 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16 [**2182-5-6**] 08:13PM LACTATE-1.0 Blood cultures ([**2182-5-6**]): MRSA 4 of 4 bottles Blood cultures ([**2182-5-7**]): MRSA 1 of 2 bottles Blood cultures ([**2182-5-8**]): negative (4 bottles) Blood cultures ([**2182-5-9**]): MRSA 1 of 4 bottles Blood cultures ([**2182-5-10**]): MRSA 2 of 4 bottles Blood cultures ([**2182-5-11**]): MRSA 1 of 4 bottles Blood cultures ([**2182-5-12**]): negative (4 bottles) Blood cultures ([**2182-5-13**]): MRSA 1 of 4 bottles Blood cultures ([**2182-5-14**] through [**2182-5-23**]): Pending, no growth to date . Wound swab ([**2182-5-7**]): moderate MRSA Wound swab ([**2182-5-10**]): heavy MRSA Wound swab ([**2182-5-12**]): sparse MRSA Wound swab ([**2182-5-14**]): sparse MRSA Wound swab ([**2182-5-17**]): rare MRSA, rare E. coli (pan-sensitive) . Left hip joint fluid culture ([**2182-5-13**]): MRSA . HIV Ab: negative HCV Ab: positive HCV viral load: 48,800 IU/mL Brief Hospital Course: 27 year old male with history of IVDU presents with MRSA bacteremia, left thigh abscess, left hip septic srthritis, and left femur osteomyelitis. He was initially admitted to the [**Hospital Unit Name 153**] due to his tachycardia and ill-appearance. There, he was put on empiric vancomycin/pip-tazo and taken to the OR for I&D by orthopedics; a wound vac was placed intra-operatively. His blood and wound cultures grew MRSA and a TTE showed no vegetations. Cardiology reviewed his TTE and felt that, given its excellent quality, a TEE was unlikely to add any diagnostic benefit and thus felt that the potential risks of TEE outweighed the benefit. He was called out to the [**Hospital Ward Name **] medicine floor on the evening of [**2182-5-8**] and his pip-tazo was discontinued. His fevers persisted and ID was consulted who recommended an MRI of his LS spine to look for osteomyelitis/discitis. His blood cultures from [**5-9**] again came back positive for MRSA. Of note, a vanco trough from the evening of [**5-9**] was 16.4 but the trough on the morning of [**5-10**] was only 4.1. Given this, his vanco was increased to 1000 mg IV q8h and linezolid was later added due to his continued fevers/bacteremia. An ultrasound of his LLE showed no DVT. He was having increased pain at his left thigh incision site and thus a CT of his pelvis/thighs was obtained which showed multiple fluid collections and possible evidence of necrotizing fasciitis, and thus he was taken urgently to the OR again late on [**2182-5-10**] for an additional washout. Intraoperatively, there was no evidence of necrotizing fasciitis. Post-operatively, he was briefly in the SICU out of concern for evolving sepsis, but he remained hemodynamically stable and was called out to the medicine floor on the evening of [**2182-5-10**]. On the floor, his fevers persisted in spite of dual therapy with vancomycin and linezolid. Due to low vancomycin levels, his dose was eventually increased up to 1500 mg IV q8h. Once vancomycin levels were therapeutic, his linezolid was stopped. Due to his continued fevers and leg/groin pain (as well as ongoing leg weakness), he was taken for CT of his abdomen/pelvis/thighs to evaluate for septic thrombophlebitis versus spinal osteomyelitis/discitis versus epidural abscess (due to pain, he could not tolerate MRI). The CT scan showed no evidence of spinal disease, but did show a new peri-articular fluid collection at his left hip concerning for a septic arthritis. CT-guided arthrocentesis of the left hip on [**2182-5-13**] had a marked leukocytosis and eventually grew out MRSA. He went for an additional washout of his thigh on [**2182-5-14**], this time with washout of the left hip joint as well (intra-operatively found to have frank pus in the joint capsule). His fevers persisted through [**5-12**] through [**2182-5-17**] in spite of the fact that his last positive blood culture was [**2182-5-13**] and his vancomycin levels were therapeutic. He was taken for an additional elective washout on [**2182-5-17**] which involved resection of a significant portion of necrotic thigh musculature. Post-operatively, his fevers were up to 105 and he required 5 units of pRBCs due to blood loss presumably related to the extensive muscle debridement. Also of note, he became somewhat leukopenic, and there was concern that his leukopenia and fevers may have both been due to vancomycin (i.e. drug fevers) so this was stopped and linezolid was resumed. On [**5-19**], his intra-op wound culture from [**5-17**] was noted to be growing GNRs (in addition to MRSA); he was put on empiric meropenem, though this was narrowed to ciprofloxacin once the GNRs returned as pan-sensitive E. coli. An MRI of his thigh done on [**2182-5-19**] was limited due to the patient's poor pain control, though it did show evidence of osteomyelitis of his proximal femur. The patient was taken for a sixth washout of his thigh on [**2182-5-20**] with biopsy of his proximal femur. Would culture [**2182-5-20**] remained positive for E.Coli. Bone biopsy results were pending at the time of discharge. The thigh wound was then closed and vac dressing was placed. Following the wound closure there was no further bleeding and his hematocrit was stable. He continued on IV Linezolid 600mg IV BID and PO Ciprofloxacin 500mg [**Hospital1 **]. ID recommended switching to PO linezolid 600mg [**Hospital1 **] and continuing PO cipro for a six week antibiotic course. His left thigh incision was evaluated prior to discharge and found to be intact without surrounding erythema or drainage. Dermatology was consulted for contact dermatitis on patient's left dorsal hand and intertriginious skin irritation and prescribed topical treatments with good effect. On [**5-24**] he was found to have a mildly puritic erythemaous macularpapular coalescing rash on his bilateral upper extremities, chest, and abdomen after restarting tizanidine. The tizanidine was subsequently discontinued. The pain service was consulted for transition to PO pain medications given the patient's high narcotics requirement with Dilaudid PCA. He was started on on Methadone 10 mg TID, MS Contin 60 mg Q8, Hydromorphone 4 mg 2-3 Tablets PO Q3H PRN, Acetaminophen 1000mg Q8, Ibuprofen 600 mg Q8H, and Gabapentin 800 mg TID with good pain control. At the time of discharge, he had been afebrile for greater than 72 hours, was on PO Linezolid and Cipro, surveillance cultures were negative for greater than 10 days, had good pain control on PO pain medications, and was ambulating with assistance. Of note, the [**Hospital 228**] hospital course was complicated by significant constipation, likely exacerbated by his narcotics requirement and prolonged immobility. This was treated with an aggressive bowel regimen including PO naloxone and multiple doses of subcutaneous methylnaltrexone with some effect. Also of note, the patient was tested for HIV Ab and HCV Ab given his IV drug use history. The HIV Ab was negative, though his HCV Ab and viral load were positive. The patient was informed of this and underwent RUQ ultrasound with plan to follow-up in Liver Clinic for further evaluation and treatment of his hepatitis. Outpatient follow-up: Per ID, Following disposition he will need antibiotic course PO linezolid and cipro through [**7-4**], will follow-up in [**Hospital **] clinic [**2182-6-26**]. As outpatient weekly CBC, LFTs, BUN/creat, ESR/CRP. Will need outpatient repeat thigh CT to assess abcess prior to ID followup [**2182-6-26**]. Will need outpatient hepatology followup for HCV. He will followup with orthopedics clinic for evaluation of his wound and healing. He will need regular follow-up with new PCP and arrangement of a chest CT to evaluate mid right lung pulmonary nodule seen on CXR. Medications on Admission: None Discharge Medications: 1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) packet PO twice a day as needed for constipation. Disp:*60 packets* Refills:*0* 7. Methadone 10 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 8. Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours. Disp:*90 Tablet Sustained Release(s)* Refills:*0* 9. Hydromorphone 4 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*300 Tablet(s)* Refills:*0* 10. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical DAILY (Daily) for 2 weeks: Apply to rash on right hand only. Disp:*1 tube or about 4 ounces* Refills:*0* 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 13. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: MRSA bacteremia Left thigh abscess Left hip septic arthritis Left femur osteomyelitis Discharge Condition: Hemodynamically stable, afebrile > 72 hours, ambulating with assistance NWB LLE. Discharge Instructions: You were admitted with bacteria in your blood and a serious infection of your left thigh mucles, thigh bone, left hip joint. You went to the operating room with Orthopedics multiple times to remove infected tissue. You were treated with antibiotics and have not had a fever for greater than three days before you were discharged. It is very important that you continue taking antibiotics, Linezolid and Ciprofloxacin, for six weeks after you are discharged. While in the hosptial you were also diagnosed with hepatitis C virus, and you will need follow-up for this as an outpaitent. You will have home nursing services to assist you with your daily activities and wound dressing and weekly lab draws after you are discharged home. You need follow-up after you are discharged. 1) New PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 26842**] [**2182-6-3**]. You new PCP will help coordinate your follow-up care. Please call your insurance company to change your PCP to Dr. [**Last Name (un) 48207**]. If you do not do this they may send you [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for your visit. 2) Infectious Disease - After you are discharged you will need weekly blood tests to monitor your infection. You will also have a CT of your left thigh as an outpatient to evaluate your healing schedule on [**6-10**]. You have an appointment with Dr. [**Last Name (STitle) **], Infectious Disease, on [**2182-6-26**]. You will need to continue the Linezolid and Ciprofloxacin until at least [**2182-7-4**]. Do not stop your antibiotics without the approval of the infectious disease doctors. 3) Orthopedics - You will follow-up in orthopedics clinic on [**6-3**] to evaluate your thigh wound and to see if your staples are ready to be removed. 4) Liver Clinic - During this admission you were diagnosed with hepatitis C virus. You had an ultrasound of your liver to look for signs of damage due to the virus. You should follow-up in Liver Clinic with Dr. [**Last Name (STitle) **] [**2182-7-10**] at 11:00am to discuss your hepatitis test results, ultrasound, and any need for treatment. You should avoid drinking alcohol because this increases the risk of damage to your liver. You should not share needles. You should use condoms to protect yourself from new infections such as HIV. 5) Substance Abuse - It is important that you stop using drugs after you are discharged, because you are at high risk of having serious complications due to your infections. If you need assistance with stopping drug use you can contact Narcotics Anonymous, Alcoholics Anonymous, or local substance abuse treatment programs. You should seek care from your PCP or return to the hospital emergency department if you experience chest pain, shortness of breath, fevers greater than 100 degrees, chills, night sweats, worsening thigh/hip pain, redness and discharge from your thigh wound, serious skin rashes, or any other worrisome symptoms. Followup Instructions: 1. New PCP [**Doctor Last Name **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2182-6-3**] 2:50pm [**Hospital6 733**] [**Location (un) 830**] 2. Orthopedics [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2182-6-6**] 11:00 [**Hospital Ward Name 23**] Building, [**Location (un) 551**] 3. Infectious disease [**2182-6-26**] at 9:30a Infectious [**Hospital 82590**] Clinic 4. Hepatology Dr. [**Last Name (STitle) **] [**2182-7-10**] at 11:00am Liver Clinic 5. CT scan of your left thigh: [**2182-6-10**] at 1:30PM at [**Hospital3 **] [**Hospital Ward Name 516**] [**Hospital Unit Name 1825**] [**Location (un) 3202**]. You need this follow up CT scan so make sure the infection your healing and your ID doctor will follow up with you. Completed by:[**2182-5-26**] Admission Date: [**2182-5-31**] Discharge Date: [**2182-6-15**] Date of Birth: [**2154-11-5**] Sex: M Service: ORTHOPAEDICS Allergies: Vancomycin Attending:[**First Name3 (LF) 8587**] Chief Complaint: Left hip infection Major Surgical or Invasive Procedure: [**2182-6-1**]: I&D Left hip with VAC placement [**2182-6-4**]: I&D Left hip with VAC change [**2182-6-7**]: I&D Left hip with partial closure and VAC change [**2182-6-11**]: I&D Left hip with VAC change History of Present Illness: Mr. [**Known lastname **] is a 27 year old man who has a history of MRSA bacteremia which he underwent multiple I&Ds of his left hip. He was discharged on [**2182-5-25**] with IV antibiotics as per [**Date Range **] Disease. He presented to the [**Hospital1 18**] [**2182-5-31**] with night sweats and fevers. Past Medical History: prior alcohol abuse (quit 3 yrs ago) IV cocaine abuse (last use 3 wks prior to admission on [**2182-5-6**]) anxiety s/p I&D Left hip x6 from [**Date range (2) 82591**] Social History: Occupation: Metal Worker Drugs: IVDU (cocaine) last approx 2 weeks prior to [**2182-5-6**] after period of sustained sobriety Tobacco: [**12-21**] ppd Alcohol: none presently; former alcohol abuse, sober for 3 years per report Family History: CAD in Father, Diabetes. Hemochromatosis in father Physical Exam: Upon admission PHYSICAL EXAM: Tmax: 99.1 T: 97.6 110/70 89 16 General: NAD HEENT: PEERl, mmm Neck: supple Lungs: CTA B Heart: RRR, II/VI systolic murmur best at LUSB Abdom: +BS, NT, ND, soft Extrem: L thigh: wound vac in place c/d/i, incision with slight warmpth, fluctuence, no erythemia, serous drainage in VAC with with ROM L hip No stigmata of endocarditis Neuro: MAE, PERRL Skin: erythematous rash on face and chest Brief Hospital Course: Mr. [**Known lastname **] presented to the [**Hospital1 18**] on [**2182-5-31**] with complaints of night sweats and fevers. He was evaluated by the orthopaedics and medical services. He was admitted to the medical services, consented, and prepped for surgery. [**Date Range **] disease was also consulted to help with his care. On [**2182-6-1**] he was taken to the operating room and underwent an I&D of his left hip with VAC placement. His care was then transferred to the orthopaedic surgery service. On [**2182-6-4**] he returned to the operating room and underwent another I&D with VAC change. He returned again to the OR on [**2182-6-7**] for another I&D of his left hip with partial closure and VAC change. On [**2182-6-11**] he again returned to the operating room and underwent an I&D of his left hip with VAC change. The VAC was then replaced at the bedside on [**6-13**]. The rest of his hospital stay was uneventful with his lab data and vital signs within normal limits and his pain controlled. He is being discharged today in stable condition. Medications on Admission: Linezolid 600 mg IV/po Q 12([**Date range (1) 82131**])([**5-18**]- cipro 500mg po 2X daily ([**5-20**]- Vancomycin ([**Date range (1) 82592**]) Zosyn ([**Date range (1) 51037**]) Meropenem 500mg po Q 6 ([**5-19**]-->[**5-20**]) 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) packet PO twice a day as needed for constipation. 7. Methadone 10 mg Tablet Sig: One (1) Tablet PO three times 8. Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours. 9. Hydromorphone 4 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed for pain. 10. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical DAILY (Daily) for 2 weeks: Apply to rash on right hand only. 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H 12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Disp:*30 Suppository(s)* Refills:*5* 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for constipation. Disp:*60 Tablet(s)* Refills:*5* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*5* 6. Hydromorphone 4 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*150 Tablet(s)* Refills:*0* 7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/spasm. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Left hip infection Discharge Condition: Stable/Good Discharge Instructions: Continue to be weight bearing as tolerated for your left leg. Please take all medication as prescribed. If you have any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Treatments Frequency: 1. wound vac changes every Mon, Wed, Fri Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Physical Therapy: Activity: Activity as tolerated Left lower extremity: Full weight bearing Treatments Frequency: VAC change every week by visiting nurse (MWF schedule) Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Please follow up with [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD [**First Name (Titles) **] [**Last Name (Titles) **] Disease on [**2182-6-26**] at 9:30 the phone to clinic is [**Telephone/Fax (1) 457**] Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2182-7-10**] 11:00 Completed by:[**2182-6-16**]

[ "693.0", "730.05", "038.12", "235.6", "728.89", "070.54", "E930.8", "998.13", "995.91", "692.9", "285.1", "518.89", "E945.2", "285.29", "284.89", "711.05", "998.12", "518.4", "998.59", "305.60", "564.09" ]

icd9cm

[ [ [] ] ]

[ "83.21", "81.91", "83.45", "77.45", "86.28", "00.14", "93.56", "80.75", "83.19", "77.65", "80.15" ]

icd9pcs

[ [ [] ] ]

24928, 25003

21791, 22861

20273, 20483

25066, 25080

2968, 7277

25856, 26495

21276, 21328

24040, 24905

25024, 25045

22887, 24017

25104, 25378

21374, 21768

25677, 25755

25777, 25833

20215, 20235

20511, 20824

20846, 21015

21031, 21260

32,005

193,670

43782

Discharge summary

report

Admission Date: [**2149-1-24**] Discharge Date: [**2149-1-28**] Date of Birth: [**2070-4-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 94074**] is a 78 y.o. male with hx of afib and DVT on coumadin, now presenting with multiple episodes of black and maroon stool at home which began at 6am. Wife noticed that he was fatigued and slightly confused in last 2 days. Incontinent of urine last night. Woke up at 6am with large amount of maroon/black stool in the bed. Several large movements at home. None in the ED so far. Denies N/V/abdominal pain. No hematemesis. No NSAIDs. No prior episodes of UGIB/LGIB. Denies CP/SOB. In ED, HR 90s on beta-blocker BP 140 systolic ---> 110. Mentating ok. NG tube in ED neg- no bile seen. Past Medical History: age [**6-28**] ARF with arthritis, heart murmur. age 20 Hypertension, 4+ labile with some [**Month/Year (2) 21636**] of 200/100 for which he has gone to ED for control. BP will often decrease by 30 points in doctors if several [**Name5 (PTitle) 21636**] are obtained. [**2110**] gout on allopurinol, no podagra since [**2137**] [**2120**] lipid abnormality, controlled with medication [**2130**] prostatism, alpha blocker started [**2140**] Fe deficiency anemia, due to GERD DVT left leg, warfarin x 6 mo [**2143**] DM type II noted. [**2144**] Barretts esophagitis, [**Doctor First Name **] [**Doctor Last Name **], now bx neg . NKDA Social History: lives with wife. no smoking. occasional etoh. accompanied by wife and daughter today. Family History: Negative for premature CAD, HTN, lipid abnormaltiy. Physical Exam: VS: 99.1 , 129/59, 88, 96RA, 11 Gen: NAD HEENT: anicteric, slightly dry MM, PERRLA, pale Chest: CTAB CV: irreg irreg, 2/6 SEM Abd: S/NT/ND/NABS Ext: no edema Neuro: Aox3, non-focal Pertinent Results: 6.7 >18.1<177 N:64.6 L:30.4 M:3.9 E:1.0 Bas:0.1 139 105 79 218 4.4 23 2.0 CK: 192 MB: Pnd Trop-T: Pnd PT: 38.2 PTT: 35.0 INR: 4.1 . Old data ([**2147**]) . Prior endoscopies: - multiple prior EGD for Barrett's surveillance- most recent [**9-23**] by Dr. [**Last Name (STitle) 94075**] short seg Barrett's - last colonoscopy [**4-22**] with mild sigmoid diverticulosis . Echo performed --> [**12-18**]+ MR, 1+ AS/AR. ETT echo no ischemia to 5 [**First Name8 (NamePattern2) **] [**Doctor First Name **], rapid AF (?aberrancy vs VT) BUN/creatinine moderately elevated. Brief Hospital Course: A/P:78 yo M w/ MMP p/w GIB in setting of elevated INR. . # GIB: EGD showed known stable esophageal disease. Colonoscopy showed an area of bleeding tissue, unable to further characterize per GI fellow. This was cauterized and ligated with bleeding stopped. Coumadin regimen was discussed with pt's cardiologist, Dr. [**Last Name (STitle) 120**], who suggested restarting coumadin on discharge (allowable by GI) with close follow up of INR in his clinic. Medications on Admission: (per OMR): ASPIRIN 81 mg--2 tablet(s) by mouth once a day ATENOLOL 100 mg--1 tablet(s) by mouth at bedtime FUROSEMIDE 40 mg--1 tablet(s) by mouth once a day LISINOPRIL 40 mg--1 tablet(s) by mouth once a day METFORMIN 500 mg--2 tablet(s) by mouth twice a day OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day SIMVASTATIN 20 mg--1 tablet(s) by mouth once a day Spironolacton-Hydrochlorothiaz 25 mg-25 mg--[**12-18**] tablet(s) by mouth qam TERAZOSIN 10 mg--1 capsule(s) by mouth at bedtime WARFARIN 5 mg--1 tablet(s) by mouth once a day dose as directed by inr GLIPIZIDE 10 mg--1 tablet(s) by mouth twice a day Discharge Medications: 1. continue all home medications 2. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Outpatient Lab Work Check INR (coumadin level) on [**2149-1-31**]. Discharge Disposition: Home Discharge Diagnosis: GI bleed Discharge Condition: stable Discharge Instructions: Please follow up with Dr. [**Last Name (STitle) 120**]. He is aware of the plan. You will need to have your coumadin level checked on [**2149-1-31**]. You be given coumadin 10 mg today in the hospital then will take coumadin 5 mg until you hear from Dr.[**Name (NI) 129**] office. You were found to have an area of bleeding tissue in your colon. Small clips were placed around it to stop the bleeding. You may see the clips (like staples) pass in your stool and that is okay. If you have any black, maroon stool or see red blood in your stool, stop the coumadin and go to the emergency room. If you have any chest pain, palpitations, dizziness, or abdominal pain, call Dr. [**Last Name (STitle) 120**]. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2149-3-5**] 10:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2149-2-4**] 3:30 -- this is a new primary care doctor [**First Name (Titles) **] [**Hospital1 **], call to cancel if you chose another primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2149-2-4**]

[ "562.10", "285.1", "403.90", "250.00", "790.92", "427.31", "578.9", "585.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.43" ]

icd9pcs

[ [ [] ] ]

3934, 3940

2630, 3087

324, 331

3993, 4002

2028, 2607

4759, 5324

1759, 1812

3747, 3911

3961, 3972

3113, 3724

4026, 4736

1827, 2009

276, 286

359, 971

993, 1640

1656, 1743

51,000

195,754

42449

Discharge summary

report

Admission Date: [**2118-4-29**] Discharge Date: [**2118-5-8**] Date of Birth: [**2067-9-14**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / lactose Attending:[**First Name3 (LF) 5790**] Chief Complaint: TBM Major Surgical or Invasive Procedure: [**2118-5-3**] Re-do right thoracotomy, intrathoracic tracheoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, right mainstem bronchus bronchoplasty with mesh. History of Present Illness: 50 y/o M with history of asthma and cystic lung changes suspected to be a result of congenital disease or infantile infection s/p right middle and lower lobectomies as an infant who was referred to [**Hospital1 18**] for tracheobronchomalacia (TBM) management after a stent trial at [**Hospital **] Hospital with Dr. [**Last Name (STitle) **]. TBM was confirmed by bronchoscopy on [**11-6**]. He underwent silicone Y stent placement on [**2118-2-8**] but was unable to tolerate the stent due to pain. Stent was removed [**2118-2-22**]. Currently, pt has SOB if supine or walking > 10 minutes, chronic wheeze, productive cough but difficulty raising phlegm. He denies chest pain, fever, chills, dysphagia. Presents for tracheoplasty with posterior tracheal splinting via right thoracotomy. Consulted for epidural placement for post-operative pain management. Past Medical History: -TBM -HTN -recurrent sinusitis -s/p RML and RLL lobectomy for congenital cystic changes/pneumonia at 12 days old (records in chart) -chronic right lung disease since infection at childbirth, bronchomalacia with possible abn of lobar bronchial cartilages found on path report at 12 days old -h/o severe chronic wheezing -bronchiectasis -GERD -s/p sinus [**Doctor First Name **] [**2093**] -asthma: no intub -aspiration pna Social History: Lives with wife in [**Name (NI) 3908**] Occupation: funeral director and embalmer, with regular exposure to formaldehyde Smoking history:never Alcohol: [**1-28**] drinks/month Family History: Mother: HTN, hyperlipidemia Father: prostate cancer, HTN Son with seizure disorder grandfather w bladder cancer Physical Exam: GENERAL: WDWN [**Male First Name (un) 4746**] in NAD HEENT: NCAT HEART: RRR no m/r/g LUNGS: diffuse wheezing BACK: epidural catheter in place; 14cm at skin ABD: s/NT/ND/+BS MSK/EXT: no c/c/e; MAEE Pertinent Results: [**2118-4-29**] 09:08PM URINE HOURS-RANDOM CREAT-90 SODIUM-25 POTASSIUM->100 CHLORIDE-99 [**2118-4-29**] 09:08PM URINE MYOGLOBIN-PRESUMPTIV [**2118-4-29**] 08:13PM UREA N-25* CREAT-1.4* SODIUM-134 POTASSIUM-6.1* CHLORIDE-103 [**2118-4-29**] 08:13PM CK(CPK)-1615* [**2118-4-29**] 08:13PM CK(CPK)-1615* [**2118-4-29**] 08:13PM CK-MB-22* MB INDX-1.4 cTropnT-<0.01 [**2118-4-29**] 07:27PM TYPE-ART PO2-77* PCO2-44 PH-7.33* TOTAL CO2-24 BASE XS--2 [**2118-4-29**] 07:27PM LACTATE-1.1 [**2118-4-29**] 07:27PM freeCa-1.10* [**2118-4-29**] 07:27PM freeCa-1.10* [**2118-4-29**] 07:11PM CALCIUM-8.2* PHOSPHATE-4.5 MAGNESIUM-1.9 [**2118-4-29**] 07:11PM CALCIUM-8.2* PHOSPHATE-4.5 MAGNESIUM-1.9 [**2118-4-29**] 07:11PM WBC-15.9* RBC-3.92* HGB-12.0* HCT-37.0* MCV-95 MCH-30.7 MCHC-32.5 RDW-12.8 [**2118-4-29**] 07:11PM PLT COUNT-390 [**2118-4-29**] 02:07PM GLUCOSE-113* LACTATE-0.9 NA+-133 K+-5.1 CL--105 [**2118-4-28**] 10:50AM WBC-10.8 RBC-4.19* HGB-12.6* HCT-39.5* MCV-94 MCH-30.0 MCHC-31.9 RDW-12.8 [**2118-4-29**] 11:13AM freeCa-1.19 [**2118-4-28**] 10:50AM PT-11.0 INR(PT)-1.0 [**2118-4-28**] 10:50AM PT-11.0 INR(PT)-1.0 [**2118-4-28**] 10:50AM WBC-10.8 RBC-4.19* HGB-12.6* HCT-39.5* MCV-94 MCH-30.0 MCHC-31.9 RDW-12.8 Brief Hospital Course: The patient was admitted after undergoing tracheoplasty via R thoracotomy. The patient tolerated the procedure well. Post-operatively, the patient was advanced with diet and self-hydration. He was able to void on his own and he was able to ambulate, including up and down two flights of stairs. The patient is being discharged in stable condition. He is to follow up with his surgeon in 1 week for clearance before he returns to [**State 3908**]. Medications on Admission: Mucomyst nebs [**Hospital1 **] Albuterol inhaler/nebs Flonase Lisinopril 20 mg daily HCTZ 12.5mg daily MVI Nexium dornase alpha inhaler neb [**Hospital1 **] Mucinex Uniphyl 400mg daily Discharge Medications: 1. acetylcysteine Miscellaneous 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Flonase Nasal 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Nexium Oral 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. Disp:*25 Tablet(s)* Refills:*0* 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Severe diffuse tracheobronchomalacia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital for surgery to repair your trachea. you have progressed very well and are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Be active and walk frequently to avoid blood clots. * Continue to eat well and stay well hydrated. * Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you develop any fevers, chills, increased shortness of breath, difficulty coughing or any new symptoms that concern you. Followup Instructions: * Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] to schedule a follow up appointment on Tuesday [**2118-5-17**]. Completed by:[**2118-5-8**]

[ "790.6", "401.9", "519.19", "494.0", "728.88", "276.7", "530.81", "493.90" ]

icd9cm

[ [ [] ] ]

[ "33.48", "31.79" ]

icd9pcs

[ [ [] ] ]

5176, 5182

3639, 4087

291, 469

5264, 5264

2364, 3616

5942, 6104

2016, 2130

4323, 5153

5203, 5243

4113, 4300

5414, 5919

2145, 2345

248, 253

497, 1359

5279, 5390

1381, 1806

1822, 2000

66,123

164,969

5377

Discharge summary

report

Admission Date: [**2136-2-13**] Discharge Date: [**2136-2-16**] Date of Birth: [**2070-8-16**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Azithromycin / Levofloxacin Attending:[**First Name3 (LF) 2108**] Chief Complaint: Shortness of breath, productive cough, fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 65 year old woman with COPD and active tobacco use (50 pack-year history) who presents with three days of worsening shortness of breath, with fever, productive cough, and increased home bronchodilator use without relief of symptoms. She was initially admitted to the ICU, and was subsequently transferred to the medical floor after management of respiratory distress and hypoxia. In the three days prior to admission, the patient notes feeling like she had a 'cold' with increasing wheezing and shortness of breath at rest that is further exacerbated by exertion. She tried escalating nebulizers and inhalers prior to presenting, with minimal improvement in her symptoms. She states that this episode is similar to her previous COPD exacerbations, although she has not required ICU stay in the past. She reports a temperature to 101F on the night prior to admission, and 100.1 on the morning of admission. She reported pleuritic chest pain, although, she denies any chest pressure or tightness and states that her current episode feels like her prior COPD exacerbations. On the day of admission, she presented to her PCP for evaluation and was noted to be severely dyspneic and appeared dehydrated. Her vitals were T 99.1, P 108-120, BP 160/80, O2 saturation 84% on RA. She was noted to have poor air movement with faint inspiratory and expiratory wheezes and rhonchi. She was sent to the [**Hospital1 18**] ED for evaluation. In the ED, initial VS were: 97.7 110 152/64 24 100% on 6L NC. On exam, she had diffuse wheezes. She was initially stable on 6L NC O2 but experienced episodes of worsening SOB during which she desaturated to the low 80s. She was placed on 15L O2 non-rebreather. EKG showed sinus tachycardia, similar to prior. CXR showed large lung volumes with no acute process. CTA chest was negative for PE. She was given 60 mg prednisone PO but vomited and subsequently received solumedrol 125 mg IVP. She was also given with nebulized inhalers x 3, Levofloxacin 500 mg x1 IV, Zofran 4 mg IVP, and 1L NS IV. She appeared comfortable, was not using accessory muscles, and was speaking in full sentences. The patient was transferred to the [**Hospital Unit Name 153**] for management of respiratory distress. In the ICU, the patient continued to appear stable on non-rebreather. Vitals were T 96.9 P 110 BP 147/52 RR 28 Sat 96% on NRB. Review of systems: Acute shortness of breath, with productive cough of 'gray-ish sputum', no nausea or vomiting, no muscle aches, no abdominal pain, positive fever for the day prior to admission, without shaking chills. She endorses anxiety, chronic non-productive cough (sometimes productive of clear sputum), occassional hot flashes. Patient did get flu shot this year. Does sometimes get nausea with her COPD flares, and is developing this now. (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pressure, palpitations, or weakness, or lower extremity edema. Denies nausea, vomiting (other than 1x in ED), 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: -COPD with frequent exacerbations, 2L NC home O2 used PRN less than daily. Climbs 4 stairs before requiring rest at baseline. Baseline PF ~ 150. -H/o breast CA in [**2123**], T2, N2 intraductal carcinoma, ER Pos, HER-2 Neg. s/p chemo/radiation, no evidence of recurrence h/o arterial clot in right great toe "years ago", treated with coumadin -Active tobacco use Social History: Patient is a widow whose husband died suddenly a few years ago. She lives alone in [**Location (un) 701**], MA. She has two adult sons who are living in the area. Former administrator at a printing company, laid off a few years ago. - Tobacco: 1 ppd/50yrs (active, not interested in quitting at this time) - Alcohol: Denies - Illicits: Denies Family History: Father died at age 52 of emphysema and coronary artery disease, had first MI in 40s-50s. Mother died of emphysema at age 72. Sister who died of breast cancer. Brother who died of lymphoma at 46y. Physical Exam: On admission to the ICU VS: T: 96.9 BP: 138/62 P: 107 R:22 O2: 91 on 6L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Minimal air movement. Inspiratory and expiratory wheezes bilaterally in all posterior and anterior fields. No rales or rhonchi. CV: Regular rate and rhythm, distant 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 On transfer to the medical floor: VS: 88% on 6L NC prior to nebulizer, 92% after nebulizer. BP 110s/60s HR 80s-90s on telemetry. General: Patient appears comfortable, mild audible wheezing, no use of accessory muscles. Able to speak short sentences without distress. HEENT: dry mucous membranes, no scleral icterus Neck: No JVD Lungs: limited air movement, extensive wheezing bilaterally. No focal rhonchi but coarse BS bilaterally. No use of accessory muscles. Abdomen: positive BS, soft, non-tender, non-distended Extremities: no pitting edema, overall decreased muscle mass. Skin: Changes consistent with chronic steroid use, with decreased turgor pressure. Pertinent Results: Imaging: CXR [**2136-2-13**]: AP upright portable view of the chest was obtained. The lungs are again hyperinflated, consistent with chronic obstructive pulmonary disease. Biapical pleural thickening is again noted. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac, mediastinal, and hilar contours are stable. The cardiac silhouette is not enlarged. Aortic knob calcification is seen. IMPRESSION: COPD. No focal consolidation seen. CTA [**2136-2-13**]: 1. No evidence of acute pulmonary embolism or acute aortic syndrome. 2. Bibasal small sub 4-mm nodules, similar in size and appearance to the prior study. A new right 3 mm lower lobe nodule, is new since the prior study. Given the history of breast cancer, recommended a followup chest CT in three to six months to assess the same. Findings added to radiology dashboard on [**2136-2-14**]. 3. Stable biapical pleural parenchymal scarring. 4. Small hiatal hernia. [**2136-2-13**] 04:40PM BLOOD WBC-14.8*# RBC-4.72 Hgb-14.8 Hct-43.1 MCV-91 MCH-31.4 MCHC-34.3 RDW-12.9 Plt Ct-369 [**2136-2-15**] 08:00AM BLOOD WBC-11.0 RBC-4.23 Hgb-12.4 Hct-40.0 MCV-95 MCH-29.2 MCHC-30.9* RDW-12.4 Plt Ct-319 [**2136-2-13**] 04:40PM BLOOD Neuts-93.9* Lymphs-3.4* Monos-1.8* Eos-0.7 Baso-0.3 [**2136-2-13**] 04:40PM BLOOD Glucose-120* UreaN-8 Creat-0.6 Na-138 K-3.9 Cl-97 HCO3-29 AnGap-16 [**2136-2-15**] 08:00AM BLOOD Glucose-119* UreaN-12 Creat-0.6 Na-139 K-4.9 Cl-97 HCO3-39* AnGap-8 [**2136-2-13**] 04:40PM BLOOD cTropnT-<0.01 [**2136-2-14**] 01:51AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8 [**2136-2-13**] 04:40PM BLOOD HCG-<5 [**2136-2-14**] 01:06AM BLOOD Type-ART Temp-36.1 pO2-79* pCO2-58* pH-7.38 calTCO2-36* Base XS-6 Brief Hospital Course: 65 year-old woman admitted with a COPD exacerbation secondary to an acute infection, in the setting of active tobacco use, known oxygen-dependent COPD (2L, per son's report), and found to have hypoxia, leukocytosis, fever and productive cough. She was initially admitted to the ICU for management of her acute hypoxia with a non-rebreather mask and IV steroids, and has responded to nebulizer therapy as well. Acute exacerbation of COPD: Respiratory distress, wheezing and productive cough most likely represents an acute exacerbation of patient's chronic COPD. More likely secondary to a viral infection given fever and leukocytosis and CXR and CT CHEST showing no infiltrates or pneumonia. Antibiotics given for 3 days and discontinued because the patient recovered to her baseline breathing function very rapidly. Influenza swab was negative. Patient returned to baseline oxygen needs on day 3 of hospitalization. Plan for 12 day taper of steroids starting at Prednisone 60 mg Daily, decreasing by 10 mg Q2 days. She was referred to pulmonary rehab (outpatient). Leukocytosis - Probably [**12-28**] viral infection causing URI. Improved during hospitalization. Tobacco use - Patient notes she has discussed cessation extensively with her PCP Dr [**First Name (STitle) **] and has not had success in the past with attempts at quitting. Is interested in nicotine patch while inpatient, I have discussed cessation with her extensively and she states she will quit and use the nicotine patch for assistance. New pulmonary nodule seen on CT CHEST. Requires [**1-29**] month follow-up with repeat CT CHEST to monitor for interval change in size of nodule. Goals of care: Patient notes that although she felt that she would not want intubation or resuscitation, she feels a strong need to discuss her wishes with her sons and hopes to do this in the coming days. She is aware that the medical team would be happy to assist in the discussion. One of her sons was at the bedside during this admission, and the patient acknowledged that she would continue the discussions with him and her other son. She also noted that she had her 'paperwork' all organized at home. Medications on Admission: Medications reconciled with patient on admission: ALBUTEROL SULFATE - 2.5 mg/3 mL 1 ampule NEB Q6 PRN SOB/wheezing (as backup) ALBUTEROL SULFATE - 90 mcg HFA - 1-2 puffs(s) Q4-6 PRN cough/wheezing BUDESONIDE-FORMOTEROL - 80 mcg-4.5 mcg/Actuation HFA 2 puffs [**Hospital1 **] TIOTROPIUM BROMIDE - 18 mcg Capsule - 1 puff daily TRAZODONE - 50 mg Tablet - PO QHS PRN insomnia VENLAFAXINE - 75 mg Tablet - PO daily (for hot flashes) Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit dose Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. budesonide-formoterol 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for hot flashes. 7. prednisone 10 mg Tablet Sig: PO taper as directed for 10 days: 50 mg daily for 2 days starting [**2-17**], then 40 mg daily for 2 days on [**2-19**], then 30 mg daily for 2 days on [**2-21**], then 20 mg daily for 2 days on [**2-23**], then 10 mg daily for 2 days on [**2-25**], then off. Disp:*30 tablets* Refills:*0* 8. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day: use daily for 4-6 weeks then taper to 14mg patch for 4-6 weeks then to the 7mg patch for 4-6 weeks. Disp:*28 patches* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: - Exacerbation of chronic obstructive pulmonary disease - Viral syndrome - Active smoker Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized for a COPD exacerbation that may have been triggered by a viral infection. You had fever and cough, but chest imaging with Xray and CT scan did not show any pneumonia. You responded to initial treatment with steroids and antibiotics. By the 3rd day of hospitalization, you felt back to your baseline state of health. We recommend finishing a 12-day taper of Prednisone. We recommend that you work closely with your doctor to quit smoking to help preserve your lung function and reduce your risk for further COPD exacerbation. MEDICATION CHANGES: 1. Prednisone taper (reduce by 10 mg daily every 2 days): Starting at 60 mg daily on [**2-15**], decrease to 50 mg daily on [**2-17**], then 40 mg daily on [**2-19**], then 30 mg daily on [**2-21**], then 20 mg daily on [**2-23**], then 10 mg daily on [**2-25**], then last dose on [**2-26**] and stop. 2. Nicotine replacement patch Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] When: TUESDAY [**2136-2-21**] at 10:50 AM With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] 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: RADIOLOGY When: TUESDAY [**2136-4-24**] at 11:10 AM With: RADIOLOGY [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call the following number to set up outpatient pulmonary rehab at [**Hospital **] rehab in [**Location (un) 701**], MA. Phone: ([**Telephone/Fax (1) 21858**]. This is the main number, please ask for [**Hospital 21859**] REHAB.' If they ask for the name of the referring doctor, please give them your primary care physician's name. ([**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5004**] MD)

[ "V46.2", "E930.8", "305.1", "491.21", "276.2", "693.0", "V10.3", "079.99" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11538, 11544

7630, 9802

353, 359

11677, 11677

5905, 7607

12758, 14017

4398, 4595

10282, 11515

11565, 11656

9828, 9864

11828, 12381

4610, 5886

2791, 3636

12401, 12735

269, 315

387, 2771

9878, 10259

11692, 11804

3658, 4022

4038, 4382

28,573

166,803

31634

Discharge summary

report

Admission Date: [**2127-8-4**] Discharge Date: [**2127-8-15**] Date of Birth: [**2046-1-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Left Internal Jugular Cordis Catheter Foley Catheter Gastroduodenal Artery Embolization History of Present Illness: HPI: 81 yo M physician with metastatic lung CA to brain s/p chemo and XRT on steroids, h/o hyponatremia-SIADH from lung CA, renal failure from ATN baseline Cr 1.1-1.9, recently discharged to rehab on [**8-1**] presents with Melena. Pt was placed on steroids without GI ppx, also discharged on hep sc tid. No anticoagulation for AF. No prior h/o GIB, no recent NSAID use. . ED Course: Initial VS T 98.0 BP 102/63 HR 105 RR 18 100% 2LNC, intial hct 23 (20 point HCT drop from [**8-1**]), NGL negative, received 2 L IVF for decreased SBP 78/45 improved to low 100s, 1 UPRBC on transfer to MICU, GI consulted in ED, Protonix 40mg IV x1 given. Admit to MICU for EGD per GI and HD monitoring. Past Medical History: -Metastatic Non Small Cell Lung CA to Brain underwent 1 cycle of Carboplatin 5 AUC and Taxol 200mg/m2 on [**2127-6-20**] and XRT -Anxiety with paranoid thinking- worsened with current illness -DM- induced by decadron -Thrush-radiation induced -BPH -Melanoma -Atrial fibrillation - noted on last hospitalization in [**Location (un) 7349**] Social History: Former practicing psychiatrist at [**Hospital1 1872**] until one month ago when mental status began to deteriorate. Lives with his wife in [**Name (NI) 7349**]. Currently in [**Location (un) 86**] where his son practices pediatrics for better coordination of care as recently home services in [**Location (un) 7349**] fell through. Remote smoking history, quit at age 45. Non-drinker. Family History: non-contributory Physical Exam: VS: 97.1 BP 106/64 HR 100 RR 20 100%2LNC GEN: NAD HEENT: MMM, No oral lesions/no mucositis, PERRL RESP: CTABL, No crackles, no wheezing CV: Irregular, Nml S1, S2, no M/R/G ABD: Soft ND, tender at LUQ/LLQ area, no rebound, no guarding +BS EXT: 2+ edema at ankles, warm, dopplerable pulses NEURO: A&O x1 (person only), no focal neuro deficits, no facial droop, voice/speech fluent, states he's confused, follows commands appropriately, understands he's here for bleeding, strength 4/5 throghout, normal sensation throughout Pertinent Results: Admission Labs: [**2127-8-4**] 07:55PM WBC-9.4 RBC-2.72*# HGB-8.0*# HCT-23.7*# MCV-87 MCH-29.5 MCHC-33.8 RDW-15.9* NEUTS-73* BANDS-4 LYMPHS-16* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* NUC RBCS-1* CALCIUM-8.3* PHOSPHATE-2.6* MAGNESIUM-1.8 [**2127-8-4**] 07:55PM CK-MB-NotDone cTropnT-0.08* [**2127-8-4**] 07:55PM CK(CPK)-29* [**2127-8-5**] 01:05AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2127-8-5**] 01:05AM BLOOD CK(CPK)-30* GLUCOSE-128* UREA N-81* CREAT-1.9* SODIUM-135 POTASSIUM-5.7* CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 HGB-8.1* calcHCT-24 K+-5.4* [**8-4**] EGD: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Excavated Lesions A single cratered 3cm ulcer was found in the proximal bulb. There was a large overlying blood clot which could not be cleared by aggressive irrigation. Full circumference of ulcer could not be visualized given size and presence of large clot- decision made not to inject or cauterize. Impression: Ulcer in the proximal bulb Recommendations: High risk for large re-bleed. Will discuss with interventional radiology re: GDA embolization and will notify surgery. [**2127-8-5**] 6:17 am SEROLOGY/BLOOD Source: Line-LIJ. **FINAL REPORT [**2127-8-6**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2127-8-6**]): NEGATIVE BY EIA. [**2127-8-5**] EKG: Atrial fibrillation with rapid ventricular response. Compared to tracing of [**2127-8-4**] ventricular response has increased. [**2127-8-7**] CXR: IMPRESSION: AP chest compared to [**7-24**] through 14: Small-to-moderate right pleural effusion, largely subpulmonic in the correct position, stable over the past two weeks. Progressive fullness in the right lower paratracheal region could be due to seriously engorged azygos vein and possible accompanying adenopathy. Previous right upper lobe edema or consolidation has largely cleared since [**8-4**]. Differential diagnosis of transient lobar edema includes acute mitral regurgitation and pulmonary venous thrombosis. Lungs are otherwise clear. Heart size is normal and there is no left pleural effusion. Following the removal of the left central venous catheter there has been no generalized mediastinal widening to suggest hemorrhage. [**2127-8-7**] CXR - IMPRESSION: AP chest compared to [**7-24**] through 14: Small-to-moderate right pleural effusion, largely subpulmonic in the erect position, stable over the past two weeks. Progressive fullness in the right lower paratracheal region could be due to seriously engorged azygos vein and possible accompanying adenopathy. Previous right upper lobe edema or consolidation has largely cleared since [**8-4**]. Differential diagnosis of transient lobar edema includes acute mitral regurgitation and pulmonary venous thrombosis. Lungs are otherwise clear. Heart size is normal and there is no left pleural effusion. Following the removal of the left central venous catheter there has been no generalized mediastinal widening to suggest hemorrhage. Findings were discussed by telephone with Dr. [**Last Name (STitle) 20858**] at the time of dictation. [**2127-8-9**] ECG - Atrial fibrillation with a rapid ventricular response. RSR' pattern in lead V1, may be normal variant. Since the previous tracing of [**2127-8-5**] no significant change Discharge Labs: [**2127-8-13**] 07:10AM BLOOD WBC-5.9 RBC-4.10* Hgb-12.1* Hct-36.0* MCV-88 MCH-29.4 MCHC-33.5 RDW-16.4* Plt Ct-234 [**2127-8-13**] 07:10AM BLOOD Glucose-93 UreaN-26* Creat-2.3* Na-139 K-4.4 Cl-106 HCO3-23 AnGap-14 [**2127-8-13**] 07:10AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9 Brief Hospital Course: AP: 81 yo M with metastatic Lung CA to brain, AF, presents with Melena. # UGIB: Patient found with significant HCT drop from most recent admission 45-->23 and BRBPR on admission. EGD in unit per GI on night of admission showed a large 3.5cm ulcer was found on the posterior duodenal bulb with a very large adherent clot. Gen surgery was consulted that evening, however given his commorbidities of metastatic Lung CA with brain mets they deferred invasive surgical intervention. IR was called that evening and patient was HD stable overnight, angio was planned to take pt in am to IR for embolization. Pt was transfussed 3UPRBC for HCT goal>30 given melena and HCT drop on 1st night of admission. A L-IJ cordis was placed for adequate acces given his UGIB. He was taken to angio in am and his Gastroduodenal artery was embolized. Pt remained stable without further PRBC transfusions in the MICU. He was maintained on PPI [**Hospital1 **]. Pt was sent to the floor on [**8-6**]. The patient's Hct continued to trend downward; however, this was difficult to interpret in the setting of the aggressive IV fluids he was receiving to treat his hypotension/tachycardia. On the evening of [**8-10**], his Hct was found to be 21, so he was transfused 2 units of PRBCs, which he tolerated well. Hct remained stable in 30s on discharge. #AFib w/ RVR: Patient was initially maintained off home diltiazem given UGIB. He then was restarted on a low dose diltiazem for better rate control. On up titration of Diltiazem, patient experienced episodes of hypotension. Patient was rate controlled and returned to home Diltiazem CR 180mg daily. However, he continued to be tachycardic, with bouts into the 170's. This was considered to be secondary to both his a-fib and worsened by probable hypovolemia. He was given several boluses of IV fluids along with maintenance fluids. By [**8-11**], his BPs were at his presumed baseline (110-140 systolic), though he was found to be slightly volume overloaded on lung exam. Fluids were held on [**8-11**] and the patient was given supplemental oxygen, both of which he tolerated well. By [**8-12**], he continued to be intermittently tachycardic, even on 240mg Diltiazem. Additional PO doses of 30mg Diltiazem continue to be successful in bringing his HR down to the high 90's. He was started on a higher dose of Diltiazem on [**8-13**], at 360mg PO daily. Anticoagulation was contraindicated given recent GIB. # Acute on CRF: Patient w/ baseline cr of 1.1 - 1.9, sustained acute renal failure secondary to hypotension in setting of UGIB. Cr did not return to normal, even with IV fluids, but remained stable around 2.2. #Onc: Patient w/ known metastic lung cancer to brain. Continued supportive care, pain control prn. He was continued on low dose steroids, changed prednisone to IV methylprednisolone while pt was NPO, then restarted on Prednisone 2.5mg taper on [**8-6**] when he was tolerating POs. Prednisone 2.5mg taper for 5 days, discontinued on [**8-11**]. Patient and family instructed to follow up with oncology outpatient for further discussion of care. However, after meeting with palliative care services on [**8-11**], it was agreed that they would work to transfer him home with hospice services. While the apartment is being set up, the plan is to discharge him to [**Hospital3 1186**] hospice for several days in the interim. # Respiratory Distress: Likely result of worsening albumin status with fluid extravesation into lungs on top of poor clearance of oral secretions and likely aspiration. Patient was treated with comfort measures of oxygen, morphine prn, oral suctioning prn, and scopalamine patch. # UTI: The patient was found with urinary frequency, sometimes complaining of pain as well. UCx revealed Enterococci (Sensitive to Ampicillin, Nitrofurantoin, Vancomycin; Resistant to Tetracycline), so he was begun on a 7-day course of Amoxicillin, beginning on [**8-10**]. Urinalysis showed [**2-24**] WBC and moderate bacteria. He remained afebrile. As of [**8-13**], he continued to complain of pain on urination. The UTI was believed to be contributing to his mental status changes. Patient discharged to hopsice with 3 day course of amoxicillin. # Depression/Mental Status Changes: Patient with known baseline of anxiety and depression. Patient had been on Paxil previously. Episodes of confusion, and combativeness, especially at night occurred throughout admission. He was frequently found to be irritated and angry, which according to his family, was startingly different from his baseline personality. Patient was resumed on paxil and provided seroquel QHS for sundowning. Current confusion most likely related to known brain metasteses and UTI. Continue seroquel, paxil, clonazepam and prn haldol on discharge. #Steroid induced DM: Covered with ISS during admission. At discharge, blood sugars ranging 78-130 and not requiring any insulin sliding scale coverage. # FEN - Patient was advanced to regular diet. Electrolytes were monitored and repleted prn. # PPX - Patient was continued on IV PPI [**Hospital1 **] and then switched to oral PPI once daily on discharge. Given the contraindication to anticoagulation, patient was maintained on pneumoboots during this admission. Patient was maintained on colace/senna bowel regimen. # ACCESS - Left IJ cordis removed on [**8-7**] without complication. One large bore IV maintained until discharge. # CODE - DNR/DNI, confirmed w/ family and primary care physician. [**Name10 (NameIs) 38133**] family also in agreement with a do not hospitalize order. Patient to be DNR/DNI on transport to [**Last Name (un) 1188**] house. Patient for hospice care at home once apartment in [**Location (un) 86**] arranged on [**2127-8-23**]. # DISPO - To hospice for end of life care. Medications on Admission: Discharge Meds from [**2127-8-1**]: #. Paroxetine HCl 20 mg daily #. Diltiazem HCl 180 mg SR daily #. Heparin (Porcine) 5,000 unit/mL TID #. Clonazepam 0.5 mg [**Hospital1 **] #. Acetaminophen 650 mg Q6HR prn fever #. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale units Injection per sliding scale: Needs qAC and qhs finger sticks. #. Prednisone TAPER 5mg daily from [**Date range (1) 74352**] and 2.5 mg from [**Date range (1) 74351**]. #. Sodium Chloride 1 g Tablet TID Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Paroxetine HCl 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation: [**Month (only) 116**] repeat prn. Disp:*60 Tablet(s)* Refills:*1* 8. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 9. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 3 days. Disp:*6 Capsule(s)* Refills:*0* 10. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) for 3 days: Please change every 72 hours. 14. Roxanol Concentrate 20 mg/mL Solution Sig: One (1) ml PO q1h as needed for pain: Please titrate to patient comfort. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Metastatic Lung Cancer Atrial Fibrillation with rapid ventricular rate Upper Gastrointestinal bleed Discharge Condition: Seriously ill with respiratory compromise. Discharge Instructions: You have been treated for a gastroentestinal bleed during your hospital stay with IV fluids and blood and embolization of an artery in your stomach. You experience no further bleeding episodes after this point. During your stay you also had a rapid irregular heart beat that was complicated by low blood pressure. You were treated with diltiazem with resolution of your rapid heart rate. Please call your physician if you have any concerns about sustaining comfort care. Followup Instructions: Please call your physician to arrange follow up as needed. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "44.44" ]

icd9pcs

[ [ [] ] ]

13969, 14042

6115, 11922

318, 408

14186, 14231

2483, 2483

14754, 14910

1908, 1926

12464, 13946

14063, 14165

11948, 12441

14255, 14731

5818, 6092

1941, 2464

273, 280

436, 1124

2499, 5801

1146, 1486

1502, 1892

75,906

190,407

53873

Discharge summary

report

Admission Date: [**2132-4-14**] Discharge Date: [**2132-4-29**] Date of Birth: [**2051-6-1**] Sex: F Service: MEDICINE Allergies: Latex Attending:[**First Name3 (LF) 31014**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Inguinal Lymph Node Biopsy History of Present Illness: Ms [**Known lastname **] is a 80 year old female who is presenting to us from rehab ([**Hospital3 2558**]) with new melena. She has a history of GAVE diagnosed in [**Month (only) 956**] of this year at [**Hospital6 2561**] diagnosed on endoscopy after her hematocrits were noted to be low near 27. Her GAVE was cauterized at this time by her gastroenterologist. Her past medical history is also significant for coronary artery disease with stents placed in [**2116**], congestive heart failure, and stage III chronic kidney disease. Ms [**Known lastname **] presents today after 2 episodes of melena at [**Hospital 7137**]. This morning she had crampy abdominal pain lasting minutes throughout her abdomen with rectal urgency. She passed 2 bowel movements and the pain subsided. Her nurse noted the stool to be black although Ms [**Known lastname **] states the stool is always black because of her ferrous supplements. Stool guiaiac was positive; apparently in the past it has been negative. No diarrhea, nausea, vomiting, or hematemesis. No fevers, chills, shortness of breath, lightheadedness, chest pain, chest pressure, or dizziness. She was recently hospitalized at [**Hospital3 **] on [**3-25**] for an exacerbation of congestive heart failure, during which time a pleural effusion was tapped; thoracentesis revealed a transudate with negative cytology. Her creatinine was elevated to 2.2. Renal ultrasound revealed a left renal hilum mass measuring 10.3 x 4.6 x 4.9 cm as well as lesions in the liver and pancreas. A CT contrast to evaluate these further could not be performed because of her acute kidney injury. She was discharged with instructions to follow up with her primary care doctor to further evaluate these lesions. Over the past two months, Ms [**Known lastname 110511**] appetite has waned. Her weight has dropped around 10 lbs. She has not had any prior episodes of melena or hematochezia. No hematemesis history. Denies abdominal pain. Other than the two episodes today, she feels well at time of transfer to MICU. Past Medical History: 1. diabetes 2. congestive heart failure 3. hyperlipidemia 4. hypertension 5. type II diabetes 6. GAVE 7. coronary artery disease s/p 2 stents - [**2116**] in circumflex, and LAD 8. aortic stenosis s/p AVR (bioprosthetic) 9. stage III CKD 10. hx of CVA Social History: She lives in [**Hospital1 **] with her younger sister. She has been back and forth between [**Hospital3 2558**] and [**Hospital3 60734**]. She used to work in a publishing house until age 75. Family History: Noncontributory Physical Exam: On admission: Vitals reveal a regular pulse 60-70. Systolic ejection murmur is heard best in aortic area. Respiratory rate is 18 with no significant accessory muscle use. Oxygen saturation is 98% on 2 L of oxygen. Her blood pressure reveals a wide pulse pressure with systolic of 140 and diastolic of 30-40. In general, she is Caucasian, a thin, pleasant, elderly woman, appropriate to conversation, inquisitive, alert, and oriented to person, place and time. Cardiovascular exam shows no appreciable JVP, pulses 2+ and equal bilaterally, with a systolic ejection murmur without clicks loudest in aortic area. Pulmonary exam reveals mild crackles at bases bilaterally, free of wheezes, with respiratory rate of 18. Abdominal exam shows a distended, tympanic abdomen, with no appreciable masses or tenderness. Extremities are quite swollen, with 3+ pitting edema to the thighs bilaterally. No cyanosis, warm fingers and toes. Neurologically non-focal. On Discharge:wt 73kg 98.8, 128/89, 72, 20 General: Less anxious than yesterday. AOx3, not tachypneic HEENT: PEERLA, MMM Cardiac: RRR, 3/6 systolic murmur at the LUSB, with split s2 Lungs: bibasilar crackles Abd: Protuberant. tympanitic, nontender, unchanged from yesterday Extremities: 2+ peripheral edema to the thighs bilaterally, 2+DP pulses bilaterally Pertinent Results: On Admission: [**2132-4-14**] 06:00PM BLOOD WBC-11.2* RBC-3.04* Hgb-7.2* Hct-25.3* MCV-80* MCH-23.6* MCHC-29.6* RDW-15.4 Plt Ct-367 [**2132-4-14**] 06:00PM BLOOD Neuts-87.2* Lymphs-6.1* Monos-1.6* Eos-4.9* Baso-0.3 [**2132-4-14**] 06:00PM BLOOD PT-16.3* PTT-37.3* INR(PT)-1.5* [**2132-4-14**] 06:00PM BLOOD Glucose-167* UreaN-88* Creat-2.4* Na-139 K-4.1 Cl-103 HCO3-20* AnGap-20 [**2132-4-14**] 06:00PM BLOOD ALT-20 AST-41* AlkPhos-66 TotBili-0.3 [**2132-4-14**] 06:00PM BLOOD proBNP-[**Numeric Identifier 87864**]* [**2132-4-14**] 06:00PM BLOOD cTropnT-0.02* [**2132-4-15**] 02:59AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.4 [**2132-4-14**] 06:00PM BLOOD Albumin-2.9* [**2132-4-16**] 05:50AM BLOOD CEA-<1.0 [**2132-4-15**] 02:59AM BLOOD Digoxin-1.0 [**2132-4-14**] 07:11PM BLOOD Lactate-2.2* Studies: CT Abd/Pelv - IMPRESSION: 1. Splenomegaly and extensive lymphadenopathy involving the root of the mesentery, retroperitoneum, pelvis, and inguinal areas most consistent with lymphoma or lymphoproliferative disease. 2. Evaluation for liver and kidney mass is limited due to lack of IV contrast. 11-mm hepatic hypodensity is a nonspecific finding. If prior imaging from outside hospital is made available, a direct comparison can be made. 3. Small bilateral pleural effusions and left basilar atelectasis. Consolidation cannot be excluded. 4. Low volume ascites. CXR - FINDINGS: Frontal and lateral views of the chest were obtained. Relatively low lung volumes. The patient is status post median sternotomy and cardiac valve replacement. There is some obscuration of the left hemidiaphragm, which may be due to a left pleural effusion with atelectasis. No large right pleural effusion is seen, although a small one would be difficult to exclude. There is prominence of the central pulmonary vasculature. LENI - IMPRESSION: No DVT in the right or left lower extremity. Right calf veins could not be seen. [**2132-4-23**] Echo The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. 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. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. The mitral valve leaflets are mildly thickened. There is mild functional mitral stenosis (mean gradient 7mmHg) due to mitral annular calcification. Mild to moderate ([**12-17**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric right and left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild-to-moderate mitral regurgitation. Well-seated aortic valve bioprosthesis with higher-than-expected gradients. Mild functional mitral stenosis from annular calcification. Moderate pulmonary artery systolic hypertension. [**2132-4-23**] CT Chest IMPRESSION: 1. Extensive mediastinal lymphadenopathy as described above. 2. Moderate left-sided pleural effusion. 3. Left lower lobe ground glass opacities which could be infectious or atelectasis due to poor inspiratory effort. Left inguinal node biopsy Lymph node, left inguinal, biopsies (A-C): Diffuse Large B-cell lymphoma (See note). Note: The lymph node sections show areas of effacement of normal architecture by medium to large lymphoid cells, with abundant cytoplasm, oval to round nuclei with irregular nuclear membrane, vesicular chromatin and prominent nucleoli. Admixed are small mature lymphocytes. There are focal areas of nodularity seen. The immunohistochemical stains show diffusely CD20 positive large B-cells, which are dimly positive for bcl-2 and CD21 (which especially highlights the nodular pattern), and negative for bcl-1, CD5 and CD138. CD3 highlights background of scattered T-lymphocytes. CD10 shows stroma staining and is positive within residual follicles. Kappa and Lambda stains are uninformative. MIB-1 staining is variable, with a proliferation rate of 30% in follicle [**Doctor First Name **] areas, and up to 80% in other areas; the overall proliferation index is 60-70%. The above findings of focal nodular areas and higher grade diffuse areas with large B-cell suggests that this is large B-cell lymphoma arising from either marginal zone lymphoma (CD10 and CD5 negative) or CD10 negative follicular lymphoma. Clinical correlation is suggested. ADDENDUM: This may be consistent with a large B-cell lymphoma associated with the elderly. [**Last Name (un) **] highlights several large cells positively hybridized. The overall diagnosis as above remains unchanged. Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Date: [**2132-4-29**] Clinical: left inguinal lymph node. Gross: The specimen is received fresh in a container labeled with the patient's name, "[**Known lastname **], [**Known firstname 110512**]", the medical record number, and "left inguinal lymph node". It consists of a single lymph node measuring 2.6 x 2.4 x 1.5 cm. A lymphoma work up is done. The specimen is serially sectioned and entirely submitted in cassettes A-C. FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 2, 3, 5, 7, 10, 19, 20, 23, 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells comprise 76% of lymphoid-gated events. B cells demonstrate a monoclonal lambda light chain restricted population. They co-express pan-B cell markers CD19, 20 along with CD10 (very dim), FMC7. They do not express any other antigens including CD5, CD23. T cells comprise 24% of lymphoid gated events. INTERPRETATION Immunophenotypic findings consistent with involvement by: Lambda light chain restricted B-cell lymphoma. Correlation with tissue morphologic diagnosis is recommended. [**2132-4-29**] 06:55AM BLOOD Fact II-67* Fact V-93 FactVII-80 Fact X-82 [**2132-4-25**] 06:50AM BLOOD LD(LDH)-311* [**2132-4-23**] 10:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2132-4-20**] 06:17AM BLOOD Hapto-391* [**2132-4-16**] 05:50AM BLOOD CEA-<1.0 [**2132-4-24**] 12:45PM BLOOD HIV Ab-NEGATIVE [**2132-4-23**] 10:00PM BLOOD HCV Ab-NEGATIVE [**2132-4-16**] 05:50AM BLOOD CA [**38**]-9 -Test Discharge [**2132-4-29**] 11:00AM BLOOD WBC-12.0* RBC-3.41* Hgb-8.3* Hct-28.0* MCV-82 MCH-24.5* MCHC-29.8* RDW-16.3* Plt Ct-446* [**2132-4-27**] 03:10PM BLOOD Neuts-87.0* Lymphs-6.2* Monos-2.0 Eos-4.7* Baso-0.2 [**2132-4-29**] 11:00AM BLOOD Plt Ct-446* [**2132-4-29**] 06:55AM BLOOD Glucose-47* UreaN-53* Creat-1.8* Na-138 K-4.5 Cl-101 HCO3-25 AnGap-17 [**2132-4-29**] 06:55AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0 Brief Hospital Course: Ms [**Known lastname **] is a pleasant, elderly female with a history of GAVE presenting with 1 day of guiaic positive stool with hematocrit slightly depressed below baseline of 27-30 (currently 25) and possible melena at [**Hospital3 2558**] (confounded by her iron supplementation). # Melena: Pt presented with reported melena from rehab and was guaiac positive. Significance of her GI bleed was unclear as her stools have always been dark due to ferrous supplementation. She has known GAVE which is likely source of her GI bleed. Hct initially was at her baseline in the high 20s. However, it fell to 22 and she was transfused 1 unit PRBC while she was in ICU. She was placed on PPI drip. GI was consulted who recommended that EGD be deferred until pt was more optimized in terms of her CHF. She remained hemodynamically stable with no BMs while in ICU. On floor, pts crits remained stable around 25-28, and had two consecutive crits of 21 on [**5-5**]. Her stools were guiaic negative and did not have BRBPR or melena. No other source of bleed was identified. She was transfused on unit and her crits remained stable from 25-28. She remained hemodynamically stable and was discharged on home sucrulfate dose and pantoprazole 40mg po BID. . # acute diastolic congestive heart failure: Pt had frequent hospitalizations for CHF exacerbation, most recently at [**Hospital3 10959**] in early [**Month (only) 547**]. She appeared volume overloaded and BNP was elevated. As there was concern for GI bleed and need for transfusion, she was admitted to the ICU. She received 100mg iv lasix in ED. She was placed on lasix gtt at 5units/hr while in ICU. She diuresed minimally in ICU. On the cardiology floor the patient was initially continued on a lasix drip with good output. Her drip was converted to intra-venous bolus of lasix 40-80 IV. She diuresed well and had repeat echo that showed ef>55%. She was transitioned to home dose lasix of 80mg PO TID and was discharged to rehab. At time of discharge, she was euvolemic, lungs were clear and she was satting in high 90s on room air. . # Lymphoma: During her recent hospitalization at OSH, a renal ultrasound revealed a left renal hilum mass measuring 10.3 x 4.6 x 4.9 cm as well as lesions in the liver and pancreas. A CT contrast to evaluate these further could not be performed because of her acute kidney injury at that time. A non-contrast CT was performed here that revealed bulky [**Doctor First Name **] in the mesentery concerning for lymphoma. The patient underwent inguinal LN biopsy that revealed diffuse b-cell lymphoma. Pt underwent heme/onc evaluation while in house. It was determined that pt was not currently symptomatic from her disease burden. Her ldh and uric acid were elevated, but she has history of hyperuricemia documented as outpt. potassium and renal function remained stable, and it was determined that she did not have tumor lysis syndrome. Treatment options were discussed with pt and her family by heme onc attending, Dr. [**Last Name (STitle) **] [**Name (STitle) 84995**] and it was determined that for the time being, treatment will be held as she does not need urgent chemotherapy. After rehab stay, she will follow up as outpt with Dr. [**Last Name (STitle) 84995**] to make decision if rituxim will be started. If so, she will require inpt treatment. . # Stage III CKD - Creatinine was initially elevated above baseline but improved over the course of her hospital stay. Creatinine remained 1.8-1.9. . # Coronary artery disease: She was continued on digoxin and statin. Dig level was wnl. Labetalol and amlodipine were initially held given concern for GI bleed. It was unclear if she was taking aspirin at home given her GAVE; this was not in her medicines at home so was held at discharge. # Diabetes: She was continued on insulin humalog sliding scale and evening lantus. . . FULL CODE: transitional issues - needs to follow up with Dr [**Last Name (STitle) 84995**] to discuss chemotherapy options after rehab stay. - pt had a VRE + dirty U/A during hospitalization. repeat cx pending at time of discharge. Pt was asymptomatic so she was not treated Medications on Admission: 1. digoxin .125 mg wmf 2. lasix 80 mg daily TID 3. crestor 10 mg daily 4. labetalol 200 mg [**Hospital1 **] 5. sucralfate 1 gm daily 6. amlodipine 10 mg daily 7. lantus 20 units daily 8. humalog insulin sliding scale 9. prilosec 40 mg daily 10. ferrous sulfate 325 mg daily 11. xalatan 0.005% 12. fish oil 1000/1200 mg 13. vitamin D 1000 U 14. colace 200 mg daily 15. tylenol 500 mg daily 16. amoxicillin 500 mg daily Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO MWF. 2. rosuvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day. 5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. insulin glargine 100 unit/mL Solution Sig: Twenty (20) U Subcutaneous once a day. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. insulin lispro 100 unit/mL Solution Sig: 2-10 units Subcutaneous once a day: Sliding scale insulin: 0-200 no units; 201-250= 2 units; 251-300=4 units; 301-350= 6 units; 351-400= 8 units; 401-450=10units; >450 call PCP. 13. furosemide 80 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Diastolic Congestive Heart Failure diffuse large b-cell lymphoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]! You were admitted due to a gastro-intestinal bleed. You were monitored carefully in the intensive care unit and had no further bleeding. You were transferred to the cardiology service. On the cardiology service it was noted that you had too much fluid on your body. You received diuretics with good response. Additionally, a CT scan of your abdomen showed enlarged lymph nodes. We performed a inguinal lymph node biopsy which revealed lymphoma. We consulted the hematology/oncology department and it was determined that your cancer is not causing any of your current symptoms and can be treated as an outpatient. See below for changes made to your home medication regimen: stop omeprazole and start pantoprazole 40mg by mouth twice daily stop amoxicillin stop amlodipine please see below for follow up instructions Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) **], MD, the Atrius oncology attending that consulted during this hospitalization. Name:[**Name6 (MD) **] [**Name8 (MD) 84995**], MD Specialty: Hematology/Oncology Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] When: We are working on a follow up appointment. You will be notified of the appointment. If you have not heard in two business days, please call above number for status.

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Discharge summary

report

Admission Date: [**2126-11-12**] Discharge Date: [**2126-12-4**] Date of Birth: [**2081-7-30**] Sex: F Service: SURGERY Allergies: Biaxin Attending:[**First Name3 (LF) 1384**] Chief Complaint: Fulminant liver failure Major Surgical or Invasive Procedure: [**2126-11-14**]: Placement of right frontal [**Last Name (un) **] ICP monitor [**2126-11-16**] Liver [**Month/Day/Year **] (ABO incompatible) and splenectomy [**2126-11-19**]: Aortogram, celiac axis and common hepatic arteriograms, Stenting of celiac trunk stenosis. --Plasmapheresis x 7 treatments History of Present Illness: 45 F who presents with jaundice and abdominal pain. She was in her usual state of good health until she developed a URI 2 weeks ago. She was prescribed clarithromycin. She reports an 'allergy' to Biaxin (nausea/vomiting/metallic taste) so when she realized she was taking Biaxin, the antibiotics was switched to amoxicillin. A few days later she noticed that her urine was dark and that she was jaundiced. She presented to her PCP and she had hepatitis B and C that were drawn and reportedly negative. She followed up again and had a hepatitis A drawn that was also reportedly negative. Last week, she was extremely fatigued with worsening jaundice she presented to an outside hospital where she was admitted with a transamanitis and elevated bilirubin. She underwent a RUQ US that, by her report showed no gallstones, but no choledocholithiasis or cholecystitis. During her course she had only minimal abdominal pain and at no time had any mental status changes beyond her fatigue. Past Medical History: Chronic Sinusitis Social History: Single. Works as a 911 dispatcher. No alcohol intake. Denies IV drug use. No cocaine or any other recreational drugs. Family History: None Physical Exam: VS T 99.7 HR 78 BP 101/61 RR 20 SAT 98% RA Gen: A and O x 3. Icteric sclera. Jaundiced Neuro: CN II-XII intact grossly. Moves all 4 extremities. Sensory intact. Card: RRR Pulm: CTA B Abd: Soft mildly TTP RUQ. No rebound or guarding. +BS. Minimal distension. Ext: No edema Labs: (OSH) 139 108 3 ----------<54 4.6 28 0.7 Ca: 8 Tylenol<10 [**Doctor First Name **] negative Alb 2.2 (2.6) Alt 2211 (2665) Ast 1705 (2331) AO 134 (184) Tb 17.4 (18.3) Cong. bili 12.3 (13.1) [**Doctor First Name **] 38 Lip 255 INR 3.7 Pertinent Results: On Admission: [**2126-11-12**] WBC-8.0 RBC-3.72* Hgb-11.1* Hct-31.4* MCV-85 MCH-29.7 MCHC-35.2* RDW-17.1* Plt Ct-233 PT-37.5* PTT-56.7* INR(PT)-3.9* Glucose-144* UreaN-5* Creat-0.8 Na-138 K-3.6 Cl-108 HCO3-26 AnGap-8 ALT-2123* AST-1671* AlkPhos-108* Amylase-37 TotBili-23.1* Albumin-2.6* Calcium-8.0* Phos-2.3* Mg-2.1 HCV Ab-NEGATIVE HIV Ab-NEGATIVE [**Doctor First Name **]-POSITIVE * Titer-1:40 CEA-1.3 AFP-126.6* HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE At Discharge: [**2126-12-4**] WBC-15.5* RBC-2.87* Hgb-8.7* Hct-27.3* MCV-95 MCH-30.4 MCHC-31.9 RDW-18.6* Plt Ct-703* PT-12.9 PTT-24.8 INR(PT)-1.1 Glucose-120* UreaN-14 Creat-0.5 Na-136 K-4.7 Cl-101 HCO3-27 AnGap-13 ALT-67* AST-35 AlkPhos-317* TotBili-2.8* Albumin-3.2* Calcium-9.0 Phos-3.3 Mg-2.0 tacroFK-10.2 Brief Hospital Course: 45 y/o female admitted to the SICU under the [**Month/Day/Year **] service and a [**Month/Day/Year **] workup ensued. A NAC drip was started and continued. Hepatology continued to follow. Due to worsening mental status, a bolt was placed on [**11-14**] and ICP/CPP were monitored. Infectious workup was completed as well as [**Month/Year (2) **] workup. She was listed for liver [**Month/Year (2) **]. [**11-16**], a L IJ HD line was placed and plasmapheresed. On [**11-16**], a liver donor was available and she underwent ABO incompatible liver [**Month/Year (2) **] with splenectomy. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. She was transferred back to the SICU postop intubated. LFTs increased. Duplex demonstrated patent appropriate directional flow of major vessels. A small-to-moderate amount of right upper quadrant free fluid was present. LFTs increased and a CTA was done to evaluate. On [**11-18**] CTA demonstrated patent hepatic and portal veins. compressive hypoperfusion by a subcapsular hematoma. No active hemorrhage. LFTs continued to increase. Anti-A titres were increased and LFTs worsened. Plasmapheresis was done. Lasix drip was started for anasarca. On [**11-19**], in IR, a celiac trunk stent was placed. LFTs improved. A post-pyloric dophoff was placed for tube feeds. Mental status improved. Bolt was removed after cryo and platelets were given. Pheresis was performed on [**11-21**]. Liver duplex on [**11-23**], showed patent hepatic and portal veins with normal hepatic arterial waveforms Hepatic duplex was repeated on [**11-23**] for elevated LFTs and was WNL. LFTs trended down. Aspirin and plavix were started. Pheresis was performed for a total of 7 treatments for antiA titers when equal or greater than 1:8. Lasix drip was changed to 40 IV BID and eventually to po lasix. Edema improved. Diet was advanced and tolerated. Kcals were insufficient therefore tube feeds continued, but were decreased to cycled feeds. Blood sugars were elevated requiring an insulin drip. This was switched to sliding scale regular and later changed to glargine with humalog sliding scale. Immunosuppression consisted of steroids that were tapered to prednisone 20mg per day. Cellcept at 1gram [**Hospital1 **] was given with intermittent nausea experienced. Prograf was titrated to trough levels. On [**12-3**], a repeat abd CT was done to re-assess the hepatic subcapsular hematoma. Findings were notable for smaller size and probable liquefecation of the hematoma. All JP drains have been removed. Please note that routine post-splenectomy immunizations were given on [**2126-12-3**] Medications on Admission: Atarax prn Allergies: Biaxin Discharge Medications: 1. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow taper schedule. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*14 Tablet(s)* Refills:*0* 13. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Outpatient Lab Work Every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin and trough prograf level 15. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 16. FreeStyle Lite Meter Kit Sig: One (1) Miscellaneous four times a day. Disp:*1 kit* Refills:*0* 17. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:*1 box* Refills:*2* 18. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous four times a day. Disp:*1 box* Refills:*2* 19. insulin syringes low dose 25-26 gauge needles qid insulin per sliding scale supply: 1 box. refill: 2 20. Hospital bed semi electric for positioning during nocturnal tube feedings. must have head of bed elevated 35-40 degrees (h/o liver [**Date Range **] [**2126-11-16**]) 21. senna 8.6 mg Tablet Sig: One (1) Tablet PO prn [**Hospital1 **]. 22. insulin glargine 100 unit/mL Solution Sig: Six (6) units Subcutaneous once a day. Disp:*1 bottle* Refills:*1* 23. insulin lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: autoimmune hepatitis vs acute toxic and/or ischemic (hypoxia-induced) liver injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call the [**Hospital1 1326**] Office [**Telephone/Fax (1) 673**] if you experience any of the following warning signs: fever, chills, nausea, vomiting, diarrhea, inability to take any of your medications, increased abdominal pain or distension, incision redness/drainage, jaundice or if feeding tube clogs You will need to have labs drawn every Monday and Thursday No driving while taking narcotic pain medication No heavy lifting Labs to be drawn every Monday and Thursday. Results to the [**Telephone/Fax (1) **] clinic You may shower using hand-held shower, pat incisions dry. No tub baths or swimming Followup Instructions: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-12-9**] 10:00 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-12-9**] 10:30 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-12-16**] 9:30 Completed by:[**2126-12-4**]

[ "473.9", "573.3", "V58.65", "571.42", "570", "790.29", "E930.3", "572.2", "E932.0", "447.4" ]

icd9cm

[ [ [] ] ]

[ "96.6", "39.50", "99.71", "50.59", "01.10", "96.72", "38.93", "38.91", "41.5", "39.90", "00.45", "00.40", "88.42", "88.47" ]

icd9pcs

[ [ [] ] ]

8210, 8266

3195, 5851

292, 593

8393, 8393

2365, 2365

9212, 9728

1801, 1808

5930, 8187

8287, 8372

5877, 5907

8576, 9189

1823, 2346

2875, 3172

228, 254

621, 1606

2379, 2861

8408, 8552

1628, 1648

1664, 1784

29,961

196,409

6579

Discharge summary

report

Admission Date: [**2115-6-20**] Discharge Date: [**2115-7-10**] Date of Birth: [**2043-2-28**] Sex: M Service: MEDICINE Allergies: Demerol / Actos Attending:[**First Name3 (LF) 1115**] Chief Complaint: Patient found down in home for up to 24 hours. Major Surgical or Invasive Procedure: Percutaneous endoscopic gastrostomy tube placement Intubation Midline placement PICC line palcement History of Present Illness: 72M with a history of VF arrest s/p AICD placement in [**2102**], Afib, DM, COPD, CHF, and HTN found down in his bedroom today after unknown down time, last seen 24 hours prior. In the ED, vitals were 98.6, 72, 121/71, 24, 97% RA, patient was given 4mg Morphine for rib pain, had a preliminarily negative head CT, c-spine CT, negative pelvis x-ray and unchanged CXR and was sent to the floor. Upon questioning on the floor, patient was somnolent, closing his eyes throughout the exam and unable to focus his attention. He did not recall any events leading up to his fall, although is able to state that he lives alone and is able to care for himself. He is AAOx2.5 (he thought he was in [**Hospital3 **]). He denies any prodrome to the events, and states that he was in his normal state of health prior to this morning when he "fell out of bed." We administered 0.8mg of naloxone to try to rouse the patient, and this had no effect, with the patient stating that he was still in no pain, but was tired and unable to keep his eyes open. We were able to get in contact with the Partners [**Name (NI) **] [**Name2 (NI) **] at [**Telephone/Fax (1) 25174**] and spoke with the on call night nurse, [**Doctor First Name **], who read from a chart that the patient had been seen on [**2115-6-19**] and was able to dress and shower without assistance, although he was incontinent of stool and had dyspnea on exertion. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - sCHF- TTE 20-25%, dry weight 198 lbs. - Paroxysmal atrial fibrillation- on Coumadin -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: [**2-22**] showed single vessel LCx disease -PACING/ICD: ACID after VF arrest in [**2102**], [**Company 1543**] [**Last Name (un) 24119**] VR 7232Cx [**12/2102**] 3. OTHER PAST MEDICAL HISTORY: - COPD - Barrett's esophagus with high grade dysplasia. Post-cryotherapy x 3, BARRx [**2-23**] - s/p GI bleed- UGIB from a gastric ulcer [**12/2102**] - s/p Appendectomy [**2063**] - s/p Bone tumor excision from shoulder [**2057**] - ?portal vein thrombosis Social History: Occupation: Retired from [**Location (un) 86**] police force and security service at [**Location (un) 745**] [**Hospital 3678**] Hospital Housing: Lives independently at Blakes Estate senior center (a retirement community) Family: Closest family is cousin [**First Name5 (NamePattern1) **] [**Name (NI) 23636**]), lives down the street from him. Adopted. Never married, no children. Tobacco: 45 year 1-2ppd history, quit 11 years ago. Alcohol: None Drugs: None Family History: Adopted. Does not know his family history. Physical Exam: Admission Physical Exam: Vitals: T:97.6 BP:116/61 P:76 R:14 O2:98%. Orthostatics positive with bp drop from 110/50 to 80/40 after 2 minutes standing. General: Extremely somnolent and unable to open eyes for longer than 30 seconds. AAO x name, day of week, and that he is in a hospital. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: Regular rate and irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild-moderately tender peri-umbilically, RUQ and RLQ moderately-distended, bowel sounds quiet, no rebound tenderness or guarding Ext: DP/PT pulses dopplerable, evidence of previous brawney edema, right foot dirty. Neuro: Unable to do months backwards beyond [**Month (only) **] CN V left sensation greater than right, otherwise II-XII not remarkable, but patient not completely compliant with exam. Motor 4+ strength throughout. +Babinski on right. Cerebellum: able to do heel to shin, some dysmetria with finger nose finger, but could be limited by sight. Sensory: reported decreased on right side initially, but then equal UE and LE upon later questioning. Gait: unable to assess, patient weak upon standing Discharge Exam: Vitals: 96.5-97.8, 101-117/56-74, 76-86, 22-27 93% on RA, 100% on 2L FS: 176, 177, 165, 199 Daily weight pending General: Alert, interactive, appropriate. HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: Diminished bs b/l, fair air movement, no evidence of crackles. CV: RRR, 2/6 systolic murmur appreciated Abdomen: bowel sounds present, soft, non-tender, Mild distension, no rebound, no guarding Neuro: Unchaged. Skin: Stage 2 decubitus ulcer in gluteal fold, unchanged from previously, not open. Ext: no edema, feet wwp. Discharge weight 180.6lbs Pertinent Results: Chemistries: [**2115-6-20**] 04:00PM BLOOD WBC-17.6*# RBC-4.79 Hgb-10.9* Hct-34.6* MCV-72* MCH-22.7* MCHC-31.5 RDW-17.7* Plt Ct-289 [**2115-6-23**] 07:30AM BLOOD WBC-25.6* RBC-4.64 Hgb-10.5* Hct-34.9* MCV-75* MCH-22.7* MCHC-30.2* RDW-19.2* Plt Ct-218 [**2115-7-9**] 07:20AM BLOOD WBC-10.1 RBC-3.76* Hgb-9.0* Hct-28.5* MCV-76* MCH-24.0* MCHC-31.7 RDW-20.7* Plt Ct-460* [**2115-7-8**] 11:05AM BLOOD PT-18.0* PTT-60.9* INR(PT)-1.6* [**2115-6-20**] 04:00PM BLOOD PT-17.1* PTT-27.8 INR(PT)-1.5* [**2115-6-20**] 04:00PM BLOOD Glucose-221* UreaN-39* Creat-1.2 Na-135 K-3.4 Cl-89* HCO3-32 AnGap-17 [**2115-7-10**] 04:22AM BLOOD Glucose-199* UreaN-62* Creat-1.2 Na-131* K-4.3 Cl-96 HCO3-28 AnGap-11 [**2115-7-9**] 07:20AM BLOOD Glucose-157* UreaN-52* Creat-1.1 Na-134 K-4.3 Cl-97 HCO3-25 AnGap-16 [**2115-7-8**] 05:15AM BLOOD Glucose-164* UreaN-40* Creat-1.0 Na-135 K-4.5 Cl-97 HCO3-29 AnGap-14 [**2115-6-20**] 09:05PM BLOOD ALT-47* AST-36 LD(LDH)-297* CK(CPK)-144 AlkPhos-97 TotBili-2.2* [**2115-6-20**] 04:00PM BLOOD cTropnT-0.03* [**2115-6-24**] 04:43PM BLOOD CK-MB-3 cTropnT-0.03* [**2115-6-25**] 11:40PM BLOOD CK-MB-2 cTropnT-0.01 [**2115-6-20**] 04:00PM BLOOD Calcium-9.0 Phos-3.1# Mg-2.2 [**2115-7-10**] 04:22AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2 [**2115-6-21**] 06:45AM BLOOD calTIBC-443 VitB12-1408* Folate-13.9 Hapto-208* Ferritn-71 TRF-341 [**2115-6-21**] 06:45AM BLOOD TSH-3.4 [**2115-6-29**] 07:00AM BLOOD Cortsol-18.4 [**2115-7-10**] 04:22AM BLOOD Digoxin-1.4 [**2115-6-20**] 05:20PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-10 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG [**2115-6-20**] 05:20PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 RenalEp-<1 Micro: Blood cultures 8/7 and [**6-24**] No growth. Urine Legionella Negative [**2115-6-25**] Urine Culture negative [**2115-6-25**] Blood cultures [**2115-7-6**] Pending RESPIRATORY CULTURE (Final [**2115-7-5**]): Commensal Respiratory Flora Absent. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. ENTEROBACTER AEROGENES. RARE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/Tazobactam REQUESTED BY DR.[**Last Name (STitle) **],[**First Name3 (LF) **] PAGER [**Numeric Identifier 25175**] [**2115-6-28**]. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ESCHERICHIA COLI. RARE GROWTH. Piperacillin/Tazobactam REQUESTED BY DR. [**Last Name (STitle) **],[**First Name3 (LF) **] [**2115-6-28**]. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. YEAST. RARE GROWTH. _______________________________________________________ ENTEROBACTER AEROGENES | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S =>16 R Imaging: EKG [**2115-6-20**]: Atrial pacing and ventricular pacing with occasional native QRS complexes. Native beats appear to have a wide QRS complex with secondary repolarization abnormalities. Compared to the previous tracing of [**2115-5-13**], sinus rhythm is absent. Morphology of the paced QRS complex is different in leads V1-V2, with now upright R waves rather than RS complex - question markedly different electrode placement versus interval change in location of the ventricular pacing lead. CXR [**2115-6-20**]: IMPRESSION: No acute cardiopulmonary process. No acute rib fracture. CT C-Spine: [**2115-6-20**] 1. No acute fracture or malalignment. 2. Multilevel degenerative disease with disc bulge at C5-C6 resulting in moderate canal narrowing. In the setting of canal narrowing, correlation with clinical symptoms is recommended and cervical spine MR can be obtained if cord injury is suspected CT Head [**2115-6-20**] Preliminary Report !! WET READ !! No acute intracranial process. Right periorbital hematoma with intact globe and no postseptal extension. X-Ray Pelvis [**2115-6-20**] No fracture or malalignment. CT Angiography [**2115-6-21**]: No pulmonary embolism Nodular consolidation in the middle lobe. Followup CT is recommended in 3 months to look for its resolution and ensure that its consolidation. Large right and minimal left pleural effusion. Moderate-to-large cardiomegaly. Persistent left SVC with abandoned left chest leads coursing through it and terminating into the right ventricle. Multi-lead right chest wall device with each lead coursing through the right SVC and terminating one into the right atrium, right ventricle, and epicardial lead to the left ventricle. Wedge compression fracture involving more than 50% of the height of D8 vertebra causing kyphotic deformity. RUQ US [**2115-6-22**]: IMPRESSION: 1. Sludge within a distended gallbladder. No gallbladder wall thickening, pericholecystic fluid, or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. 2. Right pleural effusion. 3. Right lower pole kidney simple cyst, slightly increased in size. ECHO [**2115-6-25**]: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15 %) with akinesis of the mid to apical septum, lateral hypokinesis/akinesis, apical akinesis, and anterior hypokinesis/akinesis. The right ventricular cavity is dilated with mildly depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2115-5-14**], mitral and tricuspid regurgitation are now more prmoinent. Estimated pulmonary artery systolic pressure is now higher. Left ventricular systolic function appears similar. Right ventricular systolic function appears similar. [**2115-7-1**]: Video Swallow Study FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was gross aspiration with nectar liquids. Moderate residue was seen at the valleculae with honey-thick and pureed consistencies without gross aspiration or penetration. For details, please refer to the speech and swallow division note in the OMR. IMPRESSION: Gross aspiration of nectar-thick liquids. CT SCAN Abdomen and Pelvis with Contrast [**2115-7-9**]: The lung bases are notable for a large right and moderate left pleural effusion, with expected overlying atelectasis. Cardiac pacing wires are visualized as is coronary arterial calcification. The stomach, duodenum are unremarkable, specifically with no evidence of enteric tube. The spleen, fatty pancreas, adrenal glands are unremarkable. The kidneys enhance and excrete contrast in a symmetric fashion and note is made of a large right renal cyst. The liver is unremarkable. The gallbladder is moderately distended with mild mural thickening. There is a small volume of ascites in the upper abdomen and no evidence of pneumoperitoneum. Vascular structures reveal atherosclerotic calcification. Note is made of an infrarenal inferior vena cava filter. There is moderate diffuse anasarca. CT PELVIS WITH CONTRAST: The urinary bladder, distal ureters, prostate, seminal vesicles, rectum and colon are normal. A trace amount of free fluid is present in the pelvis. There is no free gas in the pelvis. There is no pelvic sidewall or inguinal lymphadenopathy. OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion. Degenerative changes are present in the lower lumbar spine. IMPRESSION: 1. Large right and moderate left pleural effusions, anasarca, and small amount of ascites. In this context, and without free gas, the ascites is most likely related to the generalized volume status of the patient as opposed to leaking enteric contents although the latter is difficult to entirely exclude. 2. Atherosclerotic disease. 3. Distended gallbladder, which may be the result of the fasting state in the appropriate setting. Slight wall thickening could be explained by fluid overload (also suggesting by other findings) but if there are any acute symptoms which may related to gallbladder pathology, ultrasound could be given consideration. Brief Hospital Course: 72M with a history of VF arrest s/p AICD placement in [**2102**], Afib, DM, COPD, CHF, and HTN found down in his bedroom today after unknown down time, last seen 24 hours prior. #SYNCOPAL EPISODE, FOUND DOWN FOR UP TO 24 HOURS: Patient unable to give full history or recall events of day. Upon arriving to the floor, patient had positive orthostatics, and was extremely weak. The electrophysiology team was consulted to interrogate the pacemaker and did not find any episodes of AICD firing or V-tach. On telemetry, he had 1 episode of VTach which self resolved without firing. On the floor, the patient was fluid repleted slowly given EF of 15%. Troponins were trended and flat at 0.03. CT angio [**2115-6-21**] ruled out Pulmonary embolism. Normal CK argued against rhabdomyolysis. On the early morning of the [**6-23**], 3rd hospital day, the patient was found to have hemodynamicaly unstable atrial fibrillation with rapid ventricular response with SBP in the 80s and HR in the 140s. He maintained consciousness throughout the episode, but this is the likely cause of the initial event. Patient was then brought to the CCU, loaded on Digoxin, and brought back to the floor within the day with rate control. On tele, patient had many episodes of "pacer not capturing" but with pacing spikes, likely secondary to PVCs. On morning of [**2115-6-25**], HD 5, patient with continued dyspnea, with saturations of 94% on 2L NC, positive pulsus paradoxus of 14mmHg. Stat echo did not show pericardial effusion, but did demonstrate increased TR, MR, Pulmonary arterial HTN and Low EF (was 15% on [**4-27**]). Patient also had a witnessed aspiration event and had a new finding of expiratory stridor. Stat CXR showed increasing right plural effusion/ pulmonary edema. On the morning of [**2115-6-25**], the paient aspirated, and developed respiratory distress. He was transferred to the MICU, where he required intubation. He was started on vancomycin and Zosyn. The patient's respiratory status improved rapidly. He extubated himself on the morning of [**2115-6-27**]. In the ICU, the patient briefly required fluid boluses and norepinephrine to maintain his blood pressure. As his sepsis resolved, the patient was diuresed with IV Lasix. #DYSPHAGIA/ASPIRATION PNA: Following the aspiration event and self extubation, the patient was evaluated by speech and swallow, and failed the evaluation. Afeter discussion with patient and HCP, PEG tube was placed on [**2115-7-5**], but the patient pulled it out within 24 hours. Attempts were made to keep the tract open, including placing a sterile foley, however these were to no avail. Patient tolerated the insult remarkably well, with only one episode of temperature to 100.2, but with an otherwise benign abdominal exam. Surgery was consulted who recommended keeping the patient NPO until at least [**7-14**] with potential repeat PEG placement at that time pending goals of care and repeat swallow eval. PICC was placed and TPN was started for nutrition. #ALTERED MENTAL STATUS: Pt with metabolic encephalopathy on admission. Throughout the hospital course, the altered mental status improved to baseline and patient was appropriate and friendly at discharge. He was alert and oriented. He scored 26 on the mini-mental status examination, missing questions on the date, what floor he was on, remembering only [**12-20**] words, and being unable to spell "world" backwards perfectly. Per his friends/HCP - this is his baseline status. #ATRIAL FIBRILLATION WITH INR OF 1.5 EVOLVING INTO AFIB WITH RVR DURING HOSPITALIZATION: Patient was admitted in atrial fibrillation with controlled ventricular response. Morning of [**2115-6-22**] underlying atrial fibrillation developed a rapid ventricular response with HR peaks in the 140s and resultant SBP in the 80s. The patient was triggered on the medicine flood and the decision was made to transfer the patient to the CCU for better rate control acutely. Prior to transfer, the patient received 1L of NS IVF. Loaded with digoxin on in the unit and transferred back to the floor hemodynamically stable. On tele, as amiodarone was held for NPO status, patient had continued episodes of non-sustained Vtach, but these were stable. His amiodarone was held at discharge, this was communicated to his outpatient Cardiologist, Dr. [**Last Name (STitle) **], who will follow him. #DM: Patient was kept on a gentle sliding scale while NPO. #BARRETT'S ESOPHAGUS: Not currently active. Outpatient follow up. #CODE STATUS: Despite patient self extubating and pulling his own PEG while [**Doctor Last Name **] 26/30 on the MME, he consistently endorsed desire to do everything possible to keep him alive and remained full code during the hospitalization. A family meeting was held with patient's good friend and HCP [**Name (NI) **] [**Name (NI) 25176**]. Ongoing goals of care discussions will be necessary for this ill patient as an outpatient. #TRANSITIONAL ISSUES: -Nodular consolidation in the middle lobe. Followup CT is recommended in 3 months to look for its resolution and ensure that its consolidation ([**9-27**]). -Speech and swallow: Patient must be NPO through [**2115-7-14**] due to hole in stomach after he pulled out his PEG. He is discharged on TPN and needs repeat swallow eval after [**7-14**]. He will likely benefit from intensive swallowing therapy. If he fails repeat swallow eval, he should be reevaluated for potential PEG placement as an outpatient. If PEG is placed, an abdominal binder must be placed to prevent re-pulling. -Daily chemistry 7 for monitoring TPN. -Ongoing goals of care discussions will be necessary for this ill patient with pooor overall prognosis as an outpatient. Medications on Admission: amiodarone 200mg daily atorvastatin 40mg daily digoxin 125mcg daily Lantus 24U [**Hospital1 **] [**Hospital1 3435**] sliding scale once a day in the evening Lisinopril 5mg metoprolol succinate 25mg daily Nitroglycerin daily Roxicet PRN *HELD* Pantoprazole 20mg daily torsemide 20mg daily wafarin 7mg daily ASA 81 cyanocobalamin 10000mcg daily *HELD* Docusate 100mg daily Discharge Medications: 1. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. aspirin 300 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 5. metoprolol tartrate 5 mg/5 mL Solution Sig: 0.5 mL Intravenous Q6H (every 6 hours). 6. furosemide 10 mg/mL Solution Sig: Two (2) mL Injection once a day. 7. digoxin 100 mcg/mL Solution Sig: One (1) mL Injection every other day. 8. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous Q 12H (Every 12 Hours). 9. Outpatient [**Hospital1 **] Work Please check chemistry 10 daily to adjust TPN 10. TPN Please give TPN daily 11. PICC Care Please care for PICC per instutional protocol Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Atrial fibrillation, acute on chronic systolic congestive heart failure, aspiration pneumonia, altered mental status, chronic obstructive pulmonary disease, malnutrition, self discontinuation of percutaneous endoscopic gastrostomy tube, Stage 2 Decubitus ulcer Secondary: Hypertension, Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Weight at discharge: 180.6lbs Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for being found down in your house. The likely cause of your fall was a rapid heart rate from your atrial fibrillation. You were stabilized on the medicine floor, were transported to the CCU (a higher level of care) following an episode of atrial fibrillation with rapid ventricular response, and brought back to the medicine floor for further stabilization. You were then brought to the medical ICU when you were aspirated on your medications and were intubated and stablilized on antibiotics. You then had difficulty swallowing, and we placed a feeding tube to nourish you. Unfortunately, the feeding tube was pulled out and we had to place a PICC, an intravenous line, to provide you with nourishment. We looked for concerning causes of loss of consciousness including a pulmonary embolism, as well as interrogating your pacemaker for an episode of unstable heart rates, but the studies were negative. We made the following changes to your medications: STOP eating by mouth for the following 5 days. START Furosemide START insulin per sliding scale START Ipratropium nebs START Metoprolol Tartrate START Aspirin START Digoxin START Albuterol START Enoxaparin Given your swallowing dysfunction and the restrictions with your oral intake, all of your oral medications are currently being held. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Repeat speech and swallow evaluation in 1 week's time.

[ "584.9", "V45.81", "276.7", "250.82", "V45.02", "733.00", "458.0", "428.43", "427.31", "276.1", "272.4", "428.0", "V58.67", "518.81", "E849.7", "789.09", "507.0", "427.1", "E932.3", "348.31", "414.00", "276.3", "401.9", "787.20", "263.9", "695.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.97", "96.6", "96.04", "96.71", "43.11", "38.91" ]

icd9pcs

[ [ [] ] ]

21837, 21907

14706, 17733

323, 425

22262, 22262

4998, 14683

24006, 24064

3054, 3099

20860, 21814

21928, 22241

20465, 20837

22470, 23516

3139, 4360

1975, 2270

4376, 4979

22435, 22446

19687, 20439

23545, 23983

237, 285

453, 1868

22277, 22421

2301, 2560

1890, 1955

2576, 3038

65,920

169,420

31673

Discharge summary

report

Admission Date: [**2195-8-27**] Discharge Date: [**2195-8-31**] Date of Birth: [**2173-7-2**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: autonomic dysregulation/perioral numbness Major Surgical or Invasive Procedure: Right-sided bilateral transcondylar approach for resection with Microscopic dissection, Duraplasty using pericranial autograft, Cranioplasty, C1 laminectomy and Lumbar drain placement. History of Present Illness: The patient is a 22-year-old female who was recently admitted to the [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. She presented with rather vague signs of autonomic dysregulation,as well as perioral numbness and was worked up with imaging. She was found to have a lesion at the cervicomedullary junction compressing the brain stem. Past Medical History: -Abdominal pain -Endometriosis -Gastritis -IBS -Recurrent UTIs, last [**2188**]. Pyelonephritis x1 -s/p [**2188**]- LSC appendectomy -s/p [**2187**]- LSC Ovarian cystectomy/fulguration of endometriosis -s/p [**2187**]- LSC Lysis of adhesions x 2 -s/p [**2188**]- LSC lysis of adhesions x 2 . GYN Hx -G0 -Menarche 13 - regular/ [**5-18**] days/(-)dymensorrhea/(-)menometrorraghia -denies STD history -Sexually active- last 3 months ago. 1 male partner lifetime -[**Name2 (NI) **] h/o abnml paps. Last pap 6 weeks ago normal in [**State 2748**]. GC/CT cultures negative Social History: Lives in CT, but is currently in [**Location (un) 86**] as a student at [**University/College 5130**]. Drinks occasional EtOH ([**2-14**]/week), no smoking and no illicits Family History: Denies any history of cancers, HTN, diabetes, gallbladder problems. Physical Exam: On discharge: A&Ox3 PERRL 6-5mm bilaterally EOMs:intact face symmetrical, tongue midline Negative pronator drift Motor: full in all 4 extremities Incision: c/d/i with [**Month/Day (2) 2729**] in place L breast numbness improving. Pertinent Results: MR HEAD W & W/O CONTRAST [**2195-8-28**] Expected postoperative changes with no evidence for acute infarction or large hematoma. No evidence for residual neoplasm. Brief Hospital Course: 22 y/o F elective admit for removal of brainstem lesion. Patient presents with perioral numbness, dizziness, and headache. She was taken to the OR on [**8-27**] for removal of lesion. While in OR, a lumbar drain was placed. Patient was seen to have a brainstem cyst in which prelim path showed to be an epidermoid cyst. Post operatively, the patient complained of pain, but was otherwise intact. Her drain was d/c'ed on [**8-28**] and she was transferred to floor. On [**8-31**], patient was cleared bu speech and swallow to be discharged home. She was discharged with both hard and soft collar for comfort and she should follow up with Dr. [**Last Name (STitle) **] in 2 weeks for both a wound check and suture removal. She also has a BTC appointment on [**2195-10-12**]. Medications on Admission: xylocaine, ativan, lexapro, nuvaring, zantac, spironlactone 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. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 3 days. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Epidermoid with cyst formation. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your [**Year (4 digits) 2729**] are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. MEDICATIONS ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: o Narcotic pain medication such as Dilaudid (hydromorphone). o An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ACTIVITY The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 2 weeks(from your date of surgery) for removal of your [**Telephone/Fax (1) 2729**] and a wound check. Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**]. Be sure to point out any incisions, which may be covered by clothing at the time of suture removal. Please make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have been scheduled for a Brain [**Hospital 341**] Clinic appointment on [**2195-10-12**]. You will need an MRI before your appointment which is scheduled for 12:15pm at [**Hospital Ward Name 23**] 4 and then you will be seen at 2:00pm in the clinic. Please call [**Telephone/Fax (1) 1844**] for directions or with further questions. Completed by:[**2195-8-31**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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13,036

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47103

Discharge summary

report

Admission Date: [**2184-8-7**] Discharge Date: [**2184-8-12**] Date of Birth: [**2129-9-14**] Sex: F Service: MEDICINE Allergies: Ivp Dye, Iodine Containing / Thimerosal / Carboplatin / Taxol / Erythromycin Attending:[**First Name3 (LF) 477**] Chief Complaint: Dyspnea, cough, nausea, emesis Major Surgical or Invasive Procedure: central catheter placement nasogastric tube placement History of Present Illness: 54 year old female with recurrent ovarian cancer, recently d/c'd on [**8-3**] with gastritis/esophagitis, who presented on [**8-7**] with increasing SOB, cough, nausea and vomiting x 3 days and acute onset bilateral edema. Per the patient, she had experienced no diarrhea with the nausea and emesis and instead noted decreased ostomy output. No BRB in ostomy output. Cough was nonproductive. She has baseline SOB due to asthma but she felt that this had worsened over the 1-2 weeks prior to admission, particularly with exertion. No orthopnea or PND, but worse when lying on her sides (either side). + sinus congestion in week preceding admission. No fevers, chills. Of note, she had received desensitization for carboplatin on [**8-5**] with a significant amount of IVF and her primary oncologist felt that she was fluid overloaded and she was sent in for diuresis and electrolyte monitoring. . In the ED course she had a leukocytosis, elevated lactate to 3.6, hypokalemia, and an elevated pro BNP. UA showed a UTI. CTA for PE was negative but demonstrated bilateral ground glass changes and nodular opacities consistnent with acute infection, with atypical vascular congestion being more unlikely. A central line was placed for concern of sepsis and she was given 3L given, cx sent, and vanc/cefepime/fluconzole/flagyl were started. . She was transferred to the MICU for concern of sepsis where broad spectrum antibiotics were continued. CT abd/pelvis showed SBO and NGT placed, bowel rest. Cefepime was changed to levofloxacin on [**8-8**] and vancomycin and flagyl were discontinued today ([**8-9**]) due to clinical improvement. Bilateral LE U/S performed for LE edema which showed no evidence of DVT. Due to nausea/emesis/abd pain/elevated bilirubin RUQ US obtained which showed contracted gallbladder completely filled with sludge and tiny [**Known lastname **] and no evidence of cholecystitis. ECHO was performed to evaluate etiology of LE edema and showed hyperdynamic EF, small pericardial effusion, no significant change from prior. . Currently on the floor she has mild SOB with positional changes that responds to albuterol treatments. Continued cough, nonproductive, somewhat worse than admission. No hemoptysis. Nausea and vomiting has remarkably improved and she is tolerating clears without difficulty. Fatigued and worn out. . ROS negative for fevers, chills. +18lb weight loss in last 2 months d/t decreased appetite. No current sinus or nasal congestion. No sore throat. Mild dysphagia initially after removal of NGT this afternoon, now improved. No abdominal pain, dysuria. . Past Medical History: Asthma . Oncologic History: She was originally diagnosed in [**2180-4-20**] with stage III C adenocarcinoma of the ovary. Post operatively she received six cycles of carboplatin and Taxol chemotherapy, completing treatment [**2180-8-23**]. She then enrolled on the OvaRex study at the [**Hospital 4415**]. Right adnexal recurrence was noted by CT scan in [**2182-9-21**]. She received two cycles of Taxol and carboplatin, but had a severe platinum allergic reaction requiring a switch to Doxil and Taxol for several additional cycles of second line therapy. She then developed mucositis on this regimen and received 5 additional cycles of single [**Doctor Last Name 360**] Taxol. She developed a large bowel obstruction during her fifth cycle which required a diverting ileostomy performed on [**2183-11-21**]. She subsequently received four cycles of Halichondrin B as part of the 06-125 protocol, but had progressive disease and was taken off the protocol on [**2184-4-1**]. She then commenced gemcitabine at 600 mg/m2 and received three weekly doses followed by a week off. She received two cycles of gemcitabine but has progressed. She is now cycle 3 of carboplatin desensitization. Social History: She has one son who is 30 years old. She has worked as a freelance writer until recently. She lives in [**Hospital1 **], MA with her son. She drinks alcohol occasionally and has quit smoking 20 yrs ago (15yr h/o of 1ppd). Family History: She had a maternal grandmother with heart disease who at the age of 83 developed colon cancer. There is no other cancer in her family. Her mother died of COPD. Her father had a gastric ulcer and died of renal artery stenosis. Physical Exam: VS: 95% on RA, 96.8, 18, 95, 112/55 GEN: comfortable, NAD, conversive, eating broth HEENT: PRRLA, EOMI, anicteric, MMM, OP clear Neck : supple, unable to assess JVD on right d/t line but flat on left, no [**Doctor First Name **] CV: tachy, RR, no M/R/G PULM: Decreased BS bilaterally at bases, R>L, no wheezes, no crackles GI: soft, minor tenderness around umbilicus, no reboung or guarding, no tap tenderness, ileostomy in place and draining actively while in room EXT: 4+ edema b/l to thighs, pulses palpable, no cyanosis, clubbing NEURO: AAOx3. Cn II-XII grossly intact Pertinent Results: [**2184-8-7**] 01:30PM BLOOD WBC-16.3*# RBC-3.69* Hgb-11.4* Hct-35.2* MCV-95 MCH-31.1 MCHC-32.6 RDW-21.6* Plt Ct-243# [**2184-8-9**] 04:00AM BLOOD WBC-7.0 RBC-2.85* Hgb-8.6* Hct-26.3* MCV-92 MCH-30.0 MCHC-32.5 RDW-22.0* Plt Ct-180 [**2184-8-9**] 04:00AM BLOOD PT-15.7* PTT-31.1 INR(PT)-1.4* [**2184-8-9**] 03:39PM BLOOD Glucose-95 UreaN-24* Creat-0.8 Na-138 K-2.9* Cl-107 HCO3-26 AnGap-8 [**2184-8-9**] 04:00AM BLOOD ALT-34 AST-36 LD(LDH)-307* AlkPhos-170* TotBili-1.1 [**2184-8-7**] 01:30PM BLOOD Lipase-16 [**2184-8-7**] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-2181* [**2184-8-9**] 03:39PM BLOOD Calcium-7.4* Phos-1.5* Mg-2.1 [**2184-8-8**] 03:28AM BLOOD Cortsol-24.3* [**2184-8-8**] 04:09AM BLOOD Cortsol-34.3* [**2184-8-8**] 05:11AM BLOOD Cortsol-39.7* [**2184-8-7**] 03:31PM BLOOD Lactate-3.6* [**2184-8-7**] 05:59PM BLOOD Lactate-2.3* [**2184-8-8**] 12:12AM BLOOD Lactate-1.6 . CT Abd/Pelvis [**8-7**]: 1. Limited study without contrast was designed primarily to evaluate for obstruction. This demonstrates small- bowel obstruction with transition point just proximal to the stoma site. . CTA chest: 1. No evidence of pulmonary embolism. 2. Bilateral ground glass change and nodular opacities likely represent acute infection. Consider opportunistic infection based on immune status. Aspiration considered given #3 below, however anterior upper lobe involvement difficult to reconcile. Atypical edema is a less likely cause for these findings. Mediastinal lymph nodes have progressed in size, though a component of this may be reactive. 3. Dilated fluid filled esophagus may represent more distal obstruction in the abdomen. 4. Stable right greater than left pleural effusions. 5. Evidence of metastatic disease within the abdomen incompletely evaluated. . LE U/S Bilat 8/20: No evidence of DVT . ECHO [**8-9**]: Hyperdynamic left ventricular function. Small circumferential pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2183-11-24**], the findings are similar. Brief Hospital Course: A/P: 54 year old female with recurrent ovarian ca who presented with SOB, cough, nausea, emesis, and edema who was found to have SBO and pneumonia. . #)SBO - Upon admission the patient was found on CT Abdomen to likely have a small bowel obstruction with transition point at the site of her ostomy. A nasogastric tube was placed and she was made placed on bowel rest. Her diet was slowly advanced until she was tolerating solids and liquids without difficulty. Complicating her course in the last several months has been chronic appetite loss as well as chronic nausea. . #) PNA - The inital concern was for aspiration pneumonia in the setting of nausea and vomiting. Sputum gram stain showed 1+GNR and GPC. She improved on levofloxacin (vanc and flagyl stopped) and this was continued for a full course. . #) Esophagitis - She was recently hospitalized for esophagitis, and fluconazole was continued throughout her stay for concern for [**Female First Name (un) **] esophagitis. . #) LE edema - She had no evidence of systolic or diastolic dysfunction on ECHO. Also, she had no obvious pelvic or abdominal mass causing lymphatic obstruction/venous obstruction secondary to ovarian CA and mets. Most likely cause of edema is hypoalbuminemia in the setting of very poor nutritional status, which was exacerbated by fluid load from chemotherapy/ Medications on Admission: MEDS AT HOME: 1. Venlafaxine 125 QD 2. Zolpidem 10 HS prn 3. Metoclopramide 10 mg PO QIDACHS PRN (only takes occasionally 4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 5. Dronabinol 2.5 mg PO BID - just started one week ago 6. Oxycodone 10 mg Tablet Sustained Release [**Hospital1 **] 7. Oxycodone 10 mg Tablet Q6H prn 8. Lorazepam 0.5 mg Tablet PO Q8H prn 9. Simethicone 80 mg Tablet PO QID prn 10. Loperamide 2 mg Capsule PO QID prn 11. Calcium Carbonate 500 mg Tablet PO QID prn heartburn . MEDS ON TRANSFER: Venlafaxine XR 150 PO DAILY (to start in a.m.) Levofloxacin 500 mg IV DAILY Albuterol [**12-23**] PUFF IH Q6H:PRN Lorazepam 0.5 mg IV Q4H:PRN Pantoprazole 40 mg IV Q12H Fluconazole 200 mg IV Q24H Ondansetron 8 mg IV Q8H:PRN [**8-9**] Acetaminophen 500 mg NG Q6H:PRN Magnesium Sulfate IV Sliding Scale Calcium Carbonate 500 mg PO QID:PRN Simethicone 80 mg PO QID:PRN OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Oxycodone SR (OxyconTIN) 10 mg PO Q12H Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN Zolpidem Tartrate 10 mg PO HS Docusate Sodium 100 mg PO BID Bisacodyl Loperamide Dronabinol Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day for 2 weeks. 2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 10. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO twice a day. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for nausea. 12. Loperamide 2 mg Tablet Sig: One (1) Tablet PO four times a day as needed for diarrhea. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day: Take before meals. 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 16. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**5-28**] hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1.) Small bowel obstruction 2.) Aspiration pneumonia 3.) Stage II ovarian cancer 4.) esophagitis Discharge Condition: afebrile, displaying normal vital signs, tolerating regular diet. Discharge Instructions: You were admitted to the hospital with cough, difficulty breathing, and worsening nausea and vomiting. You were treated with antibiotics, and a nasogastric tube was placed. This was removed and your diet was slowly advanced. . Upon discharge be sure to continue the full course of antibiotics and continue to keep all health care appointments as scheduled. . If you develop worsening cough, shortness of breath, fever, nausea + vomiting, abdominal pain or chest pain, or if your condition worsens in any way, seek immediate medical attention. Followup Instructions: You have the following follow-up appointments with Drs. [**Last Name (STitle) 2244**] and [**Name5 (PTitle) **]. Continue to follow up with your physicians at [**Hospital3 328**] as previously scheduled. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-8-19**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-8-19**] 11:00 [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

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11632, 11703

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6349

Discharge summary

report

Admission Date: [**2178-3-18**] Discharge Date: [**2178-4-6**] Date of Birth: [**2124-9-18**] Sex: M Service: MEDICINE Allergies: Dilantin Kapseal Attending:[**First Name3 (LF) 1253**] Chief Complaint: seizure with fall and T1 pedicle fracture Major Surgical or Invasive Procedure: 1. Open treatment of extension-type fracture dislocation T8- T9 and extension type dislocation fracture of T1-T2. 2. Posterior spinal instrumentation and fusion C6-T3. 3. Posterior spinal instrumentation and fusion T7-T10. 4. Application of allograft and local autograft. History of Present Illness: A 53-year-old man a with refractory seizures on three AEDs and VNS. He presented to local hospital with a fall during a seizure. As per witnesses his seizure occurred while practicing for special Olympics, he initially hit his forehead onto an object and then fell backwards on the ground and hit his occipital area. He has no recollection of the seizure himself. At the local hospital a T1 pedicle fracture was found with no signs of facial or cranial fracture. Despite the T1 fracture he had no C/T spinal tenderness or bruising and ortho at [**Hospital1 18**] cleared him for a TLSO brace. He currently is in neck collar awaiting the TLSO to be custome made. Past Medical History: - Refractory seizures since age 7 years - VNS insertion in [**2164**] - Mentally challenged as per previous Neuropsych evaluation - cystic lesion Left temporal pole - Hyperlipidemia on statin - ? ankylosing spondylitis Social History: He lives at a group home. No history of tobacco, EtOH or recreational drug use. Family History: NC Physical Exam: Physical examination: General: Vital signs were within normal limit. Heart sounds were normal with no murmur; lungs were clear with equal air entry, abdomen was soft and non-tender, extremities were warm and pulses were palpable with no edema. Minor lacerations over nasion. Neurological: The patient was drowsy but easily arousable. He was fully oriented and had a normal language. On cranial nerve exam visual fields were full, pupils were 1.5 mm equal and reactive to light, extraocular movements were full with no nystagmus, face sensation and movements were symmetric, there was no dysarthria and tongue was midline. Strength was full throughout with no pronator drift. Postural tremor noted 2+ R and 1+ in hands, trace asterixis in the hands. Tone was normal. Finger tapping was intact in both hands. Tendon reflexes were [**12-17**] throughout and plantar responses were flexor. Sensation to pinprick, vibration and touch were normal throughout. Coordination was normal with finger-to-nose bilaterally. Gait was not assessed but he mentioned being to walk with a walker. Pertinent Results: Labs admission: [**2178-3-18**] 12:00AM PT-12.3 PTT-30.3 INR(PT)-1.1 [**2178-3-18**] 12:00AM PLT COUNT-352 [**2178-3-18**] 12:00AM NEUTS-76.4* LYMPHS-17.4* MONOS-4.9 EOS-1.0 BASOS-0.3 [**2178-3-18**] 12:00AM WBC-13.9*# RBC-4.61 HGB-14.3 HCT-44.4 MCV-96 MCH-30.9 MCHC-32.1 RDW-13.0 [**2178-3-18**] 12:00AM CARBAMZPN-5.9 [**2178-3-18**] 12:00AM VALPROATE-42* [**2178-3-18**] 12:00AM estGFR-Using this [**2178-3-18**] 12:00AM GLUCOSE-148* UREA N-19 CREAT-0.6 SODIUM-138 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-23 ANION GAP-18 [**2178-3-18**] 08:00AM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2178-3-18**] 08:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050* [**2178-3-18**] 08:00AM URINE UHOLD-HOLD [**2178-3-18**] 08:00AM URINE HOURS-RANDOM Imaging studies: CT OF THE CHEST: The thyroid gland is normal. There is no axillary, hilar, or mediastinal lymphadenopathy. There is no aortic injury and pulmonary arteries are normal. There is a small-to-moderate right simple pleural effusion. There is no mediastinal hemorrhage or pneumomediastinum. CT OF THE ABDOMEN: The liver is normal. The gallbladder, pancreas, spleen, both adrenal glands, and kidneys demonstrate no evidence of acute injury. There are bilateral up to 11 mm hypoattenuating renal lesions, too small to characterize but likely representing simple cysts. There is no retroperitoneal or mesenteric lymphadenopathy. There is no free air and no free fluid. The esophagus, stomach, small and large bowel including the appendix are normal. CT OF THE PELVIS: The prostate gland, seminal vesicles, and urinary bladder are normal. There is no pelvic lymphadenopathy. BONES: There are no suspicious lytic or sclerotic bony lesions. Fracture through the anterior longitudinal ligament calcification (DISH) at the T1/T2 level with widening of the anterior intervertebral space. The fracture extends through the T1 pedicles and lamina as seen on the OSH CT of the C-spine. This fracture involves the anterior and posterior elements and is therefore potentially unstable (series 300B, image 44). No additional fractures are seen. IMPRESSION: 1. Fracture through the anterior longitudinal ligament calcifications (DISH) at the T1/T2 level and fracture through the T1 pedicles and lamina as seen on the OSH CT of the C-spine. This fracture involves the anterior and posterior elements and is therefore potentially unstable. 2. No other acute injuries of the chest, abdomen and pelvis. 3. Small-to-moderate right pleural effusion. [**3-23**] CXR: FINDINGS: Portable AP chest radiograph demonstrates cervical and thoracic spinal fusion hardware and surgical staples overlying the mediastinum. There are low lung volumes and dependent atelectasis, greater on the right. An underlying effusion or focal consolidation cannot be excluded. The cardiomediastinal silhouette is mildly enlarged, likely related to recent surgery. There is no pneumothorax. [**3-25**] CXR: FINDINGS: The lung volumes are low. Mild- to moderate-sized right pleural effusion and associated right lung base atelectasis is unchanged. Cardiomediastinal silhouette appears unusually large but its appearance may be exaggerated because of the low lung volumes. Hardware devices are seen in the cervicothoracic and lower thoracic spine. Left lung base and the left costophrenic angle is obscured by the apparently large cardiomediastinal silhouette. Left upper lungs appear clear. BONE SCAN: IMPRESSION: 1. Left T1 pedicle and spinous process uptake consistent with subacute fractures. No T1 vertebral body fracture detected. 2. Lateral T8 tracer uptake bilaterally, corresponding to fractured osteophytes on the CT1 examination, likely subacute. There is no vertebral body fracture detected. 3. Distended bladder. EEG: MICU COURSE [**2178-4-1**] 08:03PM BLOOD WBC-9.5 RBC-3.25* Hgb-9.8* Hct-31.3* MCV-96 MCH-30.1 MCHC-31.3 RDW-15.1 Plt Ct-440 [**2178-4-2**] 02:26AM BLOOD WBC-7.4 RBC-2.97* Hgb-8.9* Hct-28.6* MCV-96 MCH-30.1 MCHC-31.3 RDW-14.9 Plt Ct-420 [**2178-4-2**] 07:50AM BLOOD Hct-29.5* [**2178-4-1**] 06:10AM BLOOD Neuts-75* Bands-0 Lymphs-12* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2178-4-2**] 02:26AM BLOOD Neuts-67 Bands-0 Lymphs-17* Monos-12* Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2178-4-1**] 06:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2178-4-2**] 02:26AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [**2178-4-1**] 08:03PM BLOOD PT-52.3* PTT-68.7* INR(PT)-5.2* [**2178-4-1**] 08:03PM BLOOD Plt Ct-440 [**2178-4-2**] 02:26AM BLOOD PT-37.4* PTT-55.5* INR(PT)-3.7* [**2178-4-2**] 02:26AM BLOOD Plt Smr-NORMAL Plt Ct-420 [**2178-4-2**] 07:50AM BLOOD PT-26.7* PTT-49.6* INR(PT)-2.6* [**2178-4-1**] 02:50PM BLOOD Fibrino-688* Thrombn-15.3 [**2178-4-1**] 06:10AM BLOOD ESR-102* [**2178-4-1**] 02:50PM BLOOD Ret Aut-2.4 [**2178-4-1**] 06:10AM BLOOD Glucose-96 UreaN-12 Creat-1.2 Na-147* K-3.5 Cl-109* HCO3-26 AnGap-16 [**2178-4-2**] 02:26AM BLOOD Glucose-83 UreaN-12 Creat-1.2 Na-146* K-3.5 Cl-108 HCO3-29 AnGap-13 [**2178-4-1**] 06:10AM BLOOD ALT-14 AST-22 AlkPhos-182* TotBili-0.4 [**2178-4-2**] 02:26AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.0 [**2178-4-1**] 05:25PM BLOOD Albumin-3.1* [**2178-4-1**] 02:50PM BLOOD D-Dimer-729* [**2178-4-1**] 02:50PM BLOOD Hapto-357* [**2178-4-1**] 06:10AM BLOOD CRP-83.6* [**2178-3-30**] 05:50AM BLOOD Vanco-2.1* [**2178-4-2**] 02:37AM BLOOD Type-[**Last Name (un) **] Temp-36.8 pH-7.45 Comment-GREEN TOP [**2178-4-2**] 02:37AM BLOOD freeCa-1.08* Brief Hospital Course: #T1 FRACTURE: Mr. [**Known lastname 24560**] was admitted to the Neurology service on [**2178-3-18**] s/p seizures and fall while training for the special Olympics. On admission, he was found to have a subacute T1 fracture. The spine service was consulted. He underwent posterior spinal fusion of C7-T3 and T7-T10 on [**2178-3-20**]. Per ortho spine, his activity is as tolerated, no need for brace, no need for log roll precautions. His staples can removed in the next 1-2 days. . #SEIZURE: The patient's baseline is [**12-15**] seizure every 2-3 days, where he looks confused for 10-30 seconds, generally no post-ictal state or tonic clonic seizures. On [**2178-3-23**] he was witnessed to have a prolonged generalized tonic seizure (unclear duration). He was transferred to the Neuro ICU for concern of status. He was given an additional dose of valproic acid and started on standing lorazepam that was slowly weaned over the next 4 days. He was placed on LTM EEG on [**3-22**] after transfer to the NeuroICU. During his stay in the ICU he had no more seizures. His mental status was obtunded immediately after the seizure on [**2178-3-23**] and he slowly returned to his baseline over the following days. CT head without acute changes. He currently is on depakote 1500mg [**Hospital1 **], Lamictal 200mg [**Hospital1 **], Carbamazepine 400mg/600mg. He is off the standing dose of ativan. He had fewer seizures, close to his baseline. His mental status continued to improve and he was shortly back to his baseline. He is stable and at baseline from the neurological stand point. . #COAGULOPATHY / BLOOD LOSS ANEMIA: He was then noted to have a slow HCT decrease to a nadir of 25.5 on [**3-28**] from 44 over 10 days. He was given 2U PRBC with appropriate bump. He had no obvious bleeding source and a CT torso on [**3-29**] revealed no hematoma. On [**4-1**], he was noted to have oozing from his surgical site which was is not normal per the ortho spine team. He was also noted to have bleeding from his penile meatus in the context of trying to remove his foley. His coags revealed PT: 150 PTT: 140.8 INR: 15.7 (highest reportable- stable on recheck). Hematology was consulted give that his only anticoagulation was heparin sq and he was transferred to the MICU for monitoring. He was was given 2 units FFP and 5 mgs of PO vitamin K with significant improvement in his coagulopathy: PT: 19.6 PTT: 37.9 INR: 1.9 on [**4-2**]. He remained hemodynamically stable for the course of his MICU stay and his hct was trended and stable around 31 with no further noted bleeding. His coagulopathy was initially felt to be related to a factor inhibitor associated with thrombin paste which was used during his surgery. He was started on 80 mg of prednisone daily (1 mg/kg) on [**4-2**] per heme/onc recs. During the patient's stay on the floor, this inhibitor screen returned negative though his factor IX level was low. It was thought that he may have a vitamin K deficiency given the rapid onset of symptoms, his rapid improvement, and the negative inhibitor screen. Factor VII, X and II levels were added on to further evaluate this hypothesis and were pending discharge. His INR was 1.2 at discharge and had been within the normal range since [**4-3**]. Would recommend checking coags within the next several days and faxing results to coagulation clinic at [**Telephone/Fax (1) 24561**]. He has follow up with hematology . #ACUTE KIDNEY INJURY: His creatinine increased on [**2178-3-29**] from baseline of 0.7 up to 1.6, which was tought to be due to vancomycin. It improved over the following days with gentle hydration. It is 1.2 on the day of discharge. Would recommend checking creatinine within five days to ensure it is stable. Would hold nephrotoxins such as NSAIDS. He had a renal ultrasound with final read pending at discharge. He wore a condom catheter at night for comfort. . #HCAP: On [**2178-3-23**] he was noticed to have rales and rhonchi with increased secretions, thought to be due to a hospital-acquired pneumonia. He was started on Vanc and Zosyn on [**2178-3-23**] with completion of seven day course of antibiotics with return of respiratory function to baseline. He was noted to have small pleural effusion on chest imaging. . #HYPERTENSION: He was started on amlodipine for blood pressures ranging from 130- 150. Would continue to monitor BP and consider d/c this medication if BP range 110s-130s. . TRANSITION ISSUES: -Acute kidney injury: Trend creatinine moving forward to ensure that continues to improve. -Coagulopathy: Trend coags and follow up with hematology regarding pending factor studies -staple removal at surgical site Medications on Admission: 1. carbamazepine 400mg / 600mg 2. divalproex DELAYED release 500mg [**Hospital1 **] 3. lamotrigine 200mg [**Hospital1 **] 4. simvastatin 20mg daily 5. MVI Discharge Medications: 1. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. carbamazepine 200 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 7. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO Q 12H (Every 12 Hours). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. bacitracin-polymyxin B Ointment Sig: One (1) Appl Topical BIDPC (2 times a day (after meals)). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Spine fracture Coagulapathy acute kidney injury blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [**Known lastname 24560**], You admitted to the [**Hospital1 18**] after a traumatic fracture to your spine following a seizure. You underwent surgery to repair the fracture. You tolerated the procedure well and will follow up with the spine surgeons as an outpatient During your hospitalization you developed a pneumonia. You were treated with antibiotics and your condition improved. One of the medications caused a transient reduction in kidney function that is improving and will continue to improve with time. Your blood count declined and your blood was found to not be clotting correctly. You were seen by the blood disorder specialists (hematologist). It may have been that this was due to deficiency of vitamin K. You were given medication and your blood started to clot effectively. You will be seen by the hematologist after you leave the hospital. Followup Instructions: We are working on a follow up plan in the Hematology Coagulation department. You will be called at home with an appointment. If you have not heard in two business days, please call [**Telephone/Fax (1) 3062**]. We are working on a follow up appointment for your hospitalization in the Spine Center with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. You need to be seen within 1 month of the discharge. The office will contact you at the facility with the appointment. If you have not heard within 2 business days or have any questions please contact the office at [**Telephone/Fax (1) 8603**]. Name: [**Last Name (LF) **],[**First Name3 (LF) **] S. Location: [**Hospital6 17557**] Address: [**Apartment Address(1) 24562**], [**Location (un) **],[**Numeric Identifier 17559**] Phone: [**Telephone/Fax (1) 15916**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.

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Discharge summary

report

Admission Date: [**2129-6-10**] Discharge Date: [**2129-6-24**] Date of Birth: [**2072-9-6**] Sex: M Service: MEDICINE Allergies: sertraline Attending:[**First Name3 (LF) 633**] Chief Complaint: Agitation, combativeness, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 56yo M with alcohol abuse and distant opioid abuse on methadone maintenance presents following recent discharge from [**Hospital 8**] Hospital for alcohol detox. According to his brother, the patient was drinking more than usual the past several months eventually leading to drinking at all hours of the day. The patient was admitted to [**Hospital1 8**] for detox and was discharged two days prior to arrival with several prescriptions including Haldol. He now presents to the ED with confusion. Of note, the patient is on a methadone maintenance program (100mg daily), and the patient continues to ask for additional methadone. In the ED, patient was somnolent, AOx2 (knows person and "hospital"), exam being unremarkable, but he was trying to get OOB every 5 minutes. Noted to be hypotensive with SBPs in the 70s, improved with IVFs. Additional banana bag also given in the ED. [**Name6 (MD) **] [**Name8 (MD) **] RN report, he was calm and polite, but forgot what he was asked as soon as someone left the room. Vitals upon transfer to the floor: 98, 50, 16, 91/48, 98% ra, [**3-31**] pain. He was admitted to the ICU because of AMS and combativeness. IN the ICU, his OSH records were obtained which revealed negative RPR, normal TSH, and an MRI scan significant for mammallary body atrophy. Pt was started on high dose thiamine and improved significantly (speech), suggesting wernickes encephalopathy. He was receiving standing haldol for several days but his qtc lengthened with peak of 486. He was then changed to prn haldol 2.5mg. He was initially on a CIWA scale but was not [**Doctor Last Name **], and this was d/ced. He was restarted on his home dose of methadone, which has helped him. Psychiatry has been consulting and advising on medication management recs. Social work and PT were also been consulted. On transfer, vitals were 105/69 HR 79, rr 17, 99% RA. He is aox3 and does not have any complaints. Past Medical History: -HTN -ETOH abuse -HCV -h/o Agoraphobia previously treated w/ sertraline, but stopped for concern of serotonin syndrome - Methadone maintenance for opioid detox Social History: Former waste management truck worker and cement mixer for 22 years. Last HIV test negative 2.5 years ago. Last drink was 5-6 weeks algo, Notes state he may have had odor of etoh at outside clinic appointment and was sent to detox. Denies ever smoking. Lives with his brother, [**Name (NI) **]. Family History: DM2 in both parents, PTSD in his father. Brother is also on methadone maintenance program. Physical Exam: ADMISSION EXAM Tmax: 37.1 ??????C (98.7 ??????F) Tcurrent: 37.1 ??????C (98.7 ??????F) HR: 84 (73 - 84) bpm BP: 107/79(85) {107/72(85) - 130/86(96)} mmHg RR: 33 (18 - 33) insp/min SpO2: 98% RA Heart rhythm: SR (Sinus Rhythm) General: Patient in 4 point restraints calling out to be let go HEENT: NorPERRL. Sclera non-icteric. dryMM. OP without eryrthema, exudate. CV: RRR. No M/R/G Lungs: Nml work of breathing with no accessory muscle use. Clear to auscultation bilaterally, anteriorly. Abd: BS+. Soft. NT/ND. Ext: Right knee bandage in place. Trace pitting edema bilaterally. 2+ DPs bilaterally. No clubbing, cyanosis. Neuro: Unable to assess CN [**12-23**] patient's mental status. Moving all 4 extremities spontaneously. Alert. Oriented only to person. Psych: [**Month/Day (2) 100549**]. flight of ideas. tearful at times. no hallucinations at present, no suicidal/homicidal ideation. DISCHARGE EXAM Vitals: 98.1/98.3 - 100s - 120s/60s-70s - 65(60-80s)- 100 RA GEN: Alert, oriented to person, place and time, no acute distress. Exited bathroom when I came in. Ambulating on own/using bathroom on own. Appropriate affect and communication skills. HEENT: Sclera anicteric, MMM, oropharynx clear, NECK: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no mrg LUNGS: Clear to auscultation bilaterally, no wheezes, rales, ronchi ABD: No ascites, soft, non-tender, non-distended, bowel sounds present, EXT: Ambulating on his own as needed, 2+ pulses, no spider angiomas NEURO: No asterixis, Non encephalopathic CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation. Slight tremor bilateral. F-t-N with slight tremor. Pertinent Results: ADMISSION LABS [**2129-6-10**] 01:25PM BLOOD WBC-6.9 RBC-3.18* Hgb-10.6* Hct-33.1* MCV-104* MCH-33.4* MCHC-32.1 RDW-13.1 Plt Ct-308# [**2129-6-10**] 01:25PM BLOOD Neuts-63.8 Lymphs-25.3 Monos-4.5 Eos-5.5* Baso-1.0 [**2129-6-10**] 01:25PM BLOOD PT-10.3 PTT-28.0 INR(PT)-0.9 [**2129-6-10**] 01:25PM BLOOD Glucose-96 UreaN-49* Creat-2.4*# Na-141 K-4.2 Cl-105 HCO3-25 AnGap-15 [**2129-6-10**] 01:25PM BLOOD ALT-48* AST-55* LD(LDH)-236 AlkPhos-45 TotBili-0.3 [**2129-6-10**] 01:25PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.4 Mg-1.9 [**2129-6-10**] 01:25PM BLOOD VitB12-765 Folate-GREATER TH [**2129-6-10**] 01:25PM BLOOD TSH-1.4 [**2129-6-14**] 04:44AM BLOOD CRP-2.5 [**2129-6-14**] 04:44AM BLOOD [**Doctor First Name **]-NEGATIVE [**2129-6-10**] 01:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2129-6-10**] 01:35PM BLOOD Lactate-1.1 DISCHARGE LABS [**2129-6-19**] 08:10AM BLOOD WBC-9.6 RBC-3.55* Hgb-12.0* Hct-36.2* MCV-102* MCH-33.8* MCHC-33.2 RDW-13.6 Plt Ct-232 [**2129-6-19**] 08:10AM BLOOD Neuts-77.9* Lymphs-11.7* Monos-4.0 Eos-5.8* Baso-0.7 [**2129-6-19**] 08:10AM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-143 K-4.3 Cl-102 HCO3-34* AnGap-11 [**2129-6-12**] 05:52AM BLOOD ALT-35 AST-45* AlkPhos-33* TotBili-0.5 [**2129-6-19**] 08:10AM BLOOD Calcium-9.7 Phos-3.6 Mg-1.7 URINALYSIS [**2129-6-10**] 10:43PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2129-6-10**] 10:43PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2129-6-10**] 10:43PM URINE RBC-<1 WBC-8* Bacteri-FEW Yeast-NONE Epi-0 [**2129-6-10**] 10:43PM URINE CastHy-3* MICRO DATA [**2129-6-11**] BLOOD CULTURE - pending [**2129-6-10**] BLOOD CULTURE - negative [**2129-6-10**] RAPID PLASMA REAGIN TEST - negative [**2129-6-10**] BLOOD CULTURE - negative ECG [**2129-6-10**] 1:19:10 PM Sinus bradycardia. Baseline artifact. Early anterior R wave transition. Lateral R wave regression. Non-specific T wave inversion in lead aVF. No previous tracing available for comparison. ECG [**2129-6-10**] 9:03:58 PM Baseline artifact. Sinus rhythm. Compared to the previous tracing of the same date the rate is slightly faster and no longer bradycardic. T wave inversion has improved in lead aVF. Anterior R wave progression is more normal out to lead V5, likely reflecting differences in precordial electrode placement. CHEST (PORTABLE AP) Study Date of [**2129-6-10**] 1:43 PM No evidence of acute disease. . [**6-15**] MRI brain IMPRESSION: Significant cortical volume loss for the patient's age, and few scattered foci of high signal intensity throughout the subcortical and periventricular white matter as well as in the pons, suggesting sequela of small vessel disease. The mamillary bodies demonstrate atrophy with no evidence of abnormal enhancement to indicate acute Wernicke's encephalopathy, however sequelae of this syndrome resulting in mamillary body atrophy cannot be completely ruled out. . [**6-19**] CT head-IMPRESSION: 1. No evidence of acute intracranial abnormality. 2. Global atrophy, likely related to the given history of alcohol abuse. Brief Hospital Course: 56yo caucasian male with chronic alcohol abuse, opioid abuse on methadone maintenance, recent detox, and hep C, presenting with hypotension, altered mental status, combativeness, dehydration induced [**Last Name (un) **], and positive urine benzo tox screen. Responded to hydration and IV thiamine, also managed with methadone and haldol. During hospital course patient became acutely confused and agitated and attempted to elope twice. Two code purples were called, and he was deemed to lack medical decision making capacity. The patient improved significantly with nutrition, vitamin support, and pain control. The patient's brother was deemed his health care proxy. . ## Altered mental status: The patient was recently discharged from detox at [**Hospital 8**] Hospital 2 prior to arrival. Differential included EtOH withdrawal versus benzo withdrawal versus Wernicke's encephalopathy/Korsakoff psychosis. Neuroimaging appeared to be consistent with subacute/chronic Wernicke Korsakoff syndrome with an element of related neurocognitive trouble (global atrophy) in the setting of long standing alcohol use. MRI finding of chronic Mamillary Body Atrophy consistent with Wernicke-Korsakoff. Pts cognition improved with Vitamin repletion, hydration, and methadone. Unlikely to be other metabolic, infectious etiologies - TSH nml, infectious workup negative (neg CXR, UA w/ WBCs and bacteria but no symptoms).Patient was placed on CIWA scale, but did not score, so this was discontinued. On the floor, patient was noted to be confabulating extensively, responding to internal stimuli and hallucinating (both auditory and visual). On [**6-17**], he patient became acutely confused, agitated and attempted to elope, code purple was called. He was re-directed and returned to the floor. On [**6-18**], he attempted to elope and was seen running outside the hospital, where he fell at some point. Security found him roughly 25 minutes later at [**Hospital1 100550**], and he returned willingly. Head CT was done to rule out trauma in the setting of recent fall and showed global atrophy with no acute intracranial bleed. In light of these events, he was evaluated by the Psychiatry team and was deemed to lack decision making capacity. Due to this he could not leave the hospital, including signing out AMA. OT deemed the patient to have poor ability with medication dosing and financial capacity.PT deemed the patient to require minimal assistance for ambulation. Subsequently the patient's brother was determined to be the [**Hospital 228**] Health Care Proxy. At a family meeting it was decided that the patient would live with his brother and the brother decided to help with daily medication dosing, and financial management. On discharge the patient was connected with Home VNA upon discharge. On day of discharge, the patient was tolerating full PO diet without nausea or emesis, ambulating independently, moving bowels and urine appropriately and independently, making rational decisions with improved insight. The patients vital signs were normal and stable. The patient's lab findings were normal and stable. Recovery could take weeks/months and may be limited by pt's discovered global brain atrophy. He was discharged with VNA/PT and his brother acting to provide some supervision. . ## h.o opiate abuse/chronic pain- Pt admitted from OSH on 100mg methadone/day. On day of discharge patient was on 40mg methadone/day. Patient, his family and Home VNA were given instructions on weaning the methadone upon discharge. Weaning methadone should also help with cognitions . ## Prolonged QT syndrome: Patient received standing haloperidol in the MICU for several days secondary to agitation and combativeness, but his QTc began to lengthen with peak of 486. As a result haloperidol was used sparingly. His electrolytes were repleted as needed and methadone was down-titrated to 80 then 60 mg QD. QT improved to 418, and haloperidol was only used with extreme caution. He was followed with serial daily EKGs. THus buspirone and haldol were discontinued. . ## Hepatitis C: Untreated. Patient was followed by Hepatology and in the past has expressed interest in treatment. Reviewe of OMR notes suggests that the patient has not initiated treatment yet. LFTs were trended and were within normal limits. Referral was made for follow-up with [**Hospital 3585**] clinic. . ## EtOH Abuse: With macrocytic anemia and Mamillary body atrophy. Recently discharged from rehab. Unclear time of last drink. Upon admission patient was placed on CIWA scale, but did not score, and this was discontinued. The patient was given MVI daily, as well as intravenous thiamine. No withdraw events during admission. Patient was interested and willing to pursue rehab and at discharge patient was connected with outpatient support groups and rehab centers. . ## Essential tremor: Well controlled with propranolol on the floor. Transitional Issues: - Please be aware that Mr. [**Known lastname **] [**Last Name (Titles) 100549**] and likely lacks medical decision making capacity. His brother, [**Name (NI) **] is his health care proxy. - Needs de-escalation of methadone, discharged at 40mg/day, please coordinate with [**Hospital 228**] [**Hospital 2514**] clinic. - Please be aware that patient has history of prolonged QT (in the setting of treatment with haloperidol and methadone), please use these medications with extreme caution and follow EKGs if haloperidol is necessary. - Patient needs follow-up with [**Hospital 3585**] clinic at [**Hospital1 18**] (with Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] at [**Hospital1 18**]). - Patient needs to see his PCP after discharge (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**]). Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Family/Caregiver. 1. Lisinopril 10 mg PO DAILY Hold for SBP < 100 2. Propranolol 20 mg PO TID Hold for SBP < 100, HR < 50 3. BusPIRone 10 mg PO TID 4. Vitamin D 400 UNIT PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Haloperidol 1 mg PO Q6HR : PRN agitation 10. Tamsulosin 0.4 mg PO HS 11. Methadone 100 mg PO DAILY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Propranolol 20 mg PO BID Hold for SBP < 100, HR < 50 4. Aspirin 81 mg PO DAILY 5. BusPIRone 10 mg PO TID 6. Thiamine 100 mg PO DAILY 7. Vitamin D 400 UNIT PO DAILY 8. Methadone 80 mg PO DAILY Please hold for RR<12, oversedation 9. Lisinopril 10 mg PO DAILY Hold for SBP < 100 10. Tamsulosin 0.4 mg PO HS 11. Thiamine 100 mg IV DAILY Duration: 4 Days at [**Hospital **] Hospital. 1. FoLIC Acid 1 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Propranolol 20 mg PO BID Hold for SBP < 100, HR < 50 RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Thiamine 100 mg PO DAILY 6. Vitamin D 400 UNIT PO DAILY 7. Methadone 40 mg PO DAILY 8. Lisinopril 10 mg PO DAILY Hold for SBP < 100 RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Tamsulosin 0.4 mg PO HS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth every night Disp #*30 Capsule Refills:*0 10. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Delirium Wernicke-Korsakoff Psychosis 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 **], Thank you for choosing your care at the [**Hospital1 827**]. You were admitted to the [**Hospital1 18**] MICU for confusion, dehydration, and low blood pressure. Later, once your blood pressure stabilized, and your confusion improved, you were transferred to the floor. You were treated with intravenous thiamine, a vitamin which can be at very low levels in people who drink alcohol. You were also re-started on your methadone, but your dose was lowered, because the high dose you had been on seemed to make you confused. While you were here, you became confused and attempted to leave the hospital twice. The second time you left, it was decided that for your safety and because of your hallucinations and confusion, you did not have decision making capacity and could not leave the hospital, including signing out AMA. Your health continued to remain stable in the hospital, and you were discharged in good condition to [**Hospital **] Hospital. While you were here, some changes were made to your medications. You were continued on methadone, but at a lower dose (80 mg per day). The doctors at your rehab facility ([**Hospital1 **]) will continue to manage this dosing. Please follow-up with them regarding how much methadone you should take at home. Please follow up with your primary care provider after discharge from the [**Hospital **] hospital/rehabilitation center. Followup Instructions: Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**], after being discharged from [**Hospital **] Hospital. Location: [**Hospital **] MEDICAL PHYSICIANS, P.C. Address: [**University/College 808**], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 823**] Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 18**] [**Hospital 3585**] clinic. Their phone number is [**Telephone/Fax (1) 463**]. Completed by:[**2129-6-26**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15212, 15287

7739, 8422

317, 323

15369, 15369

4581, 7716

16989, 17541

2803, 2895

14088, 15189

15308, 15348

13555, 14065

15552, 16966

2910, 4562

12667, 13529

230, 279

351, 2292

15384, 15528

2314, 2476

2492, 2787

22,872

100,088

10820

Discharge summary

report

Admission Date: [**2176-5-31**] Discharge Date: [**2176-6-14**] Date of Birth: [**2101-7-5**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: Constipation, fatigue, weight loss Major Surgical or Invasive Procedure: Resection of transverse colon and splenic flexure, colocolostomy, resection of small bowel (en bloc) enteroenterostomy and feeding jejunostomy. History of Present Illness: Mrs [**Known lastname 1391**] is a 74F who presents with a several month history of constipation, diarrhea, occasional nausea/vomiting, and a weight loss of approx 25lbs over the past 6 months. She first sought medical attention 3 weeks before admission, when her workup, including colonoscopy and CT scan, showed a mass in the transverse colon. Biopsy showed moderately differentiated adenocarcinoma. She denies black or bloody stools, or dysuria. Past Medical History: CAD with CABG in [**9-/2172**] Hypothyroidism Recent onset of heartburn symptoms, no formal dx of GERD Social History: 30-40py smoking history Widowed for 6 years 3 Children Family History: Mother died of pancreatic cancer, father of prostate cancer Physical Exam: Physical exam on discharge: VS: RRR CTAB Abd soft, non-tender with jejunostomy tube in place. J-tube site free of erythema or induration. Brief Hospital Course: Ms [**Known lastname 1391**] was admitted on [**2176-5-31**] to begin nutritional optimization in preparation for surgery. A pre-operative cardiology clearance was obtained with no cardiac intervention required. A central line was placed on [**6-1**] and total parenteral nutrition was initiated, although the pt continued to attempt self-support through oral intake. A CT scan on [**6-5**] for pre-operative planning was not encouraging, as it showed a metastatic lesion invading the mesentery with likely involvement of the celiac and mesenteric vessels. She underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] prep and Fleets #1 prep on [**6-5**], and was taken to the operating room on [**6-6**]. Please refer to the operative report of Dr [**Last Name (STitle) 957**] for further details on that procedure. Post-operatively she was noted to be markedly bradycardic, with heart rates as low as 29 and blood pressures that proved very difficult to measure by either machine or direct auscultation. She was thus placed in the MICU overnight at the advice of the cardiology service, who felt that in the unlikely event her HR dropped so low she was unable to support her blood pressure, it would be essential to have close monitoring. Fluid resuscitation continued, and the patient's HR gradually normalized. Electrophysiology was consulted, who recommended no pacemaker at this time, as the rhythm was Wenckebach and did not constitute an indication for a pacemaker. Although she was continued on TPN post-operatively, as her functional level improved she was returned to oral intake, with tubefeeds to supplement. On [**6-11**] she began to complain of a suprapubic burning pain, but a urinalysis was negative for UTI, and her pain was deemed post-surgical. As she improved, her TPN was stopped, her tubefeeds and oral intake were increased, and her central line was removed. She was discharged to home with services on [**6-14**]. Follow up with Heme/Onc was arranged, and pt expressed a wish to follow up with Dr [**Last Name (STitle) **] of [**Hospital3 **]. It has also been recommended that she seek care with the [**Hospital3 35292**] service at [**Hospital1 18**], as this modality may be well suited to her tumor. Medications on Admission: Atenolol 25 Fosamax 35 q week Levoxyl 88mcg 81mg ASA Ambien prn Vicodin prn, MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 7571**]Nursing Assc. Discharge Diagnosis: Colon cancer Discharge Condition: Good Discharge Instructions: Take all medications as prescribed. Do not drive while taking a narcotic pain medication such as percocet or vicodin. Please follow the VNA's instructions for your tubefeeds. If you develop fevers, chills, nausea/vomiting, cessation of bowel movements or flatus, difficulty flushing the J-tube, severe abdominal pain, or other concerning symptoms, please contact our office or a local emergency room. Please call Dr[**Name (NI) 6275**] office to schedule your follow up appoitnment. They will also be able to put you in contact with the [**Name (NI) 35292**] office, to help arrange for your chemotherapy treatments. Dr[**Name (NI) 35293**] office will be contacting you and Dr [**Last Name (STitle) **] for followup as well, if you don't hear from them within one week please call their office. Followup Instructions: Please call Dr[**Name (NI) 6275**] office to schedule your follow up appoitnment. They will also be able to put you in contact with the [**Name (NI) 35292**] office, to help arrange for your chemotherapy treatments. Dr[**Name (NI) 35293**] office will be contacting you and Dr [**Last Name (STitle) **] for followup as well, if you don't hear from them within one week please call their office.

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icd9cm

[ [ [] ] ]

[ "46.39", "99.04", "96.6", "38.93", "99.15", "45.74", "45.62" ]

icd9pcs

[ [ [] ] ]

4266, 4330

1425, 3673

348, 494

4387, 4393

5237, 5634

1186, 1247

3804, 4243

4351, 4366

3699, 3781

4417, 5214

1262, 1262

1291, 1402

274, 310

522, 972

994, 1098

1114, 1170

28,724

134,413

49230

Discharge summary

report

Admission Date: [**2201-8-7**] Discharge Date: [**2201-8-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1580**] Chief Complaint: Falls, hypotension, fatigue Major Surgical or Invasive Procedure: Left IJ placement History of Present Illness: 84 yo M with [**First Name3 (LF) **] cirrhosis, HCC status post RFA, metastatic to spine, portal vein thrombosis, grade II varices and hepatic encephalopathy, refractory ascites requiring q 2 week US-guided paracentesis presents with falls, once a few days ago where he reportedly hit arm/head, today fell and hit left leg/hip. Presented to ED as trauma, complaining of hip pain. Triggered in triage for hypotension 70/40s. Had tender abdomen, leukocytosis with left shift, though likley source of infection SBP. Was given zosyn in ED. Persistently hypotensive despite 5L IVF, had CVL placed, persistently hypotensive though always mentating. Maxed out on dopa, levophed added. Pt also noted to have guaiac positive (brown), has history of AVMs in cecum, GI informed, recommended calling liver fellow. Hct 23.7, baseline high 20s. No CP, no ecg changes. In addition to fluids, pressors and zosyn, pt received dilaudid and zofran. At time of transfer pt hypothermic to 94.1 BP 80/61, HR 80, RR 16, 99% 2L NC. . Of note pt was discharged from [**Hospital1 18**] after hospitalization for abd pain, initially thought to have SBP with negative paracentesis, after d/c c. diff cultures returned positive and pt was contact[**Name (NI) **] and prescribed PO vancomycin. . ROS conducted with patient and wife. Wife states that pt is confused at baseline and endorses several falls in the past week, states he has had copious diarrhea but this is in the setting of lactulose use. The patient denies HA, +mildly worsening SOB, no cough or sputum production, no nausea or vomiting. Mild abd pain. His chief complaint is left flank/hip pain at site of fall today. Past Medical History: 1. Cirrhosis - grade 2 varices - h/o HCC metastatic to spine, back pain - h/o hepatic encephalopathy - difficult to control ascites requiring q2 week paracenteses - Portal vein thrombosis (R,L, main); No anticoag due to bleeding risk. - h/o SBP 2. Non-obstructive cholelithiasis 3. BPH 4. DM2 ?????? diet controlled 5. HTN 6. Receovered hepatitis A infection per serologies 7. Benign polyps in the colon/GERD 8. CAD s/p stenting of the LAD ([**2196**]) 9. s/p tamponade, pericardiocentesis and window 10. GIB 11. C. difficile diarrhea 12. Depression 13. Hypothyroidism 14. Anemia 15. CKD Social History: Retired Russian army general. 3ppd smoker, but quit 30 years ago. Previously drank [**12-24**] glasses of liquor/day; endorses occasional EtOH still. Lives with his wife of 60 years. Family History: Mother with gastric cancer, CAD. Son with brain tumor. Physical Exam: Vitals: T: 95.7 BP:102/56 (66) P:78 R: 17 SaO2: 100%2L NC CVP 7 General: Awake, responding to questions, mildly confused. Ill, cachectic elderly man [**Month/Day (2) 4459**]: NCAT, [**Month/Day (2) 2994**], EOMI, no scleral icterus, MM dry, telangiectasias on face. Neck: [**Month/Day (2) **], JVP to 12cm, left IJ in place Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: + distended, ascites, non-tense. Minimally TTP diffusely, no rebound or guarding. Mild suprapubic tenderness. Extremities: No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Pale with multiple cherry angiomata and telangiectasias. Neurologic: Alert, confused with poor attention and short term memory. Responding appropriately to questions, follows commands. Pertinent Results: Labs: See below Peritoneal fluid: WBC 380 RBC 240 Poly 35% Lymph 21 Mono 38 Lactate 4.0 UA negative . Imaging: CXR: AP PORTABLE SUPINE CHEST RADIOGRAPH. The lungs are clear bilaterally. Right CP angle is partially excluded. No evidence of pneumothorax or pleural effusion. Heart size appears mildly enlarged. There is extensive widening of the mediastinum, which when compared with subsequently obtained CT scan is secondary to an unfolded thoracic aorta. Atherosclerotic calcifications are noted along the thoracic aorta. The bones appear grossly intact. Please note, subacute appearing right anterior rib fractures are better visualized on CT scan performed subsequently. Radiopaque gallstones are noted in the right upper quadrant. Vertebroplasty changes are noted at L2 vertebral body. . CT head:FINDINGS: There is no evidence for hemorrhage, mass effect, or shift of normally midline structures. The ventricles, cisterns, and sulci are mildly enlarged secondary to involutional changes. The visualized paranasal sinuses and mastoid air cells are clear. There is atherosclerotic disease in the cavernous carotid arteries. IMPRESSION: No evidence for hemorrhage or mass effect. . CT Chest/abd/pelvis: WET READ no evidence for acute injury. moderate ascites measures simple fluid. large mass in right hepatic lobe, enlarged from [**2201-4-20**] consistent with hepatoma. limited evaluation given no contrast. Mild T4 compression deformity, unchanged from chest x-ray [**2201-7-6**], probably getting slightly worse over time, fx new from [**2201-1-27**]. Unchanged metastasis L3. prior vertebroplasy L1. Dense atherosclerotic disease. New 1cm right adrenal nodule. . CT c-spine: Pelvis plain film: AP PELVIS: The bony pelvis appears intact. The pelvis is slightly rotated, which limits evaluation. Only minimal degenerative changes are noted at the lower lumbar spine and bilateral hip joints. Vascular calcifications are also noted in the pelvis and proximal thighs. . EKG:Sinus bradycardia, Q wave in aVF. Low voltage with diffuse TWF, no change from prior. Brief Hospital Course: 84M with ESLD with refractory ascites and metastatic HCC, recent c. diff p/w falls, hypotension now post-ICU s/p likely septic shock, now DNR/DNI and eventually made [**Year (4 digits) 3225**]. SEPTIC SHOCK: In the ICU, pt was found to be in severe septic shock, hypotension not responsive to IVF, presented to ED on 2 pressors, hypothermic with increase in his baseline leukocytosis with 5% bandemia. Third pressor was added. Pt had empiric coverage for his C.dif started with PO vanco and IV flagyl, and were investigating source of sepsis. Cardiogenic shock was unlikely with (-)CE and normal CXR. Alternatively adrenal insufficinecy in setting of known malignancy was considered. Pt was weaned off dopa, vasopressin, levophed. Pt also developed ARF thought to be end organ dysfxn in setting of hypotension/sepsis. Since also presented with guaic(+) stools and Hct below baseline 23.7 (per OMR baseline high 20s low 30s). Pt received 2 units PRBC, IV PPI, held ASA, and q8 Hct checks. Pt's Hct at baseline at time of transfer. Sepsis resolved once pt was trasferred to floor, off pressors, pt afebrile, HD stable with BP in 130/70s. Baseline 60-80s (presented in 90s 67.7). Normal CXR, UA. Source possibly C.diff, on broad abx, but really unknown source. Even paracentesis neg for SBP. Adrenal insuff r/o with normal random cortisol. D/c'd vanco/zosyn - finished 7d course QOD. Pt did not become febrile at any point. Pt was presumptively treated for C.diff while in the ICU, but pt's C.diff returned neg x 3, but we continued to finish the pt's course of PO vanco and flaygl until pt was made [**Year (4 digits) 3225**], and were discontinued at that point. ESLD: Pt had poor prognosis even at time of admission from how severe his end-stage liver disaseas was. Pt had a h/o of [**Year (4 digits) **] cirrhosis c/b metastatic HCC s/p RFA. Pt normally gets therapuetic paracentesis q 2 weeks. US-guided paracentesis [**8-14**]- took off 6.3L. Pt's mental status to the point where he could comprehend some sentences, but would still speak in single word sentences, like "pain" and point to the area of the foley. Pt became more somnolent and with poor progonosis family decided to make pt [**Name (NI) 3225**]. Pt was kept comfortable on morphine SL, hyoscyamine, ativan, duonebs, simethecone. Pt died [**1-24**] cardiopulmonary arrest as the immediate cause of death, and from longstanding ELSD with HCC. GIB: Pt had anemia below baseline at 23.7. Pt has h/o portal hypertension with known varices, also with known cecal AVMs p/w guaiac + brown stool. In the ICU pt's goal Hct > 30 and was given 2units PRBC, and was on IV PPI [**Hospital1 **]. Pt's Hct remained stable once on the floor. ORAL THRUSH: Pt was found to have thrush which was treated with fluconazole, and helpt his speech. ARF: Pt was prerenal. Pt improved to 2.0 with 1.5-1.8 baseline. No casts to support ischemic ATN. Pt was also hypernatremic initially 149 and with fluid came down to 143. LEUKOCYTOSIS: Not a new finding, however futher work up was done during this admission. Pt' Bcr-Abl (-), and JAK 2 (-) for CML, PV, ET. Medications on Admission: Nadolol 20 mg Tablet daily Folic Acid 1 mg Tablet daily Levothyroxine 88 mcg Tablet daily Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 Paroxetine HCl 20mg daily Thiamine HCl 100 mg Tablet daily Tamsulosin 0.4 mg Capsule QHS Pantoprazole 40 mg Tablet daily Trazodone 50 mg Tablet QHS Aspirin 325 mg Tablet Oxycodone 5 mg Tablet prn Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. Lasix 20mg daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: death Discharge Instructions: n/a Followup Instructions: n/a [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**] Completed by:[**2201-9-22**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9626, 9635

5923, 9030

289, 308

9682, 9689

3836, 4628

9741, 9912

2820, 2878

9598, 9603

9656, 9661

9056, 9575

9713, 9718

2893, 3817

222, 251

336, 1991

4636, 5900

2013, 2603

2619, 2804

73,143

107,427

6452

Discharge summary

report

Admission Date: [**2119-3-20**] Discharge Date: [**2119-3-27**] Date of Birth: [**2033-10-3**] Sex: M Service: MEDICINE Allergies: Bactrim DS Attending:[**First Name3 (LF) 1943**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Thoracentesis [**3-22**] Bronchoscopy with biopsy [**3-23**] History of Present Illness: This is an 85-year old gentleman with 6 months of dyspnea and recent diagnosis of likely right upper lung primary cancer with diffuse mets, and recent thoracentesis diagnostic on the right, who is presenting with worsening dyspnea 24 hours after a thoracentesis. He has a 15 pack year smoking history (quit 20 years ago) presenting with worsening shortness of breath and cough for the past few months. He explains that he has had worsening dyspnea with exertion for the past few months which has now progressed to shortness of breath even at rest. He has also noticed a worsening cough during this time. No hemoptysis but occassionally lightly brown tinged sputum. He denies any chest pain, fevers or chills. He reports a mild lost of weight and with decreased appetite over the past few months. A chest x-ray on [**2119-3-14**] showed two large pulmonary masses in the right upper lobe (6.7 x 5.9 and 3.9 x 2.6 cm) as well as several additional nodular opacities in both lower lobes. A subsequent CT showed stage IV lung cancer with right upper lobe primary, satellite nodules, bibasilar metastases, and bilateral effusions right greater than left. He was seen by IP on [**3-16**] who performed a right-sided ultrasound guided thoracentesis removing 1250 cc of fluid. He initially felt better however in the last few days he started having worsening shortness of breath and difficulty lying flat. No chest pain and no fever. On arrival to the ED his initial VS were 97.8 140/52 60 24 sat 92% on room air. A chest x-ray showed worsening pleural effusions. He was sent for a CTA to rule out a PE. He was given 1L NS prior to the CTA. Per report during the CTA, while lying flat and receiving the contrast, he became more acutely short of breath with increasingly labored breathing, tachypneic to 30, and desaturating to 86% on 3L NC. Expiratory wheezes and crackles bilaterally were appreciated. He was given duonebs, 40mg IV lasix, and started on a nitro drip at 0.42 mcg/kg/min. 1 SL NTG was also given. An EKG showed atrial flutter with 4:1 conduction but no ischemic changes. He was subsequently saturating 80% on FM and so was started on BiPAP, a foley was placed, and he was admitted to the ICU. Vital signs at the time of transfer were hr 57 bp 135/55 80% on FM, 99%/BiPAP. On arrival to the MICU the patient appeared to be in no acute distress and was breathing comfortably with sats of 93% on 5L NC. Past Medical History: Diabetes mellitus type 2 Hypertension Hypercholesteremia Difficulty with swallowing Coronary artery disease Congestive heart failure Peripheral vascular disease Chronic venous insufficiency in the legs Urinary incontinence Gout Osteoarthritis Chronic kidney disease Retinal detachment Past Surgical History: S/p right hernia repair S/p cataract removal S/p thyroid adenoma excision S/p TURP S/p tonsilectomy Repair of Zenker's diverticulm Social History: Tobacco: 15 pack years, quit 20 years ago Alcohol: None and none in the past Occupation: Lives with son, daughter and wife. Retired doctor [**First Name (Titles) **] [**Last Name (Titles) 24809**]l surgery. Family History: No lung cancer or congenital lung diseases Father: Died of old age (70s) but had a history of a colectomy of unknown reason Mother: Deceased age 57 unknown reasons. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 85 145/106 rr 23 sat 93%/5L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diminished breath sounds on right, bibasilar crackles left > right, no wheeze, dullness to percussion over right upper fields Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley in place Ext: 1+ edema, warm, well perfused, 2+ pulses, no clubbingm or cyanosis Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM VS: Afebrile, O2 sat 90-93% on room air at rest; 88% on room air while ambulating, weight 171# GEN: NAD CHEST: Symmetric breath sounds, but with bibasilar rales CV: RRR Pertinent Results: ADMISSION LABS [**2119-3-20**] 04:53AM BLOOD WBC-8.0 RBC-4.48* Hgb-12.0* Hct-40.2 MCV-90 MCH-26.9* MCHC-29.9* RDW-15.7* Plt Ct-226 [**2119-3-20**] 04:53AM BLOOD Neuts-76.3* Lymphs-10.9* Monos-5.5 Eos-6.9* Baso-0.5 [**2119-3-20**] 04:53AM BLOOD PT-11.1 PTT-32.8 INR(PT)-1.0 [**2119-3-20**] 04:53AM BLOOD Glucose-141* UreaN-32* Creat-1.3* Na-139 K-4.8 Cl-104 HCO3-25 AnGap-15 [**2119-3-20**] 04:53AM BLOOD proBNP-2434* [**2119-3-20**] 04:53AM BLOOD cTropnT-0.02* [**2119-3-20**] 12:43PM BLOOD CK-MB-2 cTropnT-<0.01 [**2119-3-20**] 04:15PM BLOOD CK-MB-2 cTropnT-0.01 [**2119-3-20**] 12:43PM BLOOD CK(CPK)-25* [**2119-3-20**] 04:15PM BLOOD CK(CPK)-31* [**2119-3-20**] 04:15PM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 [**2119-3-20**] 08:37AM BLOOD Lactate-0.8 DISCHARGE LABS [**2119-3-26**] 09:18AM BLOOD WBC-8.8 RBC-4.39* Hgb-12.1* Hct-38.9* MCV-89 MCH-27.5 MCHC-31.0 RDW-16.2* Plt Ct-215 [**2119-3-26**] 09:18AM BLOOD Glucose-158* UreaN-45* Creat-1.5* Na-137 K-3.9 Cl-100 HCO3-28 AnGap-13 [**2119-3-26**] 09:18AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1 MICROBIOLOGY [**2119-3-20**] Blood Culture: No growth IMAGING [**2119-3-20**] ECG: Atrial flutter with 4:1 block or this may be consistent with atrial tachycardia with 4:1 block. Non-specific septal and inferior ST-T wave changes. Compared to the previous tracing of [**2118-11-3**] findings are similar [**2119-3-20**] CHEST (PA & LAT): Known right upper lobe lung mass, and multiple bibasilar pulmonary nodules, redemonstrated. CHF. Mild increase in the moderate right pleural effusion, and stable left pleural effusion. [**2119-3-20**] CTA CHEST W&W/O C&RECONS, NON-CORONARY: Metastatic lung cancer, with a right upper lobe primary mass and multiple satellite metastatic nodules in both lungs, not significantly changed since the earlier study of [**2119-3-14**]. Moderate right and small left pleural effusion, have slightly enlarged since [**2119-3-14**], especially given the fact that the patient underwent a right thoracentesis in the interim. Increasing bibasilar atelectasis. No acute pulmonary embolism or thoracic aortic pathology. [**2119-3-20**] CT HEAD W/O CONTRAST: No acute intracranial pathology. Moderate-to-severe involutional changes and small vessel ischemic disease. No evidence of metastatic disease. Please note that a non-enhanced MRI study would be more sensitive for metastatic disease. [**2119-3-21**] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). The diameters of aorta at the sinus, ascending and arch levels are normal. The descending thoracic 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 structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderatemitral regurgitation. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2113-11-17**], the severity of mitral regurgitation has increased. CLINICAL IMPLICATIONS: The patient has moderate mitral regurgitation. Based on [**2112**] ACC/AHA Valvular Heart Disease Guidelines, a follow-up echocardiogram is suggested in 1 year. [**2119-3-21**] CHEST (PORTABLE AP): There continues to be a large opacity overlying the right upper lung which is the known mass. Lung volumes are otherwise low. There is a right-sided pleural effusion as well as a more focal area which correlates to the multiple masses on the chest CT from one day prior. Cardiomediastinal silhouette is stable in size. Brief Hospital Course: 85 year old retired dentist presenting with worsening shortness of breath and right sided pleural effusion in the setting of likely new malignancy. #. Recurrent Pleural Effusion and Acute on Chronic dCHF exacerbation: Pt appeared [**12-15**] to volume overload in the setting of a worsening pleural effusion. Moderate right pleural effusions persisted despite recent thoracentesis prior to this admission. Pleural fluid was negative for malignant cells. Breathing dramatically improved with diuresis. Pt ruled out for MI via enzymes. He was restarted on home Lasix 40. Repeat echo (last [**2113**]) showed LVEF 55% and was largely unchanged other than that the severity of mitral regurgitation increased. He was transferred to the floor, and underwent IP guided thoracentesis of 900cc fluid with placement of pleural catheter to gravity drainage. Fluid studies as above and indicate transudate (still possible with malignant effusions) He will receive continued diuresis with oral lasix and transition to IV lasix if he has continued hypoxia. Patient and family advised to weigh patient daily. Pt Cr bumped to 1.9 and came down to 1.5 following the folding of lasix for a day and then decreasing back to his home dose of 40mg daily. # Adencocarcinoma of the Lung: Pleural fluid was negative for malignant cells, but CT was suggestive of metastatic disease. He underwent bronchoscopic lung biopsy on [**3-23**] with lymph node bx confirming adenoCA. Assumed to be lung primary. Brushing still pending on discharge. [**Hospital **] clinic appointment to be arranged as outpatient. Patient will ask PCP for assistance if he has not heard from [**Hospital **] clinic by the time of his first follow-up visit with PCP. CHRONIC ISSUES: #. Hypertension: BP initially controlled in ICU with a nitro drip. Losartan was stopped because he was normotensive on a metoprolol, hydralazine, ace-I. His amlodipine dose was reduced. #. DM: Insulin sliding scale #. Hypothyroidism: No TSH in records here. Continued home dose and defer to outpatient for further management. Transitional Issues: Goals of care discussion was had with patient, family and attendings. The patient and family are aware that he has lung cancer and that it will likely be the cause of his death. He states that he is not interested in pursuing any type of care that would be too invasive or involved including surgery, chemotherapy, or radiation. He is open to speaking to an oncologist regarding his prognosis and treatment options. The option for hospice care was introduced to the patient and that he should ask his PCP to help him get more information regarding this type of care if it fits his stated goals of care. The patient's goals of care are most consistent with DNR/DNI and he and his family agreed. Medications on Admission: Lasix 40mg PO BID Hydralazine 25mg PO QID Allopurinol 200mg PO daily Amlodipine 10mg PO daily Losartan 50mg PO daily Levothyroxine 100mcg PO daily Nitroglycerin 6.5mg ER PO TID Metoprolol 25mg PO BID Quinapril 40mg PO daily Simvastatin 20mg daily Aspirin 325mg daily Fluticasone 50mcg spray 1 nasally each daily Vitamin D3 Vitamin B12 Tylenol #3 Ferrous Sulfate 325mg daily Guiafenesin Hexavitamin Humalin R sliding scale NPH insulin 20 units qAM 26 units QHS Discharge Medications: 1. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day: This dose is reduced from 40 mg twice daily. 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): This is reduced from 10 mg daily. 10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 13. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day: Previously 20 units in the morning and 26 units in the evening. 14. oxygen Diagnosis: Lung cancer, ICD-9 code: 162.9 2-3 liters continuous pulse dose for portability. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: - lung cancer, adenocarcinoma - pleural effusion - acute on chronic diastolic CHF - diabetes type 2 controlled, uncomplicated - acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were hospitalized due to shortness of breath from pleural effusions and CHF along with masses in the chest that on preliminary report appear to be adenocarcinoma. You had drainage of pleural fluid and a bronchoscopic biopsy. OTHER INSTRUCTIONS: It is important to weight yourself each day. Your discharge weight was 171-pounds. If you should gain more than 3 pounds from that weight, you are likely reaccumulating fluid in your chest and may need to have your diuretic doses increased. Please call your doctor if you have more than 3 pound weight gain (or loss). It is helpful to minimize sodium (salt) intake to minimize fluid retention or reaccumulation. You may want to also explore the option of enrolling in Hospice Care services at your next appointment with your primary care physician [**Name Initial (PRE) 648**]. MEDICATION CHANGES: 1. DOSE REDUCTION: Amlodipine (Norvasc) 5 mg daily (previously 10 mg daily) 2. DOSE REDUCTION: Furosemide (Lasix) 40 mg daily (previously 40 mg twice daily) 3. DOSE REDUCTION: NPH Insulin 10 units twice daily (previously 20 units in the morning and 26 units in the evening) 4. STOP: Losartan Followup Instructions: Department: GERONTOLOGY When: THURSDAY [**2119-3-30**] at 9:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2139-6-15**] Discharge Date: [**2139-6-23**] Date of Birth: [**2077-4-23**] Sex: F Service: MEDICINE Allergies: Cardizem / Morphine Attending:[**First Name3 (LF) 2387**] Chief Complaint: hematemesis and bright red blood per rectum Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 62 year old female with PMH significant for anemia, MI s/p multiple PCIs, bleeding PUD and Hepatitis who presented after BRBPR x 1 and hematemesis of clotted blood x 2 on Sunday (1 day PTA). Per husband, she was drinking [**12-27**] bottle hard liquor/day lately and on Sunday fell in shower. She had previous GI bleed in [**2136**] in setting of erosive gastritis. . At OSH ([**Location (un) **]), Hct found to be 19, was transfused 2 U PRBC through subclavian line, placed at the time. She received Zofran 8 mg IV x1, Protonix 80 mg IV with 8 mg/hr drip, ativan 1 mg IV x1, and 1 L Ns.and was transferred to [**Hospital1 18**]. . On admission to [**Hospital1 18**] ICU, VS were 114, 157/62, 13, 100% RA. Patient had Hct of 27 which dropped to 24. She was then transfused 1 U PRBCs which raised Hct to 26.5. She had no repeat hematemasis or BRBPR, but was found to have guiac positive stools. Patient could not tolerate NG lavage. She received protonix 40 mg IV x1, Morphine 4 mgIVx1, Ativan 1 mg IVx1, 1 L NS. GI was consulted and an EGD is planned. Troponin was elevated and cardiology was consulted for NSTEMI. Subclavian line removed in ICU. At ICU, VS: T - 98.7-100.8, HR - 80s-160s, BP (125-160/64-91), 97-100% on RA, net negative 1.9 L fluid LOS. . ROS per HPI and Denies fever, 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 nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: # H/o PUD with GIB [[**2136**] [**Hospital1 18**] admission for maroon stools and HCT 13 after recent PCI and anticoagulation- EGD on [**2137-3-27**] revealed a small erosion near GI junction which was treated with cautery] # CAD, s/p stents x 3 to RCA, s/p restenting [**2137-3-14**] with 2 BMS. --> [**3-2**] ECHO: 70% EF, # tobacco abuse # obesity s/p gastric bypass at [**Hospital1 112**] # s/p left knee replacement in [**2129**] # s/p left hip replacement in [**2130**] # s/p right hip replacement in [**2133**] with revision in [**2134**] # EtOH abuse # hepatitis - ? etoh related, no hepatitis serologies on file # panic attacks # hyperlipidemia # hypertension # depression # attempted suicide in the past # sleep apnea (not on CPAP according to the patient) # chronic back pain # Past Surgical History: as above, s/p gastric bypass, laminetcomy, hip replacement Social History: Current smoking 1pack per week, but has smoked 1ppd on and off for 20 years. She reports that she does not drink but has a prior history of etoh abuse. She tells me that her last drink was several weeks ago. She formerly works as a bus driver but is now disabled due a work-related fall. She has not worked since [**2132**]. Family History: The pt's father died at 76 from a cardiac cause. The pt's mother is alive and has arthritis. No history of premature CAD or other familial illnesses. The pt's daughter had [**Initials (NamePattern4) **] [**Name (NI) 42686**] tumor at age three. Physical Exam: PHYSICAL EXAM UPON ADMISSION: . VS: 98.7 (Tmax:[**6-15**], 10pm); HR:87 (80s-160), 148/83 (125-160/64-91); 21 (14-26); 100% on RA (97-100%). GEN: NAD, overweight, shaking/restless legs HEENT: EOMI CV: S1, S2 with systolic ejection murmur heard best over left sternal border PULM: CTAB ABD: BS+, soft, non-distended, liver edge not appreciated LIMBS: non-edematous, non-tender SKIN: ecchymoses on right hand NEURO: grossly oriented, CN 2-12 intact, [**4-29**] muscle strength throughout, sensation to light touch intact . PHYSICAL EXAM UPON DISCHARGE: . Vitals: T:98.6 BP: 176/91 then 159/83 then 120/80 P: 83 R: 20 SaO2: 97%RA General: Awake, alert, NAD. Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: CTAB, no wheezes or crackles Cardiac: [**1-31**] early peaking systolic ejection murmur at RUSB (no radiation to carotids), nl S1 S2, no rubs or gallops appreciated Abdomen: soft, +BS, ND, NT, unable to appreciate organomegaly Extremities: No edema, 2+ radial, DP pulses b/l Right groin: no hematoma, no aneursym, clean/dry/intact Neurologic: Sensation intact LE B/L no focal deficits. Pertinent Results: LABS UPON ADMISSION: #CARDIAC ENZYMES: . [**2139-6-17**] 08:55AM BLOOD CK-MB-7 cTropnT-0.19* [**2139-6-16**] 07:35PM BLOOD CK-MB-10 MB Indx-5.1 cTropnT-0.25* [**2139-6-16**] 01:08PM BLOOD CK-MB-14* MB Indx-6.2* cTropnT-0.22* [**2139-6-16**] 03:59AM BLOOD CK-MB-14* MB Indx-6.2* cTropnT-0.12* . #CBC: . [**2139-6-15**] 07:00PM WBC-12.2* RBC-2.93*# HGB-9.6* HCT-27.5* MCV-94 MCH-33.0*# MCHC-35.1* RDW-16.1* [**2139-6-15**] 11:57PM WBC-12.2* RBC-2.64* HGB-8.4* HCT-24.4* MCV-92 MCH-31.8 MCHC-34.4 RDW-16.5* [**2139-6-18**] 06:55AM BLOOD WBC-6.9 RBC-3.56* Hgb-11.1* Hct-33.2* MCV-93 MCH-31.1 MCHC-33.4 RDW-16.4* Plt Ct-207 [**2139-6-21**] 07:05AM BLOOD Hct-35.1* . [**2139-6-15**] 07:00PM PLT COUNT-206# [**2139-6-15**] 07:00PM NEUTS-80.5* LYMPHS-12.6* MONOS-6.1 EOS-0.6 BASOS-0.2 [**2139-6-15**] 11:57PM PLT COUNT-216 . #Chemistries: . [**2139-6-21**] 07:05AM BLOOD Glucose-105* UreaN-14 Creat-0.8 Na-139 K-4.0 Cl-101 HCO3-28 AnGap-14 [**2139-6-15**] 07:00PM BLOOD Glucose-142* UreaN-42* Creat-0.5 Na-133 K-5.6* Cl-100 HCO3-22 AnGap-17 [**2139-6-15**] 07:00PM GLUCOSE-142* UREA N-42* CREAT-0.5 SODIUM-133 POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-22 ANION GAP-17 . #Other: . [**2139-6-16**] 03:59AM BLOOD Albumin-3.2* Calcium-8.1* Phos-1.6*# Mg-2.1 [**2139-6-16**] 03:59AM BLOOD TSH-0.26* [**2139-6-18**] 06:55AM BLOOD TSH-1.6 . #Liver function: . [**2139-6-15**] 07:00PM PT-13.1 PTT-25.6 INR(PT)-1.1 [**2139-6-15**] 07:00PM ALBUMIN-3.3* [**2139-6-15**] 07:00PM LIPASE-30 [**2139-6-15**] 07:00PM ALT(SGPT)-20 AST(SGOT)-50* ALK PHOS-53 TOT BILI-0.6 . #toxin screen: [**2139-6-15**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . LABS UPON DISCHARGE: . [**2139-6-23**] 06:25AM BLOOD WBC-8.1 RBC-3.31* Hgb-10.5* Hct-31.2* MCV-94 MCH-31.7 MCHC-33.7 RDW-16.0* Plt Ct-317 [**2139-6-23**] 06:25AM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-137 K-4.5 Cl-103 HCO3-29 AnGap-10 [**2139-6-23**] 06:25AM BLOOD CK(CPK)-221* [**2139-6-23**] 06:25AM BLOOD CK-MB-19* MB Indx-8.6* cTropnT-0.17* [**2139-6-23**] 06:25AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9 [**2139-6-16**] 03:59AM BLOOD VitB12-284 [**2139-6-18**] 06:55AM BLOOD TSH-1.6 [**2139-6-16**] 03:59AM BLOOD TSH-0.26* [**2139-6-18**] 06:55AM BLOOD T4-5.2 T3-109 Free T4-0.94 [**2139-6-15**] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**2139-6-17**] Echo: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Increased PCWP. Mild mitral regurgitation with normal valve morphology. Compared with the prior study (images reviewed) of [**2137-3-15**], the gradient across the aortic valve is lower and the regional left ventricular systolic function is now present c/w interim ischemia/infarction. Mild mitral regurgitation is also now seen. . [**2139-6-15**] CXR: AP chest reviewed in the absence of prior chest radiographs: Dilated mediastinal veins suggest volume overload. Mild bronchial cuffing in the left mid lung could be early edema or bronchial inflammation, but there is no edema elsewhere. Lateral aspect right lower chest is excluded from the examination. The other pleural surfaces are normal with no indication of pleural effusion. Heart size normal. A right-sided central venous catheter is traceable as far as the superior cavoatrial junction. No pneumothorax. . [**2139-6-17**]: EGD There was evidence of prior gastric bypass surgery with a breakdown of the suture line leading to the pylorus. There was no evidence of bleeding to the second portion of the duodenum or in the Roux-en-Y limbs. No ulcerations were seen. Possible causes of bleeding include [**Doctor First Name **] [**Doctor Last Name **] tear vs. healed ulcer. Recommendations: Follow Hct. PPI [**Hospital1 **] (PO). If any further signs of bleeding, will repeat EGD. . CARDIAC CATHETERIZATION: [**2139-6-22**] . COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated two vessel coronary artery disease. The LMCA had minimal disease. The LAD had non-flow limiting disease. The LCx had moderate disease. The RCA had 100% in-stent restenosis. 2. Limited resting hemodynamic measurements revealed normal RA pressure of 5 mmHg. PA pressure was normal at 37/11 mmHg. Left sided filling pressure was normal with LVEDP of 10 mmHg. There was no gradient upon carefull pull back from left ventricle to aorta. Central aortic pressure was elevated at 154/68 mmHg. The cardiac output was calculated using an assumed oxygen consumption and was normal at 7.3 l/min. 3- PArtially successful PTCA to the totally occluded RCA with TIMI 2 flow and very small distal RCA branches (see PTCA Comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease, 2. Hypertension. 3. Suboptimal result of RCA PTCA due to chronic long/serial occluded (ISRS) vessel and very small/markedly diseased distal branches 4. Continue medical therapy Brief Hospital Course: 62 year old female with PMH significant for anemia, MI s/p stent placement, bleeding PUD who, on transfer from [**Hospital3 7569**], presented after BRBPR x 1 and hematemesis of clotted blood x 2 on [**2139-6-14**](1 day PTA). Her hospital course is notable for the following issues: . GI bleed: On transfer from OSH to MICU, pt had Hct of 27.4. HCT nadir of 24. Given hematemesis and BRBPR, upper GI bleed from varices, PUD, alcoholic gastritis was high on differential. However, EGD did not establish definitive source of bleed; GI reported likely healing ulcer in setting of alcoholic gastritis or previous [**Doctor First Name **]-[**Doctor Last Name **] tear as possible cause. She was maintained on pantoprazole and received a total of 3 U PRBC (last [**6-17**]). HCT uptrended over the course of the hospital stay to to 35 on discharge; no further GIB since day of EGD. Important to follow-up as outpatient for screening colonoscopy. . NSTEMI: Troponin elevation, peak Trop T of 0.25 in the setting of the GIB. EKG with baseline IVCD in LBBB pattern. These findings were felt consistent with anemia-associated demand ischemia. She underwent an echocardiogram which revealed inferior wall hypokinesis, new from previous studys. A pMIBI at the outpt cardiologist in [**6-4**] showed inferior basal wall akinesis (report does not commant on chronicity or inducibility). A recent hospitalization at [**Location (un) **] [**6-4**] was without evidence of MI. Given the patients baseline noncompiance, the new echo finding, known severe RCA disease, and significant infarction with minimal tachycardia, she underwent cardiac catheterization in house to evaluate for possible re-stenosis at RCA stent. Cardiac catheterization revealed 2 vessel disease and 100% restenosis of the RCA, angioplasty was attempted, but with suboptimal results (TIMI flow 2). Her [**Month/Year (2) 4532**] was held in the setting of her GI bleed and she was started on 81mg aspirin. . Alcohol abuse: Significant history of alcohol abuse. During her stay, her AST:ALT ratio greater than 2:1 supported recent alcohol use, however, she was not acutely withdrwaing and did not trigger CIWA. While here, Social Work evaluated her and suggested she was interested in outpatient therapy. . UTI: Ecoli, started 7 day course for complicated UTI given her age. . Hypertension: Intially lisinopril were held to maintain adequate blood pressure/perfusion in the settting of GIB, leaving only clonidine and Toprol for hypertension managment. However, as her pressures increased, she was re-started and on lisinopril, up-titrated on her beta-blocker, and discharged on her home dose of lisinopril and labetolol. . Depression: Continued on duloxetine . Bladder spasm: Was treated with tolterodine in house and discharged on trospium at home. . Thyroid: Original TSH of 0.26 concerning for hyperthyroidism, however repeat labs had normal TSH and free T4 and the patient was without symptoms of hyperthyroidism . Restless Legs: Treated with oral magnesium. . The patient was full code for this admission. . Medications on Admission: # Lasix 20 mg daily (????) # Clonidine 0.2 mg po TID # Duloxetine 60 mg daily # Potassium chloride 10 me daily # Clopidogrel 75 mg daily # Flexeril 10mg TID # Trospium 20 mg [**Hospital1 **] # Labetalol 200 mg [**Hospital1 **] (????) # Mg 200 mg po daily # Simvastatin 20 mg daily # Lisinopril 10 mg daily # Carbidopa/levodopa 25/100 1 tab [**Hospital1 **] (recently d/cd according to the patient - was apparently used to treat RLS) # Levaquin 500 mg daily (???? unsure of taking, or for how long) Discharge Medications: 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*1* 5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*16 Tablet(s)* Refills:*0* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*32 Tablet(s)* Refills:*2* 8. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days: day 1: [**2139-6-20**]. Disp:*7 Tablet(s)* Refills:*0* 9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for back pain. 10. Magnesium 200 mg Tablet Sig: Two (2) Tablet PO daily prn as needed for restless legs. 11. Trospium 20 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for breakthrough pain. Disp:*40 Tablet(s)* Refills:*0* 13. 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* 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever, sleep: do not excede 4 grams per day. Disp:*100 Tablet(s)* Refills:*2* 15. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 16. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 18. Bisacodyl 10 mg Suppository Sig: One (1) Rectal daily PRN. Disp:*10 suppository* Refills:*0* 19. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary Diagnoses: Myocardial infarction/NSTEMI Upper GI bleed Urinary Tract Infection Hypertension Substance Abuse Secondary Diagnoses Low Back Pain Constipation 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 having you in our care. You were admitted to the [**Hospital1 18**] because you were vomiting and stooling blood. You were given red blood cells to replace this blood loss. You underwent an endoscopy which did not show evidence of active bleeding. However, it is presumed that your bleeding was secondary to your alcohol use. During this time, you had a heart attack - most likely because of overwork of your heart. You underwent a cardiac catheterization to determine the cause of your heart attack and to open up any blocked heart blood vessels. You also developed a UTI and were treated with Bactrim. It is important to stop drinking alcohol and follow up with your social worker regarding counseling and support. Cheanges made to your medictations: -added Bactrim, please continue to take for a total of 7 days (day 1:[**2139-6-20**]) - Continue enteric coated Aspirin 81 mg daily - Increased your lisinopril from 10mg daily to 20 mg daily. - Continue your amlodipine - Continue Labetolol - Stop taking [**Month/Day/Year 4532**] until you follow up with your cardiologist - Continue Senna and colace for constipation - Start protonix for GI bleeding - use oxycodone only as needed for breakthrough back pain . Please follow up with your doctors as detailed below. Please follow up with your cardiologist regarding physical therapy and cardiac rehabilitation. It was a pleasure caring for you. We wish you a speedy recovery. Followup Instructions: Name: Hack, [**First Name7 (NamePattern1) 13740**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: PRIMARY CARE SPECIALISTS INC. Address: [**Apartment Address(1) 42687**], [**Location (un) **],[**Numeric Identifier 28704**] Phone: [**Telephone/Fax (1) 16827**] Appointment: Thursday [**2139-6-25**] 4:40pm Name: [**Last Name (LF) 15144**],[**First Name3 (LF) **] P. Address: [**Apartment Address(1) 41910**], [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) **] Appointment: Monday [**2139-7-6**] 3:00pm Please call the social worker that you worked with outside the hospital to make a follow up appointment in the next week to discuss your alcohol abuse. Completed by:[**2139-7-1**]

[ "578.9", "996.72", "401.9", "333.94", "V45.86", "272.4", "V43.65", "305.01", "410.71", "599.0", "305.1", "V43.64", "041.4", "596.8", "E879.0" ]

icd9cm

[ [ [] ] ]

[ "00.40", "37.23", "45.13", "88.56", "00.66" ]

icd9pcs

[ [ [] ] ]

15357, 15425

9578, 12654

324, 350

15633, 15633

4652, 4659

17298, 18036

3255, 3501

13204, 15334

15446, 15612

12680, 13181

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2836, 2897

3516, 3532

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4067, 4633

6354, 9320

378, 2001

4674, 4675

15648, 15792

2023, 2813

2913, 3239

20,603

177,557

43786

Discharge summary

report

Admission Date: Discharge Date: [**2115-10-22**] Date of Birth: Sex: Service: CHIEF COMPLAINT: Syncope and headache. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 94081**] is an 81-year-old gentleman with a complicated past medical history who presented from an outside hospital with a large subarachnoid hemorrhage and subdural hematoma. The patient had a headache a syncopal event with loss of consciousness for approximately five minutes. He had no history of trauma. The patient may have hit his head with the syncopal episode. The patient does have mild baseline dementia which waxes and wanes. PAST MEDICAL HISTORY: Shows a right parietal stroke in [**2115-4-13**], prostate cancer, coronary artery disease, carotid disease, abdominal aortic aneurysm, polycystic kidney disease, chronic renal insufficiency and renal artery stenosis, congestive heart failure (with an ejection fraction of approximately 35 to 40 percent) diagnosed in [**2115-5-14**], and hypercholesterolemia. PAST SURGICAL HISTORY: Shows a carotid endarterectomy in [**2111-9-13**], abdominal aortic aneurysm repair in [**2104-10-13**], and a coronary artery bypass grafting in [**2103-10-14**]. MEDICATIONS ON ADMISSION: Aspirin 325 mg once daily, folic acid 1 mg once daily, Lasix 40 mg two in the morning and one in the evening, hydralazine 50 mg three times daily, Lipitor 40 mg once daily, Lopressor 100 mg twice daily, Plavix 75 mg once daily, and Isordil 10 mg three times daily. ALLERGIES: He had no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: The temperature was 98.4, the blood pressure was 116/33, the heart rate was 71, the respirations were 18, and oxygen saturation was 95 percent on 3 liters nasal cannula. The patient was lethargic. Arousable to stimulation. Followed simple commands appropriately. Oriented times two - to person and place. The pupils were equal, round, and reactive to light and accommodation at 4 to 3 brisk. The extraocular movements were intact. The face was symmetrical. The tongue was midline. He had normal palate elevation. He was moving all extremities. No pronator drift. Difficult to test strength secondary to lethargy. Sensation was grossly intact. The toes were upgoing bilaterally. RADIOLOGIC STUDIES: A CAT scan did show a massive subarachnoid hemorrhage and left subdural with rightward subfalcine herniation. SUMMARY OF HOSPITAL COURSE: The patient was admitted to Medicine Service for workup of syncope. An arterial line was placed for blood pressure management. He was placed in a hard collar. He was also seen in consultation by the Trauma Service. Dr. [**First Name (STitle) **] [**Name (STitle) 739**], then Neurosurgery attending, did have a long discussion with the family regarding his situation and surgical versus nonsurgical treatment, and all his comorbidities were also discussed. Based on their wishes, he was to be treated aggressively medically. His systolic pressure was to be maintained at 130 to 160. He was admitted to the Intensive Care Unit for close monitoring. He was started on Nipride to maintain the above- mentioned blood pressure parameters. The next day he was arousable, and verbal, and was following commands (left more so than right) with a noticeable right hemiparesis. The syncopal workup recommended ruling out myocardial infarction, obtaining a transthoracic echocardiogram, cardiac monitoring; which were all performed. The patient was also started on Dilantin for seizure prophylaxis, and therapeutic levels were maintained. On [**10-15**], the patient was more lethargic and hard to arouse. He did open to stimulation but was not following commands. A repeat head CT was performed which was stable in appearance. He did have a central line placed without difficulty. He also had a cervical spine MRI to assess for a ligamentous injury which showed no ligamentous disruption. On [**10-17**], the patient's examination off propofol did show some purposeful left upper extremity movements. He was able to withdraw bilaterally in the lower extremities, but little movement in the right upper extremity. His eyes were opened and reactive. He did have a question of a pneumonia seen on chest x-ray and was started on Levaquin. He was getting tube feedings. He was transfused with 2 units of packed red blood cells on [**10-21**] for a hematocrit of 25.9. There was family meeting with Dr. [**First Name (STitle) **] [**Name (STitle) 739**], and members of the team, with the family on [**2115-10-21**]. The family did request that the patient be made comfort measures only secondary to his prognosis which at best was expected to recover with significant impairment of functional mobility. The patient did expire on [**2115-10-22**]. [**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2116-2-14**] 13:55:17 T: [**2116-2-14**] 18:53:27 Job#: [**Job Number 94082**]

[ "V45.81", "428.0", "E888.9", "430", "593.9", "807.03", "753.12", "276.0", "401.9", "427.31", "518.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1254, 2429

1062, 1227

2458, 5050

137, 160

189, 653

676, 1038

63,875

179,275

10483

Discharge summary

report

Admission Date: [**2138-3-31**] Discharge Date: [**2138-4-7**] Date of Birth: [**2072-8-11**] Sex: F Service: NEUROSURGERY Allergies: Cephalosporins / Dulcolax / Advil / Ciprofloxacin / Aromasin / Tape / Xeloda / Doxorubicin / Dexamethasone / Acyclovir / Arimidex / Neurontin Attending:[**First Name3 (LF) 2724**] Chief Complaint: NECK PAIN Major Surgical or Invasive Procedure: PROCEDURES: 1. Posterior segmental instrumentation C2 to C7. 2. Posterior arthrodesis C2 to C7. 3. Local autograft. 4. Tumor resection left C3 lateral mass. 5. Foraminotomy on the left at C4-C5 for weakness of the deltoid. BLOOD TRANSFUSIONS ECHOCARDIOGRAM History of Present Illness: This 65-year-old woman had a history of metastatic breast CA now with intractable neck pain. MRI and CT scan demonstrated complete destruction of the C3 lateral mass on the left side. There was disease at C4 as well. Past Medical History: #. Metastatic Left Breast Cancer - diagnosed in [**6-/2134**] - infiltrating with ductal and lobular features - ER/PR positive, LVI negative, HER-2/neu indeterminate - [**12-29**] lymph nodes positive - known metastases to the L3 vertebral region and the sacrum - treated with radiation in the past - failed multiple chemo agents due to intolerance of side effects - taking Faslodex with quarter-annual Zometa infusions - peripheral neuropathy since chemo #. Osteopenia - last BMD -2.46 in [**1-26**] - currently on Zometa for bone mets #. Paroxysmal atrial fibrillation - s/p ablation at [**Hospital1 2025**] ~[**2129**] - also had cardiac cath at that time, negative per patient - large LLE hematoma on Warfarin - unwilling to continue this med despite Cardiology recs - refuses further cardiology followup #. Obstructive sleep apnea - CPAP about 7 hours a night #. Asthma #. Ocular migraines #. Rheumatoid arthritis in the hands #. Benign Familial Microscopic Hematuria - worked up and felt to be benign - worrisome causes were ruled out #. Gyn History - G3, P3 - Paps always negative prior to hysterectomy #. Past Surgeries - hysterectomy for fibroids - Laparoscopic salpingectomy [**8-24**] #. Childhood Illnesses - Ruptured appendix at age five - Rheumatic heart disease at age seven - Herpes zoster age eleven #. OTHER - Right knee meniscal tear as noted by MRI [**12-1**] - Hx of colonic adenomas, found [**4-26**], colonoscopy [**8-31**] negative - Diverticulosis incidentally found on CT [**3-27**] - Gallstones discovered incidentally during surgery, ~[**2122**] - Loss of hearing left ear due to car accident - Left lower extremity cellulitis ~[**2132**], Resistant bug requiring long term IV infusion pump, Salmonella UTI around the same time Social History: Widowed since [**77**], no romantic involvement since. Teaches at [**University/College 34597**] and the [**Location (un) 1468**] Police Academy. Formerly smoked ~70pack years, quit at age 30. Mother of three, youngest daughter currently applying to med school. Family History: Father with MI at age 47, subsequently had 8 MI's before passing away in his 60's. Brother also had MI in his 60's. Physical Exam: On admission pt was A&Ox3, HT: rrr, lungs: CTA, Cranial Nerves II-XII intact, decreased ROM of RUE however 5/5 strength through out except right deltoid [**3-30**] Upon Discharge: Cranial nerves II-XII intact, motor she is 5/5 strength throughout except for her R deltoid is [**3-30**] (per pt has previous weakness and decreased ROM). She did not have clonus or [**Doctor Last Name 937**] sign. HR irregular irregular. LS CTA bilat. GI/GU no issues. Pertinent Results: [**2138-3-31**] 02:05PM BLOOD WBC-7.2# RBC-3.27* Hgb-10.0* Hct-27.5* MCV-84 MCH-30.6 MCHC-36.3* RDW-15.0 Plt Ct-148* [**2138-4-1**] 02:25AM BLOOD WBC-6.7 RBC-3.02* Hgb-9.4* Hct-24.9* MCV-83 MCH-31.1 MCHC-37.6* RDW-15.1 Plt Ct-106* [**2138-4-2**] 01:50AM BLOOD WBC-6.3 RBC-2.31* Hgb-7.2* Hct-19.6*# MCV-85 MCH-31.0 MCHC-36.6* RDW-15.1 Plt Ct-105* [**2138-4-4**] 02:31AM BLOOD WBC-6.2 RBC-3.02* Hgb-9.0* Hct-26.3* MCV-87 MCH-29.8 MCHC-34.1 RDW-14.7 Plt Ct-161 [**2138-3-31**] 02:05PM BLOOD PT-14.7* PTT-25.7 INR(PT)-1.3* [**2138-4-2**] 03:50PM BLOOD PT-14.0* PTT-25.2 INR(PT)-1.2* [**2138-4-3**] 01:56AM BLOOD PT-13.0 PTT-23.0 INR(PT)-1.1 [**2138-3-31**] 02:05PM BLOOD Glucose-176* UreaN-16 Creat-0.6 Na-138 K-4.3 Cl-110* HCO3-21* AnGap-11 [**2138-4-2**] 05:53PM BLOOD Glucose-112* UreaN-9 Creat-0.6 Na-137 K-3.7 Cl-103 HCO3-28 AnGap-10 [**2138-4-4**] 02:31AM BLOOD Glucose-126* UreaN-11 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [**2138-3-31**] 02:05PM BLOOD Calcium-7.3* Phos-3.9 Mg-1.6 [**2138-4-2**] 01:50AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.9 [**2138-4-3**] 01:56AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.3 [**2138-4-4**] 02:31AM BLOOD Calcium-8.5 Phos-1.7* Mg-2.2 [**4-3**] FRONTAL & LATERAL VIEWS OF THE CERVICAL SPINE: C1 through C7 are seen on the lateral view. Posterior fusion devices are noted in C2 through C7. Normal cervical lordosis is maintained. There are no fractures or subluxations. There is mild loss of disc height most prominent at C5-6 and C6-7. Vertebral body heights are maintained. Anterior osteophyte formation is noted in the lower cervical spine. A central venous catheter ends at the lower SVC/right atrium. Skin staples are noted over the posterior neck. Brief Hospital Course: Pt was admitted to the hospital electively and was taken to the OR where under general anesthesia she underwent posterior cervical instrumented fusion under general anesthesia. She did have an episode of hypotension intra-op at end of surgery and pt was kept intubated post-op and transferred to PACU. She was monitored closely and received massive fluid resuscitation. She was lightened from sedation and was moving all 4 extremities well. She did not have cuff-leak so remained intubated and was transferred to TICU. She had known history of atrial fibrillation and required diltiazem drip for rate control. Cardiology followed pt and made recommendations. She was able to be extubated POD#1. Her hematocrit was followed post-op and she required several PRBC transfusuions. Pain management was done with consultation of Pain Service who has followed pt in past. She had JP drain in surgical site that was removed POD#2. Right deltoid remained slightly weak as pre-op. Diet and activity were advanced. PT evaluated pt and recommended discharge to home with outpatient PT. Incision was clean and dry with staples. Medications on Admission: albuterol prozac propranolol 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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. Outpatient Physical Therapy 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: metastatic breast cancer to cervical spine atrial fibrillation POST-OP HYPTOTENSION/HYPOVOLEMIA Discharge Condition: neurologicaly stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/take daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO THE SPINE CENTER -[**Hospital Ward Name **] 2- ON TUESDAY, [**4-15**] AT 11:15 AM DAYS FOR REMOVAL OF YOUR STAPLES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED AP/Lat C-SPINE XRAYS PRIOR TO YOUR APPOINTMENT FOLLOW UP WITH YOUR PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] FOLLOW UP WITH CARDIOLOGY DR [**Last Name (STitle) **].PLEASE CALL [**Telephone/Fax (1) 62**] FOR APPT. Provider: [**Name10 (NameIs) **] PSYCHOLOGY Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2138-4-15**] 8:00 Provider: [**Name10 (NameIs) 1089**] [**Name11 (NameIs) 1090**], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2138-4-15**] 9:30 Completed by:[**2138-4-7**]

[ "458.29", "285.1", "198.3", "338.3", "276.52", "V10.3", "198.5", "427.32", "357.6", "427.31", "E849.7", "E933.1" ]

icd9cm

[ [ [] ] ]

[ "81.63", "81.03", "03.4" ]

icd9pcs

[ [ [] ] ]

7585, 7604

5323, 6443

415, 679

7744, 7767

3610, 5300

9033, 9814

3004, 3121

6522, 7562

7625, 7723

6469, 6499

7791, 9010

3136, 3301

366, 377

3318, 3591

707, 927

949, 2706

2722, 2988

29,692

128,551

53483

Discharge summary

report

Admission Date: [**2107-11-19**] Discharge Date: [**2107-11-29**] Date of Birth: [**2026-9-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: R sided weakness . ICU admission: hypoxia Major Surgical or Invasive Procedure: PICC History of Present Illness: Mr [**Known lastname 109963**] is an 81 yo male with lung cancer ([**2078**]), throat cancer (approx [**2101**]), and new diagnosis of mandible cancer who was found down on his kitchen floor by a neighbor after 24+ hours. At this point he reported awakening with new R arm weakness. He states that he was in his usual state of health at this time and thinks he "must have slipped." He denied any preceding weakness or numbness in his extremities. He does have approx 1 month hx of dysarthria and pain from jaw mass. Additionally denies fever, chills, cough or respiratory symptoms. During the interview he is coughing, but states that this started once he got to the hospital. No sick contacts. Denies headache or neck stiffness. He was taken by EMS to the ER at which point his O2 sat was 88% and he was placed on a NRB. . Upon arrival to the ED his vitals were T 98.9, HR 67, BP 116/62, RR 20, O2 sat 96% on NRB, and while there failed a trial on nasal cannula and placed on 70% cool mist mask. ABG revealed:7.40/51/135 on NRB, and CXR showed RLL opacity suspicious for pneumonia. He received 3L of IVFs as well as Levoflox 750mg IV x 1 and Flagyl 500mg IV x 1. Stat CT Head showed no evidence of bleed. Neurology was consulted and recommended MRI Brain and C-spine +/- gadolinium to eval for mets once respiratory status stabilized (not emergent) as well as EEG. Past Medical History: Lung cancer- s/p radiation Neck Cancer- newly diagnosed/awaiting biopsy, pt has severe dysarthria x1month as a result. Large mandibular mass for which he is followed at [**Hospital 13128**] Institute Social History: Patient lives alone in [**Location (un) 583**], widowed x3 years, no children, quit smoking in [**2069**]'s, drinks on Saturdays up to 5 glasses of alchohol - denies any withdrawal symptoms. No no illicit druges. Distant cousins check in on him: [**Name (NI) **] [**Name (NI) 83028**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83028**] [**Telephone/Fax (1) 109964**], [**Telephone/Fax (1) 109965**] (cell). Family History: non-contributory Physical Exam: Admission: VS: Temp: 96.2 BP: 126/46 HR: 63 RR: 13 O2sat 86% on RA, 95% on 70% cool mist mask GEN: pleasant, comfortable, mild respiratory distress, loose cough HEENT: L pupil slightly larger than R, both briskly reactive to light, EOMI, anicteric, very large mass both in R oral cavity and on jaw - greenish and crusted. NECK: supple RESP: fine crackles R greater L, rhoncherous BS CV: bradycardic, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses, weak rt UE SKIN: no rashes/no jaundice NEURO: AAOx3 but confabulates. Horner's syndrome on R. R sided UE weakness. Pertinent Results: Lactate:2.2 . PT: 15.9 PTT: 33.4 INR: 1.4 . ABG: pH 7.40 pCO2 51 pO2 135 HCO3 33 BaseXS 5 . u/a: 1.023, +ket 50, few bacteria, otherwise negative . Lactate:2.4 . CK: 1391 MB: 15 MBI: 1.1 Trop-T: 0.02 . Labs: [**2107-11-19**] 05:15PM GLUCOSE-91 UREA N-19 CREAT-0.6 SODIUM-134 POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-28 ANION GAP-16 [**2107-11-19**] 05:15PM ALT(SGPT)-45* AST(SGOT)-98* LD(LDH)-282* CK(CPK)-1391* ALK PHOS-80 TOT BILI-0.5 [**2107-11-19**] 05:15PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-2.4 [**2107-11-19**] 05:15PM WBC-15.9* RBC-3.87* HGB-11.7* HCT-35.9* MCV-93 MCH-30.3 MCHC-32.7 RDW-15.7* [**2107-11-19**] 05:15PM NEUTS-93.3* LYMPHS-3.7* MONOS-2.8 EOS-0 BASOS-0.2 [**11-25**]: Na 143 K3.7 Cl 105 Bicarb 29 BUN 1 Cr 0.5 Glucose 115 [**11-25**]: WBC 9.6 HCT 30 PLT 302 [**11-25**]: PT 17 INR 1.6 . Microbiology: Blood Cx [**11-19**]: [**12-30**] lactobacillus Blood CX [**11-22**] and [**11-23**]: no growth . LE Doppler: Partially occlusive DVT noted in the left mid SFV to the popliteal vein, with eccentric shape, likely chronic. . Non-contrast Head CT: multiple prior lacunar infarctions, age related atrophy with widened ventricles, no hemorrhage or mass effect. . CXR: RLL infiltrate c/w pneumonia versus large mass . CTA prelim read: 1. Segmental pulmonary embolism to the right middle lobe. Smaller subsegmental filling defect in a left lower lobe branch. 2. Pleural-based mass, the right lung base mass and extensive pleural thickening in the setting of pathologically enlarged mediastinal and left axillary lymph nodes appear consistent with the patient's reported history of mesothelioma. 3. Centrilobular emphysema and right basilar honeycombing are consistent with advanced chronic interstitial lung disease. 4. Air-bronchograms present at the medial aspect of the right lung base could be consistent with pneumonia. Clinical correlation recommended. . MRI/MRA head: IMPRESSION (prelim):Scattered throughout the left cerebral hemisphere, predominantly within the left parietotemporal lobe, but also including the occipital and frontal lobes, there are multiple focal areas of restricted diffusion with accompanying FLAIR hyperintensities likely to represent acute/subacute infarctions, probably secondary to multiple emboli. No areas of restricted diffusion are demonstrated in the right cerebrum. There is no evidence of intracranial hemorrhage, mass effect, or shift of normally midline structures. There is moderate periventricular T2 and FLAIR hyperintensity consistent with chronic microvascular infarction. 1. Multifocal left cerebellar areas of restricted diffusion with associated edema, most likely representing acute/subacute infarction. Given distribution, this probably represents embolic phenomenon. The distribution of these lesions favors infarction over encephalitis. 2. Slightly heterogeneous clivus which although not overtly consistent with metastasis, can be followed up with bone scan if there is further clinical concern. 3.MRA CIRCLE OF [**Location (un) **]: There is no evidence of stenosis, aneurysm, or vascular malformation. . Video Swallow Evaluation: This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of 2, moderately-severe dysphagia. RECOMMENDATIONS: 1. Suggest having a discussion with the pt regarding his options for nutrition (POs alone vs POs with supplemental tube feeds vs tube feeds only). Pt will need to understand the risks of continued aspiration prior to making his decision. 2. If he decides to continue with PO intake, I would recommend a PO diet of nectar thick liquids and pureed solids with the following aspiration precautions: a) alternate between every bite and sip b) small, single sips of liquid only -no straws and no chugging c) pills crushed with purees . Brief Hospital Course: He was briefly admitted to the floor and then transfered to the ICU for hypoxia. In the ICU, his hypoxia resolved and he was transitioned from NRB to NC. He was transfered back to the hospital wards. During his hospital stay, he was treated for PE and pneumonia. He was followed by neurology for new left hemisphere strokes. He was also seen by the palliative care team given his deteriorating performace status and poor prognosis. The patient decided that he would like further treatment and rehabilitation and would consider hospice in the future. Transfer to the VA was arranged, but on the day of transfer, the patient became somnolent. After discussion with his brother, the patient was made [**Name (NI) 3225**]. After being made [**Name (NI) 3225**], he received morphine for pain and air hunger. On [**11-28**], morphine was discontinued per the brother's request. In discussion with his brother, he was to be given sparing amounts of morphine only if the patient was suffering. Overnight on [**10-29**], the patient was agitated, moaning and tachypnic per nursing report and was given 1 dose of Morphine 2mg IV at 3:30 am. He passed away at 11:45 am on [**2107-11-29**]. . # Somnolence: On [**11-25**], the patient became increasingly somnolent and was unarousable. At the time he was not hypoxic and had not received any morphine, or sedating medications. ABG's noted hypercarbia which is the most likely cause of his somnolence. The patient had decided to be DNR/DNI, but Bipap was discussed with his brother. The causes of his hypercarbia were felt to be irreversible - advance lung CA-, and he was changed to comfort measures only. . # Found down: The patient can not elucidate further any events surrounding being found on his kitchen floor. The reason for his fall is likely multifactorial with PNA, gait instability, vasovagal episode?, arrhythmia?, deconditioning and possible dehydration. He was noted to have a wandering atrial pacemaker on EKG and possible old anterior MI but no AV block or arrhythmia that would explain loss of consciousness. He was given IVF to resolve dehydration and antibiotics for likely PNA. An echo to evaluated for structural heart abnormalities or vegetations was attempted but the patient was too agitated to tolerate the study. He has been occaisonally delerius during his hospital stay but has normal mental status at the time of discharge. He responded well to Zyprexa or Risperdal during episodes of agitation. . # Hypoxia: On admission the patient was hypoxic with SaO2 88%. He was started on oxygen. On Chest CT , he was found to have large pelural mass (consistent with known Lung CA) and a possible post-obstructive pneumonia. In addition, the CT showed segmental RML PE. LE U/S showed left femoral DVT. CTA also showed advanced interstitial lung disease on CTA - the patient has a known extensive history of asbestos exposure and 100 pack year smoking history. MRI of the head showed no metastasis making him lower risk of intracranial hemorrhage. Given, the lack of intracranial mets, he was kept on heparin for PE. He was also started on coumadin originally but this was stopped when he had an episode of GIB. He may be switched to lovenox when consistently without GIB. He was also given albuterol and ipratropium nebs PRN, but did not require them. His was treated for PNA with Unasyn. He was weaned off the oxygen. . # Stroke: On admission, the patient was found to have right arm weakness, possible right facial droop and possible right horner's syndrome on exam. Neurology was consulted and followed the patient during his hospital stay. Head CT noted multiple non-specific lesions. An MRI/MRA was performed which showed multifocal left cerebral acute infarction. Given distribution, it was thought that these lesions probably represent embolic phenomenon although metastatic disease is also possible. Given his DVT/PE, thromboembolic disease is likely although it is unkown if patient has a PFO. The patient had no new heart murmur, no physical findings of septic embolic disease and only 1/4 bottles lactobaccillus (an unlikely endocarditis pathogen) making endocartitis unlikely. An echo to evaluate for endocarditis was attempted but the patient was too agitiated to tolerate it. Given the low suspicion for endocarditis, echo was not pursued further. As the patient was already on heparin for PE, and this was continued. Neurology would recommend ASA if heparin is changed to lovenox. The patient also received a speech and swallow evaluation which showed significant dysphagia and aspiration. It was recommended that he avoid oral intake. However, given his prognosis, the patient elected to continue with oral intake (thickened fluids and pureed solids) knowing the risks of aspiration and pneumonia. He was followed by OT and PT. . # GI Bleeding: Several days after the patient was started on heparin for PE, he had a bowel movement with bright red blood on the exterior, no melena. The patient remained hemodynamically stable with no change in serial HCT's. His GI bleed was presumed to be due to hemrrhoids. He was continued on heparin but coumadin was stopped in order be able to stop anticoagulation if GI bleed became more significant. He had no further episodes of bloody stool. One could consider switching to daily therapeutic lovenox if he continues to be stable w/o bloody bowel movements. . # Lung cancer/ Head & Neck Cancer: The patient has know extensive disease, confirmed by Chest CT and Head MRI. Head MRI found multiple areas of infarction but no overt metastasis. Per his PCP, [**Name10 (NameIs) **] was originally scheduled to have his jaw mass biopsied at [**Hospital 13128**] 2 weeks from the date of admission. However, given his poor prognosis and the patient's prior decision not to have his lung CA worked up or treated, the patient decided not to have any biopsies performed. No evaluation/treatment was performed for his Lung/HEENT CA. . # PNA: CT notes a possible post-obtructive PNA. In the setting of fever, leukocytosis and left shift, the patient was presumed to have a PNA and given antibiotics. In the ED he was given Vancomycin, Levofloxacin and Flagyl for PNA but this was changed to Unasyn given likelihood of aspiration of gram positive oral anaerobes with his mouth cancer. He became afebrile and his WBC trended down. . # LFT elevations: Initially, he was found to have mild LFT elevations with AST 98 and ALT 45 of unclear etiology. LFT's promptly trendended down. . # CK elevations: On admission, his CK was elevated (peak 1391), with Troponin 0.02 making AMI unlikely. Given that he was found down over 24h, his CK was elevated due to mild rhabdomyolysis. He never had any electrolyte abnormalities or myoglobin in his urine. He was given fluids and his CK's trended down. . # Communication:[**First Name5 (NamePattern1) **] [**Name (NI) 109963**] (brother)[**Telephone/Fax (1) 109966**] Medications on Admission: Clindamycin Ativan Zolpidem Percocet PRN Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary: Pulmonary Embolism and Left Hemisphere Stroke Secondary: DVT, Lung CA, ? Mandibular CA vs Lung metastasis, Pneumonia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "455.2", "195.0", "799.02", "515", "453.41", "434.91", "162.8", "728.88", "415.19", "486" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13980, 13989

6952, 13860

357, 363

14159, 14168

3131, 4203

14220, 14226

2447, 2465

13952, 13957

14010, 14138

13886, 13929

14192, 14197

2480, 3112

276, 319

391, 1759

4212, 6929

1781, 1983

1999, 2431

30,472

167,065

23098

Discharge summary

report

Admission Date: [**2190-2-16**] Discharge Date: [**2190-2-23**] Date of Birth: [**2113-8-18**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: fatigue, chest pain Major Surgical or Invasive Procedure: [**2-16**] CABGx1(LIMA-LAD)MV Repair(26 [**Doctor Last Name 405**] Band Annuloplasty) History of Present Illness: 76 yo F with known CAD, recent chest pain and NSTEMI [**12-17**]. Also with known MR with medical management. Recent increase in symptoms referred for surgery. Past Medical History: MR, TR, CAD, HTN, hyperlipidemia, chronic neck pain Social History: retired office worker no tobacco rare etoh Family History: Denies Physical Exam: HR 64 BP 159/82 NAD Lungs CTAB Heart RRR 2/6 SEM Abdomen benign Extrem wawrm, no edema Superficial bilateral varicosities No carotid bruits Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2190-2-23**] 09:30AM 14.8* [**2190-2-23**] 09:15AM 14.6* [**2190-2-22**] 07:15AM 13.4* 4.11* 12.5 37.3 91 30.3 33.4 15.4 399 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2190-2-22**] 07:15AM 140* 12 0.6 141 3.5 103 26 16 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2190-2-23**] 09:30AM 15.1*1 1.3* [**2190-2-16**] ECHO PRE-BYPASS: 1. The left atrium is moderately dilated. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) with noted hypokinesis of the apical anterior segment and apex. 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen with provocative maneuvers (Trendelenberg and phenylephrine bolus). 8. There is mild to moderate tricuspid regurgitation. POST-BYPASS: Pt removed from cardiopulmonary bypass on phenylephrine infusion and AV paced. 1. No mitral regurgitation is noted after mitral valve annuloplasty. MVA by PHT is 2.4cm2. The annuloplasty ring is well seated. 2. Biventricular function is unchanged LVEF 40%, no new wall motion abnormalities are noted. [**2190-2-18**] ECHO The chest tube, Swan-Ganz catheter, endotracheal tube, nasogastric tube, and mediastinal drains have all been removed. No pneumothorax. Some residual atelectatic changes at the left and possibly also right bases. 3. Mild to moderate tricuspid regurgitation is unchanged. 4. Aortic contours are intact post-decannulation. Operative Note Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 59496**] Service: CSU Date: [**2190-2-16**] Date of Birth: [**2113-8-18**] Sex: F Surgeon: [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] PROCEDURE: 1. Coronary artery bypass surgery times one; left internal mammary artery to left anterior descending. 2. Mitral valve repair with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 405**] band annuloplasty, size 26. CO-SURGEONS: [**Doctor Last Name **] [**Last Name (Prefixes) **], [**Initials (NamePattern4) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10585**], MD ASSISTANT: [**Name6 (MD) 59497**] [**Name8 (MD) **], MD [**First Name (Titles) 59498**] [**Last Name (Titles) 59499**], MD [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 50417**], Intern ANESTHESIOLOGIST: [**Name6 (MD) 59500**] [**Name8 (MD) 3893**], MD PREOPERATIVE DIAGNOSES: Coronary artery disease, moderate mitral regurgitation. BRIEF HISTORY: This is a 76 year-old female patient, known coronary artery disease with recent non-ST elevation myocardial infarction on [**12-17**]. She was also known to have mitral regurgitation with medical management. Recently, her symptoms increased and surgery was advised. FINDINGS: Her coronary angiograms showed an 80% stenosis of the left anterior descending. Intraoperative echo showed a moderate mitral regurgitation. This appeared to be central with the defect being at the mid posterior leaflet. It was decided to do a band annuloplasty on this patient. The 26 [**Doctor Last Name **] [**Doctor Last Name 405**] band was used for the annulus. The pump time was 70 minutes; cross clamp time 48 minutes. OPERATIVE DETAIL: The chest, abdomen and lower extremities were scrubbed with Betadine and prepped with Betadine solution. The chest was opened through a midline sternal- splitting incision. Hemostasis was secured along the sternal borders and the left internal mammary artery was taken down. This artery was small but had good flow. The heparin was given. The pericardium was opened. The patient was cannulated with an ascending aortic cannula in the distal ascending aorta and a 3 stage venous cannula into the right atrium. A cardioplegia needle was inserted into the ascending aorta which will also be used for de-airing. The temperature was allowed to drift down and an aortic cross clamp was placed in the distal ascending aorta and cold antegrade blood cardioplegia was now given. The heart was arrested and a total of 1000 ml was infused. The left atrium was opened and the [**Doctor Last Name 405**] retractors were placed for exposure. The central jet was noted. Then 2-0 non-pledgeted Ethibond sutures were placed along the posterior annulus from one commissure to the other. [**Doctor Last Name 405**] 26 band was then sutured and seated over the posterior annulus. The sutures were tied and on testing once again, there was no central jet. The left atrium was then sutured in a single layer with 3-0 Prolene. During the cross clamp time, a further 400 ml of cold blood cardioplegia was given through the antegrade cannula. The patient was rewarmed and the LAD vessel was exposed. There was diffuse disease and the internal mammary artery was then anastomosed end-to- side using 8-0 Prolene. The aorta cross clamp was removed in the head down position and de-airing measures were taken. Atrial and ventricular pacing wires were placed and atrially paced. For a brief period, the EKG showed an ischemic pattern of the inferior leads; however, this reverted back to baseline. The hemostasis was checked with [**First Name8 (NamePattern2) **] [**Last Name (un) 30565**] expander and the patient was taken off from bypass with some Nor-epinephrine. The heparin was reversed with Protamine and successfully decannulated from the cardiopulmonary bypass machine. Chest tubes were placed through separate incisions; one in the left pleural and 2 in the mediastinum. Once again, hemostasis was checked and chest wall was then closed in layers. The sternum was approximated with stainless steel wires, followed by Monocryl for the fascia and subcutaneous tissues. The skin was closed as a subcuticular stitch with Monocryl. The needle and sponge counts were correct. The patient tolerated the procedure well and went to the cardiovascular intensive care unit in stable condition. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2190-2-16**] and taken to the operating room where she underwent single vessel coronary artery bypass grafting and a mitral valve repair. Please see separate dictated operative note for details. Postoperatively she was transferred to the ICU in stable condition. She was extubated later that same day. She was weaned from her vasoactive drips and transferred to the floor on POD #1 for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She was started on coumadin and amiodarone for rate controlled atrial fibrillation. She became confused and was started on Haldol and required a 1:1 sitter. She was transfused for a HCT of 23. Her confusion improved. She was started on macrodantin for a UTI. Her INR became supratherapeutic and she was given FFP and vitamin K. Her confusion resolved and her INR came down to 1.3. She will receive 0.5 mg of coumadin today. She was discharged to rehab in stable condition on POD#7. Medications on Admission: Imdur 30', Lasix 30', Lisinopril 10', Prilosec 20', ASA 81', MVI, Percocet prn, Fent 50 mcg q72, caltrate Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day: Titrate to INR goal of [**3-13**].5. Discharge Disposition: Extended Care Facility: [**Hospital3 15644**] Long Term Health - [**Location (un) 47**] Discharge Diagnosis: CAD/MR now s/p CABG/MV Repair TR, HTN, hyperlipidemia, chronic neck pain Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2190-2-23**]

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icd9cm

[ [ [] ] ]

[ "36.15", "35.33", "39.61", "99.04" ]

icd9pcs

[ [ [] ] ]

9626, 9716

7547, 8670

341, 429

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953, 7524

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282, 303

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640, 693

709, 753

63,024

144,024

8696

Discharge summary

report

Admission Date: [**2188-6-19**] Discharge Date: [**2188-7-1**] Date of Birth: [**2142-5-7**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: back pain Major Surgical or Invasive Procedure: [**2188-6-27**]: Thoracic endovascular aortic repair with cook venous TX2 30 x 120-mm aortic endograft. History of Present Illness: Ms. [**Known lastname **] is a 46 year old female who awoke this AM with tearing pain across her thoracic back radiating into left chest. Pain was constant, not associated with SOB. She denies any prior episodes. She denies LOC, but does report some associated dizzeness. She denies any abdominal pain, melana, or hematochezia. She presented to an OSH where a CTA of the chest revealed a type B aortic dissection. She was transferred to [**Hospital1 18**] for further care. Past Medical History: PAST MEDICAL HISTORY: Crohns disease, anxiety/depression, uncontrolled HTN PAST SURGICAL HISTORY: lap chole, lap oopherectomy for ovarian cyst, umbilical hernia repair x 2, knee surgery Social History: SOCIAL HISTORY: Married, smokes 1 ppd x 30 years, occasional alcohol use, denies drug use Family History: FAMILY HISTORY: Father and brother with history of peripheral vascular disease Physical Exam: On discharge: Gen: wdwn female in nad Card: rrr Lungs: cta bilat Abd: Soft no m/t/o Extremities: Warm, well perfused, no edema Wound: Groin puncture sites c/d/i Pulses: RLE Femoral: P. Popiteal: P. DP: P. PT: P. LLE Femoral: P. Popiteal: P. DP: P. PT: P. Pertinent Results: [**2188-6-19**] CTA: 1. Type B aortic dissection arising from the aorta just distal to the origin of the left subclavian artery and extending to the proximal left common iliac artery. 2. All major mesenteric branches are supplied by the true lumen, except for the left renal artery, which appears to be supplied by both the true and the false lumina. There is subtle hypoperfusion of the left kidney. 3. Intramural fat deposition within segments of the colon and distal ileum, which can be seen in patients with history of inflammatory bowel disease. Correlation with the patient's history is recommended. discharge labs: [**2188-7-1**] 03:55AM BLOOD WBC-4.3 RBC-3.35* Hgb-9.7* Hct-30.8* MCV-92 MCH-29.0 MCHC-31.4 RDW-16.2* Plt Ct-191 [**2188-7-1**] 03:55AM BLOOD Glucose-114* UreaN-10 Creat-0.5 Na-141 K-4.0 Cl-113* HCO3-26 AnGap-6* [**2188-7-1**] 03:55AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 other pertinent labs: [**2188-6-19**] 08:03PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* [**2188-6-19**] 08:03PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NE05/18/12 2:54 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2188-6-29**]** MRSA SCREEN (Final [**2188-6-29**]): No MRSA isolated. G Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Brief Hospital Course: She was found to have a type B aortic dissection after presenting with back pain. She was started on IV labetalol and admitted to the ICU for monitoring. Her blood pressure was well controlled with first IV labetalol and then PO. Her pain resolved overnight and she only had trace back pain on HD 1. She was kept in the ICU overnight HD 2 and had a CTA done on [**2188-6-22**] that showed no increase in dissection however she did continue to have back pain. Given her ongoing symptoms, despite appropriate blood pressure control, it was determined that she needed operative repair. Of note her initial CT scan showed "Intramural fat deposition within segments of the colon and distal ileum, which can be seen in patients with history of inflammatory bowel disease". Given the patient has a 20yr history of Chron's disease, we asked the GI team to see her. They felt there was no need for any change in care at the time, and will see her in their office in a few weeks. On [**2188-6-27**] she was taken to the operating room and underwent a TEVAR. This procedure went well and she was transported to the CVICU for close monitoring. Post-operatively she did not have back pain. On POD 1 she was weaned off a nitro gtt. Her BP goal was 120-150, and this was ultimately achieve on an oral regimen of labetalol. She was monitored closely in the ICU. Her lumbar drain was d/c'd on POD 3. Her foley was removed and she voided without difficulty. She did have a persist ant headache and anesthesia offered a blood patch, but was resistant to this. By POD 4 she was ambulating independently, tolerating a regular diet and headache free. She was stable for discharge home with close follow up. We have advised her to get a home BP cuff and check her pressure twice a day, recording her numbers. Given the location of the stent graft and the risk of spinal cord ischemia in the short post op period, we would like her sbp 110-140 in the first few weeks, with lower parameters to 100-130 thereafter. She will follow up with her PCP this week and with vascular surgery in a month. If her BP is elevated >140 we'd like her to call her pcp for guidance with bp meds. Medications on Admission: alprazolam [Xanax] fluoxetine [Prozac] mercaptopurine mesalamine [Asacol HD] omeprazole [Prilosec] trazodone Discharge Medications: 1. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 2. mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. fluoxetine 40 mg Capsule Sig: Two (2) Capsule PO once a day. 6. 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* 7. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. labetalol 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Type B aortic dissection 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 you were found to have a type B aortic dissection, which is a tear in the wall of your descending thoracic aorta. The main treatment for this is blood pressure control. You were admitted to intensive care unit for close mointoring and your blood pressure was tightly controlled first with IV medications and then PO blood pressure medications. You continued to have back pain and so the decision was made to repair the dissection. You had a stent graft placed in your thoracic aorta. The procedure went well. You were then taken back to ICU for monitoring, and eventually transfered to the floor. You were started on a new medication called labetolol, for blood pressure control. It is extremely important that you keep your blood pressure well controlled for the rest of your life. For the first 4-6 weeks after your surgery your blood pressure goal is 110-140. After 4-6 weeks the limit should be lowered to 100-130. You should get a home blood pressure cuff and check your pressure daily. Keep a log to share with your PCP. Division of Vascular and Endovascular Surgery Medications: ?????? Take Aspirin once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, and take the new prescription for labetolol ?????? You make take Tylenol for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**3-14**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Keep your follow up appointment with vascular surgery in 1 month. You also need to follow up with your PCP [**Name Initial (PRE) 30449**]. What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] will see Dr. [**Last Name (STitle) 30450**] [**Last Name (LF) **], [**First Name3 (LF) 30451**] [**7-3**] 4pm Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] L. Address: 454 [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 30452**] Phone: [**Telephone/Fax (1) 30453**] Fax: [**Telephone/Fax (1) 30454**] GASTROENTEROLOGY: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2188-7-17**] 1:45 VASCULAR SURGERY: CAT SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2188-8-4**] 1:45 followed by office visit DR. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2188-8-4**] 2:30 Completed by:[**2188-7-1**]

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icd9cm

[ [ [] ] ]

[ "88.42", "39.73" ]

icd9pcs

[ [ [] ] ]

6172, 6178

2974, 5132

311, 417

6247, 6247

1635, 2246

9991, 10831

1279, 1344

5291, 6149

6199, 6226

5158, 5268

6398, 9411

9437, 9968

2262, 2532

1047, 1138

1359, 1359

1373, 1616

262, 273

445, 926

2555, 2951

6262, 6374

970, 1024

1170, 1247

3,471

136,780

44707

Discharge summary

report

Admission Date: [**2187-1-22**] Discharge Date: [**2187-1-26**] Date of Birth: [**2106-3-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1148**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 80 y/o female with COPD, Cardiomyopathy, and left pleural effusion which was recently tapped on [**2186-12-15**], presents with acute worsening of chronic dyspnea. Patient unable to give her own history secondary to dementia. Her husband reports she had some mild dysuria the day before and had given her a dose of cipro (which she needs periodically per him). Day of admission awoke and suddenly became very short of breath. No recent change in diet, no change in orthopnea, had not been lying more flat. No fevers of chills. Normal urine output. . In the ED, she presented with O2 sat 98% on 2L, but became hypoxic to 88% on 2L, with elevated blood pressure, and trop of 0.06 without EKG changes. Her blood pressure and hypoxia improved with SL nitro and a 100% NRB. She received aspirin. CXR showed left pleural effusion. CT chest without contrast showed no mass or underlying PNA. . ROS: Negative Past Medical History: HTN PVD S/P Aortofemoral Bypass [**2163**] Left Brain CVA in [**8-/2180**] with right sided weakness and dysarthria Cardiomyopathy EF 50-55%, mild symmetric LVH, 1+AR, 2+MR, by Echo [**2186-12-27**] Left Pleural Effusion -known since [**2186-12-11**]- last tapped [**2186-12-15**]- appears transudative, no malignant cells CRI -since [**2183**] (best Cr since [**2183**] was 2.2), current baseline 2.8-3.0, worsening since [**2183**], renal U/S [**2187-1-2**] showed thinned slightly echogenic cortex Chronic Anemia COPD/Emphysema/Asthma- PFT's [**3-/2180**] showed FEV1 1.41L(72%), FEV1/FVC 74% predicted, Decreased Diffusion Capacity Lupus- Thrombocytopenia, Arthritis, Uveitis/Iritis- ? Lupus anticoagulant PMR- Elevated ESR requiring steroids S/P partial Gastrectomy for GI Bleed in [**2181**] Social History: SOCIAL: Former smoker, stopped in [**2161**], 30 pack-years, no alcohol, no drugs. Cared for by husband at home. Uses a walker at home. Family History: NC Physical Exam: EXAM: Vitals T 97.5 HR 91 BP 190/102 RR 26 Sat 100% on 4L NC GENRAL: Using accessory muscles to breathe, but not in distress Neuro: Expressive aphasia HEENT: PERRL, EOMI, dry mucous membranes Neck: no JVP elevation CHEST: Hyperresonance over upper lung fields, hyperexpansion of lung fields, rales at right base, decreased breath sounds over left lower lung fields with decreased tactile fremitus HEART: Regular, with systolic murmur over upper sternal border with audible S2. No Gallop. Slightly laterally displaced PMI. ABD: NABS, non distended, soft, NT, no organomegaly EXT: good popilteal and radial pulses but poor DP pulses, no edema Pertinent Results: [**2187-1-22**] 01:20PM PT-30.0* PTT-58.0* INR(PT)-3.2* [**2187-1-22**] 01:20PM PLT COUNT-258 [**2187-1-22**] 01:20PM HYPOCHROM-1+ MICROCYT-1+ [**2187-1-22**] 01:20PM NEUTS-72.7* LYMPHS-12.8* MONOS-4.2 EOS-9.0* BASOS-1.2 [**2187-1-22**] 01:20PM WBC-7.9 RBC-3.44* HGB-9.0* HCT-28.0* MCV-82 MCH-26.1* MCHC-32.1 RDW-15.8* [**2187-1-22**] 01:20PM CK-MB-NotDone cTropnT-0.06* proBNP-[**Numeric Identifier 95658**]* [**2187-1-22**] 01:20PM CK(CPK)-65 [**2187-1-22**] 01:20PM estGFR-Using this [**2187-1-22**] 01:20PM GLUCOSE-93 UREA N-37* CREAT-3.9* SODIUM-137 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-22 ANION GAP-15 [**2187-1-22**] 01:22PM K+-5.4* [**2187-1-22**] 08:12PM PT-29.1* PTT-55.2* INR(PT)-3.0* [**2187-1-22**] 08:12PM PLT COUNT-256 [**2187-1-22**] 08:12PM NEUTS-80.7* BANDS-0 LYMPHS-8.3* MONOS-3.7 EOS-6.8* BASOS-0.6 [**2187-1-22**] 08:12PM WBC-8.1 RBC-3.14* HGB-8.3* HCT-24.8* MCV-79* MCH-26.6* MCHC-33.6 RDW-15.6* [**2187-1-22**] 08:12PM calTIBC-140* FERRITIN-170* TRF-108* [**2187-1-22**] 08:12PM ALBUMIN-2.8* CALCIUM-8.1* PHOSPHATE-5.3* MAGNESIUM-2.5 IRON-31 [**2187-1-22**] 08:12PM CK-MB-4 cTropnT-0.06* [**2187-1-22**] 08:12PM LIPASE-33 [**2187-1-22**] 08:12PM ALT(SGPT)-13 AST(SGOT)-25 LD(LDH)-214 CK(CPK)-56 ALK PHOS-110 AMYLASE-56 TOT BILI-0.3 [**2187-1-22**] 08:12PM GLUCOSE-100 UREA N-39* CREAT-4.0* SODIUM-138 POTASSIUM-5.8* CHLORIDE-107 TOTAL CO2-21* ANION GAP-16 [**2187-1-22**] 10:11PM URINE RBC-2 WBC-37* BACTERIA-MANY YEAST-NONE EPI-1 [**2187-1-22**] 10:11PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM [**2187-1-22**] 10:11PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2187-1-22**] 10:11PM URINE HOURS-RANDOM UREA N-312 CREAT-68 SODIUM-85 TOT PROT-270 PROT/CREA-4.0* . CXR: There is severe underlying emphysema. There has been interval development of a large left pleural effusion. The aorta remains tortuous. Cardiac silhouette size is difficult to assess given the presence of the large effusion, although stable cardiomegaly is likely present. No pneumothorax is evident. Scattered calcified nodules are again identified and relatively stable, consistent with prior granulomatous insult. The previously noted focal nodular outpouching on the lateral aspect of the aortic knob is now more prominent. . CHEST CT: 1. Aortic arch contour abnormality suspicious for a saccular aneurysm. Given the patient's chronic renal insufficiency, which precludes the use of iodinated intravenous contrast with CT imaging, further evaluation is recommended by thoracic aortic MRA. 2. Small right and moderate left pleural effusions. No evidence of a mass, although evaluation of the hila is limited. 3. Mildly enlarged mediastinal lymph nodes. 4. Mildly enlarged main pulmonary artery, consistent with pulmonary hypertension. 5. 7 mm anterior listhesis at L3/4 with associated narrowing of the central canal and the neural foramina bilaterally. Brief Hospital Course: A/P: 80 y/o female with COPD and left pleural effusion presents with dyspnea and hypoxia, likely due to worsening left pleural effusion of unknown etiology. . # Dyspnea/Hypoxia: She likely has contributions from non ventilated alveoli (atelectasis from pleural effusion), decreased oxygen diffusion(COPD). Echo [**1-23**] unchanged EF 50%. She was able to be weaned quite quickly back to room air without significant intervention in MICU, making mucus plugging or mild pulm edema from hypertensive urgency more likely. Effusion was believed to be transudative based on previous tap albumin, T prot, and no malignant cells (although no concurrent bloodwork was done to get true light's criteria). Differential includes nephrotic syndrome, protein losing enteropathy, heart failure (cardiomyopathy and MR), renal failure, pulmonary embolism (although INR supratherapeutic); exudative causes include malignancy, lupus, pneumonia. Since patient was no longer symptomatic by time of transfer to the floor and INR still above 2, decision made to do thoracentesis next week as outpatient. -patient's husband told to bring her to interventional pulmonary as outpatient to get tap (diagnostic and therapeutic) and to get bloodwork (inr, ldh, prot, albumin, chem 7) on same day -to follow up these results with PCP who can refer them to pulmonologist if needed . # CRI/ARF: Creatinine elevated again on admission. Renal consulted and concern that patient is rapidly approaching end stage renal disease requiring HD. Family clear that she would not want HD. Per renal recs, ACE-I stopped and patient started on isosorbide dinitrate and hydralazine for afterload reduction. Cont calcium acetate. Will follow up with renal as outpatient. Small bump in troponin believed secondary to renal insufficiency in face of some cardiac strain (no EKG changes). . # HTN: Blood pressure elevated on admission but improved with additional agents. On diltiazem, hydralazine, isosorbide dinitrate. . # Anemia: dropped 6 points [**Date range (1) **], but up to 26.2 on recheck. Patient has evidence of anemia of chronic disease. Can address as outpatient starting on epo. On ferrous sulfate. . # Cardiomyopathy: EF 50-55% combination of valvular disease from 2+MR/?ischemic disease, no known h/o CAD, though significant vasculopath. BNP is ~37,000. Echo shows no change in EF. . # PVD: h/o aortofemoral bypass, on warfarin. Also thoracic aortic aneurysm seen, may be slightly larger in size. If patient considered surgical candidate could get MRA to further evaluate in future. Otherwise, blood pressure control. - hold warfarin for thoracentesis . # H/O CVA: unclear of etiology (embolic vs. hemorrhagic), but on warfarin, so likley not hemorrhagic. Warfarin held during this admission and family told not to restart until after thoracentesis next week. . # Lupus: Has been stable. . # H/O GI bleed/partial gastrectomy. Continue PPI . # UTI: Treat with levo 7 days total. . # N/V: possibly due to renal failure, dehydration, IMI, or UTI. Should follow up as outpatient and could consider antiemetics and supplements prn. . # Access. PIV x 2. . # FEN: Passed speech and swallow eval on [**1-24**]. Renal, Cardiac diet. . # Code: DNR/DNI, no heroic measures per her husband (including hemodialysis), her unofficial proxy, [**First Name8 (NamePattern2) **] [**Name (NI) 10132**] ([**Telephone/Fax (1) 95659**] Medications on Admission: Coumadin 2 mg QHS Accupril 20 mg TID Cardizem 60 mg QID Zocor 10 mg daily Prevacid 30 mg daily Paxil 10 mg daily Ditropan 10 mg XL daily FeSo4 325 mg daily Centura cream Cipro PRN Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Do not restart until after your procedure next Tuesday. 5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Ditropan XL 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1) Tab,Sust Rel Osmotic Push 24HR PO once a day. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 3 days. Disp:*2 Tablet(s)* Refills:*0* 12. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 13. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 14. Outpatient Lab Work Please get chem 7, cbc, inr, ldh, protein, albumin Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Hypoxia quickly resolving, possibly from mild pulmonary edema with hypertensive urgency or mucus plugging Pleural effusion Chronic renal failure Thoracic aortic aneurysm Urinary Tract Infection Discharge Condition: Good Discharge Instructions: Take your medications as prescribed. Do not take your coumadin until after your appointment to get the fluid tapped from your lung. Restart the coumadin the following day. We have stopped your accupril (for blood pressure). Instead you have been started on hydralazine and imdur. We have given you levofloxacin for your urinary tract infection. Please take every other day for the next 3 days. We have also started you on calcium acetate to protect your body from your renal failure. You are also receiving senna and colace stool softeners. Followup Instructions: Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] to make a follow up appointment with him next week. Please go to the pulmonary suite on [**Hospital1 **] 2, [**Apartment Address(1) 22087**] on Tuesday [**1-30**] at noon to get fluid in lung tapped. Please also go and get blood drawn that day. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2187-2-6**] 11:40 Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2187-2-15**] 2:30

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11035, 11093

5953, 9348

323, 330

11331, 11338

2945, 5930

11935, 12570

2262, 2266

9579, 11012

11114, 11310

9374, 9556

11362, 11912

2282, 2926

276, 285

358, 1270

1292, 2092

2108, 2246

23,179

184,235

4865

Discharge summary

report

Admission Date: [**2158-3-17**] Discharge Date: [**2158-3-29**] Service: HISTORY OF PRESENT ILLNESS: This is a 78 year old gentleman with coronary artery disease, status post coronary artery bypass graft in [**2153**], a long history of congestive heart failure (ejection fraction less than 20%). He was last admitted in [**2158-2-16**], for cellulitis and noted to have fluid overload, requiring increasing doses of Lasix. Blood urea nitrogen/creatinine increased to 140/3.7 but creatinine returned to baseline after Cozaar was held and Foley was placed. He was discharged to the TCU where his weight gradually increased from 151 pounds on [**2158-3-1**], to 165 pounds on [**2158-3-17**], despite increasing Lasix doses with positive fluid balance and increasing creatinine from 1.9 on [**2158-3-9**], to 4.2 on [**2158-3-17**]. He has chronic orthopnea, dyspnea on exertion and lower extremity swelling which has severely worsened over the past several days prior to admission. He denied chest pain, palpitations, light-headedness, fever or chills. Of note, he completed fourteen days of Vancomycin and five days of Gentamicin from [**2158-3-9**], to [**2158-3-14**], for recurrent highly resistant E. coli urinary tract infection. PAST MEDICAL HISTORY: 1. Coronary artery disease for which the patient had a coronary artery bypass graft in [**2143**]. He had a left internal mammary artery to the left anterior descending and saphenous vein graft to the right coronary artery and saphenous vein graft to the OM. These grafts were found to be patent in [**2154**]. 2. Congestive heart failure times eight years and ejection fraction less than 20% noted [**2157-12-15**]. 3. Mitral regurgitation, moderate. 4. Diabetes mellitus type II times forty years with triopathy. 5. Chronic renal insufficiency, baseline creatinine of 2.0 to 3.0. 6. Atrial fibrillation/atrial tachycardia. 7. Sick sinus syndrome, status post DDD pacer. 8. History of ventricular fibrillation arrest. 9. Hypertension. 10. Benign prostatic hypertrophy. 11. Mild chronic obstructive pulmonary disease. 12. History of Methicillin resistant Staphylococcus aureus, positive anal swab in [**2157-2-15**]. 13. History of right foot cellulitis. 14. History of anemia and thrombocytopenia. INCOMING MEDICATIONS: 1. Albuterol two puffs q.i.d. 2. Amiodarone 200 milligrams q.d. 3. Beclovent six puffs twice a day. 4. Coumadin 3 milligrams q.d. 5. Hydralazine 30 milligrams q.i.d. 6. Digoxin 0.125 milligrams q.o.d. 7. Atrovent four puffs q.i.d. 8. Lasix 160 milligrams intravenously b.i.d. 9. Norvasc 5 milligrams q.d. 10. Proscar 5 milligrams q.d. 11. Triazolam 0.25 milligrams q.h.s. 12. Imdur 60 milligrams q.d. 13. Flomax 0.4 milligrams q.d. 14. Epogen 10,000 units every Wednesday. 15. Iron Sulfate 325 milligrams q.d. 16. Ciprofloxacin 500 milligrams b.i.d. ALLERGIES: Penicillin, question if the patient has a reaction. Had a fever in the setting of being given Tetanus boost and Penicillin. Also by history, states allergy to Sulfa, Minipress, Procainamide, Mexiletine. All these have unknown reactions. PHYSICAL EXAMINATION: Vital signs revealed blood pressure 140/70, pulse 66, respiratory rate 20, temperature 96.5, oxygen saturation 96% in room air. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Moist mucous membranes. The oropharynx is clear. Anicteric. Neck - 12.0 centimeter jugular venous pressure, supple, no bruits, no lymphadenopathy. Heart regular rate and rhythm, no murmurs, gallops or rubs, S3 was appreciated. Lungs - bibasilar rales, dullness one third the way up bilaterally. Extremities 4+ pitting edema to the thighs bilaterally. Genitourinary - Marked scrotal edema. Neurological examination alert and oriented times three, no gross motor deficits. Cranial nerves II through XII are intact. Nonfocal examination. LABORATORY DATA: White blood cell count 6.1, hematocrit 11.7, platelets 136, INR 1.8. Sodium 131, potassium 4.3, chloride 92, bicarbonate 24, blood urea nitrogen 130, creatinine 4.2, albumin 3.3. Creatinine kinase enzymes were the following: 79, then 97, then 92. [**Year (4 digits) **] on [**2158-3-17**], showed an ejection fraction of 20%, mild concentric left ventricular hypertrophy, severe global left ventricular hypokinesis, right ventricle markedly dilated, severe global right ventricular hypokinesis, right ventricular volume overload, moderate mitral regurgitation, severe tricuspid regurgitation, severe pulmonary hypertension, no pericardial effusions. There were no changes from a previous [**Date Range 461**] on [**2157-12-15**]. Electrocardiogram showed AV paced at 64 beats per minute. HOSPITAL COURSE: 1. Cardiovascular, congestive heart failure - The patient was admitted with severe ischemic cardiomyopathy, biventricular congestive heart failure, and profound azotemia secondary to poor cardiac output. Initially, he was placed on a Lasix drip with Zaroxolyn to promote aggressive diuresis. He was also continued on Hydralazine for afterload reduction with nitrates. However, both the Lasix drip and then Bumex infusions were ineffective. He was then transferred to the CCU for a Dobutamine trial off nitrates and Hydralazine, but this intervention too was unsuccessful. He was oliguric, and blood urea nitrogen and creatinine continued to rise. He therefore underwent four episodes of dialysis which he tolerated well without hemodynamic instability. His congestive heart failure became far more compensated, his breathing significantly improved, no longer having orthopnea or paroxysmal nocturnal dyspnea. His rales and peripheral edema markedly decreased and his oxygen saturation remained in the 90s at room air. Afterload reduction was resumed with Captopril which was switched to Lisinopril prior to discharge, and his outpatient Digoxin was also resumed for his profoundly decreased ejection fraction and history of atrial fibrillation. 2. Cardiovascular, rate and rhythm - The patient remained AV paced while on his outpatient dose of Amiodarone. Doctor [**First Name (Titles) 73**] [**Last Name (Titles) **] the telemetry readings and noted no significant episodes of atrial tachycardia which the patient has had a history of in the past. 3. Renal - It was felt that the patient had a predominant prerenal azotemia with a questionable component of Gentamicin toxicity. After failing Lasix, Bumex, then Dobutamine, hemodialysis was started as a bridge to chronic hemodialysis given profound fluid overload, metabolic acidosis and uremia, all of which significantly improved once dialysis was begun. On [**2158-3-27**], the patient had a permacath placed for long term dialysis on a Tuesday, Thursday, Saturday schedule. The patient also received TUMS for hyperphosphatemia and hypocalcemia. 4. Infectious disease - The patient was admitted with a recurrent E. coli urinary tract infection resistant to Ciprofloxacin which was discontinued on admission. While the patient has a listed allergy to Penicillin, the family stated he had developed a fever and diaphoresis while receiving Penicillin and Tetanus booster concurrently. He was therefore started on and completed a seven day course of Ceftriaxone without complications. Urine culture on [**3-25**]/.01, showed gram negative rods at 1000 colonies and therefore no further antibiotics were given. 5. Hematology - The patient was maintained on his Epogen. His hematocrit was 29.2 with a MCV of 79 on discharge. Renal team plans to give intravenous iron for low iron state. OUTGOING MEDICATIONS: 1. Insulin 70/30 8 units q.a.m. and 4 units q.p.m. 2. Coumadin 5 milligrams p.o. q.d. 3. Aspirin 81 milligrams p.o. q.d. 4. Epogen 10,000 units every Wednesday. 5. TUMS 1.5 grams t.i.d. p.o. 6. Beclovent six puffs b.i.d. 7. Albuterol two puffs q.i.d. p.r.n. 8. Ambien 5 milligrams p.o. q.h.s. 9. Digoxin 0.0625 milligrams q.o.d. p.o. 10. Lisinopril 20 milligrams p.o. q.d. 11. Amiodarone 200 milligrams p.o. q.d. 12. Colace 100 milligrams p.o. b.i.d. DISCHARGE DIAGNOSIS: Profound decompensated congestive heart failure and prerenal acute renal failure. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17872**], M.D. [**MD Number(1) 17873**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2158-3-31**] 17:17 T: [**2158-4-2**] 08:06 JOB#: [**Job Number 20333**]

[ "585", "041.4", "427.31", "250.00", "496", "414.01", "428.0", "584.9", "599.0" ]

icd9cm

[ [ [] ] ]

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icd9pcs

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8574+55952

Discharge summary

report+addendum

Admission Date: [**2175-5-16**] Discharge Date: [**2175-5-19**] Service: SURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo female s/p fall down stairs; unknown LOC. Taken to an area hospital, found to have a left temporal subarachnoid hemorrhage. She was transferred to [**Hospital1 18**] for continued trauma care. Past Medical History: CAD CRI AAA s/p repair COPD PVD CHF AFib h/o DVT Social History: Married, lives with husband who reportedly has some Dementia. Has a son and daughter. Family History: Noncontributory Physical Exam: VS upon admission to the trauma bay: GCS 15 BP 144/palp HR 80 RR 16 EOMI, occipital laceration, TM's clear, clotted blood in pharynx, mid face stable Cervical collar, no crepitus Midthoracic tenderenss, no stepoffs, BS clear Abdomen soft, nontender, reducible hernia Pelvis stable Normal rectal tone, guaiac negative Extr no deformities Pertinent Results: [**2175-5-16**] 04:59PM GLUCOSE-149* LACTATE-1.7 NA+-135 K+-7.7* CL--98* TCO2-23 [**2175-5-16**] 04:50PM UREA N-49* CREAT-3.1* [**2175-5-16**] 04:50PM AMYLASE-101* [**2175-5-16**] 04:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2175-5-16**] 04:50PM WBC-11.3* RBC-5.10 HGB-12.9 HCT-39.7 MCV-78* MCH-25.3* MCHC-32.5 RDW-16.6* [**2175-5-16**] 04:50PM PT-34.8* PTT-41.1* INR(PT)-3.8* [**2175-5-16**] 04:50PM PLT COUNT-331 CT HEAD W/O CONTRAST [**2175-5-17**] 9:56 AM CT HEAD W/O CONTRAST Reason: F/u head bleed [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with AH/SDH REASON FOR THIS EXAMINATION: F/u head bleed CONTRAINDICATIONS for IV CONTRAST: renal failure CT OF THE HEAD WITHOUT CONTRAST, DATED [**2175-5-17**] HISTORY: 81-year-old female with known intracranial hemorrhage after trauma; followup. TECHNIQUE: Contiguous 5-mm axial tomographic sections were obtained from the skull base through the vertex and viewed in brain and bone window. Much of the study is significantly degraded by patient motion artifact and several sections were repeated. FINDINGS: The study is compared with the examination obtained approximately 17 hours earlier. Allowing for the motion-degradation, there has been no significant change in the bifrontal parenchymal hemorrhages, likely representing hemorrhagic contusions. There is no interval increase in adjacent edema, mass effect or associated shift of the midline structures. Assessment of the small hemorrhagic focus in the anterior aspect of the right middle cranial fossa is limited, but this, too, is not grossly changed, and no new hemorrhagic focus is identified. Again demonstrated are large right occipital scalp subgaleal hematoma with underlying right basiocciput fracture and fluid layering in the right sphenoid sinus, with no definite sphenoid fracture seen. IMPRESSION: Motion-limited study, with no significant change since the admission examination obtained on the preceding day. CT C-SPINE W/O CONTRAST [**2175-5-16**] 4:45 PM CT C-SPINE W/O CONTRAST Reason: ? fx [**Hospital 93**] MEDICAL CONDITION: 82 year old woman s/p fall on coumadin REASON FOR THIS EXAMINATION: ? fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 82-year-old female with status post fall, on Coumadin. Evaluate for fracture. No prior studies for comparison. TECHNIQUE: Axial non-contrast images of the cervical spine were obtained. Sagittal and coronal reconstructions were performed. FINDINGS: On sagittal images, the base of the occiput to the T2 vertebra is clearly visualized. The prevertebral soft tissues are unremarkable. There is slight grade 1 retrolisthesis of C4 on C5. A C4 inferior endplate deformity most likely represents a Schmorl node, although inferior endplate fracture cannot be definitively excluded. Moderately severe degenerative changes of the cervical spine. Facet joint proliferative changes and posterior osteophytes result in mild spinal canal narrowing, most marked at C5/6. There are emphysematous changes of the lungs with scarring of the right lung apex. MRI is better in the evaluation of the thecal sac, but there are no gross thecal sac abnormalities. IMPRESSION: 1. Grade 1 retrolisthesis of C4 on C5. A C4 inferior endplate deformity likely represents a Schmorl's node, although inferior endplate fracture cannot be definitively excluded. Clinically correlate. 2. Degenerative changes of the cervical spine. NOTE ADDED IN ATTENDING REVIEW: 1. Right basiocciput fracture well seen in coronal reformatted images; exits at the jugular foramen but spares the occipital condyle, and atlanto- occipital relationship is maintained. 2. Moderately severe degenerative changes, particularly at the C5/6 > C4/5, with moderate canal stenosis and slight indentation of the thecal sac (and cord). Might be at risk for "central cord" injury at these levels (with appropriate mechanism). b/l neural foraminal narrowing at these levels. 3. Evidence of severe bullous emphysema, w/irreg, focal pleuroparench thickening, R lung apex; a pleural-based mass is a consideration. 4. D/W Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] (Trauma [**Doctor First Name **]), 0915h, [**2175-5-17**]. CT CHEST W/CONTRAST [**2175-5-16**] 4:45 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: ? bleeding Field of view: 50 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 82 year old woman s/p fall on coumadin REASON FOR THIS EXAMINATION: ? bleeding CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 82-year-old female status post fall, on Coumadin. Comparison to prior CT abdomen/pelvis of [**2169-4-7**]. TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained after the administration of IV Optiray contrast. Multiplanar reformatted images were also obtained. CT CHEST WITH IV CONTRAST: Heart and great vessels are unremarkable. There are scattered mediastinal lymph nodes. A pretracheal lymph node measures 1.2 cm. There is apical scarring. A right upper lobe pulmonary nodule measures 4 mm. There is bibasilar atelectasis. Incidental note is made of a 1-cm spiculated right breast opacity concerning for malignancy. CT ABDOMEN WITH IV CONTRAST: The liver, pancreas, adrenal glands, and left kidney are unremarkable. Right kidney hydronephrosis and ureteral stent is seen. A right kidney hypodensity likely represents a cyst, but cannot be further characterized on this examination. The spleen is heterogeneous likely secondary to the phase of filling. There is a small gallstone. Again seen is a suprarenal abdominal aortic aneurysm measuring 3.7 cm. This has decreased in size compared to the prior examination and there is evidence of surgical intervention. There are bilateral common iliac artery grafts with partial thrombosis. No free fluid or free air within the mesentery. CT PELVIS WITH IV CONTRAST: The rectum is normal. There is sigmoid diverticulosis without evidence of diverticulitis. A 1.5 x 1.0 cm cystic structure is seen within the uterus. There is a moderate amount of high- attenuation fluid within the pelvis, likely representing hematoma. Incidental note is made of left internal iliac aneurysm. OSSEOUS WINDOWS: Demonstrate a partially displaced sacral fracture. IMPRESSION: 1. Partially displaced sacral fracture with adjacent presacral pelvic hematoma. 2. Suprarenal abdominal aortic aneurysm measuring 3.7 x 3.2 cm, decreased in size compared to the previous examination. There are common iliac artery grafts with partial thrombosis. 3. Right-sided hydronephrosis with right ureteral stent. 4. Gallstone. 5. Spiculated opacity in the right breast concerning for malignancy, for which mammogram is recommended. 6. Cystic density within the uterus, for which pelvic ultrasound is recommended. Brief Hospital Course: Patient admitted to the trauma service. Neurosurgery and Orthopedic surgery were consulted because of her injuries. Her SAH was managed non operatively; she was loaded with Dilantin and will continue for the next 4 weeks until follow up with Dr. [**Last Name (STitle) **], Neurosurgery in 3 months at which time she will have a repeat head CT scan. Her Coumadin should not be restarted until [**2175-5-25**]. Her Orthopedic injuries were managed conservatively as well. There were no cervical spine fractures identified and so her cervical collar was removed. She can be WBAT with her sacral fracture. For pain control she was placed on ATC Tylenol and prn Dilaudid 1 mg for breakthrough pain. Geriatrics was consulted because of her age and mechanism of injury. Several recommendations regarding her medication regimine were made; she was also started on Calcium and Vit D prophylaxis. Her HCTZ was restarted at a lower dose; was on 50 mg QD at home. There was an incidental finding on her chest CT scan; a spiculated opacity right breast was noted and on exam there is a palpable mass. Her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30106**] was contact[**Name (NI) **] regarding this; a copy of the CT report was forwarded to him as well. She will need to follow up with him after discharge from rehab. Physical and Occupational therapy were consulted and have recommended short term rehab stay. Medications on Admission: Verapamil 180' HCTZ 50' Dig .125' Coumadin 2' Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold fro HR <60 and/or SBP <110. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Continue for 4 weeks then discontinue. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: s/p Fall Left Temporal Subarachnoid Hemorrhage Transverse Sacral Fracture Discharge Condition: Stable Discharge Instructions: DO NOT restart your Coumadin until [**2175-5-25**] Follow up in 2 months with Orthopedics Follow up with Neurosurgery in 3 months Followup Instructions: Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30106**] regarding the finding on chest CT; you will also need a mammogram scheduled within the next 1-2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment in 2 months with Dr. [**Last Name (STitle) 1005**], Orthopedics. Call [**Telephone/Fax (1) 2731**] for an appointment with Dr. [**Last Name (STitle) **], Neurosurgery. Infrom the office that you will need a repeat head CT scan for this appointment. Completed by:[**2175-5-19**] Name: [**Known lastname 5246**],[**Known firstname 3344**] Unit No: [**Numeric Identifier 5247**] Admission Date: [**2175-5-16**] Discharge Date: [**2175-5-19**] Date of Birth: [**2093-6-13**] Sex: F Service: SURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 813**] Addendum: [**Name (NI) **] PTH level came back at 131; her Vitamin D should be changed to either Vitamin D3 or calcitriol. Also her Dilantin was 10.0 today as well. This information was provided to [**Location (un) 5248**] which is where patient was discharged to today and also provided to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5249**], patient's primary care physician. Discharge Disposition: Extended Care Facility: [**Hospital6 3465**] - [**Location (un) 824**] [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**] Completed by:[**2175-5-19**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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12050, 12281

7866, 9327

223, 230

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1039, 1602

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649, 666

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5460, 5499

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9353, 9401

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480, 530

546, 633

50,237

150,681

6516

Discharge summary

report

Admission Date: [**2111-8-28**] Discharge Date: [**2111-9-2**] Date of Birth: [**2034-7-19**] Sex: M Service: MEDICINE Allergies: Keflex / Levaquin / Nafcillin Attending:[**First Name3 (LF) 19193**] Chief Complaint: GI bleed/Acute renal failure Major Surgical or Invasive Procedure: EGD - [**2111-8-28**] History of Present Illness: 77 y/o M with history of DM, HTN, afib on coumadin, PVD c/b right sided arterial ulcer s/p surgical debridement on [**8-18**] who presented with lethargy and hypotension. . Patient was in USOH until Tuesday when he began to feel fatigued. Reported dark black hard stools at that time without BRBPR. Denied abdominall pain and nausea/vomiting. As week progressed, continued to feel lethargic and started having shortness of breath. Also had LH. Had BM on Thursday which was also dark black and without BRBPR. VNA saw patient Thursday and noted BPs were in 80s/40s (normal is 130s/70s). Repeat BPs taken on family were also in 80s and so patient was taken to OSH. . In OSH ED, patient was noted to have Hct 17, INR 5.7 and Cr of 7.0. Rectal exam showed heme-positive stool. Patient was given 2 units of pRBCs, 1 unit of FFP, 10mg of vitamin K, D50, 10 units of regular insulin Calcium gluconate 4g, Protonix 80mg IV, and Kayexalate 30g. BPs ranged from 86-121/27-65 with HRs in high 40s. EKG was notable for QRS 202 with RBBB and LAFB. With 2 units of pRBCs, repeat Hct was 22.8. Patient was then transferred to [**Hospital1 18**] for further evaluation and treatment. Prior to transfer patient was started on a 3rd unit of pRBCs. . In [**Hospital1 18**] ED, Hct was 23.2, Cr was 6.2 with K of 6.7. Patient was given a total of 4g of calcium gluconate, insulin 10 units, and 1 amp of D50. Was also started on protonix gtt. NGL was completed and showed ?coffee grounds. GI and renal were consulted. Patient rec'd total of 1LNS and had 250cc of UOP. BPs in ED ranged from 96-107/45-54 with HRs in 48-52. Patient was noted to desat and was placed on 4LNC. Patient was then transferred to MICU for further care. . Of note, patient was recently admitted from [**Date range (1) 24996**] on vascular surgery for elective fem-[**Doctor Last Name **] bypass. Patient went to OR on [**8-18**] however procedure was aborted after posterial tibial artery was found to be occluded. Instead surgical debridedment of arterial ulcer on right ankle. Patient did not receive contrast durign this hospitalization however was started bactrim prior to discharge. . On MICU, patient was resting comfortably and was hungry. Otherwise had no complaints. Past Medical History: - CKD - dCHF - Mild Aortic Stenosis - DM - HTN - A-fib (on coumadin) - H.pylori gastric ulcer in [**2103**] causing upper GI bleed - PVD c/b right arterial ulcer s/p surgical debridement on [**8-18**] - MICU admission [**7-/2111**]: GIB with EGD showing [**Year (4 digits) 24997**] lesion in 3rd part duodenum with brisk arterial bleed, clipped; also with renal failure from ATN - Hypothyroid - Gout - BPH PSH: L hip replacement [**5-9**]; open prostatectomy [**12-8**]; L CEA [**11-7**]; I&D R hallux abscess [**8-2**], [**10-3**]; Vein patch angioplasty fem-peroneal distal anastomosis [**7-31**]; L CFA to peroneal bypass w GSV [**5-31**]; L3-4 laminectomy [**1-31**]; Right femoral to below knee popliteal bypass. Social History: Smoker, quit in [**2083**] Family History: Non-contributory Physical Exam: Admission: Vitals: 96.7 49 117/46 94% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles at baseline CV: Bradycardic, 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, rectal exam with empty vault Ext: cool, +2 radial pulses, dopplerable DP pulses, well healing ulcer of right medial mallelous, no fluctuance, stitches in place, wound c/d/i Pertinent Results: Admission labs: [**2111-8-28**] 04:35AM BLOOD WBC-10.4 RBC-2.52* Hgb-7.9* Hct-23.2* MCV-92 MCH-31.6 MCHC-34.2 RDW-20.2* Plt Ct-239 [**2111-8-28**] 04:35AM BLOOD Neuts-84.4* Lymphs-10.9* Monos-4.0 Eos-0.3 Baso-0.4 [**2111-8-28**] 04:35AM BLOOD PT-34.5* PTT-40.1* INR(PT)-3.4* [**2111-8-28**] 04:35AM BLOOD Glucose-136* UreaN-168* Creat-6.7*# Na-136 K-6.7* Cl-100 HCO3-23 AnGap-20 - EGD in [**2103**]: with arterial bleed EGD Report [**7-/2111**]: Normal mucosa in the esophagus Blood in the whole stomach Clotted blood in the antrum and pylorus Normal mucosa in the stomach Bright red blood in the third part of the duodenum [**Year (4 digits) 24997**] lesion in the Third part of the duodenum (endoclip, injection) Otherwise normal EGD to third part of the duodenum EKG: HR 49 RBBB with LAFB, QTc 477 QRS 180, slow atrial fibrillation Discharge labs: [**2111-9-2**] 05:05AM BLOOD WBC-8.7 RBC-2.92* Hgb-9.0* Hct-28.4* MCV-97 MCH-30.8 MCHC-31.7 RDW-20.3* Plt Ct-286 [**2111-9-2**] 05:05AM BLOOD Plt Ct-286 [**2111-9-2**] 05:05AM BLOOD PT-15.1* PTT-30.2 INR(PT)-1.3* [**2111-9-2**] 05:05AM BLOOD Glucose-126* UreaN-68* Creat-2.2* Na-143 K-4.7 Cl-109* HCO3-24 AnGap-15 Brief Hospital Course: 77 year old male with h/o diabetes, CKD III,mild aortic stenosis, hypertension, hyperlipidemia,and severe PVD with chronic R malleolar arterial ulcer, s/p recent debridement, who had been on on aspirin/plavix, and coumadin for AFib, who was admitted soon after his home VNA found him hypotensive. He was found to have profound anemia from a [**Month/Day/Year 24997**] lesion in the 3rd part of the duodenum and hospital course complicated by poorly controlled atrial fibrillation and new ARF secondary to hypovolemia induced ATN. See below for additional problem based hospital course. . 1. GIB: Patient was admitted to the ICU for concern of upper GI bleed, given h/o duodenal bleeding. In total, pt received 5u PRBC's (3 at outside, 2 here), 2u FFP, 1u Plts and Vitamin K for INR 5.7 at OSH. Hct was 23.2 on admission, was hemodynamically stable by MICU admission after resuscitation, Hct's were trended. ASA, Plavix and Coumadin were held. He was continued on Protonix gtt. GI did EGD on day of admission with report as above, he had coffee ground blood in stomach and blood in duodenum with [**Month/Day/Year 24997**] lesion in 3rd part duodenum and 3 clips were applied. He received 2u PRBC's after the procedure (5 total) and no further bleeding was seen, and his Hct stabilized. Hct reached as high as 29.3 during the admission and he was discharged with a stable Hct of 28.4. We discussed the patient's anticoagulation with the GI team and Vascular Surgery and they collectively agreed that we discontinue his ASA and Plavix until follow-up with GI specialist Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] given the recent bleed. On discharge, we will be sending him home on 3MG/day of Coumadin monotherapy for his Atrial Fibrillation, giving his CHADS2 score of 4. He will follow-up with INR monitoring and general anticoagulation with his PCP Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] on [**2111-9-9**]. 2. Acute Renal Failure: Baseline Cr 1.5-1.9, was 6.2 with K 6.7 on ED evaluation. He was treated for hyperK as below. Renal was consulted who saw muddy brown casts indicating ATN likely from severe hypotension with 80/40s BPs and acute anemia with nadir HCT 17 range. There was no immediate need for renal replacement therapy though given he was improving steadily and UOP was in acceptable ranges. There was also question of post-obstructive element given reports that he had a prior Foley in place at OSH that a nurse had removed, with poor UOP thereafter, in the setting of known BPH. ACEi, Lasix, [**Last Name (un) **], Bactrim were held as all could contribute to worse renal funciton. On discharge, we restarted the Lisinopril at 20 MG/day (down from 60 MG/day) and his Lasix at 20 MG/day (down from 40 MG/day). He was making good urine and his urine output was nearly balanced with intake fluids (clinically euvolemic), suggesting that these medications would be well tolerated by his kidneys and put him closer back to his home regimen. We continued to hold his Atacand and Aliskiren, but he will discuss these medications with his PCP Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] next week on [**2111-9-9**]. 3. Hyperkalemia: He received Calcium, D50 and insulin, and Kayexalate in the ED. In the MICU, Kayexalate was held given GIB, but pt received scheduled albuterol, D5 in his IVF's and insulin, and his K trended downwards with blood/IVF resuscitations. His K+ eventually stabilized and he was discharged with a value of 4.7. We are restarting him on his Lasix and Ace Inhibitor, but his K+ will be initially followed by VNA services. 4. Atrial fibrillation: Initially had poor control with atrial fibrillation with RVR on admission that was attributed to his severe hypovolemia. Then, he had metoprolol held in the ICU with limited control over his atrial fibrillation. Rates improved after both blood products and IVFs. Patient was slowly uptitrated on his beta blocker for better rate control. After 4 days of stable HCTs and no GIB after he underwent EGD with clipping of duodenal ulcer, he was restarted on his home coumadin. There was also some initial concern for QRS prolongation on EKG in the setting of hyperkalemia , however, he has a fascicular block at baseline and his QRS was at baseline. This longer QT improved with hyperkalemia treatment. He was notably not in atrial fibrillation later in hospital course. 5. PVD: Longstanding peripheral vascular disease. He is followed closely by Dr. [**Last Name (STitle) 1391**] here at [**Hospital1 18**]. He has a chronic right arterial ulcer: S/p surgical debridement by vascular surgery on [**8-18**] which was his last hospital admission. Wound care was consulted and recommendations were followed. RLE chronic wound appeared clean, non-infected for entirety of hospital course. Dr. [**Last Name (STitle) 1391**], was notified of the admission and agreed Bactrim could be discontinued as clean wound and no fevers or leukocytosis at time of discharge. As noted above, he was discharged on 3MG/day of Coumadin and his ASA and Plavix were discontinued for now and patient will re-address need to restart ASA/Plavix in near future with Dr. [**Last Name (STitle) 1391**] and his PCP. 6. Diabetes: Last A1c 8.7 in [**2109**]. On home oral hypoglycemics, which were held, patient was given Humalog ISS while in house. At discharge he was restarted on usual Januvia at home. 7. Hyperlipidemia: Continued zetia 8. Gout: Held allopurinol given ARF, and once Cr near baseline 2 range at discharge he was placed on a reduced renal dose of 100mg daily, down from his prior 300mg daily dosing. No signs of active flares. 9. Hypothyroidism: Continued usual synthroid medication, no dose alterations Medications on Admission: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. allopurinol 300 mg Tablet Sig: One (1) Tablet PO every other day. 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 11. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 13 days. Disp:*26 Tablet(s)* Refills:*0* 15. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day: Pre-admission medication. 16. Atacand 16 mg Tablet Sig: One (1) Tablet PO once a day: pre-admission medication. 17. texturna Sig: One (1) 150 once a day: pre-admission medication. 18. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Oral 19. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Pt received 2mg coumadin prior to discharge [**8-19**]. INR should be checked in [**3-5**] days, then regularly for INR goal [**3-5**]. . Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis: Upper Gastrointestinal Bleed ([**Company 24997**] Lesion) Secondary Diagnosis: Acute Renal Failure, Atrial Fibrillation with Rapid Ventricular Response Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname **], It was a pleasure taking care of you at the [**Hospital3 **] [**Hospital 1225**] Medical Center. While here, you were treated for a upper gastrointestinal bleed. On endoscopy, the GI doctors [**Name5 (PTitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24997**] lesion that was actively bleeding. They clipped the lesion and this controlled the bleeding. You also received a number of blood transfusions, and over the course of your hospitalization, your red blood cell level (hematocrit) improved significantly back to your baseline level. In addition, your creatinine was significantly elevated when you arrived at the hospital, suggesting that you were in acute renal failure. You were aggressively treated with fluids and we carefully watched and repleted your electrolytes. In particular, we paid close attention to your potassium given that it was also elevated. Both your creatinine and potassium have now come down nicely to their appropriate baseline levels. Finally, you had an episode of atrial fibrillation with rapid ventricular response on [**2111-8-29**], that led to a very high heart rate and low blood pressure. This was likely the result of your acute blood loss and low red blood cell level (hematocrit). We started you on Metoprolol and this brought your heart rate down and we subsequently increased the dosage back up to your home dose of 50 MG twice a day and you tolerated this well. Your heart rate and blood pressure since have been in the appropriate ranges and we will be recommending and sending you home on the same dose of Metoprolol. Given the bleeding that you experienced in your small intestine, we have recommended that you STOP taking your Aspirin and Plavix which thin your blood. We recommend that you continue on the Coumadin alone, at 3 MG/day. This was a joint decision by the GI doctors, your vascular surgeon Dr. [**Last Name (STitle) 1391**], and our team. In addition, we have outlined other medication changes and the appropriate doctors to follow up with. You have an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**], your PCP, [**Name10 (NameIs) **] [**2111-9-9**] at 11AM and an appointment with GI specialist Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] on [**2111-9-30**] at 10AM. The MEDICATION CHANGES that we have suggested are the following: 1) STOP taking Aspirin until you are seen by Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] 2) STOP taking Plavix until you are seen by Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] 3) STOP taking the Atacand until you see your PCP Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] 4) STOP taking your Bactrim 5) STOP taking your Texturna until you see your PCP Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] 6) CONTINUE taking Protonix 40 MG/day. STOP taking Omeprazole 20 MG/day 7) CONTINUE taking Coumadin at 3 MG/day 8) CONTINUE taking Lasix at 20 MG/day until you are seen by your PCP Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] 9) CONTINUE taking Lisinopril at 20 MG/day until you are seen by your PCP Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] 10) CONTINUE taking your Allopurinol at 100 MG/day Please take all other medications as before. Followup Instructions: Department: INTERNAL MEDICINE STE 2F When: WEDNESDAY [**2111-9-9**] at 11:00 AM With: [**First Name11 (Name Pattern1) 11595**] [**Last Name (NamePattern4) 19195**], MD [**Telephone/Fax (1) 19196**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD Specialty: Gastroenterology Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 682**] Appointment: Wednesday [**9-30**] at 10AM Completed by:[**2111-9-2**]

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icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

12731, 12780

5211, 10994

320, 343

12996, 12996

4018, 4018

16629, 17278

3404, 3422

12801, 12801

11020, 12708

13147, 16606

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371, 2601

12900, 12975

4034, 4857

12820, 12879

13011, 13123

2623, 3343

3359, 3388

2,598

113,200

44119

Discharge summary

report

Admission Date: [**2180-4-9**] Discharge Date: [**2180-4-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 317**] Chief Complaint: diaphoresis, black bowel movement Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 87yoW with history of CAD s/p PCI to LAD [**2177**], CHF with EF 47%, breast cancer, colitis NOS presenting with melana. Patient was in her normal state of health until [**2180-4-8**] when she felt sweats at night. She awoke on the morning of [**2180-4-9**] again diaphoretic with palpitations and lightheadedness. She called for help and went to the bathroom where she passed a large black bowel movement. She noted mid-epigastric pain that has been ongoing for several weeks. She denied any abdominal cramping, nausea, or vomiting. . In the ED, initial Hct 26.5. She received one unit PRBC and was admitted to MICU. EGD showed a single non-bleeding ulcer at the GE junction, blood in the body and fundus of the stomach. She received an additional three units PRBC overnight and was ruled out for acute coronary syndrome by three negative sets of cardiac enzymes. She denied chest pain or shortness of breath. . On ROS she denies fevers, chills, headache, cough, dysuria, hematuria, new skin changes or rashes. She does note some RLE muscle cramps for the past few days. All other systems per HPI. Past Medical History: 1. 2-v Coronary artery disease s/p MI [**1-/2178**]; Cath with PCI to LCx, LAD; reversible defect IL pMIBI [**1-/2180**], EF 47% 2. Breast cancer s/p B mastectomy 3. Colitis NOS 4. Secundum ASD (L -> R), 2+AR, [**11-21**]+MR 5. Squamous cell cancer 6. Hypothyroid 7. Hypercholesterolemia 8. Depression 9. s/p Appendectomy 10. s/p TAH Social History: lives alone with [**Hospital 2241**] home health aides present at baseline, she dresses herself, walks without assistance, and prepares meals widowed two months ago previously worked in development office at [**Hospital **] Hosp for 47yrs denies tob, EtOH . Contact: daughters [**Name (NI) **] [**Telephone/Fax (1) 94693**] (HCP) [**Name (NI) **] [**Telephone/Fax (1) 94694**] Family History: non-contributory Physical Exam: On admission: 98.0 94 104/41 14 98%RA Gen: elderly woman, comfortable, NAD HEENT: PERRL, anicteric, conjunctiva pale, OP clear with modestly dry MM HEENT: supple, no LAD, no JVD CV: RRR, III/VI pansystolic murmur, no s3s4, 2+radial and DP pulses Resp: CTAB Chest: mastectomy scars, sternal wound 1.5cm diameter, dressed with cream and dry gauze Back: winged scapula, nontender Abd: +BS, soft, ttp mid-epigastric, no rebounding or guarding, no HSM Ext: no edema, mildly ttp right calf Skin: diffuse nevi on neck, chest, abdomen, B arms, large nevi on abdomen, echymoses on right knee, left arm Pertinent Results: [**2180-4-9**] 11:40AM PT-13.5* PTT-19.6* INR(PT)-1.2 [**2180-4-9**] 11:40AM PLT SMR-NORMAL PLT COUNT-250 [**2180-4-9**] 11:40AM NEUTS-88.3* BANDS-0 LYMPHS-9.5* MONOS-2.1 EOS-0.1 BASOS-0.1 [**2180-4-9**] 11:40AM WBC-9.4 RBC-3.05* HGB-8.8* HCT-26.5* MCV-87 MCH-28.7 MCHC-33.0 RDW-13.1 [**2180-4-9**] 11:40AM DIGOXIN-1.1 [**2180-4-9**] 11:40AM CK(CPK)-63 [**2180-4-9**] 11:40AM GLUCOSE-165* UREA N-92* CREAT-1.2* SODIUM-141 POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-24 ANION GAP-16 [**2180-4-9**] 12:44PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2180-4-9**] 12:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2180-4-9**] 08:10PM HCT-26.9* [**2180-4-9**] 08:10PM CK(CPK)-62 EGD Report: Impression: Angioectasia in the stomach body Ulcers in the distal esophagus Recommendations: EGD in 2 months: Scheduled with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 7307**] for [**6-8**] (thursday) at 10:30 am. Pt to be on [**Hospital Ward Name 121**] 8 at 9:30 am. Please hold asa and plavix for 1 week if ok with primary team. High dose (double dose) PPI Additional notes: The attending physician was present for the entire procedure. Biopsies of esophagus not performed due to recent bleeding and recent ASA and plavix use. Will bring back after therapy for reassessment. Brief Hospital Course: 87yo woman with history of coronary artery disease, congestive heart failure, presenting with diaphoresis, melana, and found to have upper GI bleed. During her hospitalization, the following problems were addressed:. #. GI bleed: Patient was initially admitted to the ICU and transfused three units PRBC. Emergent EGD was done in the MICU showing an ulcer at the GE junction, but it was too obscured by blood for further investigation. She was monitored overnight in the MICU and then transferred to the floor. She underwent repeat EGD which showed two distal esophageal ulcers. It was later noted that the patient had been taking only a minimal amount of water with her weekly Fosamax, and this was thought to be the cause. Fosamax was held until further discussion with the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], can be had. Aspirin and Plavis were also held, and she was treated with big iv Protonix. Hct stabilized, and her diet was advanced. She was discharged to home on Prevacid 30mg [**Hospital1 **], liquid formula. She will resume taking Plavix 75mg daily on [**2180-4-19**]. She was instructed to resume Aspirin 81mg daily 4 weeks after discharge. She will follow-up with Dr. [**First Name (STitle) **] to review her hospital course On [**2180-4-18**]. She will follow-up with Dr. [**Last Name (STitle) **] for repeat endoscopy [**2180-6-8**], 8 weeks after initial evaluation. #. Leg twitching: On day two of her hospitalization the patient began complaining of bilateral leg twitching. A neurology consult was called and found her exam to be consistent with myoclonus due to metabolic insult. Specifically they felt the elevated urea level after her GI bleed likely resulted in the muscle spasms. Other sources of metabolic insult were evaluated including tests for thyroid function, and were nondiagnostic. The neurology services believed it would resolve spontaneously with clearance of the urea. The remainder of her neurologic exam was within normal limits. #. CAD: There were no acute issues. She was ruled out for acute MI and continued on her outpatient regimen of captopril, carvedilol, and statin for secondary prevention. Plavix will be restarted [**2180-4-19**], aspirin 4weeks after discharge.. #. CRI: Baseline creatinine 1.0-1.1, and was elevated as high as 1.3 during her hospitalization. It was thought to be prerenal in etiology and treated with gentle iv fluids. #. Hypothyroid: continued Synthroid per outpatient regimen. A TSH was checked and was mildly elevated at 4.4; however, free T4 was within normal limits at 1.6. #. Psych: continued citalopram, trazadone per outpatient regimen #. Osteoporosis: We discontinued weekly Fosamax out of concern that this was related to the developed of GE ulcers. The patient was instructed to discuss resuming Fosamax with her primary care physician. #. Dispo: The patient was discharged to home. She has full time home health aides. Health care proxy is her daughter [**Name (NI) **] [**Telephone/Fax (1) 94693**]. She will follow-up with Dr. [**First Name (STitle) **] [**2180-4-18**]. Medications on Admission: Captopril 25mg [**Hospital1 **] Citalopram 60mg daily Coreg 6.25mg [**Hospital1 **] Digoxin 0.125mg daily Folate 4mg daily Trazodone 50mg qHS Fosamax 70mg qweek Lasix 40mg daily Levothyroxine 75mg daily Plavis 75mg daily Zocor 20mg daily Discharge Medications: 1. Captopril 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QOD (). 6. Levothyroxine Sodium 50 mcg Tablet Sig: 0.5 Tablet PO QOD (). 7. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily) as needed. 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety, sleeplessness. 10. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleeplessness. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: Please do not start taking this medication until [**2180-4-19**]. 15. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO twice a day. Disp:*qs mg* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed . Secondary: Coronary artery disease Congestive heart failure Discharge Condition: stable Discharge Instructions: If you develop any further episodes of bleeding, or if you develop dizziness, lightheadedness, chest pain, shortness of breath, abdominal cramps, fever, or any other concerning symptom, please contact your primary care physician [**Name Initial (PRE) **]/or return to the emergency department. . Please follow-up for a repeat endoscopy on [**2180-6-8**]. . Please do not restart your Plavix until next Wednesday [**2180-4-19**]. Please resume taking aspirin in 4 weeks. Please do not take Fosamax again until you discuss this further with Dr. [**First Name (STitle) **]. Taking Fosamax without sufficient water may have been related to development of the ulcers. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2180-6-8**] 8:30 Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Where: GI ROOMS Date/Time:[**2180-6-8**] 8:30 . Please follow-up with Dr. [**First Name (STitle) **] Tuesday [**2180-4-18**] at 3:00pm. You can call [**Telephone/Fax (1) 40745**] with any questions or concerns.

[ "333.2", "398.91", "E935.9", "396.3", "531.40", "733.00", "V45.82", "V10.3", "285.1", "414.01", "244.9", "272.0" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

8998, 9004

4303, 7460

294, 306

9134, 9142

2890, 4280

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2222, 2240

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9025, 9113

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9166, 9831

2255, 2255

221, 256

334, 1444

2269, 2871

1466, 1811

1827, 2206

4,588

186,721

43980

Discharge summary

report

Admission Date: [**2113-3-3**] Discharge Date: [**2113-3-8**] Date of Birth: [**2073-1-19**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: CC: SOB & hyperglycemia Major Surgical or Invasive Procedure: none History of Present Illness: . HPI: 40 y/o male with PMHx of alpha-1 anti-trypsin deficiency, Type 1DM, Hep C cirrhosis presents with 1 week of cough productive of yellow sputum, general malaise, night sweats & fever to 101 on Wednesday. Pt c/o sore throat, nausea but no emesis/diarrhea. Pt reports that BS have been running high in "400s" this week and he has been unable to control with ISS. Pt denies any change in bowel habits, no BRBPR/melena, dysuria or hematuria. +Increased frequency and nocturia x2/night. Sick contacts- [**Name (NI) 94444**] all with fever/URI. Pt describes some mild SOB/DOE and using nebulizer more frequently. He has had 3 days of L lateral chest wall ache approx [**5-13**], worse with coughing or deep breath. Pt has some orthostasis, recent wt loss, lightheadedness, PND & sleeps with 4 pillows for comfort not SOB with lying flat. . Pt presented to the ED with T 98, HR 119, BP 120/83, RR 20, Sats 95% on RA. He received Solumedrol 125mg IV, Duonebs and Levofloxacin for presumed bronchitis triggering COPD exacerbation. Pt was found to have BS of 250s, that came up to 500 with dinner & steroids. Pt received a total of 10u & 5u regular insulin with little improvement in BS. Pt was refused transfer to floor for BS >400. . On arrival to ICU, pt was comfortable, sating well on RA and denying any SOB at rest. Past Medical History: 1. Alpha 1 Anti-Trypsin Disorder (Liver/Lung) 2. Diabetes Mellitus, Type I 3. Cirrhosis secondary to Alpha 1 Anti-Trypsin Disorder 4. Hypothyroidism (s/p XRT to thyroid) 5. COPD (emphysema/bronchiectasis) 6. Depression 7. Anxiety w/ h/o panic attacks 8. GERD 9. Rheumatoid Arthritis 10. Chronic Pain (jaw with hardware, back, knees) 11. Carpal Tunnel Syndrome 12. Hepatitis C 13. IVDU (cocaine) 14. Previous TB exposure (?-positive PPD) Social History: h/o IVDU (cocaine). Has had multiple relapses, most recently in [**8-10**]. Does not share needles. Former Tobacco (approx 30 pack-years). Occasional EtOH (former heavy EtOH). Lives with 2 roommates. Has family nearby. Family History: Mother: RA/SLE/fibromyalgia Physical Exam: PE: T- 95.2 HR-98 BP-126/89 RR-13 Sats 94 % on RA GEN: NAD, pale, comfortable, no e/o resp distress HEENT: PERRLA, EOMI, sclera anicteric, oropharynx with scattered white plaques, precervical lymphadenopathy, MMM CV: regular, nl s1, s2, no m/r/g. +TTP over L lateral ribs/chest wall PULM: occais crackle at LLL base, no wheezes or rales, moving air well but coughing with deep inspiration ABD: soft, NT, ND, + BS, mild TTP over RUQ, no HSM EXT: warm, 2+ dp/radial pulses BL NEURO: alert & oriented x 3, CN II-XII grossly intact Pertinent Results: 129 95 20 Gluc 549 AGap=15 ------------ 4.4 25 1.0 . WBC-14.2, Hgb-14.3, Hct-40.6, Plts-221 Diff- N:63 Band:3 L:22 M:8 E:1 Bas:0 Atyps: 3 . Micro: Sputum GRAM STAIN [**2113-3-3**] >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS IN CHAINS. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. [**2113-3-3**] CXR PA & Lateral: Pruning of the pulmonary vasculature and emphysematous changes prominent at the lung bases are consistent with patient's known alpha-1 antitrypsin deficiency. There are no pleural effusions. There are no focal pulmonary opacities identified to indicate pneumonia. IMPRESSION: No acute cardiopulmonary process. Stable emphysematous changes at the lung bases. . ECHO [**3-10**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . EKG [**2113-3-3**]: NSR, mildly tachy, normal axis & intervals, poor r wave progression, essentially unchanged from prior tracings Brief Hospital Course: 40 y/o M with alpha 1 antitrypsin dz, COPD, hepatitis C, cirrhosis and DM I admitted with c/o SOB, cough with sputum production & hyperglycemia. #Cough/SOB/COPD exacerbation. Pt with h/o alpha 1 antitrypsin defic & assoc COPD who presented with SOB, cough. CXR without infiltrate but sputum culture grew S. pneumo. He was treated with levofloxacin x 5 days, pulse steroids x 3 days, nebs with rapid improvement in his sx. His breathing is quite comfortable at this time and he is ambulating without difficulty. He is to continue his home inhalers. He is now off steroids. #Hyperglycemia: Pt with history of brittle type I & labile blood sugars. BS have been running high this week, likely [**2-4**] URI & fevers. Pt presented with BS of 278 & gap of 12. Pt received IV solumedrol & BS rose to 550 with Gap of 15. Urine was positive for ketones & glucose. He required admission to the ICU for insulin gtt with q1hr BS checks. He was closely followed by [**Last Name (un) **] during ICU and floor stays. As he has now completed his steroid pulse, his sugars are easier to control. He expressed on several occasions that he wanted a more conservative lantus and ISS as he has had some problems with morning hypoglycemia in past. He is now agreeable to Lantus 24 units bedtime and has a sliding scale Apidra, copy provided for him at time of discharge. He has a f/u appt at [**Last Name (un) **] in 1 week . # Hepatitis C: Pt with active Hep C, last VL 29 400 in [**11-10**] followed by GI at [**Hospital1 112**], and there is ongoing discussion regarding initiation of interferon therapy, currently untreated. Has has had some mild RUQ tenderness, stable transminitis. No evidence of biliary obstruction on labs. . # [**Hospital1 **]: Pt with chronic [**Hospital1 11395**] followed by ENT, has white plaques scattered over oropharynx on exam and precervical LN. He was given nystatin swish and swallow and clotrimazole troches. HIV testing [**8-10**] was negative . # Depression/Panic disorder: Pt denying any current SI/HI, also denies substance abuse since [**7-10**]. - continue amitriptyline, citalopram, and risperidone at prior home doses . # Chronic pain: managed by pain clinic; Rx go through [**Hospital 191**] clinic. - continued on home regimen of amitriptyline, citalopram, gabapentin, oxycodone, and methadone. - he requested refills on the day of discharge, but I spoke with his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] and it appears he was last given refill on [**2-22**] (2 week supply). As he was admitted [**2-/2034**], he should still have approximately 5 days left. He was instructed to call [**Hospital 191**] clinic for refill. # Hypothyroidism: continued home Synthroid 100mcg daily . # GERD: stable, continue PPI. . Medications on Admission: Advair 500-50 1 puff [**Hospital1 **] Atrovent 21 mcb 2 sprays tid prn Flonase 2 puffs daily Ventolin nebulizer Amitriptyline 75 mg [**1-4**] tab qhs prn Apidra SQ SS Aralast IV q week Celexa 60 mg daily Lantus 10u sc qhs Docusate 1 cap daily Senna [**Hospital1 **] Oxycodone 15-30 mg q6-8h prn Methadone 30 mg tid Neurontin 400 mg tid Prilosec 40 mg daily Synthroid 200 mcg daily Lamisil 1% top to feet [**Hospital1 **] Risperdone 0.25mg [**Hospital1 **] Discharge Disposition: Home Discharge Diagnosis: Hyperglycemia COPD exacerbation Secondary: Alpha 1 Anti-Trypsin deficiency COPD/emphysema and bronchiectasis Type 1 DM Cirrhosis secondary alpha 1 antitrypsin deficiency + HCV HCV Depression Anxiety h/o panic attacks Chronic pain (jaw with hardware) Discharge Condition: stable Discharge Instructions: Please seek medical attention if you develop worsening shortness of breath, cough, fever. Keep your [**Last Name (un) **] appointment as below. I have spoken to Dr. [**First Name (STitle) **] about your pain medications. Your last refill was on [**2-22**] for a 2-week supply. As you were hospitalized beginning [**2-/2034**], you should still have approximately 5 day supply left at home. Dr. [**First Name (STitle) **] is aware and is anticipating your need for refill in about 5 days. Please call your [**Hospital 6435**] clinic to reschedule your follow-up appointment and also to obtain your pain med prescriptions. Followup Instructions: Please call [**Hospital 191**] clinic [**Telephone/Fax (1) 250**] for follow-up with your PCP in the next 2-3 weeks Please keep your [**Last Name (un) **] appointment next week. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2113-5-26**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7733, 7739

4444, 7226

292, 299

8034, 8043

2952, 4421

8718, 9020

2359, 2388

7760, 8013

7252, 7710

8067, 8695

2403, 2933

228, 254

327, 1646

1668, 2107

2123, 2343

69,469

179,397

7182

Discharge summary

report

Admission Date: [**2119-11-9**] Discharge Date: [**2119-11-14**] Date of Birth: [**2037-3-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5134**] Chief Complaint: S/p fall, found down, rapid atrial fibrillation Major Surgical or Invasive Procedure: None History of Present Illness: 82F w hx HTN, atrial fibrillation, s/p partial thyroidectomy, remote seizure disorder, who presented to ED last night. She had fallen 4 days prior, mechanical fall from toilet, no loss of consciousness; pt lives alone but did not use her lifeline because she was concerned that EMS would not be able to open her locked bathroom door. She was apparently able to phone her neighbors 2 days ago, but remained on the floor at home until yesterday when she called EMS. She denied overall weakness but did state that her legs would not support her. Though she does have a remote history of seizures, she denied any seizure activity, tongue-biting, bladder/bowel incontinence, or loss of consciousness during this episode. She notes that she had just been leaning forwards on the toilet and lost her balance. She did miss [**First Name (Titles) **] [**Last Name (Titles) 4982**] for at least 2 days while on the bathroom floor and had very limited po intake. . In the ED, patient was noted to be in Afib with RVR to 180s, refractory to boluses of IV metoprolol and diltiazem, but responded to diltiazem drip, for which she was admitted to the medical ICU. CT head was negative, and CXR had cardiomegaly. In the MICU, diltiazem drip was weaned off overnight. She was placed on diltiazem 60mg QID and metoprolol tartrate 50mg TID (home doses: diltiazem XR 240mg daily and metoprolol tartrate 100mg [**Hospital1 **]). She was also noted to have a urinary tract infection, for which she was given a dose of ceftriaxone in the ED then switched to ciprofloxacin this morning. She did have a supratherapeutic INR on presentation, was given a dose of po vitamin K 5mg in the ED. . Prior to transfer to floor, vitals as follows: T 98.2 HR 90 (irregularly irregular) BP 142/69 RR 22 O2 Sat 93% RA . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -Atrial fibrillation -Hypertension -Remote seizure disorder (per patient, last seizure > 30 years ago) -S/p partial thyroidectomy, now with hypothyroidism Social History: Lives at home alone in an apartment in [**Location (un) **]. Occasional half-glass of etoh. No tobacco or illicits. Family History: No heart disease, cancer, or other seizure history Physical Exam: VS: Temp:96.9 BP: 150/115 HR:103 (afib) RR:18 O2sat92% RA GEN: pleasant, comfortable, NAD, sweaty HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, JVP to 8 cm at 30 degrees elevation, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: tachycardic, irregularly irregular, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or HSM EXT: no c/c/e. + ecchymosis over left knee. 2+ DP/PT/radial pulses bilaterally. NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. 2+DTR's-patellar and biceps RECTAL: deferred Pertinent Results: Labs on Admission: [**2119-11-9**] 02:35PM URINE HOURS-RANDOM [**2119-11-9**] 02:35PM URINE GR HOLD-HOLD [**2119-11-9**] 02:35PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.021 [**2119-11-9**] 02:35PM URINE BLOOD-LG NITRITE-POS PROTEIN-150 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2119-11-9**] 02:35PM URINE RBC-[**3-31**]* WBC-[**12-16**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2119-11-9**] 12:30PM PT-51.3* PTT-39.6* INR(PT)-5.6* [**2119-11-9**] 12:15PM GLUCOSE-95 UREA N-51* CREAT-1.2* SODIUM-138 POTASSIUM-3.0* CHLORIDE-94* TOTAL CO2-29 ANION GAP-18 [**2119-11-9**] 12:15PM estGFR-Using this [**2119-11-9**] 12:15PM CK(CPK)-2098* [**2119-11-9**] 12:15PM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-1.8 [**2119-11-9**] 12:15PM WBC-8.7# RBC-4.98# HGB-14.9 HCT-44.2 MCV-89# MCH-29.8 MCHC-33.6 RDW-15.1 [**2119-11-9**] 12:15PM NEUTS-84.9* LYMPHS-7.6* MONOS-6.3 EOS-0.8 BASOS-0.5 [**2119-11-9**] 12:15PM PLT COUNT-362 Labs on Discharge: [**2119-11-14**] 05:10AM BLOOD WBC-5.4 RBC-3.83* Hgb-11.4* Hct-33.9* MCV-89 MCH-29.7 MCHC-33.5 RDW-15.5 Plt Ct-320 [**2119-11-14**] 05:10AM BLOOD Glucose-94 UreaN-19 Creat-0.8 Na-137 K-3.9 Cl-99 HCO3-30 AnGap-12 Imaging: ECG Study Date of [**2119-11-9**] 12:07:06 PM Atrial fibrillation with rapid ventricular response. Consider left ventricular hypertrophy with repolarization abnormality. No previous tracing available for comparison. ECG Study Date of [**2119-11-9**] 3:05:52 PM Atrial fibrillation. Since the previous tracing the rate has decreased. QRS voltage has increased and is probably more apparent. Clinical correlation is suggested. CT HEAD W/O CONTRAST Study Date of [**2119-11-9**] 12:26 PM IMPRESSION 1. No evidence of acute intracranial injury. 2. Nonspecific hypodense bony lesions in the frontal bone. Correlation with history of malignancy and comparison with prior CTs if available is recommended. CT C-SPINE W/O CONTRAST Study Date of [**2119-11-9**] 12:29 PM IMPRESSION: 1. No evidence of acute injury to the cervical spine. 2. Enlarged left thyroid gland, likely multinodular goiter, but clinical correlation recommended. 3. Fibrotic changes in bilateral lung apices, most likely related to prior granulomatous disease. CHEST (SINGLE VIEW) Study Date of [**2119-11-9**] 3:51 PM IMPRESSION: Retrocardiac atelectasis or pneumonia. Cardiomegaly. Enlarged left thyroid gland. Brief Hospital Course: 82 y/o F with hypertension, atrial fibrillation, remote seizure disorder and thyroidectomy, past episodes of self-neglect, presenting to ED after several days of immobilization [**2-28**] fall at home. . #. Atrial fibrillation: Likely [**2-28**] withdrawal of dual rate control with diltiazem and metoprolol in addition to significant dehydration while the patient was on the floor of her home. The patient was transferred to the ICU for rate control with a diltiazem drip, to which she responded. Ultimately was able to control rate on the drip, with hemodynamic stablitiy (mildly elevated blood pressures). Was transferred to the floor on a PO regimen of diltiazem and metoprolol similar to her home regimen. On telemetry, patient was noted to have atrial fibrillation, mostly in 50s-60s, with occasional asymptomatic bradycardia to 40s. The patient did not have any further episodes of Afib with RVR on the floor. She was hemodynamically stable, and was discharged on her home dose of diltiazem and 50 mg of metoprolol [**Hospital1 **], as opposed to 100 mg [**Hospital1 **], given her asymptomatic bradycardia. #. Social: This is the second time patient has been immobilized on ground for several days after falling, without seeking medical care. Per EMS report, patient's house very messy. Daughter markedly concerned for mother's ability to care for herself. Elder care services was notified and prefer to evaluate patient in home setting. It was decided upon discharge that the patient would return to her home with her daughter, for further evaluation by elder care services. #. Hypertension: On ACE-i, [**Last Name (un) **], thiazide, beta blocker, hydralazine at home. Mildly hypertensive on arrival, in setting of not taking [**Last Name (un) 4982**] for several days. Upon discharge, the patient was restarted on all of home [**Last Name (un) 4982**] except for the hydralazine. #. Nonspecific hypodense bony lesions: In hospital, we were unable to correlate with a history of malignancy. Patient will benefit from a comparison to prior CTs as an outpatient. Of note, per [**2118-6-23**] [**Hospital6 2561**] Radiology, at that time there was no evidence of intracranial traumatic injury, remote ischemic injury and nonspecific white matter change, cervical spondylosis without evidence of fracture or dislocation, and enlarged left thyroid mass status post right thyroidectomy. Follow-up as an outpatient is recommended. #. Remote seizure disorder: Per patient, no seizure activity for past several decades. No reported epileptiform symptoms, although patient's insight to her own medical issues is in doubt, given the events of the past week. #. Supratherapeutic INR: Per patient, last INR check 1-2 weeks ago was elevated at 3.5. Warfarin dosing of 6 mg daily was not changed at that time, but the patient was instructed to eat spinach daily. While in the hosptial, the patient's INR trended downwards to 1.7; the patient was ultimately discharged on her home dose of warfarin, and instructed to follow-up have her INR drawn in two days and faxed to her PCP's office who manages her warfarin dosing. #. Renal insufficiency: Baseline Creatinine generally 0.8-1.0. Patient had a mildly elevated BUN/Cr on admission to 51/1.2, in setting of elevated CK and poor PO intake. Elevated BUN/creatinine ratio consistent with perfusion-related injury. THe patient received IVF in the ED, PO intake was encouraged, and in the hospital the patient's ACE, [**Last Name (un) **], and HCTZ were held until her [**Last Name (un) **] resolved with hydration #. Elevated CK: Likely [**2-28**] being down on ground for several days. Elevated EK resolved with hydration, and did not cause significant renal impairment. #. S/p thyroidectomy/hypothyroidism: Per patient, had part of thyroid removed 1-2 years ago. On home levothyroxine, though not documented in OMR. TSH 1.4 in [**Month (only) 958**], as measured at [**Hospital3 2568**]. On recheck here, TSH was noted to be 2.8. #. UTI: Grossly positive u/a without culture sent. Ceftriaxone x1 in ED. No fevers or SIRS physiology on arrival. Past urine cultures at [**Hospital3 2568**] have grown E coli sensitive to everything except tetracycline. Urine [**11-9**] growing Klebsiella, S to everything tested except nitrofurantion. PO Cipro was started for a total 3 day course for uncomplicated UTI (Day 1 [**2119-11-11**] to end on [**2119-11-13**]). #. Ketonuria: Normoglycemic and no history of diabetes. Suspect starvation ketosis. Comm: Daughter [**Name (NI) **] [**Name (NI) 12424**] (HCP: Cell: [**Telephone/Fax (1) 26655**], Home: [**Telephone/Fax (1) 26656**]). Friend [**Name (NI) 1439**] [**Name (NI) **] [**Telephone/Fax (1) 26657**] Code: Full [**Telephone/Fax (1) **] on Admission: -Warfarin 6 mg PO Daily -Klor-con 10 mEq PO daily -Dilt-XR 240 mg PO Daily -HCTZ 25 mg PO daily -Calcium citrate/Vit D3 (?dose PO daily) -Hydralazine 35 mg PO TID -Benicar 40 mg PO Daily -Lisinopril 80 mg PO daily vs 40 mg PO BID -Metoprolol tartrate 100 mg PO BID -Levothyroxine 112 mcg daily Discharge [**Telephone/Fax (1) **]: 1. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day. 2. Klor-Con 10 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day. 3. DILT-XR 240 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day. 4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. calcium citrate-vitamin D3 200 mg(calcium) -250 unit Tablet Sig: One (1) Tablet PO once a day. 6. Benicar 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 8. levothyroxine 112 mcg Capsule Sig: One (1) Capsule PO once a day. 9. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: - Atrial fibrillation with rapid ventricular rate Secondary Diagnoses: - Hypertension 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: Ms. [**Known lastname 12424**], you were admitted to the hospital after you were found on the floor of your bathroom, unable to get up. At that time, you had a very high fast rate, likely from the fact that you hadn't been taking your [**Known lastname 4982**] to help slow down your heart. You were admitted to our hospital to further manage your heart rate. Your physicians and family were concerned about your fall, as this has happened before, and recommended that you have somebody nearby to assist you at all times. When you leave the hospital: 1. STOP taking Hydralazine 35 mg by mouth three times a day 2. DECREASE your dose of Metoprolol to 50 mg twice a day (previously you had been taking 100 mg twice a day) Your primary care physician can make changes to these [**Known lastname 4982**] as needed. We did not make any other changes to your [**Known lastname 4982**], so please continue to take them as your normally do. On your CT scan of your head, we noted that there was a small area of the skull that was slightly less dense than the rest of your skull. Please have your primary care doctor evaluate this further. Followup Instructions: Please be sure to keep all of your followup appointments as listed below. Department: Primary Care Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 26658**] When: Tuesday [**2119-11-21**] at 10:30 AM Location: PHYSICIAN ASSOCIATES AT [**Hospital3 **] Address: [**Hospital3 26659**] [**Apartment Address(1) 26660**], [**Hospital1 **],[**Numeric Identifier 26661**] Phone: [**Telephone/Fax (1) 26662**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

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6072, 10826

364, 371

12221, 12221

3653, 3658

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136,509

336

Discharge summary

report

Admission Date: [**2145-3-11**] Discharge Date: [**2145-3-17**] Date of Birth: [**2101-3-21**] Sex: F Service: MEDICINE Allergies: Clindamycin / Zemplar / Levofloxacin / Trazodone / Doxycycline Attending:[**First Name3 (LF) 348**] Chief Complaint: hypotension, line infection Major Surgical or Invasive Procedure: IR placement on tunelled HD line on [**3-16**] History of Present Illness: 43F with ESRD on HD, DM1, CAD s/p CABG, h/o poor access with failed AV fistulas presenting with pus coming from HD line. Systolic BPs to 80s, patient appeared sick and was not mentating well. Lactate was 3.0. Therefore peripheral dopamine started (patient did not want central line). She did not have arterial line. On arrival on the floor hypotensive to sbp of 84, but talkative, mentating. says baseline BP is in 110s. Given that patient does not have dialysis access, she was not given IVF. Pressure has now improved to mid-90s systolic. Of note, patient admitted to [**Hospital1 18**] [**12/2144**] for tunelled line infection. the line was removed and replaced at that time. A TTE did not show evidence of endocarditis at that time. A TEE was attempted but not completed because of patient intolerance. She denies known exposure to line site to cause infection. She wonders about sterility of dressings at her outpatient HD center. Upon arrival at the [**Hospital1 18**] ED, patient was febrile to 101.5, later peaking at 102.6. Central line considered but patient refused. Past Medical History: 1. CAD s/p CABG x 3 in [**10-27**] 2. DM1 since age of 6 3. ESRD on HD, being worked up for transplant 4. h/o MRSA rt stump infection 5. anemia 6. PVD s/p TMA 7. h/o epistasis from right nostril 8. Bell's Palsy (right side, s/p valtrex x 7 days, last [**1-2**]) 9. AAA repair in '[**39**] 10. h/o previous tunelled line infection. Social History: No tobacco, alcohol or illicit drug use Family History: Mother: [**Name (NI) 2481**] disease and CAD Father: deceased from prostate CA Siblings are all alive and well Physical Exam: Exam on transfer to floor Vitals: T 94.5 84/doppler 67 16 98%RA General: well-appearing Neck: no JVD CV: RRR nl S1, S2 no murmurs Lungs: Crackles at bases bilaterally Abd: Soft, NT, ND, +BS Ext: No c/c; 1+ pitting edema in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l Neuro: mentating well, conversant, slightly aggitated/aggravated with concern over BP Skin: Multiple excoriations and scabbed over lesions on arms Pertinent Results: CXR on admission: FINDINGS: There has been interval placement of a large bore dual-lumen dialysis catheter with the distal tip projecting over the right atrium. Prominence of the [**Last Name (Prefixes) 1106**] pedicle is again identified with mild cephalization. This is relatively stable. No overt edema is noted. There is no consolidation. Lung volumes are low. The cardiac silhouette remains enlarged, but stable. Clips and median sternotomy wires are consistent with prior CABG. No effusion or pneumothorax is evident. The bones are diffusely osteopenic. The patient has had prior cholecystectomy. IMPRESSION: Interval placement of a dialysis catheter. Stable findings otherwise with no definite superimposed acute process. . HD line placement: IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided tunneled dialysis catheter placement via the left internal jugular venous approach. . [**2145-3-11**] 05:55PM BLOOD WBC-9.4 RBC-4.18*# Hgb-13.4# Hct-42.9# MCV-103* MCH-32.0 MCHC-31.2 RDW-19.8* Plt Ct-161 [**2145-3-17**] 10:50AM BLOOD WBC-6.1 RBC-3.97* Hgb-11.9* Hct-39.7 MCV-100* MCH-29.9 MCHC-29.8* RDW-20.5* Plt Ct-205 [**2145-3-11**] 05:55PM BLOOD Neuts-89.8* Bands-0 Lymphs-7.0* Monos-2.1 Eos-0.8 Baso-0.4 [**2145-3-13**] 02:34AM BLOOD Neuts-74.1* Lymphs-16.7* Monos-8.3 Eos-0.1 Baso-0.9 [**2145-3-11**] 05:55PM BLOOD PT-15.8* PTT-34.1 INR(PT)-1.4* [**2145-3-16**] 05:35AM BLOOD PT-14.0* PTT-30.3 INR(PT)-1.2* [**2145-3-11**] 05:55PM BLOOD Glucose-287* UreaN-24* Creat-3.5*# Na-136 K-4.2 Cl-91* HCO3-27 AnGap-22* [**2145-3-17**] 10:50AM BLOOD Glucose-320* UreaN-51* Creat-5.7*# Na-134 K-4.9 Cl-95* HCO3-22 AnGap-22* [**2145-3-13**] 07:57AM BLOOD Vanco-11.4 [**2145-3-15**] 06:30AM BLOOD Vanco-9.4* [**2145-3-16**] 03:40PM BLOOD Vanco-20.5* [**2145-3-11**] 06:11PM BLOOD Lactate-3.0* . [**Month/Day/Year **] (4/34): prelim The left atrium is elongated. The left atrium is dilated. There is severe regional left ventricular systolic dysfunction with akinesis and thinning of the entire inferior wall and hypokinesis of the remaining segments. Diastolic function could not be assessed. The remaining left ventricular segments are hypokinetic. Right ventricular chamber size is normal. with borderline normal free wall function. 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. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 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. 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetation seen. Mild mitral and tricuspid regurgitation. Severe regional and moderate global LV systolic dysfunction. Compared with the prior study (images reviewed) of [**2144-12-25**], the pulmonary artery systolic pressures are slightly elevated. The other findings are similar. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Brief Hospital Course: #MRSA Sepsis Patient has history of line sepsis previously with MRSA. Source of sepsis unclear. [**Name2 (NI) **] had a TTE to evaluate valves which was of suboptimal quality but did not show large vegetations. Plan is for two weeks of treatment with vancomycin starting on [**3-12**]. If, after two week course of treatment, patient has persistent bacteremia, she should be considered for TEE. . #Hypotension when hypotensive on admission, patient was not mentating well and had elevated lactate. Hypotensive on the floor to mid-80s systolic however patient was mentating well. On discharge BP 116-128/64-72. She required peripheral dopamine in the ICU. . #ESRD on HD Patient was without HD between [**3-11**] and [**3-16**]. She did not have uremic signs or symptoms except for some non-specific itching. We continued nephrocaps, Cinacalcet, and calcium carbonate. She may have a high-protein diet while on HD. # DM I Continued outpatient Insulin regimen of 12 units NPH qAM. fasting blood glucose in AM was elevated, however given multiple periods of being NPO, her regimen was not adjusted. This may be titrated at rehab. . # Diarrhea Patient had 36hrs of diarrhea and was C.diff negative x3. Diarrhea resolved with imodium. She was afebrile and had minimal abdominal pain. . # Skin breakdown Patient was admitted with skin breakdown felt to be from prolonged imobilization. She was treated with therapeutic boots, air mattress, and skin care. She refused air mattress after an explanation of the risks and benefits including development of pressure ulcers. Medications on Admission: 1. Folic Acid 1 mg PO QD 2. Nephrocaps PO QD 3. Calcium Carbonate 1000 mg PO QID w/ meals 4. Pantoprazole 40 mg PO QD 5. Insulin NPH 12 U QAM w/ Insulin Lispro sliding scale 6. Cinacalcet 60 mg PO QD 7. Heparin 5000 U SC TID 8. Aspirin 325 mg PO QD . Allergies/Adverse Reactions: Clindamycin (diarrhea) Zemplar (rash) Levofloxacin (diarrhea) Trazodone (unknown) Doxycycline (nausea/vomiting) Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day as needed: give with meals. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 11. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for itching. 12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twelve (12) units Subcutaneous qAM. 13. Insulin Lispro 100 unit/mL Cartridge Sig: sliding scale Subcutaneous four times a day. 14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 8 days: last day [**3-25**]. Discharge Disposition: Extended Care Facility: Courtyard - [**Location (un) 1468**] Discharge Diagnosis: Primary: MRSA septic shock infected tunelled HD line Diabetes Mellitus type I Discharge Condition: Good. Blood pressure 116-128/64-72 at discharge. Discharge Instructions: You were admitted because of septic shock with pus coming from your hemodialysis catheter. This was treated with a stay in the ICU with temporary use of medications to support your blood pressure. The old line was removed and your were given antibiotics. You have had a new line put in for dialysis access. You had an [**Location (un) 461**] to find a source for your recurrent MRSA infections. It is not clear why you are having recurrent infections of your hemodialysis line. You will continue to get vancomycin at dialysis for a total of two weeks. After this time if you have recurrent positive cultures, we would recommend having a trans-esophageal [**Location (un) 461**]. Please speak with your kidney doctor regarding this. Followup Instructions: Please followup with your PCP when you leave rehab. please continue to have dialysis

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icd9cm

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[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

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50,722

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38274

Discharge summary

report

Admission Date: [**2146-5-10**] Discharge Date: [**2146-5-21**] Date of Birth: [**2092-3-6**] Sex: F Service: CARDIOTHORACIC Allergies: Vancomycin / Ciprofloxacin Attending:[**First Name3 (LF) 1505**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: [**2146-5-16**] 1. Coronary artery bypass grafting x 3 with left internal mammary artery graft to left anterior descending and reverse saphenous vein graft to the diagonal and the posterior descending artery. 2. Ligation of a LAD pseudoaneurysm. History of Present Illness: 54 year old female with knowncoronary artery disease, with history of multiple (4) stents,HTN, hyperlipidemia, and positive tobacco use presented [**Hospital 85297**] hospital with unstable angina and a marginally elevated troponin. Cardiac cath revealed mltivessel coronary disease with in-stent stenosis. She was transferred to [**Hospital1 18**] for surgical evaluation of coronary revascularization. Past Medical History: CAD-s/p PCI and multiple coronary stents [**2139**]/[**2140**]/[**2142**] HTN hyperlipidemia Social History: Occupation:manages real estate property Tobacco: current 1/2-1 ppd; >30 PY ETOH:previous 2 "large" scotches/day-has been cutting down over last month to 1 shot/day-last drink Friday denies other illicit drugs Family History: Father died of liver cancer. Mother is 92 Physical Exam: Pulse:65 Resp:16 O2 sat: 99 on RA B/P Right:99/64 General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema/Varicosities: None [x] Neuro: Grossly intact[x] Pulses: Femoral Right: 2+-cath site w/o hematoma Left: 2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: none Left:none Pertinent Results: Intra-Op Echo [**2146-5-16**] PRE-BYPASS: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved [**Hospital1 **]-ventricular systolci function. 2. No change in valve structure and function. 3. Intact aorta [**2146-5-20**] 05:40AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.5* Hct-27.9* MCV-93 MCH-31.5 MCHC-34.0 RDW-14.7 Plt Ct-240# [**2146-5-20**] 05:40AM BLOOD Plt Ct-240# [**2146-5-20**] 05:40AM BLOOD UreaN-10 Creat-0.7 Na-138 K-3.5 Cl-99 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2146-5-16**] where the patient underwent CABG x 3 as detailed in the operative report. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis, given the preoperative LOS of greater than 24 hours. POD 1 found the patient extubated, alert and oriented and breathing comfortably. By POD 2 the patient was hemodynamically stable, weaned from vasopressor/inotropic support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without incident. Ms. [**Known lastname 85298**] was evaluated by the physical therapy service for evaluation of her strength and mobility. By the time of discharge on POD five the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was cleared by Dr [**Last Name (STitle) 914**] for discharge to home on POD# five. All follow up appointments were advised. Medications on Admission: Plavix 75(1)/Zetia 10(1)/Metoprolol 12.5(2)/Lipitor 40(1)/Gemfibrozil 600 (2)/HCTZ 25(1)/Wellbutrin 150(2)-tobacco cessation Discharge Medications: 1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. 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* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for stents. Disp:*30 Tablet(s)* Refills:*0* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*2* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:*40 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking percocet, for constipation. Disp:*60 Capsule(s)* Refills:*2* 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: VNA of [**Doctor Last Name **] Discharge Diagnosis: Coronary Artery Disease, s/p CABG PMH: CAD-s/p PCI and multiple coronary stents [**2139**]/[**2140**]/[**2142**] HTN hyperlipidemia 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2146-6-23**] 1:00 Please call to schedule appointments Cardiologist Dr. [**Last Name (STitle) 8579**] [**Telephone/Fax (1) 23882**] in [**11-20**] 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:[**2146-5-21**]

[ "V45.82", "458.29", "995.27", "411.1", "305.1", "401.9", "V16.0", "E931.9", "996.72", "272.4", "E930.8", "E878.1", "414.11", "414.01", "512.1" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "36.15", "36.91" ]

icd9pcs

[ [ [] ] ]

6221, 6282

3113, 4364

308, 568

6458, 6614

2045, 2728

7400, 7852

1362, 1405

4539, 6198

6303, 6437

4390, 4516

6638, 7377

1420, 2026

253, 270

596, 1002

1024, 1119

1135, 1346

2739, 3090

55,591

115,558

35900

Discharge summary

report

Admission Date: [**2136-9-1**] Discharge Date: [**2136-9-15**] Date of Birth: [**2053-12-8**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Tramadol Hcl / Hydrocodone Attending:[**Doctor Last Name 69321**] Chief Complaint: Transfer from OSH for obtundation Major Surgical or Invasive Procedure: lumbar puncture [**2136-9-3**] History of Present Illness: 82 yo F with h/o dementia, HTN, AS s/p AVR ([**Hospital1 18**]), vasculitis on mycophenolate (Cellcept), admitted [**2136-8-20**] to [**Hospital3 2737**] with VZV encephalitis (1.8 million copies on PCR) with course c/b ARF and worsening obtundation. Pt presented to OSH on [**8-20**] with increasing confusion and weakness over 48 hours. On presentation she was nonverbal after being able to speak earlier in the morning, and zoster rash was noted on her right hip. She was started on acyclovir on empirically on [**8-21**] and LP on [**8-22**] reportedly was postive for VZV PCR, although report is not included. Patient apparently improved initially, and MRI on [**8-27**] showed scattered lacunar infarcts but was otherwise unremarkable. However, she developed increased confusion on [**8-28**]. Repeat NCHCT on [**8-29**] was unremarkable, and repeat LP was performed on [**8-30**], but again, I have no records of the result. Patient's course was also c/b ARF, with Cr increasing from 0.72 on [**8-26**] to 1.5 on [**8-30**]. Renal US showed no hydronephrosis, and acyclovir was DC'd on [**8-30**]. However, Cr improved to 1.1 on [**8-31**] and acyclovir was restarted. Unfortunately patient remained obtunded and was transferred to [**Hospital1 18**] for further management. On the floor, patient is minimally responsive. She does open her eyes to voice and intermittently attempts to vocalize, but ROS is unable to be obtained. Past Medical History: -Hypertension -Hyperlipidemia -Aortic stenosis s/p AVR (21mm [**Company 1543**] Mosaic Ultra Porcine Valve) [**2133-2-4**] -Osteoarthritis -Pending bilateral knee replacements -Colectomy with h/o colostomy for bowel obstruction/?diverticulitis Social History: She is a widow with 5 grown children. Lives with her son. She does not smoke or drink. Family History: Her brother with a cardiac stent in his 60??????s Physical Exam: Admission Physical Exam: Vitals: T:97.8 BP:136/78 P:60 R: 20 O2:96%RA General: Opens eyes briefly to command, attempts to vocalize but unable. Minimally attentive to examiner HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Nonlabored, mildly decreased BS on right with expiratory wheeze, although patient intermittently vocalizing CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM c/w prior AVR Abdomen: soft, non-distended, bowel sounds present, grimaces diffusely to palapation. No HSM noted. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: 2-3mm scab over right hip with a few surrounding erythematous macules distriubuted in a linear fashion Exam on transfer [**2136-9-7**]: VS: afebrile, BP 110s/70s HR in 80-100s, RR 20-30s O2 96% on nonrebreather CV: tachycardic, normal S1/S2 and 2/6 systolic murmur PULM: tachypneic, poor air movements throughout, decreased breath sounds in LLL and bibasilar crackles NEURO: obtunded, opens eyes only to loud voice and noxious stimuli (such as sternal rub and nailbed pressure on extremities). Does not follow midline or appendicular commands. With nailbed pressure, withdraws all extremities and grimaces. Tone increased in upper extremities, RUE>LUE. Right toe upgoing, left toe mute. Pertinent Results: Admission Labs: [**2136-9-1**] 07:10AM BLOOD WBC-7.5# RBC-3.87* Hgb-11.3*# Hct-35.3*# MCV-91 MCH-29.3 MCHC-32.1 RDW-15.3 Plt Ct-253# [**2136-9-1**] 07:10AM BLOOD Neuts-72.4* Lymphs-18.2 Monos-6.0 Eos-2.3 Baso-1.1 [**2136-9-1**] 07:10AM BLOOD PT-12.6* PTT-28.6 INR(PT)-1.2* [**2136-9-1**] 03:01PM BLOOD Glucose-160* UreaN-21* Creat-0.8 Na-142 K-3.2* Cl-104 HCO3-29 AnGap-12 [**2136-9-1**] 07:10AM BLOOD ALT-13 AST-20 AlkPhos-56 TotBili-0.4 [**2136-9-1**] 07:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9 [**2136-9-1**] 02:00PM BLOOD Type-ART Temp-37 pO2-85 pCO2-33* pH-7.54* calTCO2-29 Base XS-5 [**2136-9-1**] 02:00PM BLOOD Lactate-0.8 [**2136-9-1**] 05:18AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2136-9-1**] 05:18AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2136-9-1**] 05:18AM URINE Eos-NEGATIVE [**2136-9-1**] 05:18AM URINE Hours-RANDOM UreaN-234 Creat-25 Na-86 K-21 Cl-91 [**2136-9-1**] 05:18AM URINE Osmolal-300 Discharge Labs: Imaging: CXR [**2136-9-1**]: Left PICC line terminates in mid SVC. Nasogastric tube terminates in the stomach. MRI [**2136-9-2**]: 1. No definite acute intracranial abnormality; specifically, there is no evidence of edema, slow diffusion or abnormal enhancement to specifically support the apparently established diagnosis of varicella zoster encephalitis. 2. No pathologic focus of enhancement, though sensitivity for subtle cranial nerve enhancement (as may be seen with varicella zoster infection) is severely limited. 3. Global, particularly central atrophy and extensive sequelae of chronic small vessel ischemic disease with right basal ganglionic chronic lacunes. 4. Unremarkable cranial MRA with no flow-limiting stenosis. 5. Fluid-opacification of the mastoid air cells, bilaterally, as on the OSH CT dated [**2136-8-29**]; this should be correlated clinically. LENI [**2136-9-4**]: Deep vein thrombosis of both left posterior tibial veins. CTA chest [**2136-9-4**]: 1. Left lower lobe pulmonary embolus. Small left pleural effusion with adjacent atelectasis. 2. Esophageal catheter with retained fluid and aeroselized material in the proximal and mid esophagus. When clinically feasible, upper GI study may be helpful. 3. Sequelae of aortic stenosis (now status post valve replacement), including 4.1 cm ascending aortic dilation and severe left ventricular hypertrophy. Extensive arterial atherosclerotic calcifications, including the coronary arteries. 4. Left PICC terminates at the top of the superior vena cava. MRI head [**2136-9-11**]: 1. New subarachnoid and intraventricular hemorrhage with associated enhancement in the subarachnoid space, in the interpeduncular cistern and right ambient cistern, as well as areas of scattered enhancement in the leptomeninges in the vermis and right frontal lobe. Abnormal signal in the pons and left medulla with intraparenchymal hemorrhage in the left medulla. These findings could represent a combination of hemorrhage as well as meningitis and encephalitis. 2. Slightly larger ventricular size when compared to the prior examination of [**2133-2-7**]. While this could be due to global cerebral volume loss, the possibility of communicating hydrocephalus should be considered. Microbiology: +Varicella PCR on CSF at OSH (1.8 million copies -> <3000 copies) [**2136-9-4**]: VZV PCR <500 copies, negative for HSV, negative [**Male First Name (un) 2326**] Brief Hospital Course: A/P:82 yo F with h/o dementia, HTN, AS s/p AVR ([**Hospital1 18**]), vasculitis on mycophenolate (Cellcept), admitted [**2136-8-20**] to [**Hospital3 2737**] with VZV encephalitis (1.8 million copies on PCR) with course c/b ARF and worsening obtundation. Her repeat LP here showed increased WBC in CSF, so she was started on IV bactrim given concern for listeria meningitis by the ID team. Patient also developed DVT/PE during this hospitalization likely due to her immobility. Her respiratory status worsened with desaturation to 70s on room air, requiring a nonrebreather and transfer to ICU. Patient was also found to have new subarachnoid hemorrhage and decision was made to transition her to comfort care. Her pain was managed with morphine and her secretion was managed with scopolamine patch and prn hyocyamine/glycopyrrolate. # Obtundation: Unclear if this was related to the patient's VZV meningoencephalitis, as she reportedly improved with tx at OSH, but became and remained obtunded throughout this hospital stay. Review of reports from OSH showed imaging without signficant acute new process and labs relatively unremarkable. Patient was continued on acyclovir for treatment of VZV meningoencephalitis and EEG was obtained to evaluate for seizures, which showed slowing and PLEDs but no actual seizure activity. She was started on Keppra and lacosamide was added to improve the EEG without clinical improvement. Her initial MRI/MRA of head did not show any evidence of CVA or enhancing area and no evidence of vasculitis on MRI/MRA. Her repeat MRI on [**2136-9-11**] showed new subarachnoid hemorrhage, and her anticoagulation for DVT/PE were reversed, but upon discussion with her family, decision was made to focus on comfort care given the poor prognosis. # Pulmonary Embolus: patient developed worsening tachypnea on [**2136-9-4**], doppler of legs showed DVT in left calf. Patient was started on heparin and CTA was obtained, which showed left lower lobe segmental pulmonary embolus. She was continued on heparin gtt with bridge to coumadin. Her anticoagulation was reversed when she was found to have subarachnoid hemorrhage. # VZV meningoencephalitis: Patient received at least 7 days acyclovir tx at OSH with reported initial improvement. At OSH, acyclovir was discontinued due to ARF, but restarted a day later when ARF resolved. Her CSF showed 1.8 million copies of VZV on the initial LP, and subsequent LPs showed decreasing copies of VZV (~2900 copies on LP from [**2136-8-30**], and <500 copies on [**2136-9-3**]). Acyclovir was continued per ID recommendations. Acyclovir was discontinued when decision was made to focus on comfort care. # ARF: Baseline 0.9 back in [**2132**]. Currently 1.1 per OSH reports, but was up to 1.5 and attributed to acyclovir tx. Should be noted patient was continued on celebrex daily as well. Also possibly due to urinary retention, foley placed after retention x2. Her creatinine remained stable around 0.7-0.8. # History of PAN: Per her outpatient rheumatologist, patient had a history of muscle biopsy proven polyarteritis nodosa 5-6 years ago. Presented with abdominal/leg pains. Initially treated with prednisone and methotrexate, but has been on cellcept for years and doing very well, so dose has been weaned off. Cellcept was held during this hospitalization given ongoing infections. # HTN: Amlodipine increased to 10mg at OSH, but antihypertensives held in house given ongoing infectious issues and concern for sepsis. # HLD: continued on home pravastatin 20mg, and discontinued when decision was made to focus on comfort care. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from OSH. 1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 2. Acetaminophen 325-650 mg PO Q6H:PRN pain 3. Aspirin 81 mg PO DAILY 4. Amlodipine 2.5 mg PO DAILY 5. Bumetanide 0.5 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. Psyllium 1 PKT PO Frequency is Unknown 8. CeleBREX *NF* (celecoxib) 200 mg Oral daily 9. Pravastatin 20 mg PO DAILY 10. Ditropan XL *NF* (oxybutynin chloride) 10 mg Oral daily 11. Fish Oil (Omega 3) 1000 mg PO BID 12. Timolol Maleate 0.25% 1 DROP BOTH EYES Frequency is Unknown 13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES Frequency is Unknown 14. Gentamicin 0.3% Ophth. Ointment Dose is Unknown BOTH EYES Frequency is Unknown 15. Multivitamins 1 TAB PO DAILY 16. Vitamin E 400 UNIT PO DAILY 17. Ascorbic Acid 250 mg PO DAILY 18. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) unknown Oral unknown 19. Mycophenolate Mofetil Dose is Unknown PO Frequency is Unknown Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: VZV encephalitis, deep vein thrombosis, hospital acquired pneumonia Secondary Diagnosis: dementia, aortic stenosis s/p tissue aortic valve replacement, hypertension, polyarteritis nodosum Discharge Condition: expired Discharge Instructions: The patient was transferred from [**Hospital3 **] where she was found to have VZV encephalitis (infection of the brain) because she had worsening level of awakefulness. Repeat lumbar puncture was done and showed that she still had a lot of white blood cells, suspicious for infection. She were treated with acyclovir and Bactrim was also added to treat possible infection with listeria. Her course was also complicated by a pulmonary embolism and then bleeding into the brain. After discussion with family it was decided that given the grave medical issues comfort measures would be more appropriate. Time of death 5pm [**2136-9-15**] Followup Instructions: Expired. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 69324**]

[ "788.29", "272.4", "447.6", "V49.86", "401.9", "V45.72", "348.30", "486", "320.7", "276.1", "415.19", "430", "027.0", "V42.2", "294.20", "453.42", "331.9", "799.02", "053.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "03.31" ]

icd9pcs

[ [ [] ] ]

11788, 11797

7078, 10683

336, 368

12048, 12057

3615, 3615

12741, 12845

2224, 2275

11759, 11765

11818, 11818

10709, 11736

12081, 12718

4635, 7055

2315, 3596

263, 298

396, 1835

11926, 12027

3631, 4618

11837, 11905

1857, 2103

2119, 2208

7,671

117,672

10048

Discharge summary

report

Admission Date: [**2197-9-29**] Discharge Date: [**2197-10-3**] Date of Birth: [**2148-4-6**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old female with known coronary artery disease, status post myocardial infarction, status post coronary artery bypass graft times three in [**2193**], angioplasty in [**2197-1-31**], peripheral vascular disease, status post aortofemoral bypass, and axillobifemoral bypass, hypercholesterolemia, recent subdural hematoma in [**2197-3-31**] who presented to [**Hospital3 33594**] Center on the morning of admission with anginal chest pain refractory to medications, lateral ST segment depressions, and negative cardiac enzymes. The patient was transferred to the [**Hospital1 190**] for cardiac catheterization. Upon admission, the patient reports waking up from her sleep at 5 a.m. on the morning of admission with 7/10 substernal chest pain with radiation of the pain to the jaw and both arms, accompanied by diaphoresis. The patient reports similar symptoms in the past with relief from nitroglycerin; however, this morning the pain was unrelieved with nitroglycerin tablets times three. At the time, the patient went to [**Hospital3 25150**] where she was put on a nitroglycerin drip, received 5 mg p.o. of Lopressor times two, and morphine sulfate without relief. Her cardiac enzymes were negative times one, and an electrocardiogram relieved lateral ST segment depressions. Given the patient's history of coronary artery disease, vasculopathy, and multiple cardiac catheterizations in the past, the patient was transferred to [**Hospital1 190**] for cardiac catheterization. At the [**Hospital1 69**], the patient's cardiac catheterization revealed occlusion of her saphenous vein graft to first diagonal artery with 100% acute thrombotic occlusion, 70% occlusion of the lower pole of her first obtuse marginal, percutaneous transluminal coronary angioplasty that was opened; 100% right coronary artery proximal occlusion with collateral filling. Given the small caliber of the diagonal graft and small amount of myocardium provided, and the patient's extremely high risk for reocclusion, percutaneous transluminal coronary angioplasty was deferred at this time and conservative medical management was initiated. The patient was continued on medications and transferred to the floor. Upon arrival, the patient continued to complain of substernal chest pain described to be [**6-9**] and was somewhat relieved with morphine. At the time of arrival to the Coronary Care Unit, the patient denied shortness of breath, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and edema. The patient denies any recent fevers, chills, diarrhea, melena, and headaches. The patient does report numbness in the left lower arm since intervention on the day of admission. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post myocardial infarction in [**2195**] (as per patient), multiple catheterizations (the last in [**2197-1-31**] when she received a stent of her saphenous vein graft to first diagonal and underwent a percutaneous transluminal coronary angioplasty of her first obtuse marginal). She is status post coronary artery bypass graft times three with saphenous vein graft to both her right coronary artery and first diagonal. 2. Peripheral vascular disease; status post aortofemoral bypass in [**2194**]. Also status post axillofemoral bypass. 3. Hypercholesterolemia. 4. Hypothyroidism. 5. Seizure disorder. 6. Heparin-induced thrombocytopenia. 7. Subdural hematoma in [**2197-3-31**]. 8. Of note, the patient has anti-K alloantibodies. PAST SURGICAL HISTORY: 1. Coronary artery bypass graft. 2. Aortofemoral bypass with right subclavian to femoral bypass. 3. Craniotomy; status post subdural hematoma. 4. Spinal surgery. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Zocor 80 mg p.o. q.d. 3. Lopressor 100 mg p.o. t.i.d. 4. Accupril 5 mg p.o. q.d. 5. TriCor 108 mg p.o. q.d. 6. Pepcid 20 mg p.o. q.d. 7. Synthroid 125 mcg p.o. q.d. 8. Depakote 500 mg p.o. 9. Folic acid 1 mg p.o. q.d. 10. Isosorbide 10 mg p.o. t.i.d. ALLERGIES: HEPARIN, CODEINE, SULFA, CECLOR. SOCIAL HISTORY: The patient is a reformed smoker after smoking one and a half packs times 20 years. The patient denies any current alcohol use. The patient lives in [**Location (un) 7498**] with her husband. FAMILY HISTORY: Family history is remarkable for peripheral vascular disease and coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: On admission, the patient's vital signs were as follows; the patient was afebrile, heart rate was 98, blood pressure was 132/61, respiratory rate was 17, with an oxygen saturation of 100% on 2.5 liters of nasal cannula. In general, she was alert and awake, in no acute distress. Head, eyes, ears, nose, and throat revealed pupils were equally round and reactive to light. Her oropharynx was clear. No lymphadenopathy. No jugular venous distention. Remarkable for bilateral carotid bruits. Chest examination was clear to auscultation bilaterally. Cardiovascular examination revealed second heart sound and second heart sound, tachycardic, a [**4-5**] decrescendo murmur at her left sternal border. There were no rubs or gallops appreciated on examination. The abdomen was obese, soft, nontender, and nondistended. Decreased bowel sounds in all four quadrants. Extremities revealed there was no clubbing, no cyanosis, and no edema. Pulses were 3+ by Doppler in her dorsalis pedis, posterior tibialis, and her left radial arteries; however, the patient had no right radial pulse. On neurologic examination, cranial nerves II through XII were intact. Normal speech. Moved all extremities. 5/5 strength in extremities, decreased pinprick sensation at a median distribution of the left hand notable for flexion contracture of left forearm, and her right palate drop. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission showed sodium was 138, potassium was 3.8, chloride was 99, bicarbonate was 25, blood urea nitrogen was 9, creatinine was 0.5, blood glucose was 135. White blood cell count was 8.7, hematocrit was 31.8, platelets were 274. On admission to [**Hospital1 69**], her creatine kinase was 335, and she had a troponin of 11.2. RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at 80 beats per minute, normal axis, and normal intervals. No chamber abnormalities. There were 1-mm ST depressions in leads I, II, aVL, and V3 through V6. T wave flattening in I, aVL, and aVF which were consistent compared to baseline electrocardiogram in [**2197-3-31**]. Cardiac catheterization on the day of admission revealed a proximal left anterior descending artery lesion of 50% with the first diagonal occluded, the left main coronary artery with a 30% lesion, left circumflex was patent with the prior first obtuse marginal, status post percutaneous transluminal coronary angioplasty, lower first obtuse marginal with a 70% lesion, right coronary artery with known occlusion with collateral filling. The saphenous vein graft of first diagonal had a freshly occluded proximal thrombus. Her left internal mammary artery was patent, and the left subclavian stent patent with 20% to 30% in-stent restenosis and normal central aortic pressures. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit for conservative management of her acute bilateral myocardial infarction. 1. CARDIOVASCULAR: The patient was continued on aspirin, beta blocker, ACE inhibitor, statin, and received a nitroglycerin drip, and was given morphine as needed for pain. Anticoagulants were held secondary to her recent history of subdural hematoma and known heparin-induced thrombocytopenia. Creatine kinase levels were followed throughout the course of her hospital stay and peaked at a level of 910. The patient remained on a medical regimen throughout her hospital course, and remained on telemetry throughout the remainder of her hospital stay. The patient was examined by Cardiothoracic Surgery for any possibility of revascularization. The patient was told to follow up with Cardiothoracic Surgery as an outpatient upon discharge. The patient was weaned off her nitroglycerin drip on hospital day three and remained off the nitroglycerin drip for the remainder of her hospital stay, and the patient remained hemodynamically stable throughout her hospital admission. (b) Myocardial function: The patient underwent an echocardiogram on the day of discharge which revealed the following; the left atrium was mildly dilated, left ventricular wall thickness was normal, left ventricular cavity size was normal, overall left ventricular systolic function was normal with a left ventricular ejection fraction of 50%; the mid ventricular apical segments of inferior free wall and anterior free wall were hypokinetic. Right ventricular chamber size and free wall motion were normal. The aortic valve leaflets were structurally normal with good excursion and no aortic regurgitation. The mitral valve leaflets were structurally normal. There was no mitral valve prolapse. Moderate 2+ mitral regurgitation was seen. The mitral regurgitation was extrinsic. There were no pericardial effusions. Compared with a previous study in [**2196-5-31**], focal left ventricular hypokinesis was now present. (c) Rhythm: There were no events on telemetry throughout the time while the patient had a acute myocardial infarction. (d) Hyperlipidemia: Of note, the patient has a history of hypercholesterolemia and was referred to the [**Hospital **] Clinic as an outpatient for evaluation and management of her hypercholesterolemia as it was believed that this may be a contributing factor to her severe vascular disease. 2. HEMATOLOGY: The patient has a known history of heparin-induced thrombocytopenia. Heparin and other anticoagulants were held throughout this hospital stay. 3. NEUROLOGY: The patient has a history of seizure disorder and subdural hematoma in [**2197-3-31**]. The patient was continued on her usual outpatient regimen of Depakote throughout this stay. The patient had remained neurologically stable throughout her hospital stay with no seizure activity noted. 4. ENDOCRINE: The patient has a history of hypothyroidism and was continued on her Synthroid medication throughout her hospital stay. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharged to home with physical therapy as needed. DISCHARGE DIAGNOSES: Acute myocardial infarction. MEDICATIONS ON DISCHARGE: (Medication regimen at discharge is the same as outpatient medications on admission with the exception of a change in her dose of Lopressor from 100 mg p.o. t.i.d. to 50 mg p.o. b.i.d. as the patient's blood pressure remained systolically around 95 throughout the remainder of her hospital stay). 1. Aspirin 325 mg p.o. q.d. 2. Zocor 80 mg p.o. q.d. 3. Lopressor 50 mg p.o. b.i.d. 4. Accupril 5 mg p.o. q.d. 5. TriCor 108 mg p.o. q.d. 6. Pepcid 20 mg p.o. q.d. 7. Synthroid 125 mcg p.o. q.d. 8. Depakote 500 mg p.o. 9. Folic acid 1 mg p.o. q.d. 10. Isosorbide 10 mg p.o. t.i.d. DISCHARGE INSTRUCTIONS: 1. The patient was told to follow up with her primary care physician within the next two weeks. 2. The patient was to follow up with Dr. [**Last Name (STitle) **] of Cardiology within the next few weeks. 3. The patient was given the number to follow up with Cardiothoracic Surgery with regard to revascularization. DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 12.749 Dictated By:[**Last Name (NamePattern4) 33595**] MEDQUIST36 D: [**2197-10-4**] 16:15 T: [**2197-10-11**] 06:46 JOB#: [**Job Number **]

[ "412", "780.39", "V45.81", "414.00", "410.51", "272.0", "V45.82", "286.9", "244.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.53", "37.22" ]

icd9pcs

[ [ [] ] ]

4446, 7376

10607, 10637

10664, 11262

3870, 4217

7394, 10464

11286, 11845

3676, 3843

10479, 10585

155, 2853

2875, 3653

4234, 4429

5,060

148,207

24313

Discharge summary

report

Admission Date: [**2183-1-29**] Discharge Date: [**2183-2-3**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1257**] Chief Complaint: Intoxication Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 24927**] is a 38yo gentleman with a long history of alcohol abuse and multiple admissions for alcohol withdrawal. He was found at the [**8-17**] at [**Location (un) **] and brought to the ED. He reports that a homeless gentleman was trying to steal $10 from him while he was drunk and onlookers called the police. His last drink was about 8 hours ago. . In the ED, initial VS were: 98.3 170/130 88 16 98%. He was agitated and felt to be intoxicated. Labs revealed an alcohol of 400. He received valium 10mg PO x 2, 1 tablet of vicodin, and morphine 4mg IV. He also was given a GI cocktail. He was noted to have periods of apnea associated with desaturations to 60%. A right IJ was placed and he was sent to the ICU for further care. . Upon arrival to the ICU, he stated that this admission was different from his prior admissions. This time, he wants to quit alcohol. A friend of his froze to death in the snow, and he knows he needs to change his ways or he will die. He then states that he is having terrible pain in his hands and in both of his legs and is asking for narcotic pain medications and threatening to pull his IJ and leave the unit if he is not given narcotics. Past Medical History: Polysubstance abuse (alcohol, heroin, IVDU, benzodiazapines) Personality disorder Hepatitis C Hepatitis B Anxiety Depression Possible obsessive compulsive disorder Seizures from alcohol withdrawal h/o head trauma Peripheral neuropathy Compartment syndrome of RLE in [**2171**] Chronic bilateral hand swelling Dermatitis in [**2182-5-8**]: unclear if due to scabies Social History: He is homeless and spends time in [**Hospital1 8**] and at the [**Location (un) 7073**] T Station. Not in contact with his family. Drinks rum, vodka, and/or listerine. He does not recall using cocaine, although his tox in the ED was positive for cocaine. Has history of opiate use and IVDU. Has served jail time for possession. Has had multiple section 35s. Family History: Father with alcohol abuse. Mother with DM Physical Exam: VS: No temp taken yet 139/76 141 18 99% RA GENERAL: Energetic, lying with his head off the pillow, poor hygiene HEENT: No conjunctival pallor. No scleral icterus. Pupils equal and average in size, EOMI. MMM, but he refuses to open his mouth wide for further exam because his breath is bad. Neck is supple, no thyroid enlargement. Right IJ in place, site looks clean but is oozing slightly. CARDIAC: Regular tachycardia, no murmur appreciated. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM. Later in exam he winces and states it hurts all over. EXTREMITIES: Both hands are diffusely swollen and erythematous. 2+ dorsalis pedis/ posterior tibial pulses. SKIN: Dry skin NEURO: A&Ox3. Slight flattening of left nasolabial fold. Moving all four extremities equally. Poor coordination, +intention tremor. States he cannot feel any light touch in his LE b/l. PSYCH: pressured speech making repetitive statements but with a very labile mood Brief Hospital Course: 38 year old man with long standing alcohol abuse and anxiety admitted with intoxication and apnea. Hospital course by problem: . # Witnessed apnea due to the combination of multiple sedating medications in the setting of intoxication. There was no recurrence of these episodes and his respiratory status was stable. . # Alcohol abuse: Patient has well-documented history of manipulating the CIWA scale so as to be given as many benzodiazepines as possible. Treatment of his alcohol withdrawal is also complicated by his severe anxiety. In ICU, he was only given PO Valium for objective signs of withdrawal. He was started on thiamine IV, MVI, folate and an addictions consult was made. He was stable during his ICU stay and transferred [**1-30**] to the floor. He expressed a desire to go to [**Location (un) 1475**] or [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 61609**] house for detoxification, which we did our best to coordinate. He however left AMA as he no longer was interested in waiting for a bed. He had no evidence of alcohol withdrawal, delirium, confusion on the day of discharge. He was competent and was not suicidal or severely depressed. Although, he faked severe ataxia through out his hospitalization ( he may have some baseline ataxia from neuropathy or cerebellar atrophy from alcohol), he was able to walk away with no problems once he decided to leave AMA. Patient verbalized his understanding of the dangers of continued drinking behavior. Again, he was completley competnant to make his own desicions when I examined him on the day of discharge. He was not given any narcotics or benzodiazepines during his floor stay as he had no objective withdrawal symptoms. We discontinued his IJ just before he left AMA to prevent abuse of this IV access. . # Pain in hands and feet: chronic pain due to neuropathy from alcohol or other chemicals in Listerine that he drank in past and chronic exposure to cold. He was offered gabapentin for neuropathy, which he turned down. He was given tramadol for pain control. We avoided narcotics . # Chronic abdominal pain: On recent evaluation, team was concerned that he may have had gastritis. He has chronic mild elevation of lipase but pancreas was normal in appearance on CT abd earlier this month (he is at risk for chronic pancreatitis). His abdominal exam was unremarkable when he was distracted. He was given famotidine for possible gastritis. . # Hepatitis B and C: Has documentation of both Hep B and C that is not being treated. Had stably elevated LFT's here. Contact will need to be made with his PCP prior to discharge. Medications on Admission: none Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Peripheral alcoholic neuropathy Polysubstance abuse Gastritis Abdominal pain Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted with intoxication and trouble walking. You were observed in the ICU and then transferred to the floor for management. You did not require valium. You left AMA as you did not want to stay until we find you a bed at your rehab facility of choice. Followup Instructions: Follow up with your PCP, [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1105**] [**Telephone/Fax (1) 5139**], in the next 2 weeks.

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6074, 6080

3392, 6019

284, 290

6221, 6221

6655, 6856

2323, 2367

6101, 6200

6045, 6051

6365, 6632

2382, 3369

232, 246

318, 1538

6235, 6341

1560, 1926

1942, 2307

67,559

183,991

36302

Discharge summary

report

Admission Date: [**2126-3-25**] Discharge Date: [**2126-3-30**] Date of Birth: [**2046-9-21**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1145**] Chief Complaint: DOE Major Surgical or Invasive Procedure: Aortic valvuloplasty [**2126-3-28**] History of Present Illness: 79 yo F h/o AS leading to CHF, CAD, HTN, PVD s/p aorto-bifem s/p RLE stent, chronic kidney disease, AAA with stenting who was transferred from [**Hospital **] Hospital to [**Hospital1 18**] on [**3-25**] for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] evaluation of critical AS w/ [**Location (un) 109**] 0.3 cm2. She was thought not to be a surgical candidate, however. Cr 1.5 --> 1.8 this am. Got mucomyst, HCO3 in cath lab. Then had valvuloplasty without event. . On the floor, she is feeling well without complaint. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. She denies recent fevers, chills. She denies exertional buttock or calf pain. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. She does have orthopnea and sleeps with a wedge. She states for the last several months she has had dyspnea sometimes with dizziness when walking up stair. . She does state that she has had an occassional cough productive of white sputum worse when she drinks liquids for the last 2 months. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: No prior MI, CABG, PCI, PM or ICD. 3. OTHER PAST MEDICAL HISTORY: Hyperlipidemia HTN PVD-s/p aorto-bifem [**2098**] and RLE stenting [**2121**] Aortic Stenosis causing CHF for the last 2 months AAA s/p stenting ~ [**2116**] CAD CRI s/p dental extraction 2 weeks ago. s/p LUE thrombectomy 3 years ago. Osteoarthritis of the hips Social History: retired and lives alone in [**State 792**]with 2 of her children close by. Has a 10 pk yr hx of smoking- quit 20 years ago. Denies drug use. Drinks EtOH approx once per year. At baseline, pt can walk up [**Last Name (LF) 5927**], [**First Name3 (LF) **] laundry. Independent in ADLs. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=98.8 BP=130/39 HR=78 RR=16 O2 sat=93% on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. No xanthalesma. NECK: Supple with JVP no visible. CARDIAC: RRR, normal S1, S2. [**2-22**] harsh holosystolic murmur radiating to the carotids. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. 2+ TP bilat SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Discharge labs: [**2126-3-30**] 06:50AM BLOOD WBC-6.2 RBC-2.70* Hgb-8.2* Hct-25.0* MCV-93 MCH-30.3 MCHC-32.8 RDW-14.8 Plt Ct-163 [**2126-3-30**] 06:50AM BLOOD Plt Ct-163 [**2126-3-30**] 06:50AM BLOOD Glucose-94 UreaN-22* Creat-1.7* Na-139 K-3.8 Cl-105 HCO3-24 AnGap-14 [**2126-3-30**] 06:50AM BLOOD CK(CPK)-79 [**2126-3-30**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2126-3-29**] 10:15AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2126-3-29**] 02:55AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2126-3-30**] 06:50AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 [**2126-3-26**] 01:50AM BLOOD %HbA1c-6.2* . [**2126-3-27**] TTE: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal to mid inferolateral segments. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). There is mild aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Severe calcific aortic stenosis. Mild symmetric LVH with mild hypokinesis of the basal to mid inferolateral segments. Moderate to severe mitral regurgitation. . [**2126-3-28**] TTE: There is mild regional left ventricular systolic dysfunction with basal inferior and inferolateral akinesis and mid inferolateral hypokinesis. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Compared with the prior study (images reviewed) of [**2126-3-27**], the severities of aortic stenosis and mitral regurgitation have decreased. No aortic regurgitation was seen in either study. . [**2126-3-29**] CT torso: IMPRESSION: 1. Negative examination for aortic dissection. There is no significant narrowing in the visualized portions of the subclavian arteries. 2. Extensive atherosclerotic calcifications, mural thrombus, and ulcerated plaques along the aorta and visualized arteries. Patent SMA stent. Patent graft in right common iliac artery. Significant stenosis at the origin of the celiac trunk. Focal aneurysm of the right common femoral artery. 3. Focal bulging of the infrarenal abdominal aorta measuring up to 25 mm. 4. Centrilobular and paraseptal emphysema. 5. Multiple lung nodules as described in the text, the largest one measuring 7.6 mm. Initial followup chest CT is recommended in three months. 5. Bilateral small pleural effusions and adjacent atelectasis. 7. Gallstones without evidence of cholecystitis. 8. Multiple areas of thinning of the renal cortex that suggested scars, prior ischemic/injury. Brief Hospital Course: Ms. [**Known lastname 56636**] is a 79 yo F h/o AS leading to CHF, CAD, HTN, PVD s/p aorto-bifem s/p RLE stent, chronic kidney disease, AAA with stenting who was transferred from [**Hospital **] Hospital to [**Hospital1 18**] on [**3-25**] for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] evaluation of critical AS w/ [**Location (un) 109**] 0.3 cm2. She was deamed not a good surgical candidate and went to cardiac cath [**3-29**] for uneventful valvuloplasty. . # Aortic stenosis- s/p valvuloplasty. See post valvuloplasty TTE aboce. Asymptomatic but pt never had symptoms at rest. Pt was up and walking well prior to discharge on [**2126-3-30**]. She will follow up with her PCP and [**Name9 (PRE) 3782**] cardiologist. . # CORONARIES: Pt w/ 90% ostial left main lesion, occluded right coronary artery on cardiac cath at OSH. Apparently, disease was not nearly as severe on cardiac cath here today. Final cath report is still pending at time of discharge summary. Continued ASA, statin, ACEI, BB. . # PUMP: LVEF >55% here. Does not look to be fluid overloaded or in CHF this admission. Discontinued home lasix as pt may not need after valvuloplasty. . # RHYTHM: Pt in NSR on tele this admission. No h/o arrhythmia . # Chronic renal failure: Cr rose this admission to 1.8 from 1.5 on admission. Pt got mucomyst, bicarb with cardiac cath. At time of discharge, Cr. was stable at 1.7. . # UTI- Treated with cipro for a total of 5 days treatment. Medications on Admission: Bisopropol 5 mg PO daily, Quinipril 10 mg PO daily, ASA 81 mg PO daily, Niaspan 1000 mg PO qhs, Crestor 10 mg PO daily, Prilosec 20 mg PO daily, Vitamin B12 1000 mg PO daily, Calcium ED 600 mg PO BID, MVI 1 PO daily, Lasix 10 mg PO daily, Plavix 75 mg PO daily (d/c'd 2 weeks ago) Discharge Medications: 1. Bisoprolol Fumarate 5 mg Tablet Sig: One (1) Tablet PO daily (). 2. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Niaspan 1,000 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Aortic stenosis Secondary diagnoses: CAD Acute on Chronic renal failure Discharge Condition: Good. Chest pain free. No dyspnea on exertion. Discharge Instructions: You were admitted with heart failure due to your aortic valve stenosis. While you were here, we did not think you were a surgical candidate so we did a valvuloplasty. This opened up your valve well. You did not have any complications from this procedure. . Please make sure to have your blood checked within the next [**1-22**] days to make sure your kidney function is stable. Please call your PCP to have your blood drawn. . Please continue your medications as prescribed. We did STOP your lasix as with your valve improvement, you should no longer need this. . Please call your doctor or return to the ED if you have any chest pain, shortness of breath, dizziness, lightheadedness, fever, bruising in your groin or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4334**] within 2 weeks. The office number is [**Telephone/Fax (1) 82248**]. . Please follow up with your cardiologist Dr. [**Last Name (STitle) 4541**] within 2 weeks. Completed by:[**2126-4-1**]

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icd9cm

[ [ [] ] ]

[ "88.55", "35.96", "37.23", "39.64" ]

icd9pcs

[ [ [] ] ]

8904, 8910

6291, 7757

276, 315

9045, 9094

3091, 3091

9891, 10195

2399, 2514

8092, 8881

8931, 8931

7783, 8069

9118, 9868

3108, 6268

2529, 3072

8987, 9024

1752, 1787

233, 238

343, 1658

8950, 8966

1818, 2082

1680, 1732

2098, 2383

75,160

191,205

41806

Discharge summary

report

Admission Date: [**2165-8-29**] Discharge Date: [**2165-9-4**] Date of Birth: [**2083-4-19**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**8-30**]:Coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to first diagonal coronary artery; reverse saphenous vein single graft from the aorta to first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the posterior descending coronary artery History of Present Illness: Mr. [**Known lastname 74255**] is an 82 year old male with recent admission to [**Hospital6 33**] for chest pain. Myoview cardiac imaging was equivocal and the patient was discharged with cardiology follow-up. On the day of admission, cardiac catheterization at [**Hospital6 33**] revealed left main and three vessel coronary artery disease. He was subsequently transferred for surgical revascularization. On transfer, he was stable and pain free on medical therapy. Past Medical History: Hypertension Benign prostatic hyperplasia Hyperlipidemia Social History: Race:aucasian Lives with:wife -[**Name (NI) 90793**] Contact: wife Phone #[**Telephone/Fax (1) 90794**] [**Name2 (NI) **]ttes: Smoked no [] yes [x-quit 60 years ago] ETOH: < 1 drink/week [] [**3-4**] drinks/week [x] >8 drinks/week [] Family History: Denies premature coronary artery disease Physical Exam: Pulse:79 Resp:18 O2 sat: 100RA B/P Right: 169/64 Left: Height: Weight: 91kg 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: groin site Left:+2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: None Left:None Pertinent Results: [**2165-8-29**] WBC-8.9 RBC-4.82 Hgb-14.9 Hct-44.2 Plt Ct-234 [**2165-8-29**] PT-11.6 PTT-19.8* INR(PT)-1.0 [**2165-8-29**] Glucose-141* UreaN-14 Creat-1.0 Na-139 K-3.7 Cl-99 HCO3-29 A [**2165-8-29**] ALT-15 AST-19 LD(LDH)-200 AlkPhos-53 TotBili-0.4 [**2165-8-29**] Albumin-4.5 [**2165-8-29**] %HbA1c-5.6 eAG-114 . [**2165-9-3**] WBC-8.6 RBC-2.77* Hgb-8.7* Hct-24.9* Plt Ct-193 [**2165-9-2**] WBC-11.1* RBC-3.12* Hgb-9.6* Hct-27.7* Plt Ct-157 [**2165-9-1**] WBC-11.0 RBC-2.96* Hgb-9.4* Hct-27.0* Plt Ct-161 [**2165-9-3**] Glucose-166* UreaN-23* Creat-1.0 Na-138 K-4.0 Cl-102 HCO3-26 [**2165-9-2**] Glucose-107* UreaN-23* Creat-1.1 Na-138 K-4.0 Cl-101 HCO3-27 [**2165-9-1**] Glucose-150* UreaN-15 Creat-1.0 Na-131* K-3.9 Cl-97 HCO3-27 [**2165-9-3**] 08:00AM BLOOD Mg-2.1 . Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2165-8-30**] where the patient underwent a coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to first diagonal coronary artery; reverse saphenous vein single graft from the aorta to first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the posterior descending coronary artery. 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, confused, oriented x 1 but breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. He was kept in the CVICU for confusion/aggitation and treated with Haldol. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Patient was started on Amiodarone for paroxysmal atrial fibrillation. Amiodarone was titrated while beta blockade was advanced as tolerated. The patient was transferred to the telemetry floor for further recovery. His mental status slowly improved and Haldol was no longer required. He remained in a normal sinus rhythm and no further episodes of atrial fibrillation were noted. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on postoperative five, the patient was ambulating freely, the wound was healing and pain was controlled with Tylenol. The patient was discharged [**Hospital **] Healthcare Center in good condition with appropriate follow up instructions. Medications on Admission: Avodart 0.5 daily metoprolol 50mg [**Hospital1 **] aspirin 325mg daily lipitor 10mg hs HCTZ 25mg daily Discharge Medications: 1. atorvastatin 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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day: 400 mg twice a day for one week then decrease to 400 mg once a day on [**9-11**], for one week then decrease to 200 mg daily on [**9-18**] until follow up . 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 11. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a day. 12. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Discharge Diagnosis: Coronary Artery Disease s/p CABG Hypertension Benign prostatic hyperplasia Hyperlipidemia Postop Atrial Fibrillation, resolved Postop Confusion Postop Right Arm Phlebitis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Trace Edema. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**2165-10-1**] @ 1PM Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11300**] [**2165-10-8**] @ 12PM Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 32467**] in [**4-30**] weeks [**Telephone/Fax (1) 85079**] **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:[**2165-9-4**]

[ "414.01", "451.84", "997.1", "600.00", "427.31", "V15.82", "788.20", "600.01", "411.1", "401.9", "E878.2", "293.9", "272.4", "285.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6150, 6203

3097, 4868

319, 712

6418, 6644

2299, 3074

7484, 8075

1580, 1622

5022, 6127

6224, 6397

4894, 4999

6668, 7461

1637, 2280

269, 281

740, 1210

1232, 1291

1307, 1564

25,772

131,022

43750

Discharge summary

report

Admission Date: [**2172-6-22**] Discharge Date: [**2172-7-9**] Date of Birth: [**2123-6-21**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / Morphine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending:[**First Name3 (LF) 165**] Chief Complaint: Endocarditis Major Surgical or Invasive Procedure: [**2172-6-26**] redo sternotomy/Bentall with #21mm St. [**Male First Name (un) 923**] mechanical valve History of Present Illness: This is a 49 yo man with a history of bicuspid aortic valve, s/p mechanical AVR and repair of ascending aortic aneurysm in [**2166**], HTN, past episodes of chest pain, s/p gastric bypass surgery, GERD, s/p multiple knee, shoulder, and spine surgeries, prior narcotic and EtOH abuse, and a history of IV heroin abuse, who presented to NWH on [**6-20**] after a syncopal episode at home, and transferred to [**Hospital1 18**] CCU for further management of mechanical AVR endocarditis. Regarding his syncopal event, he reports getting out of the shower and "things turned black" and he woke up in the ambulance. Per the NWH discharge summary, he felt dizzy before blacking out (and had been feeling dizzy on standing for a week prior). His girlfriend found him over the toilet and was awake and talking - she apparently estimated that he had been down for 5 minutes. The patient had been feeling ill for ~2 wks, with sweats, chills (didn't take his temp), nausea, loss of appetite, productive cough, and non-bloody diarrhea. Over that time he also has had episodes of shortness of breath and a sensation that his chest is "collapsing" associated with chills. He also has had palpitations. He also noted a pustule on his skin which had drained several days prior to presenting. He also notes an MVA 2 months ago where he broke a tooth. He denies any IV heroin use in the last 7 months but notes snorting heroin within the last week to "make himself feel better". Per the NWH ED report, they saw fresh bilateral track marks on [**6-20**]. He is on Coumadin for his prosthetic valve but notes having not taken this for the week prior to presenting - he says he ran out of his prescription and does not have a doctor [**First Name (Titles) **] [**Last Name (Titles) **] it. He says he last checked his INR 3-4 weeks ago. INFECTIOUS DISEASE: --CRP 18.2, HIV and Hep B/C serologies negative, Lyme neg, BCx on [**6-20**] POSITIVE 3/4 bottles for coag neg staph, NGTD x 1 on [**6-21**], UCx neg on [**6-21**] He was admitted to the ICU. --TTE showed LVEF 65%, mild LVH (concentric), mild LAH, mildly dilated RA, aortic valve well-seated with NL function, no perivalve leak, trace AR, mild MR, mild TR, est RV sys pressure 36.4mmHg with RA pressure 10mmHg ID was consulted and the patient was treated with IV vancomycin 1500 mg q12h, IV zosyn 2.25 g q6h, and a one-time dose of gentamicin (3 mg/kg) on [**6-21**]. Repeat EKG showed 1st degree AV conduction delay with PR 200-210. --TEE showed LVEF 50-55%, abn function in [**Month/Year (2) **] valve with diffuse echodensity surrounding it and mobile masses c/w vegetations and possible thrombus. aortic root abscess noted. ant leaflet of MV thickened Regarding thromboprophylaxis for his mechanical St. [**Month/Year (2) 923**] valve, he initially was started on a heparin drip but this was stopped. He was bridged with lovenox 90 mg [**Hospital1 **] and started on warfarin 10 mg qd. In terms of his [**Last Name (un) **], his Cr returned to baseline (1.0) with IVF. He was then transferred to the [**Hospital1 18**] CCU for further management and evaluation by Cardiac surgery for possible valve replacement. Past Medical History: Bicuspid AV s/p [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] size 23-mm AVR/Aortic root replacement with size 28 Gelweave graft in '[**66**], on coumadin IVDA Gastric bypass in [**2161**] with Dr. [**Last Name (STitle) 40029**] GERD hx EtOH abuse hx of narcotics abuse OA back pain HLD h/o bilat shoulder surgery h/o bilat knee arthroscopy Social History: lives with girlfriend. abstinent from heroin for 7 months but relapsed over past week and notes that he has been sniffing heroin (denies IV use). Denies current ETOH, tobacco, or other illicit drugs. Family History: grandfather died suddenly of "heart attack" at age 70. other grandfather also died of a heart attack at age 66. no h/o CAD in immediate relatives. Physical Exam: Physical Exam on Admission: VS: T=99.5 BP=121/82 HR=100 RR= 14 O2 sat=100% RA GENERAL: Ill-appearing. Oriented x3. Somewhat irritable. HEENT: NCAT. Left-sided front tooth is broken with purulent drainage noted. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no JVD. CARDIAC: RR, normal S1, mechanical S2. II/VI systolic murmur heard throughout the precordium. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Anterior surgical scar noted. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Focal exquisite tenderness to palpation of left lateral wrist and left gastrocnemius muscle. No tenderness, edema, erythema of left knee or ankle. Left hand is swollen and slightly erythematous. SKIN: No visible Osler's nodes, [**Last Name (un) 1003**] lesions, or splinter hemorrhages. No obvious signs of recent IVDU. PULSES: Strong DP pulses bilaterally Neuro: CN II-XII intact. 4+/5 strength in left upper extremity flexors and extensors, except wrist and hand muscles as this exam was limited by pain. Lower extremity strength exam on the left was limited by pain but no weakness appreciated on the right. Sensation intact to light touch throughout. Pertinent Results: Relevant Labs: [**2172-6-23**] 06:10AM BLOOD %HbA1c-5.6 eAG-114 [**2172-6-24**] 06:20AM BLOOD HIV Ab-NEGATIVE Imaging: CT head w/ and w/o contrast [**6-22**] FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarction. No evidence of enhancing mass lesion or rim-enhancing fluid collections is seen. The ventricles and sulci are normal in size and configuration. [**Doctor Last Name **]-white matter differentiation is preserved. There is no fracture. Imaged paranasal sinuses and mastoid air cells reveal air-fluid levels in the ethmoid air cells, with left greater than right partial opacification. Inspissated secretions are seen in the sphenoid air cells. IMPRESSION: No evidence of enhancing or ring-enhancing lesions to suggest abscess. CT chest w/ contrast [**6-22**]: 1. Soft tissue surrounding the aortic root. Recommend correlation to prior imaging to determine whether this finding is old (postoperative) or new (infectious). Of note, the CT scanner containing the source data was experiencing technical difficulties, and thus more detailed images could not be retrieved. 2. No evidence of lung, pleural or pericardial infection. 3. Central lymphadenopathy predates surgery. US left UE [**6-22**]: FINDINGS: There is no fluid collection identified. Patent veins with hypoechoic halo suggests edema and more generally edematous tissue in the region of the patient's pain suggest inflammation. Trace synovial fluid is demonstrated (1 mm). US LLE [**6-22**]: FINDINGS: No abscess or fluid collection is identified. Substantial inflammation or phlegmon cannot be excluded, however, by ultrasound. Chest x-ray [**6-24**]: CHEST, PA AND LATERAL: Changes of median sternotomy and aortic valve replacement are present. The cardiomediastinal and hilar contours are within normal limits. Lungs are clear. There are no pleural effusions or pneumothorax. Degenerative changes are noted in the lower thoracic spine, with anterior bridging osteophytes. IMPRESSION: No acute intrathoracic process. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Intra-op TEE [**2172-6-26**] Conclusions PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No thrombus or mass is seen in the left atrial appendage. No mass or thrombus is seen in the right atrium or 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 for the patient's body size. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta tube graft appears abnormal with large mobile echogenic masses seen in the aortic root & sinuses. The aortic valve prosthesis appears abnormal and is obscured by echogenic masses.. There is a large vegetation on the aortic valve. An aortic annular abscess is seen. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A low flow is seen in the abscess cavity. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at the time of the study. POST-BYPASS: On epinephrine 0.02 mcg/kig/min Normal RV systolic function. Reduced/hypokinetic anterior and inferior septum. However, anterior, inferior and lateral wall functioning normally. Overall LVEF is 45%. There is a mechanical aortic valve seen in the native aortic position with peak and mean gradients of 35 and 14mm of Hg. No periprosthetic leaks were seen. Other valves are as prebypass,. Ascending aorta tubular graft was seen and appears intact. 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) **] [**2172-7-3**] 11:50 ?????? [**2163**] CareGroup IS. All rights reserved. . [**2172-7-7**] 07:19AM BLOOD WBC-9.9 RBC-3.10* Hgb-8.9* Hct-27.4* MCV-88 MCH-28.7 MCHC-32.6 RDW-16.1* Plt Ct-472* [**2172-7-6**] 05:22AM BLOOD WBC-7.8 RBC-2.91* Hgb-8.4* Hct-25.8* MCV-89 MCH-28.9 MCHC-32.6 RDW-15.8* Plt Ct-497* [**2172-7-7**] 07:19AM BLOOD PT-29.2* INR(PT)-2.8* [**2172-7-6**] 05:22AM BLOOD PT-39.2* INR(PT)-3.8* [**2172-7-5**] 03:31AM BLOOD PT-26.5* INR(PT)-2.5* [**2172-7-4**] 06:29AM BLOOD PT-30.0* PTT-70.2* INR(PT)-2.9* [**2172-7-3**] 10:07AM BLOOD PT-19.5* PTT-33.4 INR(PT)-1.8* [**2172-7-3**] 03:05AM BLOOD PT-20.0* PTT-67.1* INR(PT)-1.9* [**2172-7-2**] 04:30AM BLOOD PT-20.2* PTT-49.5* INR(PT)-1.9* [**2172-7-1**] 12:52PM BLOOD PT-14.9* PTT-60.1* INR(PT)-1.4* [**2172-7-1**] 05:03AM BLOOD PT-14.3* PTT-36.5 INR(PT)-1.3* [**2172-7-1**] 12:23AM BLOOD PT-14.3* PTT-36.0 INR(PT)-1.3* [**2172-7-7**] 07:19AM BLOOD Glucose-109* UreaN-7 Creat-1.4* Na-136 K-4.1 Cl-102 HCO3-26 AnGap-12 [**2172-7-3**] 03:05AM BLOOD Glucose-104* UreaN-12 Creat-1.7* Na-131* K-4.1 Cl-97 HCO3-23 AnGap-15 [**2172-7-9**] 04:24AM BLOOD WBC-7.8 RBC-2.86* Hgb-8.2* Hct-25.4* MCV-89 MCH-28.7 MCHC-32.3 RDW-16.4* Plt Ct-502* [**2172-7-9**] 04:24AM BLOOD PT-29.1* INR(PT)-2.8* [**2172-7-9**] 04:24AM BLOOD UreaN-7 Creat-1.5* Na-134 K-3.7 Cl-100 [**2172-7-9**] 04:24AM BLOOD Mg-2.2 Brief Hospital Course: This is a 49 year old man with a history of AVR with a St. [**Male First Name (un) 923**] mechanical valve, ascending aortic aneurysmal repair, IVDU, HTN, hyperlipidemia, GERD, and gastric bypass who was transferred from NWH with Coag-negative Staph Endocarditis. Possible sources include skin flora from possible IVDU (though patient denies) or drained chest wall pustule, or mouth flora from tooth purulence. Most likely, from tooth. Pre-op Cr 2.2 on presentation to NWH, thought to likely be pre-renal secondary to dehydration. Improved to 1.0 (baseline) with IVF. Unclear if patient only relapsed with sniffing heroin or if he also injected IV (patient denies having used IVDU in the last 7 months). HIV serolgies neg, Hep B/C serologies negative. SW was consulted for possible substance abuse counseling. On [**2172-6-26**] Mr.[**Name14 (STitle) 94022**] was taken to the operating room and underwent Redo Bentall procedure with a size 29-mm St. [**Male First Name (un) 923**] mechanical composite graft. Please see operative report for further details. He tolerated the procedure well and was transferred to the CVICU for further invasive monitoring. He awoke neurologically intact and was extubated. All lines and drains were discontinued per protocol. His postop ECG showed ST elevations and a TTE was obtained. Echo revealed on epinephrine 0.02 mcg/kig/min his echo revealed:Normal RV systolic function. Reduced/hypokinetic anterior and inferior septum. However, anterior, inferior and lateral wall functioning normally. Overall LVEF is 45%. There was a mechanical aortic valve seen in the native aortic position with peak and mean gradients of 35 and 14mm of Hg. No periprosthetic leaks were seen. Ascending aorta tubular graft was seen and appeared intact. Cardiology was consulted regarding evaluation and management of abnormal ECG/elevated troponin and felt that he had a myocardial infarction with little territory affected. Due to absence of chest pain and elevated creatinine cardiac catheterization was not pursued but medical management cotinued. Nephrology was consulted postop for [**Last Name (un) **], renal ultrasound was obtained which was negative. His reanal decline was felt to be related to ATN and the offending [**Doctor Last Name 360**] to be Gentamicin which was discontinued. On POD#3 Electrophysiology was consulted regarding intermittent high-grade AV block seen on ECG and telemetry. They felt no intervention required at this time and this should hopefully resolve with time and all AV nodal blocking agents were held. Anticoagulation was initiated with Coumadin and bridged with Heparin drip for his mechanical valve. He has been very sensitive to coumdin with two spikes in his INR requiring Vit K. Pre operatively he was taking 10mg of coumadin daily but not tolerating high doses in the postopetive period. His INR will need to be moniotored closely and if supratheraputic he may need TTE to evaluate for pericardial effusion as he is at high risk for this developing. ID continued to follow Mr.[**Known lastname **] throughout his postoperative course with antibiotic recommendations. He is to continue on Nafcillin and Rifampin through [**2172-8-7**] to complete a 6 week course. On POD#5 he was transferred to the step down unit for further monitoring.He continued to progress well. His appetite is poor and he has intermittent nausea. He has been moving his bowels and nausea is improving slowly. LFTS normal. Physical Therapy was consulted for evaluation of strength and mobility. His Creatinine is trending downward. By the time of his discharge on POD#13 he was ambulating freely, wounds healing well and pain controlled failrly well with po dilaudid. All but his PCP's follow up appointments were arranged. He was discharged on stable condition with PICC in place to [**Hospital1 **] State Hospital. Medications on Admission: coumadin 10mg po daily (not taken for at least 1 week because Rx ran out) lisinopril 20mg daily metoprolol tartrate 200mg po qAM, 100mg po qPM crestor (unclear dose) Discharge Medications: 1. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): through [**2172-8-7**]. Disp:*63 Capsule(s)* Refills:*0* 2. Nafcillin 2 g IV Q4H give over 30-60 min 3. Antibiotic Duration Nafcillin through [**2172-8-7**] 4. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed for pruritus. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 11. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): take 1mg tonight [**2172-7-9**]. Disp:*120 Tablet(s)* Refills:*2* 12. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 **] state hospital Discharge Diagnosis: Prosthetic Aortic Valve endocarditis-redo sternotomy/Bentall with #21mm St. [**Male First Name (un) 923**] mechanical valve Post operative myocardial infarction Acute kidney injury High grade AV nodal block Secondary diagnosis Chronic Back pain Chronic Headaches Gastroesophageal reflux disease s/p Gastric Bypass '[**61**] s/p bilateral shoulder surgery s/p bilateral knee arthroscopy s/p thoracic aortic aneurysm s/p stent [**2-/2170**] s/p Aortic valve replacement(23-mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **])ascending aorta replacement(28 Gelweave graft) [**2166**] 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 - trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2172-8-4**] 1:45 Cardiologist:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2172-7-24**] 10:20 Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 36510**] after discharge from rehab **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication: mechanical AVR Goal INR: 2.5-3 First draw [**7-10**] Rehab to manage coumadin - please arrange coumadin follow with PCP prior to discharge from rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2172-7-9**]

[ "V58.61", "780.2", "V45.86", "041.19", "715.90", "719.43", "E878.8", "530.81", "790.92", "426.11", "V43.3", "429.89", "E930.8", "997.1", "584.5", "790.7", "285.1", "421.0", "305.50", "V15.81", "E928.9", "276.1", "410.91", "401.9", "873.63" ]

icd9cm

[ [ [] ] ]

[ "35.22", "38.97", "38.93", "39.61", "37.26", "39.49" ]

icd9pcs

[ [ [] ] ]

16468, 16526

11264, 15123

344, 449

17175, 17346

5776, 11241

18149, 19129

4255, 4403

15339, 16445

16547, 17154

15149, 15316

17370, 18126

4418, 4432

292, 306

477, 3637

4446, 5757

3659, 4021

4037, 4239

8,942

104,923

25499

Discharge summary

report

Admission Date: [**2178-8-29**] Discharge Date: [**2178-9-7**] Date of Birth: [**2124-1-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac catheterization Aortic balloon pump insertion arterial line placement intubation swan-ganz catheter placement History of Present Illness: Pt is a 54 y/o man w/ a PMH significant for HTN who developed substernal chest pressure while working outside in his yard. He went inside and lay down on the floor in front of the fan where he was found by his wife. She called EMS and he denied fall or LOC when they arrived. He received aspirin, nitro, and NS and was transfered to the [**Hospital3 3583**]. In [**Hospital1 46**], he was hypertensive to 164/118 and bradycardic to 42. His EKG was significant for complete heart block with ST elevations in II, III, aVF, and V3-6 as well as ST depressions in I, aVL, V1-2. He was started on heparin, aggrastat, asa and morphine prior to being transfered to [**Hospital1 18**]. Of note, his wife said that he has developed mild pedal edema over the past few days and states that his exercise tolerance has dropped recently. . In the cath lab, he was seen to be actuely vagal with hypotension and emesis. He was also acutely acidotic and hypoxic. He was intubated for airway protection. An intra-aortic balloon pump was placed secondary to his hypotension. He had several episodes of VT that aborted with amiodarone 150mg bolus and lidocaine 75mg bolus. He was started on an amiodarone drip. His cath demonstrated a totally occluded mid-RCA that was stented. His RPL was ballooned. His right sided filling pressures were elevated with a PCW 37, RA 27, RV 62/18, and PA 62/38. He had no step up. He received 80mg of lasix in the lab. Past Medical History: HTN asthma lumbar disc herniation Social History: no smoking, social alcohol, no ivdu. lives w/ wife and daughter. Family History: father died at 49 from MI and mother w/ cardiac issues "at birth" and died at 49 from "cardiac issues". siblings w/out medical issues Physical Exam: Gen: Pt intubated and sedated with an OG tube HEENT: PERRL Neck: -LAD CV: RRR, s1/s2 intact, -M/G/R Lungs: Coarse breath sounds b/l Abd: S/NT/ND, + BS Groin: R groin oozing w/out hematoma/bruit, L groin w/out O/H/B Ext: -C/C/E, palpable LE pulses b/l Pertinent Results: [**2178-8-29**] 03:57PM BLOOD WBC-18.3* RBC-4.67 Hgb-14.6 Hct-41.6 MCV-89 MCH-31.4 MCHC-35.2* RDW-13.6 Plt Ct-223 [**2178-8-29**] 03:57PM BLOOD Neuts-85.3* Lymphs-10.9* Monos-3.4 Eos-0.2 Baso-0.1 [**2178-8-29**] 03:57PM BLOOD PT-16.4* PTT-150* INR(PT)-1.8 [**2178-8-29**] 03:57PM BLOOD Glucose-159* UreaN-18 Creat-1.4* Na-139 K-3.4 Cl-108 HCO3-15* AnGap-19 [**2178-8-29**] 11:30PM BLOOD CK(CPK)-3357* [**2178-8-30**] 04:51AM BLOOD CK(CPK)-4161* [**2178-8-30**] 11:49AM BLOOD CK(CPK)-4962* [**2178-8-31**] 12:37AM BLOOD CK(CPK)-4473* [**2178-8-31**] 04:43AM BLOOD CK(CPK)-3865* [**2178-9-1**] 03:57AM BLOOD ALT-104* AST-169* LD(LDH)-975* AlkPhos-40 TotBili-1.8* [**2178-8-29**] 11:30PM BLOOD CK-MB-GREATER TH [**2178-8-30**] 04:51AM BLOOD CK-MB-GREATER TH [**2178-8-30**] 11:49AM BLOOD CK-MB-420* MB Indx-8.5* [**2178-8-31**] 12:37AM BLOOD CK-MB-235* MB Indx-5.3 cTropnT-10.06* [**2178-8-31**] 04:43AM BLOOD CK-MB-149* MB Indx-3.9 [**2178-9-2**] 03:27AM BLOOD calTIBC-186* VitB12-210* Folate-11.4 Ferritn-451* TRF-143* [**2178-8-30**] 04:51AM BLOOD Triglyc-80 HDL-43 CHOL/HD-3.2 LDLcalc-80 . ECHO [**8-21**]: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior and inferio-lateral hypokinesis. The RV size and systolic function are probably within normal limits (suboptimal views). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. . Cath [**8-21**]: 1. Selective coronary angiography revealed a right dominant system with acute occlusion of a large right coronary artery before it gave off any marginal branches. The LMCA had no significant disease. The LAD had mild diffuse luminal plaquing up to 40% along its length. The LCx was non-dominant and had no significant coronary artery disease. After the RCA thrombotic stenosis was treated, there was evidence of distal emoblization with an abrupt cut off of the terminal R PDA. 2. Hemodynamics revealed severely elevated left and right heart filling pressures. The RV and PA pressures were elevated above 50mm Hg systolic, suggesting some element of chronic pulmonary hypertension. The cardiac output and index were preserved however this was in the face of dopamine infusion which was probably causing some degree of splanchnic vasodilation and L > R shunting. 3. Left ventriculography was not performed. 4. Successful placement of temporary 5 French pacing wire during procedure for heart block via the right femoral vein without complications. The pacing wire was removed at the conclusion of the procedure. 5. Successful placement of 8 French, 40 cc IABP via the left femoral artery under fluoroscopic guidance without complications. Appropriate systolic unloading and diastolic augmentation were noted with invasive hemodynamic measurements. 6. Intubation for hypoxemia, acidemia, and airway control during the procedure without complications and with fluoroscopic confirmation of appropriate ETT placement. 7. Successful treatment of culprit mid-RCA with a 3.5 x 18 mm Cypher drug-eluting stent postdilated with a 3.75 mm balloon. Final angigraphy demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 8. Successful treatment of thrombus migration to the r-PL using balloon inflations with a 2.5 x 15 mm Voyager balloon. Final angiography demonstrated no significant residual stenosis, no angiographically apparent dissection, and normal flow Brief Hospital Course: A/P: Pt is a 54 y/o man w/ a PMH significant for HTN who presented to [**Hospital1 18**] for urgent cath in the setting of an acute infero-posterior STEMI. . 1. CAD - pt presented after an acute infero-posterior STEMI and received an RCA stent. he was intubated during this process for respiratory compromise in the setting of cardiogenic shock during his catheterization. he was started on aspirin, statin, bb, plavix, and ace in the post-catheterization setting. he received an echo showing an EF of 45% and inferior/infero-lateral hypokinesis. he developed a large hematoma at the groin site that resolved throughout his stay. he did not have cp after the intervention and tolerated PT evaluation w/out complaint. he was d/c home on his inpatient medications w/ close follow-up. . 2. Hypotension: the patient developed cardiogenic shock during his catheterization requiring IABP and dopamine. he received 9 L total between OSH and [**Hospital1 18**]. he was weaned off both the pressors and iabp in the ccu in the days after his catheterization w/out problem. his bp was monitored w/ an a-line until transfer to the floor. he was started on bb and ace after his pressors were weaned and his pressure had normalized. he tolerated both of these well and was d/c home to continue bp titration as an outpatient. . 3. Arrhythmia - pt w/ VT in the cath lab that spontaneously aborted and was most likely secondary to ischemia and subsequent reperfusion. he was transiently placed on an amiodarone drip overnight but was taken off this the next morning and did not have recurrence of arrhythmia throughout his stay. . 4. Respiratory - pt w/ a hx of asthma and was intubated for airway protection during cath. he bit through his ngt while in the ccu and was noted to have aspirated. empiric abx were started and the pt subsequently developed a fever/wbc bump that responded well to abx. he was slowly weaned off his sedation and extubated successfully following a spontaneous breathing trial. he was on supplemental oxygen after extubation but this was slowly weaned both in the ccu and on the floor. . 5. ARF - pt developed mild arf w/ Cr of 1.4 here (1.2 at outside hospital). his cr normalized throughout his stay and his ace-i was started after his cr normalized. . Medications on Admission: Univasc primatene mist Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-18**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*0* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:*12 Capsule(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Infero-lateral ST elevation MI Discharge Condition: Stable Discharge Instructions: Please keep all your appointments as scheduled Please take all of your medications as directed Do NOT stop your plavix or aspirin without taking to your cardiologist first. Return to the ER/Call your PCP [**Name Initial (PRE) **]: 1. chest pain 2. shortness of breath 3. fever to 101 4. fainting spells 5. other alarming symptoms Followup Instructions: Please see Dr. [**Last Name (STitle) 63700**] in [**Hospital Ward Name 23**] 7 on [**2178-10-5**] at 1:15pm ([**Telephone/Fax (1) 4022**]) Please see Dr [**Last Name (STitle) 32467**] Completed by:[**2178-10-20**]

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icd9cm

[ [ [] ] ]

[ "36.05", "96.72", "37.61", "96.04", "36.07", "99.20", "38.91", "37.23", "39.64", "88.56", "00.17" ]

icd9pcs

[ [ [] ] ]

9633, 9639

6225, 8508

324, 443

9713, 9721

2498, 6202

10099, 10315

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274, 286

471, 1919

1941, 1976

1992, 2059

44,787

127,732

9268

Discharge summary

report

Admission Date: [**2124-2-13**] Discharge Date: [**2124-2-19**] Date of Birth: [**2044-4-18**] Sex: M Service: MEDICINE Allergies: Calcium / Penicillins / Cephalosporins Attending:[**First Name3 (LF) 10593**] Chief Complaint: shortness of breath for past five days Major Surgical or Invasive Procedure: None. History of Present Illness: 79 year old male with HTN, DMII, systolic heart failure (EF 45%) and CVA ([**2101**], [**2121**]) with residual right hemiplegia and dysarthria presenting for dyspnea for five days. The patient became somnolent with fever of 100.0 and hypoxia to 89%RA on [**2-10**] while at his nursing home. CXR showed LL opacity and WBC 30.7, and he was started on Levofloxacin 500 mg po daily x10 days and albuterol nebulizers but continued to have fevers. The day of admission, [**2-13**], he was noted to have increased work of breathing and fever of 102.5, and was sent from rehab by EMS. He was placed on CPAP at 10/5 with ~6-7 liters of minute ventilation in the ED and given Vanc/Levaquin, and weaned down to 4L NC. He was admitted to the MICU for possible non-invasive ventilation, but remained stable from a respiratory standpoint. CXR showed retrocardiac opacity compared to CXR [**12-31**]. He was also found to have acute renal failure with Cr 2.5 from baseline 0.7 last year, hyperkalemia 5.7, and hyperglycemia 485. VBG: 7.34/49/38 with lactate of 3.4, which improved with 2L NS. CT abd/pelvis showed non-obstructing renal calculus, tree and [**Male First Name (un) 239**] opacities in lung bases, ?consolidation of LLB and the patient was switched to Meropenem with improvement. C. diff and UA were negative. ARF also improved with IVF and hypernatremia improved with increase of FW flushes through the G-tube. He was called out to the medicine floor for further management. . Also, the patient had G-tube replaced on [**2124-2-10**] due to blockage without complications and without residuals since the replacement. . Of note, the patient was admitted to [**Hospital1 18**] from [**2124-1-5**] - [**2124-1-6**] for clogged G-tube and IR replacement and [**2123-12-18**] - [**2124-1-4**] for hypoxic respiratory failure in the setitng of H. flu pneumonia requiring intubation with hospital course complicated by upper GI bleed from G-tube site and C. difficile infection. . Currently, the patient remains non-verbal and does not follow commands, which per the MICU team seems to be chronic. . Review of systems: Patient is nonverbal at baseline. Unable to obtain ROS. Past Medical History: - multiple strokes: 1)old remote left frontal stroke in [**2101**] that per NH notes purportedly left him with R-hemi and dysarthria (per son, able to think of words he wants to say and makes grammatically intact sentences, but is often unintelligible) grammatically intact sentences, but is often unintelligible) 2)[**4-13**](MRI [**2122-4-6**] showing acute infarcts in the R medial temporal lobe, R basal ganglia, and high signal in the petrous portion of the R-ICA thought to be 2/2stenosis/occlusion started on asa/plavix, thought to be too [**Month/Day/Year 65**] a fall risk for anticoagulation - DM2 - HTN - CRI (baseline Cr ~1.6) - Gout - GERD - Systolic and diastolic heart failure with EF of 45% Social History: Prior to recent stroke, lived at home with wife now at rehab. Remote history of alcohol and smoking cigarettes (quit 1 year ago.) Family History: NC Physical Exam: Vitals: 103.2 140 112/40 36 100%4LNC General: Alert. In moderate respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple. JVP at 7 cm CV: Tachycardic. Regular rhythm. No murmurs or gallops appreciated Lungs: Clear to auscultation bilaterally except few upper airways sounds on left middle zone Abdomen: Soft and nontender. Mildly distended. Hypoactive bowel sounds GU: Foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: Difficult to assess. Nasolabial fold intact. No meningismus. Pertinent Results: [**2124-2-13**] 10:10AM WBC-10.8 RBC-4.69# HGB-15.0# HCT-45.8# MCV-98 MCH-32.0 MCHC-32.7 RDW-12.3 [**2124-2-13**] 10:10AM PLT COUNT-251# [**2124-2-13**] 10:10AM NEUTS-88.1* LYMPHS-7.7* MONOS-2.9 EOS-0.6 BASOS-0.7 [**2124-2-13**] 10:10AM GLUCOSE-485* UREA N-87* CREAT-2.5*# SODIUM-139 POTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-24 ANION GAP-19 [**2124-2-13**] 10:10AM CALCIUM-8.9 PHOSPHATE-1.6* MAGNESIUM-3.4* [**2124-2-13**] 03:13PM PT-10.9 PTT-35.0 INR(PT)-1.0 [**2124-2-13**] 10:17AM LACTATE-3.4* [**2124-2-13**] 10:17AM LACTATE-3.4* [**2124-2-13**] 10:17AM PO2-38* PCO2-49* PH-7.34* TOTAL CO2-28 BASE XS-0 COMMENTS-ADD ON ABG [**2124-2-13**] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG Micro: BCx [**2-13**] negative C. diff [**2-13**] negative UCx [**2-14**], [**2-16**] negative BCx [**2-16**], [**2-17**] negative C. diff [**2-16**] POSITIVE CXR [**2124-2-13**]: No definite acute cardiopulmonary process. KUB [**2124-2-13**]: No evidence of bowel obstruction. Clinical evaluation is advised and followup imaging should be based on clinical assessment. CT Abdomen [**2124-2-13**]: 1. No evidence of acute intra-abdominal process, pneumoperitoneum or leakage of oral contrast. 2. 12 mm non-obstructing left renal calculus. 3. Bronchial wall thickening with centrilobular nodules at the lung bases, some demonstrating a tree-in-[**Male First Name (un) 239**] appearance. Findings may be seen with aspiration and correlation clinically is recommended. There is a small area of atelectasis or consolidation at the left lung base posteriorly. LLE US [**2124-2-16**]: No evidence of deep vein thrombosis in the left leg. Brief Hospital Course: 79 year old male with HTN, DMII, systolic heart failure (EF 45%) and CVA ([**2101**], [**2121**]) with residual right hemiplegia and dysarthria presenting for dyspnea [**1-6**] pneumonia, also in ARF. . #. Pneumonia: Five days prior to admission, the patient became somnolent with fever of 100.0 and hypoxia to 89%RA on [**2-10**] while at his nursing home. CXR showed LL opacity and WBC 30.7, and he was started on Levofloxacin 500 mg po daily x10 days and albuterol nebulizers but continued to have fevers. The day of admission, [**2-13**], he was noted to have increased work of breathing and fever of 102.5, and was sent to [**Hospital1 18**] from rehab by EMS. He was placed on CPAP at 10/5 with ~6-7 liters of minute ventilation in the ED and given Vanc/Levaquin, and weaned down to 4L NC. He was admitted to the MICU for possible non-invasive ventilation, but remained stable from a respiratory standpoint. CXR showed retrocardiac opacity compared to CXR [**12-31**]. CT chest showed cetrilobular nodules and tree-in-[**Male First Name (un) 239**] appearances at bases consistent with aspiration PNA, failed outpatient Levofloxacin treatment, broadened in-house to Meropenem first on [**2-13**], and Vancomycin subsequently added on [**2-15**] for persistent white count. Cultures remained negative, with two blood cultures pending on discharge. He was discharged with on an 8 day course of Meropenem (last day [**2-20**]) and Vancomycin (last day [**2-22**]) for HCAP. Given his sinus tachycardia, his albuterol nebulizer was switched to Xopenex nebulizers q4h standing and he was started on Ipratropium q6h standing, given he had significant wheezing and tachypnea. His respiratory symptoms improved with antibiotics and nebulizers. . #. Fever/C. difficile colitis: The patient was afebrile for several days following initiation of Vancomycin, but began having low grade fevers on [**2-15**]. UA negative, initial C. diff negative, initial CT abdomen negative although without contrast. He was re-cultured, and the second C. diff study on [**2-16**] returned positive. He was started on PO Vancomycin with decrease and subsequent resolution of his leukocytosis. He was constipated rather than having diarrhea, which is likely an atypical but well known presentation of a C. difficile infection. LENI's were checked in the setting of fever, tachycardia, and mild LLE edema, and was negative for LLE DVT. . #. Sinus tachycardia: Patient was found to have sinus tachycardia, persistent despite resolution of dehydration and resolution of fevers. PE also on the differential but he was not hypoxemic, tachypnea improved with antibiotics and nebulizers, and LENI's were negative. Given he presented in acute renal failure that subsequently resolved with IVF, CTA was not obtained to decrease the risk of acute renal failure. Metoprolol was increased with improvement of the tachycardia. . #. Diabetes mellitus: The patient had persistent elevated blood sugars since admission, initially in the 400's, likely due to cortisol surge in the setting of two acute infections. There was no anion gap. His Glargine was aggressively up-titrated to 26 units qhs, and SSI was also up-titrated. Will likely need to be weaned down as his infections resolve. His home home glyburide was discontinued in setting of ARF. . #. Hypernatremia: Patient with hypernatremia which improved with increase of free water flushes, likely component of dehydration as well as osmotic diuresis from hyperglycemia. He was continued FW flushes in-house, the protocol which which will be included in his discharge paperwork. . #. Acute Renal Failure: The patient presented in acute renal failure with Cr 2.5 from a baseline 0.7, which improved with IVF hydration, consistent with pre-renal etiology. UA was negative. He was noted to have a 12 mm non-obstructing left renal calculus. . #. s/p CVA: Continued on pravastatin 20 mg po qdaily and plavix 75 mg po qdaily. . #. Hypertension,b benign: Continue metoprolol, which was increased for rate control of his tachycardia. His home Triamteren/HCTZ was discontinued in-house for dehyration. . #. ?BPH: Continued tamsulosin. . #. CHF: Hypovolemic, held diuretics and repleted with IVF as above. Continued Metoprolol. . # Communication: Patient; son ([**Doctor First Name **]: [**Telephone/Fax (1) 31777**]) # Code: DNR/DNI. Ok for noninvasive and central line Transitions of Care: - Sinus tachycardia resolved here. Metprolol was INCREASED for rate control in the meantime. - Follow up blood sugars and titrate insulin regimen for glucose control. [**Month (only) 116**] have declining insulin requirement as acute infections resolve. Home Glyburide was STOPPED and insulin was INCREASED in-house. - Triamterene-HCTZ was STOPPED. Follow up volume status and blood pressures. - Foley catheter may be removed for a voiding trial - Hct mildly low at 31.3 on last check. The following antibiotics were started: - Vancomycin IV was STARTED, to be continued until [**2124-2-22**] - Meropenem was STARTED, to be continued until [**2124-2-20**] - Vancomycin oral was STARTED, to be continued until [**2124-2-29**] - Iptratropium nebulizers were STARTED - Albuterol was CHANGED to Xopenex nebulizers Medications on Admission: MVA PG daily Omeprazole 20 mg PG qdaily Plavix 75 mg PG qdaily Triamterene-HCTZ 37.5/25 mg PG qdaily Pravastatin 20 mg PG qdaily Ferrous sulfate liquid 300 mg PG [**Hospital1 **] Glyburide 3 mg PG [**Hospital1 **] Vitamin C 500 mg PG [**Hospital1 **] Albuterol prn metprolol 50 mg PG TID Tamsulosin 0.4 mg PG daily Levaquin 500 mg PG daily x 10 days (started [**2124-2-10**]) day 4 today Citalopram 20 mg PG daily Glucerna 1.0 cal @ 75 cc/hr PG Humalog sliding scale (received 6-12 units every other day) Discharge Medications: 1. 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. 2. multivitamin Tablet [**Year (4 digits) **]: One (1) Tablet PO at bedtime. 3. clopidogrel 75 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 4. pravastatin 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Year (4 digits) **]: Three Hundred (300) mg PO BID (2 times a day). 6. ascorbic acid 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day). 7. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Year (4 digits) **]: One (1) nebulization Inhalation q4h (). 8. metoprolol tartrate 25 mg Tablet [**Year (4 digits) **]: Three (3) Tablet PO TID (3 times a day): 75 mg tid. 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Year (4 digits) **]: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 10. citalopram 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 11. heparin (porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1) mL Injection TID (3 times a day). 12. ipratropium bromide 0.02 % Solution [**Year (4 digits) **]: One (1) Inhalation Q6H (every 6 hours). 13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. meropenem 500 mg Recon Soln [**Last Name (STitle) **]: Five Hundred (500) mg Recon Soln Intravenous Q8H (every 8 hours) for 2 days: Last dose on [**2-20**]. 15. vancomycin 500 mg Recon Soln [**Month/Year (2) **]: Seven [**Age over 90 1230**]y (750) mg Recon Soln Intravenous Q 12H (Every 12 Hours) for 4 days: last dose on [**2-22**]. 16. Miralax 17 gram Powder in Packet [**Month/Year (2) **]: One (1) packet PO once a day as needed for constipation. 17. Senna with Docusate Sodium 8.6-50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day as needed for constipation. 18. vancomycin 125 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO Q6H (every 6 hours): last dose on [**2124-2-29**]. 19. insulin glargine 100 unit/mL Solution [**Date Range **]: Twenty Six (26) units Subcutaneous at bedtime. 20. Humalog 100 unit/mL Solution [**Date Range **]: as directed per sliding scale Subcutaneous qachs. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Healthcare Associated Pneumonia Acute Renal Failure secondary to dehydration Sinus tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital for low oxygen saturations and shortness of breath. A CT scan of your chest showed evidence of a pneumonia, and you were started on antibiotics with improvement of your respiratory symptoms. You also had worsening kidney function which was due to dehydration, and improved with intravenous fluid hydration. While you were in the hospital, you were found to have an infection of the stool called a Clostridium difficile infection, and you were started on antibiotics to treat this. The following changes were made to your outpatient medications: - Vancomycin IV was STARTED, to be continued until [**2124-2-22**] - Meropenem was STARTED, to be continued until [**2124-2-20**] - Vancomycin oral was STARTED, to be continued until [**2124-2-29**] - Ipratropium inhalers were STARTED - Glyburide was STOPPED - Triamterene-HCTZ was STOPPED - Albuterol was CHANGED to Xopenex nebulizers - Omeprazole was CHANGED to Lansoprazole disintegrating tablets - Metprolol was INCREASED - Insulin was INCREASED - Tube feeds were CHANGED, information included Followup Instructions: Please follow up with the physician at your rehab facility.

[ "438.20", "250.00", "530.81", "585.9", "600.00", "507.0", "V58.67", "518.81", "428.0", "008.45", "V49.86", "584.9", "438.13", "274.9", "276.0", "V15.82", "403.90", "428.22" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

13971, 14054

5778, 10191

339, 347

14193, 14193

4039, 5755

15434, 15497

3450, 3454

11584, 13948

14075, 14172

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2576, 3286

3302, 3434

24,981

167,592

48251

Discharge summary

report

Admission Date: [**2192-11-28**] Discharge Date: [**2192-12-8**] Date of Birth: [**2121-4-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2024**] Chief Complaint: Fever, hypotension. Major Surgical or Invasive Procedure: Transthoracic echocardiography. History of Present Illness: 71M with T2N0M0 soft palate squamous cell CA, undergoing adjuvant chemoradiation week [**5-8**] of low dose [**Doctor Last Name **]/Taxol and daily XRT, admitted from Heme/Onc (Dr. [**Last Name (STitle) **] clinic with hypotension 72/47, tachycardia 115; presumed dehydration. Pt on antihypertensives. Reports diarrhea 2x daily and decreased usage of Jevity tube feeds (not keeping up). Family helps him with this when they can but he lives alone. He is denying CP/SOB/N/V/Abd pain/fevers/chills or other acute symptoms. Reports feeling LH today while standing but no syncope or falls. Rt received 500cc NS en route. . Onc Hx: Presented [**8-6**]: difficulty swallowing/globus. throat. Saw Dr. [**Last Name (STitle) **] (ENT) who visualized squamous cell carcinoma of soft palate, biopsy confirmed dx. Staging done with a PET CT scan: No regional lymphadenopathy or systemic disease. Referred to Dr. [**First Name (STitle) **] [**Name (STitle) 3929**] for Radiation. Started Chemoradiation on [**2192-10-29**], plan for 7weeks in total for curative intent. Past Medical History: 1. Hypertension, denies prior MI 2. Bilateral Carotid Artery Disease 3. Brain aneurysm (repaired [**2181**]) 4. s/p G-tub insertion to maintain nutrition pre-chemo/XRT . Social History: Retired florist. He lives alone in [**Location (un) 620**]. Family involved. 50pkyrs, quit 8weeks ago. Reports heavy ETOH in the past, quit 15years ago. Family History: Father with AML Physical Exam: PE: Tm 99, HR 84, 98/55 (in office 72/47), 93%RA GEN: NAD HEENT: PERRL, hoarse, losing hair, OP: dry MM, mucositis with ulcerations. Facial and neck erythema NECK: Erythema, no swelling/LAD CV: reg rate, S1, S2, no MRG PULM: CTAB ABD: soft, G-tube site c/d/i, mild distention, NT EXT: no CCE Pertinent Results: [**2192-11-28**] 09:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2192-11-28**] 09:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-8.0 LEUK-NEG [**2192-11-28**] 09:43PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2192-11-28**] 10:15AM UREA N-43* CREAT-1.7* SODIUM-136 POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-28 ANION GAP-20 [**2192-11-28**] 10:15AM PHOSPHATE-2.4*# MAGNESIUM-2.0 [**2192-11-28**] 10:15AM WBC-1.2*# RBC-3.12* HGB-9.8* HCT-28.6* MCV-92 MCH-31.3 MCHC-34.1 RDW-14.7 [**2192-11-28**] 10:15AM PLT COUNT-169 [**2192-11-28**] 10:15AM GRAN CT-980*. . UA [**11-28**] neg stool cx [**11-29**] pend Sputum [**11-29**]: OP flora [**11-28**] blood pend Imaging CXR [**2192-11-28**]: LLL multilobar infiltrate [**2192-12-6**] AP & LATERAL CHEST: The heart size is within normal limits. Mild pulmonary edema has decreased. Small to moderate bilateral pleural effusions and bibasilar pulmonary opacities are unchanged. IMPRESSION: 1) Decreased mild pulmonary edema. 2) Unchanged bilateral pleural effusions and bibasilar opacities. [**2192-12-5**] Echocardiograph Poor echo windows.The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is probably mildly depressed. Basal to mid antero-septal and inferior hypokinesis is suggested, but not confirmed. Right ventricular chamber size and free wall motion appear normal. The aortic root is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [**2176-12-20**], regional LV systolic dysfunction is now suggested. If clinically indicated, a repeat TTE with contrast (Definity) may better characterize LVEF and regional LV function. Discharge laboratories: [**2192-12-8**] 06:30AM BLOOD WBC-5.0 RBC-3.09* Hgb-9.8* Hct-28.5* MCV-92 MCH-31.6 MCHC-34.3 RDW-16.6* Plt Ct-281 [**2192-12-8**] 06:30AM BLOOD Glucose-116* UreaN-23* Creat-0.9 Na-138 K-3.6 Cl-102 HCO3-26 AnGap-14 [**2192-12-8**] 06:30AM BLOOD Calcium-7.7* Phos-3.9 Mg-1.7 Brief Hospital Course: This is a 71 year old gentleman with T2N0M0 soft palate squamous cell CA, undergoing adjuvant chemoradiation week [**5-8**] of low dose [**Doctor Last Name **]/Taxol and daily XRT. He was iniitally admitted on [**11-28**] with hypotension, tachycardia, ARF. Felt to be dehydrated at that time. He was hydrated with NS and then developed fevers and was noted to have LLL opacity. He was initially given cefepime, fluconazole (concern for esophagitis), flagyl. This was then switched to Levo and vanco. Later, flagyl was re-started. He had frequent desaturations that were found to be secondary to mucus plugging and which resolved with deep suctioning. His sputum cultures then grew back Coag + staph sensitive to oxacillin and vanco was switched to oxacillin. . On [**2192-12-4**] pt respiratory status deteriorated to the point he could only maintain adequate oxygenatin on non-rebreather. By this time he had been getting significant amounts of fluid with a daily fluid balance positive 500-1000ml per day. CXR's have also shown progressive pulmonary edema In [**Name (NI) 153**], pt. did not require intubation. It was felt his resp distress was secondary to pulm edema/volume overload and we was therefore diuresed with PRN lasix 40 mg. Over LOS in [**Hospital Unit Name 153**] he was roughly -1.2 L. An echocardiogram revealed the patient had deteriorated LV function and new wall motion abnormalities. His resp. status did improve such that he was saturating adequately on 40% FM. He had been afebrile and otherwise hemodynamically stable and was therefore transferred back to the floor. Over the subsequently few days of his hospital course the pt. felt his breathing had improved and he had no fevers, chest pain, or cough. His volume status returned to euvolemic state. He was slowly weaned from oxygen support and by discharge was down to 3L face mask. Repeat CXR revealed stable lower lobe infiltrates but almost complete resolution of pulmonary edema. Aggressive diuresis was no longer pursued. External radiation therapy for his oral squamous cell CA was resumed. On discharge, the patient remained afebrile and hemodynamically stable. He was to continue 5 more days of levo/flagyl, oxacillin was discontinued. He was transferred to a rehabilitation hospital to enable further improvement of his respiratory status and for reconditioning. In summary, this is a 71 year old gentleman with oral squamous cell carcinoma on radiation therapy who was admitted for fever and finding of lower lobe lung infiltrates. He developed respiratory distress from a combination of pneumonia, new CHF seen on echocardiography, and mucus plugging and required a brief stay in intensive care but not intubation. He did well with diuretic therapy for his CHF, antibiotics for his MSSA pneumonia and was transferred to a rehabilitation hospital to enable further improvement of his respiratory status. . Issues and plan arising from this hospitalization: 1) Respiratory Failure/Hypoxia- Now appears resolved. Secondary to combination of PNA, CHF exacerbation, ? mucus plugging. No intubation was required. - albuterol/atrovent nebs q4h. - Chest PT, aggressive suctioning as needed - Aggressive diuresis no longer needed. 2) CHF. now with apparently worsened EF, new wall motion abnormalities - Will need oupatient follow up with Cardiology. - Continue Lasix, Lisinopril, and metoprolol. - Watch for signs of overload (weight gain, edema) . 3) RLL and LLL multilobar PNA: Initially with LLL opacity with sputum cultures growing MSSA. Also satrted on levofloxacin and flagyl for possible aspiration PNA after developing RLL opacity. Currently afebrile with normal, WBC. - continue flagyl and levofloxacin for broad coverage for 5 days . 4) Squamous cell CA of mouth: Chemoradiation. Last dose chemo [**11-20**](taxol/carboplatinum) Per Dr. [**Last Name (STitle) **] will not continue chemo. Pt will continue XRT. -Mucositis: Improved during admission. Cont KBL, aspiration precautions, Nystatin, Roxicet. -continue aquaphor 5) Anemia: Hematocrit remains stable. Pt is s/p 2 units PRBC [**11-29**] for hct 22.6, likely chemo related. 6) FEN: Tube Feeds at goal.. . 7) Prophylaxis: Aspiration Precautions, Hep SC . 8) Code status remains full. . 10) Disposition: Rehabilitation facility. Medications on Admission: . Metoprolol 150mg [**Hospital1 **] 2. Prazosin 2mg [**Hospital1 **] 3. Dyazide 37.5/25 qd 4. Imodium prn 5. Comapazine prn 6. KBL (Magic mouthwash) 7. Roxicet prn 8. Procrit qweek 9. ASA 81mg Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 11. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. medication Maalox/diphenhyrdamine/lidocaine 15-30 mL three times a day 13. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 5 days: per g-tube. 14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Per g-tube. 15. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis Congestive Heart Failure Left Lower Lobe pneumonia Hypoxia from mucus plugging Secondary diagnosis Oral squamous cell carcinoma on radiation therapy. Chronic G-tube Discharge Condition: Fair. Respiratory status much improved saturating 97-99 on 3 L face mask. Otherwise afebrile and hemodynamically stable. Beginning to work with physical therapy to ambulate more frequently. Discharge Instructions: Please return pt to hospital if respiratory status begins to deteriorate or if chest pain starts to develop. Please continue all current medications. Please have patient follow up with oncologist. Patient should also have follow up with a cardiologist. Followup Instructions: Please have patient follow up with his oncologist, Dr. [**First Name (STitle) **] [**Name (STitle) 79**] of [**Hospital1 18**], at ([**2193**]. Please have patient schedule an appointment with a cardiologist, he may schedule one with [**Hospital1 18**] Cardiology ([**Telephone/Fax (1) 2037**]. Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2192-12-15**] 11:00 Provider: [**Name Initial (NameIs) 4426**] 7 Date/Time:[**2192-12-15**] 11:00 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] VASCULAR [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2193-1-8**] 8:30

[ "V44.1", "285.9", "145.3", "528.0", "584.9", "518.81", "507.0", "482.49", "401.9", "428.0", "276.51" ]

icd9cm

[ [ [] ] ]

[ "92.29", "96.6" ]

icd9pcs

[ [ [] ] ]

10576, 10655

4682, 8990

335, 369

10883, 11076

2185, 4659

11377, 12023

1840, 1857

9234, 10553

10676, 10862

9016, 9211

11100, 11354

1872, 2166

276, 297

397, 1457

1479, 1652

1668, 1824

16,590

118,309

29762

Discharge summary

report

Admission Date: [**2181-5-26**] Discharge Date: [**2181-6-8**] Date of Birth: [**2137-1-1**] Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 1271**] Chief Complaint: Traumatic brain injury s/p motorcycle accident Major Surgical or Invasive Procedure: Placement of [**Last Name (un) **] Bolt on [**5-26**] Tracheostomy and PEG [**2181-6-1**] History of Present Illness: 44M motorcycle driver involved in accident, slid approximately 100ft. was reportedly GCS 15 at scene. went to OSH, GCS down to 12 and then required intubation. Head CT there showed diffuse SAH and small R IPH. Pt transferred to [**Hospital1 18**] ED for further management. Pt was evaluated by trauma in ED and other than abrasions and brain trauma, had no other acute injury. Past Medical History: Previous intracerebral hemorrhage in [**2177**] diabetes mellitus type II hypertension Social History: Lives alone. Denies tobacco and drugs. Rare alcohol. Works as an EMT. Family History: Mother had stroke, both parents have hypertension and diabetes. Physical Exam: On admission: Intubated, sedated in hard collar and on back board examined in ED. no eye opening,intubated, min itermittent movement of L UE and bilat LE Gen:abrasions on right side of body especially R shoulder Toes downgoing bilaterally On discharge: Tracheostomy in place, opens eyes to voice, eyes track, follows commands in all extremities Pertinent Results: [**2181-5-26**] 05:20PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2181-5-26**] 05:20PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2181-5-26**] 05:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2181-5-26**] 05:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.036* [**2181-5-26**] 05:20PM FIBRINOGE-440* [**2181-5-26**] 05:20PM PLT COUNT-184 [**2181-5-26**] 05:20PM PT-12.3 PTT-21.6* INR(PT)-1.0 [**2181-5-26**] 05:28PM GLUCOSE-384* LACTATE-2.8* NA+-136 K+-3.9 CL--94* TCO2-26 [**2181-5-26**] 05:20PM UREA N-24* CREAT-1.2 [**2181-5-26**] 05:20PM estGFR-Using this [**2181-5-26**] 05:20PM LIPASE-52 [**2181-5-26**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**5-26**] CT Head: IMPRESSION: 1. Interval increase in the prominence of a left subdural acute hemorrhage. 2. Mild increase in a left subarachnoid hemorrhage and unchanged right subarachnoid hemorrhage. 3. Increasingly prominent right frontal intraparenchymal hemorrhage measuring 5 x 7 mm. [**5-26**] CT Torso: IMPRESSION: 1. No acute fracture. 2. Peripheral round-glass opacities in the right upper lobe concerning for pulmonary contusions. 3. A septated right mid polar and a high-density right lower pole cyst should be further evaluated with a renal ultrasound on a non-emergent basis. 4. ETT terminates ~ 1 cm above the carina, suggest withdrawal by [**11-19**] cm. 5. Bibasilar atelectasis and possible aspiration. [**5-26**]: CT C-spine: IMPRESSION: Rotation of C1 on C2 is likely positional. No acute fracture. [**5-27**]: CT Head: IMPRESSION: 1. New trace IVH. Decreased left SAH and rightward shift. Unchanged diffuse SAH and focal IPH. 2. ICP monitor. 3. Paranasal sinus disease. [**5-29**]: Chest X ray Diffuse opacities in left lower lung with atelectasis. [**5-29**]: Sputum gram stain and culture 2+ Gram negative rods, gram positive rods and gram positive cocci. [**5-31**] CXR In comparison with the study of [**5-29**], there is continued opacification involving much of the lower half of the left lung. Again this is consistent with volume loss and pleural effusion. However, suggestion of some air bronchograms would be consistent with the clinical suspicion of supervening pneumonia. The right lung remains essentially clear and the monitoring and support devices are unchanged. [**6-1**] CXR Moderate left pleural effusion with left lower lobe opacity that could represent pneumonia or atelectasis. [**2181-6-5**] In comparison with study of [**6-1**], the endotracheal tube has been removed and has been replaced by a tracheostomy tube. Nasogastric tube has been removed. There is enlargement of the cardiac silhouette with engorgement of ill-defined pulmonary vessels consistent with elevated pulmonary venous pressure. Atelectatic changes are seen at the bases and the left hemidiaphragm is poorly seen. This is consistent with atelectasis and effusion, though supervening pneumonia can certainly not be excluded. [**2181-6-5**] No evidence of right or left lower extremity DVT. [**6-5**] CTA chest 1. Solitary fresh non-occlusive pulmonary embolism segmental branch of the right middle lobe. No evidence of pulmonary infarction, right heart strain or pulmonary hypertension. 2. Progression of now complete atelectasis of both lower lobes is more likely to account for the patient's shortness of breath. CXR [**2181-6-6**]: Tracheostomy is in standard position. Left lower lobe opacity is a combination of moderate pleural effusion and left lower lobe collapse. Right pleural effusion is small. There is a platelike atelectasis in the right mid lung. Cardiomediastinal silhouette is unchanged. There is mild cardiomegaly. Brief Hospital Course: Mr [**Known lastname **] is a 44M motorcycle accident with traumatic brain injury, he was admitted to the ICU for close neurological exam and placed on seizure prophylaxis medications. During the first few hours of his hospitalization he had a poor neurological exam for which a bolt was placed. His ICPs remained within normal level and the bolt was discontinued on [**5-28**]. His neurological exam was stable with him MAE's, but did not follow commands. On [**5-29**] his SBP was liberalized to 160. He was written for transfer to the SDU but his oxygenation decompensated and he dropped to 70% O2 saturations. He was intubated and stat chest x ray showed complete white out of his left lung. A bronchoscopy was performed and secretions were cleared. A gram stain of the sputum showed GPC, GNR and GPR. Antibiotics were started on [**5-30**] for empiric treatment of VAP. His WBC remained in normal limits and he was afebrile. On [**5-31**], he remained intubated. His neuro exam improved as per nurses. He is scheduled for a tracheostomy and Percutaneous G-tube placement on [**6-1**]. He tolerated the procedure well without complications. His sedation was weaned and neurologically he began to improve. On [**6-4**], he was trasnferred to SDU in stable condition. He was screened for rehab by pt/ot and speech. He was started on Vancomycin for MRSA pneumonia. On [**6-5**], his WBC raised to 18 and a UA was sent. IT was without sign of infection. sputum culture showed....His oxygen saturation was in the low 90's and a RR in the 30's. CTA showed a small subsegmental PE. While in the scanner, saturation dropped to the 70's. ABG showed a metabolic alkalosis. Medicine was consulted. They recommended continuing Vancomycin to treat MRSA PNA and wanted ID consulted. They recommended transfering the patient to the ICU for closer observation and possible need of vent and frequent chest PT. For his PE it was decided due to the small size it would only be treated with SQ Heparin and full anticoagulation was held due to intracranial hemorrhages. Early on [**6-7**] he was transferred out of the ICU his most recent sputum and urine cultures were finalized as negative. His respiratory status was much improved now respirations were in the 20s and saturing 98% on 40% FIO2. On [**6-8**], pat was afebrile and respiratory status was stable. A picc line was placed in routine fashion. ID recommend he continue Vancomycing for 14 days from the date of [**6-7**]. He was set for d/c rehab in stable condition and will follow-up accordingly. Medications on Admission: Unknown Discharge Medications: 1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for oral thrush. 2. docusate sodium 50 mg/5 mL Liquid Sig: [**11-19**] PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever > 101F. 8. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Tablet(s) 11. insulin regular human Injection 12. vancomycin 1,000 mg Recon Soln Sig: One (1) 1000mg Intravenous every eight (8) hours for 13 days. 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Traumatic Brain Injury Subarachnoid hemorrhage Cerebral edema Hospital acquired pneumonia Respiratory failure Malnutrition oral candidiasis PE metabolic alkalosis Pyrexia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? 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. ?????? OK with SQH but hold all anticoagulation ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in _4-6___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**]. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2181-6-8**]

[ "401.9", "482.42", "415.19", "852.02", "112.0", "518.5", "348.5", "861.21", "250.01", "276.4", "E816.2", "852.22", "518.0", "263.9" ]

icd9cm

[ [ [] ] ]

[ "43.11", "38.97", "96.6", "33.21", "01.10", "96.71", "33.24", "96.04", "31.1" ]

icd9pcs

[ [ [] ] ]

9006, 9080

5289, 7849

318, 410

9295, 9295

1479, 2311

10151, 10906

1032, 1097

7907, 8983

9101, 9274

7875, 7884

9475, 10128

1112, 1112

1366, 1460

232, 280

438, 818

3145, 5266

1126, 1352

9310, 9451

840, 928

944, 1016

23,707

104,950

5352

Discharge summary

report

Admission Date: [**2153-10-22**] Discharge Date: [**2153-10-25**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Gadolinium-Containing Agents / Demerol / Morphine / Haldol Attending:[**First Name3 (LF) 1936**] Chief Complaint: mast cell degranulation flare Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 61 yo F with Mast Cell Degranulation Syndrome s/p 3 intubations, htn, depression, GERD and erosive OA who presents with SOB, CP, epigastric pain and n/v/d consistent with her typical mast cell degranulation attacks. . Pt was admitted twice since [**2153-9-3**]; in [**Name (NI) **] pt was intubated prophylactically for laryngeal edema in the context of a flare. Last admission was in early [**Month (only) 359**] and pt was sent home on a steroid taper which was completed 4 days PTA and a Z-pack completed 1 wk PTA. Pt reports the day PTA, she developed worsening epigastric pain which bores through to her back, constant squeezing chest pain, wheezing, and shortness of [**Month (only) 1440**]. While she has similar symptoms at baseline, these symptoms worsened gradually over the day yesterday and she went to the ED. She also had diarrhea x 4 BM yesterday, x2 today, and vomitting x 2 today. She reports a chronic productive cough of yellow-green sputum and several weeks of low grade fevers and night sweats. She denies wt loss. . ROS was notable for ha similar to her typical headaches and stiff neck. Pt denies photophobia, confusion, dysuria, hematuria, melena, bloody stool. She is unaware of any particular stressor (no falls, recent illness). . In the [**Name (NI) **] pt had an EKG showing sinus tach. VS were 97.4 120 141/89 24 97% RA. Pt received epi 0.3 1:1000 SQ epi, 2mg iv dilaudid x 2, 50iv benadryl x1 and 25mg x1, Solumedrol 80mg, Zofran 8mg, albuterol neb, ativan iv lmg. CXR no pneumonia, no acute process. Symptoms intitially got better then recurred. . On the floor, pt reports symptoms have improved from the ED. She now reports [**7-12**] epigastric pain, unchanged. Her wheezing has improved. She reports her breathing is uncomfortable and worrisome, but not yet at the point of intubation. Past Medical History: PMH: - Mast Cell Degranulation Syndrome as above - sx for >10 [**Month/Year (2) 1686**] but dx 6 [**Month/Year (2) 1686**] ago. Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **], allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI ;has had LFT abnl with attacks in past. Has been intubated three times, most recently [**9-10**]. Hospitalized 10 times in [**2152**] for attacks. - MI after given wrong dose of epi in anaphylaxis - HTN - pt reports is episodic and exacerbated during flares - Erosive osteoarthritis - GERD, gastritis and esophagitis on recent EGD [**2151-1-8**] - Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy - spinal stenosis - anemia - ? iron deficiency; received 2 transfusions in the past - Hemorrhoids - ADHD - depression/anxiety - hospitalized once after husband's divorce. - pt reports EGD demonstrated vegetable bezoar (?[**12-7**]). - h/o hyperparathyroidism with nl Ca, low nl Vit D [**2151**]; never had BMD - h/o MRSA infection (porthacath associated) - h/o L wrist cellulitis concerning for necrotizing fasciitis s/p what appears to have been a fasciotomy - portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection - portacath placed [**2151-6-9**] . PSH: - s/p cholecystectomy - s/p tonsillectomy - Status post hysterectomy and oophorectomy Social History: Pt lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. She is divorced after 37 yr marriage. Her son [**Name (NI) **] is her HCP [**Telephone/Fax (1) 21738**]; he lives in [**Location **] ME . She denies every using ETOH/recreational drugs / smoking. Pt reports frustrated mood but no current depression; no SI/HI. Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: Vitals - 98.2 168/96 107 20 98% on 2L GENERAL: obese woman with cushingoid face, eyes closed, easily distracted, in mild respiratory distress HEENT: NC, AT, MM dry, tongue appears red but not obstructive. no cervical lymphadenopathy. Neck supple. End expiratory wheeze in tracheal area; no stridor currently. CARDIAC: tachycardiac, regular no m/g/r LUNG: CTAB. No wheezes. ABDOMEN: soft, mild tenderness to palpation diffusely. No CVAT. No spinal tenderness. EXT: warm, 2+pulses, trace edema SKIN: many bruises on arm, larm bruise on L breast after fall prior to last admission. Pertinent Results: [**2153-10-22**] 07:05AM GLUCOSE-251* UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13 [**2153-10-22**] 07:05AM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-2.0 [**2153-10-22**] 07:05AM WBC-8.8 RBC-3.52* HGB-10.4* HCT-30.3* MCV-86 MCH-29.6 MCHC-34.4 RDW-15.3 [**2153-10-22**] 07:05AM PLT COUNT-247 [**2153-10-22**] 07:05AM PT-12.1 PTT-26.8 INR(PT)-1.0 [**2153-10-22**] 12:35AM NEUTS-74.0* LYMPHS-19.0 MONOS-5.7 EOS-1.2 BASOS-0.2 Brief Hospital Course: 61 yo F with Mast Cell Degranulation admitted for likely acute mast cell degranulation attack. . # Mast Cell Degranulation: Pt's symptoms were classic for a flare (CP, SOB, ha, n/v). On admission, pt was started on solumedrol 80 IV Q8, Famotidine 20 mg Q12H and she continued home Gastrocrom 300 mg Oral qid, cromolyn, fexofenadine. She was given supportive cocktail of Dilaudid 2mg IV q-4h, Benadryl 50mg IV q4h, Ativan 1mg IV q3h, Albuterol nebs q4h. On day 2 of admission, she reported increasing difficulty breathing and her tongue was moderately edematous and erythematous. She requested an epi pen, which was given with no effect as well as supplements from her cocktail. After an hour she still exhibited signs of acute respiratory distress and she requested prophylactic intubation. She was intubated and transferred to the MICU. Per anesthesia, there was no sign of laryngeal edema and intubation was easy. However, anesthesia team noted that prophylactic intubation is necessary in this pt given her cushingoid habitus and difficult intubation if laryngeal edema was present. After return from MICU to the floor, pt was transitioned to PO medications and started a 2 wk course of steroid taper, starting at 60 mg PO prednisone QD. . # Chronic pain - after pt's extubation, pt demanded IV Dilaudid and threatened multiple times to leave the hospital AMA. She also refused PO pain medications at this time, stating that they do not work. She complained of headache and chest pain. The team counseled her that headaches do not require IV pain medicines unless they are very serious and require imaging. She replied that she knew this was a mast flare and they required IV Dilaudid only. At this time, she had no shortness of [**Month/Day/Year 1440**], wheezing, pruritus, neuro sx, or any other symptoms. She appeared well and was pacing about the room. She was finally convinced to take PO medications, including multiple extra doses of Benadryl and Ativan. Pt reports that at baseline, she takes Dilaudid at home for headaches. . # Chest pain/SOB - While sx were classic for flare, CXR was obtained to r/o infx which showed no signs of pna or congestion. PCP was considered given pt's chronic steroids, and sputum obtained during intubation was negative. LDH was not checked due to chronic elevation. Pt's allergist at OSH was also contact[**Name (NI) **] re:PCP prophylaxis with Bactrim but allergist never responded. Per providers at [**Hospital1 18**], PCP prophylaxis has been discussed without resolution. . # diarrhea - pt complained of diarrhea on admission, but did not supply stool sample until day prior to discharge. Given pt's recent exposure to antibx (z-pack as outpt), C dif was checked and was negative. . # anemia - HCT 30, MCV 86; baseline HCT 30-35. Per pt, has been told she has iron deficiency in the past. Colonoscopy in [**2151**] showed hemorrhoids. Pt was recommended to consider iron replacement as an outpt. . # HTN: pt was continued on her home dose of diltiazem. Her bp ran high, but per pt, this is normal for her flares. . # chronic steroids/iatrogenic [**Location (un) **] - per pt, is on steroids >50% of year. Pt has very cushingoid appearance that per multiple providers, has increased over the past year. HbA1c was 6.1%; she was treated with an insulin SS while on high dose steroids. Pt continued Ca/Vit D, and pt was recommended to get BMD as outpt. Bactrim prophylaxis was considered, and pt was counseled to discuss with her allergist risks/benefits. . gastritis/GERD - cont ranitidine, omeprazole [**Hospital1 **] . # Depression/anxiety: - team discussed contribution of severe anxiety to her flares. Team recommends outpt psychiatry follow-up. Pt continued home Duloxetine, Ativan, Doxepin. . # ADHD - pt continued home Amphetamine-Dextroamphetamine . # Osteoarthritis: - pt continued home Plaquenil . # hx of hyperPTH with nl ca - etiologies most often due to Vit d deficiency . - pt now on Vit d/ca. Pt was recommended BMD as outpt. . . MICU COURSE: [**10-23**] - [**10-24**] . On the floor, pt reports symptoms have improved from the ED. She now reports [**7-12**] epigastric pain, unchanged. Her wheezing has improved. She reports her breathing is uncomfortable and worrisome, but not yet at the point of intubation. . Since admission she was given Solumedrol 80mg IV q8H x 3 with plan to transition to a prednisone taper the day of transfer. She was also on a supportive cocktail of Dilaudid 2mg IV q-4h, Benadryl 50mg IV q4h, Ativan 1mg IV q3h with planned transition to po. Day of transfer to the MICU, patient complained of worsening SOB without concomitant CP. Her O2 sat remained > 92. Given epi-pen, diphenhydramine IV, Ativan IV and Dilaudid IV. Code blue was called for elective intubation. ABG with pH 7.42, pCO2 40, pO2 526, HCO3 27 while being bag-masked. Patient was intubated by anesthesia on the floor without complication and transported to the MICU for further management. Upon transfer, patient was following commands. . # Shortness of [**Month/Year (2) 1440**]: This represented the 4th intubation for the patient. Per the intubating anesthesiologist, there was no evidence of tracheal or laryngeal edema. Of not the patient was without desaturation by pulse-oximetry or ABG. Thus, not truly hypercarbic or hypoxic respiratory failure. In the past, patient has been on steroid tapers which seemingly have helped her flairs. The patient was briefly placed on pressure support and continued on her regimen of Q4H ipratroprium/albuterol, steroids IV, diphenhydramine IV q6 and ranitidine for possible H2 component. The patient was subsequently extubated without complication. . # Mast Cell Degranulation: Pt initially stated that her presenting symptoms are consistent with her flairs. The patient was continued on solumedrol 80 IV BID; transition to PO prednisone post-extubation, Famotidine IV, continued pt on home Gastrocrom 300 mg Oral qid, cromalyn, fexofenadine. Once extubated the pt was continued on her home cocktail of Dilaudid 2mg IV q-4h, Ativan 1mg IV q3h, her scheduled diphenhydramine, Albuterol nebs q4h and Zofran. The pt was continued on insulin SS while on steroids. . Medications on Admission: Zolpidem 10 mg PO HS prn insomnia Hydroxyzine HCl 25 mg PO QID Ranitidine HCl 300 mg PO HS Duloxetine 60 mg Capsule once a day Hydroxychloroquine 200 mg PO BID Fexofenadine 180 mg PO BID Omeprazole 20 mg [**Hospital1 **] Cromolyn 100 mg/5 mL Solution 600 mg PO QID Diltiazem HCl Sustained Release 180 mg PO DAILY Hydromorphone 4 mg every four 4 hours as needed for pain. Amphetamine-Dextroamphetamine SR 15 mg once a day. Promethazine 12.5 mg TID prn nausea Doxapine 50 mg [**Hospital1 **] Epi pen prn Gastrocrom 30Ml (3amps) QID Iron Ca/Vit D Miralax PRN Discharge Medications: 1. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 2. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Cromolyn 100 mg/5 mL Solution Sig: Six (6) PO twice a day. 9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 11. Amphetamine-Dextroamphetamine 15 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 12. Promethazine 12.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 13. Doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime. 14. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular as needed. 15. Gastrocrom 100 mg/5 mL Solution Oral 16. Iron Oral 17. CALCIUM 500+D Oral 18. Miralax Oral 19. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 13 days: 60mg x 1 days 40mg x 2 days 20mg x 2 days 10mg x 4 days 5mg x 4 days. Disp:*24 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Mast cell degranulation flare Respiratory failure Hypertension GERD Depression/anxiety Discharge Condition: Hemodynamically and respiratory stable to home. Discharge Instructions: You were admitted to the hosptial for a mast cell degranulation flare. Blood tests were done, which showed that you are anemic, meaning you have low blood counts. Your level of anemia is unchanged from your baseline. You were treated with IV steroids (solumedrol) for 24 hours, and switched to prednisone. You were also treated with dilaudid, benadryl, albuterol nebulizers, zofran and ativan. Your other home medications were continued. You should follow up with your allergist, Dr. [**Last Name (STitle) **], and your primary care doctor after leaving the hospital. If you develop shortness of [**Last Name (STitle) 1440**], severe wheezing or chest pain, please go to the ED or call your doctor immediately. Followup Instructions: Please call your allergist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]) and make an appointment for within 2 weeks of leaving the hospital. Please also call your primary care doctor, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 21748**]. Please discuss with him your anemia. Please also discuss with him the bennefits of a bone mineral density scan for you, a tool to screen for osteoporosis. Completed by:[**2153-10-27**]

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Discharge summary

report

Admission Date: [**2197-8-27**] Discharge Date: [**2197-9-5**] Date of Birth: [**2123-8-11**] Sex: M Service: MEDICINE Allergies: Penicillins / Persantine / Allopurinol / Cipro I.V. Attending:[**First Name3 (LF) 106**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac cath- [**8-29**] Flex Sigmoidoscopy- [**9-4**] History of Present Illness: The patient is a 73 year old man with pmh significant for CAD s/p multiple stents to LAD, RCA, and LCX presenting with chest pain while recovering in the PACU from Laparascopic cholecystectomy. The patient had been experiencing symptoms of biliary colic for a week. He had an ERCP on [**8-16**] during which he underwent sphincterotomy with removal of multiple stones. The patient then returned on [**8-27**] with similar abdominal pain and underwent laparascopic cholecystectomy today. While in the PACU he developed chest pain which was relieved by dilaudid. ECG at this time showed ST depressions in V1-V4, and ST elevations in I, II, and III. Bedside echo showed LVEF of 30-40% with posterior wall hypokinesis and mitral regurgitation. The patient was started on heparin IV, beta blocker, and aspirin. He was also hypertensive during this episode with blood pressures 160/100. He was started on nitro and had foley placed, after which his blood pressure dropped to 130/80's, his pain resolved and his ekg changes resolved as well. On admission to the CCU the patient is in noticable discomfort. he was reporting epigastric burning pain with nausea. He reported the pain was unlike his anginal episodes. His anginal episodes usually present as substernal pressure. The patient was on 5mcg of nitro gtt at the time without resolution of pain. an ekg taken at this time did not show ischemic ekg changes. 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: h/o transaminitis Prostate CA T3b N0M0 [**Doctor Last Name **] 4+3 stage III s/p radiation and argon tx CAD s/p mulitple PCIs with stents PAF HTN DM 2 on oral [**Doctor Last Name 360**] Parkinsons with UE tremor, R>L Cholelithiasis Migraine and Cluster HA Gout with chronic B knee pain CKD baseline Cr 1.3 S/p hip replacement with multiple dislocations H/o childhood hepatitis Social History: Married, has several children. Wife is [**Name (NI) 4489**] [**Name (NI) 93090**]. Lives in half time in [**Location (un) 55**] and half in [**State 108**]. Retired airline pilot. No EtOH, tobacco or drugs Family History: Father had MI at age 40, DM, HTN. Brother with CAD s/p CABG at a young age. Mother with cancer, unknown type. Physical Exam: GENERAL: WDWN male in pain. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVP. CARDIAC: normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, LLQ tenderness. obese. Steristrips covering umbilicus and three other areas over RUQ and epigastric area. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Popliteal 2+ DP 2+ PT 2+ Left: Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2197-8-27**] 02:10AM BLOOD WBC-5.3 RBC-3.23* Hgb-10.1* Hct-30.0* MCV-93 MCH-31.2 MCHC-33.6 RDW-13.0 Plt Ct-164 [**2197-8-27**] 02:10AM BLOOD Neuts-66.0 Lymphs-21.0 Monos-8.9 Eos-3.1 Baso-1.0 [**2197-8-27**] 02:10AM BLOOD Plt Ct-164 [**2197-8-27**] 02:21AM BLOOD PT-13.6* PTT-26.5 INR(PT)-1.2* [**2197-8-30**] 04:49PM BLOOD Fibrino-444* [**2197-8-27**] 02:10AM BLOOD Glucose-202* UreaN-31* Creat-1.8* Na-139 K-4.0 Cl-[**2197-8-27**] 02:10AM BLOOD ALT-31 AST-22 AlkPhos-94 TotBili-0.3 [**2197-8-29**] 01:21PM BLOOD CK(CPK)-2140* [**2197-8-27**] 02:10AM BLOOD Lipase-43 [**2197-8-29**] 04:14AM BLOOD CK-MB-143* MB Indx-7.7* cTropnT-3.88* [**2197-9-5**] 05:10AM BLOOD WBC-7.5 RBC-3.34* Hgb-9.6* Hct-29.9* MCV-90 MCH-28.8 MCHC-32.1 RDW-14.0 Plt Ct-186 [**2197-9-5**] 05:10AM BLOOD Plt Ct-186 [**2197-9-5**] 05:10AM BLOOD Glucose-141* UreaN-18 Creat-1.2 Na-138 K-4.2 Cl-106 HCO3-23 AnGap-13 [**2197-9-5**] 05:10AM BLOOD WBC-7.5 RBC-3.34* Hgb-9.6* Hct-29.9* MCV-90 MCH-28.8 MCHC-32.1 RDW-14.0 Plt Ct-186 [**2197-9-5**] 05:10AM BLOOD Plt Ct-186 [**2197-9-5**] 05:10AM BLOOD Glucose-141* UreaN-18 Creat-1.2 Na-138 K-4.2 Cl-106 HCO3-23 AnGap-13 EKG [**8-28**]- Sinus rhythm with atrial premature beats. Non-specific ST-T wave changes. Consider myocardial ischemia. Compared to the previous tracing of [**2197-8-27**] ST-T wave changes and atrial premature beats are new. ECHO [**8-28**]- The left ventricular cavity size is top normal/borderline dilated. There is mild to moderate regional left ventricular systolic dysfunction with inferior and lateral hypokinesis. Right ventricular chamber size appears normal with preserved free wall motion in focused views. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Very mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Cardiac Cath [**8-29**]- 1. One-vessel significant coronary artery disease with very late stent thrombosis of LCX 2. Successful thrombectomy, PTCA, and drug-eluting stenting of the LCX. ECHO [**8-30**]- The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the inferior and inferolateral walls and distal lateral wall. The remaining segments contract well (LVEF 35-40%). 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 structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: The patient is a 74 year old man with diabetes, coronary artery disease, presenting with a STEMI in the setting of hypertension while recovering from laparoscopic cholecystectomy, s/p thrombectomy with DES to LCX at cath lab with hospital course complicated by lower GI bleeding. . # CORONARIES: Patient has a history of significant cortonary artery disease s/p multiple percutaneous coronary interventions. His chest pain was accompanied by EKG changes and a newly depressed ejection fraction to 35-40%, along with posterior wall hypokinesis. He continued to have chest pain with CE elevation and was taken to the cath lab on [**8-29**]. The cath showed two-vessel disease. The LCx had moderate in-stent restensosis and thrombus extending from the proximal portion to the middle of the vessel. The RCA had diffuse mild disease and minimal in-stent restenosis and a moderate discrete lesion in the mid PDA. He had a successful thrombectomy, PTCA, and stenting of the proximal and mid LCx with a 2.5 x 28mm Xience drug eluting stent which was postdilated to 3.0mm. Final angiography revealed no angiographically apparent dissection, no residual stenosis, and TIMI 3 flow. His CEs showed a peak CK=2140 with Trop 3.88 and MB 143 on [**8-29**]. Patient was continued on aspirin and plavix upon return to the unit. Experienced occasional chest discomfort while in-house but each episode was mild and lasted no more than 10 seconds. No EKG changes. Upon discharge, patient was comfortable. Denied any chest pain, shortness of breath, palpitations, edema. He will need to be continued on aspirin 325mg indefinitely as well as Plavix 75mg daily for at least one year. He is also on metoprolol succinate 25 mg daily and high dose Atorvastatin. . # Atrial fibrillation: The patient has a history of paroxysmal atrial fibrillation. He converted to normal sinus rhythm after amiodarone was started and he was amiodarone loaded with 400mg [**Hospital1 **] for 1 week. He will be discharged on amiodarone 400mg daily for 1 week and then amiodarone 200mg daily indefinitely. Coumadin was held in the setting of his lower GI bleed and he will continue on metoprolol succinate 25 mg daily . # BRBPR: The patient has known radiation proctitis s/p XRT for prostate cancer. He had a colonoscopy with argon plasma coagulation in early [**Month (only) 205**] for a GI bleed then. His GI bleed was reactivated once anticoagulation was restarted before his cardiac cath. His hematocrit dropped significantly and he required 5 units of pRBCs during his hospital course to maintain his hematocrit. GI was consulted and at first recommended Carafate enemas to help coat his known radiation proctitis ulcers. These enemas seemed to induce bowel movements which further irritated his GI bleed. They were discontinued and the patient was scheduled for a repeat flex sig with argon plasma coagulation in an attempt to stop the bleeding source. This took place [**9-4**] and was successful, although GI reports that he will likely rebleed and need a repeat procedure as an outpatient. . # Acute renal failure: His baseline creatinine was around 1.2, but was 1.8 on admission. It was likely of pre-renal etiology and his creatinine improved with increased PO intake and holding his Lasix. Low dose Lasix was restarted on discharge as his creatinine had normalized. . # Cholecystectomy: He initially had an elevated white count s/p procedure which resolved. Surgery followed him throughout his admission. He was able to tolerate a low fat diet prior to discharge. He is scheduled to see his surgeon after discharge. . # Hypertension: He did have some hypotension early on in his admission. His home metoprolol and valsartan were continued on discharge. . # Acute Systolic Congestive heart failure: His clinical exam was monitored closely to evaluate his fluid status and his home dose lasix of Lasix was restarted at discharge. . # Diabetes mellitis: Blood sugars were well controlled on an insulin sliding scale in addition to glipizide. . # Parkinson's disease: His home selegiline was continued. . # Gout: His home colchicine was continued on discharge after being held in the setting of his acute coronary syndrome. . # Migraine and cluster headaches: Pain was treated with Percocet PRN and his home cyclobenzaprine with good effect. . CODE: The patient's code status was confirmed as full code. . COMM: [**Name (NI) 4489**] [**Name (NI) 93090**] wife, [**Telephone/Fax (1) 93092**] home, [**Telephone/Fax (1) 93093**] Medications on Admission: Atorvastatin [Lipitor] 40 mg Tablet one Tablet(s) by mouth daily Colchicine 0.6 mg Tablet 1 Tablet(s) by mouth once a day Cyclobenzaprine 10 mg Tablet 1 Tablet(s) by mouth three times a day as needed for back pain Furosemide 20 mg Tablet 1 Tablet(s) by mouth daily Glipizide 5 mg Tablet 0.5 (One half) Tablet(s) by mouth once a day Isosorbide Mononitrate 10 mg Tablet 1.5 Tablet(s) by mouth twice a day 15 mg twice a day Leuprolide [Lupron Depot] Dosage uncertain Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**1-13**] Tablet(s) by mouth once a day Nitroglycerin 0.4 mg Tablet, Sublingual 1 (One) Tablet(s) sublingually as needed Selegiline HCl 5 mg Capsule 1 Capsule(s) by mouth DAILY (Daily) Valsartan 80 mg Tablet 1 Tablet(s) by mouth DAILY (Daily) Warfarin 5 mg Tablet 1 Tablet(s) by mouth as directed Docusate Sodium 100 mg Capsule 1 Capsule(s) by mouth twice a day hold for diarrhea Sodium Chloride 0.65 % Aerosol, Spray [**1-13**] Aerosol(s) intranasally four times a day as needed for nasal dryness Discharge Medications: 1. Selegiline HCl 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Glipizide 2.5 mg Tablet Extended Rel 24 hr (b) Sig: One (1) Tablet Extended Rel 24 hr (b) PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not discontinue unless Dr. [**Last Name (STitle) 171**] tells you to. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for flatus. 11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: Take for one week until [**9-11**], then decrease to 200 mg daily. 14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: ST Elevation Myocardial Infarction Acute Systolic Dysfunction Atrial fibrillation Acute Blood Loss Anemia Acute Renal Failure Status Post Laproscopic Cholecystectomy Hypertension Discharge Condition: Hct= 29.4 Discharge Instructions: You had a heart attack during your gall bladder removal. A cardiac catheterization was done and found a blockage in your left circumflex artery. A drug eluting stent was placed in this artery to keep it open. You will need to take aspirin and plavix for one full year. Do not stop taking Plavix unless Dr. [**Last Name (STitle) 171**] tells you to. You had some bleeding from your urinary tract that was because of the blood thinners your received. You also had some bleeding from the area in your rectum that was the proctitis you had before. . Medication changes: 1. Increase Atorvastatin for your coronary artery disease to 80 mg 2. Plavix: to take every day for one year to keep the stent open 3. Take aspirin every day for one year to keep the stent open 4. Stop taking Imdur 5. Decrease your Metoprolol Succinate to 25 mg daily 6. Start Amiodarone to keep you in a normal rhythm. 7. Stop taking coumadin . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Neurology: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2197-10-3**] 3:30 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2197-9-21**] 11:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2197-10-19**] 11:00 . Primary care: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 93095**]: [**Telephone/Fax (1) 10011**] please make an appt to see Dr. [**Last Name (STitle) **] after you get out of rehab. . Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] Phone: [**Telephone/Fax (1) 62**] Date/Time: Wednesday [**10-11**] at 3:00pm . Surgery: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: call [**Telephone/Fax (1) 2723**] and schedule an appointment in 2 weeks time.

[ "E878.8", "410.71", "403.90", "997.1", "414.2", "V10.46", "414.01", "427.31", "574.00", "332.0", "250.00", "574.10", "274.9", "428.21", "346.90", "556.2", "569.3", "285.1", "428.0", "585.9", "E879.2", "E934.2", "584.9", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.66", "99.20", "45.43", "51.23", "36.07", "00.45", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

13382, 13472

6386, 10900

321, 377

13695, 13707

3418, 6363

14768, 15856

2645, 2757

11974, 13359

13493, 13674

10926, 11951

13731, 14277

2772, 3399

14297, 14745

271, 283

405, 2003

2025, 2404

2420, 2629

19,449

176,756

8581

Discharge summary

report

Admission Date: [**2135-4-21**] Discharge Date: [**2135-4-23**] Date of Birth: [**2076-4-4**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old gentleman with metastatic melanoma referred by Dr. [**Last Name (STitle) 1729**] for a large right frontal mass with associated edema. For the past few weeks prior to admission the patient noted some slurred speech, difficulty using his left hand for fine has become frustrated very easily and his memory is poor. These symptoms improved with starting Decadron. He denies any headaches, seizure activity, nausea, vomiting or falls. His oncological history began in [**12/2132**] with a left axillary melanoma resection. On [**2133-6-23**] he had a right thoracotomy and wedge resection for a melanoma. This was followed by phase two protocol consisting of four cycles of IL2 resection of melanoma by Dr. [**Last Name (STitle) 175**] in 4/[**2133**]. He was also enrolled in a protocol after surgery. MEDICATIONS ON ADMISSION: Decadron 4 mg q.i.d., Prilosec 20 mg po q day. HOSPITAL COURSE: On [**2135-4-20**] the patient underwent right frontal craniotomy for resection of metastatic tumor without intraoperative complications. Postoperatively, the patient was monitored in the recovery room overnight. His vital signs remained stable. He was afebrile. He was awake, alert, and oriented times three. His pupils were 2 down to 1 mm. His extraocular movements were full. He had no facial asymmetry. Tongue was midline. Palate elevated symmetrically. He had 5 out of 5 in all muscle groups. His incision was clean, dry and intact. He was transferred to the regular floor. On postoperative day number one he was seen by physical therapy and occupational therapy and found to be safe for discharge to home. He was discharged on [**2135-4-23**] in stable condition. The patient was discharged to home in stable condition and will follow up in the Brain [**Hospital 341**] Clinic in ten to fourteen days for staple removal. MEDICATIONS ON DISCHARGE: Atarax 25 mg po as needed, Compazine 10 mg po every eight hours as needed, Imodium 2 mg po every four hours as needed, Naprosyn 375 mg po one tab po twice a day as needed, Serax 15 mg po as needed for sleep. The patient was also discharged on a Decadron taper, Zantac 150 mg po b.i.d. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2135-4-26**] 10:47 T: [**2135-4-26**] 10:57 JOB#: [**Job Number 30117**]

[ "535.40", "197.0", "198.3", "172.8" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

2056, 2626

1020, 1068

1086, 2029

158, 993

70,072

121,215

36717

Discharge summary

report

Admission Date: [**2188-6-28**] Discharge Date: [**2188-7-5**] Date of Birth: [**2109-11-22**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: Laparoscopic converted to open and partial cholecystectomy [**2188-6-30**]. History of Present Illness: 78 yo man with hypertension, SVT, hyperlipidemia, here with acute onset epigastric pain. He awoke early this morning with these symptoms. The pain was epigastric and did not radiate, and he has not had similar pain. It is associated with nausea, but no vomiting. He has had no fevers or chills. No associated shortness of breath, palpitations, change in bowel habits. He has had no recent weight loss and no jaundice. No new medications. Had a heavy meal one day prior to celebrate a birthday, and thinks this might have exacerbated his symptoms. . He presented to the ED at [**Hospital3 **], EKG showed T wave flattening V1-V5. He received SL NTG, maalox, morphine, zofran. He was found to have a lipase of 1067 and amylase of 190. He had abdominal ultrasound that showed diffuse fatty liver, a pancreatic duct of 3 mm, common bile duct of 3 mm, and no gallstones. He was transferred for possible [**Hospital3 **]. . On arrival, his pain was controlled with morphine, and he complained of dry mouth. He had no further nausea or vomiting. . ROS positive as above, and otherwise reviewed in detail and negative. Past Medical History: Barrett's esophagus Hyeprtension Hypothyroidism Hyperlipidemia SVT Prediabetes . Past surgical history: appendectomy, tonsillectomy, herniorrhaphy, s/p ORIF R ankle, s/ thoracotomy with excision of granuloma. Social History: Married, retired professor of business in SUNY system. Several children, nephew is [**Name (NI) **] [**Name (NI) **]. No tobacco, intermittent alcohol. Active at baseline, though not in past several weeks due to scheduling difficulties. Supportive family structure. Lives part of the year in [**State 108**]. Family History: Coronary disease in his paternal grandfather (died at 72) and in father (died at 75) with CVA, CAD. Physical Exam: VS: T: 98.1, BP: 130/80, HR: 68, RR: 12, SaO2: 94% RA Gen: In NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Mucous membranes moist. No oral ulcers. Neck: Supple, no LAD, no JVP elevation. Lungs: Bilateral basilar crackles, do not clear with coughing. Normal respiratory effort. CV: RRR, no murmurs, rubs, gallops. Abdomen: soft, mild epigastric tenderness, no HSM, no RUQ tenderness. No rebound or guarding. Extremities: warm and well perfused, no cyanosis, clubbing, edema. Neurological: alert and oriented X 3, CN II-XII intact. Grossly nonfocal. Skin: No rashes or ulcers. Psychiatric: Appropriate. GU: deferred. Pertinent Results: WBC 5, RHgb 14, Hct 42, MCV 86, Plts 219 . Na 141, K 4.6, Cl 105, CO2 28, BUN 21, Cr 1.2 CPK 144, Trop I < .04 . INR 1.0 . Alk phos 185, ALT 27, AST 49, amylase 190, Lipase 1067, Alb 5, T prot 8.1, T bili 0.8. . [**2188-6-30**] CTA ABD W&W/O C & RECONS: 1. No definite dilation of the pancreatic duct or pancreatic mass. A 2.3-cm duodenal diverticulum slightly indents the pancreatic head, although there is no overt obstructive mass effect upon the CBD or pancreatic duct at this time. 2. Focal density in CBD that could represent choledocholithiasis, without intrahepatic or significant extrahepatic biliary dilation. Mildly distended gallbladder with questionable small pericholecystic fluid/ mild pericholecystic hyperemia. Correlation with the ultrasound reportedly obtained at OSH recommended as findings are not specific by CT, but if concern for cholecystitis is present a dedicated ultrasound would be recommended. 3. No CT evidence of pancreatitis, although this does not exclude a clinical diagnosis of pancreatitis. 4. Extensive colonic diverticulosis in the visualized portion of the colon, although without evidence of acute diverticulitis. 5. Small hiatal hernia. Small simple splenic cyst. Tiny left renal hypodensity, too small to characterize. Fatty infiltration of the liver. 6. Multilevel degenerative changes in the spine. . [**2188-6-30**] Gallbaldder Scan: Non-visualization of gallbladder compatible with acute cholecystitis. However in a setting of prolonged fasting state and incomplete pre-treatment with CCK the accuracy of the study is limited. The common bile duct is patent. . [**2188-6-30**] Liver/Gallbladder U/S: 1. Gallbladder distension with mild wall thickening and mild pericholecystic fluid. Imaging appearance is suspicious for cholecystitis; a small echogenic focus at the wall may represent a tiny stone or tiny focus of gas. Although the imaging findings are more consistent with cholecystitis, laboratory data is not as supportive (increased bilirubin levels are the only abnormal LFTs), and imaging findings should be correlated with the clinical context. 2. Study is limited by bowel gas artifact, which limits evaulation of the distal common bile duct, grossly measuring 7mm in diameter. 3. There is diffusely increased hepatic echogenicity, most consistent with fatty liver. Other, more serious forms of disease including cirrhosis and advanced hepatic fibrosis cannot be excluded. . [**2188-7-1**] Echocardiogram: The left atrium is mildly dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Overall normal biventricular systolic function. No clear evidence for right ventricular pressure or volume overload. . [**2188-7-1**] CXR: Vascular congestion may be slightly improved, although bibasilar pleural effusion and atelectasis persist. In the face of low lung volumes and basilar atelectasis, particularly in the left retrocardiac region, superimposed infection cannot be excluded in the lung bases. . [**2188-7-2**] [**Month/Day/Year **]: Free extravasation of contrast from the cystic duct remnant. A plastic stent catheter was placed at the end of the procedure. For additional details, please refer to the [**Month/Day/Year **] report from the same day. . [**2188-6-30**] Pathology: SPECIMEN SUBMITTED: gallbladder. DIAGNOSIS: Gallbladder: Acute cholecystitis with transmural inflammation. Clinical: Not given. Gross: The specimen consists of a gallbladder that measures 6.5 x 4.7 x 1.2 cm, and is previously opened to reveal a brown mucosal surface with yellow exudate. The specimen is represented in A. . [**2188-6-30**] EKG: NSR, TW flattening V2-V5. Brief Hospital Course: 78 yo man with hypertension, hyperlipidemia, here with acute pancreatitis. . # Cholecystitis: Ptient was found to have evidence of cholecystitis on CT abdomen and HIDA scan. He was taken to the OR on [**2188-7-1**] for laparoscopy cholecystectomy, which was converted to open cholecystectomy. He had 2 drains in place. Peritoneal cultures grew pan-sensitive E. coli. He was continued on Unasyn, which had been started on [**2188-6-29**]. He was observed in the ICU overnight after his surgery. The following day he was noted to have persistently elevated obstructive pattern of LFTs. He underwent [**Date Range **] on [**2188-7-2**]. There was no CBD filling defect. CBD was not dilated. A sphincterotomy was successfully performed and a biliary stent was placed. He needs repeat [**Date Range **] in 8 wks for stent removal and reevaluation of CBD. Lateral drain was discontinued [**2188-7-4**]. Medial drain .......... . # Hypoxia respiratory failure: This was due to volume overload, splinting from pain, and rapid shallow breathing from pain/sepsis. Pt remained intubated overnight after his surgery. He was extubated the following morning and transitioned to nasal cannula without any problems. [**Name (NI) **] was weaned off supplemental oxygen by [**2188-7-4**]. . # Acute pancreatitis: Patient was initially was treated for acute pancreatitis with IVFs and NPO. He had no significant alcohol consumption, no gallstones on CT, no new drugs. He then developed an obstructive pattern suggestive of biliary obstruction. CT pancreas was obtained, which had shown the cholecystitis. Post-operatively, patient was able to tolerate a regular diet without nausea, vomiting, abdominal pain. . # Hypertension: Patien was continued on his metoprolol except during his ICU stay. Blood pressure remained stable. . # Hyperlipidemia: His lipitor was held in the acute phase during hospitalization. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged to home. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Patient drain teaching for discharge. Medications on Admission: Lipitor 20 mg po [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg po [**First Name3 (LF) **], Travatan Z eye drops, Prevacid 30 mg po daily, Levothyroxine 125 mcg po daily, Metoprolol ER 25 mg po bid, Viagra 100 mg prn Discharge Disposition: Home With Service Facility: CareGroup VNA Discharge Diagnosis: Priamry: 1. Gangrenous cholecystitis Secondary: 1. Hypertension 2. Hypothyroidism Discharge Condition: Good. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-18**] 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. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. Patient was instructed to f/u with his PCP if his stools continue to be black for more than two days. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2188-7-16**] 1:00; Location: [**Location (un) 620**] Office. Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2188-8-28**] 11:00 Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2188-8-28**] 11:00 Completed by:[**2188-7-5**]

[ "E878.6", "518.0", "427.89", "514", "518.81", "575.0", "577.0", "576.8", "997.4", "511.9", "244.1", "567.22", "401.9", "530.81", "995.91", "272.4", "038.42", "560.1", "V64.41" ]

icd9cm

[ [ [] ] ]

[ "51.85", "51.21", "51.87" ]

icd9pcs

[ [ [] ] ]

9981, 10025

7380, 9707

330, 408

10152, 10160

2934, 7357

12840, 13298

2139, 2240

10046, 10131

9733, 9958

10184, 11639

11655, 12817

1687, 1793

2255, 2915

275, 292

436, 1561

1583, 1664

1809, 2123

13,486

122,087

49142

Discharge summary

report

Admission Date: [**2111-11-18**] Discharge Date: [**2111-12-3**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: [**First Name9 (NamePattern2) 103107**] [**Last Name (un) **]/thymoma Major Surgical or Invasive Procedure: partial sternotomy for thymoma resection related to [**First Name9 (NamePattern2) **] [**Last Name (un) **] History of Present Illness: Admitted on [**11-18**] for [**First Name9 (NamePattern2) **] [**Last Name (un) **] and in process thymoma discoved Past Medical History: essential tremor, Cataracts, Thymoma Social History: 32 pack year, no ethoh, Family History: no history of neurology illness Physical Exam: [**Known lastname **],[**Known firstname **]: [**Hospital1 18**] Notes Detail - CCC Record #[**Numeric Identifier 103108**] Initial - CCC Neurology Chief Resident Admission Note HPI: Mrs. [**Known lastname 18806**] is a 79 yo rh woman with a history of essential tremor who is presenting with ~ a 20 year history of progressive ascending weakness in the legs. For many years she did not think it was significant enough to warrant attention, however, last year she began to have difficulty climbing stairs. She saw Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] and had an EMG which showed severe motor and sensory neuropathy in the legs with so little preserved that it was difficult to further characterize. A nerve biopsy and LP were suggested, but a family member highly discouraged this. She therefore decided not to have further workup at the time. Now for the last few months she has noted some involvement of her arms and neck as well. She is having difficulty opening jars, combing her hair, keeping her head up and gets fatigued at walking very short distances. Sunday she fell twice due to "fatigue". She has seen a rheumatologist for this complaint which she felt to be arthritis. Her ESR was found to be elevated a few months ago but she decided against taking prednisone at the time. She reports that a scan of her chest revealed a thymus tumor that she was told is benign and doesn't need to be removed. She denies any diurnal variation to her weakness. She has not noted shortness of breath, dysphagia, diplopia or blurred vision. However, she did note that the TV in her hospital room (on a high dresser) became blurry after watching for ~ 15 minutes. PAST MEDICAL HISTORY: essential tremor cataracts thymoma as above ALLERGIES: NKDA MEDS: prednisone 10mg lasix 40mg timolol ambien prn SOCIAL HISTORY: 32 pyh, quit 28 [**Last Name (un) **], no etoh, no ivda FAMILY HISTORY: no history of neurologic illness PHYSICAL EXAM: General Exam: Vitals: afebrile BP: 130/60 P: 73 R: 14 Counts to 35 on one breath Gen: obese, NAD Head: NC/AT, non-icteric, MMM Neck: supple, no LAD, no carotid bruits Abd: S,NT,ND Ext: 3+ edema bilaterally in legs, no rashes Neurological Exam: Mental Status: Awake, alert, cooperative and attentive. Memory intact to distant and recent past. Speech is fluent without paraphasic errors. Naming and repitition are intact. [**Location (un) **] and writing are normal per patient report. There is no neglect nor signs of frontal release. Cranial Nerves: II. visual fields intact to confrontation. pupils normal, round and reactive to light, no rAPD III, IV, VI. Extraocular movements intact and without nystagmus, on upgaze held > 1 minute she has variable diplopia at near V, VII. Normal facial sensation. No facial droop. Strength full and symmetric. VIII. Hearing intact to finger rub bilaterally IX, X, XII. Normal oropharyngeal movemement. Tongue midline without fasciculations. Sternocleidomastoid and trapezius normal bilaterally Motor: Normal tone with some action and postural tremor. In arms proximal weakness in 4+ range. Triceps easily fatigue with thirty repititions foot and toe extensors [**3-5**], flexors 4: and IPs 4+ Sensory: Reports intact to light touch, pinprick, cold, and few mistakes on proprioception in great toes. No escuchion deficit to pp. Reflexes: Tri [**Hospital1 **] Br Pat Ach Toes L 2 2 2 1 0 mute R 2 2 2 1 0 mute Coordination: Without dysmetria, intact to FNF Imaging: MRI spine OSH: no evidence of cord compression Assessment & Plan: Mrs. [**Known lastname 18806**] is a 79 year old woman who is presenting with an subacute on chronic weakness. In the past she has had a very prominent EMG proven neuropathy. I do not see a sensory component on today's exam, but this would certainly explain the reverse strength gradient in the legs. However, I believe that her neck weakness and reports of quick fatigue as well as bluriness when watching the TV in her hospital room are very suspicious for myasthenia [**Last Name (un) 2902**]. If this is true a thymectomy would likely be indicated. Additionally it would explain her recent declining strength while tapering down on prednisone as an extremely slow taper is often necessary in myasthenia patients. I would like to get an EMG/NCS also with single fiber or repetitive stim testing for neuromuscular junction disease. It appears that a tensilon test would be difficult as there are not good objective exam findings to track with it. Additionally cardiac side effects do necessitate caution. She does not complain of SOB or dysphagia, however, I would like to get a baseline NIF and VC. Serum is being sent for Ach antibodies. LP may still be necessary to further investigate her neuropathy and CIDP must be entertained given its long and insidious course. Pertinent Results: [**2111-11-18**] 05:10PM SED RATE-12 [**2111-11-18**] 05:00PM GLUCOSE-108* UREA N-30* CREAT-0.8 SODIUM-139 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-29 ANION GAP-13 [**2111-11-18**] 05:00PM PT-12.9 PTT-28.3 INR(PT)-1.1 Brief Hospital Course: Therapeutic Pheresis Allergies: Documented in the OMR option (4) Medication Sheet Type of Procedure: (x) Therapeutic Plasma Exchange () White Blood Cell Reduction () Platelet Reduction () Red Blood Cell Exchange () Other: Indication/Diagnosis: Myasthenia [**Last Name (un) **] Treatment #: 4 Length of Procedure: 76 min. Replacement Fluid: (x) Albumin () FFP () Red Blood Cells () None Required () Other: Venous Access: (Describe) () Peripheral: (x) Central: right IJ Catheter Site Assessment: erythema noted around insertion site. Instilled Heparin Removed at Start of Procedure: Yes (x) No ( ) Aliquots Saved: Yes ( ) No (x) Pre Labs: Hct/Hgb: Hemacue 11.8 Plt: LDH: Haptoglobin: Ca: Other: VS: T: 98.4 P: 88 R: 18 BP: 160/50 Medications Given: None given () TUMS () IV Calcium: amps (1amp = 1 gram) () Tylenol 650mg () Benadryl PO mg () Benadryl IV mg () Hydrocortisone IV: mg () Other: Post Labs: None drawn Hct/Hgb: WBC: Plt: LDH: Haptoglobin: Ca: Other: Fluid Balance: Volume In: 2419 cc Volume Out: 2526 cc Net Balance: +216 cc Dressing Changed? Yes ( ) No (x) N/A ( ) Pheresis Catheter Care: () 10 cc Normal Saline () 100 U heparin (x) 1000 U heparin Heparin Volume = Lumen Volume Red Port 1.1 cc Blue Port: 1.4 cc AVOID USE OF PHERESIS CATHETER 4CC BLOOD MUST BE WITHDRAWN PRIOR TO USE Assessment: (x) Stable () Complicated (See Comments) () Deferred Plan: (x) Verbal Post Pheresis Instructions Reviewed () Written Post Pheresis Instructions Reviewed () Return Appointment Scheduled: Discharge Disposition: () Ambulatory (x) Wheelchair () Stretcher () N/A Discharge to: () Home (x) Hospital () Nursing Home () Other: Comments: THis was Mrs. [**Known lastname 18806**] fourth and final treatment. She tolerated it well. Her Pheresis Catheter needs to pulled by Interventional Radiology. IR was notified and was unable to do at the end of the procedure. THey stated they will pull it by the end of the day. * Additional details may be available in the Pheresis Unit chart ([**Hospital1 **] 127). Medications on Admission: MEDS: prednisone 10mg lasix 40mg timolol ambien prn Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (). 2. Multivitamin Capsule Sig: One (1) Cap PO QD (). 3. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Metoclopramide HCl 5 mg/mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 13. Morphine Sulfate 1-5 mg IV Q2H:PRN 14. Dolasetron Mesylate 12.5 mg IV Q6H:PRN nausea 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Heritage Manor Discharge Diagnosis: Thymoma Discharge Condition: Stable Discharge Instructions: Please continue to ambulate and practice incentive spirometery Followup Instructions: F/U in [**3-3**] weeks however call the office of Dr. [**Last Name (STitle) **] next week to set up appointment and also f/u with Neurology call for appointment Completed by:[**2111-12-3**]

[ "212.6", "358.01", "715.90", "355.8", "333.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "03.31", "99.71", "07.82" ]

icd9pcs

[ [ [] ] ]

9244, 9285

5872, 7389

339, 449

9337, 9345

5628, 5849

9456, 9648

2702, 2737

8014, 9221

9306, 9316

7937, 7991

9369, 9433

2752, 2978

2997, 2997

230, 301

477, 594

3304, 5609

3012, 3288

2499, 2613

2629, 2686

24,739

102,056

15276

Discharge summary

report

Admission Date: [**2179-10-26**] Discharge Date: [**2179-11-6**] Date of Birth: [**2119-5-18**] Sex: M Service: OMED HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male with history of metastatic [**Year (4 digits) 499**] cancer to the liver with low back pain times four to five weeks with an acute worsening of pain last night while sleeping. The patient says he "rolled onto his side or something" and awoke in severe pain. No history of recent fall. No bladder or bowel incontinence. The patient states his pain is constant and localizes to the bone and muscle; however, it is worse in the bone. He localizes his pain to the L1 level. No fevers, chills, weight loss, or diarrhea. The patient states his appetite is good. He reports a mild cough with sore throat and hoarseness for the past couple of days, but otherwise review of systems is negative. PAST MEDICAL HISTORY: Metastatic [**Year (4 digits) 499**] cancer to the liver- possible candidate for trisegmentectomy with wedge resection (referred to Dr. [**Last Name (STitle) **] secondary to rapidly progressing liver metastasis despite recent chemotherapy. Status post sigmoid colectomy with low anterior resection on [**2178-9-23**] with one moderately differentiated and one poorly differentiated lesion with 11 out of 12 lymph nodes positive, status post adjuvant chemotherapy from [**11-9**] to [**6-10**] consisting of 5-FU plus leucovorin. CEA on [**2179-9-27**] elevated to 29, at which time a CT revealed new large liver metastasis. MEDICATIONS: 1. Tylenol p.r.n. 2. Vitamin B6 q.d. ALLERGIES: ALEVE CAUSES URTICARIA. FAMILY HISTORY: Sister with [**Name2 (NI) 499**] cancer. Father deceased at 52 secondary to a CVA. Mother deceased at 92 secondary to natural causes. SOCIAL HISTORY: No tobacco or alcohol. The patient is married with three sons. [**Name (NI) **] is a retired pipe fitter. He denies IV drug use, blood transfusions, or hepatitis. PHYSICAL EXAMINATION: Temperature 97.4 degrees, blood pressure 138/88, heart rate 79, respiratory rate of 20, and O2 saturation 97 percent on room air. General: The patient is clearly in distress secondary to pain, unable to move in the bed without complaints of pain. HEENT: Pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae is anicteric. Neck: No lymphadenopathy. Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Pulmonary: Clear to auscultation bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended; no masses or hepatosplenomegaly. Extremities: No clubbing, cyanosis, or edema. Neuro: Cranial nerves II through XII grossly intact, moving legs bilaterally. No complaints of weakness. Intact to vibration bilaterally. Back: Point tenderness over L1. Rectal: Good rectal tone. Guaiac negative. LABORATORY AND DIAGNOSTIC DATA: Admission white count 9.5 increased to 16.4 during this admission, hematocrit 44.2 decreased to 34.9 during this admission, platelets 265 with a decrease to 85 over his hospital stay. Initial chem-7 within normal limits. Increasing creatinine to 1.3 following episode of hypotension. LFTs increased into the 1000s following episode of hypotension. Troponin 0.16 following episode of hypotension. Lactate of 8.0 during the course of this admission. Hepatitis B surface antigen positive, hepatitis B core antibody positive, hepatitis A virus antibody positive, hepatitis C virus antibody negative. MRI of the spine: Metastatic involvement of T12 without pathologic compression or deformity. Moderate cervical spondylosis most notably at C5-C6 level; also minor spondylosis at C4-C5 and C3-C4. Loss of signal within the body of L1 with mild loss of height anteriorly and perhaps slightly posteriorly. An epidural mass extending posterior to L1 without compression of the cauda equina. Mild disc narrowing at L3-L4 and L4-L5 without evidence of canal stenosis or focal disc protrusion. Gallbladder ultrasound from [**2179-10-30**]: No gallstones, no common bile duct dilation, portal vein patent. CT of the head from [**2179-10-30**]: No acute intracranial hemorrhage, mass effect, or enhancing lesion. Small lacunar infarct within right basal ganglia, likely remote. Blood cultures from [**2179-10-30**] and [**2179-11-3**] are negative for growth. Sputum culture from [**2179-10-31**] consistent with MSSA. Urine culture from [**2179-10-30**] negative. Stool culture from [**2179-10-30**] and [**2179-11-5**] negative for Clostridium difficile and other cultures. GGT 130. HOSPITAL COURSE: This is a 60-year-old male with history of metastatic [**Month/Day/Year 499**] cancer to the liver presenting with acute worsening of chronic low back pain with evidence of metastatic spinal disease on admission MRI involving T12 and L1. Metastatic [**Month/Day/Year 499**] cancer: The patient is status post 5-FU and leucovorin completed in [**6-10**], however, with rapid development of liver metastases on CT diagnosed prior to admission. He was prior in consideration for hepatic resection due to his single site of metastasis. However, he now presents with new bony metastasis. During the course of his admission, Surgery was consulted and the patient was staffed with Dr. [**Last Name (STitle) **], whom he was referred to in the past for liver lesion resection. The decision was made that resection is not appropriate at this time given the two sites of metastatic disease. Thus, Radiation Oncology was consulted with a plan to initiate palliative radiation for pain control. The patient will likely also undergo further chemotherapy as an outpatient. Due to ongoing pain, difficult to control by p.o. medications, the patient's palliative radiation was started in-house. Pathologic vertebral body compression fracture: The patient was started on MS Contin, which was titrated up to permit adequate mobility. Neurosurgery was consulted regarding the benefit of a potential brace. It was their opinion that a brace will offer the patient little to no benefit. Due to ongoing pain despite p.o. medication, the patient was initiated on palliative radiation. However, this seemed to acutely worsen his back pain and his MS Contin was gradually titrated up. However, this was complicated by hypercarbic respiratory failure due to likely narcotic overdose plus or minus history of aspiration due to decreased mental status and supine positioning necessary due to the patient's ongoing back pain. In addition to narcotic analgesia, the patient received a dose of IV pamidronate on [**2179-10-27**] and was managed on Vioxx. He was ultimately discharged on rofecoxib, OxyContin, and hydromorphone p.r.n. Epidural mass at L1: On admission MRI, patient was noted to have an epidural mass at the level of L1 vertebral body without compression in the cauda equina. He received IV steroids; however, these were discontinued the following day due to the confirmation of no cord compression, and the approval of Radiation Oncology for the absence of need for steroids with the initiation of palliative radiotherapy. Hypercarbic respiratory failure: The patient was noted to be unresponsive and hypoxic with saturations in the 80s on [**2180-10-30**]. ABG at that time was 7.18/58/79. Initial thought for narcotic overdose as the underlying etiology, thus the patient received one dose of Narcan with some improvement in his oxygenation and respiration. However, he continued to be poorly responsive and agitated with a drop in his blood pressure following intubation, thus suspicious for sepsis secondary to possible aspiration pneumonia in the setting of narcotic analgesia and the patient's supine position, all necessary for control of his back pain. The patient was initially managed with vancomycin, cefepime, and Flagyl; and continued on cefepime to complete a total of 10 days of antibiotics following a sputum culture revealing MSSA. The patient's narcotic analgesia was titrated down prior to discharge. His O2 saturations had returned to 97 percent on room air. Sepsis: Following hypercarbic respiratory failure and unresponsiveness, the patient was intubated, at which time his systolic pressures dropped into the 70s. He responded well to peripheral dopamine and IV fluids. A central line was placed and he was continued on pressors for two days to maintain his blood pressure while on broad-spectrum antibiotics. His sputum culture grew out MSSA. His antibiotics were narrowed to cefepime alone. His blood pressures recovered and his lactate decreased from its initial level of 8. However, the patient suffered shock liver with elevation of his LFTs into the 1000s; acute renal failure with bump of the creatinine to 1.3, which has subsequently improved; in addition to cardiac-demand ischemia and mild DIC. All these values have improved since his initial insult. His blood cultures remain negative, stool cultures negative including Clostridium difficile times two. Thus likely, the patient's sepsis is secondary to aspiration pneumonia. Prophylaxis: Subcutaneous heparin, PPI, aspiration precautions. FEN: Patient maintained on the house diet. Full code. DISCHARGE DIAGNOSES: Metastatic [**Date Range 499**] cancer to liver and vertebral body. Pathologic compression fracture. Aspiration pneumonia. Sepsis. Disseminated intravascular coagulation. Shock liver. Acute renal failure secondary to acute tubular necrosis/hypotension. DISCHARGE CONDITION: Good. Pain controlled. Saturating well on room air. DISCHARGE STATUS: The patient is to be discharged to home with services. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Colace 100 mg p.o. b.i.d. 3. Senna 8.6 mg 2 tablets p.o. b.i.d. p.r.n. constipation. 4. Rofecoxib 12.5 mg p.o. q.d. 5. Oxycodone SR 20 mg p.o. q.12 h. 6. Calcium carbonate 500 mg p.o. t.i.d. 7. Hydromorphone 1 to 2 mg p.o. q.3 h. p.r.n. pain. 8. Levofloxacin 500 mg p.o. q.d. x3 days. FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 150**] for continued care. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**], [**MD Number(1) 32196**] Dictated By:[**Last Name (NamePattern1) 19957**] MEDQUIST36 D: [**2180-6-19**] 19:13:25 T: [**2180-6-20**] 02:25:43 Job#: [**Job Number 44447**]

[ "733.13", "518.81", "287.5", "V10.05", "198.5", "197.7", "570", "507.0", "038.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.71", "38.91", "38.93", "92.29" ]

icd9pcs

[ [ [] ] ]

9551, 9681

1653, 1790

9269, 9529

9704, 10022

4639, 9247

10034, 10391

1997, 4621

167, 896

919, 1636

1807, 1974

17,411

178,331

1573

Discharge summary

report

Admission Date: [**2125-1-24**] Discharge Date: [**2125-1-26**] Date of Birth: [**2048-3-4**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Nsaids / Adhesive Tape Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transfer to CCU for hypotension status post elective peripheral angiography Major Surgical or Invasive Procedure: Right lower extremity angiography Percutaneous coronary angioplasty of right anterior tibial artery History of Present Illness: Ms. [**Known lastname 9164**] is a 76 year-old female with a complicated PMHx that includes CAD s/p Lcx stenting, DM type 2, s/p dual pacemaker placement for bradycardia, atrial fibrillation on chronic Coumadin therapy, with severe PVD s/p multiple stents, angioplasties and atherectomies, with claudication symptoms. She recently developed a RLE ulcer, and was referred for RLE angiography and PTCA of her right tibial anterior tibial artery. One hour after the procedure, Ms. [**Known lastname 9164**] became hypotensive with SBP down to 30s when the sheath was pulled, HR paced at 60. She also complained of severe right groin pain at the cath site. She was given Atropine X 2, IVF bolus, and transfused 2 units of PRBCs. Her HR subsequently increased to 120s, then she went into atrial fibrillation with RVR in 160s. She spontaneously converted back to NSR with HR 88. Her BP improved with the above resuscitation measures, and she was trasnferred to the CCU for further management and care. An emergent CT scan was performed on arrival to CCU, which revealed a right-sided RP bleed. Past Medical History: 1. CAD s/p LCX stent in 2/[**2122**]. LM with 60% ostial stenosis, total occlusion of RCA on last cardiac catheterization 05/[**2123**]. 2. Congestive heart failure, mild LV systolic dysfunction with EF 48% on last ventriculogram 05/[**2123**]. 3. Peripheral [**Year (4 digits) 1106**] disease s/p left EIA and SFA stenting [**3-/2123**], and s/p atherectomy/PTA of LSFA [**12/2123**] for instent restenosis. 4. Bradycardia status post [**Company 1543**] dual chamber pacemaker placement [**2123-12-29**]. 5. Intermittent atrial fibrillation noted on PPM interrogation, on chronic Coumadin therapy. 6. Hypercholesterolemia 7. Chronic ITP with [**Doctor First Name **]. BM bx normal in [**2113**]. 8. Diabetes mellitus type 2, diet controlled 9. Peripheral neuropathy 10. Mild COPD 11. PUD 12. Gastritis, Barrett's esophagus 13. Multinodular goiter Past surgical history: 1. Status post cholecystectomy 2. s/p TAH-BSO 3. s/p right THR 4. s/p L4, L5 discectomy 5. s/p appendectomy Social History: Widow. She lives with her son. She has 6 adult children. Ex-smoker. She quit smoking 12 years ago; 120 pack-year smoking history. Family History: Family history positive for CAD: brother died of MI at age 44, another brother died at age 53 of MI. Physical Exam: Physical examination on admission to CCU: VITALS: HR 65, V-paced, BP 120/46, RR 12, Sat 100% on 4L NC. GEN: Alert, confused. HEENT: PERRL. NECK: JVP not elevated. RESP: Limited to anterior chest. Clear to auscultation. CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub. GI: BS normoactive. RLQ firm to palpation, tender. No clear palpable hematoma. EXT: Right groin with dressing in place. Tender to palpation. Pedal pulses present via Doppler. NEURO: Limited examination, patient non-cooperative. Moves all 4 extremities. Pertinent Results: Relevant laboratory data on admission to CCU: CBC: WBC-13.5*# RBC-3.39* HGB-11.4* HCT-32.8* MCV-97 MCH-33.6* MCHC-34.6 RDW-16.3* Chemistry: GLUCOSE-153* UREA N-10 CREAT-0.8 SODIUM-140 POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-27 ANION GAP-9 CALCIUM-7.0* PHOSPHATE-4.5 MAGNESIUM-1.3* Coagulation profile: PT-13.8* PTT-23.5 INR(PT)-1.2 EKG: V-paced, rate 60 bpm, LBBB morphology. [**2124-1-24**] RLE angiography: Initial angiography showed a severely diseased AT. We planned to treat this vessel with PTA and atherectomy. Heparin was given for anticoagulation. Access was obtained in an antegrade fashion of the RCFA and a 7 French Arrow sheath was advanced to the mid SFA. The AT was crossed with great difficulties with numerous wires, including PT [**Name (NI) 9165**], [**Name (NI) 9166**] and Shinobi. However, attempts to cross the distal lesion with atherectomy or angioplasty devices failed. Finally, a 2.0x20 mm Maverick crossed the lesion, which was dilated at 12 Atm. Next, a 2.5x20 mm Quantum Maverick balloon was used to dilate the entire AT at 12-22 Atm. Final angiography showed no residual stenosis with flow to the foot through the PA and AT. The patient left the lab in stable condition. [**2125-1-24**] CT OF THE ABDOMEN WITHOUT CONTRAST: Changes of emphysema are seen at both lung bases. There is bibasilar dependent atelectasis, without significant pleural effusion or pneumothorax. Coronary artery calcifications and coronary [**Month/Day/Year 1106**] calcifications are seen. Pacemaker wires are also present. There is residual contrast within the kidneys from recent interventional procedure. The liver, spleen, adrenal glands, kidneys, stomach, pancreas, and small bowel are within normal limits. Marked [**Month/Day/Year 1106**] calcifications are seen of the aorta, celiac axis, SMA, [**Female First Name (un) 899**], and iliac/femoral arteries. The gallbladder is not identified, and the patient may be status post cholecystectomy. There is a small hiatal hernia present. There is a large amount of retroperitoneal hemorrhage present, tracking from the right groin to the right posterior pararenal space. In the greatest axial dimensions, this measures approximately 7.0 x 7.8 cm in size, and it extends a length of approximately 20 cm in the SI dimension. There is no significant abdominal lymph adenopathy present, and no ascites fluid is present. CT OF THE PELVIS WITHOUT CONTRAST: Diverticuli are seen, and the large bowel is otherwise unremarkable in appearance. Hyperdense free fluid is seen within the pelvis, possibly tracking from the retroperitoneal hemorrhage. The bladder appears unremarkable, with a Foley catheter in place. A right-sided hip replacement is present. No significant osseous abnormalities are seen aside from degenerative changes and right-convex scoliosis centered at the thoracolumbar junction. IMPRESSION: 1. Large right-sided retroperitoneal hemorrhage, extending from the right groin to the right posterior pararenal space. 2. No significant hemorrhage is seen within the right groin or extending into the right leg. Brief Hospital Course: 76 year-old female with a complicated PMHX that includes CAD s/p LCx stenting in [**2122**], DM type 2, s/p PPM placement for bradycardia, atrial fibrillation on Coumadin, with severe PVD s/p mutliple interventions, now s/p RLE angiography and right anterior tibial artery PTCA with post-procedure hypotension and RP bleed. Transferred to the CCU for further care. 1) Retroperitoneal bleed: Her hypotension was felt secondary to her retroperitoneal bleed and likely vagal response at the time of the sheath pull. As mentioned in the HPI, she was transfused 2 units of PRBCs in the cath lab, and was transfused an additional unit in the CCU. She was also given IVF. She remained hemodynamically stable throughout her stay in the CCU, without need for pressors, and her HCT also remained stable following the 3 units of PRBCs. Coumadin was held in the setting of her RP bleed, to be restarted as an outpatient. Aspirin was resumed on [**2125-1-25**] and well tolerated. Her hematocrit was 31.1 at discharge. 2) s/p PTCA to right [**Doctor First Name **]: She was continued on aspirin while in hospital. Pedal pulses were present via Doppler. She will follow-up with Dr. [**First Name (STitle) **] in the week following discharge. 3) CAD: No acute issues in hospital. She was continued on Lipitor. Aspirin, Atenolol, Diovan, and Lisinopril were gradually resumed in hospital following the procedure. 4) Mental status change: On arrival to the CCU, Ms. [**Known lastname 9164**] was noted to be confused, belligerent. Her acute mental status change was felt most likely medication-related s/p administration of Fentanyl in the cath lab, sedatives. No gross electrolyte abnormalities, ABG unremarkable. She responded to Haldol for acute agitation/confusion. She was alert and oriented the following morning without recurrence of confusion. 5) Diabetes mellitus type 2: She was kept on a regular insulin sliding scale in hospital. Her diabetes appears to be diet-controlled as an out-patient. Medications on Admission: Atenolol 50 mg PO QD Diovan 160 mg PO QD Colace 200 mg PO QD Ecotrin 81 mg PO QD Effexor 150 mg PO QHS HCTZ 12.5 mg PO QD Lipitor 40 mg PO QD Lisinopril 40 mg PO QD MVI 1 tab PO QD Prilosec 40 mg PO QD Trazodone 200 mg PO QHS Warfarin last dose on [**2125-1-20**] Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 6. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 10. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Trazodone HCl 100 mg Tablet Sig: Two (2) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: 1. RLE Angiography and PTCA of right anterior tibial artery 2. Complicated by large retroperitoneal bleed Discharge Condition: Pt was in good condition, with a stable hematocrit, ambulating, and good oxygen saturations on room air. Discharge Instructions: Please call Dr. [**First Name (STitle) **] or return to the hospital if you experience bleeding, weakness, dizziness, shortness of breath, chest pain, groin, abdomen or back pain. Dr.[**Name (NI) 3101**] office will call you Monday for an appointment next week. Stop taking your Coumadin until Dr. [**First Name (STitle) **] tells you to resume it. Followup Instructions: See Dr. [**First Name (STitle) **] in one week. His office will call you Monday. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**], [**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2125-2-21**] 2:00 Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-5-15**] 11:00 Completed by:[**2125-1-27**]

[ "428.22", "998.11", "428.0", "E935.2", "707.19", "250.00", "427.31", "E879.8", "412", "V45.01", "492.8", "292.81", "440.23", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "39.50", "99.04", "88.48" ]

icd9pcs

[ [ [] ] ]

9702, 9708

6535, 8528

378, 479

9858, 9964

3429, 6512

10363, 10922

2765, 2867

8842, 9679

9729, 9837

8554, 8819

9988, 10340

2493, 2602

2882, 3410

263, 340

507, 1599

1621, 2470

2618, 2749

61,118

106,641

41217

Discharge summary

report

Admission Date: [**2136-7-24**] Discharge Date: [**2136-7-29**] Date of Birth: [**2071-11-14**] Sex: M Service: CARDIOTHORACIC Allergies: Keflex Attending:[**First Name3 (LF) 1505**] Chief Complaint: pre-syncope Major Surgical or Invasive Procedure: Aortic valve replacement 25mm tissue [**7-25**] History of Present Illness: Mr. [**Known lastname 1007**] is a 64 year old with a five year history of aortic stenosis. He is physically active without symptoms, but he does describe one episode of pre-syncope 3 years ago while driving home from work without loss of conciousness. Past Medical History: aortic stenosis hypertension hyperlipidemia detached retina and cataracts on left Past Surgical History: repair of left retina and cataracts Left TKR Right knee surgery for meniscus tear appendectomy, remotely Social History: He lives with his wife and has three grown children. He works in sales and coaches basketball. He denies smoking and reports drinking ten to twelve beers per week. Family History: Both Mr. [**Known lastname **] mother and sister have aortic stenosis. Physical Exam: Pulse: 60 regular Resp: 16 O2 sat: B/P Right: Left: 144/90 Height: 6'1" Weight: 215lb General: NAD, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] right pupil round and reactive to light, left fixed s/p multiple surgeries Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**4-15**] 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: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: radiation of cardiac murmur, +thrill on left Discharge: VS: T: 98.3 HR: 64 SR BP: 126/64 Sats: 94% RA WT: 101.4 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 throughout GI: benign Extr: warm no edema Incision: sternal clean, dry intact Neuro AA& O MAE Pertinent Results: Date/Time: [**2136-7-25**] Test Type: TEE (Complete) Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: >= 60% >= 55% Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm Aorta - Ascending: *3.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - Peak Gradient: *86 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 54 mm Hg Aortic Valve - LVOT diam: 2.3 cm Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2 Findings 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. Mild symmetric LVH. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. 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. There is mild symmetric left ventricular hypertrophy. 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 ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is atrially paced. There is normal biventricular systolic function, There is a bioprosthesis in the aortic position. It appears well seated. The leaflets cannot be well seen. No aortic regurgitation isn appreciated. The maximum pressure gradient across the aortic valve is 32 mmHg with a mean of 15 mmHg at a cardiac output near 7 liters/minute. The mitral regurgitation is improved - now trace to mild. The thoracic aorta appears intact after decannulation. CXR: [**2136-7-28**]: Enlargement of the cardiac silhouette is stable since recent postoperative study but somewhat increased from the first postoperative radiograph of [**2136-7-25**], suggesting pericardial effusion. Bibasilar atelectasis has worsened in the interval and is accompanied by small bilateral pleural effusions. Retrosternal and subcutaneous gas on the lateral view near the sternal wires is probably related to recent sternotomy. IMPRESSION: 1. Worsening bibasilar atelectasis. Small bilateral pleural effusions. 2. Widened cardiac silhouette, possibly representing postoperative pericardial effusion. Brief Hospital Course: On [**7-25**] Mr. [**Known lastname 1007**] [**Last Name (Titles) 1834**] an aortic valve replacement. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He did develop atrial fibrillation and was started on amiodarone converted to sinus rhythm with no further ectopy. His ACE was restarted on discharge. He was transfused 1 unit of PRBC for HCT of 22.9 to a HCT of 23.7. By the time of discharge on POD5 the patient was ambulating independentanly, the wound was healing and pain well controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: Lipitor 40mg daily Carvedilol 6.25mg [**Hospital1 **] Lisinopril 40mg daily Omeprazole 20mg daily Aspirin 81mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily): take for 30 days. Disp:*30 Tablet(s)* Refills:*2* 6. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 5 days: take with lasix. Disp:*5 Capsule, Extended Release(s)* Refills:*0* 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take 400mg (2 tabs) x 7 days then 200 mg daily. Disp:*30 Tablet(s)* Refills:*2* 10. 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* 11. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain: take with food and water. 12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 13. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: aortic stenosis hypertension hyperlipidemia detached retina and cataracts on left Past Surgical History: repair of left retina and cataracts Left TKR Right knee surgery for meniscus tear appendectomy remotely Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2136-8-7**] 10:15 [**Hospital Unit Name 4081**] Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD:[**Telephone/Fax (1) 170**] Date/Time:[**2136-8-23**] 1:00 [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) 656**] [**8-30**] at 12:30pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1112**] R. [**Telephone/Fax (1) 79975**] in [**5-15**] 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:[**2136-7-29**]

[ "401.9", "427.31", "272.4", "V43.65", "E878.4", "424.1", "997.1", "530.81" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "88.56" ]

icd9pcs

[ [ [] ] ]

9371, 9430

6306, 7583

286, 336

9683, 9901

2281, 6283

10825, 11593

1054, 1126

7751, 9348

9451, 9533

7609, 7728

9925, 10802

9556, 9662

1141, 2262

235, 248

364, 620

642, 724

869, 1038

13,265

174,815

48394

Discharge summary

report

Admission Date: [**2142-11-7**] Discharge Date: [**2142-11-25**] Date of Birth: [**2079-5-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Cardiac arrest Major Surgical or Invasive Procedure: CPR Endotracheal intubation and extubation Cardiac catheterization History of Present Illness: Ms. [**Known lastname 101915**] is a 63yo female with ESRD on HD s/p VF arrest. She completed dialysis (1L off, 3.0K bath), tolerated ok, and was then found unresponsive. On arrival of CCU team, pt found ashen, pulseless, apneic, unresponsive. CPR initiated with good effect, lasted approximately 3 min. CPR prior to monitor leads being placed-> identified polymorphic VT/VF. Shocked 200J-> CPR continued, pt intubated. Given insulin 10U, D50. Rhythm checked -> narrow complex brady, but still no pulse. CPR reinitiated, [**11-27**] amp calcium given, Epi, bicarb, and atropine prepared, but rhythm revealed sinus tach w/ good pulses. Initial postcode blood pressure = 170/110, pt responsive and fighting tube attempting to pull out. Transferred to CCU for further management (did not receive remaining code drugs). On arrival to CCU, pt requesting extubation, good MS, passed SBT 5/0. Therefore extubated, but then became anxious, tachypneic, Sats high 80s on NRB->99-100 on CPAP NPPV. Subsequently, BP to 80s, and echo revealed new WMA and depressed EF. Therefore, pt taken to cath lab emergently. Revealed no flow limiting disease, PCWP 21. Post-cath continued to do well, initiated on CVVHD for slow fluid removal. Past Medical History: CAD (s/p NSTEMI-> OM1 stent in [**10-1**]) CHF/volume overload Amyloidosis Smoldering Myeloma Schizotypal Disorder Major depressive d/o Basal cell carcinoma Hypothyroidism Hypercholesterolemia ESRD on HD Hypertension Social History: Divorced with two sons. Currently lives in [**Location 86**] with one of her sons. Formerly worked as a teacher but currently lives off SS assistance. Former smoker but quit 20yr ago. Prior EtOH abuse, denies current. Denies illicits. Family History: Mother w/ CVA, brother w/ CAD, and another brother w/ IVDU. Physical Exam: Upon arrival to CCU: Temp: 98F HR 112 BP 166/89 RR 29 O2sat 100% Intubated: AC 550/ RR 14/ PEEP 5/ FIO2 1 Gen: Intubated and sedated HEENT: PERRL, EOMI, ETT in place Neck: JVP to thyroid cartilage Chest: paradoxical sternal movement with inspiration. crackles at lateral bases CV: RRR harsh [**1-29**] late peaking systolic murmur at RUSB no radiation Abd: soft, NT, ND, +BS Ext: warm, 2+DP pulses Neuro: intubated and sedated on vent. moving all 4 extremities symmetrically Pertinent Results: Laboratory results: [**2142-11-6**] 11:00AM BLOOD WBC-7.7 RBC-3.29* Hgb-10.0* Hct-30.4* MCV-92 MCH-30.5 MCHC-33.0 RDW-17.2* Plt Ct-354 [**2142-11-25**] 07:35AM BLOOD WBC-6.4 RBC-3.32* Hgb-10.3* Hct-31.1* MCV-94 MCH-31.0 MCHC-33.2 RDW-17.6* Plt Ct-394 [**2142-11-25**] 07:35AM BLOOD PT-12.0 PTT-88.9* INR(PT)-1.0 [**2142-11-25**] 07:35AM BLOOD Glucose-104 UreaN-23* Creat-7.6*# Na-136 K-4.2 Cl-97 HCO3-27 AnGap-16 [**2142-11-17**] 12:05AM BLOOD CK-MB-NotDone cTropnT-0.34* [**2142-11-19**] 09:30AM BLOOD calTIBC-164* Ferritn-863* TRF-126* [**2142-11-11**] 09:49AM BLOOD TSH-2.0 [**2142-11-11**] 09:49AM BLOOD Free T4-1.4 [**2142-11-8**] 04:43PM BLOOD PEP-HYPOGAMMAG b2micro-15.4* Relevant Imaging: Cardiac Catheterization ([**11-7**]): 1. Coronary angiography in this right dominant system demonstrated an LMCA free of angiographically significant disease. The first diagonal branch had a 70% stenosis at its origin. The LCX system demonstrated a widely patent previously placed stent in OM1; OM2 had a 50% stenosis. The RCA had a distal 40-50% lesion at the crux involving the RPDA and RPL branches. 2. Resting hemodynamics revealed normal systemic arterial pressures. There was moderate pulmonary artery hypertension and elevated right ventricular filling pressure. ECHO ([**2142-11-9**]): There is moderate symmetric LVH. The LV cavity is unusually small. There is mild to moderate global LV hypokinesis. The ascending aorta is mildly dilated. The AV leaflets are severely thickened/deformed. AS is estimated as severe although severity may be overestimated. The MV leaflets are mildly thickened. Trivial MR is seen. The LV inflow pattern suggests impaired relaxation. Compared with the prior study (images reviewed) of [**2142-11-7**], there is no definite change. [**2142-11-11**]: CTA chest/abd/pelvis: 1. No evidence of pulmonary embolism. 2. Bilateral pleural effusion with bibasilar atelectasis. New confluent opacity in the right upper lobe, most likely representing atelectasis, however, pneumonia cannot be excluded. Follow-up imaging to document resolution and exclude an underlying mass is advised Brief Hospital Course: In brief, the patient is a 63 yo female with Primary Amyloidosis, ESRD on HD, CAD with stent placement in OM in [**10-1**] and fixed septal defects in the lateral segments, hypothyroidism, major depressive d/o, schizoaffect personality d/o, s/p vtach/v.fib arrest in HD on [**2142-11-7**], PEA, and then returned to NSR but with persistent hypotension and oxygen requirement. Hypotension resolved with re-hydration and initiation of midodrine. 1. CV. -Coronary Artery Disease: The patient has a history of CAD with stent placement in OM1 in [**10-1**] and fixed septal defects in the lateral segments. Repeat catheterization following the cardiac arrest revealed patent vessels with stable coronary disease. Repeated EKGs showed no ischemic changes. She continued to receive aspirin and plavix daily. Throughout her hospitalization she c/o persistent CP which was likely due to chest compressions, not ischemia related. No BB or ACE-I was initially started due to tenuous blood pressure post HD sessions. Her BP was supported w/Midodrine. As her BP improved she was started placed on Lopressor 12.5mg [**Hospital1 **] which she was able to tolerate. The Midodrine was stopped since her blood pressure stabilized and Free Care was not able to cover this at time of discharge. -Rhythm: The patient presented with a VF arrest in the setting of hemodialysis. The likely cause for the arrest was multifactorial including: dehydration exacerbated by severe aortic stenosis, electrolyte shifts associated with hemodialysis, and QT prolongation secondary to anti-psychotics. She was evaluated by the EP service and it was concluded that her given her overall co-morbidities particularly the amyloidosis that had been found in both bone marrow and kidney would likely limit any benefit an ICD placement could offer. Furthermore, as she would be treated with myelosuppressive therapy for the amyloidosis/smoldering myeloma, the risk of infection and needed to explant the device also made device placement not indicated. She was started on amiodarone as VF suppressive therapy. -Pump: The patient has a diminished EF following the cardiac arrest. The EF mildly improved when repeated during the hospital stay. Her severe aortic stenosis with AV area 0.8cm2 limited her cardiac output. However, given her active co-morbidities she was not considered a surgical candidate. Also, the valve area was already at the estimated post-balloon valvuloplasty diameter so pursuing this procedure would offer no benefit. To optimize her blood pressure, her pre-load was increased with re-hydration and she was started temporarily placed on midodrine both of which acheived a good result. 2. Respiratory Failure: The patient was initially intubated during the cardiac arrest and was successfully extubation. She did have a persistent oxygen requirement that was thought to be multifactorial including: pulmonary contusion, pulmonary edema, aspiration pneumonia during the arrest, and splinting from the sternal trauma of CPR. She was maintained with CVVH and HD near her outpatient dry weight. She was treated for 10 days with antibiotics for the aspiration pneumonia with flagyl and ceftriaxone last day of abx [**11-20**]. Supplemental oxygen was provided and weaned as tolerated. 3. Schizoaffective disorder and depression: She has a history of schizoaffective disorder and depression. She had been on paxil and zyprexa prior to admission. These medications were discontinued following the arrest as there was concern for QT prolongation and she was not showing signs of psychosis. She remained persistently anxious and depressed given her poor prognosis. She was restarted on Prozac and standing Ativan. Social work was very involved in her care. Hospice care was consulted to help with goals of care and transition to home w/hospice care given poor prognosis. 4. ESRD: The patient has end-stage renal disease secondary to amyloid nephropathy. She had her cardiac arrest during the HD session as described above. While she was hypotensive she was maintained with CVVHD in the CCU and transitioned back to tradition HD. She was started on midodrine as above which was stopped since Free Care does not cover this mediation. Her blood pressure remains stable. 5. ? Multiple Myeloma versus Amyloid: The patient has a relatively new diagnosis of amyloidosis and smoldering myeloma. She has had prior chemotherapy with melphalan and steroids during a prior hospitalization however she did not follow-up with her therapy. The hematology consult service recommended resuming therapy assuming that proper steady adherance to treatment could be assured. However, given pt's difficulty to comply w/appointments and treatment (she failed to keep her outpatient Heme appointments as well as a few HD sessions prior to this admission)heme was reluctant to initiate chemotherapy. Given pt's overall poor prognosis and advanced involvement of kidneys/heart, and lack of insight to comply w/treatment discussions w/the pt and Attendings on service were had to address goals of care. She was made DNR/DNI and will be discharged to home with hospice services. Medications on Admission: CCU Meds: Heparin 5000 UNIT SC TID Levothyroxine Sodium 75 mcg PO DAILY Aspirin 325 mg PO DAILY Lorazepam 0.25-0.5 mg PO Q6H:PRN anxiety Atorvastatin 80 mg PO DAILY Morphine Sulfate 1-2 mg IV Q2H:PRN Calcium Carbonate 500 mg PO TID Oxycodone-Acetaminophen [**11-27**] TAB PO Q4-6H:PRN Clopidogrel Bisulfate 75 mg PO DAILY Docusate Sodium 100 mg PO BID Ezetimibe 10 mg PO DAILY Senna 1 TAB PO BID:PRN Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*3* 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*3* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (MO,WE,FR): please take on days of hemodialysis only. Disp:*180 Tablet(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD () as needed for pain. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1* 13. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: 1)Amyloidosis 2)ESRD on HD 3)s/p VF arrast 4)Severe aortic stenosis 5)Schizoaffective personality d/o 6)Depression 7)Anxiety 8)CAD 9)Hyperlipidemia 10)Hypothyroidism Discharge Condition: Stable Discharge Instructions: 1)Please continue to take all your medications as directed. 2)Please attend all appointments scheduled for you below. 3)You will continue to undergo dialysis once you are discharged here at [**Hospital1 18**]. Your next dialysis will be Wednesday, [**11-28**] at 11:30 on Floor 7 of the [**Hospital Ward Name 121**] Building. 4)If you notice increasing chest pain, nausea, vomiting, fevers, lightheadedness or other worisome symptoms call your physician or go to the emergency room. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2143-2-12**] 2:00

[ "V45.82", "427.5", "244.9", "285.21", "414.01", "585.6", "997.1", "428.0", "410.72", "424.1", "507.0", "785.51", "301.22", "583.81", "277.39", "427.41" ]

icd9cm

[ [ [] ] ]

[ "99.62", "39.95", "96.71", "99.60", "37.23", "93.90", "88.56", "96.04" ]

icd9pcs

[ [ [] ] ]

11916, 11967

4876, 10021

330, 398

12177, 12186

2738, 3418

12720, 12868

2162, 2224

10472, 11893

11988, 12156

10047, 10449

12210, 12697

2239, 2719

276, 292

3436, 4853

426, 1649

1671, 1890

1906, 2146

45,994

182,023

39168

Discharge summary

report

Admission Date: [**2196-1-1**] Discharge Date: [**2196-1-15**] Date of Birth: [**2145-1-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 45**] Chief Complaint: DOE and angina Major Surgical or Invasive Procedure: -Cardiac Catheterizations: 1. [**2196-1-1**] 2. [**2196-1-8**] with a tandem heart: s/p two drug eluting stents in Left Main Artery and Diagonal Artery -ICD Placement [**2196-1-11**] -Attempted CABG [**2196-1-7**] (Patient intubated, echo performed in OR, and surgery aborted, no incision made) History of Present Illness: 51 yoM smoker w/ a h/o hyperlipidemia presents for elective cath. The patient has had 3 months of dyspnea on exertion (6 stairs while carrying boxes, in addition to chest pain if he proceeded beyond 6 stairs). He did not experience any lightheadedness, or any palpitations. He did not see a physician about this until last week where he saw his PCP. [**Name10 (NameIs) **] was sent for a stress this week, was positive and sent for cath today. He was noted to have elevated LV pressures consistent with fluid overload. Was admitted for diuresis. . He denies any rest symptoms. The symptoms have not been very progressive, they have been relatively stable over the past few weeks. He had no radiation of his symptoms, no association with nausea or other symptoms. . He denies orthopnea, PND, pedal edema. He has had some diaphoresis at nighttime in addition to possible claudication symptoms (R calf cramping during sleep). . For these symptoms he had a stress test which was positive (limited exercise tolerance, nuclear imaging with an EF 18%, marked LV dilation and large inf wall fixed defect, small apical fixed defect, reversible septal perfusion abnormality- performed on [**2195-12-29**]). Based on these stress results he was referred to the [**Hospital1 18**] for cardiac cathterization. . His cardiac cath revealed 3VD in addition to Left Main disease (LMCA ostial 70%, 100% mid LAD, 80% prox D1, LCx 50-60% proximal, OM1 70%, RCA 100% mid- fills via L--> R collaterals from LAD. Past Medical History: Hypercholesterolemia Hypertension Depression Minor Arthritis MVA at the age of 17, with head injury (no-residual) History of Alcoholism Social History: + tobacco abuse- quit two days prior to admission, 30 pk year history. ETOH abuse in past, in remission since [**2179**]. Works as a brick layer, lives with his girlfriend. Brother [**Name (NI) **] [**Name (NI) **] (cell [**Telephone/Fax (1) 86755**]) would like to be contact[**Name (NI) **] upon discharge Family History: Mother w/ onset of angina in mid 50s. Physical Exam: VS - 98/77 88 97% RA Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP to ear CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at bases bilaterally. Abd: Soft, obese, NTND. No HSM or tenderness. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: Pertinent Results: [**2196-1-1**] 01:10PM ALT(SGPT)-61* AST(SGOT)-38 ALK PHOS-57 AMYLASE-10 TOT BILI-0.5 DIR BILI-0.2 INDIR BIL-0.3 [**2196-1-1**] 01:10PM ALBUMIN-3.4* CHOLEST-186 [**2196-1-1**] 01:10PM VIT B12-657 [**2196-1-1**] 01:10PM %HbA1c-6.1* eAG-128* [**2196-1-1**] 01:10PM TRIGLYCER-79 HDL CHOL-40 CHOL/HDL-4.7 LDL(CALC)-130* [**2196-1-1**] 01:10PM GLUCOSE-128* UREA N-24* CREAT-1.0 SODIUM-141 POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-22 ANION GAP-12 [**2196-1-1**] 01:10PM PT-15.6* INR(PT)-1.4* [**2196-1-1**] 01:10PM WBC-8.8 RBC-4.64 HGB-13.3* HCT-41.0 MCV-88 MCH-28.7 MCHC-32.5 RDW-13.9 [**2196-1-1**] 01:10PM PLT COUNT-282 Imaging: Cath: [**1-1**] COMMENTS: 1. Selective coronary angiography in this right dominant system deonstrated left main with three vessel coronary artery disease. The LMCA had a 70% ostial stenosis. The LAD was totally occluded in the mid-vessel and there were no collaterals seen to the mid or distal LAD. There was an 80% stenosis of the first diagonal branch. The LCx had 50-60% stenosis of the proximal vessel. There was a 70% stenosis at the origin of the OM1 branch. The RCA had a long 60% proximal stenosis and was totally occluded in the mid vesel. The mid RCA filled via right to right and left to right collaterals. 2. Resting hemodynamics revealed elevated right but primarily elevated left sided filling pressures with RVEDP mildly elevated at 16mmHg, adn LVEDP elevated at 32 mmHg with mean PCWP 26mmHg. There was moderate pulmonary arterial systolic hypertension. The cardiac index was depressed at 1.3 l/min/m2. 3. There was no evidence of aortic stenosis on careful pullback of the angled pigtail catheter from the left ventricle to the ascending aorta. 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel and left main coronary artery disease. 2. Marked left ventricular systolic and diastolic dysfunction. 3. Moderate pulmonary hypertension. 4. No evidence of constrictive or restrictive cardiomyopathy or intracardiac shunt by oximetry. TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = 10-15%). The estimated cardiac index is depressed (<2.0L/min/m2). A large (1.7 x 1.7-cm) apical thrombus is seen in the left ventricle. Doppler parameters are most consistent with Grade III/IV (severe) left ventricular diastolic dysfunction. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. 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 leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary hypertension. There is no pericardial effusion. IMPRESSION: Dilated left ventricle with severe global systolic dysfunction, c/w multivessel CAD. Large apical LV thrombus. Moderate mitral regurgitation. Elevated filling pressures with mild pulmonary hypertension. Cath. [**1-8**]: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated 3 vessel coronary artery disease. The LMCA had 70% ostial stenosis. The LAD had 100% mid LAD, and sequential 80% diagonal branch lesions. The LCX had 70% origin diesease in a small OMB1. The RCA was 100% occluded in the proximal vessel. 2. Limited resting hemodynamics were performed. The systemic arterial pressure was borderline low measuring 90/68mmHg despite inotrpic support through dopamine infusion. 3. Successful placement of Tandem Heart. 4. Successful PTCA and stenting of the D1 with a 2.5x15mm and a 2.5x23mm Promus stents that were postdilated to 2.5mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). 5. IVUS was performed confirming full stent expansion to the diagonal branch and a 5.3mm2 CSA in the LMCA suggesting hemodynamically significant stenosis. 6. Successful direct stenting of the LMCA stenosis with a 3.5x12mm Promus stent. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). 7. Unsuccessful attempt to cross the RCA CTO with multiple wires. 8. Successful weaning of hemodynamic support and removal of Tandem Heart cannulas. 9. Successful deployment of angioseal closure device through the left common femoral artery. 10. Successful deployment of 3 Proglide Perclose device across the the right common femoral artery with good hemostasis. 11. Transthoracic echocardiogram performed in the cath lab demosntrated no evidence of pericardial effusio and severely reduced LV function. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. LMCA coronary artery disease. 3. Successful placement of TandemHeart cardiac assist device. 4. Successful PCI of the Diag. 5. Successful PCI of the LMCA. 6. Unsuccessful attempt to cross the RCA CTO Brief Hospital Course: CORONARY ARTERY DISEASE: 50 year old male with Left Main and 3 vessel disease initially admitted for diuresis to the [**Hospital1 1516**] service given dyspnea on exertion x three months and elevated pulmonary capillary wedge pressure of 26 noted in first catheterization, concerning for systolic congestive heart failure. A pre-operative trans-thoracic echo was performed which showed an LVEF of [**9-2**]%, LV diastolic diameter of 7 cm and a large left ventricular apical thrombus. Given these findings, it was felt that CABG should be done more urgently. Patient was started on a heparin drip and a cardiac MRI was performed to assess viability. It showed transmural scar at apex only, therefore the rest of the tissue was felt to be viable. Given these findings, cardiac surgery then proceeded with CABG. In the operating room, an intra-operative echo noted an almost akinetic heart with only slight basilar function. His heart [**Doctor Last Name 1754**] were dilated and he had moderate MR. His mixed venous sats were in the high 60's and his PA pressure was initially in the 60's/40's. The decision was made not to proceed with CABG due to the severe cardiac dysfunction and concern for lack of benefit. He was placed on levophed and phenylephrine and transferred to the CCU while still intubated. He was transitioned to dopamine and successfully weaned off of all pressors. He was then evaluated by Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**], who felt that he would benefit from revascularization therapy. On [**2196-1-8**] he underwent high risk PCI with tandem heart support and received drug eluting stents to his left main coronary artery and diagonal. He returned to the CCU and was extubated on [**1-9**]. He was started on aspirin 325, Plavix 75, and 80 mg of Simvastatin daily. When his blood pressure stabilized he was continued on metoprolol succinate and lisinopril. He will follow up with his primary cardiologist, Dr. [**Last Name (STitle) **], within the next week. SEVERE SYSTOLIC CONGESTIVE HEART FAILURE: He was noted to have elevated PCWP of 26 in cath [**1-1**]. TTE showed a LVEF of [**9-2**]% with LV diameter of 7.0 cm. Likely secondary to severe CAD, however patient's history of alcohol abuse is also likely a component of his dilated cardiomyopathy. In preparation for CABG he was noted to have akinesis of most areas of his heart. Metoprolol and lisinopril were held in setting of hypotension, but slowly re-introduced once patient's hemodynamics stabilized. He was also started on furosemide 20 mg daily as patient did appear mildly volume overloaded in the final days of his hospitalization. He will follow up with Dr. [**First Name (STitle) 437**] in his heart failure clinic in the next two weeks. RHYTHM: He was in normal sinus rhythm on transfer from the floor to the CCU. However, on [**2196-1-10**], the patient went into a polymorphic VT that appeared to be torsades. He spontaneously terminated this rhythm. On [**2196-1-11**], he underwent ICD placement and received a [**Company 1543**] single chamber pacemaker. No complications arose from this procedure. He will follow up in the device clinic for further management. LEFT VENTRICULAR APICAL THROMBUS: Noted on first echocardiogram. Continued on heparin drip, and when decision was made that no surgical intervention would be sought, Coumadin was started. Heparin bridge continued until INR was between [**12-23**]. He was discharged on 5 mg of Coumadin daily with close follow up within one week of discharge with his PCP. [**Name10 (NameIs) **] will likely need at least three months of anti-coagulation with follow up echocardiogram. If thrombus not resolved, he will need an extension of his anti-coagulation. Close follow up with his PCP and cardiologist have been arranged. HYPERTENSION: Patient was hypotensive after sedation for CABG. He was on pressors post aborted CABG, which were quickly weaned. Upon discharge he was continued on low dose metoprolol succinate and lisinopril as his pressures would allow. HYPERLIPIDEMIA: Continued Simvastatin. DEPRESSION: Continued on Bupropion. (held briefly while intubated). SMOKING CESSATION: Patient with strong desire to quit smoking. He was continued on nicotine patch as well as bupropion. Medications on Admission: BUPROPION 150mg po bid METOPROLOL SUCCINATE 25mg po daily SIMVASTATIN 40mg po daily ASPIRIN 81mg po daily MULTIVITAMIN daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. Disp:*60 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): Use as directed. Disp:*30 Patch 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Systolic Congestive Heart Failure s/p ICD placement for primary prevention Left Ventricular Apical Thrombus Coronary Artery Disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted because you had difficulty breathing as your body was holding on to more fluid than it should due to your congestive heart failure. We gave you intravenous lasix through your veins that improved your symptoms. During your hospitalization, you had a cardiac catherization that showed that you have severe coronary artery disease. Initially, the cardiac surgeons were going to perform heart surgery to treat your disease, however after you were sedated they felt that you would not benefit from the bypass operation. You therefore underwent stenting of the arteries that supply your blood while being supported by a partial heart bypass machine called a tandem heart. You did well after the procedure and the breathing tube that was placed to help you breath was removed without difficulty. Because of your severe heart failure, you also had a defibrillator implanted to protect you from dangerous heart rhythms. Also, a blood clot was found in your heart. You were treated with blood thinning medications to treat this, and will be discharged on a medication called Warfarin (or coumadin). You will follow up closely with your primary care doctor for close monitoring of this medication. Your appointments are below. Your medications changes are as follows: Warfarin (also called coumadin) 5 mg daily Metoprolol Succinate 50 mg daily Lisinopril 5 mg daily Lasix 20 mg daily Aspirin 325 mg daily Plavix 75 mg daily Simvastatin 80 mg daily Nicotine Patch You are to weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. You are STRONGLY advised to stop smoking. You are starting a medication called Coumadin that thins your blood. There is a blood test, called INR, that we follow to make sure your blood is thinned enough. Your goal INR will be between 2 and 3. Your dosage of Coumadin will have to be adjusted until You are to call your doctor or go directly to the emergency room if you experience worsening shortness of breath, severe weight gain, chest pain or any other symptom that is concerning to you. Followup Instructions: You have the following appointments scheduled: 1. The Device Clinic: Phone:[**Telephone/Fax (1) 62**] Date/Time: Monday, [**2196-1-18**] 9:30 2. Dr. [**First Name4 (NamePattern1) 86756**] [**Last Name (NamePattern1) 174**]: (your PCP) [**Telephone/Fax (1) 37165**] Date/Time: Tuesday, [**2196-1-19**] at 1:00 PM - He will be following your INR results. Please discuss this with him at your appointment. 3. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]: (Primary Cardiologist) [**Telephone/Fax (1) 4475**] Date/Time: Wednesday, [**2196-1-20**] at 2:15 PM. 4. Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]: (Heart Failure Cardiologist) [**Telephone/Fax (1) 62**] Date/Time: Monday, [**2196-2-1**] at 9:00 AM. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]

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icd9cm

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icd9pcs

[ [ [] ] ]

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326, 626

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14,195

120,515

24672

Discharge summary

report

Admission Date: [**2175-9-9**] Discharge Date: [**2175-9-27**] Date of Birth: [**2124-11-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Back pain s/p fall Major Surgical or Invasive Procedure: PROCEDURES: 1. Open reduction of the fracture/dislocation at T4-5. 2. Transpedicular decompression of T4 3. Total laminectomy of T5. 4. Fusion C7-T10. 5. Instrumentation from C7-T10. 6. Right iliac crest bone graft. 7. Tracheostomy 8. PEG History of Present Illness: 50 yo male. S/p 30 ft fall from roof; + LOC. Upon arrival to trauma bay patient with no sensation below nipple line. Hemodynamically stable. Past Medical History: Type II Diabetes Hypertension L5 spine surgery in past Social History: Lives at home with wife. Retired firefighter. Family History: Noncontributory Physical Exam: NAD, AOX3 PERRLA, EOMI IN C COLLAR. 1CM LAC TO OCCIPUT RRR CTA BILAT NO SENSATION TO FINE TOUCH, PIN PRICK BELOW NIPPLES BILATERALLY ABD S/F/NTND. FAST NEG BACK: NO STEP OFF. C/T TTP. NEURO: NEG BULBOCAVERNOSUS Pertinent Results: [**2175-9-24**] 03:57AM BLOOD WBC-10.4 RBC-3.67* Hgb-11.3* Hct-33.3* MCV-91 MCH-30.9 MCHC-34.0 RDW-13.2 Plt Ct-360 [**2175-9-23**] 04:54AM BLOOD WBC-13.0* RBC-3.40* Hgb-10.4* Hct-29.9* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.4 Plt Ct-299 [**2175-9-22**] 02:38AM BLOOD WBC-17.4* RBC-3.53* Hgb-10.6* Hct-32.2* MCV-91 MCH-30.1 MCHC-33.0 RDW-13.6 Plt Ct-317 [**2175-9-10**] 08:13PM BLOOD WBC-6.4# RBC-4.35* Hgb-13.8*# Hct-37.9* MCV-87 MCH-31.7 MCHC-36.4* RDW-13.2 Plt Ct-57* [**2175-9-9**] 08:23PM BLOOD WBC-16.0* RBC-4.65 Hgb-14.3 Hct-40.3 MCV-87 MCH-30.9 MCHC-35.6* RDW-12.3 Plt Ct-257 [**2175-9-24**] 03:57AM BLOOD Plt Ct-360 [**2175-9-23**] 04:54AM BLOOD Plt Ct-299 [**2175-9-22**] 02:38AM BLOOD Plt Ct-317 [**2175-9-15**] 02:51AM BLOOD Plt Ct-129* [**2175-9-14**] 02:05AM BLOOD Plt Ct-94* [**2175-9-13**] 01:46AM BLOOD Plt Ct-76* [**2175-9-12**] 01:54PM BLOOD Plt Ct-79* [**2175-9-12**] 12:45AM BLOOD Plt Ct-60* [**2175-9-11**] 10:25AM BLOOD Plt Ct-60* [**2175-9-11**] 04:20AM BLOOD Plt Ct-58* [**2175-9-10**] 05:00PM BLOOD Fibrino-188 [**2175-9-10**] 03:00PM BLOOD Fibrino-237 [**2175-9-9**] 08:23PM BLOOD Fibrino-228 [**2175-9-24**] 03:57AM BLOOD Glucose-154* UreaN-21* Creat-0.6 Na-137 K-4.2 Cl-102 HCO3-27 AnGap-12 [**2175-9-16**] 01:57AM BLOOD Glucose-101 UreaN-32* Creat-0.8 Na-142 K-3.9 Cl-111* HCO3-22 AnGap-13 [**2175-9-14**] 03:52PM BLOOD Glucose-186* UreaN-32* Creat-0.7 Na-142 K-3.7 Cl-110* HCO3-21* AnGap-15 [**2175-9-9**] 08:23PM BLOOD UreaN-26* Creat-1.1 [**2175-9-10**] 05:50AM BLOOD Glucose-194* UreaN-31* Creat-1.1 Na-142 K-4.5 Cl-101 HCO3-26 AnGap-20 [**2175-9-22**] 02:38AM BLOOD ALT-95* AST-39 AlkPhos-127* TotBili-0.6 [**2175-9-9**] 08:23PM BLOOD Amylase-27 [**2175-9-24**] 03:57AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0 [**2175-9-14**] 02:05AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.2 [**2175-9-10**] 05:50AM BLOOD Calcium-8.3* Phos-5.0* Mg-1.9 [**2175-9-23**] 12:22PM BLOOD Ammonia-26 [**2175-9-24**] 03:57AM BLOOD Vanco-15.7* [**2175-9-23**] 04:54AM BLOOD Vanco-38.1 [**2175-9-21**] 12:18AM BLOOD Vanco-9.7* [**2175-9-18**] 05:41AM BLOOD Vanco-11.8* [**2175-9-16**] 06:20AM BLOOD Vanco-11.0* [**2175-9-16**] 12:40AM BLOOD Vanco-9.5* [**2175-9-9**] 08:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2175-9-23**] 12:30PM BLOOD K-3.3* [**2175-9-9**] 08:34PM BLOOD Glucose-180* Lactate-4.4* Na-140 K-4.4 Cl-100 calHCO3-27 [**2175-9-10**] 06:27AM BLOOD Lactate-6.1* [**2175-9-10**] 11:48AM BLOOD Glucose-215* Lactate-3.9* K-4.3 [**2175-9-10**] 05:57PM BLOOD Glucose-190* Lactate-7.7* Na-140 K-4.0 Cl-106 [**2175-9-12**] 01:50PM BLOOD Lactate-1.5 [**2175-9-13**] 02:08AM BLOOD Lactate-1.8 [**2175-9-14**] 11:49PM BLOOD Lactate-1.0 CT T-SPINE W/O CONTRAST [**2175-9-9**] 8:30 PM CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: S/P [**2175**]0 FT [**Hospital 93**] MEDICAL CONDITION: 50 year old man s/p 30-foot fall REASON FOR THIS EXAMINATION: dedicated recons of T, L spine CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Status post fall from 30 feet. COMPARISON: No previous studies. Torso CT performed on the same day is available for correlation. TECHNIQUE: Axial noncontrast multidetector CT images of the thoracic spine were obtained. Sagittal and coronal reformatted images were performed. FINDINGS: There is a comminuted fracture of T4 vertebra, which involves the body, right pedicle, and bilateral posterior elements - lamina and facets. Since all three columns of the spine are involved, this fracture is highly unstable. It is associated with a moderate to severe anterior dislocation of T4 with respect to T5. There are multiple fragments in the spinal canal, which is narrowed by roughly 50%-75%. These findings are suggestive of severe spinal cord injury. There is a superior anterior corner fracture of the T5 vertebra. There is a fracture through the T5 spinous process. There are fractures of the left fourth rib and right fifth ribs at the costovertebral junctions. There is associated anterior paraspinal hematoma at T4 through T6. Degenerative spurring is present in the endplates at T8-9. There are bilateral pulmonary contusions and bilateral hemothoraces. Please refer to the torso CT of the same day for further detail. Radiopaque contrast from the preceding torso CT is present in the renal collecting systems. IMPRESSION: 1. Highly unstable, a comminuted fracture of T4 vertebra involving all three columns of the spine. Greater than 50% narrowing of the spinal canal by fracture fragments with findings consisitent with cord injury and compression. Dislocation of the T4-5 interspace. 2. Bilateral pulmonary contusions and hemothoraces. Please refer to the torso CT of the same day for further detail. CT C-SPINE W/O CONTRAST [**2175-9-9**] 8:30 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: S/P [**2175**]0 FT [**Hospital 93**] MEDICAL CONDITION: 55 year old man with fall 30ft REASON FOR THIS EXAMINATION: frac CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Status post traumatic fall from 30 feet. COMPARISON: No previous studies. TECHNIQUE: Axial noncontrast multidetector CT images of the cervical spine were obtained. Sagittal and coronal reformatted images were performed. FINDINGS: There is a fracture through the base of C7 spinous process, which involves the confluence of the right and left lamina. There may also be a fracture of the C6 spinous process, only visible on the sagittal images. There is no subluxation. There is no prevertebral soft tissue swelling. Mild loss of disc space height and moderate degenerative endplate spurring is noted at C5/6 and C6/7. IMPRESSION: Fracture of C7 posterior elements, and perhaps C6 spinous process. MR THORACIC SPINE [**2175-9-10**] 2:31 AM MR CERVICAL SPINE; MR THORACIC SPINE Reason: C7 SPINOUS PROCESS FX. PRE-OP FOR T1-T10 POSTERIOR FUSION. [**Hospital 93**] MEDICAL CONDITION: 50 year old man with 30ft fall and C7 spinous process fx; preop for T1-T10 posterior fusion REASON FOR THIS EXAMINATION: eval for fx CONTRAINDICATIONS for IV CONTRAST: None. THORACIC SPINE: As noted on the CT scan, there is a fracture dislocation of T4 and T5. There is severe spinal canal compromise at the T4 level with compression of the spinal cord. Edema is identified within the spinal cord. Detail is limited due to motion artifact. Above and below the level of cord compression, the spinal cord has a normal course and caliber and normal signal intensity. There is edema in the paravertebral soft tissues of the upper thoracic spine, associated with a fracture dislocation at T4 and T5. Findings were telephoned to Dr. [**Last Name (STitle) **] at 8:10 a.m. on [**2175-9-10**]. MRI OF THE CERVICAL SPINE AND THORACIC SPINE INDICATION: Fall from 30 feet with fractured spine. TECHNIQUE: Cervical spine imaging was performed with sagittal T1, T2, gradient echo, and inversion recovery scans as well as axial T2-weighted images. Comparison is made to the cervical spine CT performed on [**2175-9-9**]. Thoracic spine imaging was performed with sagittal T1, T2 and inversion recovery scans as well as axial T2-weighted images. Comparison is made to the thoracic spine CT from [**2175-9-9**]. FINDINGS: CERVICAL SPINE: Images of the cervical spine are limited by motion artifact. However, there is clearly evidence of increased T2 signal in the posterior spinal musculature, consistent with edema associated with injury. A mild degree of prevertebral edema is also present, especially anterior to the inferior cervical segments. There is slightly increased T2 signal in the C6 and C6 vertebral bodies. Posterior element fractures in these locations were identified on CT. There is also protrusion of the C5-6 and C6-7 discs. In the axial and sagittal planes, these disc protrusions result in moderate spinal canal stenosis. There is no clear evidence of cord compression. Gradient echo images show no evidence of susceptibility artifact within the spinal cord or canal to indicate the presence of blood products. IMPRESSION: Cervical spine injury with soft tissue edema in the prevertebral space and posterior cervical musculature. There is suspicion of bony injury of C6 and C7 as the vertebral bodies are slightly T2 hyperintense. Fractures of the posterior elements of these vertebral segments were identified on CT. There is spinal canal narrowing due to disc protrusions at C5-6 and C6-7, but there is no cord compression at this time. CHEST (PORTABLE AP) [**2175-9-23**] 6:26 AM CHEST (PORTABLE AP) Reason: interval change [**Hospital 93**] MEDICAL CONDITION: 50 year old man s/p trach REASON FOR THIS EXAMINATION: interval change AP CHEST 6:30 A.M. HISTORY: Tracheostomy tube placement. IMPRESSION: AP chest compared to [**9-21**] and 4th: Small right pleural effusion and minimal pulmonary edema have decreased. Left lower lobe remains collapsed. Tip of the tracheostomy tube abuts the left wall of the trachea, probably a function of the orientation of ventilator tubing. Heart is normal size, mediastinum remains shifted to the left. Right subclavian line tip projects over the SVC. Right pleural tube has been removed. No pneumothorax. Brief Hospital Course: Patient admitted to the trauma service; transferred to the TSICU. He received TD/Solu-Medrol in the trauma bay. Orthopedic Spine was immediately consulted due to his spine injuries. He was taken to the operating room for spine fusion. Patient later fitted for a TLSO brace which must be worn while OOB. He will need to follow up with Dr. [**Last Name (STitle) 363**] in [**2-22**] weeks after discharge from hospital. Patient was difficult to wean from ventilator and had actually failed extubation trial requiring re-intubation. A Tracheostomy was placed on [**9-21**] along with a PEG, both without complication on. Speech and Swallow evaluated patient for Passy-Muir valve; his Trach was down sized to #7 Portex on [**9-26**] without complication. Vascular surgery consulted for IVC filter placement; this was placed on [**2175-9-11**]. Infectious disease was consulted because of persistent fevers; Bronch/BAC [**9-20**] MRSA; aspiration pneumonia by CXR. ID has recommended that he continue on Vanco and Ceftazidime; both will need to continue through [**9-30**]; and to continue with Flagyl for another 5 days. If patient re-spikes it has been recommended to re-culture at that time. Physical and Occupational therapy have been working with patient closely during his hospitalization. Social work has been closely involved with patient and his family since his admission. Family meetings were held intermittently to discuss patient's progress and disposition. Medications on Admission: Glucophage Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:*30 * Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*33 Tablet(s)* Refills:*0* 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*3 * Refills:*2* 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*30 Tablet(s)* Refills:*2* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*33 ML(s)* Refills:*0* 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*33 ML(s)* Refills:*0* 9. Lorazepam 1-2 mg IV Q2-4H:PRN 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 13. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 15. Sliding Scale Regular Insulin Sig: One (1) Units Subcutaneous four times a day: See attached sliding scale. 16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every eight (8) hours: 1250 mg Stop date [**2175-9-30**]. 17. Ceftazidime 2 g Recon Soln Sig: One (1) Intravenous every eight (8) hours: Stope date after last dose on [**2175-9-30**]. Discharge Disposition: Extended Care Facility: [**Hospital6 **] - Rehab and SCI Discharge Diagnosis: 1. s/p Fall (30 ft) 2. 5th Thoracic vertebrae fracture with spinal cord compromise 3. MRSA pneumonia Discharge Condition: Stable Discharge Instructions: Continue antibiotics through [**2175-9-30**] MRSA precautions You must continue to wear your TLSO brace until you follow up with Dr. [**Last Name (STitle) 363**] in 4 weeks and he will determine length of time it needs to be worn. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 363**], Orthopedic Spine in 4 weeks, call [**Telephone/Fax (1) 3573**] for an appointment. Follow up in Trauma Clinic in [**2-22**] weeks, call [**Telephone/Fax (1) 6439**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2175-9-27**]

[ "250.00", "507.0", "806.09", "850.11", "V09.0", "285.1", "806.26", "873.0", "806.24", "807.2", "E882", "807.06", "482.41", "861.21", "860.4", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.04", "81.64", "38.91", "38.7", "96.72", "81.03", "31.1", "81.05", "43.11", "34.04", "96.6", "38.93", "03.31", "77.79", "03.53", "86.59", "33.24" ]

icd9pcs

[ [ [] ] ]

13648, 13707

10316, 11789

333, 582

13855, 13864

1177, 3969

14143, 14537

910, 927

11850, 13625

9707, 9733

13728, 13834

11815, 11827

13888, 14120

942, 1158

275, 295

9762, 10293

610, 753

775, 831

847, 894

6,835

131,552

11306

Discharge summary

report

Admission Date: [**2109-9-27**] Discharge Date: [**2109-9-27**] Date of Birth: [**2037-6-26**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] has a history of small cell lung cancer. She was admitted to the medical intensive care unit after being found with hypoxic respiratory failure at her nursing home. At the time of presentation to [**Hospital1 69**] she was febrile with an absolute neutrophil count of 40. She required large amounts of intravenous fluid and hemodynamic support from her time of presentation. On arrival in the NICU she was on Neo-Synephrine and Levophed. She was also on mechanical ventilation at that time. She reached maximum doses on Neo-Synephrine and Levophed. At that point Vasopressin was added. Despite these measures, it was difficult to maintain her blood pressure. Her oxygenation and ventilation continued to decline over several hours. Despite numerous interventions on the mode of ventilation and numerous boluses of intravenous fluid, the patient was unable to maintain a blood pressure sufficient to profuse her vital organs. She passed away on the evening of [**2109-9-27**]. FINAL DIAGNOSES: 1. Septic shock, secondary to MRSA pneumonia. 2. Small cell lung cancer. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Last Name (NamePattern1) 15710**] MEDQUIST36 D: [**2109-9-30**] 22:18 T: [**2109-10-1**] 19:54 JOB#: [**Job Number 36269**]

[ "482.41", "284.8", "162.9", "785.59", "428.0", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

1186, 1535

156, 1169

19,359

164,957

26743

Discharge summary

report

Admission Date: [**2137-11-25**] Discharge Date: [**2137-12-2**] Date of Birth: [**2077-5-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD with banding of bleeding varices History of Present Illness: 60 yo male with h/o cryptogenic cirrhosis, DM, HTN who presents after episode of hematemesis. Pt had 1-2 episodes of non-bloody emesis over the past week. Last night, about an hour after dinner, he had one episode of one episode of bloody emesis that filled a napkin. He came to the ER and has not noted any further episodes of emesis since that time. He denies recent fevers, chills, abdominal pain, diarrhea, melena, hematochezia or constipation. . In ED he was hemodynamically stable and noted to have melanotic stool. NG lavage showed 750cc of bright red blood that wouldn't clear. He was started on octreotide gtt, IV protonix, ceftazidime and received 10 units of SC vitamin K. A blood transfusion of one unit of PRBCs was started in the ER. He remained hemodynamically stable during this time. CXR also showed a patchy right upper lobe opacity. Pt was electively intubated for airway protection in the ER and admitted to MICU. Past Medical History: Decompensated cirrhosis of unclear etiology Diabetes Osteoarthritis Hypertension Chronic venous insufficiency umbilical and inguinal hernias Social History: Originally from [**Country 2559**]. He is married, has 4 children, lives in [**Location 11333**], [**State 350**]. Does not drink, smoke, or do any drugs. He states he did drink [**1-4**] glasses of wine a day for a long period of time, but stopped doing this 5 years ago. Family History: Mother had stomach cancer, dad had a bleeding ulcer, 2 sisters who are alive and healthy and children who are alive and healthy. Physical Exam: temp 98.6, BP 125/77 (110-130/50-70), HR 89 (80-90), R 16, O2 96%RA I/O 3.4/800 today; +2.5L LOS Gen: jaundiced, pleasant, talkative HEENT: icteric sclera, MM moist Cardio: RRR, 2/6 systolic murmur at LUSB Pulm: min crackles at bases B Abd: +BS, distended, nontender, tympanic on percussion Ext: 1+ edema B Neuro: AO x 3, follows commands, moves all ext, CN 2-12 intact Pertinent Results: [**2137-11-25**] 12:30AM FIBRINOGE-113* D-DIMER-1337* [**2137-11-25**] 12:30AM PT-24.1* PTT-39.5* INR(PT)-2.4* [**2137-11-25**] 12:30AM PLT COUNT-109* [**2137-11-25**] 12:30AM ANISOCYT-1+ MACROCYT-3+ [**2137-11-25**] 12:30AM NEUTS-84.6* LYMPHS-8.0* MONOS-5.7 EOS-1.4 BASOS-0.4 [**2137-11-25**] 12:30AM WBC-8.2 RBC-1.91*# HGB-7.4*# HCT-20.9*# MCV-109* MCH-38.7* MCHC-35.4* RDW-17.8* [**2137-11-25**] 12:30AM HAPTOGLOB-<20* [**2137-11-25**] 12:30AM LIPASE-60 [**2137-11-25**] 12:30AM ALT(SGPT)-43* AST(SGOT)-66* ALK PHOS-123* AMYLASE-45 TOT BILI-6.9* [**2137-11-25**] 12:30AM GLUCOSE-293* UREA N-55* CREAT-0.9 SODIUM-126* POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-19* ANION GAP-15 [**2137-11-25**] 12:34AM HGB-7.4* calcHCT-22 [**2137-11-25**] 04:01AM HGB-6.6* calcHCT-20 [**2137-11-25**] 04:01AM LACTATE-2.6* [**2137-11-25**] 04:05AM URINE MUCOUS-FEW [**2137-11-25**] 04:05AM URINE HYALINE-0-2 [**2137-11-25**] 04:05AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**2-3**] [**2137-11-25**] 04:05AM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR GLUCOSE-100 KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-TR [**2137-11-25**] 04:05AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2137-11-25**] 04:05AM URINE GR HOLD-HOLD [**2137-11-25**] 04:05AM URINE HOURS-RANDOM [**2137-11-25**] 02:24PM HCT-24.7* [**2137-11-25**] 04:30PM HCT-22.5* [**2137-11-25**] 11:07PM HCT-29.9*# . RUQ US: Small shrunken liver with large amount of ascites. Brief Hospital Course: 60 y.o. male with cryptogenic cirrhosis, DM who presented with hematemesis. The following issues were investigated during this hospitalization: . # Upper GI Bleed/Hematemesis: In the MICU, pt had EGD which showed grade 3 varices with several cherry spots indicative of recent bleed. 3 bands were placed and pt remained hemodynamically stable. He was initially given 4 units of PRBCs and his hct did not bump appropriately. A central line was placed and he received an additional 4 units of PRBCs and hct stablized. He also received 5U FFP, 1U of plts and 1U of cryo. He was given ceftriaxone and azithromycin to cover for variceal bleed and possible CAP. He was treated with lactulose for encephalopathy. Patient had a 5 L therapeutic paracentesis on [**11-26**]. His octreotide gtt was stopped on [**11-27**] and changed to SC. He was also started on clear liquids and tolerated them well. UOP decreased and he was given a total of 75 gm of albumin and UOP increased. RIJ pulled on [**11-27**] after 2 large bore IVs placed, at which point he was called out to the floor for further management. . # Cirrhosis: Pt.'s cirrhosis gradually became poorly compensated with continued ascites and encephalopathy and eventually, renal failure. Despite Lactulose, Octreotide/Midodrine and albumin infusions, his symptoms gradually worsened. He triggered on the morning of [**12-1**] for altered mental status. A head CT showed no acute bleed. The family was contact[**Name (NI) **] and made the decision to take the patient home as there were no additional medical options for him and he was DNR/DNI, CMO. . # DM: Patient's DM was well-controlled as an outpatient with a HbA1C of 5.5. During this hospitalization, he was maintained on a RISS with QID FS. Medications on Admission: Glyburide Discharge Medications: 1. Bed Patient needs semi-automatic mechanical hospital bed due to end stage liver disease and hepatocellular carcinoma. 2. Morphine 10 mg/5 mL Solution Sig: [**12-3**] mL PO Q 1-2 hours as needed for pain. Disp:*100 mL* Refills:*0* 3. Morphine Concentrate 20 mg/mL Solution Sig: 0.5-1 mL PO Q [**12-3**] hrs as needed for pain. Disp:*50 mL* Refills:*0* 4. Ativan 1 mg Tablet Sig: 1-2 mg PO Q 3-4 hours as needed for anxiety/agitation. Disp:*20 tablets* Refills:*0* 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). Disp:*3600 ML(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) 2646**] VNA Discharge Diagnosis: Primary Cryptogenic Cirrhosis/Hepatocellular Carcinoma . Secondary DM Osteoarthritis Hypertension Chronic venous insufficiency Umbilical and Inguinal Hernias Discharge Condition: Decompensated from baseline with plans for Hospice care. Discharge Instructions: You were seen and evaluated for vomiting up blood, which was determined to be due to bleeding varices (veins in your esophagus or food tube) caused by your liver disease. You received several blood transfusions in order to replace the blood you lost and once you became stable, you were transferred from the intensive care unit to a regular floor where you continued to be monitored. It is now believed that your liver disease is progressing and as a result your kidneys are no longer working as well as they had. After a discussion with your family, it has been decided that you would be best served at home with Hospice. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2422**] Call to schedule appointment

[ "789.5", "553.1", "401.9", "287.5", "788.5", "572.3", "715.90", "456.20", "459.81", "155.0", "578.1", "571.5", "572.2", "250.00", "550.90" ]

icd9cm

[ [ [] ] ]

[ "42.33", "96.07", "99.07", "96.71", "99.05", "54.91", "99.04", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

6248, 6308

3845, 5593

326, 365

6510, 6569

2339, 3822

7240, 7389

1802, 1933

5653, 6225

6329, 6489

5619, 5630

6593, 7217

1948, 2320

275, 288

393, 1330

1352, 1495

1511, 1786

6,686

124,618

45313

Discharge summary

report

Admission Date: [**2136-8-23**] Discharge Date: [**2136-8-27**] Date of Birth: [**2074-8-27**] Sex: F Service: PLASTIC Allergies: Bactrim / Percocet Attending:[**First Name3 (LF) 7733**] Chief Complaint: Basal cell carcinoma L orbit, s/p L orbit exenteration Major Surgical or Invasive Procedure: 1. [**Last Name (un) 5884**] free flap to L orbit History of Present Illness: Patient is a 61 yo female who presents s/p L orbit exenteration ([**2127**]) for a history of basal cell carcinoma in her L orbit. She had previously had some reconstruction of the orbit with a facial flap and bone flap from the left hip in [**2129**]. She was admitted to plastic surgery for further reconstruction with a [**Last Name (un) 5884**] free tissue flap tothe L orbit. Past Medical History: 1. Basal cell carcinoma of L orbit 2. Mitral Valve prolapse 3. s/p removal of L eye, sinus, surrounding tissue ([**2127**]) 4. s/p L orbit reconstruction ([**2129**]) 5. s/p appendectomy ([**2132**]) Social History: No EtoH, tobacco or other substances Family History: Noncontributory Pertinent Results: [**2136-8-23**] 01:09PM freeCa-1.12 [**2136-8-23**] 01:09PM HGB-10.3* calcHCT-31 [**2136-8-23**] 01:09PM GLUCOSE-96 LACTATE-2.1* NA+-141 K+-3.5 CL--107 [**2136-8-23**] 01:09PM TYPE-ART PO2-201* PCO2-37 PH-7.46* TOTAL CO2-27 BASE XS-3 INTUBATED-INTUBATED [**2136-8-23**] 04:19PM freeCa-1.06* [**2136-8-23**] 04:19PM HGB-10.6* calcHCT-32 [**2136-8-23**] 04:19PM GLUCOSE-96 LACTATE-1.8 NA+-143 K+-3.4* CL--110 [**2136-8-23**] 04:19PM TYPE-ART PO2-167* PCO2-35 PH-7.48* TOTAL CO2-27 BASE XS-3 Brief Hospital Course: Patient was admitted [**2136-8-23**] for [**Last Name (un) 5884**] free flap to L orbit. The operation was without complications, and the patient was admitted to the surgical ICU for hourly flap checks. On POD#2, the patient was stable, and transferred to the floor. Flap checks were decreased to q 2hours. Throughout the hospital course, the flap demonstrated strong arterial and venous Doppler signals, was warm and well perfused, and had good capillary refill. By POD#3, the patient was ambulating in the hallways, tolerating PO intake, and not requiring significant analgesia medications. The patient was discharged to home on POD#4. Medications on Admission: Verapamil 240mg qd Prozac 20mg qd Discharge Medications: Verapamil 240mg qd Prozac 20mg qd ASA 325 qd Discharge Disposition: Home Discharge Diagnosis: 1. status post [**Last Name (un) 5884**] free flap to Left orbit 2. History Basal cell carcinoma Left orbit. Discharge Condition: Stable Discharge Instructions: Please continue to monitor your condition. If your skin flap becomes pale, blue, [**Doctor Last Name 352**] or dusky looking, or feels cold, call Dr. [**Last Name (STitle) 5385**] immediately or come to the Emergency Department. Please take Aspirin 325mg once per day for the next 3 months. You may use Tylenol for pain. Followup Instructions: Please call Dr.[**Name (NI) 23346**] office today or tommorrow to arrange for your follow up appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]

[ "V45.78", "V10.84", "V58.41", "424.0" ]

icd9cm

[ [ [] ] ]

[ "86.74", "16.63" ]

icd9pcs

[ [ [] ] ]

2444, 2450

1652, 2291

333, 384

2602, 2610

1123, 1629

2981, 3211

1087, 1104

2375, 2421

2471, 2581

2317, 2352

2634, 2958

239, 295

412, 794

816, 1017

1033, 1071

10,262

177,578

47609

Discharge summary

report

Admission Date: [**2175-2-14**] Discharge Date: [**2175-2-16**] Date of Birth: [**2126-9-26**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 48 year old African-American female with nonsmall cell lung cancer who has three brain metastases. Her oncological problems began in [**2173-4-16**] when she developed nausea and a cough with yellow sputum. X-rays showed three synchronous lesions in the right upper lobe. She underwent right upper lobectomy by Dr. [**Last Name (STitle) 175**] in [**2173-5-16**]. She was treated with three cycles of carboplatin and Taxol. In [**2174-4-16**] she developed left hip pain where she had metastasis to her left hip. She was enrolled in the Aresa trial from [**2174-9-16**] to [**2174-12-17**]. She developed elevated liver functions and was taken off the Aresa at that time. While being evaluated for another protocol, staging and MRI showed that she had three enhancing lesions, one measuring 2.5 cm in the right frontal brain, another 0.5 cm lesion posterior right frontal brain and a third one measuring 0.5 cm in the right insula. She was completely asymptomatic. Did not have any headache, nausea, vomiting or psychomotor slowing, personality change, unsteady gait, seizures or falls. PAST MEDICAL HISTORY: She has asthma. History of iron deficiency anemia. PAST SURGICAL HISTORY: She had right thyroidectomy which she thinks was for thyroid cancer. FAMILY HISTORY: There are members of her family who had or has a brain tumor, thyroid cancer, CAD, hypertension and asthma. SOCIAL HISTORY: The patient smoked [**11-17**] pack of cigarettes per day for 40 years. She drinks an occasional beer. MEDICATIONS ON ADMISSION: Celexa 40 mg p.o. q.d., Decadron 4 mg p.o. q.six hours, oxycodone 10 mg p.o. q.four to six hours p.r.n., fentanyl patch 75 mcg q.72 hours, Protonix 40 mg p.o. q.day, Compazine p.o. p.r.n. q.day, albuterol inhaler, Atrovent inhaler, stool softener. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Blood pressure was 130/88, heart rate 100, respiratory rate 20. HEENT was unremarkable. Neck was supple, no cervical, axillary or supraclavicular lymphadenopathy. Cardiac exam revealed regular rhythm and rate. Lungs were clear. Abdomen soft. Extremities did not show cyanosis, clubbing or edema. Neurological exam showed that she was awake, alert and oriented times three. There was no right to left confusion or finger agnosia. Calculation was intact. Language was fluent with good comprehension, naming and repetition. Visual fields were full. Extraocular movements were full. Pupils were reactive to light 4 mm to 2 mm. Face was symmetric. She had no drift. Muscle strength was [**3-20**]. Reflexes were 3+ bilaterally. HOSPITAL COURSE: The patient was brought to the operating room on [**2-14**] where she underwent right frontal craniotomy and resection of right frontal metastasis. Frozen section was sent to the lab. Patient did very well overnight and was monitored in the post anesthesia recovery unit where her vital signs remained stable. She was awake, alert and showed no deficits after surgery. On the second post-op day she was ambulating in the hallway, tolerating a complete diet. Pain was well controlled. No nausea, vomiting. She was cleared by physical therapy to go home safely. DISCHARGE MEDICATIONS: On [**2-16**] patient was discharged home on the same medications except for the addition of Percocet one to two p.o. q.four to six hours p.r.n. pain. She was to continue on Protonix. She will be started on a Decadron taper. She will take 4 mg b.i.d. on discharge day; on [**2-17**], 4 mg b.i.d.; on [**2-18**], 4 mg in the a.m., 2 mg in the p.m.; same on the 6th; on the 7th she is to decrease to 2 mg b.i.d. until further notice. She has a followup appointment in the brain tumor clinic on [**2-20**] at 3:00 p.m. She will be meeting with Dr. [**First Name (STitle) **] at that time and she will have her staples removed at that time. CONDITION AT DISCHARGE: Patient was discharged neurologically stable. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**First Name3 (LF) 100593**] D: [**2175-2-16**] 09:17 T: [**2175-2-17**] 11:51 JOB#: [**Job Number 100594**]

[ "493.90", "198.3", "V10.11", "198.5", "197.7" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

1458, 1567

3375, 4028

1716, 2003

2784, 3352

1371, 1441

2026, 2766

4044, 4351

156, 1271

1294, 1347

1584, 1689

49,053

153,986

54857

Discharge summary

report

Admission Date: [**2149-5-24**] Discharge Date: [**2149-5-24**] Date of Birth: [**2064-7-27**] Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hypoxic respiratory failure Major Surgical or Invasive Procedure: Intubated prior to transfer History of Present Illness: The patient is an 85 y/o M with h/o T cell leukemia, CAD s/p CABG, CKD, hx of tumor lysis syndrome, COPD, OSA on home BiPap who presents from OSH intubated for hypoxic respiratory failure. The patient was admitted at [**Hospital3 **] earlier in the month for a CAP. He was treated initially with ceftriaxone and azithromycin, then transitioned to cefuroxime prior to d/c to LTAC. This hospitalization was complicated by [**Last Name (un) **] and hyperK as well which were treated with IVF and kayexalate. He was discharged on 5L NC - at baseline he uses no supplemental O2. It seems he had a few days of worsening respiratory distress with mild cough and was sent to [**Hospital3 **]. He was trialed on Bipap but he failed and was intubated, sedated with propofol. Labs showed trop of 0.18, CKMB 4.1, WBC 377, K>12. He had a temporary right femoral line placed for dialysis for 2 hours and then decision was made to transfer to [**Hospital1 18**] for further care. Prior to transfer, he was given vanc/zosyn, lasix, solumedrol 125mg IV x1, and started on heparin for presumed PE. Was hypotensive en route to the 80s and started on norepinephrine, also satting in the 80s on the vent. When he arrived 94% on Vent and normotensive. In the ED, initial VS were not recorded. He had repeat labs sent and a CXR/EKG done. Renal and Heme/Onc were consulted but had not provided full recommendations at the time of signout. The patient was given 2grams calcium IV. On transfer, vitals were: HR: 93, BP 126/71 - on norepi 0.3, satting 97% on CMV 550/18 100% PEEP 15. On arrival to the MICU, the patient is intubated and sedated. He moves all 4 extremities equally. Review of systems: Unable to be obtained Past Medical History: 1. CKD w/ baseline creatinine 2.5 2. Tumor Lysis Syndrome 3. Hypertension 4. COPD 5. OSA on BiPAP 6. T-cell lymphocytic leukemia s/p recent chemotherapy 7. Hypertension 8. CAD s/p MI and 4 vessel CABG in [**2116**] 9. BPH s/p TURP 10. Cholecystectomy Social History: Lives with wife in [**Name (NI) 7661**] at daughter's house. Independent with ADL. Does not drink alcohol/smoke. Family History: NC Physical Exam: General: Intubated and sedated HEENT: Sclera anicteric, PERRL, ruddy skin of forehead and cheeks Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation on anterior exam, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, palpable abdominal pulsation GU: foley in place Ext: warm, well perfused, 2+ pulses, [**12-9**]+ lower extremity edema Neuro: moves all 4 extremities spontaneously, did not follow commands when sedation lightened. Pertinent Results: CXR:[**2149-5-24**] 1. Endotracheal tube in standard position. 2. Congestive heart failure. [**2149-5-24**] 04:18AM BLOOD WBC-336.7* RBC-3.10* Hgb-10.6* Hct-33.7* MCV-109* MCH-34.2* MCHC-31.5 RDW-20.1* Plt Ct-103* [**2149-5-24**] 09:51AM BLOOD WBC-471.7* RBC-2.81* Hgb-9.8* Hct-30.6* MCV-109* MCH-34.8* MCHC-31.9 RDW-18.6* Plt Ct-107* [**2149-5-24**] 09:51AM BLOOD Neuts-5* Bands-0 Lymphs-90* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2149-5-24**] 09:51AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Stipple-OCCASIONAL [**2149-5-24**] 04:18AM BLOOD PT-12.4 PTT-150* INR(PT)-1.1 [**2149-5-24**] 04:18AM BLOOD Fibrino-144* [**2149-5-24**] 09:51AM BLOOD Fibrino-151* [**2149-5-24**] 04:18AM BLOOD Glucose-203* UreaN-49* Creat-2.2* Na-141 K-3.7 Cl-106 HCO3-26 AnGap-13 [**2149-5-24**] 09:51AM BLOOD Creat-2.6* Na-141 K-3.6 Cl-104 HCO3-27 AnGap-14 [**2149-5-24**] 04:18AM BLOOD ALT-4 AST-12 LD(LDH)-242 CK(CPK)-73 AlkPhos-20* TotBili-0.1 [**2149-5-24**] 09:51AM BLOOD LD(LDH)-955* CK(CPK)-217 [**2149-5-24**] 04:18AM BLOOD Lipase-45 [**2149-5-24**] 04:18AM BLOOD CK-MB-7 proBNP-1452* [**2149-5-24**] 04:18AM BLOOD cTropnT-0.30* [**2149-5-24**] 09:51AM BLOOD CK-MB-8 cTropnT-0.48* [**2149-5-24**] 04:18AM BLOOD Albumin-2.8* Calcium-9.3 Phos-3.5 Mg-2.5 UricAcd-5.6 [**2149-5-24**] 09:51AM BLOOD Calcium-9.2 Phos-5.1*# Mg-2.2 UricAcd-6.4 [**2149-5-24**] 04:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2149-5-24**] 09:56AM BLOOD Type-ART Temp-37.3 Rates-28/ Tidal V-420 PEEP-15 FiO2-100 pO2-46* pCO2-52* pH-7.34* calTCO2-29 Base XS-0 AADO2-615 REQ O2-100 -ASSIST/CON Intubat-INTUBATED [**2149-5-24**] 04:16AM BLOOD Type-ART pO2-51* pCO2-57* pH-7.31* calTCO2-30 Base XS-0 Intubat-INTUBATED [**2149-5-24**] 04:16AM BLOOD Glucose-214* Lactate-1.3 Na-141 K-3.5 Cl-103 calHCO3-28 [**2149-5-24**] 04:16AM BLOOD Hgb-9.8* calcHCT-29 O2 Sat-79 COHgb-1.4 MetHgb-0.5 [**2149-5-24**] 04:16AM BLOOD freeCa-1.22 Brief Hospital Course: Hospital Course: This is an 85 y/o M with h/o T cell leukemia, CAD s/p CABG, CKD, hx of tumor lysis syndrome, COPD, OSA on home BiPap who presents from OSH with hypoxic respiratory failure and shock of unclear etiology. Due to the patients rapid decline and multi-system organ dysfunction, he was made comfort measures only and expired shortly after extubation and cessation of pressor support. His family was at his bedside. . # Acute hypoxic respiratory failure with ARDS - Unclear etiology. CXR revealed hyperinflated lungs with evidence of pulmonary edema and central venous congestion. He had a history of COPD and OSA and a COPD flare may have contributed given the history of a few days of shortness of breath. He was recently hospitalized as well so HCAP considered althought no evidence on cxr. ACS is possible given the elevated troponin and and MB although cardiogenic shock less likely given warm extrmities, low JVP and nor obvious pulmonary edema. On arrival to the MICU, he was on 100% FiO2 and PEEP of 15 with PaO2 of 51 showing significant A-a gradient concerning for shunt. He was continued on a heparin gtt for treatment of ACS and possible PE given A-a gradient. A TTE-bubble study was ordered. Diuresis with torsemide was started for possible pulmonary edema. He was started on vancomycin, cefepime and levofloxacin to cover HCAP. . # Shock - Likely vasodilatory given presentation - not consistent with cardiogenic at this time given warm extremities and low JVP. He was continued on peripheral levophed with goal MAP > 65. An HD line with VIP port were planned for HD and pressor support. . # Troponin leak - Concern for ischemia vs demand process given respiratory failure. In setting of [**Last Name (un) **], elevated troponin not unexpected, however his MB was elevated as well which is more concerning for cardiac ischemia. A TTE-bubble study was ordered and cardiac enzymes were planned to be cycled. A cardiac consult was placed. Coreg was held and a full dose aspirine was continued. . # T cell leukemia/Leukocytosis - WBC of 336.7K. It appeared that he had a history of a T cell lymphocytic leukemia but his definitive diagnosis was not clear. A hematology oncology consult was urgently placed for possible leukopheresis. Examination of his blood smear revealed few, if any, blasts were identified. In the setting of what apepared to be baseline renal function, normal electrolytes, uric acid and coags with the exception of elevated PTT on IV heparin, he had no evidence of tumor lysis or DIC although fibrinogen was slightly low at 144. Given that his smear showed mature lymphocytes, it was felt unlikely that leukostasis would have occured until the WBC > 400K and therefore not the cause of his acute respiratory failure. His tymor lysis labs were planned to be trended. Of note, later on repeat CBC, his WBC was 471.7K. . # Comfort Measures: On arrival to the MICU, the patients clinical course rapidly declined, his A-a gradient widened, shock worsened despite initial rescussitation efforts outlined above. After discussion with the patient's family regarding his clinical status, including his wife, multiple children and grandchildren at the bed-side, the decision was made to transition him to comfort measures. He was extubated, antibiotics, diuresis and pressor support were discontinued. He passed shortly thereafter in the presence of multiple family members. An autopsy was declined. Given death within 24 hours of admission the medical examiner was notified who also declined autopsy. Medications on Admission: Vytorin 10/40 1 tab daily Lasix 40mg daily Bactrim DS 1 tab daily Coreg 6.25mg [**Hospital1 **] Aspirin 81mg daily Allopurinol 75mg daily Acyclovir 400mg daily calcium carbonate 500mg daily Fish Oil Simvastatin 40mg daily MVI Cefuroxime (for recent pneumonia) Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Hypoxic Respiratory Failure Discharge Condition: The patient expired Discharge Instructions: The patient expired Followup Instructions: The patient expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

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icd9pcs

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9174

Discharge summary

report

Admission Date: [**2163-6-25**] Discharge Date: [**2163-7-2**] Date of Birth: [**2117-7-11**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: IVC Filter [**2163-6-28**] History of Present Illness: 55 y/o male s/p minimally invasive mitral valve repair on [**2163-6-7**] presented to the ED for increasing dyspnea on exertion and fatigue. Past Medical History: s/p minimally invasive mitral valve repair on [**2163-6-7**] (for Mitral Regurgitation/Mitral Valve Prolapse) borderline Hypertension borderline Hypercholesterolemia s/p ing. herniorrhaphy, appy, T & A, vasectomy Social History: lives with wife and children auto repair business no tobacco use ETOH use socially Family History: non- contributory Physical Exam: VS: 99.8 100 130/68 20 95% General: WD/WN, appears confortable HEENT: NCAT, EOMI, OP WNL Chest: +Crackles right base Heart: RRR 3/6 SEM Abd: +BS, soft, NT/ND Ext: -C/C/E Neuro: CN 2-12 intact, 5/5 strength, A&O x 3 Pertinent Results: Chest CT [**6-25**]: Limited study due to poor enhancement of the pulmonary artery. Massive filling defeat in bilateral main pulmonary arteries, representing bilateral central PE, probably extending to segmental branches of bilateral upper and lower lobes, however, segmental branches are not fully evaluated. Small right pleural effusion. Opacity in right upper and lower lobes, which may be due to infartion, however, other processes such as pneumonia or aspiration cannot be excluded. Opacity in right upper lobe is somewhat rounded and measures 2 cm. Echo [**6-25**]: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). The right ventricular cavity is markedly [**Month/Year (2) 6878**] with severe hypokinesis of the basal 2/3rds of the free wall. The apex is dynamic ([**Last Name (un) 13367**] sign). Valvular [**Male First Name (un) **] is suggested, but an outflow tract gradient was not assessed. A mitral valve annuloplasty ring is present. Mitral regurgitation is present (?mild-moderate) but cannot be fully quantified. Compared with the study of [**2163-6-7**] (images reviewed), the right ventricular cavity dilation and systolic dysfunction are new and c/w acute pulmonary process (e.g., pulmonary embolism). Tha mitral valve repair has been performed and the severity of mitral regurgitation is reduced. Abd CT [**6-27**]: Thrombus identified within the distal IVC, measuring upwards of 5-6cm in length. 2. Peripheral-based opacities in the right lower lung, consistent with atelectasis, although possibly representing infarct if patient has known clot on the right side. [**2163-6-25**] 02:48PM BLOOD WBC-12.6* RBC-4.84 Hgb-14.4 Hct-40.7 MCV-84 MCH-29.7 MCHC-35.4* RDW-13.6 Plt Ct-189 [**2163-6-29**] 05:50AM BLOOD WBC-6.6 RBC-4.37* Hgb-12.6* Hct-36.4* MCV-83 MCH-28.9 MCHC-34.7 RDW-13.3 Plt Ct-92* [**2163-6-25**] 07:34PM BLOOD PT-12.5 PTT-23.4 INR(PT)-1.1 [**2163-6-30**] 05:50AM BLOOD PT-23.6* PTT-30.4 INR(PT)-2.4* [**2163-6-25**] 02:48PM BLOOD Glucose-99 UreaN-20 Creat-1.3* Na-137 K-4.0 Cl-100 HCO3-25 AnGap-16 [**2163-6-29**] 05:50AM BLOOD Glucose-100 UreaN-13 Creat-1.3* Na-140 K-4.3 Cl-102 HCO3-27 AnGap-15 [**2163-6-26**] 12:27AM BLOOD HEPARIN DEPENDENT ANTIBODIES-POSITIVE Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] presented to the ED with increased dyspnea on exertion since his minimally invasive mitral valve repair on [**2163-6-7**]. He underwent a chest CT which showed a "massive" bicentral pulmonary embolism. He was immediately started on anticoagulation (Heparin, Coumadin) and admitted to the Cardiac surgery ICU. TPA was not indicated secondary to bleeding risk from recent surgery. He also underwent an Echo which appeared consistent with an acute pulmonary process (e.g., pulmonary embolism). Subsequently had a bilateral lower extremity U/S which was negative for DVT. He had a Hematology consult and HIT panel on hospital day two. HIT panel came back positive on hospital day three and Argatroban was started (Heparin stopped). Platelet count decreased 3 straight days to a low of 58 and then trended back upwards after Heparin was stopped and while on Argatroban. He was transferred to the cardiac surgery telemetry floor and later on this day an Abdominal/Pelvic CT was performed which revealed a large thrombus in the distal IVC. On hospital day four Vascular surgery was consulted and brought patient to the catheterization lab and placed a IVC filter proximal to the thrombus. He then returned to the cardiac surgery step down floor. Over hospital course he remained on Coumadin and it was titrated for a goal INR of 2.5-3.5. Mr. [**Known lastname **] remained stable over the next several days. Argatroban was stopped prior to discharge and he was discharged with a platelet count of 111K on [**6-30**] and an INR of 3.3 on [**7-2**]. His Coumadin will be followed by Dr. [**Last Name (STitle) 12816**]. He was discharged home with VNA services and the appropriate follow-up appointments on hospital day #8. Hypercoagulability workup recommended as oupt. with Dr. [**Last Name (STitle) 12816**]. First blood draw on Monday [**7-4**] with VNA with results to be faxed to Dr. [**Last Name (STitle) 12816**]. Medications on Admission: Motrin, Lopressor, Aspirin, Amiodarone, Lipitor Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 3. Coumadin 5 mg Tablet Sig: 2.5mgm Tablets PO once a day: Take as directed by Dr. [**Last Name (STitle) 12816**] for a goal INR 2.5 - 3.5. Disp:*30 Tablet(s)* Refills:*1* 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. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Pulmonary Embolism IVC Thrombus Heparin Induced Thrombocytopenia (HIT) PMH: s/p minimally invasive mitral valve repair on [**2163-6-7**] (for Mitral Regurgitation/Mitral Valve Prolapse), borderline Hypertension, borderline Hypercholesterolemia, s/p ing. herniorrhaphy, appy, T & A, vasectomy Discharge Condition: good Discharge Instructions: Please resume previous discharge instructions. Take Coumadin as directed by Dr. [**Last Name (STitle) 12816**]. (Goal INR is 2.5 - 3.5) Followup Instructions: Dr. [**Last Name (STitle) **] if decision is made to remove IVC filter. [**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A Date/Time:[**2163-7-7**] 2:00 Dr. [**Last Name (STitle) 12816**] in [**1-17**] weeks (will follow Coumadin and INR, goal 2.5-3.5) Dr. [**Last Name (STitle) **] in [**2-18**] weeks (if you have not seen since surgery) Completed by:[**2163-7-18**]

[ "415.11", "272.0", "E934.2", "401.9", "E878.8", "453.2", "287.4" ]

icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

6104, 6154

3384, 5348

300, 328

6489, 6495

1119, 3361

6679, 7053

850, 869

5446, 6081

6175, 6468

5374, 5423

6519, 6656

884, 1100

241, 262

356, 498

520, 734

750, 834

48,969

121,435

41958

Discharge summary

report

Admission Date: [**2195-11-9**] Discharge Date: [**2195-11-18**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1515**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: CoreValve procedure Pulmonary Intubation History of Present Illness: 88 yo male with known aortic stenosis and history of CABG x 4 ([**2175**]) who reports worsening shortness of breath with exertion. He is able to walk less than a block without DOE. On [**9-19**] he experienced an episode of dyspnea, chest pain, and witnessed collapse with no LOC. He was taken to an OSH for r/o NSTEMI. Workup included cardiac cath revealing patent grafts, and an echo revealing severe AS ([**Location (un) 109**] 0.7cm2, mean gradient 53, EF 45%). He evaluated by cardiac surgery and is deemed to be of high but not prohibitive risk with an STS risk score of 6.5% for standard surgical aortic valve placement. He completed informed consent for Corevalve study protocol in the high-risk arm, and has been randomized for Corevalve TAVI. Prior to elective procedure, he had a mechanical fall and sufferred rib injury and lip laceration. Antibiotic course initiated and completed by OSH. . The procedure was completed on the day of arrival to the CCU. In the OR, TEE revealed increased MR with increasing PA pressures and EKG changes. This was thought to be secondary to catheter placement changes. The catheter was repositioned and PA pressures returned to 50/20 by the end of the procedure. During the procedure, he was given 2L of IVF with 200cc of UOP and 200cc of blood loss. He was given cefazolin 2grams at 8:45 AM and Metoprolol 1mg IV. His PA catheter was replaced with a transvenous pacer. At the end of the case, he needed propofol and phenylephrine, but did not need this upon arrival to the ICU. . Upon arrival to the CCU, he was initially hypertensive at 164/80. Nitro was hung as a precaution. ABG and labs sent. Access includes a right 5F IJ CVL, right aline, two 16G PIV's, and left 9F venous MAC introducer. He was complaining of chest pain per nursing report and EKG was obtained. The patient was able to open his eyes. . Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -Severe aortic stenosis -myocardial infarction ([**2161**]) -CABG ([**2175**])(LIMA-LAD, vein grafts x3 to diag, circ, and PDA) - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -Prosate Cancer - s/p radiation -progressive dementia Social History: Retired restaurant owner. Lives with his wife in [**Location (un) 21946**] NY Spends [**Doctor Last Name 6165**] in an [**Hospital3 **] facility in [**State 108**]. Supportive daughters. [**Name (NI) 91067**] tobacco for 15 pack years but quit in [**2144**]. Drinks one scotch daily. . Family History: Non-contributory Physical Exam: ADMISSION EXAM: GENERAL: Intubated, sedated from procedure. Opens his eyes and nods his head to verbal stimuli. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, trachea midline. JVD mildly elevated but hard to evaluate with right IJ CVL in place. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, no m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no, wheezes or rhonchi. ABDOMEN: +BS, soft, NT, ND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: wwp, no c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Right upper lip sutures in place. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . Exam at Discharge: Vitals - Tm/Tc: 98.1/98.1 HR: 74-88 BP:119-136/56-58 RR:18 02 sat:98(room air) In/Out: Last 24H: 1550/680 Last 8H: 100/750 Weight: 71.8kg . Tele: First degree AVB, blocked PAC's . FS: 136,219,256,208,142 . GENERAL: Elderly male lying flat supine in bed,in no acute distress HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP non elevated, neck supple, trachea midline CHEST: CTABL no wheezes, no rales, no rhonchi,decreased bases bilat CV: S1 S2 Normal in quality and intensity RRR no rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs 2+. Groin sites clean and dry, no erythema, no bruits. GI/GU: incontinent of cherry colored urine, no visible clots NEURO: CNs II-XII intact. 4/5 strength in upper extremities. [**4-23**] lower extremities. No tremors. SKIN: no rash, no decubiti PSYCH: pleasant, compensates with jokes/complements when questions asked. Pertinent Results: ADMISSION LABS: [**2195-11-9**] 03:30PM GLUCOSE-122* UREA N-30* CREAT-1.2 SODIUM-142 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-25 ANION GAP-16 [**2195-11-9**] 03:30PM estGFR-Using this [**2195-11-9**] 03:30PM ALT(SGPT)-11 AST(SGOT)-18 CK(CPK)-36* ALK PHOS-48 TOT BILI-0.4 [**2195-11-9**] 03:30PM WBC-6.6 RBC-3.94* HGB-12.0* HCT-36.2* MCV-92 MCH-30.6 MCHC-33.3 RDW-12.6 [**2195-11-9**] 03:30PM WBC-6.6 RBC-3.94* HGB-12.0* HCT-36.2* MCV-92 MCH-30.6 MCHC-33.3 RDW-12.6 [**2195-11-9**] 03:30PM PT-13.2 PTT-29.2 INR(PT)-1.1 [**2195-11-9**] 02:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2195-11-9**] 02:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 PERTINENT LABS: [**2195-11-9**] 03:30PM BLOOD CK-MB-2 proBNP-1560* [**2195-11-11**] 12:45AM BLOOD cTropnT-0.11* [**2195-11-10**] 09:08PM BLOOD CK(CPK)-65 [**2195-11-9**] 03:30PM BLOOD %HbA1c-6.6* eAG-143* DISCHARGE LABS: [**2195-11-18**] 05:50AM BLOOD WBC-8.0 RBC-3.24* Hgb-9.8* Hct-29.6* MCV-92 MCH-30.1 MCHC-32.9 RDW-12.7 Plt Ct-253 [**2195-11-18**] 05:50AM BLOOD Glucose-118* UreaN-29* Creat-1.1 Na-137 K-4.3 Cl-105 HCO3-27 AnGap-9 ECHO [**11-10**] Pre valve implant: No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Drs [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 914**] were notified in person of the results on [**2195-11-10**] at 845 am. Post valve implant: Corevalve seen in the aortic position. It appears well seated. There is a mild eccentric perivalvular leak present. The peak gradient across the valve is 12 mm Hg and mean gradient is 7 mm Hg. Mild mitral regurgitation persists. Overall LVEF unchanged. RV function is normal. ECHO [**11-11**] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with distal septal hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. Mild (1+) aortic regurgitation (paravalvar) is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2195-11-10**], no change. [**2195-11-17**] 2:00 am URINE Source: Catheter. URINE CULTURE (Preliminary): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: 88 yo male with CAD s/p remote CABG and severe symptomatic AS now s/p Core Valve procedure. . ACTIVE ISSUE: # Severe symptomatic AS: Patient presented with SOB and syncope found to have a mean gradient of 50mmHg, a peak gradient of 83mmHg, and a valve area of 0.7cm2. He was randomized to Corevalve TAVI. The procedure was successful with no further AS and without any new AI. He had prolonged intubation after the procedure because of difficult oygenation, but was later extubated without complication. He later developed wenckebach AV block in the setting of B-blocker use so b blockers were stopped. EP did not think a pacemaker would be required. . CHRONIC ISSUES: . # CAD: Patient with history of HTN, HL, DM, and CAD with remote CABG (LIMA-LAD, vein grafts x3 to diag, circ, and PDA) in [**2175**]. His grafts were patent upon last cath. Mild chest pain s/p procedure with EKG changes appearing to be strain from hypertension. His HTN was manged with nitroglycerin drip at first with transition to oral medicines. . # Chronic Diastolic CHF: Patient with history of diastolic CHF with EF 45-50%. Euvolemic during hospitalization. . # HTN: BP initially controlled with nitroglycerin drip then transitioned back to home PO medications. Because he developed wenckebach in setting of B blocker this was discontinued. . # Dyslipidemia: Continue home lovastatin . # Diabetes: A1C currently 6.6%. Insulin sliding scale while hospitalized. Rstarted metformin at discharge. . # Dementia: Continued namenda, donezipil. Standing Risperidone was used during hospitalization to manage hospital associated delirium. He is currently alert and pleasantly confused, at baseline per family. Pt should have fall precautions during rehab stay. . # Hematuria: thought [**1-21**] foley trauma but urine grew enterococcus 10-100K on [**11-18**] so ampicillin started empirically for UTI. Pt has been urinating in urinal but mostly incontinant of cherry red urine. No clots have been seen and pt is not retaining urine by bladder scan. He will need a 7 day course of antibiotics for a complicated UTI and will get pyridium for three days to help with bladder spasm and discomfort. Medications on Admission: DONEPEZIL 10 mg Tablet by mouth everyday FOSINOPRIL 10 mg Tablet by mouth one at bedtime LOVASTATIN 40 mg Tablet by mouth every day MEMANTINE 10 mg by mouth twice a day METFORMIN 500 mg Tablet by mouth two times a day METOPROLOL ER SPIRONOLACTONE 25 mg Tablet by mouth every day DIPHENHYDRAMINE HCL 25 mg Capsule by mouth one at bedtime Discharge Medications: 1. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. memantine 10 mg Tablet Sig: One (1) Tablet PO bid (). 3. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. fosinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 7 days. 9. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Discharge Disposition: Extended Care Facility: [**Location (un) 8985**] Health And Rehab Discharge Diagnosis: primary diagnosis: aortic stenosis dementia coronary artery disease Wenkebach. chronic diastolic congestive heart failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [**Known lastname 91068**], You were admitted to [**Hospital1 18**] for CoreValve procedure. You required intubation following the procedure but you were successfully extubated. Your heart is in a slow rhythm and you should not take beta blocking medications. Please note the following changes in your medications: - STOP taking metoprolol, diphenhydramine, and spironolactone - START aspirin every day to keep the valve working well - START Plavix every day to keep the valve working well, do not stop taking this medicine unless Dr. [**Last Name (STitle) **] says that it is OK. - START ampicillin to treat a urinary tract infection - START pyridium for three days to treat bladder pain because of the infection Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2195-12-11**] at 2:00 PM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will see Dr. [**Last Name (STitle) **] on that day as well

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icd9cm

[ [ [] ] ]

[ "35.05", "37.23", "88.56", "88.42" ]

icd9pcs

[ [ [] ] ]

11363, 11431

8100, 8754

272, 315

11597, 11597

4852, 4852

12529, 12854

2914, 2932

10653, 11340

11452, 11452

10292, 10630

11782, 12506

5823, 7990

2947, 3857

2317, 2508

3871, 4833

213, 234

8025, 8077

343, 2213

4868, 5601

11471, 11576

11612, 11758

5617, 5807

2539, 2594

8770, 10266

2235, 2297

2610, 2898

3,133

135,744

15610

Discharge summary

report

Admission Date: [**2173-7-5**] Discharge Date: [**2173-8-11**] Date of Birth: [**2131-2-13**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 174**] is a 42-year-old male with a history of end-stage liver cirrhosis secondary to hepatitis C and ethanol abuse, who for a long time had been followed by Dr. [**First Name (STitle) **] at [**Hospital1 69**] for possible liver transplant. He presented to the [**Hospital 1474**] Hospital on [**2173-7-1**] with worsening confusion, lethargy, and increased fatigue. There was no evidence of bleeding or infection. It was thought that he would do better with being transferred to [**Hospital1 69**] and that this would expedite his chances for getting a new liver. The patient was transferred to [**Hospital1 188**] on [**2173-7-5**]. By the time of transfer, he was admitted with acute renal failure as well as encephalopathy. PAST MEDICAL HISTORY: 1. Hepatitis C with cirrhosis. 2. Gastroesophageal reflux disease. 3. Bipolar-affective disorder. 4. History of pneumonia. ALLERGIES: There are no known drug allergies. MEDICATIONS ON ADMISSION: 1. Lamictal 200 mg po bid. 2. Protonix 400 mg po q day. 3. Ursodiol 300 mg po tid. 4. Nadolol 20 mg po q day. 5. Aldactone 25 mg po bid. 6. Seroquel 100 mg po q hs. 7. Lorazepam 0.5 mg po bid. 8. Levaquin 500 mg po q day x6 days. 9. Lasix 800 mg po q day. 10. Mycelex five pills a day. SOCIAL HISTORY: Occasional [**3-30**] cigarettes a day. He denies any alcohol use, and the patient is single with one son, never married, and he lives with his sister. PHYSICAL EXAMINATION: The patient appeared lethargic and jaundice appearing and is arousable in no acute distress. Vital signs: Blood pressure 100/48, pulse 70, respiratory rate 20. Head, eyes, ears, nose, and throat is normocephalic, atraumatic. Extraocular movements are intact. Sclerae icteric. Neck: There is no jugular venous distention, no lymphadenopathy. Heart: Regular, rate, and rhythm, normal S1, S2. Lungs with crackles bilaterally at the base. Abdomen: Bowel sounds present, soft, slightly distended and nontender. Extremities: No edema. Neurologically, the patient is drowsy, but arousable, alert and oriented times three, moves all four extremities. PERTINENT LABORATORY TESTS: Sodium 127, potassium 4.8, chloride 99, bicarb 22, BUN of 42, creatinine of 2.4 from baseline of 1.0. Total bilirubin 19.8, direct bilirubin 9.5, indirect 3.1. Amylase 78, lipase 57, alkaline phosphatase 115. AST 60, ALT 40. CHEST X-RAY: Revealed a large right sided density probably representing a large pleural effusion. ECHOCARDIOGRAM: On [**2173-3-12**] showed a left ventricular ejection fraction of 55%, mild mitral regurgitation, mild dilated left atria, with mild pulmonary hypertension. SUMMARY OF HOSPITAL COURSE: This is a 42-year-old gentleman with end-stage liver disease secondary to hepatitis C as well as ethanol use in the past, who was transferred from [**Hospital 1474**] Hospital on [**2173-7-5**]. He had a variety of metabolic abnormalities, and he was encephalopathic. He was transferred for better management and for possible liver transplant. The patient had a thoracentesis the following day of his right pleural effusion. He was also taken to the operating room on [**2173-7-7**] for orthotopic liver transplant. The consent was obtained. The operation went well as described in the operative note. The patient was started on the usual prophylaxis of Bactrim, fluconazole, and Valcyte, and additionally on Unasyn as well as Vancomycin. Patient was weaned off propofol as well as ventilation and extubation was attempted on postoperative day one. An ultrasound of his liver was obtained indicating normal blood flow to the liver and a large pleural effusion on the right side. That pleural effusion was tapped and cultured and there was no growth of organism. Additionally, blood cultures as well as sputum cultures were sent. All cultures were negative. A sputum sample was negative as well. A bronchoalveolar lavage indicated no microorganisms seen, however, there was [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] on fungal culture and no other organisms. The patient was continued on ventilation and was noted to have a lot of secretions. The patient was placed on Lopressor as well as hydralazine and actively diuresed. Patient was started on TPN. The patient was extubated on postoperative day three, and oxygen saturation was in the high 90s. He is having aggressive chest PT. During the hospital stay, the patient was transfused several units of blood as well as platelets. The patient was maintaining excellent urine output. His liver function tests have been trending downward. An angiogram of his liver showed normal flow. The patient had been doing well on the floor, however, he is transferred back to the unit on postoperative day #7 with respiratory failure, decrease in oxygen saturation. Sedation was avoided. Imaging of his lungs were consistent with ARDS. Collapse of the left upper lobe as well as the left lower lobe. The patient required increase in FIO2 as well as PEEP requirement, ...................and bronchoscopy was done as well as a bronchoalveolar lavage, which revealed no organism. TPN was discontinued and tube feedings started in its place. The patient was eventually weaned off the vent and extubated, and remained hemodynamically stable. [**Hospital **] clinic was consulted regarding blood sugar management. Physical Therapy and Occupational Therapy was working with patient for rehabilitation. Again on postoperative day #18, the patient was transferred from the unit to the floor. It was noted at that time that there was a large amount of ascites leaking from the upper aspect of his wound which required several stitches to be placed. The patient had an ultrasound guided paracentesis, which was within normal limits. The patient was cleared by Speech and Swallow for po intake. Tube feeds were eventually discontinued, and patient's oral intake was supplemented with Boost shakes. The patient was started on Fludrocortisone for some adrenal insufficiency. Urology was consulted for a history of renal calculus as well as dysuria and positive urine culture. He was taken to the operating room on [**8-9**] for uroscopy and laser lithotripsy, where a temporary stent was placed. He was additionally placed on Levaquin for one week. As per patient's request, Psychiatry was consulted for his history of bipolar disorder, and appropriate recommendations were made. The patient remained in the hospital for several extra days secondary to the patient not having medical insurance and could not go to a rehabilitation center. The patient was to be discharged with his sister with whom he lives with at home. Review of the patient's medications as well as medications schedule was reviewed with his sister by the Transplant Coordinator. The patient was scheduled to review [**Month (only) 269**] services. The patient was to have laboratory work done twice a day on Monday and Thursdays at [**Hospital3 **]. The patient was cleared by Physical Therapy as well as our service to return home on postoperative day #35 under the guidance of her sister at home as well as [**Name (NI) 269**] services. At that time, is on a combination of an immunosuppressive regimen of Neoral, prednisone, and CellCept. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSES: 1. End-stage liver disease with encephalopathy. 2. Hepatitis C alcoholic cirrhosis. 3. Gastroesophageal reflux disease. 4. Acute respiratory distress requiring reintubation. 5. Vancomycin resistent enterococcus. 6. Bipolar-affective disorder. 7. Renal calculus/urinary tract infection. INVASIVE/SURGICAL PROCEDURES: 1. Status post orthotopic liver transplant. 2. Status post ureteroscopy with laser lithotripsy. 3. Status post thoracentesis. DISCHARGE MEDICATIONS: 1. Valcyte 450 mg one tablet po q day. 2. Risperidone 1 mg/ml solution one tablet oral po bid. 3. Bactrim SS one tablet po q day. 4. Metoprolol 50 mg one tablet po bid. 5. Fluconazole 200 mg tablet two tablets po q day. 6. Fludrocortisone 0.1 mg tablet one tablet po q day. 7. Percocet 1-2 tablets po q4-6h prn pain. 8. Famotidine 20 mg tablet one tablet po bid. 9. CellCept [**Pager number **] mg tablet two tablets po bid. 10. Prednisone 12.5 mg po q day. 11. Insulin NPH 4 units at breakfast and 4 units q hs. 12. Furosemide 10 mg tablet po q day. 13. Neoral 100 mg capsule one capsule [**Hospital1 **]. RECOMMENDED FOLLOW-UP APPOINTMENTS: 1. The patient is to followup with Dr. [**Last Name (STitle) 365**] at the [**Hospital 159**] Clinic in [**Hospital Ward Name 516**]. He is to schedule an appointment in one month at telephone number [**Telephone/Fax (1) 6445**]. 2. He is to followup with Dr. [**Last Name (STitle) **] at the Transplant Center in the [**Hospital Unit Name **] at area code [**Telephone/Fax (1) 673**] on [**2173-8-18**] at 11:20 am. 3. He is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at the [**Hospital Unit Name 20119**] in the Transplant Center, same telephone number on [**2173-8-25**] at 9:10 in the morning. 4. To follow-up again with Dr. [**Last Name (STitle) **] on [**2173-9-1**] at 10:10 am. 5. He is to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the same telephone number at the [**Hospital 1326**] Clinic. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D. Dictated By:[**Last Name (NamePattern1) 12360**] MEDQUIST36 D: [**2173-8-12**] 17:41 T: [**2173-8-20**] 12:01 JOB#: [**Job Number 45112**]

[ "511.8", "567.2", "518.5", "572.2", "571.5", "287.5", "571.2", "285.1", "070.54" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.15", "88.47", "33.24", "54.91", "50.59", "34.91", "59.8", "96.04", "56.0", "38.91", "51.22" ]

icd9pcs

[ [ [] ] ]

7490, 7934

7957, 8577

1132, 1419

2831, 7469

8601, 9893

1613, 2802

155, 912

934, 1106

1436, 1590

1,426

132,722

15566

Discharge summary

report

Admission Date: [**2100-7-7**] Discharge Date: [**2100-7-20**] Date of Birth: [**2020-2-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Left frontal lobe mass with hemorrhage Major Surgical or Invasive Procedure: -neurosurgery with removal of left-frontal lobe brain mass -gastric tube placement by gastroenterology History of Present Illness: Patient is an 80 year old right handed [**Country **] Rican male with past medical history of diabetes, hypertension, hypercholesterolemia, who presents to [**Hospital1 18**] ED for evaluation after abnormal MRI result. Patient is accompanied by his daughter, who relates the majority of the history. Patient was doing well and living independently up until [**4-22**]. At that time, he went to [**Male First Name (un) 1056**] for a visit. While there, he had an unwitnessed fall. Unclear if he had LOC. Unclear what kind of evaluation he had. Returned to [**Location 86**] in late [**Month (only) 116**]. Was then hospitalized for several days with anemia and acute on chronic renal failure. After discharge, went back to living independently. Per his daughter, shortly after he returned home, she noted a dramatic change. He has had progressive memory problems. [**Name (NI) **] has stopped eating and cooking for self. He had a small kitchen fire at home. He has stopped doing his daily excercises. Has seemed to lack motivation. He has been less talkative. Daughter started checking on him more often 2 weeks ago and found that he was intermittently confused. Seemed to need directions repeatedly multiple times. Was forgetting recent conversations. His confusion has seemed worse the past few weeks. She was concerned about this dramatic change so she took him to see his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] referred him for outpatient MRI, which demonstrated the large left frontal hemorrhage with midline shift, mass effect, edema. Patient referred to ED after MRI resulted. No other recent illnesses, fevers, chills, chest pain, shortness of breath, nausea, vomiting, dysuria. No headaches, visual changes, speech or language disturbance, numbness, weakness, incoordination. Past Medical History: 1) NIDDM x 18 years 2) HTN 3) Hypercholesterolemia 4) CRI, baseline Cr 1.4-1.7 5) Insomnia 6) Constipation 7) BPH 8) Dyspepsia 9) h/o hypercalcemia PSH: 1) TURP 2) Hernia x 2 3) Exp Lap many years ago for unknown reasons 4) R cataract surgery [**3-21**] or [**4-20**] Social History: Pt. lives at [**Location 45041**] Towers - a senior citizen home in [**Location (un) **], mass. He denies tobacco or alcohol use. He is very close with his daughter, [**Name (NI) **], who takes care of him ever since his wife of 50 years passed away 2 years ago. Family History: 1) [**Name (NI) 5895**] Dz - nephew 2) Early onset [**Name (NI) 11964**] - niece 3) Colon CA, CAD, DM, alcoholism - run in family 4) Esophageal CA - father Physical Exam: Tc: 97.2 BP: 114/47 HR: 56 RR: 20 O2Sat.: 99%/RA Gen: WD/WN, comfortable, NAD. HEENT: NC/AT. Anicteric. MMM. Neck: Mildly restricted in anterior/posterior direction but no pain. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: CTA bilaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place. Date is [**100-12-10**]. Able to recite [**Doctor Last Name 1841**] forwards and backwards in Spanish. Registration intact. Recalled [**12-21**] objects at 5 minutes. Speech fluent with good comprehension for simple tasks. Perseverative. Needed complex directions repeated many times. Had problems with complex repetition, but unclear if due to language barrier. Naming intact. No dysarthria or paraphasic errors. No apraxia, no neglect. [**Location (un) **] intact. +Glabellar, snout. Unable to learn graphomotor sequence. Cranial Nerves: I: Not tested II: Pupils post surgical, but reactive 3 to 2 mm bilaterally. Visual fields are full to confrontation. Optic disc margins sharp. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-22**] throughout. No pronator drift. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 1 tr Left 2 2 2 1 tr Grasp reflex absent. Right toe equivocal. Left toe downgoing. Coordination: Normal on finger-nose-finger, rapid alternating movements, heel tapping. Gait: Did not assess. Pertinent Results: CT head: Again, note is made of a large left frontal hematoma, measuring 23 x 22 mm on CT scan, surrounded by edema. Again, note is made of associated mass effect to the frontal horns, as well as shift of normally midline structures to the right. No evidence of other areas of hemorrhage is noted. No evidence of subarachnoid hemorrhage is noted. IMPRESSION: A large left frontal hematoma surrounded by edema, with mass effect and shift of normally midline structures to the right, as noted on the prior MRI study performed on the same day of which the results have been communicated to the referring physician. [**Name10 (NameIs) **] evidence of subarachnoid hemorrhage. . MRI head with contrast: Large hematoma in left frontal lobe 48 x 52 mm in diameter. Surrounding vasogenic edema. Mass effect with midline shift. Contrast enhanced images show ring enhancement around hematoma but no evident mass lesion noted. Some subarachnoid extension. . Echo [**2099-3-6**] LV EF 60%. No LVH. nl RV. nl PASP no significant valve dz . [**2099-3-31**] Stress Mibi: normal perfusion scan. no sx or ECG signs of ischemia 7 minutes, fair functional excercise tolerance. . [**2100-7-15**] LE compression US: patent and compressible veins. . [**2100-7-14**] EEG: IMPRESSION: Abnormal portable EEG due to the left fronto-central slowing and due to the slowing of the background. The first abnormality signifies a focal subcortical dysfunction in the left anterior quadrant. Vascular disease is one possible cause. The slow background indicates an encephalopathy. Medications, metabolic disturbances, and infectionare among the most common causes. There was some occasional sharp feature in the left frontal area but no overtly epileptiform abnormalities. . CT Head [**2100-7-12**] FINDINGS: Again seen is left frontal craniotomy with partial left frontal lobectomy. The lobectomy defect has been packed with Surgicel according to operative notes, which explains the air within the lobectomy defect. Two foci of hyperdensity within the left frontal lobe remnant with surrounding edema signify intraparenchymal hemorrhage, which is stable. However, the edema seems to have increased somewhat, causing increased subfalcine herniation rightward, approximately 7-8 mm (previously 6-7 mm). There is persistent pneumocephalus in the left frontal lobectomy defect and a small amount of subdural blood along the craniotomy site, which is stable. No new regions of hemorrhage or major vascular territorial infarct are identified. There is edema in the scalp overlying the craniotomy site. . IMPRESSION: Status post left frontal lobectomy, with apparent slight increase in edema causing slight increase (1 mm) in contralateral subfalcine herniation. . CT Chest / Abd / Pelvis [**2100-7-12**]: IMPRESSION: No sclerotic bone lesions were noted. No chest lesions suspicious for malignancy 1. Abnormal soft tissue density lesion appearing within the left posterior aspect of the bladder and which displaces the Foley balloon rightward. This lesion appears separate from the prostate, possibly representing a neoplasm within the bladder. Further evaluation with cystoscopy is suggested. 2. No evidence of renal masses. 3. Enlarged prostate. . Bone Scan [**2100-7-12**]: No evidence of osseous metastatic disease. . Speech and Swallow evaluation: SUMMARY / IMPRESSION: Pt is presenting with s&s of aspiration with both thin and nectar thick liquids. The pt is too lethargic to take in any substantial amount of POs at this time, and will continue to require alternate means of nutrition/hydration. While he did not appear to aspirate with purees, given he fell asleep with them in his mouth, it is recommended that the pt continues to stay NPO. Discussed with the team that the pt's daughter has been giving him liquids at the bedside, which they have been aware of and has been discussed with her previously. Also discussed the possibility of a PEG with the team ,given the pt's current status. He is going in for surgery tomorrow and the team has discussed with the pt getting the tube simultaneously. The pt would benefit from the PEG as it is not expected he will be able to take a full PO diet given his current status. RECOMMENDATIONS: 1. Remain NPO with alternate means of nutrition/hydration. 2. Would recommend a PEG tube for the pt for longer alternate means of nutrition. 3. PLease reconsult when pt is more awake and can better participate. . CXR Portable [**2100-7-19**]: PORTABLE AP CHEST AT 16:02: Comparison is made to the torso CT and chest radiographs from [**2098-7-11**]. There is a new crescentic lucency under the right hemidiaphragm, which is suspicious for free intra-abdominal air. A similar appearance is seen in the left hemidiaphragm, which could be explained by the gastric bubble. Cardiac size remains within normal limits. Pulmonary vasculature and mediastinal contours are normal. There are no focal consolidations. IMPRESSION: Free intra-abdominal air. (the free air is a normal finding given G-tube placement a few days prior). . Day of discharge labs: WBC 9.4 Hgb 11.0 Hct 33.1 Plt 179 Na 135 K 4.3 Cl 103 Bicarb 24 BUN 30 Cr 1.5 Glucose 257 Ca 8.4 Phos 2.6 Mg 1.5 [**7-19**] Urine osm 362 Urine Na 75 K 12 Cl 62 Brief Hospital Course: 80 year male with past medical history of hypertension, hypercholesterolemia, diabetes, tremo, presenting to ED after outpatient MRI for several weeks of altered mental status showed a large left frontal lobe ring enhancement, MRI of underlying process was limited by blood. He was admitted to the Neuro ICU for close monitoring, and transferred to the floor prior to surgery for this lesion. On [**2100-7-9**] he had a left frontal mass resection and biopsy for diagnosis. Preliminary pathology by frozen section in the OR suggested renal cell carcinoma. Postop day #1 postop his Head CT showed small hemorrhage posterior to resection. He received one unit of blood for a hematocrit of 25.7. His motor exam was initially minimal, but gradually improved. He was not able to follow commands for several days following his surgery, but gradually his mental status improved, although he remained disoriented to place, date and situation. On Head CT [**2100-7-12**] there was a slight increase in edema causing a slight increase (1 mm) in contralateral subfalcine herniation. His dexamethasone dose was increased 4mg to 8mg Q6 hours. Primary malignancy work up for chest and abdominal, CT and bone scan was negative for any suspicious malignancy. Pelvic CT revealed left posterior bladder abnormal soft tissue hyperdensity measuring 2.7x1.9cm. Urology felt that a cystoscopy was indicated, and this was performed on [**7-16**]. The cystoscopy was negative, and the mass seen on CT was in fact the median lobe of the prostate, which was enlarged and on CT had been mistaken for bladder mass. Medical oncology had been following the patient during his admission and suggested that the tumor could be metastatic from kidney, melanoma, or colorectal, for example, or primary glioma. While the pathology was pending, the patient had a swallow evaluation, which he failed. GI was consulted, and the patient underwent PEG tube placement [**7-16**] after consent had been obtained from his daughter [**Name (NI) **]. His hospitalization was complicated by persistently high blood sugar, with his diabetes and on decadron. [**Last Name (un) **] endocrinology followed the patient and recommended Lantus for basal insulin requirements while continuing his sliding scale. The dose of Lantus was increased from 15 units to 45 units qpm qhs for better blood sugar control. Radiation oncology and Neuro-oncology were involved during his admission, and will follow him after discharge for further management of XRT/Chemo. . 1.Brain Mass: s/p resection of L frontal mass [**7-9**]. After surgery, the pt was lethargic and unresponsive. His level of consciousness and muscle stregth has improved steadily over the post-operative course, almost back to his preoperative level. -Continue dexamethasone taper. Patient to be discharged on 4 mg Dexamethasone TID until seen in Brain tumor clinic in 6 days. -continue dilantin for seizure prophylaxis, now PO through tube. -maintain BP control -Pathology having difficult time identifying results given hemorrhagic nature of mass. -Patient scheduled for Brain [**Hospital 341**] Clinic appointment on [**Hospital 766**], [**2100-7-26**] with Dr. [**Last Name (STitle) 45042**]. This will coordinate Rad-Onc and Heme-Onc follow-up necessary. . 2. CA: Primary cancer remains obscure. DDx: kidney, melanoma, or colorectal, or primary glioma. Pathology from brain lesion pending. Frozen section initially thought to be consistent with renal cell, although no renal mass noted on CT. Pathology is pending as mass difficult analyze given hemorrhagic nature. CT chest/abd/pelvis is negative. Cystoscopy shows no bladder CA. -oncology following. -continue metastatic work-up while an inpatient. . 3. Anemia: Stably low, no evidence of blood loss. S/p 3U pRBCs [**7-14**]. -followed Hematocrit. transfuse as necessary . 4. DM2: -continue SSI and lantus at night. [**Last Name (un) **] consulted given high blood sugars in 300's. Lantus dose increased as recommended to 30 U on [**7-18**] and 45units on [**7-19**] [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. On discharge, [**Last Name (un) **] recommended Lantus 55 unit qhs. This will likely need adjusting at rehab. -insulin requirements will likely decrease over the week with the steroid taper. Blood sugars also likely running high given Tube feeds started and at goal on [**7-18**]. Called nutrition to see if tube feeds could be changed to a diabetic formulation, but they felt at this time, that increasing the insulin would be appropriate at this time, especially given that steroids have been tapered in the past few days, and would like to start stable tube feed regimen. . 5. CRI: Cr 1.6. At baseline -renal dose meds. monitor FEN. . 6. HTN: well controlled off meds . 7. FEN: G-tube placed by GI [**2100-7-16**]. -start tube feeds on [**7-17**]. Tube feeds at goal 65 cc/hr on [**7-18**] with Probalance. -continue IVF at maintenence. -CXR on [**7-19**] showed free air under right hemidiaphragm. This is likely from G-tube placement. Patient without abdominal pain, GI called and they said this is not an unexpected finding. G-tube site non-tender without erythema or discharge. . 8. Pain: well controlled with dilaudid . 9. Hyponatremia - Patient with Sodium of 131 on [**7-19**]. This is likely because he has been receiving iv fluids: 1/2 NS at 70 cc/hour. Fluids were stopped given tube feeds at goal. Will repeat Na for [**7-20**]. CXR checked on [**7-19**] and no acute pulmonary process. Urine osms checked. Hyponatremia resolved the next day after 1/2 NS was stopped the afternoon prior. . 10. Proph: subq heparin and changed from H2 blocker to Protonix on day of discharge in the setting of steroids being administered for GERD prophylaxis. . 11. PT consult - Patient will need acute rehab facility on discharge. Accepted at [**Hospital1 **] on [**7-19**], but stayed additional night in hospital given hyponatremia. . 12. Hypercholesterolemia: continued statin . 13. Dispo - Patient to be discharged to [**Hospital1 **]. Tube feeds are at goal. Speech and Swallow exam (results above) recommended only feedings through G-tube for now. However, patient with increased level of consciousness since this exam. Patient may be able to take thicker liquids at rehab now that he is more alert. Patient is afebrile with normal vital signs, heart rate 60's-70's, systolic blood pressure 104-118 and normal O2 sats. Pain is well-controlled by Dilaudid. He is scheduled for follow-up appointment with his PCP and with [**Name9 (PRE) **] [**Hospital 341**] Clinic. Blood sugars still remaining high and will be discharged on insulin sliding scale with Lantus to be increased to 55 units qhs [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommedations. Medications on Admission: 1. Glipizide ER 2.5 mg po qd 2. Omeprazole 20 mg po bid, not taking per dtr 3. Primidone 100 mg po bid, prescribed by Dr. [**Last Name (STitle) **] for tremors 4. Lipitor 10 mg po qHS 5. Colace 100 mg po bid Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Primidone 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4-6H (every 4 to 6 hours) as needed for pain. 9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 55 Subcutaneous at bedtime. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times a day: Please [**Last Name (un) **] crushed and per the G- tube. Please continue this dose until you are seen at the Brain [**Hospital 341**] Clinic on [**7-26**], [**2099**]. 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: metastatic carcinoma to the brain intracranial hemorrhage into cancer lesion diabetes mellitus, type 2 delirium hypertension Discharge Condition: stable, tolerating tube feeds Discharge Instructions: contact MD if you develop fever/chills, shortness of breath, chest pain, or other concerning symptoms Followup Instructions: Please follow-up in Brain [**Hospital 341**] Clinic with Dr. [**Last Name (STitle) 45042**] [**Telephone/Fax (1) 45043**] on [**Last Name (LF) 766**], [**2100-7-26**] at 4 p.m. Dr. [**Last Name (STitle) 45042**] will set you up with the appropriate Hematology-Oncology appointments after that. You have a scheduled follow-up appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. . Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2100-7-26**] 4:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2100-7-28**] 9:00 Completed by:[**2100-7-20**]

[ "438.82", "285.21", "331.0", "357.4", "403.91", "250.00", "431", "600.01", "V58.65", "277.3", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "01.59", "43.11", "99.04", "96.6", "44.43", "57.32" ]

icd9pcs

[ [ [] ] ]

18976, 19055

10383, 17202

354, 459

19224, 19255

5121, 5121

19405, 20226

2933, 3091

17462, 18953

19076, 19203

17228, 17439

19279, 19382

10186, 10360

3106, 3518

275, 316

487, 2344

4156, 5102

5130, 10170

3533, 4140

2366, 2636

2652, 2917

57,330

147,942

42150

Discharge summary

report

Admission Date: [**2132-9-2**] Discharge Date: [**2132-9-6**] Date of Birth: [**2054-12-31**] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**First Name3 (LF) 2265**] Chief Complaint: pericardial effusion with tamponade physiology Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: 77yo M with HTN, HL, COPD presenting with cardiac tamponade s/p pericardiocentesis and drainage. Patient presented for scheduled echocardiogram today and was found to have a large pericardial effusion with tamponade physiology. The pericardial effusion was noted on a CT chest performed [**2132-8-26**], at which time a 2cm spiculated mass was also noted in the RUL concerning for malignancy. Patient reports that over the past several months he has had worsening fatigue. He swims regularly (1000 yards in 52 minutes) and has noted that lately he is unable to swim the same distance and it takes him much longer. He also reports worsening shortness of breath. Patient presented to his PCP with these symptoms, and labs were significant for anemia, macrocytosis, thrombocytopenia and small IgG kappa and IgM kappa monoclonal proteins. Patient was referred to a hematologist who was concerned about the potential for a lymphoid neoplasm associated with IgM such as lymphplasmacytic lymphoma, multiple myeloma or Waldenstroms. The hematologist ordered a CT chest/abd/pelvis to investigate for adenopathy and organomegaly, and the above findings were discovered. Patient denies recent weight loss or change in appetite. He reports a brief episode recently when his right lower leg was dragging and "not responding". This improved after several hours and was not associated with numbness or tingling in the limb, speech deficits, word finding difficulties or vision changes. He has never had similar symptoms and they have not recurred since this original episode. He reports shortness of breath which has been worsening over the past several weeks. He does not use oxygen at home. He denies chest pain or palpitations. He reports constipation, without change in caliber of stool, melena or hematochezia. He denies urinary urgency or frequency, hematuria or dysuria. He denies bowel or bladder incontinence. He has had two episdoes of prolonged bleeding; one nosebleed and one post-operative bleeding after MOHS. . Today after echocardiogram showed pericardial effusion with tamponade physiology, patient was taken to cath lab for drainage. Approximately 1L of bloody fluid was drained and sent for cytology, hematology and chemistries. Patient tolerated procedure without issue and a drain was left in place. Patient was transferred to CCU for further management. Past Medical History: 1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: None. 3. OTHER PAST MEDICAL HISTORY: - squamous cell carcinoma, s/p MOHS - colonic polyps, last colonoscopy 1 year ago - COPD - gastritis - h/o gout - h/o nephrolithiasis Social History: Lives with his wife in [**Location (un) **]. Retired hardware store owner. Has two boys, both live in [**State **], and one grandson. - Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd - ETOH: 1 glass of wine/night - Illicit drugs: denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death - Mother: chronic leukemia, died at age 89 - Father: h/o MI, pancreatic cancer, died at age 69 Physical Exam: Admission physical exam: VS: T= 97.1 BP= 126/78 HR= 82 RR= 21 O2 sat= 91% RA GENERAL: NAD. Oriented x3. Pursed lip breathing. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at 5cm. CARDIAC: RRR, normal S1, S2. II/VI holosystolic murmur best heard at left lower sternal border. +rub. No S3 or S4. Pericardial drain at lower right sternal border draining bloody fluid. LUNGS: Poor inspiratory effort, course crackles diffusely with diffuse end-expiratory wheezes. ABDOMEN: Soft, obese, NTND. +BS. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Discharge physical exam: Vital signs stable, afebrile Exam largely unchanged. Cardiac exam notable for lack of pericardial rub. Drain site c/d/i with no erythema or exudate. Lungs with diffuse inspiratory and expiratory wheezes, course crackles Pertinent Results: Pertinent admission labs/studies: WBC 10.1 Hgb 11.9 Hct 34.6 Plts 172 PT 16.2 INR 1.4 TSH 1.7 Pericardial fluid: Hct 27.5 WBC 8900- 40L 11M 12E 9Mac Total protein 5.5 gluc 6 LDH 6690 Amylase 276 Albumin 3.1 GRAM STAIN (Final [**2132-9-2**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2132-9-5**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2132-9-3**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): PENDING FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. TTE ([**2132-9-2**]): The estimated right atrial pressure is 5-10 mmHg. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a moderate to large sized pericardial effusion. There is left atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. CT Chest/Abd/Pelvis ([**2132-8-26**]): 2 cm spiculated mass right upper lobe extending normal margins worrisome for malignancy. Mediastinal and right hilar adenopathy present, full extent difficult to ascertain in the absence of IV contrast. Moderate to large pericardial effusion. Pertinent labs/studies: Pericardial fluid cytology ([**2132-9-4**])- POSITIVE FOR MALIGNANT CELLS, consistent with non-small cell carcinoma. MRI Brain- pending Discharge Echocardiogram ([**2132-9-6**])- pending. Preliminary read: trace to small effusion without evidence of tamponade Discharge labs: WBC 10.1 Hgb 13.4 Hct 39.8 Plts 220 Na 140 K 4.4 Cl 100 HCO3 30 BUN 37 Cr 1.7 Glucose 120 Brief Hospital Course: 77 yo M with h/o HTN, HL, COPD with RUL lung mass and pericardial effusion recently noted on CT scan, presenting with pericardial effusion causing tamponade physiology, s/p drainage of approximately 1L bloody fluid with malignant cells on cytology # Pericardial effusion - Given findings on CT scan of lung mass and bloody fluid drained from pericardium, there was concern for a malignant effusion. A pericardiocentesis was done with a pericardial drain placed for two days until fluid output slowed to a minimal level with a total of roughly 1L output from initial drainage plus drain output. The drain was clamped and a TTE was done 24hrs later which showed no significant fluid reaccumulation and the drain was then pulled. Preliminary cytology is positive for malignant cells, most likely non-small cell lung cancer but final results and additional tissue staining was pending at time of discharge. At the time of discharge, echocardiogram showed small to trace reaccumulation of fluid. Patient had negative pulsus paradoxus on exam and JVP was not elevated. There was no ongoing pericardial rub. # RUL mass - Patient has been in the process of being worked up for recent fatigue and anemia. Outpatient laboratories were concerning for a macrocytosis and IgG/IgM monoclonal gammopathy. Patient was seen by hematology who wanted to work him up further for concern for a lymphocytoclastic leukemia. Patient had prior lung imaging with a spiculated lung nodule concerning for malignancy. In addition, the pericardial effusion was found which was positive for malignant cells. Due to suspicion for lung cancer, a brain MRI was done looking for metastatic disease. Patient was followed by the [**Location (un) 2274**] oncology service during admission and they will follow up with him as an outpatient regarding final diagnosis and treatment. Decision was made to hold off on a bronchoscopy until final results from the pericardial fluid and until a PET scan was obtained as an outpatient. # HTN- Blood pressures were stable throughout pericardial drainage and continue to be lowish but stable on arrival to CCU. He was continued on his home lisinopril during admission. Because of his lowish blood pressures, his home HCTZ dose was decreased to 25mg daily and his verapamil was stopped as it provides relatively little blood pressure control and their was no need for nodal blocking. # Smoking dependence- Patient has an extensive smoking history, and currently smokes 1.5ppd. He was started on a nicotine patch durin the hospitalization. There will need to be follow-up to ensure complete smoking cessation. # COPD - Patient was wheezing on exam but without gross sputum production or fever. Patient is not on home oxygen. He was continued on home fluticasone and albuterol PRN during admission. # H/o gout - No active flare. Continue home allopurinol and colchicine . # Gastritis - Continue home omeprazole # Transitional Issues: - Discussion with patient of final MRI results - Discussion of patient with final pre-discharge ECHO results - Follow-up on final cytology/pathology from pericardial fluid - Outpatient PET Scan - Possible outpatient bronchoscopy if final cytology not diagnostic - Outpatient [**Location (un) 2274**] heme/onc f/u to discuss diagnosis and treatment - Continuing support for smoking cessation Medications on Admission: - Verapamil SR 240mg po daily - Lisinopril 20mg po daily - Hydrochlorothiazide 50mg po daily - Aspirin 81mg po daily - Colchicine 0.6mg po daily - Allopurinol 200mg po daily - Albuterol INH 1-2puffs q4-6hrs PRN - Flutcasone 220mcg/INH 2puffs [**Hospital1 **] - Omeprazole 20mg po BID Discharge Medications: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation q4-6 hours as needed for SOB, wheezing. 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*1* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Malignant pericardial effusion Secondary diagnosis: 1. Hypertension 2. COPD 3. Right upper lobe pulmonary nodule 4. Gastritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 5057**], It was a pleasure taking care of your during your recent admission to [**Hospital1 69**]. You were admitted because of an effusion that developed around your heart and caused compression of your heart. The effusion was drained and we were able to pull the tube as the fluid was not reaccumulating. The preliminary findings in the fluid are for a malignancy. We discussed that the most likely source of the malignancy is the mass in your right upper lung which was found recently on a CAT scan. You were seen by the oncologists and pulmonologists, and will follow-up closely with them, as well as with the cardiologists, as an outpatient. Your home medications were continued as prescribed with the exception of Verapamil and hydrochlorothiazide as your blood pressures were low. You should discuss these medication changes with your primary care doctor at your follow-up appointment. In addition, it will be important that you follow-up with your oncologist regarding the results of your brain MRI and final cytology results. Followup Instructions: Name: [**Name6 (MD) 17529**] [**Name8 (MD) 17528**], MD Specialty: Internal Medicine When: Friday [**9-12**] at 8:40am Location: [**Location (un) 2274**]-[**University/College **] Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**] Phone: [**Telephone/Fax (1) 17530**] Cardiac Imaging: Echocardiogram When: Wednesday, [**9-24**] at 10am Location: [**Location (un) 2274**]-[**Location (un) **] Square, [**Location (un) 4363**] [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] Cardiology Appointment, Thursday, [**10-2**] at 8:50am With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**], MD Location: [**Location (un) 2274**]-[**University/College **] Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**] Phone: [**Telephone/Fax (1) 72622**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]

[ "584.9", "420.90", "423.3", "443.0", "354.0", "401.9", "272.4", "V12.72", "162.3", "V10.83", "V13.01", "493.20", "273.1", "305.1", "535.50", "274.9", "562.10" ]

icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

11455, 11461

6894, 9816

352, 373

11656, 11656

4672, 5045

12901, 13889

3363, 3548

10566, 11432

11482, 11482

10257, 10543

11807, 12878

6777, 6871

3588, 4406

2895, 2901

5216, 5225

5258, 6761

266, 314

401, 2796

11555, 11635

11502, 11534

5081, 5183

11671, 11783

2932, 3073

9839, 10231

2818, 2874

3089, 3347

4431, 4653

79,426

121,700

5896

Discharge summary

report

Admission Date: [**2114-8-27**] Discharge Date: [**2114-8-30**] Date of Birth: [**2055-8-18**] Sex: M Service: SURGERY Allergies: Percocet / Ultram / Hydrochlorothiazide Attending:[**First Name3 (LF) 598**] Chief Complaint: Struck by car while crossing crosswalk on motorized vehicle. Major Surgical or Invasive Procedure: None. History of Present Illness: 59 y/o M crossing a crosswalk in a motorized wheelchair when struck by a car, thrown 30ft. +LOC. Past Medical History: - H/o stroke with residual left-sided facial droop - COPD on home O2 (2L NC) - Lung nodule? - CAD with prior anteroseptal MI on ECG - Hypertension - Mildly dilated ascending aorta (3.8 cm) - Peripheral vascular disease s/p right SFA stent - ETOH abuse - Tobacco abuse - H/o anxiety/panic attacks - Hepatitis B - PUD (H. pylori) - Migraine headaches - Seizure disorder - S/p cholecystectomy - S/p appendectomy - S/p cataract surgery Social History: He is single. He lives alone in [**Location (un) **]. He has been disabled since [**2093**]. He is a former barber. He smokes 1-2 packs of 'cigars' daily. He previously smoked cigarettes for 30 years, approximately one pack per day. He quit smoking cigarettes in [**2097**]. He does not use any illicit substances. He does not exercise and he does not follow any special diet. Family History: His father died at age 74 of lung cancer. His mother is age 86 and apparently has a "hole" in her heart. She also sustained a stroke. He is estranged from his one brother. There is no family history notable for hypertension, hyperlipidemia, or diabetes. He is unsure about any early coronary artery disease or sudden cardiac death history in his family. Physical Exam: GEN: alert and oriented x 3, NAD Patient refused full physical exam, as he left before his official discharge planned time. Pertinent Results: [**2114-8-27**] 06:56PM GLUCOSE-105* UREA N-9 CREAT-0.8 SODIUM-142 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14 Brief Hospital Course: He was monitored closely in the TSICU. He was alert and responsive. He had a L flank hematoma and his hct was monitored closely, it was stable. His diet was advanced but he had a possible aspiration event. His o2 sats remained stable, however, in the low 90s. He was placed on metoprolol for his tachycardia. He was restarted on his home anti-seizure medications. He had a speech and swallow consult. Patient was transferred to the floor once stable. He remained on the floor and was doing well until the evening of [**8-30**] when he began to become agitated, stating "I've had enough," and warning that he would leave that night despite knowing that his primary team did not think it was wise. Pt was also aware that he was likely to be discharged to rehab the following day. The intern on call had multiple conversations with him totaling about 30 minutes explaining the risks of leaving against the team's advice in his condition (requiring 4L of oxygen d/t severe COPD and incomplete transition to rehab). As patient was ambulatory at this time, he proceeded to walk out of floor despite advice, after all lines were d/c'd. He was directed towards the lobby at this time and left hospital. Discharge Medications: 1. Amlodipine 5 mg PO DAILY hold for syst BP<100 2. Lisinopril 40 mg PO DAILY 3. Metoprolol Tartrate 50 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 7. Tiotropium Bromide 1 CAP IH DAILY 8. Gabapentin 300 mg PO TID 9. ALPRAZolam 0.5 mg PO TID:PRN annxiety 10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 11. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain Discharge Disposition: Extended Care Discharge Diagnosis: Left fibula fracture Left flank hematoma Acute encephalopathy 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 being struck by a car. You were thrown 20 - 30 feet and lost consciousness. Your injuries include a left fibula fracture (smaller of the two long bones connecting your knee to ankle) and a left flank (side) hematoma. You were admitted to the intensive care unit after the accident. You were transferred to the floor after you were assessed to be stable enough for transfer. You are slowly recovering and will need continuing rehab after your inpatient stay. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Followup Instructions: Please follow up in clinic with ACS service in [**2-5**] weeks. Please follow up in clinic with orthopedic surgery in the next 2-3 weeks. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

[ "414.01", "348.30", "870.8", "412", "780.09", "346.90", "305.00", "300.01", "496", "070.30", "V12.71", "793.11", "305.1", "E813.0", "440.20", "438.83", "V46.2", "345.90", "823.01", "401.9", "919.0", "922.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3713, 3728

2018, 3214

359, 367

3834, 3834

1872, 1995

4784, 5031

1358, 1713

3237, 3690

3749, 3813

3985, 4761

1728, 1853

259, 321

395, 493

3849, 3961

515, 948

964, 1342

7,438

143,878

21130

Discharge summary

report

Admission Date: [**2168-8-2**] Discharge Date: [**2168-8-10**] Date of Birth: [**2097-8-15**] Sex: M Service: CSU CHIEF COMPLAINT: The patient is a 70 year old patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 56051**], referred to [**Hospital1 188**] for an outpatient catheterization which was done on [**2168-7-22**], at which time he was found to have two vessel disease and normal left ventricular function. CT surgery was consulted and the patient was accepted for coronary artery bypass grafting. HISTORY OF PRESENT ILLNESS: This is a 70 year old man with many years of chest pain, exertional relieved by rest and antacids at times and at other times no relief with rest, progressively worsening with increasing shortness of breath along with substernal chest pain. No orthopnea or paroxysmal nocturnal dyspnea. No palpitations, cough, hemoptysis. Exercise tolerance on [**2168-7-15**], was positive and he was referred for catheterization on [**2168-7-22**]. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Tobacco use. Transient ischemic attacks with bilateral carotid endarterectomy five years ago. No transient ischemic attacks since. Peripheral vascular disease. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg once daily. 2. Atenolol 50 mg once daily. 3. Lipitor 20 mg once daily. 4. Vitamins and Flaxseed Oil. The patient's catheterization done on [**2168-7-22**], showed an ejection fraction of 65 percent and a left ventricular end diastolic pressure of 14, 100 percent right coronary artery, 90 percent proximal left anterior descending coronary artery, 70 percent distal left anterior descending coronary artery, and 30 percent circumflex. SOCIAL HISTORY: Wife and two daughters are well. He lives at home with his wife. Remote tobacco history. Occasional ETOH use. PHYSICAL EXAMINATION: Prior to admission, in general, the patient is in no acute distress. Neck - two plus carotids without bruits. No jugular venous distention. The lungs are diminished in the bases bilaterally and otherwise clear. Cardiovascular is regular rate and rhythm, S1 and S2, no murmurs, rubs or gallops. The abdomen is soft, nontender, nondistended with positive bowel sounds and no bruits and no masses. Peripheral - bilateral femoral pulses two plus, no bruits, no edema, two plus dorsalis pedis and radial pulses. Neurologically, alert and oriented times three, moves all extremities. LABORATORY DATA: White blood cell count was 5.7, hematocrit 42.0, platelet count 192,000. Sodium 138, potassium 4.6, chloride 99, CO2 32, blood urea nitrogen 22, creatinine 1.4. Electrocardiogram is sinus rhythm at 58 beats per minute with normal intervals, flattened T waves in aVL, otherwise nonspecific ST changes. HOSPITAL COURSE: Following catheterization, the patient was discharged to home. He returned as an outpatient admission directly to the operating room on [**2168-8-2**], at which time he underwent coronary artery bypass grafting times two. Please see the operative report for full details. In summary, the patient had a coronary artery bypass graft times two with left internal mammary artery to the left anterior descending coronary artery and saphenous vein graft to the diagonal. His bypass time was 51 minutes with a cross clamp time of 39 minutes. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, he was atrial paced at 80 beats per minute with a mean arterial pressure of 100. His only medication at the time of transfer was Propofol at 20 mcg/kg/minute. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. He remained hemodynamically stable throughout the operative day. On postoperative day number one, the patient remained hemodynamically stable. He required Neo-Synephrine drip to maintain adequate blood pressure. He was weaned from his Neo- Synephrine infusion over the course of postoperative day number one. Other than that, the patient remained stable. On postoperative day number two, the patient remained stable. He had been weaned from his Neo-Synephrine infusion on postoperative day number one. His pulmonary artery catheter was changed to a triple lumen catheter and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Postoperative day number three, the patient's chest tubes were discontinued. He was started on Levaquin for gram negative rods in his sputum. His Foley catheter was discontinued and his activity was increased with the assistance of physical therapy staff and the nursing staff. Over the next several days, the patient continued to advance on the postoperative cardiac protocol. His hospital course was uneventful. On postoperative day number eight, the patient finally made it to a level five activity and, at that time, it was decided that he was stable and ready to be discharged to home. At the time of this dictation, the patient's physical examination is as follows: Vital signs revealed temperature 97.9, heart rate 73, sinus rhythm, blood pressure 135/55, respiratory rate 18, oxygen saturation 94 percent in room air. Laboratory data revealed white blood cell count 8.7, hematocrit 28.8, platelet count 246,000. Potassium 4.4, blood urea nitrogen 24, creatinine 1.4, magnesium 2.3. Neurologically, he is alert and oriented times three, moves all extremities, follows commands. Respiratory clear to auscultation bilaterally. Cardiac - regular rate and rhythm, S1 and S2 with no murmurs. The sternum is stable and incision with Steri-Strips, open to air, clean and dry. The abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused. Right saphenous vein graft site with Steri-Strips, open to air, clean and dry. Right groin with Steri-Strips, open to air, clean and dry. Weight preoperatively 89 kilograms and at discharge is 90.4 kilograms. MEDICATIONS ON DISCHARGE: 1. Amiodarone 400 mg p.o. once daily times two weeks and then 200 mg once daily. 2. Atenolol 100 mg once daily. 3. Norvasc 10 mg once daily. 4. Lipitor 20 mg once daily. 5. Plavix 75 mg once daily. 6. Lasix 20 mg once daily times two weeks. 7. Potassium Chloride 20 mEq once daily times two weeks. 8. Lisinopril 10 mg once daily. DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass grafting times two, left internal mammary artery to the left anterior descending coronary artery and saphenous vein graft to the diagonal. Hypertension. Hypercholesterolemia. Status post transient ischemic attacks and bilateral carotid endarterectomy. Peripheral vascular disease. Renal insufficiency. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is to be discharged home with visiting nurses. FOLLOW UP: He is to have follow-up in the [**Hospital 409**] Clinic in two weeks. Follow-up with Dr. [**Last Name (STitle) 56051**] in two to three weeks and follow-up with Dr. [**Last Name (STitle) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2168-8-10**] 18:23:03 T: [**2168-8-10**] 19:06:30 Job#: [**Job Number 56052**]

[ "414.01", "413.9", "593.9", "272.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "36.11", "37.78", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

6533, 6901

6176, 6511

1327, 1781

2858, 6150

7025, 7508

1935, 2840

153, 555

584, 1022

1045, 1301

1798, 1912

6926, 7013

80,308

162,983

35532

Discharge summary

report

Admission Date: [**2124-8-15**] Discharge Date: [**2124-8-20**] Date of Birth: [**2069-10-13**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: cerebellar hemorrhage Major Surgical or Invasive Procedure: [**8-18**]:Posterior fossa hemorrhage, s/p emergent crani History of Present Illness: Patient is a 54M on warfarin therapy who presented to the ED on [**8-15**] with new incranial hemorrhage within the cerebellum. Past Medical History: -Aortic (mechanical) valve replacement 10 years ago -Dilated cardiomyopathy LVEF 30%, -Liver disease with unclear etiology/cirrhosis/hep C. -Right upper extremity aneurysm s/p surgical intervention 10 years ago -? Resection clavicular mass? 2year ago Aortic aneurysm dissecting Social History: Patient visting US from Guatamala. Arrived 3 weeks ago, seeing medical care, plans to stay 6 months in the US. Patient quit smoking 11 yrs ago, previously smoked 1 PPD for 10 years. Social ETOH. Married, with five children. Family History: Father and Uncle with heart disease. Physical Exam: Pt Expired Pertinent Results: Labs On Admission: [**2124-8-15**] 06:55PM BLOOD WBC-3.8* RBC-3.34* Hgb-10.7* Hct-31.2* MCV-93# MCH-32.1* MCHC-34.4 RDW-14.5 Plt Ct-80* [**2124-8-15**] 06:55PM BLOOD PT-23.3* PTT-32.0 INR(PT)-2.2* [**2124-8-15**] 06:55PM BLOOD Glucose-95 UreaN-32* Creat-0.9 Na-137 K-5.0 Cl-105 HCO3-24 AnGap-13 [**2124-8-15**] 06:55PM BLOOD ALT-13 AST-29 AlkPhos-87 TotBili-1.1 [**2124-8-15**] 06:55PM BLOOD Calcium-9.0 Phos-2.9 Mg-2.2 Labs on Discharge: [**2124-8-20**] 01:00AM BLOOD WBC-7.6 RBC-3.04* Hgb-9.4* Hct-27.8* MCV-91 MCH-30.7 MCHC-33.7 RDW-15.4 Plt Ct-118* [**2124-8-19**] 08:21AM BLOOD Neuts-82.2* Lymphs-9.8* Monos-7.2 Eos-0.7 Baso-0.1 [**2124-8-20**] 01:00AM BLOOD PT-14.9* PTT-29.5 INR(PT)-1.3* [**2124-8-20**] 01:00AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-142 K-3.9 Cl-109* HCO3-24 AnGap-13 [**2124-8-19**] 07:30AM BLOOD Fibrino-239 [**2124-8-19**] 08:21AM BLOOD ALT-12 AST-23 LD(LDH)-195 AlkPhos-68 TotBili-1.6* [**2124-8-20**] 01:00AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.7 [**2124-8-19**] 07:06AM BLOOD Glucose-171* Lactate-2.1* Na-127* K-5.2 Cl-97* Imaging: Head CT [**8-19**]: FINDINGS: Study is somewhat limited due to motion. Within this limitation, there is a large acute intracranial hemorrhage in the posterior fossa likely within the cerebellum (2, 10) measuring approximately 3.0 x 4.1 cm. An additional focus of hemorrhage seen in the left cerebellum (2, 7) measures approximately 1.4 x 1.8 cm. There is complete effacement of the fourth ventricle with effacement of the quadrigeminal cisterns bilaterally, concerning for uncal herniation as well as transtentorial herniation. There is no evidence of subfalcine herniation. There is no significant hydrocephalus. The visualized paranasal sinuses are clear. IMPRESSION: Large intraparenchymal cerebellar hemorrhage as described above with effacement of the fourth ventricle and quadrigeminal cisterns consistent with herniation. Head CT [**8-19**] 4am; IMPRESSION: Since the previous CT examination obtained on the same day earlier at 2:13 a.m., there is increase in size of the posterior fossa hemorrhage with fluid-fluid level, increased mass effect and slightly increased ventricular size. Head CT [**8-19**] 8am: IMPRESSION: 1. Enlargement of the lateral ventricles, third ventricle, and temporal [**Doctor Last Name 534**] concerning for obstructive hydrocephalus. 2. Hyperdense blood in the third ventricle, and posterior horns of the lateral ventricles representing new intraventricular hemorrhage. 3. Diffuse blood and pneumocephalus in the posterior fossa with obscuration of the architectural detail of the cerebellum concerning for edema. There is upward transtentorial herniation. Head CT [**8-19**] 9pm: Provisional Findings Impression: JMGw SAT [**2124-8-19**] 9:39 PM 1. Right frontal approach ventriculostomy catheter courses into the third ventricle and the tip is adjacent to the left temporal [**Doctor Last Name 534**] and ventricle. The ventricles have decreased in size compared to prior study. 2. Continued presence of blood in the ventricles, stable. 3. Stable appearance to diffuse blood products in the posterior fossa along with pneumocephalus. 4. Unchanged effacement of the basilar cisterns and quadrigeminal plate consistent with transtentorial herniation. Brief Hospital Course: Patient is a 54M admitted on [**8-15**] for a therapeutic paracentesis.After that he was started on IV heparin and PTT was difficult to control with occasional numbers >150 On [**8-19**], he was noted to have severe headache and CT scan was performed and revealed a sizable cerebellar hemorrhage. Protamine was recommended to be given immediately for stabilization. patient deteriorated and FU CT 2 hrs later showed massive cerebellar hemorrhage with upward herniation. The family was consulted and advised against surgery due to multiple medical issues and poor prognosis of hemorrhage. However they wanted everything possible even if he was going to be on a vegetative state. INR was 1.8 and after 2UFFP was 1.7 He was then taken to the OR emergently for posterior fossa decompression to attempt to abate the progression of herniation. Surgery was difficult due to continuous hemorrhage and factor VII had to be given. however his neurological exam did not improve. Post op when his PTT came back as 1.0 an external drain was placed for hydrocephalus. However he progressesd to pupils fixed, dilated, and absent gag and corneal reflex. On [**8-20**], Family was counseled at the bedside and decided to pursue comfort measures. He was extubated at the bedside with family present, and he subsequently expired on [**8-20**]. Medications on Admission: Carvedilol 6.25'', digoxin 250, lasix 40'', lisinopril 20, HCTZ 25, warfarin 7.5, Potassium chloride 20 Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Subtherapeutic INR in setting of prosthetic aortic valve Cerebellar Hemorrhage. Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2124-8-20**]

[ "V58.61", "780.01", "070.54", "348.8", "V45.89", "427.89", "V43.3", "287.5", "276.8", "331.4", "571.5", "441.00", "425.4", "431", "275.2", "518.81", "275.3" ]

icd9cm

[ [ [] ] ]

[ "02.2", "99.05", "01.39", "96.04" ]

icd9pcs

[ [ [] ] ]

6002, 6011

4485, 5816

342, 402

6134, 6144

1204, 1209

6200, 6334

1120, 1158

5970, 5979

6032, 6113

5842, 5947

6168, 6177

1173, 1185

281, 304

1644, 4462

430, 559

1223, 1625

581, 862

878, 1104

11,466

159,610

19138

Discharge summary

report

Admission Date: [**2107-5-25**] Discharge Date: [**2107-5-28**] Date of Birth: [**2038-12-4**] Sex: F Service: CME HISTORY OF PRESENT ILLNESS: This is a 68-year-old female with a history of CAD status post LAD stenting in [**8-16**] with restenosis and PTCA, admitted for aspirin desensitization prior to catheterization. The patient had a history of chest hives, exacerbated by aspirin and NSAIDs, hence the patient is admitted for aspirin desensitization. ALLERGIES: ASPIRIN, NSAIDS, CODEINE, SHELLFISH. PAST MEDICAL HISTORY: Significant for anxiety. Panic attacks. Diabetic nephropathy. Arthritis. History of diverticulitis. History of nephrolithiasis. Question of emphysema versus asthma. SOCIAL HISTORY: She is a prior smoker, quit 20 years ago. No ETOH. FAMILY HISTORY: Significant for her father who passed at age 54 of CAD related causes. MEDICATIONS: 1. Plavix 75 mg 1 p.o. q.d. 2. Amitriptyline 25 mg 1 p.o. t.i.d. 3. Advair Diskus. 4. Alprazolam 0.5 mg 1 p.o. b.i.d. 5. Colace. 6. Lisinopril 2.5 mg 1 p.o. q.d. 7. Toprol XL 25 mg 1 p.o. q.d. 8. Sublingual nitroglycerin p.r.n. 9. Isosorbide 30 mg 1 p.o. q.d. 10. Lasix 20 mg 1 p.o. q.o.d. PHYSICAL EXAMINATION: Vitals: Temperature 98.2 degrees, heart rate 108, respiratory rate 24, blood pressure 142/99, saturating at 96 percent on room air. Generally, the patient is very pleasant female, in no acute distress, lying in bed with no discomfort. HEENT: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is clear with no lesion. Neck is supple with no lymphadenopathy. No JVD. Heart: Regular rate and rhythm with normal S1, normal S2, and no murmurs. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, and nondistended with no hepatosplenomegaly palpated. Extremities: Free of any clubbing, cyanosis, or edema. Skin is clean, dry, and intact. Neurologic: Cranial nerves II through XII are intact. Strength is [**5-18**] and symmetric throughout. Soft touch is intact. Peripheral pulses are 2 plus throughout; 2 plus carotid pulses are palpated, there are no bruits; 2 plus femoral pulses are palpated, there are no bruits. The patient has intact dorsalis pedis and posterior tibialis pulses bilaterally. LABORATORY DATA: Patient's data on admission includes CK of 110, troponin less than 0.01. LFTs within normal limits and white count 9.8, hematocrit 32.2, platelet count 220, sodium 140, potassium 3.8, chloride 105, bicarbonate 25, BUN 11, creatinine 0.8, and glucose 133. Cardiac catheterization on [**2107-3-1**] reveals apical hypokinesis, prior LAD 90 percent, type A restenosis. PTCA with 10 percent residual TIMI-3 flow, RA pressure 1, RV 51/30, pulmonary capillary wedge pressure of 30, and EF of 29 percent. HOSPITAL COURSE: The [**Hospital 228**] hospital course by system is as follows: Aspirin desensitization. The patient was administered aspirin per allergy protocol in addition to Benadryl and epinephrine as needed. The patient required no Benadryl or epinephrine. She tolerated the aspirin desensitization without complication. For CAD, the patient was continued on Plavix and Lipitor. The patient was maintained on ACE inhibitor for rhythm. The patient was maintained on telemetry with no evidence of ectopy throughout her hospitalization for diabetes. The patient was maintained on fingersticks q.i.d. as well as regular insulin sliding scale. During her 24-hour hospitalization, the patient had no abnormal events on telemetry. Had no cardiac dysrhythmias. Had no chest pain, shortness of breath, or other difficulties. The patient was, for prophylaxis, maintained on bowel regimen and subcutaneous heparin. For psychiatry issues, the patient was maintaining on amitriptyline, and the patient was discontinued from CCU the next day for cardiac catheterization. For remainder of the [**Hospital 228**] hospital course, please refer to dictation by the C-MED Service. [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 15194**] Dictated By:[**Last Name (NamePattern1) 18827**] MEDQUIST36 D: [**2107-8-31**] 13:46:58 T: [**2107-9-1**] 14:07:36 Job#: [**Job Number 52230**]

[ "414.01", "496", "250.60", "272.0", "401.9", "300.01", "V58.83", "357.2", "412" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "88.49", "36.01", "36.07", "99.12" ]

icd9pcs

[ [ [] ] ]

813, 1195

2812, 4283

1218, 2794

165, 532

555, 727

744, 796

75,353

122,227

37727

Discharge summary

report

Admission Date: [**2151-11-16**] Discharge Date: [**2151-11-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1515**] Chief Complaint: Chest pain/STEMI Major Surgical or Invasive Procedure: None. History of Present Illness: 77 year old female who presented to OSH [**Hospital **] Hospital with chest pain. Patient's VS on presentation were BP 139/69, HR 75, RR 33, T 97.8, O2 97% 2 L. EKG demonstrated ST elevation V1-V5. Patient was given ASA, Plavix load, Metoprolol 5 mg X 2 and Heparin bolus. Patient was transferred to [**Hospital1 18**] for possible cath. . In [**Hospital1 18**] ED patient's VS BP 130/80, HR 72, RR 18, 91 RA. Heparin drip was continued, integrillin bolus and 1 L NS given. For pain control patient was started on Nitro drip and Morphine. Patient was given Levofloxacin for questionable infiltrate on CXR. . Patient is poor historian and currently denies chest pain. However, since admission patient has described intermittent left chest "achiness". She describes nausea of 1 day duration. To other members of medical team describes shortness of breath and chest pain over past week. Unable to obtain further history due to orientation to name only. Per nursing home medicine sheet patient was given 3 SL Nitro at 6 am today. Past Medical History: 1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: No scars -PERCUTANEOUS CORONARY INTERVENTIONS: Not according to history -PACING/ICD: Yes. 3. OTHER PAST MEDICAL HISTORY: Altered MS [**First Name (Titles) **] [**Last Name (Titles) 3495**] Disease (no further definition in chart) Diverticulosis Dementia with psychosis Depression Overactive bladder Small hiatal hernia Social History: Patient lives at [**Hospital **] Nursing Care Center. Has legal gaurdian ([**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 72187**]), no family. -Tobacco history: Unknown -ETOH: Unknown Family History: Unable to obtain Physical Exam: T94.6 P72 BP 138/59 R18 PO2 96% GENERAL: Oriented to name only. No acute distress. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP to mandible. CARDIAC: RR, systolic [**3-19**] murmur left upper border. No thrills, lifts. No S3 or S4. LUNGS: Diffuse rhonchi throughout. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: +1 pitting edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2151-11-16**] 11:20AM GLUCOSE-212* UREA N-37* CREAT-1.2* SODIUM-143 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 [**2151-11-16**] 11:20AM WBC-11.5* RBC-4.61 HGB-13.1 HCT-40.5 MCV-88 MCH-28.3 MCHC-32.3 RDW-14.0 [**2151-11-16**] 11:20AM CK(CPK)-156* [**2151-11-16**] 11:20AM cTropnT-0.10* [**2151-11-16**] 11:20AM CK-MB-14* MB INDX-9.0* [**2151-11-16**] 11:20AM NEUTS-86.7* LYMPHS-10.2* MONOS-2.3 EOS-0.6 BASOS-0.2 [**2151-11-16**] 05:26PM CK(CPK)-1387* [**2151-11-16**] 05:26PM CK-MB-147* MB INDX-10.6* cTropnT-0.95* [**2151-11-16**] 10:17PM CK-MB-272* MB INDX-10.9* cTropnT-2.13* [**2151-11-16**] 10:17PM CK(CPK)-2505* TTE [**11-16**] The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the anterior septum and anterior walls and apex. The remaining segments contract normally (LVEF = 40-45%). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. The study is inadequate to exclude significant aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([**2-12**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Prominent symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (mid-LAD distribution). Severe pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. Possible aortic valve stenosis. . . TTE [**11-20**] No atrial septal defect is seen by 2D or color Doppler. LV systolic function appears depressed. There is no ventricular septal defect. with depressed free wall contractility. Significant aortic stenosis is present (not quantified). Trace aortic regurgitation is seen. Mild to moderate ([**2-12**]+) mitral regurgitation is seen. There is no pericardial effusion. . . CXR [**11-16**] Findings suggestive of pulmonary edema. Recommended repeat chest radiograph after appropriate diuresis, to rule out underlying infection. . Pertinent labs on discharge: [**2151-11-23**] WBC-13.7* RBC-4.58 Hgb-13.2 Hct-40.9 MCV-89 MCH-28.8 MCHC-32.3 RDW-14.7 Plt Ct-265 [**2151-11-23**] Glucose-101 UreaN-52* Creat-1.4* Na-142 K-4.9 Cl-102 HCO3-25 AnGap-20 [**2151-11-23**] Calcium-8.3* Phos-2.7 Mg-2.3 Brief Hospital Course: Mrs. [**Known lastname **] is an 87 year old female with a PMH significant for dementia, hyperlipidemia, hypertension, PPM placement transferred from an OSH with medically managed STEMI. Patient's code status was DNR/DNI, which was reversed temporarily to manage the STEMI, and is now changed back to DNR/DNI, confirmed with legal guardian (see below). 1. GOALS OF CARE: PATIENT IS DNR/DNI/DNH WITH HOSPICE REFERAL. After discussion with [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] (legal guardian), decision was made for no further escalation of care and request for hospice referral. Legal guardian can be reached at ([**Telephone/Fax (1) 84522**], fax number [**Telephone/Fax (1) 84523**] (c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 553**] [**Last Name (NamePattern1) **]). . # PUMP: Patient with lower extremity edema and pulmonary rales on exam. Cardiomegaly on chest x-ray. Lasix listed as outpatient medication. Fluid overload in setting of congestive heart failure. TTE showed EF 40-45% with prominent symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (mid-LAD distribution). Severe pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. Possible aortic valve stenosis. Lasix drip re-started, patient diuresed >4L over the hospital stay, nearing dry weight. Lasix drip was d/c'ed prior to discharge; patient discharged on Lasix PO 40mg twice a day. She was continued on Metoprolol on discharge . # RHYTHM: Patient was in sinus on admission and intermittently V-pacing. On [**11-19**], patient went into atrial fibrillation/flutter with HR 80??????s-110??????s with BP 70's-80's. She did not respond to Metoprolol IV boluses, and due to low BPs, Metoprolol was decreased in dose and Digoxin was initiated. However, pt continued to have low BP and was DC cardioverted and loaded on Amiodarone. Digoxin was d/c'ed as pts BPs increased in sinus, and Heparin drip was initiated. However, patient went from sinus rhythm back to a fib/flutter, and it was decided to medically manage the patient with rate control. Heparin was d/c'ed after patient went back into a fib. . # CORONARIES: OSH EKG demonstrates ST elevations in anterior leads. Elevation V1 > 2.5 mm suggests occlusion LAD distal to septal branch resulting in anterior MI. EKG on admission to CCU showed decreasing ST elevations in V1-V3 and q waves in V4-V5, this morning with worsening ST elevations. Patient was initially tachycardic in 90??????s-100??????s with chest pain and significant nausea, which responded to Nitro drip and Morphine. Metoprolol up-titrated for HR control, and patient was initially on Heparin drip for her STEMI. Due to medical co-morbidities, improving EKG with q waves, and hemodynamic stability, STEMI was managed medically. CEs trended down after peaking at CK 272, MB 10.9, Trop 3.66, but had improved but persistent ST elevations on EKG. Focused TTE was obtained, as pt was observed to have an RV lift on exam, which was negative for VSD as possible complication of STEMI. Patient was discharged on Metoprolol, Plavix, Atorvastatin, ASA. . # Renal failure: Acute renal failure, likely [**3-15**] hypoperfusion from STEMI, resolved with stable Cr ~1.0. Patient's blood pressure was running on the lower side, and she also had acute renal failure, so the patient was not put on an ACEinhibitor/[**Last Name (un) **] medication. . # Leukocytosis: Patient with reported diarrhea, new leukocytosis but no fevers. C.difficile negative. . # Dementia/Depression: Continue outpatient Aricept 10 mg qhs, Mitrazapine 15 mg qhs, Seroquel 25 mg [**Hospital1 **]. Patient extremely agitated needing Haldol one night for delerium/dementia with psychosis. Has documented history of dementia with psychosis, ruled out infectious cause of delirium. . # Overactive bladder: Detrol was discontinued as patient did not require it. . # Osteoporosis: Continued home calcium, fosamax. Vitamin D, per nursing home, is dosed monthly, so was not given while hospitalized. Medications on Admission: Metoprolol 25 mg [**Hospital1 **] Calcium Carb 500 mg TID Aricept 10 mg qhs Detrol 4mg qhs Mitrazapine 15 mg qhs Simvastatin 40 mg qd Milk Magnesia 30 ml prn constipation Bisacodyl 10 mg supp prn Docusate 100 mg tab Fleet enema prn Antacid 10 mg [**Hospital1 **] Tylenol 325 mg 2 tabs q4hr prn Nitro SL prn chest pain Fosamax 70 mg tab weekly Vitamin 50,000 units K 1 tab daily Lasix 40 mg daily Seroquel 25 mg [**Hospital1 **] Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Milk of Magnesia 800 mg/5 mL Suspension Sig: One (1) PO as needed as needed for constipation. 10. Bisacodyl 10 mg Suppository Sig: One (1) Rectal as needed as needed for constipation. 11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO as needed as needed for constipation. 12. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal as needed as needed for constipation. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO q4h prn as needed for pain. 14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed: Take 1 pill every 5 minutes for chest pain, up to 3 pills. 15. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 16. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a day. 17. Potassium 99 mg Tablet Sig: One (1) Tablet PO once a day. 18. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day. 19. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): After 5 days, on [**11-27**], Amiodarone dose will need to be decreased from 200mg tid to 200mg daily. Discharge Disposition: Extended Care Facility: [**Location (un) **] Manor - [**Location (un) **] Discharge Diagnosis: ST elevation myocardial infarction Atrial fibrillation/flutter Dementia with psychosis Discharge Condition: Medically stable. Discharge Instructions: After discussion with your legal guardian ([**Name (NI) 553**] [**Name (NI) **]), it was decided that no further escalation of care will be pursued. You were discharged from the hospital with the decision to be DNR/DNI/DNH (do not [**Last Name (LF) **], [**First Name3 (LF) **] not intubate, do not hospitalize). You will return to your nursing home with plans for hospice/palliative care, and will be medically managed for comfort at your nursing home. . You presented to the hospital for chest pain, and were found to have a heart attack. Because of the risks involved with an interventional procedure, your heart attack was managed with medications in the intensive care unit. While in the hospital, you developed an abnormal heart rhythm and had medications and a shock delivered to your heart. These measures put your heart back in a normal rhythm but your heart rhythm became abnormal again prior to your discharge. You were given medications to slow your heart rate down, and it was decided that you would be managed at your nursing home with comfort and palliative care measures. . The following changes were made to your medications: -Metoprolol was increased to 25mg three times daily -Aspirin was added -Plavix was added -Atorvastatin was added -Simvastatin was stopped -Amiodarone was added: After 5 days, on [**11-27**], Amiodarone dose will need to be decreased from 200mg tid to 200mg daily. -Detrol was stopped, as you did not need this medication. -Lasix 40mg twice a day; based upon your volume status (measuring daily fluid balance, daily weights, symptoms, physical exam) this dose can be increased/decreased as your nursing home feels is appropriate . You will follow up with your doctor at the nursing home. Followup Instructions: You will be followed by your doctor at your nursing home. . You should also follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 84524**], your primary care physician. [**Name10 (NameIs) 357**] call his number at [**Telephone/Fax (1) 84525**] to schedule an appointment. . Your lasix dose should be adjusted as necessary by your nursing home, based upon your volume status on physical exam, your daily weights, your daily intakes & outputs, and symptoms. Completed by:[**2151-11-23**]

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icd9cm

[ [ [] ] ]

[ "99.62", "99.20" ]

icd9pcs

[ [ [] ] ]

11674, 11750

5438, 9494

281, 289

11881, 11901

2680, 5162

13685, 14201

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1570, 1769

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17,698

175,476

12949

Discharge summary

report

Admission Date: [**2116-11-12**] Discharge Date: [**2116-11-18**] Date of Birth: [**2056-10-13**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 7934**] Chief Complaint: Rapid heart rate Major Surgical or Invasive Procedure: Cardioversion History of Present Illness: 60yo woman with past medical history significant for ventilator-dependent asthma/COPD with tracheostomy, CAD s/p MI, diabetes, CHF w/ EF 25-30%, h/o multiple pneumonias including pseudomonas and [**Hospital 34241**] transferred from [**Hospital3 672**] for supraventricular tachycardia and found to be septic. She was recently admitted to [**Hospital1 2177**] ([**11-2**]) with respiratory distress, diagnosed with ventilator-associated pneumonia and sepsis with hypotension to 60s/40. While at [**Hospital1 2177**], she was started on vancomycin, gentamycin, and cefepime; urine cultures were neg. Sputum pos for klebsiella ([**First Name9 (NamePattern2) 39751**] [**Last Name (un) **] to amikacin, imipenum, zosyn) and pseudomonas (pseudomonas [**Last Name (un) 36**] resist to cipro, levo, intermdi to gent). She was also treated with pressors which were slowly weaned prior to discharge on [**2116-11-9**]. She was transferred to [**Hospital3 672**] Hospital Rehabilitation Center on an antibiotics course of IV vancomycin, amikacin, and cefepime. She was sent to [**Hospital1 18**] for SVT with HR 130-160 beginning at 1020am. She was given cardizem 20+25mg and adenosine 6+12mg without confersion. She was also noted to have a fever of 103. On arrival to the ED, T104.6, HR 155, BP 140/75, RR 23/ SaO2 98%. She was given tylenol 650mg, hydrocortisone 100mg iv, vancomycin (patient got cefepime and amikacin at rehab earlier in the day). Adenosine 6mg IVP revealed underlying aflutter which reverted back to SVT in the 150s. She was given an additional 20mg IV diltiazem, HR remained in 150s and BP dropped to 90s/50s. She was placed on a diltiazem drip. . On diltiazem drip patient rate remained in 150s, decision was made to cardiovert patient and she returned back to sinus rhythm. Past Medical History: 1. Chronic respiratory failure, vent-dependent, weaned off the ventilator at [**Hospital3 672**] in early [**10-12**] but placed back on the ventilator at an unknown time. - h/o severe asthma and chronic hypercarbia w/ baseline PCO2 in the 70s, on chronic steroids - s/p tracheostomy, last changed in [**7-12**] and associated with trach malposition after that 2. CAD s/p MI 3. CHF, EF 25-30% 4. NIDDM 5. peripheral neuropathy 6. s/p [**Month/Day (1) 282**] 7. CRI, baseline Cr 1.5-2 8. schizoaffective d/o 9. steroid myopathy 10. ?bipolar d/o Social History: Living in the community in [**2115**], hospitalized since. H/o tobacco. Has a caseworker in the community from dept of mental health. Large family. Family History: noncontributory per report Physical Exam: VS: T 104.6, HR 157, BP 139/76, RR 24, SaO2 99% CPAP 5 FiO2 0.5 Tv 400 RR 25 (FiO2 increased from 0.4 and now on CPAP) Gen: Obese african american female who is awake but does not respond to commands. Patient unkept. HEENT: PERRL, uncooperative with eye exam. Patient will not open her mouth. Neck: No JVD appreciated. Patient with left subclavian TLC CV: Tachycardic, unable to tell if has murmur Pulm: Course breath sounds ant/lat b/l Abd: obese, [**Year (4 digits) 282**] tube in place. Foley in place. Ext: + edema L>R with 2+ pitting edema in left, 1+ in right Neuro: Patient awake, otherwise not responsive or follows commands Pertinent Results: [**2116-11-12**] 01:05PM WBC-11.4* RBC-3.79* HGB-11.2* HCT-35.1* MCV-93 MCH-29.5 MCHC-31.9 RDW-16.0* [**2116-11-12**] 01:05PM NEUTS-96.2* LYMPHS-2.7* MONOS-0.9* EOS-0.1 BASOS-0 [**2116-11-12**] 01:05PM PLT COUNT-317 [**2116-11-12**] 01:05PM PT-13.5* PTT-29.8 INR(PT)-1.2 [**2116-11-12**] 01:05PM D-DIMER-[**2065**]* [**2116-11-12**] 01:05PM TSH-0.45 [**2116-11-12**] 01:05PM GLUCOSE-337* UREA N-42* CREAT-1.8* SODIUM-154* POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-31 ANION GAP-17 [**2116-11-12**] 01:18PM LACTATE-2.5* [**2116-11-12**] 01:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2116-11-12**] 01:25PM URINE RBC-[**12-27**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 [**2116-11-12**] 01:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2116-11-13**] 12:00AM ALT(SGPT)-22 AST(SGOT)-18 LD(LDH)-261* CK(CPK)-151* ALK PHOS-62 AMYLASE-80 TOT BILI-0.3 [**2116-11-13**] 12:00AM LIPASE-53 [**2116-11-13**] 12:00AM ALBUMIN-2.7* CALCIUM-9.4 PHOSPHATE-2.9 MAGNESIUM-1.7 Labs on discharge [**2116-11-17**]: [**2116-11-17**] 06:06AM BLOOD WBC-8.5 RBC-3.23* Hgb-9.5* Hct-28.9* MCV-90 MCH-29.3 MCHC-32.7 RDW-15.2 Plt Ct-238 [**2116-11-17**] 06:06AM BLOOD Plt Ct-238 [**2116-11-17**] 06:06AM BLOOD PT-15.6* PTT-74.7* INR(PT)-1.7 [**2116-11-17**] 06:06AM BLOOD Glucose-117* UreaN-48* Creat-1.3* Na-146* K-3.3 Cl-103 HCO3-38* AnGap-8 [**2116-11-17**] 06:06AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0 [**2116-11-13**] 05:48AM BLOOD Free T4-0.9* . Micro: RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. OF THREE COLONIAL MORPHOLOGIES. . L SUBCLAVIAN CATH TIP CULTURE (Final [**2116-11-14**]): DUE TO MIXED BACTERIAL TYPES ( >= 3 COLONY TYPES) . URINE CULTURE (Final [**2116-11-14**]): NO GROWTH. Brief Hospital Course: . ## Asthma/ventilation dependence - Patient after cardioversion required to be on assist control vantilation. A chest xray showed patchy opacities R>L and sputum culture was sent which was consistent with Pseudomonas. patient was continued on Amikacin and Cefepime which she was already on before she was brought to [**Hospital1 18**]. A total 14 day course of cefepime will be complete on [**11-21**] and amikacin was extended for 7 more days and should be complete on [**11-21**]. Patient was conitnued on vancomycin for MRSA PNA that she was already being treated for. Her course of vancomycin was finished on [**2116-11-16**]. She quickly improved on the ventilator with good O2Sat and was switched to pressure support of [**11-11**] and [**6-11**] and then tried on trach mask which she tolerated well. Patient was evaluated for possible PM valve but it was noticed that she has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] air cuff and the pilot to the air cuff has been removed. Not quite clear why pilot to air cuff removed or if it was torn off. Patient has been doing fine with current tracheostomy so deferred any intervention of changing tracheostomy to facility who placed the trach to evaluate. Please make sure patient trach changed if need be. . ## Cardiac: 1) Tachycardia - Patient cardioverted and quickly returned to sinus rhythm with good rate and remained in sinus rhythm. Patient was started on low dose Bblocker which was not able to be titrated up given low HR and low BP. Could try to titrate up BBlocker if HR and BP tolerate. She was started on anticoagulation s/p cardioversion. She will need to be anticoagulated for total 3 weeks. On discharge patient on heparin gtt until INR theraputic at 2-3. would check daily INR and titrate coumadin until INR stable and therputic. Can stop coumadin after 3 weeks. 2) CHF - Patient with reported EF of 30%. Repeat CXR shows persistant R sided pulmonary opacity/effusion. Restarted patient on lasix 40mg IV bid. Can titrate up lasix up or down as tolerated and would keep patient even to slightly negative. can decrease lasix if blood pressure low. If patient blood pressure stable she should be started on ACEI as tolerated outpatient given her chronic renal insufficiency and diabetes. . ## Fever - Patient intially febrile when admitted. Her fever curve improved while in hospital and WBC returned to [**Location 213**]. CXR shows b/l patchy infilitrate R>L which could represent aspiration PNA. Patient treated for klebsiella,MRSA/Pseudomonas PNA. Sputum cx here shows Pseudomonas. Patient had left IJ placed and left subclavian removed (tip grew back > 3 colonies of bacteria), which could have been source of fever. Patient should complete antibiotic course as stated above. . ## Hypotension - Patient blood pressure running 90-100. On admission patient given hydrocortisone 100mg q8 as was on prednisone outpatient. Tapered down to 75mg q8, and then switched to prednisone 40mg daily. Would continue to 2 week prednisone taper to off or low dose if patient needs chronic steroids for COPD. . ## Diabetes - Patient on 80am and 20pm NPH and RISS on admission. Given patient gets continuous tube feeds changed NPH to 60units am/pm and RISS. Can titrate NPH up and down as needed. . ## Hypernatremia - Patient intially hypernatremic with Na 154. She was given free water via IV and [**Location 282**] tube and switched to just free water via [**Location 282**] tube as her Na corrected. Would continue to monitor Na and adjust free water flushed via [**Location 282**] as needed. . ## Hypothyroidsim - Patient found to have and borderline low TSH and low freeT4 so was started on levothyroxine 50mcg. Patient should have her thyroid function tests rechecked in 3 months. . ## Chronic renal insufficiency - Most likely diabetic nephropathy. Patient at baseline 1.5-2. Cre currently stable at 1.2 . ## Psych - Continued clozapine and valproic acid, and lexapro at current dose. Valproic acid level 24 and clozaril level sent out. Appreciate psych assistance. . ## [**Location 282**] tube - Patient [**Location 282**] tube was noticed to be leaking. GI was contact[**Name (NI) **] and [**Name2 (NI) 282**] tube fixed. . ## Access - Patient left subclavian line was removed and noticed to have puss. A new left IJ was placed. Once patient off heparin gtt and IV antibiotics would consider removing central line. Medications on Admission: lasix 80mg [**Hospital1 **] lovenox 150mg sc qd x 10d beginning [**11-11**] vancomycin 1000mg iv q48h, doses due [**11-12**], [**11-14**], [**11-16**] amikacin 500mg iv q24h last dose 10/9 cefepime 2gm iv q12h 40mg qd (started [**11-7**], last dose 10/15) lactulose 30gm [**Hospital1 **] thiamine 100mg qd montelukast 10mg qpm atovaquone 1500mg q24h FeSo4 300mg tid clozapine 100mg qhs valproic acid 750mg qam and 500mg qhs simethicone 80mg [**Hospital1 **] simvastatin 20mg qhs MVI 15ml qd ASA 81mg qd oscal +D qd glucerna at 55cc/hr SSI NPH 80units at 6a, 20units at 6p lexapro 20mg qam protonix 40mg qd colace 100mg [**Hospital1 **] Prednisone 40mg daily Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 3. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO Q 24H (Every 24 Hours). 4. Clozapine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO QAM (once a day (in the morning)). 6. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO HS (at bedtime). 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day) as needed. 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 13. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO TID (3 times a day). 14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 16. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please give at least 30 minutes separate from iron supplement. 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Amikacin 250 mg/mL Solution Sig: Four Hundred (400) mg Injection Q24H (every 24 hours) for 3 days. 22. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 23. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): Please continue until INR theraputic . 24. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 25. Cefepime 2 g Piggyback Sig: One (1) Intravenous every twelve (12) hours for 3 days. 26. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty (60) units Subcutaneous twice a day: Please titrate as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary Diagnosis: Atrial Flutter s/p cardioversion Pseudomonas Pneumonia Hypernatremia Central Line infection Secondary Diagnosis: Diabetes Mellitus Schizoaffective disorder/Bipolar disorder Asthma COPD Chronic renal insufficency CHF Discharge Condition: Stable - Patient still on ventilator however appears to tolerate trach mask and should be on trach mask if tolerates. Patient currently being treated for Pseudomonas PNA with Amikacin and cefepime. Discharge Instructions: Please continue to take medications as directed. While you were in the hospital you were treated for a fast heart rhythm. You were started on a medication called metoprolol which you should continue. You were also started on blood thinning medication which you should continue for total 3 weeks. You were also found to have a pneumonia which you are on antibiotics for and should continue. You were also found to have hypothyroidism and should continue to take thyroid medications (levothyroxine) as directed. Y Followup Instructions: Please follow up with your primary care doctors to [**Name5 (PTitle) **] over your medications. You will need to have your thyroid function tests rechecked in 3 months. You should also stay on anti-coagulation medication for 3 weeks and have blood levels checked to make sure on appropriate dose of coumadin. Please follow up with your psychiatrist to go over your psychiatry medications and make sure they are appropriate.

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icd9cm

[ [ [] ] ]

[ "96.72", "99.62", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

13050, 13105

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315, 331

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2735, 2884

53,596

122,638

1296

Discharge summary

report

Admission Date: [**2162-1-13**] Discharge Date: [**2162-1-15**] Date of Birth: [**2086-7-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalothin / Trazodone / Avelox / piperacillin-tazobactam Attending:[**First Name3 (LF) 3991**] Chief Complaint: Fever, Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 75 year old male with hx of large B cell lymphoma c/b mets to spinal cord and paraplegia, as well as neurogenic bladder with indwelling catheter and multiple hospital admissions for recurrent UTIs who presented with fever and hypotension. Patient reports that about three days ago, he experienced temperature to 101, 'tremors' (possibly chills), and noted that the output from his foley was 'orange' and more cloudy than normal. His 24 hour aide also noted some hematuria which eventually resolved. He has a history of chronic abdominal distension which he feels is diffusely worse currently because he needs to stool, but denied any abdominal pain around the time of his symptoms. Denies nausea/vomiting, chest pain, shortness of breath, cough productive of sputum, constipation or diarrhea (last BM was yesterday), or new rashes. Denies any suprapubic pain. Denies sick contacts. [**Name (NI) **] new medications or antibiotics recently. Patient is followed for his neurogenic bladder by Dr. [**Last Name (STitle) **]; Foley last changed one month ago in urology clinic on [**2161-12-9**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7986**] NP. . In the ED VS were 98.4 66 81/48 18 97% RA. Patient received 4 L NS and 1 L LR in the ED. BP initially 81/40 -> SBPs 110s with fluids, and did have a few dips in his BPs down to 80s which once again responded to IVFs. Labs significant for a UA with [**11-28**] white, bacteria, leuks, nitrites; sodium 132, HCT 31.6, WBC 10.3. INR 2.8. CT Abd/Pelvis negative for any process. Patient also received Received 400 mg IV ciprofloxacin x1 for UTI and flagyl 500 mg IV x1 for abdominal distension. Blood and urine cultures pending. VS prior to transfer were HR 65 116/68 14, 97% on RA. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Large B cell lymphoma with metastasis to spinal cord with resultant paraplegia - [**10-14**] (followed per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 328**]) 2. Prior L4 compression fracture s/p posterior fusion 3. Hypertension 4. History of C.diff 5. Large basal cell carcinoma of L upper eyelid s/p Mohs excision 6. h/o DVT, PE after surgery in [**10-14**] 7. Spinal myoclonus and tremor 8. Anxiety/Depression 9. Chronic Nephrolithiasis 10. Dyslipidemia 11. h/o UTIs 12. L retina surgery [**63**]. Osteoporosis Social History: Was an artist and continues to be involved with MFA. Denies history or current use of tobacco, also denies ETOH and IVDU. Lives in [**Hospital3 **] with aides. Wheelchair-bound. Family History: per prior DCS "Father had a tremor and he believes his paternal GF also had a tremor. No lymphoma. No PD." Physical Exam: Vitals: 99.5 117/60 67 18 99% on RA General: elderly male, Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, NTTP, distended, bowel sounds present, no rebound tenderness or guarding GU: foley draining slighly cloudy fluid Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs [**2162-1-13**] 03:20AM BLOOD WBC-10.3# RBC-4.65# Hgb-10.3*# Hct-31.6*# MCV-68* MCH-22.1* MCHC-32.5 RDW-23.2* Plt Ct-268 [**2162-1-13**] 03:20AM BLOOD Neuts-63.1 Lymphs-25.5 Monos-7.3 Eos-3.3 Baso-0.9 [**2162-1-13**] 03:20AM BLOOD PT-28.6* PTT-35.6* INR(PT)-2.8* [**2162-1-13**] 03:20AM BLOOD Glucose-102* UreaN-17 Creat-1.1 Na-132* K-3.9 Cl-95* HCO3-27 AnGap-14 [**2162-1-13**] 03:20AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.9 [**2162-1-13**] 03:36AM BLOOD Lactate-1.4 . Microbiology [**2162-1-13**] 03:40AM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD [**2162-1-13**] 03:40AM URINE RBC-0 WBC-0-2 Bacteri-MANY Yeast-NONE Epi-0 [**2162-1-13**] 07:43AM URINE Blood-MOD Nitrite-POS Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [**2162-1-13**] 07:43AM URINE RBC-[**3-13**]* WBC-[**11-28**]* Bacteri-MANY Yeast-NONE Epi-0 Blood cultures ([**2162-1-13**]) x 2 pending Urine culutres ([**2162-1-13**]) pending . CT abdomen/pelvis ([**2162-1-13**]): 1. No acute abdominal or pelvic process including no evidence of appendicitis. 2. Hypoattenuating left renal lesions, increased in size compared to prior studies. Renal ultrasound is recommended for further work-up. Brief Hospital Course: The patient is a 75 yo male with B-cell lymphoma complicated by spinal cord metastases resulting in paraplegia and neurogenic bladder and frequent UTIs who presents with one day history of fever and chills with hypotension in ED consistent with urosepsis. # Hypotension: Patient with fever, hypotension to SBP of 80s in the ED, and positive urine analysis concerning for severe urosepsis. Hypotension responded to aggressive early fluid resuscitation in the ED. Did not require pressors or central line placement. Patient has had past UTIs including Proteus mirabilis (sensitive to CFTX) and Serratia (sensitive to Zosyn, Ciprofloxacin and third generation cephalosporins.), and most recent hospitalization on [**2161-12-13**] for UTI due to Klebsiella (pan-sensitive, intermediate to nitrofurantion) and Pseudomonas (sensitive to meropenemen, gentamycin, and tobramycin). No other localizing symptoms concerning for pneumonia and CT abdomen/pelvis negative for intra-abdominal pathology. No symptoms concerning for cardiogenic shock. Neurogenic shock considered given patient with history of paraplegia, but unlikely given his immediate responsiveness to fluids. Continued on IV Ciprofloxacin (likely will need 10 day course for complicated UTI/urosepsis). Urology was consulted to replace the foley. The patient quickly stabilized in the ICU and was transferred to the floor. On the floor, he was switched to PO ciprofloxacin. He was discharged for a total 10 day course. A culture was contaminated and was not repeated as he was clinically improving. . # Renal hypodensities -- A renal ultrasound demonstrated a simple cyst, however a lower hypodensity could not be visualized. Review of previous CTs also showed stability of this finding. This could be pursued as an outpatient by MRI if clinically warranted. # Sacral Decubitus Ulcer -- wound care. . # Hyponatremia - hypovolemic hyponatremia, improved with IVF. . # Conjunctivitis - the patient was prescribed erythromycin ointment. . # Anemia - Patient with history of iron deficiency anemia. Started on iron supplementation during last admission, Hct up to 31.6 from 22, indicating response to iron supplementation. . # Hypertension - hold all outpatient blood pressure medications in the setting of hypotension (propanolol and lasix). These were restarted on discharge. . # H/o DVT/PE after surgery in '[**57**]: Currently therapeutic on coumadin. Continued on coumadin ([**1-10**] home dose tonight). Monitor INR closely given antibiotic treatment (goal INR [**2-11**]). His coumadin dose was halved to 3mg due to interaction between warfarin and coumadin. . # Anxiety and depression - continued Celexa and Seroquel . # s/p paraplegia - continued baclofen, neurontin (both with hold parameters) and fludrocortisone. . #. GERD - continued omeprazole . #. Tremor - followed by neurology at [**Hospital1 18**]. continued primidone, sinemet. Patient was also found to be MRSA positive by nasal swab on this admission. Medications on Admission: Alendronate 70 mg PO qweekly (Sunday) Propanolol 20 mg PO TID Lasix 20 mg PO BID Citalopram 20 mg PO DAILY Warfarin 6 mg PO Daily at 4 PM Quetiapine 12.5 mg Tablet PO QHS Fludrocortisone 0.1 mg PO DAILY Omeprazole 20 mg PO DAILY (ER) Baclofen 20 mg PO TID Primidone 100 mg PO HS Docusate sodium 100 mg PO BID Gabapentin 600 mg Capsule PO TID Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Bisacodyl 10 mg One Suppository Rectal DAILY (Daily) as needed for constipation. Ferrous sulfate 300 mg (60 mg Iron) PO DAILY (Daily). Camphor-menthol 0.5-0.5 % Lotion Topical QID:PRN rash Sinemet 25-100 mg PO TID Align 4 mg PO daily Vitamin D 50,000 U PO qweekly Tylenol Calcium Carbonate-Vitamin D3 daily Cranberry OTC Lactobacilluis CRANBERRY - (OTC) - Dosage uncertain LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] 2 capsules TID per VNA med list and Dr. [**Last Name (STitle) **] - Dosage uncertain Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day: Adjust this dose as instructed by the coumadin clinic. 3. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 4. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. primidone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. primidone 50 mg Tablet Sig: Two (2) Tablet PO at bedtime. 9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 14. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 15. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) application Ophthalmic [**Hospital1 **] (2 times a day) as needed for redness, crusty drainage for 5 days. Disp:*qs application* Refills:*0* 16. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days. Disp:*16 Tablet(s)* Refills:*0* 17. cranberry extract Oral 18. lactobacillus acidophilus Oral 19. Align 4 mg Capsule Sig: One (1) Capsule PO once a day. 20. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 21. propranolol 20 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: Urinary tract infection, urosepsis 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 8004**], You were admitted to the hospital because your blood pressure was low and you were found to have a urinary tract infection. Your symptoms improved with IV fluids and antibiotics. You were started on an antibiotic, ciprofloxacin while admitted. You should continue to take this for another 8 days. You were also given a prescription for erythromycin ointment for your eye if it is still bothering you. Your coumadin dose was decreased to 3mg due to an interaction with the antibiotics. You should follow-up closely with your coumadin clinic concerning your dose. Followup Instructions: You have the following appointments scheduled: Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2162-1-20**] at 1:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2162-2-2**] at 12:00 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2162-3-25**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: MONDAY [**2162-5-31**] at 2:15 PM With: [**Name6 (MD) 6821**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**] DO 12-BJM Completed by:[**2162-1-17**]

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15931

Discharge summary

report

Admission Date: [**2131-11-5**] Discharge Date: [**2131-11-30**] Date of Birth: [**2054-1-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 287**] Chief Complaint: COPD flair, hypercarbic respiratory failure Major Surgical or Invasive Procedure: Intubated (3x), central line (2x), arterial line (2x) History of Present Illness: 77 year old woman with a history of COPD (FEV1 0.4/FVC 1.2 in [**2131-9-13**]), on chronic home O2 at 3L, nocturnal BiPAP at night for hypercarbia, who was directly admitted to MICU from the clinic by Dr. [**First Name (STitle) **] for management of COPD with mental status changes and ABG of 7.29/96/101. . Ms. [**Known lastname **] has been in her usual state of health until several months ago when whe started to complain of HAs which were attributed to her hypercarbia. Her nocturnal BiPAP settings were changed from [**10-17**] to 13/5, however, the patient did not do well on these new settings and developed abdominal distension that made her dyspnea worse. In the last few weeks she completed two courses of Levaquin and Prednisone for COPD exacerbation. She did have cough productive of yellow sputum and increased shortness of breath. She completed last course of prednisone taper last Firday, 4 days prior to this admission. Prior to her current admission, she has had increased confusion and was noted to be more lethargic and somnolent at home. The patient was seen in the ED complaining of subacute progressive episodes of confusion and forgetrullness, on [**2131-11-2**], where her ABG was 7.36/77/63. HCO3 39. Head CT was done and was negative for intracranial hemorrhage but did show suprasellar mass. She then was discharged home. Over the weekend, she reports that she did not feel well. On [**11-5**], the day of admission, she saw her pulmonologist, and an ABG showed 7.29/96/101. Following these labs, she was admitted to the MICU. . She denies fevers, chills, nightsweats. She does complain of nausea, no vomiting, and diminished appetite while on prednisone. She denies urinary urgency, frequency or incontinence. No chest pain. Past Medical History: 1. COPD. PFTs on [**2131-9-28**] showed FEV1 0.4, FVC 1.2. On O2 chronically, 4L when active, 2L at rest. One prior intubation at time of diagnosis in [**2118**]. Followed by Dr [**First Name (STitle) **] 2. Hypertension 3. Hypercholesterolemia 4. Lung mass (lingula), enlarging, on Chest CT, presumed neoplasm, 10 mm in [**2130**]. 5. Sellar mass ?????? noted on head CT [**10-17**], thought to be benign pituitary adenoma, prolactin nl, TSH slightly elevated at 4.9 6. Anxiety/depression 7. Impaired glucose tolerance ?????? 2hr glucose of 197, hgba1c of 6.2 [**10-17**]. No polyuria, polydipsia, visual changes 8. Bilateral cataract surgery Social History: ~70pack years. No EtOH. Lives in [**Location **] ([**Location (un) **]) with 2 sons, 3 other children live nearby. Husband died a couple of decades ago. Not formerly employed. Family History: Father died at 80 of lung cancer (smoker). Mother at 79 from ??????diabetes??????. Four sisters in good health, one died from ??????alcohol??????. Five children. One son with [**Name2 (NI) 499**] cancer at age 50. Physical Exam: Vitals 98.6 117/52 122 25 92% on 3L NC Gen: Elderly woman lying in bed, no apparent distress, able to speak in full sentences HEENT: NCAT, mucous membranes dry, oropharynx clear, EOMI. +dentures. Surgical pupils. Neck: Supple, no bruits, no masses, no LAD. JVD non-elevated. CV: nl S1, S2. No murmurs, rubs, gallops. Pulm: Soft crackles bilaterally, decreased air movement, no wheezes Back: No CVA tenderness, no spinal tenderness Abd: NABS, soft, NT, ND, no organomegaly Ext: Warm, well-perfused. No clubbing, cyanosis, or edema. DP 1+ bilaterally Skin: No exanthems Neuro: Alert and oriented x 3. Confused at times, but answers questions appropriately. CNII-XII intact. Motor: good tone, [**5-17**] strength in upper and lower extremities; Sensation: intact to light touch and vibration sense in upper and lower extremities bilaterally. Reflexes: 1+ in UE and LE Bilaterally. Pertinent Results: [**2131-11-5**] 08:37PM BLOOD WBC-10.3 RBC-4.19* Hgb-13.2 Hct-41.5 MCV-99* MCH-31.5 MCHC-31.8 RDW-13.3 Plt Ct-254 [**2131-11-6**] 04:39AM BLOOD WBC-12.8* RBC-4.12* Hgb-12.8 Hct-39.5 MCV-96 MCH-31.0 MCHC-32.4 RDW-13.4 Plt Ct-323 [**2131-11-9**] 02:58AM BLOOD WBC-19.1* RBC-3.95* Hgb-12.4 Hct-37.4 MCV-95 MCH-31.5 MCHC-33.3 RDW-13.6 Plt Ct-271 [**2131-11-11**] 04:26AM BLOOD WBC-18.6* RBC-3.87* Hgb-11.7* Hct-37.9 MCV-98 MCH-30.2 MCHC-30.8* RDW-13.4 Plt Ct-83*# [**2131-11-12**] 04:01AM BLOOD WBC-47.6*# RBC-3.49* Hgb-11.0* Hct-33.2* MCV-95 MCH-31.5 MCHC-33.1 RDW-13.6 Plt Ct-164 [**2131-11-13**] 04:09AM BLOOD WBC-33.5* RBC-3.51* Hgb-11.0* Hct-34.4* MCV-98 MCH-31.2 MCHC-31.9 RDW-13.2 Plt Ct-157 [**2131-11-14**] 04:40AM BLOOD WBC-19.9* RBC-3.29* Hgb-10.4* Hct-32.0* MCV-97 MCH-31.5 MCHC-32.4 RDW-13.3 Plt Ct-150 [**2131-11-16**] 03:08AM BLOOD WBC-18.1* RBC-3.42* Hgb-10.7* Hct-32.1* MCV-94 MCH-31.2 MCHC-33.3 RDW-13.3 Plt Ct-140* [**2131-11-18**] 03:29AM BLOOD WBC-17.4* RBC-3.30* Hgb-10.1* Hct-31.9* MCV-97 MCH-30.7 MCHC-31.7 RDW-13.1 Plt Ct-138* [**2131-11-20**] 03:40AM BLOOD WBC-15.0* RBC-3.28* Hgb-10.5* Hct-31.1* MCV-95 MCH-31.9 MCHC-33.7 RDW-13.5 Plt Ct-151 [**2131-11-21**] 04:10AM BLOOD WBC-19.1* RBC-3.41* Hgb-10.9* Hct-32.7* MCV-96 MCH-32.1* MCHC-33.4 RDW-13.5 Plt Ct-152 [**2131-11-5**] 08:37PM BLOOD Neuts-76* Bands-2 Lymphs-10* Monos-5 Eos-5* Baso-0 Atyps-2* Metas-0 Myelos-0 [**2131-11-10**] 03:02AM BLOOD Neuts-93.7* Bands-0 Lymphs-2.6* Monos-3.4 Eos-0.1 Baso-0.1 [**2131-11-11**] 04:26AM BLOOD Neuts-95.7* Bands-0 Lymphs-1.7* Monos-2.2 Eos-0.3 Baso-0.1 [**2131-11-13**] 04:09AM BLOOD Neuts-98.3* Bands-0 Lymphs-0.8* Monos-0.8* Eos-0.1 Baso-0 [**2131-11-15**] 04:16AM BLOOD Neuts-96* Bands-2 Lymphs-1* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2131-11-21**] 04:10AM BLOOD Neuts-97.0* Bands-0 Lymphs-1.8* Monos-0.8* Eos-0.4 Baso-0.1 [**2131-11-5**] 08:37PM BLOOD PT-12.6 PTT-30.6 INR(PT)-1.1 [**2131-11-6**] 01:41AM BLOOD PT-12.6 PTT-31.7 INR(PT)-1.1 [**2131-11-8**] 03:53AM BLOOD PT-11.9 PTT-35.9* INR(PT)-0.9 [**2131-11-14**] 04:40AM BLOOD PT-11.6 PTT-30.6 INR(PT)-0.9 [**2131-11-5**] 08:37PM BLOOD Glucose-159* UreaN-9 Creat-0.5 Na-141 K-4.2 Cl-93* HCO3-45* AnGap-7* [**2131-11-6**] 01:41AM BLOOD Glucose-223* UreaN-9 Creat-0.6 Na-144 K-4.5 Cl-101 HCO3-37* AnGap-11 [**2131-11-8**] 03:53AM BLOOD Glucose-124* UreaN-11 Creat-0.4 Na-143 K-4.4 Cl-103 HCO3-35* AnGap-9 [**2131-11-11**] 08:45AM BLOOD Glucose-175* UreaN-13 Creat-0.5 Na-142 K-4.1 Cl-97 HCO3-41* AnGap-8 [**2131-11-13**] 04:09AM BLOOD Glucose-190* UreaN-12 Creat-0.3* Na-140 K-4.2 Cl-98 HCO3-39* AnGap-7* [**2131-11-16**] 03:08AM BLOOD Glucose-88 UreaN-16 Creat-0.4 Na-142 K-3.6 Cl-95* HCO3-42* AnGap-9 [**2131-11-19**] 03:32AM BLOOD Glucose-178* UreaN-15 Creat-0.3* Na-139 K-4.3 Cl-93* HCO3-43* AnGap-7* [**2131-11-21**] 04:10AM BLOOD Glucose-145* UreaN-14 Creat-0.3* Na-137 K-4.4 Cl-93* HCO3-39* AnGap-9 [**2131-11-5**] 08:37PM BLOOD ALT-11 AST-17 AlkPhos-89 [**2131-11-6**] 01:41AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2131-11-5**] 08:37PM BLOOD Albumin-4.1 Calcium-9.8 Phos-3.4 Mg-2.1 [**2131-11-6**] 04:39AM BLOOD Calcium-9.1 Phos-1.6*# Mg-1.9 [**2131-11-8**] 03:53AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.1 [**2131-11-11**] 08:45AM BLOOD Calcium-9.0 Phos-1.6*# Mg-1.9 [**2131-11-13**] 04:09AM BLOOD Calcium-9.0 Phos-2.1* Mg-2.0 [**2131-11-15**] 04:16AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0 [**2131-11-17**] 02:48AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0 [**2131-11-19**] 03:32AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.2 [**2131-11-21**] 04:10AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.2 [**2131-11-5**] 08:37PM BLOOD TSH-2.3 [**2131-11-7**] 03:37AM BLOOD Free T4-0.8* [**2131-11-7**] 02:38PM BLOOD Cortsol-40.4* [**2131-11-7**] 01:59PM BLOOD Cortsol-32.5* [**2131-11-5**] 04:13PM BLOOD Type-ART pO2-101 pCO2-96* pH-7.29* calHCO3-48* Base XS-15 [**2131-11-6**] 01:07AM BLOOD Type-ART Temp-37.1 pO2-353* pCO2-151* pH-7.14* calHCO3-54* Base XS-15 Intubat-NOT INTUBA Comment-BIPAP [**2131-11-6**] 04:55AM BLOOD Type-ART Temp-36.7 pO2-201* pCO2-50* pH-7.46* calHCO3-37* Base XS-10 [**2131-11-6**] 12:41PM BLOOD Type-ART Temp-37.1 Rates-14/0 Tidal V-550 PEEP-5 FiO2-40 pO2-146* pCO2-55* pH-7.44 calHCO3-39* Base XS-11 [**2131-11-7**] 04:13AM BLOOD Type-ART Temp-36.0 pO2-152* pCO2-56* pH-7.38 calHCO3-34* Base XS-6 [**2131-11-7**] 11:55AM BLOOD Type-ART pO2-92 pCO2-76* pH-7.24* calHCO3-34* Base XS-1 [**2131-11-7**] 03:58PM BLOOD Type-ART Temp-36.1 Rates-/20 Tidal V-400 PEEP-5 FiO2-35 pO2-84* pCO2-74* pH-7.29* calHCO3-37* Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU [**2131-11-7**] 09:21PM BLOOD Type-ART Temp-36.9 Rates-/20 Tidal V-400 PEEP-5 FiO2-30 pO2-72* pCO2-75* pH-7.31* calHCO3-40* Base XS-7 Intubat-INTUBATED Vent-SPONTANEOU [**2131-11-8**] 04:03AM BLOOD Type-ART Temp-35.7 Rates-/20 Tidal V-400 PEEP-5 FiO2-30 pO2-68* pCO2-84* pH-7.30* calHCO3-43* Base XS-11 Intubat-INTUBATED [**2131-11-8**] 03:14PM BLOOD Type-ART pO2-87 pCO2-68* pH-7.35 calHCO3-39* Base XS-8 [**2131-11-8**] 03:46PM BLOOD Type-ART pO2-60* pCO2-60* pH-7.41 calHCO3-39* Base XS-10 Intubat-NOT INTUBA [**2131-11-8**] 05:28PM BLOOD Type-ART pO2-89 pCO2-63* pH-7.43 calHCO3-43* Base XS-13 [**2131-11-9**] 02:05AM BLOOD Type-ART pO2-133* pCO2-66* pH-7.39 calHCO3-41* Base XS-12 -ASSIST/CON Intubat-INTUBATED [**2131-11-10**] 01:07AM BLOOD Type-ART Temp-36.4 Rates-/12 Tidal V-500 PEEP-5 FiO2-36 pO2-93 pCO2-67* pH-7.38 calHCO3-41* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU [**2131-11-11**] 08:32AM BLOOD Type-ART Rates-20/ Tidal V-400 PEEP-5 FiO2-35 pO2-38* pCO2-75* pH-7.37 calHCO3-45* Base XS-13 -ASSIST/CON Intubat-INTUBATED [**2131-11-15**] 05:03AM BLOOD Type-ART pO2-108* pCO2-65* pH-7.40 calHCO3-42* Base XS-12 [**2131-11-17**] 03:12AM BLOOD Type-[**Last Name (un) **] Temp-38.3 Tidal V-400 PEEP-5 FiO2-35 pO2-49* pCO2-77* pH-7.38 calHCO3-47* Base XS-15 Intubat-INTUBATED Vent-SPONTANEOU [**2131-11-19**] 06:37AM BLOOD Type-ART Temp-36.9 Rates-/14 PEEP-5 FiO2-35 pO2-100 pCO2-73* pH-7.42 calHCO3-49* Base XS-19 Intubat-INTUBATED [**2131-11-21**] 06:35AM BLOOD Type-ART Temp-36.6 Rates-/8 PEEP-5 FiO2-35 pO2-90 pCO2-67* pH-7.42 calHCO3-45* Base XS-14 Intubat-INTUBATED [**2131-11-6**] 04:55AM BLOOD Lactate-2.2* [**2131-11-17**] 04:28PM BLOOD Lactate-1.8 . CT Head ([**2131-11-11**]) Stable appearance of the brain parenchyma since the prior examination including unchanged appearance of large round sellar mass. No intracranial hemorrhage noted. . CT-Chest ([**2131-11-20**]) An enlarging mass in the lingula, suspicious for cancer. Multiple stable noncalcified pulmonary nodules. New 1.4-cm nodule at the left lung base. Attention to this on the followup CT is recommended. Severe diffuse emphysema. Diffuse esophageal wall thickening with air along the esophageal wall extending from the inlet to the carina, likely esophagitis. . CT-Chest/Abd/Pelvis ([**2132-11-27**]) 3.5 x 3.3 cm region of inflammatory fat stranding in the midline abdomen, just medial to the G-tube insertion site, most consistent with a phlegmon. No focal fluid collections are identified. This region of inflammation extends from the subcutaneous tissues into the peritoneum. This is most likely related to the recent G-tube manipulation. Unchanged left lingula mass. Unchanged mediastinal lymph nodes. Interval resolution of the left lung base nodule, which likely was infectious in etiology on the prior scan. The esophageal wall thickening, unchanged. Emphysematous changes throughout the lungs, unchanged. . CXR ([**2131-11-5**]) AP chest compared to [**9-28**] and [**11-2**], [**2127**]. Hyperinflation indicates COPD. Aside from the left lung nodule, lungs are clear of any focal abnormality. Heart is normal size. There is no pneumothorax or pleural effusion. Thoracic aorta is tortuous and calcified, but not focally dilated. Heart size normal. . CXR ([**11-19**]) 1. Left mid lung zone nodular opacity, which has grown compared to older chest radiographs and is highly concerning for primary lung malignancy. 2. Emphysema. 3. Minor bibasilar atelectatic changes. . EKG [**2131-11-5**]: sinus tachycardia, no ischemic changes, occasional PVCs. . Echo ([**2131-11-13**]):The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The 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 mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. . Cytology ([**2131-11-22**]): BAL washings positive for squamous cell carcinoma. . Micro: . Blood cultures: ([**2131-11-11**]) - MRSA; ([**Date range (3) 45680**]) NGTD . Sputum cultures: ([**2131-11-22**], [**2131-11-26**], [**2131-11-29**]) - MRSA . Urine cultures: ([**2131-11-23**], [**2131-11-26**]) - NG . Stool cultures: ([**2131-11-28**]) - C. diff neg . Tissue (esophagus) culture ([**2131-11-21**]) - [**Female First Name (un) **] Brief Hospital Course: Hospital course by problem: . 1. Respiratory failure. Mrs [**Known lastname **] was admitted with hypercarbia and mental status changes. At baseline, she has severe COPD with an FEV1 of 0.4L, and was on nocturnal bipap with settings of [**12-17**] prior to admission without resolution of symptoms, and with ABG of 7.29/96/101/48. On admission to the MICU, she was placed on bipap and started on a methylprednisolone taper and continued on albuterol and ipratropium. At 10pm that evening, ABG was 7.24/115/82/52. At approximately 1am that night, she suffered respiratory arrest, and was emergently intubated and placed on mechanical ventilation with fentanyl and versed sedation. On [**11-8**], her ventilatory requirements were weaned, and that morning she was extubated. However, she quickly went into respiratory distress and was re-intubated. Midday, she self-extubated, and with increased work of breathing and respiratory distress, she was again re-intubated. Subsequently, she was maintained on mechanical ventilation with continuous sedation via fentanyl and versed. She was evaluated daily for possibility of extubation, but the combination of her anxiety and agitation on lowering of sedation and low tidal volumes with low pressure support led to the conclusion that she was not a candidate for extubation. On [**11-22**], she went to the OR and a tracheostomy, left lingular BAL, EGD, and open G tube were performed. Notably she had concretized tube feeds in her esophagus, and follow up formal EGD and biopsy were recommended. The procedure was otherwise uncomplicated. Post op, her course was marked by tachycardia and hypertension, with sputum cultures continuing to grow MRSA. A 14 day course of vancomycin was completed, and the patient was placed on a 14 day course of linezolid. The patient successfully underwent multiple trach mask trials. On [**11-29**], the patient pulled out her tracheostomy tube; after briefly being intubated, the tracheostomy tube was re-placed that morning, and trach mask trials were re-initiated. . 2. Blood pressure. During the intubation on the night of arrival, she became hypotensive with SBPs in the 80s and was given IVF boluses and started on phenylephrine and norepinephrine drips. Cortisol stimulation test was normal. This episode of hypotension was ascribed to hypovolemia, LV preload dependence, and sedation. Following placement of a central line, she was given fluid boluses to maintain CVP 12-14. She was again placed on pressors -- a neosynephrin drip -- on her re-intubation; this pressor requirement quickly resolved. She then maintained her blood pressure ~90-100 systolic, with hypertensive episodes when anxious/agitated. . 3. MRSA bacteremia. On [**2056-11-8**], she spiked fevers to 103.5, developed thickened and copious secretions and failed to wean from vent, and was started on vancomycin and zosyn for presumed vent associated pneumonia. Central line and A-line were replaced. Central line culture grew MRSA, as did blood cultures and sputum cultures. Her WBC jumped to 47.6 with a clear left shift on [**11-12**], and then trended down to baseline (high 10's, low 20s) over the next several days. Zosyn was d/c'd and a five day course of gentamicin was added for synergy with vancomycin. TTE was negative for vegetations or lesions. By [**11-14**], secretions were no longer thick, and were minimal; WBC was at baseline. Her last positive blood culture was from [**11-11**], and surveillance cultures remained no growth. . 4. Pneumonia. Pt had been treated prior to admission with levaquin for two courses of management of COPD flairs. CXR on admission showed bilateral lower lobe interstitial infiltrate concerning for pneuomonia. She was given a five day course of azithromycin for empiric treatment of CAP. Rapid viral cultures were negative. Initial sputum sample was positive for gram positive cocci in pairs, a second sample was negative, and cultures only grew sparse oropharyngeal flora. Sputum cultures on [**2131-11-22**] grew MRSA, and she was treated with vancomycin, which she was on for MRSA bacteremia, and then linezolid (14 day course, initiated [**11-26**]). . 5. Mental status. While intubated, patient was kept on versed and fentanyl drips. However, she had periods of agitation concerning for thrashing movement and for her episodes of self-extubation. After attempting pharmacological intervention with ativan, haldol, ambien, and zyprexa, her regimens were simplified. She was weaned entirely off fentanyl and versed, and maintained only on prn ativan and zyprexa. She continued to have waxing and [**Doctor Last Name 688**] mental status, requiring restraints at night when in bed. . 6. GI. Post-intubation, nutrition was provided by tube feeds of Probalance at 55cc/hr. She had an open g-tube placement at the time of tracheostomy, and the g-tube was subsequently used for feeding. CT-abd on [**2131-11-28**] done for complaint of abdominal tenderness as well as persistent low grade fevers revealed a phlegmon extending from the subcutaneous tissues to the peritoneum with no focal fluid collections. This was deemed by surgery not concerning for abscess, and the tube remained in use. . 7. Hyperglycemia. As an outpatient, she had been described as borderline diabetic, with elevated 2 hr glucose of 197 and hgba1c of 6.2. In addition, she was on steroids while admitted, and consequently her elevated blood glucose levels were managed with insulin drip and then insulin sliding scale with standing NPH. . 8. Hyperlipidemia. Maintained on home dose of Lipitor. . 9. Lung mass. Cytology of bronchoalveolar lavage done at the time of tracheostomy was positive for squamous cell carcinoma. Family is aware. Medications on Admission: Ativan 0.5mg po bid prn anxiety Albuterol 90mcg ih 2puffs qid prn O2 4L when active, 2L at rest Lipitor 20 mg po qd Lisinopril 5 mg po qd Servent diskus 50 mcg/dose 1 puff [**Hospital1 **] ASA Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). Disp:*[**Numeric Identifier 31034**] units* Refills:*0* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. Disp:*30 neb* Refills:*0* 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:*900 mg* Refills:*0* 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. Disp:*60 neb* Refills:*0* 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 1 weeks. Disp:*140 ML(s)* Refills:*0* 7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days: last dose 11/19. Disp:*1 Tablet(s)* Refills:*0* 9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Four (24) units Subcutaneous QAM. Disp:*50 cartridges* Refills:*2* 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Two (22) units Subcutaneous QHS. Disp:*50 cartridges* Refills:*0* 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-14**] Puffs Inhalation Q6H (every 6 hours) for 1 months. Disp:*QS mcg* Refills:*0* 12. Lorazepam 0.5 mg IV Q4H:PRN agitation 13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days: 14 day course; started [**11-26**]. Disp:*18 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital - [**Hospital1 1559**] Discharge Diagnosis: COPD/respiratory failure MRSA bacteremia MRSA pneumonia s/p tracheostomy and open g-tube Discharge Condition: Stable Discharge Instructions: Notify a physician or nurse if you have difficulty breathing, chest pain, abdominal pain, dizziness or any other concerns. Followup Instructions: Your physicians at the rehab center will arrange any necessary follow-up for your lung mass or other conditions. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**] MD, [**MD Number(3) 289**]

[ "996.62", "276.52", "599.0", "491.21", "V09.0", "536.49", "250.00", "272.4", "935.1", "790.7", "401.9", "518.81", "227.3", "482.41", "V58.65", "162.3" ]

icd9cm

[ [ [] ] ]

[ "45.13", "31.1", "43.19", "97.23", "98.02", "38.91", "96.6", "33.24", "96.72", "96.04", "00.17", "38.93" ]

icd9pcs

[ [ [] ] ]

21052, 21127

13403, 13403

359, 414

21259, 21268

4212, 13380

21439, 21682

3077, 3293

19381, 21029

21148, 21238

19164, 19358

21292, 21416

3308, 4193

276, 321

13431, 19138

442, 2200

2222, 2868

2884, 3061

19,309

158,568

23919

Discharge summary

report

Admission Date: [**2190-9-24**] Discharge Date: [**2190-9-27**] Date of Birth: [**2157-1-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: melena Major Surgical or Invasive Procedure: EGD History of Present Illness: 33M s/p Lap-Roux-en-Y gastric bypass on [**5-/2189**], presented to ED with coffee ground emesis and melena. On the night prior to admission, patient ate a steak and cheese [**Location (un) 6002**]. His stomach had been feeling uneasy earlier in the day and he took antacids. 20 minutes after eating he vomited. While at his girlfriend's apartment, he had another episode of vomiting with a fair amount of red blood in the toilet bowl. At 6 a.m. on day of admission, he had a large liquid black stool. He went to work, was feeling lightheaded and passed a second liquid black stool so he left wor and came to ED. While in the ED, his Hct was noted to be 23 down from baseline 47. He went to bathroom where he felt lightheaded, grabbed the doorhandle and called for help. Systolic bp high 70's-low 80's at that time. He states he passed out but was caught, so did not fall down. ED: 2 large bore iv's, type and crossed and ordered for 2 u pRBCs. NG lavage with blood, cleared with 500cc, sbp responded to iv lfuids. GI and Surgery consulted in ED. Past Medical History: Morbid Obesity s/p roux-en-y gastric bypass on [**5-17**] Dyslipidemia Osteoarthritis Type 2 Diabetes - now resolved Carpal Tunnel syndrome Bilateral carpal tunnel release Knee surgery in '[**86**] Tonsillectomy Social History: No tobacco, rare EtOH. He has a remote history of drug use but no IV use. He works as a truck driver for [**Company 22957**]. He teaches scuba diving. Family History: Father-- MI at age 56 Mother-- jejunoileal bypass for obesity, died of pancreatic cancer Sister-- insulin-dependent diabetes Physical Exam: Vitals:T 99.4F HR 100 BP 113/72 RR 16 100RA Gen: awake, alert, oriented, appears in mild discomfort HEENT: PERRL, EOMI, anicteric sclera, OP clear, MM sl dry Neck: supple CV: S1, S2, regular, tachycardic Pulm: CTAB Abd: (+) BS< soft, ND/NT, no rebound or guarding Ext: WWP, no edema, 2+ PT pulses b/l Pertinent Results: [**2190-9-24**] 10:20AM WBC-9.8 RBC-3.88*# HGB-11.5*# HCT-32.0*# MCV-82 MCH-29.5 MCHC-35.9* RDW-13.3 [**2190-9-24**] 10:20AM NEUTS-61.2 LYMPHS-32.6 MONOS-5.0 EOS-1.0 BASOS-0.2 [**2190-9-24**] 10:20AM PLT COUNT-375 [**2190-9-24**] 10:20AM PT-12.8 PTT-21.7* INR(PT)-1.1 [**2190-9-24**] 10:20AM GLUCOSE-131* UREA N-29* CREAT-0.9 SODIUM-136 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13 [**2190-9-24**] 10:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Last Hct on [**9-27**] was ~26 . Brief Hospital Course: # GI Bleed: - GI aware: await recs, likely EGD - await surgery recs: page [**Numeric Identifier 60975**] Surgery Powers after results of EGD - iv PPI [**Hospital1 **] - 2 units pRBCS ordered in ED - q4-6 h Hcts - NPO - Type and screen/consented for blood . # FEN: NPO - MVI . # Proph: pneumoboots, PPI . Full Code Medications on Admission: carafate 1gram po QID (for 2 weeks) protonix 40mg po BID (indefinitely) MVI iron b12 calcium/Vit D Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 4. iron 325mg po daily 5. B12 6. calcium/Vit D Discharge Disposition: Home Discharge Diagnosis: Upper gastrointestinal bleed secondary to a gastrojejunal marginal/anastamotic ulcer Blood loss anemia s/p transfusion Discharge Condition: Stable, afebrile, normal vital signs with a stable hematocrit (26) Discharge Instructions: Please call if continued bright red blood per rectum is passed, worsening dizziness, shortness of breath or syncopal (passing out) event occurs. Should take carafate for 2 weeks, protonix indefinitely and a multivitamin. Call Dr.[**Name (NI) **] office for a follow-up appointment in [**1-15**] weeks. Return to work in 2 weeks and abstain from working out for 2 weeks. Followup Instructions: Call for an appointment ([**Telephone/Fax (1) 305**]) and return to clinic in ~ 3 weeks Completed by:[**0-0-0**]

[ "258.1", "534.40", "272.4", "V45.86" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

3667, 3673

2890, 3205

321, 326

3836, 3905

2299, 2867

4326, 4441

1833, 1959

3354, 3644

3694, 3815

3231, 3331

3929, 4303

1974, 2280

275, 283

354, 1413

1435, 1648

1664, 1817

25,966

162,084

28356

Discharge summary

report

Admission Date: [**2142-10-9**] Discharge Date: [**2142-10-22**] Date of Birth: [**2067-1-11**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 473**] Chief Complaint: Painless Jaundice Major Surgical or Invasive Procedure: Pylorus Perserving Whipple Open Cholecystectomy History of Present Illness: This is a 75 year old male who developed painless obstructive jaundice starting in [**2142-7-14**]. He went to ERCP for a metal biliary stent placement. Preoperative CT angiography demonstrates resectability and he now presents for a Whipple procedure. There was no guaranteed diagnosis of cancer in the preoperative period, however, on the basis of a suspected but unproven malignancy, we decided to proceed. He reports weight loss of about 30 pounds in 2 months, dark urine and light stools. Past Medical History: DM, AAA, HTN, Hyperchol Social History: Tobacco: 2.5 pks/day x 50 years. He quit in [**2137**]. ETOH: occasional use Family History: Father died at age 60 of a MI Mother and sister with Breast Cancer. Physical Exam: VS: 100, 132/64 Gen: Anicteric, A+O x 3 CV: RRR, S1, S2 Resp: CTA bilat Abd: soft, nontender Inguinal: no hernia Pertinent Results: CHEST (PORTABLE AP) [**2142-10-17**] 5:51 AM CHEST (PORTABLE AP) Reason: Consol, infil? [**Hospital 93**] MEDICAL CONDITION: 75 year old man with s/p whipple with high WBC REASON FOR THIS EXAMINATION: Consol, infil? AP CHEST, 6:23 A.M., [**10-17**] HISTORY: Whipple procedure. High white count. IMPRESSION: AP chest compared to [**10-14**]: Small bilateral pleural effusion unchanged. Bibasilar atelectasis, improved. Upper lungs clear. Heart size normal. No pneumothorax. CT ABDOMEN W/O CONTRAST [**2142-10-17**] 6:08 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: 75 yo s/p whipple with n/v Field of view: 42 [**Hospital 93**] MEDICAL CONDITION: 75 year old man with REASON FOR THIS EXAMINATION: 75 yo s/p whipple with n/v CONTRAINDICATIONS for IV CONTRAST: Cr= 1.4 INDICATION: 75-year-old man status post Whipple with nausea and vomiting. COMPARISON: [**2142-8-30**]. TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis was performed with oral contrast only. FINDINGS: There are bilateral small pleural effusions. Atherosclerosis of the coronary arteries is incompletely visualized as is calcification of the aortic valve. Visualized pericardium appears normal. There is bibasilar atelectasis. A feeding tube tip terminates in the stomach. Lack of intravenous contrast limits assessment. There is expected pneumobilia seen, principally in the left lobe. The liver parenchyma is otherwise unremarkable. The adrenal glands and spleen appear unremarkable. Only the distal pancreas is visualized consistent with the prior Whipple procedure. Inflammatory changes are seen in the region of the pancreaticojejunostomy. No drainable fluid collections are identified. A pancreatic duct stent and surgical suture material is seen. There is a moderate amount of ascites. The gastro-jejunal anastamosis is seen in the left upper quadrant. Slightly distended loops of contrast- filled small bowel are seen in the left abdomen without distal decompression. No free intraperitoneal air is identified. There is diffuse mild mesenteric stranding. Mesenteric vessels are not well assessed, but appear somewhat unusual in configuration, which may be an expected post operative finding. CT OF THE PELVIS: The bladder, prostate, seminal vesicles, and rectum appear normal. Bilateral small fat-containing inguinal hernias are seen. A small amount of free fluid is seen in the pelvis. The osseous structures demonstrate no concerning lytic or sclerotic lesions. IMPRESSION: 1. Inflammatory change around the pancreaticojejunostomy surgical site, with milder stranding throughout the mesentery. Pneumobilia and ascites. 2. Mildly distended small bowel loops with air and stool seen throughout the colon. 3. Mesenteric vessels not well assessed on this non contrast study. Atrial flutter with controlled ventricular response. Compared to the previous tracing of [**2142-10-14**] atrial flutter with controlled ventricular response has appeared. Otherwise, no diagnostic interim change. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 71 0 96 400/422.14 0 -13 51 CHEST (PA & LAT) Reason: ? pneumonia [**Hospital 93**] MEDICAL CONDITION: 75 year old man with s/p whipple with high WBC REASON FOR THIS EXAMINATION: ? pneumonia EXAMINATION: Two views of the chest. INDICATION: Post-op fever. PA and lateral views of the chest are obtained [**2142-10-14**] at 09:44 hours and are compared with the prior radiograph performed on [**2142-10-12**]. The nasogastric tube and the right IJ line have been removed since the prior examination. The lateral view of the chest does, however, appears to show a drain or tube in the upper abdomen anteriorly. There remains bibasilar atelectasis with a right-sided pleural effusion. A left-sided pleural effusion has almost completely resolved. There is no evidence of congestive failure on the current examination. IMPRESSION: Bibasilar atelectasis with persistent right pleural effusion and likely small left pleural effusion. PATIENT/TEST INFORMATION: Indication: New Onset Atrial fibrillation/flutter. Left ventricular function. Height: (in) 68 Weight (lb): 180 BSA (m2): 1.96 m2 BP (mm Hg): 124/70 HR (bpm): 100 Status: Inpatient Date/Time: [**2142-10-12**] at 16:24 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W038-0:14 Test Location: West Echo Lab Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.4 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.5 cm Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: RV not well seen. AORTA: Normal aortic root diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. CHEST (PORTABLE AP) [**2142-10-12**] 6:04 AM CHEST (PORTABLE AP) Reason: r/o cardiopulmonary pathology [**Hospital 93**] MEDICAL CONDITION: 75 year old man s/p whipple now with afib. REASON FOR THIS EXAMINATION: r/o cardiopulmonary pathology CHEST RADIOGRAPH INDICATION: 75-year-old man status post Whipple procedure, now with atrial fibrillation. COMPARISON: [**2142-10-9**]. FINDINGS: Since prior examination, there is interval development of bibasilar opacities with increased pulmonary vasculature consistent with CHF. There is no evidence of pneumothorax. The lung volumes are low. The cardiac silhouette cannot be accurately assessed due to overlying opacity. IMPRESSION: Interval development of CHF. SPECIMEN SUBMITTED: GALLBLADDER AND CONTENTS, DUCT STENT GROSS ONLY, JEJUNUM, WHIPPLE (4). Procedure date Tissue received Report Date Diagnosed by [**2142-10-9**] [**2142-10-9**] [**2142-10-12**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma?????? DIAGNOSIS: A. Gallbladder: Chronic cholecystitis. B. Duct stent, gross examination. C. Jejunum: Within normal limits. D. Duodenum, pancreatic head, common bile duct (Whipple specimen): Pancreatic adenocarcinoma; see synoptic report. Pancreas (Exocrine): Resection Synopsis MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head. Tumor Size Greatest dimension: 1.5 cm. Additional dimensions: 1.5 cm x 1.5 cm. Other organs/Tissues Received: Gallbladder, duct stent, jejunum segment. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G1: Well differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 2. Number involved: 1. Distant metastasis: pMX: Cannot be assessed. Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 2 mm. Specify which margin: pancreatic neck margin. Venous/Lymphatic vessel invasion: Present. Perineural invasion: Present. Additional Pathologic Findings: Chronic pancreatitis. Comments: The tumor invades into duodenal wall. Clinical: Pancreatic mass. [**2142-10-15**] 7:23 am SWAB Site: ABDOMEN Source: Abd. GRAM STAIN (Final [**2142-10-15**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Final [**2142-10-17**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). GRAM NEGATIVE ROD(S). MODERATE GROWTH. OF THREE COLONIAL MORPHOLOGIES. PROBABLE ENTEROCOCCUS. SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: Pt under went a pylorus perserving whipple, open chole for painless jaundice, pruritis, weight loss his post operative course was complicated by rapid a-fib (HR in 120s) and a wound infection. At the time of discharge he was rate controlled and hemodynamicly stable, tolerating a regular diet, had good pain control on po pain medications, ambulating, had return of bowel and bladder function and had the central portion of his wound opened and packed with wet to dry dressings. Discharge Medications: 1. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) ML Injection every eight (8) hours. Disp:*90 ML* Refills:*0* 2. Diltiazem HCl 240 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 3. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:*120 Tablet(s)* Refills:*0* 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) u Injection ASDIR (AS DIRECTED). Disp:*1000 u* Refills:*2* 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. Disp:*30 Suppository(s)* Refills:*0* 10. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Outpatient Lab Work Check INR every day and give coumadin to keep INR [**2-16**]. Pt should be on coumadin for one month. Check Fingerstick glucose qAC and qHS. Discharge Disposition: Extended Care Facility: health alliance [**Last Name (un) **] Discharge Diagnosis: Pancreatic Mass Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain Please resume all of your regular medications and take any new medications as ordered. Continue to walk several times per day. You may wash and shower your incision. Pat dry. Keep clean and dry. Your steri strips will fall off in [**7-23**] days. Wet to dry drssing changes TID. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in [**2-16**] weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment. Completed by:[**2142-10-22**]

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icd9cm

[ [ [] ] ]

[ "52.7", "51.22", "45.62" ]

icd9pcs

[ [ [] ] ]

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298, 348

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935, 1013

59,674

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39771

Discharge summary

report

Admission Date: [**2179-7-21**] Discharge Date: [**2179-8-3**] Date of Birth: [**2103-1-18**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1515**] Chief Complaint: CoreValve for AS Major Surgical or Invasive Procedure: Perutaneous Corevalve after unsuccessful unsuccessful direct approach History of Present Illness: This 74 year old woman has symptomatic severe aortic stenosis (valve area 0.8-1.0cm2, peak gradient 66 mm Hg), as well as a history of PVD,CVA, COPD how presented for an elective CoreValve placement. She reports her symptoms have progressed to shortness of breath [**12-14**] block, inability to climb greater than 4 stairs without stopping due to shortness of breath, and worsening fatigue. In addition, she now reports episodes of intermittent chest pain with activity. She presented to [**Hospital1 18**] on [**2179-7-22**] for elective direct aortic corevalve, but was found to have anatomy that was not appropiate following a mini-sternotomy. She ended up undergoing percutanous placement of the valve. She was intubated for the procedure and following the procedure she was taken to CVICU. She was found to be in volumne overload following the procedure and was transfered to the CCU for treament. . Vitals on transfer were 98.9 73 115/72 20 100% on assist/control FiO2 50%. Past Medical History: Aortic stenosis NYHA Class III MI x 2 COPD/ Emphysema PVD Left SFA stents/right iliac stent [**2177-8-25**] Cerebrovascular aneurysm s/p clipping Left renal artery stenosis Diverticulosis Cholelithiasis Hypertension Hyperlipidemia CVA [**2173**] with no residual s/p left carotid endarterectomy [**2173**] Diet Controlled diabetes - denies Anxiety/depression Arthritis Mild renal insufficiency C section x 2 Partial hysterectomy Tonsillectomy as a child Social History: Psycho/Social: Divorced Primary Language English Lives with: Son and Daughter live with her Occupation: retired quality control Home Services: none Tobacco: quit 5 yrs ago - prior 1ppd x 40 yrs ETOH: No Recreational drug use: no Family History: Mother died at 93 and had congestive heart failure. Father died at 53/MI and cancer. Brother had CABG in his 40's and was found dead at the age of 50 and no post mortem was performed. Physical Exam: VS: 98.9 73 115/72 20 100% on assist/control FiO2 50% GENERAL: WDWN woman, intubated and sedated. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 9 cm. 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: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Discharge:Vitals - Tm/Tc: 98.8/97.8 HR:84-100 BP:108-158/42-72 RR:20-22 02 sat:99% 3l In/Out: Last 24H: 1330/2870 Last 8H: Weight: 89.7(90.4) NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 9 cm. 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: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ b/l le pitting edema. No femoral bruits. SKIN: sternotomy site c/d/ dressing intact. No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: 2D-ECHOCARDIOGRAM: [**2177-7-21**] Pre implant A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. There is moderate symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-14**]+) mitral regurgitation is seen. Drs [**Last Name (STitle) **] , [**Name5 (PTitle) **] and [**Name5 (PTitle) **] were notified in person of the results on [**2179-7-22**] at 845 am. Post implant Corevalve seen in the aortic position. It appears well seated. There is mild perivalvular aortic insufficiency seen. There is mitral mitral regurgitation present. Rest of the examination is unchanged. Admission Labs and pertinent results: [**2179-7-21**] 12:45PM BLOOD WBC-6.6 RBC-3.78* Hgb-11.9* Hct-35.7* MCV-94 MCH-31.6 MCHC-33.5 RDW-15.0 Plt Ct-280# [**2179-7-21**] 12:45PM BLOOD Glucose-102* UreaN-66* Creat-1.3* Na-145 K-4.2 Cl-102 HCO3-34* AnGap-13 [**2179-7-25**] 05:24AM BLOOD Calcium-7.6* Phos-2.4* Mg-2.7* Left femoral US for pseudoanneurysm: CONCLUSION: Negative study. CXR [**7-23**] FINDINGS: The ET tube is in similar location. There is a new right IJ line with tip in the SVC. The NG tube tip is off the film, at least in the stomach. There continues to be severe cardiomegaly. The amount of pulmonary vascular redistribution and perihilar haze has increased. Bilateral pleural effusions have increased. Volume loss/infiltrate is increased in both lower lobes. The overall impression is that of worsened fluid status and underlying infectious infiltrate in the lower lobes cannot be excluded. HgA1c:[**2179-7-27**] 08:34PM BLOOD %HbA1c-6.8* eAG-148* [**7-27**]: LE doppler: IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. Disharge labs: [**2179-8-2**] 05:21AM BLOOD WBC-5.8 RBC-3.02* Hgb-9.2* Hct-28.5* MCV-95 MCH-30.5 MCHC-32.3 RDW-14.7 Plt Ct-319 [**2179-8-2**] 05:21AM BLOOD Glucose-117* UreaN-37* Creat-0.8 Na-145 K-3.8 Cl-100 HCO3-39* AnGap-10 [**2179-8-2**] 05:21AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.2 Discharge Echo [**8-3**] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Well seated, normal functioning aortic CoreValve prosthesis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Compared with the prior study (images reviewed) of [**2179-7-29**], the findings are similar. CLINICAL IMPLICATIONS: Based on [**2173**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis IS recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: Ms [**Known lastname 87579**] is a 76 yo female with hx of severe Aortic stenosis, CAD, CHF, COPD POD2 s/p elective core valve procedure for critical Aortic valve stenosis. Course complicated by difficulty extubating and respiratory disress. # Severe Aortic Stenosis. Patient is s/p core valve placement on [**2179-7-21**]. Initially had planned for an "open approach" however secondary to extensive aortic calcification decision made to intervene percutaneously. Procedure was uncomplicated and patient's preoperative murmur resolved. Posteroperative course was complicated by difficulty extubating patient. Pt's bp remained labile following procedure and she was intermittenly on both levophed and phenylephrine for several days. A temporary pacer wire was placed and pulled 2 days following procedure. Patient's sternotomy site continued to heal well and was regularly assessed by CT [**Doctor First Name **] throughout admission. #Respiratory Distress: Following [**Name (NI) 1291**], pt failed extubation. CXR showed bilateral pleural effusions and sputum culture was notable for GNR so patient was started on an 8 day course for VAP with Vanc/Meropenem. Ms. [**Known lastname 87579**] had a difficult intubation and a #7ETT was used. It was thought that poor SBT trial results were secondary to resistentence of tube. ETT was eventually pulled without complication and patient was transitioned to Bi-Pap for 2 days as o2 saturations remained low. Her Respiratory distress was most likely multifactorial with underlying hx of COPD, CHF, and infection playing a role. Pt received standing nebulizer treatments and her home COPD meds were restarted. She was also diuresed with a lasix drip with improvement in SOB. Pulmomology saw the patient and believed symptoms were most likely secondary to COPD and recommended the patient continue spiriva as an outpt. #CHF (acute on chronic diastolic dysfunction: Pt has long standing CHF and had signs of fluid overload (b/l peripheral edema, cardiogenic pulm edema)over course of admission.Diuresis was conservative at first in setting of hypotension. Once pressors discontinued, shed failed to have good urine outpt with lasix bolus and was started on a drip. She was transitioned to PO toresemide 20mg daily at discharge. She is instructed to weigh herself daily and will follow up with Dr.[**Last Name (STitle) **] as an outpt. #CAD/PVD Pt is s/p stent placement to left common iliac and external iliac in 6/[**2178**]. Ms. [**Known lastname 87579**] had no episodes of CP, lightheadedness, or dizziness throughout the admission. She was continued on ASA, Plavix, and simvastatin throughout admission. Metoprolol and valsartan were orginally held in setting of hypotension and restarted as pt's bp tolerated. Home imdur was held throughout the admission. It is being held on discharge until follow up with Dr. [**Last Name (STitle) **]. #R Foot Pain: Pt developed plantar surface tenderness several days post op. Foot was notable warm and slightly erythemic and the pain was thought to be secondary to gout. Pt noted a similar episode during a previous admission. She was started on colchicine with moderate improvement. She also had a doppler venous study of the R extremity to r/o dvt, which was negative. #Hyperglycemia: Pt had no history of diabetes as an outpt. Her post-op course was complicated by hyperglycemia and she was started on a insulin drip while in the CCU. A HgA1c was checked and was 6.8. Hyperglycemia was most likely secondary to stress response and underlying pre-diabetes. She was transitioned to glargine and humalog with meals with improved blood sugar management. On discharge she is being transitioned to glypizide and will f/up with her PCP and Dr.[**Last Name (STitle) **]. Chronic Issues Managed: #Chronic renal insufficiency: Patient has a baseline cr in the 1.2-1.3 range most likely secondary to HTN. Pt only had a slight increase to 1.4 while on pressors with decreased UO. Cr trended down to baseline after hemodymanmics improved. . # Hx of HTN: Patient's bp meds were held post-op secondary to hypotension. Metoprolol and valsartan were continued once bp tolerated and imdur was held for entire admission. # Hx of Depression: Patient showed no signs of depression and home regimen of Paroxetin continued. . # Insomnia:The pt takes occasional alprazolam qhs. She was transitioned to trazodone during admission. # Normocytic Anemia: Chronic anemia with baseline hct of 33-34. Continued with ferrous sulfate during admission Transitions of Care: 1.Holding Imdur at discharge. Will consider redosing as oupt with Dr.[**Last Name (STitle) **] 2.Pt's home lasix 40mg [**Hospital1 **] dose transitioned to toresimide 20mg daily 3.Pt will continue treatment of COPD with home regimen and spiriva added 4. She is started on glypizide on discharge for elevated bs and will follow up with PCP for monitoring. 5. Full Code . Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. ALPRAZolam 0.25 mg PO TID:PRN anxiety 2. Clopidogrel 75 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 4. Furosemide 80 mg PO ONCE Duration: 1 Doses 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO BID 7. Nitroglycerin SL 0.3 mg SL PRN cp 8. Paroxetine 10 mg PO DAILY 9. Potassium Chloride 10 mEq PO DAILY Hold for K > 10. Simvastatin 40 mg PO DAILY 11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 12. Valsartan 160 mg PO DAILY 13. Aspirin 81 mg PO DAILY 14. Ferrous Sulfate 325 mg PO DAILY 15. Fish Oil (Omega 3) 1000 mg PO TID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Metoprolol Tartrate 25 mg PO BID hold for SBP <100, HR <60 4. Paroxetine 10 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 7. Valsartan 80 mg PO DAILY hold for SBP <100 8. Docusate Sodium 100 mg PO BID 9. Miconazole Powder 2% 1 Appl TP [**Hospital1 **] 10. Ferrous Sulfate 325 mg PO DAILY 11. Fish Oil (Omega 3) 1000 mg PO TID 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 13. Nitroglycerin SL 0.3 mg SL PRN cp 14. Potassium Chloride 10 mEq PO DAILY Hold for K > 15. Outpatient Lab Work Please check fasting chem 7(basic chemistry) in 1 week. Please fax results to [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) 32655**] NP[**Telephone/Fax (1) 87580**]. 16. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 17. Milk of Magnesia 30 mL PO DAILY:PRN constipation 18. Oxycodone-Acetaminophen (5mg-325mg) [**12-14**] TAB PO Q4H:PRN pain 19. Senna 1 TAB PO BID 20. Tiotropium Bromide 1 CAP IH DAILY 21. Torsemide 20 mg PO DAILY 22. ALPRAZolam 0.25 mg PO TID:PRN anxiety 23. GlipiZIDE XL 2.5 mg PO DAILY may need to increase dose pending blood glucose levels 24. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Aortic stenosis- s/p transcatheter percutaneous aortic valve replacement with the CoreValve device. Myocardial infarction x 2 COPD/ Emphysema PVD Cerebrovascular aneurysm s/p clipping x 2 Hypertension Hyperlipidemia CVA [**2173**] with no residual s/p left carotid endarterectomy [**2173**] Diet Controlled diabetes Mild renal insufficiency Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance Discharge Instructions: Dear Ms. [**Known lastname 87579**], It has been a pleasure to have had the opportunity to care for you here at [**Hospital1 18**]. You came her for treatment for your severe symptomatic aortic stenosis. You noted your symptoms of fatigue and shortness of breath to be worsening and increasing in frequency. Studies determined you to be a candidate for the Corevalve transcatheter aortic valve replacement procedure. The initial plan for the procedure was through the front of the chest using a incision. However, your aorta was found to be heavily calcified and therefore the change was made to a transfemoral approach. Your postoperative course was complicated by your COPD disease and a pulmonologist was consulted who made some changes in your inhalers. It is important that you continue to take them consistently and as directed. During your stay you received Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2179-8-25**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2179-8-25**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "88.42", "96.71", "37.12", "00.40", "39.64", "37.23", "39.50", "35.05", "38.97" ]

icd9pcs

[ [ [] ] ]

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41470

Discharge summary

report

Admission Date: [**2183-5-19**] Discharge Date: [**2183-5-23**] Date of Birth: [**2107-4-8**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: [**2183-5-19**] Mitral valve replacement (27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Porcine) History of Present Illness: 76 year old female with worsening fatigue ove rthe past several months. In addition, she complains of chest discomfort and occasional dyspnea on exertion. Because of these symptoms she was worked up and eventually underwent a cardiac echocardiogram which revealed moderate to severe mitral stenosis. More recently, a repeat echo showed severe mitral stenosis with the addition of worsening mitral and aortic regurgitation. She was seen by Dr. [**Last Name (STitle) **] in [**Month (only) 956**] for surgical evaluation, and surgery was delayed for recurrent UTI. Past Medical History: Mitral Stenosis Urinary tract infection Seizure disorder (last seizure 25 yrs ago) Peptic Ulcer disease s/p surgery Left pelvic fracture s/p repair Hypothyroidism Osteoporosis Hard of hearing (worse in right ear) Fractured sternum / R foot/ R ankle(from MVA) kyphosis Hemorrhoids Colon polyp removal B laser eye [**Doctor First Name **] s/p open surgery for PUD s/p Left hip/femur surgery Social History: Lives alone: has daughter Occupation: Retired Tobacco: Denies ETOH: Denies Family History: non-contributory Physical Exam: T 98 Pulse: 64 B/P Right: 135/58 RR 16 O2 sat: 98% Height: 61" Weight:135 General: NAD, small stature, kyphotic Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclerae, OP unremarkable, B lens cloudiness Neck: Supple [x] Full ROM []no JVD appreciated Chest: Lungs clear bilaterally [x] kyphosis Heart: RRR [x] Irregular [] Murmur- [**1-12**] diastolic, 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]hypoactive; dealed midline abd scar Extremities: Warm [x], well-perfused [x] Edema: none on L, chronic R ankle swelling since fx; healed left hip scar Varicosities: None appreciated Neuro: Grossly intact, MAE [**3-11**] strengths, nonfocal exam Pulses: Femoral Right: 2+ Left:2+ DP Right: NP Left:NP PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 1+ Left:1+ Carotid Bruit Right: none Left:none Pertinent Results: [**2183-5-19**] 10:33AM BLOOD WBC-13.0*# RBC-2.82*# Hgb-9.0*# Hct-25.3*# MCV-90 MCH-32.0 MCHC-35.6* RDW-13.3 Plt Ct-114* [**2183-5-19**] 10:33AM BLOOD Neuts-86* Bands-6* Lymphs-7* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2183-5-19**] 10:33AM BLOOD Plt Smr-LOW Plt Ct-114* [**2183-5-19**] 10:33AM BLOOD PT-14.7* PTT-30.4 INR(PT)-1.3* [**2183-5-19**] 10:33AM BLOOD Fibrino-180 [**2183-5-19**] 11:49AM BLOOD UreaN-11 Creat-0.4 Na-139 K-3.5 Cl-104 HCO3-24 AnGap-15 [**2183-5-21**] 05:35AM BLOOD Mg-1.9 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Findings LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or vegetation on mitral valve. Mild mitral annular calcification. Moderate thickening of mitral valve chordae. Calcified tips of papillary muscles. Severe valvular MS (MVA <1.0cm2). Moderate to severe (3+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PRE-CPB:1. The left atrium is markedly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. There is moderate thickening of the mitral valve chordae. There is severe valvular mitral stenosis (area <1.0cm2). Moderate to severe (3+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. Brief Hospital Course: She was admitted same day surgery and was brought to the operating room for mitral valve replacement. See operative report for further details. She received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. That afternoon she was weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one her chest tubes were removed, started on betablockers and diuretics. She continued to progress and was ready for transfer to the floor. On post operative day two physical therapy worked with her on strength and mobility. Epicardial wires were removed. By post-operative day 4 she was ready for discharge to rehab. She is discharged with small bilateral pleural effusions, and Lasix will be continued [**Hospital1 **] for 1 week, then she will resume her home dose of 20mg daily. All follow-up appointments were advised. Medications on Admission: Dilantin 100mg [**Hospital1 **] Atenolol 25mg dialy Prilosec 20mg daily Lasix 20mg daily Levothyroxine 75mcg daily Phenobarbital 30mg [**Hospital1 **] Fosamax 70mg q Sunday Vitamin D 1000 unit daily Calcium + D daily MVI daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. phenobarbital 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. 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* 17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day). 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day: 20mg [**Hospital1 **] x 1 week, then 20mg daily. 19. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO twice a day: 20mEq [**Hospital1 **] x 1 week, then 20mEq daily. Discharge Disposition: Extended Care Facility: [**Location (un) **] at [**Location (un) 701**] Discharge Diagnosis: Mitral Stenosis s/p MVR Urinary tract infection Seizure disorder Peptic Ulcer disease Hypothyroidism Osteoporosis Hard of hearing Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2183-6-12**] 1:30 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 10740**] [**Telephone/Fax (1) 40144**] in [**3-11**] weeks [**Telephone/Fax (1) 40144**] Cardiologist: Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] **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:[**2183-5-23**]

[ "389.8", "274.9", "345.90", "511.9", "396.8", "244.9", "737.10", "733.00" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.23" ]

icd9pcs

[ [ [] ] ]

8566, 8640

5484, 6429

305, 433

8814, 8975

2491, 5461

9900, 10523

1547, 1565

6707, 8543

8661, 8793

6455, 6684

8999, 9877

1580, 2472

258, 267

461, 1025

1047, 1438

1454, 1531

31,454

117,800

34334

Discharge summary

report

Admission Date: [**2143-8-21**] Discharge Date: [**2143-8-28**] Date of Birth: [**2073-4-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: Cardiac Cath. History of Present Illness: Pt is a 70 y.o Vietnamese speaking male, nursing home resident, with h.o HTN, PVD, DM, ESRD on HD (M/W/F) who became SOB yesterday after HD. Pt returned to his NH and was given 80mg lasix and xeroxlyn. SOB worsened over 24 hrs, sats found to be 80-90's, 92% on 5L. Pt sent to [**Hospital3 8834**] where troponins found to be elevated from "baseline" of 0.05 to 0.68. CPK 548, MB 10. BNP found to be 43,000. ST elevations in V1-V3 that were reportedly "new" compared to prior EKG. Pt started on heparin, given [**Hospital3 **] 325mg and lopressor 5mg IV and intubated due to increased work of breathing. Vitals at OSH HR 64, BP 123/57, RR 30, 02 99-100% on NRB. On Vent 7.42/52.5/76 . In [**Hospital1 18**] [**Name (NI) **], pt given 300mg [**Name (NI) 4532**], 20mg lipitor, and 325mg [**Name (NI) **] per cardiology fellow. Cardiology was consulted. Also given valium for sedation. . Unable to obtain current cardiac ROS including CP, DOE, PND, orthopnea, palpitations, syncope or other such as h.o stroke, TIA, DVT, PE, bleeding, myalgias, joint pains, cough, claudication. Past Medical History: ESRD on HD BPH h/o MRSA sepsis legally blind PVD s/p multiple toe amputations h/o osteomyelitis chronic nonhealing ulcer of left foot . Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension Cardiac History: no known history of CABG. No known PCI or pacemaker. Social History: Pt lives at home w/his wife, he has ?60pack year smoking hx, but quit 5years ago. nondrinker. Retired officer from [**Country 3992**]. Family History: n/a Physical Exam: PHYSICAL EXAMINATION: Vital signs stable Gen: NAD, able to ambulate with assistance. HEENT: impaired visual function CV: S1S2 RRR, no audible M/R/G Chest: GAEB, CTAB Abd: +bs in 4Q, soft, NT/ND Ext: No c/c/e. No femoral bruits, no signs of groin hematoma. L.foot with metarsal ambutation. Skin: No rash Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: Admission labs: [**2143-8-21**] 01:30AM WBC-11.4* RBC-2.67* HGB-8.3* HCT-25.3* MCV-95 MCH-31.3 MCHC-33.0 RDW-16.4* [**2143-8-21**] 01:30AM NEUTS-86.9* LYMPHS-6.8* MONOS-5.9 EOS-0.2 BASOS-0.2 [**2143-8-21**] 01:30AM PLT COUNT-168 [**2143-8-21**] 01:30AM GLUCOSE-230* UREA N-45* CREAT-7.4* SODIUM-140 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-30 ANION GAP-18 [**2143-8-21**] 01:30AM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.6 [**2143-8-21**] 01:30AM PT-15.4* PTT-143.9* INR(PT)-1.4* [**2143-8-21**] 01:30AM CK(CPK)-724* [**2143-8-21**] 01:30AM CK-MB-62* MB INDX-8.6* [**2143-8-21**] 01:30AM cTropnT-0.95* [**2143-8-21**] 01:41AM LACTATE-2.0 [**2143-8-21**] 09:15AM CK(CPK)-648* [**2143-8-21**] 09:15AM CK-MB-60* MB INDX-9.3* cTropnT-2.17* [**2143-8-21**] 04:50PM ALT(SGPT)-31 AST(SGOT)-79* LD(LDH)-398* CK(CPK)-455* ALK PHOS-87 TOT BILI-0.4 [**2143-8-21**] 04:50PM CK-MB-44* MB INDX-9.7* . Discharge labs: [**2143-8-28**] 08:30AM BLOOD WBC-9.0 RBC-3.02* Hgb-9.3* Hct-28.4* MCV-94 MCH-30.8 MCHC-32.8 RDW-16.9* Plt Ct-290 [**2143-8-28**] 08:30AM BLOOD Glucose-155* UreaN-50* Creat-8.6* Na-138 K-4.9 Cl-96 HCO3-28 AnGap-19 [**2143-8-27**] 06:50AM BLOOD CK(CPK)-40 [**2143-8-28**] 08:30AM BLOOD Calcium-9.5 Phos-5.4* Mg-2.2 . Microbio data: [**2143-8-22**] 12:08 am SWAB Source: anterior left foot. **FINAL REPORT [**2143-8-26**]** GRAM STAIN (Final [**2143-8-22**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2143-8-26**]): 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.. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2143-8-26**]): NO ANAEROBES ISOLATED. . Imaging: ECG: Cardiology Report ECG Study Date of [**2143-8-27**] 7:38:28 AM Sinus rhythm Consider left ventricular hypertrophy Anterolateral ST-T changes are nonspecific Since previous tracing of [**2143-8-26**], no significant change Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 172 82 [**Telephone/Fax (2) 79003**]04 Cardiac Cath: Cardiology Report C.CATH Study Date of [**2143-8-26**] COMMENTS: 1. Selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. The LMCA had a 20% distal stenosis. The LAD had no angiographically apparent stenosis but the first diagonal had an 80% lesion. The Lcx had moderate disease thoughout. The OM1, OM2, and OM3 each had 50% lesions at their ostia. The distal RCA had a 90% ulcerated lesion. 2. Limited resting hemodynamics demonstrated normal systemic pressure with a central aortic pressure of 130/56/63 mmhg. 3. Succseeful POBA of an ulcerated mid RCA lesion. Unable to pas a stent to the affected segment due to calcified and tortuous vessl. Final angiography revealed Type A dissection without flow limitation and 30% residual stenosis. No angiographically-apparent distal emboli was noted. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal systemic pressure. 3. Successful POBA of the mid RCA with Type A dissectiona nd 30% residual stenosis. 4. Reopro gtt overnight without a bolus. Cardiac Echo: Portable TTE (Complete) Done [**2143-8-23**] at 9:52:56 AM FINAL The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) with basal to mid inferior hypokinesis and midinfero-septal hypokinesis. The apex is not well seen. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2143-8-21**], the LVEF has improved. Brief Hospital Course: 70 yo M w/ PMH significant for DM/ESRD on HD, HTN, DMII, peripheral [**Year (4 digits) 1106**] insufficiency who presented [**8-21**] in respiratory failure with inc enzymes and EKG changes suggestive of ACS. Had cardiac cath Monday [**8-26**] with successful POBA of an ulcerated RCA. . # CAD/ ISchemia: s/p cath on [**8-26**] showing 2VD, D1 with 80% stenosis, RCA with distal 90% ulcerated lesion, POBA of mid RCA but unable to pass stent to affected segment due to Ca/tortous vessel. Type A dissection w/o flow limitation. [**Last Name (LF) **], [**First Name3 (LF) **], and statin were continued as well as an ace inhibitor and a beta blocker as tolerated. . # Pump: Presented with Heart Failure likely [**2-16**] to volume overload with ? ACS. BNP elevated at [**Numeric Identifier **] unclear [**Name2 (NI) **] given renal failure. Respiratory exams were clear, the goal was for even status -- Hemodialysis was done during his stay to remove fluid. . # Rhythm: Patient was in normal sinus rhythm post catheterization. . # Valves: The patient has no known valvular disease . # HTN: Has intermittant elevations to SBP's 160, patient was continued on home meds of BB, ACE-I, his CCB was held . # Respiratory failure: Resolved, o2 sats >95 on RA, the patient was continued on levofloxacin for total of 14 days for question of PNA va. sepsis picture. (day 1 was [**8-21**]). . # Left Foot ulcer/Osteo: Pt has known foot ulcer w/ + MRSA culture. On vanco for ?2 month course to end on [**9-3**]. Vascualar evaluation (Non invasives arterial studies) scheduled as outpatient with follow-up in clinic. . #ESRD: Patient undergoes hemodialysis on mondays, wednesdays, and fridays, no change in schedule during stay. Medications on Admission: glipizide Sr 5mg daily Lantus 12 units QHS prandin 2mg TID protonix 40mg daily nephrocaps 1 cap daily flomax 0.4mg daily renagel 800mg daily omeprazole 20mg daily simvastatin 20mg daily amlodipine 10mg daily toprol XL 150mg daily lisinopril 20mg daily tylenol MOM Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 8 doses. Disp:*8 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] units Injection PRN (as needed) as needed for line flush: for dialysis. 7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2 times a day) as needed. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime: titrate up for high blood sugars. Disp:*1 bottle* Refills:*2* 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 13. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Restoril 15 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. 16. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for pain. Disp:*30 Capsule(s)* Refills:*0* 17. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 18. Renagel 800 mg Tablet Sig: Two (2) Tablet PO three times a day. 19. Prandin 2 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. 20. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol) for 6 days: End date [**9-3**]. Disp:*6 Recon Soln(s)* Refills:*0* 21. ACCUZYME 830,000-10 unit/g-% Ointment Sig: One (1) Topical once a day: Apply thin layer to the periwound tissue with each drsg [**Name5 (PTitle) **]. . Disp:*1 tube* Refills:*1* 22. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1) syringe Miscellaneous once a day. Disp:*30 syringes* Refills:*2* Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: Reason for Admission: Respiratory failure secondary to acute diastolic heart dysfunction. Past Medical History: Stage IV end stage renal disease on hemodialysis, hypertension, advanced Type II diabetes, peripheral [**Name5 (PTitle) 1106**] insufficiency, blind. Discharge Condition: Stable. Labs on discharge: Glucose 71 UreaN 36 Creat 6.4 Na 141 K 4.7 Cl 98 HCO3 30. HCT 29.2. Discharge Instructions: Mr. [**Known lastname **], you were admitted at the [**Hospital1 18**] in [**Location (un) 86**] for respiratory failure which appears to have been secondary to acute dyastolic heart dysfunction in the setting of a myocardial infarction (a heart attack). At the time of your presentation to the hospital, we could not rule out an infection and so we began you on Levofloxacin, an antibiotic with good coverage for community aquired pneumonia. We are discharging you with an additional 8 days of Levofloxacin 250 mg PO DAILY so you will have completed a 14 day course. We continued your Vancomycin which from the [**Hospital1 **] chart appears to have been for MRSA osteomyelitis diagnosed on [**2143-7-7**] so that you would have completed 6 weeks total. You will need to continue to get the vancomycin at hemodialysis until [**2143-9-3**]. As well, given your cardiac dysfunction, we are giving you Clopidogrel 75 mg PO DAILY, Aspirin EC 325 mg PO DAILY, Lisinopril 5 mg PO DAILY, and Atorvastatin 80 mg PO DAILY. You will continue to follow with the [**Hospital 79004**] healthcare team at [**Location (un) 2199**]. In summary, we added the following medications to your current regimen: 1) Clopidogrel 75 mg PO DAILY 2) Aspirin EC 325 mg PO DAILY 3) Lisinopril 5 mg PO DAILY 4) Levofloxacin 250 mg PO DAILY for 8 days 5) Lantus insulin 14 units SC daily at bedtime We changed the following medications: 1) Changed Zocor to Atorvastatin 80 mg PO DAILY 2) Discontinued Norvasc 3) Redosed the Metoprolol XL to 50 mg PO on discharge (to be titrated up for a goal HR of 60-70 as tolerated) Other medications were continued. Action ambulance phone: [**0-0-**] will pick you up at 10:15am on Friday [**8-30**] to take you to dialysis and will continue every Monday/Wednesday and Friday. Followup Instructions: 1) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor Last Name 5858**]/Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Cardiology, [**Telephone/Fax (1) 62**]) on [**9-10**] at 2:00pm, [**Hospital Ward Name 23**] 7 [**Hospital Ward Name **]: 2) Dr. [**Last Name (STitle) 47598**] Phone: ([**Telephone/Fax (1) 79005**] [**Doctor First Name **] from Dr.[**Name (NI) 79006**] office will call you at home for an appt at the hospital . Primary Care: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11622**], MD Phone: [**Telephone/Fax (1) 250**] Date/Time: [**10-14**] at 2:00 pm. [**Hospital Ward Name 23**] clinical Center, [**Location (un) 448**]. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2143-9-11**] 2:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2143-9-11**] 3:15 . [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA: works at [**Company 2199**] dialysis and coordinates care for him there, he has been updated and will give vancomycin with dialysis runs. pager: [**Telephone/Fax (1) 79007**] Completed by:[**2143-8-29**]

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icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "38.93", "00.66", "00.40", "99.04", "88.53", "96.71", "39.95" ]

icd9pcs

[ [ [] ] ]

12160, 12200

7593, 9317

322, 337

12506, 12514

2384, 2384

14438, 15778

1901, 1906

9632, 12137

12221, 12311

9343, 9609

6363, 7570

12627, 14415

3307, 6346

1921, 1921

1943, 2365

274, 284

12533, 12603

365, 1442

2400, 3291

12333, 12485

1749, 1885

21,457

174,154

352

Discharge summary

report

Admission Date: [**2120-8-14**] Discharge Date: [**2120-8-19**] Date of Birth: [**2059-6-19**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old female with a history of brain tumor. MRI scan showed right cerebellar mass. PAST MEDICAL HISTORY: Past medical history includes breast cancer with lumpectomy in [**2114**], carpal tunnel syndrome, sleep apnea, gastroesophageal reflux disease. PAST SURGICAL HISTORY: Previous surgery included lumpectomy in [**2114**], hysterectomy in [**2114**], thyroid nodule excision. ALLERGIES: The patient had no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: On physical examination, this was an obese woman in no acute distress. HEENT was anicteric. A well-healed incision. Chest was clear to auscultation. Cardiac revealed S1 and S2, a regular rate and rhythm. Abdomen was obese, soft, a well-healed midline incision. Extremities revealed slight edema of the bilateral lower extremities, nonpitting, easily palpable dorsalis pedis and posterior tibialis pulses. HOSPITAL COURSE: The patient was admitted on [**2120-8-14**], status post right suboccipital craniotomy for resection of cerebellar mass. There were no intraoperative complications. Postoperatively, the patient was monitored in the Surgical Intensive Care Unit where she was awake, alert, and oriented times three, moved all extremities with good strength. No drift. Lungs were clear to auscultation. A regular rate and rhythm. The patient was transferred to the regular floor on postoperative day one in stable condition. Her face was symmetric. Extraocular movements were full. Followed 3-step commands, awake, alert, and oriented times three. The patient was seen by Physical Therapy and found to require three to four days of Physical Therapy treatment prior to discharge to home. The patient did receive that treatment, and is now stable for discharge home. MEDICATIONS ON DISCHARGE: Her medications at the time of discharge were Decadron taper off over two weeks time, Percocet one to two tablets p.o. q.4h. p.r.n, Zantac 150 mg p.o. b.i.d. She is also on Lopressor 50 mg p.o. b.i.d. DISCHARGE DISPOSITION: Vital signs were stable, and the patient was afebrile at the time of discharge. DISCHARGE FOLLOWUP: The patient was to follow up in the Brain [**Hospital 341**] Clinic in one week for staple removal and follow up in the Brain [**Hospital 341**] Clinic with Dr. [**First Name (STitle) **]. CONDITION AT DISCHARGE: Her condition was stable at the time of discharge. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2120-8-19**] 10:01 T: [**2120-8-21**] 13:47 JOB#: [**Job Number 3206**]

[ "530.81", "780.57", "781.3", "424.0", "786.52", "V10.3", "198.3" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

2209, 2290

1982, 2185

1098, 1955

471, 652

2526, 2854

2311, 2511

170, 278

667, 1079

301, 447

61,179

153,971

47781

Discharge summary

report

Admission Date: [**2127-10-21**] Discharge Date: [**2127-10-29**] Date of Birth: [**2056-3-12**] Sex: F Service: MEDICINE Allergies: Sotalol Attending:[**First Name3 (LF) 7333**] Chief Complaint: Dyspnea, bilateral leg edema Major Surgical or Invasive Procedure: Pericardial tap and drain placement History of Present Illness: 71yo F PMhx Afib on coumadin and amiodarone, systolic CHF (LVEF 15-20% on TTE [**2127-1-17**]), nonischemic cardiomyopathy, VT s/p ablation and ICD/PPM, complete heart block, severe TR, CKD, with two recent hospital stays in since [**Month (only) 359**] for shortness of breath thought to be secondary to CHF exacerbations who now presents after being referred from her PCP's office for SOB, orthopnea, LE edema, and lethargy. Patient was recently admitted to [**Hospital1 18**] [**Date range (1) 57530**] and [**Date range (1) 60504**] for dyspnea on exertion. On both admissions patient was diuresed, second admission was also notable for cardioversion of afib and increase in her amiodarone from 100mg daily to 400mg daily. Of note, patient reports she never returned to her baseline after each admission. Since her recent discharge, patient reports worsening BLE edema, weight gain of 2lbs, and worsening DOE, orthopnea (now sleeping on couch because her breathing is better) and cough. On day of admission, patient was seen by her PCP with above complaints as well as reports of single episode blood streaked sputum, and single episode of non-positional non-exertional L shoulder pain that resolved with tramadol at home. PCP felt patient was volume overloaded and in need of inpatient diuresis, referred patient to [**Hospital1 18**] for further evaluation and management. . In the [**Hospital1 18**] ED, she was afebrile with normal and stable vital signs. Exam was significant for crackles throughout lungs. CXR demonstrated enlarged cardiac silhouette. Bedside echo performed by ED staff demonstrated pericardial effusion and cardiology consult was obtained. On evaluation by consult, bedside TTE demonstrated large circumferential pericardial effusion without ventricular diastolic collapse. Given hemodynamic stability, patient was scheduled for AM pericardiocentesis and admitted to CCU for further monitoring Past Medical History: # Dyslipidemia # Hypertension # Nonischemia Cardiomyopathy # Systolic CHF -- LVEF 15-20% by TTE [**2127-1-17**] # Mitral regurgitation -- Mild to moderate [[**12-8**]+] (TTE [**2127-1-17**]) # Tricuspid regurgitation -- Severe [4+] (TTE [**2127-1-17**]) # Pulmonary artery systolic hypertension (TTE [**2127-1-17**]) # Cardiac catheterization ([**2108**] at [**Hospital1 2025**]) -- reportedly with clean coronaries # Complete heart block -- AICD, PPM, anticoagulated with Coumadin -- PPM placed originally in [**2112**], then repaired in [**2114**] and [**2115**] # Osteoporosis # GERD Social History: # Home: Lives with her son on the [**Location (un) 448**] of an apartment building. She does not have VNA, but her son is closely involved in her care. # Work: She is a retired factory worker. # Tobacco: Never smoked # Alcohol: None # Drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathy, diabetes, hypertension, or hyperlipidemia. # Mother: Killed during bombing in [**Name (NI) 3106**] # Father: Died from MI at age 52 # Siblings: Unsure of medical issues. Physical Exam: Vitals: 96 | 83 | 95/58 | 15 | 97% -In general, well developed, well nourished, A&O X3, NAD. Eyes - Pallor and icterus absent. Oral cavity - Moist. Neck - No lymphadenopathy. Axilla - No lymphadenopathy. Chest - Normal vesicular breath sounds. Basal crackles. CVS - Pulse irregularly irregular. Normal heart sounds. Abdomen - Soft. Non tender. No palpable organomegaly. Normal bowel sounds. Extremities - [**12-8**]+ edema -skin examination: on the bilateral lower extremities are multiple tan-brown to erythematous macules predominantly on the pretibial surface. scattered individual lesions have telangiectatic prominence. occasional tan brown papular lesions as well. R and L arm, neck, as well as the upper back are similar lesions as described above. areas of focal linear excoriation along lateral forearm. no lesions on the palms or soles, scattered red papules c/w cherry angiomata Pertinent Results: [**2127-10-29**] WBC-6.4 RBC-3.40* Hgb-10.5* Hct-32.6* MCV-96 MCH-30.8 MCHC-32.1 RDW-17.5* Plt Ct-158 PT-15.8* PTT-44.8* INR -1.4* Glucose-114* UreaN-65* Creat-1.9* Na-140 K-4.3 Cl-99 HCO3-33* AnGap-12 ALT-354* AST-191* LDH-280* AlkPhos-152* TotBili-1.2 Calcium-8.6 Phos-2.7 Mg-2.4 Echo [**10-29**]: The estimated right atrial pressure is at least 15 mmHg. LV systolic function appears (moderately to severerly) depressed. RV with (mildly) depressed free wall contractility. Moderate to severe [3+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade Liver/ gallbladder US: 1. No hepatic mass identified and no biliary dilatation seen. 2. Bilateral pleural effusions, ascites in the right upper quadrant, and pulsatile bidirectional flow within the portal vein all of which are consistent with right heart failure and possible congestive hepatopathy Brief Hospital Course: 71yo F PMHx multiple cardiac issues including non-ischemic cardiomyopathy (LVEF 15-20% on TTE [**2127-1-17**]), complete heart block s/p ICD/pacemaker, severe TR, two recent hospital stays for dyspnea found to have large pericardial effusion without evidence of tamponade, now s/p drainage w cytology demonstrate primary effusion lymphoma #Acute on Chronic Renal Insufficiency: followed by renal consult team. Unclear CIN vs ATN. Creatinine high was 6.6, decreased to 4.3 at discharge. Spironolactone was held at the time of discharge because of renal function. Chem-7 should be checked in 2 days to monitor. #Hyponatremia: Thought [**1-8**] pseudohyponatremia. Resolved at discharge #Transaminitis. DDx includes lymphoma, amiodarone effect vs Shock liver. RUQ US no hepatic mass, no biliary dilation. LFT's improved over the course of hospitatization but were still elevated at discharge. Amiodarone was decreased to 100 mg daily. Simvastatin was held at discharge. # Primary Effusion Lymphoma ?????? Drain placed for effusion, removed uneventfully. ECHO showed no accumulation at discharge. Cytology demonstrating primary effusion lymphoma, HIV neg and HHV8 labs are negative. Pt was seen by oncology service who will see pt after discharge for f/u of pending tests and plan of treatment. Incidental lung nodules, sub-4 mm nodules in the right lower lobe, noted on CT chest from [**2125-10-1**], recommended a [**5-18**] month f/u exam based on pt's risk factors which was not done at this institution. Allopurinol was started. # Skin Lesions ?????? chronic purpuric lesions over extremities, in setting of PEL, concern for KS. Dermatology team sent biopsy of lesions which were not suggestive of Kaposi's sarcoma. # Acute on Chronic Systolic CHF: Signs of volume overload on history and exam, likely exacerbation by worsening pericardial effusion as described above. All meds held [**1-8**] [**Last Name (un) **] initially. Pt was diuresed with lasix drip. Oral Lasix was restarted at discharge but spironolactone and ACE inhibitor were held. Carvedilol was continued. # Atrial Fibrillation: Afib on coumadin and amiodarone. History of CHB following remote ablation procedure for vtach, currently A/V paced. Amiodarone was decreased to 100 mg daily for increased LFT's. Warfarin was restarted prior to discharge. . # HTN: well controlled on carvedilol. Hydralazine and isordil for afterload reduction was held because of borderline low blood pressure at discharge. . Transitional care: 1. VNA assessment of VS and fluid status, monitoring of daily weights 2. Consider chest CT in near future to evaluate pulmonary nodules if not done already 3. Oncology f/u for treatment of Primary effusion lymphoma. 4. Labs on Friday [**2127-10-31**] to check kidney function and INR 5. Suture removal on [**2127-11-10**] of biopsy sites on leg and arm. Medications on Admission: Amiodarone 2 x 200mg PO daily Carvedilol 3.125mg PO BID Furosemide 40mg PO daily Hydralazine 25mg PO BID Isosorbide Dinitrate 20mg PO BID Simvastatin 10mg PO daily Spironolactone 12.5mg PO daily Tramadol 50mg PO BID PRN pain Warfarin 2.5mg PO daily Aspirin 81mg PO daily Calcium carbonate-VitD3 600mg-400u PO BID Ferrous Sulfate 32mg PO Daily Multivitamin PO daily Discharge Medications: amiodarone 100 mg PO DAILY carvedilol 3.125 mg PO BID furosemide 40 mg PO DAILY tramadol 50 mg PO twice a day as needed for pain. warfarin 2.5-5 mg PO daily aspirin 81 mg PO DAILY Calcium 600 + D(3) 600 mg(1,500mg) -400 PO twice a day. ferrous sulfate 300 mg PO DAILY multivitamin PO DAILY allopurinol 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: Primary Effusion Lymphoma Pericardial effusion s/p tap and drain Severe tricuspid regurgitation Transaminitis Secondary diagnosis: Systolic heart failure Atrial fibrillation Cardiomyopathy Ventricular tachycardia Complete heart block Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized in the ICU with fluid around your heart. The fluid was found to be lymphoma (primary effusion lymphoma). You had the fluid drained and a drain placed to help remove the excess fluid, this has now resolved and the drain has been removed. You had an echocardiogram on the day of discharge which showed a left pleural effusion (unchanged from prior). You will need a follow up echocardiogram in ** to make sure the fluid has not re accumulated. You will need to follow up with hematology/oncology as an outpatient to start treatment for your cancer. Your kidney function declined because of your illness. The kidney function is improving but not yet back to normal. We are adjusting some of your medications for this reason. Your blood pressure was low during this admission. You should hold some of your medications for this reason. Please discuss resuming these medications when you see Dr. [**Last Name (STitle) 410**] and Dr. [**Last Name (STitle) **] in follow up. Your liver tests were very elevated during this admission also. This is improving but not back to normal. For your heart failure diagnosis: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 5 lbs in 3 days, follow a low salt diet, fluid restriction 1500cc/ day. The following changes were made to your medication regimen: START Allopurinol 100mg every day (for elevated uric acid levels in your blood) STOP Simvastatin (because your liver tests are elevated) STOP Hydralazine (because your blood pressure is low) STOP Isosorbide dinitrate (because your blood pressure is low) STOP Spironalactone (because your kidney function is not normal) Decrease Amiodarone to 100mg daily (take [**12-8**] your 200mg pill) You should resume your Coumadin tonight ([**2127-10-29**]). Your dose may be adjusted in the future because we have changed your Amiodarone dose. You should have your INR checked on Monday [**11-3**] (by the VNA). You will have blood work done on Friday ([**2127-10-31**]) and Monday ([**2127-11-3**]) to check your kidney function, electrolytes and INR. Please call the heartline or Dr. [**Last Name (STitle) **] if you experience chest pain, shortness of breath, worsening swelling in your feet, fevers, chills or other concerning symptoms. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: TUESDAY [**2127-11-4**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: ECHO LAB When: FRIDAY [**2127-11-7**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: MONDAY [**2127-11-10**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You need to follow up with hematology/ oncology to discuss treatment options for your cancer. The office will call you to schedule this appointment. Please call [**Telephone/Fax (1) 22**] if you don't hear from them by Monday [**11-3**]. . Department: CARDIAC SERVICES When: THURSDAY [**2127-12-4**] at 3:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2127-11-6**]

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icd9cm

[ [ [] ] ]

[ "37.0", "86.11", "37.21" ]

icd9pcs

[ [ [] ] ]

8916, 8973

5301, 8154

299, 337

9271, 9271

4337, 5278

11747, 13236

3181, 3411

8570, 8893

8994, 8994

8180, 8547

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231, 261

365, 2288

9145, 9250

9013, 9124

9286, 9398

2310, 2900

2916, 3165

48,524

122,218

34823

Discharge summary

report

Admission Date: [**2103-12-31**] Discharge Date: [**2104-1-9**] Date of Birth: [**2029-11-23**] Sex: F Service: OTOLARYNGOLOGY Allergies: Codeine / Egg Attending:[**First Name3 (LF) 7729**] Chief Complaint: Squamous cell carcinoma of mouth floor Major Surgical or Invasive Procedure: 1. Laryngoscopy 2. Rigid esophagoscopy 3. Bilateral modified radical neck dissection 4. Resection of anterior floor of mouth tumor 5. Full-thickness skin graft to the floor of mouth History of Present Illness: Patient is a 74 y/o woman recently diagnosed with squamous cell carnicoma on the anterior floor of her mouth. She denies any difficulty eating or swallowing. She was seen and evaluated by Dr. [**Last Name (STitle) 79745**], [**First Name3 (LF) **] oral surgeon in [**University/College **], who appropriately obtained a biopsy demonstrating a moderately differentiated squamous cell carcinoma. She has decided to proceed with surgical resection with a free tissue transfer. Past Medical History: GERD, CAD (MI), HTN, peripheral neuropathy [**2-17**] diabetes, IDDM Social History: ETOH abuse, sober for the past 4 years. 60 pack year history, quit 1 year ago. No IVDA. Lives with her partner [**Name (NI) **]. Family History: NC Physical Exam: HEENT: Oral cavity remarkable for a 2 cm tumor which is somewhat mobile over the periostium of the inner surface of the mandible. No cervical LAD. Chest: CTAB Cor: RRR, no murmurs Abd: Soft, NT/ND Ext: no c/c/e Pertinent Results: Labs: On admission: [**2103-12-31**] 04:35PM BLOOD WBC-13.0*# RBC-3.26* Hgb-10.6* Hct-30.6* MCV-94 MCH-32.5* MCHC-34.6 RDW-13.2 Plt Ct-257 [**2103-12-31**] 04:35PM BLOOD Neuts-86.4* Lymphs-9.2* Monos-3.2 Eos-1.0 Baso-0.3 [**2103-12-31**] 04:35PM BLOOD PT-12.4 PTT-26.2 INR(PT)-1.0 [**2103-12-31**] 04:35PM BLOOD Glucose-156* UreaN-9 Creat-0.6 Na-140 K-3.9 Cl-105 HCO3-25 AnGap-14 [**2104-1-2**] 02:07AM BLOOD ALT-18 AST-30 AlkPhos-50 TotBili-0.3 [**2103-12-31**] 04:35PM BLOOD Calcium-7.9* Phos-4.2 Mg-1.5 Cardiac enzymes: [**2104-1-6**] 09:05AM BLOOD CK-MB-14* MB Indx-2.4 cTropnT-<0.01 [**2104-1-6**] 05:05PM BLOOD CK-MB-16* MB Indx-2.8 [**2104-1-7**] 01:25AM BLOOD CK-MB-14* MB Indx-3.0 cTropnT-<0.01 Prior to DC: [**2104-1-3**] 09:15PM BLOOD WBC-10.3 RBC-3.33* Hgb-10.8* Hct-31.8* MCV-96 MCH-32.5* MCHC-33.9 RDW-13.3 Plt Ct-318 [**2104-1-8**] 06:00AM BLOOD Glucose-132* UreaN-18 Creat-0.8 Na-134 K-5.1 Cl-96 HCO3-32 AnGap-11 [**2104-1-8**] 06:00AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.2 Intraop pathology: pending Brief Hospital Course: Patient was admitted for resection of the anterior floor of mouth SCC with free tissue transfer. Please see Dr. [**Name (NI) 79746**] and Dr.[**Name (NI) 27488**] operative notes for details. She tolerated the procedure well, was transferred to the PACU, and then the SICU intubated and in stable condition. She was tramsfererd to the floor on POD3. Her postoperative course is summarized below by systems: Neuro: Patient became agitated and confused with hallucinations on POD1, consistent with post op delirium. Psychiatry was consulted and followed daily. She was given haldol PRN with good effect. Her QTc was normal and was monitored closely. By POD 3 she was lucid and calm, remaining so for the rest of her hospital course. Her home dose of 0.5 haldol qAM (which by report she takes as a "mood stabilizer") was held. Her neurontin and amitriptyline qHS (for peripheral neuropathy) were initially held given her altered mental status and then restarted on POD8. CV: She was placed on a home dose equivalent of Lopressor. Patient had one brief, asymptomatic run of paroxysmal SVT to 150 BPM, treated successfully with a one time 5mg dose of Lopressor. Her electrolytes were repleted daily PRN. Her blood pressure was adequately controlled. She did have frequent asymptomatic PVCs and an episode of bigeminy on [**1-6**]. An ECG showed no acute changes from baseline. Serial cardiac enzymes were drawn and were negative. Her Lopressor dose was increased from 50 [**Hospital1 **] to 75 TID with good effect. Respiratory: No issues. Patient was sating well on RA by POD5 and continued so to the day of discharge. GI/GU: Patient was made NPO. She received chlorhexidine washes QID. A Dobbhoff was placed intraoperatively and was started on continuous TFs on POD1. Cycling TFs started on POD4 and continued until discharge. Plastics would like her NPO for 2 weeks from the time of her surgery (end date [**2104-1-15**]). ID: No active issues. Prophylactic augmentin while drain in place. Hem: HCT low 30s (chronically anemic), no active issues. It is encouraged that she follow up with her primary care physician to discuss another colonoscopy given her anemia and h/o GI bleeds. Endocrine: Blood sugars were managed with both a RISS and her home dose of Lantus qHS. Endocrine followed in house and made minor adjustments to RISS to tailor cycled tube feeds. Her blood sugar tended to bottom out late afternoon but peaked during cycled tube feeding at night. Her RISS was adjusted accordingly. Surgical wounds: Intraoral bolster was taken down by plastics on POD5. JP drain #2 of the neck was removed on POD4. The left sided JP drain (#1) will remain until f/u with plastics. Flap was viable before discharge. Plastics followed daily to manage wounds. Electrolytes: She developed a mild hyperkalemia (without ECG changes) and mild hyponatremia. A medicine consult was obtained to help define etiology and management. It was concluded that her episodic hyperkalemia was likely secondary to her episodic hyperglycemia, particularly during TFs at nights. Her RISS was adjusted accordingly. She also probably has a mild elevation in total body potassium. Other causes such as RTA type IV and adrenal insufficiency were unlikely sources. Her renal function was normal. Before discharge she was given 30mg kayexelate x 1. Her hyponatremia was likely caused by mild dehydration - with an appropriate increase in ADH - even though she had adequate UO and no creatinine bump during her postoperative course. She did appear dry on exam. Free water boluses were increased to 200mL TID. She also received 500ml NS IV bolus before discharge today. It will be important to continue to trend her electrolytes while at rehab. Nutrition: Patient currently on fibersource HN full strength cycled at night at 90cc/hr x 12 hours, with free H20 boluses at 200mL q8H. She is NPO until [**2104-1-15**]. She is receiving all meds via the dobhoff. Medications on Admission: amitryptiline 25'qhs, haldol 0.5 qAM ("mood stabilizer"), lantus 8 qHS, omeprazole 20 qd, neurotin 100 TID, albuterol inhaler Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): per NGT. Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 2. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 2.5-5 mL PO Q4H (every 4 hours) as needed for pain: per NGT. Disp:*200 mL* Refills:*0* 3. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15) ML Mucous membrane TID (3 times a day). Disp:*1350 ML(s)* Refills:*2* 4. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2 times a day): per NGT. Disp:*600 mL* Refills:*2* 5. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours): Per NGT. 6. Metoprolol Tartrate 50 mg Tablet [**Age over 90 **]: 1.5 Tablets PO TID (3 times a day): per NGT. 7. Senna 8.6 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a day) as needed: per NGT. 8. Haloperidol Lactate 5 mg/mL Solution [**Age over 90 **]: One (1) mg Injection Q6H (every 6 hours) as needed for agitation. 9. Amoxicillin-Pot Clavulanate 500-125 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q8H (every 8 hours): Per NGT; continue until follow up with Dr. [**First Name (STitle) **]. 10. Albuterol 90 mcg/Actuation Aerosol [**First Name (STitle) **]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 11. Insulin Regular Human 100 unit/mL Solution [**First Name (STitle) **]: One (1) Injection per SS: See attached sliding scale protocol. 12. Gabapentin 250 mg/5 mL Solution [**First Name (STitle) **]: Two (2) mL PO TID (3 times a day). 13. Amitriptyline 25 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 14. Insulin Glargine 100 unit/mL Solution [**First Name (STitle) **]: Eight (8) units Subcutaneous at bedtime: see RISS. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Location (un) 86**] Discharge Diagnosis: Anterior floor of mouth squamous cell carcinoma. Discharge Condition: good Discharge Instructions: Please call your doctor or go to the emergency room if your have a fever >101.5F, increased drainage, erythema, swelling, difficuly swallowing, shortness of breath, chest pain, abdominal pain, or any other concerning signs or symptoms. You cannot eat or take med by mouth until [**2104-1-15**]. Your neck drain will be removed when you follow up in clinic with Dr. [**First Name (STitle) **] one week from now. Followup Instructions: Please call and schedule an appointment to see Dr. [**Last Name (STitle) 1837**] and Dr. [**First Name (STitle) **] in 1 week. Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**1-17**] weeks. Completed by:[**2104-1-9**]

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icd9cm

[ [ [] ] ]

[ "42.23", "27.49", "31.42", "27.56", "40.42", "96.6" ]

icd9pcs

[ [ [] ] ]

8581, 8647

2555, 6519

320, 504

8740, 8747

1515, 1521

9209, 9479

1265, 1269

6695, 8558

8668, 8719

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242, 282

532, 1008

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1030, 1101

1117, 1249