ChanBeDu/relevant_section_length · Datasets at Hugging Face

24,929

168,533

11755+56278

Discharge summary

report+addendum

Admission Date: [**2136-12-3**] Discharge Date: [**2136-12-7**] Date of Birth: [**2060-11-18**] Sex: M Service: CT SURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 76-year-old male with a history of hypertension, hypercholesterolemia, a positive family history for coronary artery disease, and a cigar smoker in the past, who presented originally with one month of exertional chest pain. He subsequently underwent a stress echocardiogram on [**2136-10-27**], that showed ST segment depression in Leads I and AVL. There was also minimal inferior ST segment elevation and lateral and inferior hypokinesis seen on echocardiogram after nine minutes of exercise. This ultimately prompted him to undergo a cardiac catheterization by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] that was completed on [**2136-11-26**]. At that time, the cardiac catheterization showed the inferior wall to be severely hypokinetic. Also there was mild posterobasal hypokinesis. The coronary artery lesions included a 90% proximal and mid-right coronary artery stenosis, an 80% distal right coronary artery stenosis. The left main had diffuse disease with 20% stenosis. The proximal left anterior descending was additionally noted to be diffusely diseased with 70% stenosis. The mid-left anterior descending was diffusely diseased and had a 70% lesion. The diagonal I was diffusely diseased with 70 to 80% stenosis, and the intermedius was noted to be diffusely diseased with a 50 to 60% stenosis. The final diagnosis from the catheterization by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was that this patient was suffering from three vessel coronary artery disease with mild left ventricular systolic function. Given that the echocardiogram and cardiac catheterization showed an ejection fraction of approximately 45%, he was therefore slated for an elective coronary artery bypass graft. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: Cataract, tonsillectomy, bowel perforation with primary anastomosis. HO[**Last Name (STitle) **] COURSE: He was admitted on [**2136-12-3**] by Dr. [**Last Name (Prefixes) 411**]. His preoperative chest x-ray had no acute cardiopulmonary disease. Electrocardiogram preoperatively showed no evidence of ischemia. Urinalysis preoperatively was additionally noted to be negative. He was brought to the operating room and underwent a coronary artery bypass graft x 2, including conduit from left internal mammary artery to the left anterior descending, saphenous vein graft to the posterior descending artery, and a right saphenous vein graft to the diagonal. The right saphenous vein graft was performed using a hybrid technique and using the endovascular procedure. It was done on cardiopulmonary bypass with cross-clamping. The patient tolerated the procedure very well. His pericardium was left open. He had an arterial line upon leaving, as well as a CVP right atrial catheter. He had two atrial pacing wires, two mediastinal tubes, and one left pleural tube upon discharge from the operating room. He was brought to the Cardiac Surgical Recovery Unit, where he was rapidly extubated on the night of surgery. He stayed hemodynamically stable overnight, however, he was A-paced given his intrinsic rhythm was found to be in the 50s, and this did not support his blood pressure adequately. On A-pacing of 80, his blood pressure was 106/41. Otherwise his examination was unremarkable. His postoperative hematocrit was noted to be 29.3 compared to a preoperative hematocrit of 39. His BUN and creatinine were 18 and 1.0 compared to 20 and 1.3 preoperatively. Neurologically, the patient was intact. Cardiovascular-wise, he was placed on lasix and aspirin. His Lopressor was held, however, due to the A-pacing and blood pressure issues. He was given chest physical therapy for pulmonary toilet. His diet was advanced accordingly, and his insulin drip was removed, as he was not diabetic. On postoperative day number one, the patient was transferred to the regular floor where, on his first attempt, he made a Level IV activity. He was able to walk 400 feet without assistance with the physical therapist walking alongside. By postoperative day number two, he continued to be afebrile. His A-pacer was removed. His intrinsic rhythm had returned to the low 60s, supporting a blood pressure of 120s to 130s systolic. His chest tube was continued from Intensive Care Unit to the floor secondary to a small air leak that persisted into the second day postoperatively. His sternum remained stable, with no evidence of drainage. The right lower extremity was clean, dry and intact, with no pedal edema. The right saphenous vein graft harvest site was clean, dry and intact. His hematocrit was 28, with a BUN and creatinine of 16 and 1.1. He had calcium and magnesium electrolytes repleted as needed. His chest tube was removed later on the day of postoperative day two after evidence of no air leak was seen. Chest x-ray showed no evidence of pneumothorax. The Foley catheter was subsequently removed. He was tolerating a full diet by postoperative day number three. He was ambulating at a Level V, having completed stairs. He remained in sinus rhythm. It was noted that he had spiked a temperature to 101.6 on postoperative day number three. Subsequently blood cultures, urine cultures, sputum cultures were sent and grew out no organisms. His wounds were clean, dry and intact, with no evidence of cellulitis or drainage. It was felt that this may just be secondary to atelectasis, given no focal abnormality on examination and no specific findings on his panculturing workup. Upon leaving the hospital, he was afebrile, with a temperature of 99.1, blood pressure of 122/72, pulse rate of 72 and sinus. His chest was again noted to be stable, open to air, no dressings present. His lungs were clear. The heart was regular, with no murmurs, gallops or rubs. The abdomen was benign. His right lower extremity showed a well-healing right saphenous vein graft harvest site. Some trace pedal edema was present however, otherwise no issue. DISCHARGE MEDICATIONS: Lopressor 12.5 mg by mouth twice a day, Lipitor 10 mg by mouth once daily, lasix 20 mg by mouth every morning for seven days, K-Dur 20 mEq by mouth once daily for seven days, Colace 100 mg by mouth twice a day, percocet 5/325 one to two tablets by mouth every four to six hours as needed, Protonix 40 mg by mouth once daily. CONDITION ON DISCHARGE: Stable, afebrile, in sinus rhythm. DISCHARGE STATUS: Transferred to home. DISCHARGE DIAGNOSIS: 1. Severe three vessel coronary artery disease status post coronary artery bypass graft x 3 2. History of hypertension 3. History of hypercholesterolemia FO[**Last Name (STitle) 996**]P: The patient is to see Dr. [**Last Name (Prefixes) **] in six weeks. He will follow up with a cardiologist or primary care physician in three weeks. He will be discharged to home, with a wound check to be completed seven to ten days from the time of discharge. The patient is instructed not to drive for 30 days, no heavy lifting greater than ten pounds for 30 days. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2136-12-7**] 00:36 T: [**2136-12-7**] 01:21 JOB#: [**Job Number 37181**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6649**] Admission Date: [**2136-12-3**] Discharge Date: [**2136-12-7**] Date of Birth: [**2060-11-18**] Sex: M Service: CA/TH [**Doctor First Name 1379**] ADDENDUM: Discharge medications include Lipitor 10 mg po q day, Lopressor 25 mg po bid, Lasix 20 mg po q AM time seven days, K-Dur 20 mEq po q day times seven days, aspirin 325 mg po q day, Colace 100 mg po bid, Protonix 40 mg po q day, and Percocet one to two tabs po q four to six hours prn 5/325 one to two tablets po q four to six hours prn pain. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Last Name (NamePattern4) 935**] MEDQUIST36 D: [**2136-12-7**] 00:46 T: [**2136-12-13**] 07:58 JOB#: [**Job Number 6650**]

[ "518.0", "401.9", "997.3", "272.0", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6233, 6559

6683, 8400

2033, 6208

174, 2008

6585, 6662

27,751

168,762

32631

Discharge summary

report

Admission Date: [**2172-10-30**] Discharge Date: [**2172-11-7**] Date of Birth: [**2093-12-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Left subclavian central line [**2172-11-1**] Right PICC line [**2172-11-4**] Paracentesis [**2172-11-5**] Right Internal Jugular Venous Line [**2172-11-7**] History of Present Illness: 78 year-old woman with hypothyroidism, hypertension, diastolic CHF, liver disease, history of colitis and diverticulitis transferred from OSH for GI bleed and new ascites. Patient has a 3 month history of nausea,vomiting and diarrhea (3 times a day for 3 months) with occasional blood in vomit and stool. Also progressive fatigue and dyspnea on exertion. No sick contacts, no recent antibiotics or travel. No abdominal pain. Also distended abdomen over last few days. Per family and patient, liver disease is new but per GI note from OSH past work-up for liver disease ([**2169**] at [**Hospital1 1774**]). . Pt went to referring institution on [**10-25**], found to have Hct of 24, acute renal failure and elevations in LFTs. Per verbal report and notes, patient had intermittent bright red blood per rectum. She received at least 4 units of packed red cells with hematocrit remaining stable. EGD showed only esophagitis. Tagged RBC scan unrevealing. She was administered and IV proton pump inhibitor and octreotide drip. Lactulose started for altered mental status and high ammonium. Creatinine came down from up to 4 to 1.5 with IV crystalloid and blood. Abdominal CT revaled ascites. Paracentesis was performed and peritoneal fluid showed no signs of spontaneous bacterial peritonitis. Family requested transfer to [**Hospital1 18**] for further care on [**10-30**]. . On transfer, she was hemodynamically stable but actively bleeding from below. Octreotide drip was running at 5 mcg/hr. . ROS: On admission, she denied fever, chills, nausea, vomiting, chest pain, abdominal pain, dizziness. Otherwise positive as above Past Medical History: Hypertension Diastolic congestive heart failure Hypothyroidism Colitis [**2168**] colonoscopy at [**Hospital3 2358**] Diverticulitis Ethanol abuse Chronic liver disease Social History: No smoking. Alcohol use in the past (last drink one month ago; 4-5 drinks per week in the past). No intravenous drug use. No past blood transfusions. Family History: Non-contributory Physical Exam: Physical Exam on Admission: VS: Temp: 98.8 BP: 91/43 HR: 87 RR: 12 O2sat: 100% 2L NC GEN: comfortable, NAD, somewhat lethargic HEENT: PERRL, EOMI, icteric, dry MM, op without lesions NECK: supple, JVP approx 7cm RESP: No rales or rhonchi, decreased BS at bases b/l CV: RR, S1 and S2 wnl, no m/r/g ABD: distended, ++b/s, mild discomfort to palpation, no rebound or guarding EXT: no c/c, [**12-3**]+ b/l LE edema, warm, good pulses SKIN: bruises on UE b/l/?mild jaundice NEURO: AAOx1 ("[**Location (un) 76060**] Hospital, [**2162-12-2**]"). Moves all extremities, flapping tremor RECTAL: BRBPR currently, hemorrhoids visible Pertinent Results: At OSH from [**10-30**]: . Na 146, K 4.2, Cl 115, HCO3 22, BUN 36, Cr 1.6 Tbili 6.2, Ammonia 96, AST 63, ALT 50, TSH 14.04 WBC 6.9, Hct 30.2, Plt 50 . EKG (from [**10-30**] at OSH): NSR at 98, nl axis, no acute ST changes, old Qs in V1-V3 . Imaging: . Abd CT at OSH: per verbal report no acute findings except for ascites Head CT at OSH: per verbal report no acute changes EGT at OSH: per verbal report only esophagitis, no ulcer or varices . CXR [**10-31**] (read pending): small b/l pleural effusions, no definite infiltrate or volume overload, R SC in place (upper IVC) Brief Hospital Course: 78 year-old woman with transferred from outside hospita; for GIB and new ascites. Initially admitted to medical ICU and transferred to liver service on [**2172-11-3**] for further management of liver disease. . # Gastrointestinal Bleed: Presented with bright red blood per rectum and thought to have an upper GI bleed. However, she subsequently had several episodes of melena during the hospitalization in the MICU. At OSH received 4 units of PRBC's for a hematocrit of 24. At [**Hospital1 18**], she underwent inpatient EGD and which revealed portal hypertensive gastropathy, a hiatal hernia, schatzki's ring, and NO esophageal varices. Colonoscopy revealed sigmoid diverticulosis without evidence of bleeding. Once on the medical floor her hematocrit remained stable. . # Liver disease / cryptogenic cirrhosis Patient had prior work-up at [**Hospital1 1774**] which concluded possible iron overload versus alcohol-induced hepatic cirrhosis. At the referring institution she underwent diagnostic paracentesis which reportedly showed no evidence of spontaneous bacterial peritonitis. On exam she was icteric, had asterixis and fluctuating mental status consistent with hepatic encephalopathy. Iron studies were consistent with iron overload. Hemochromatosis gene study was sent and is pending at the time of this note. Hepatitis panel was positive for hepatitis A antibodies but negative for hepatitis B or C exposure. [**Doctor First Name **] / AMA / Anti-smooth antibodies were negative. On the liver service she was started on lactulose and rifaximin. For her ascites, she was started on spironalactone and furosemide. For her varices she was started on low dose nadalol. On the liver service paracentesis on was repeated on [**2172-11-5**] and was not consistent with SBP. Her INR remained elevated and platelets low but stable for both. . #Septic Shock- On Hospital day 7, patient was noted to have decreased urine output, hypotension to a nadir of 50s-70s systolic at which time she was transferred to the MICU for further management. A right internal jugular venous line was placed emergently for fluid resuscitation as well as administration of pressors. She was intubated for respiratory distress. Putative sources of sepsis included pulmonary (nosocomial vs. aspiration pneumonia), urinary and gastrointestinal (given recent procedures and possible bacterial translocation). She was started on vancomycin, piperacillin-tazobactam and metronidazole to cover for these potential sources. Despite maximum doses of four pressors her blood pressure continued to remain low. Blood cultures came back positive 4/4 bottles for gram negative rods. Urine culture grew 10,000-100,000 gram negative rods. Peritoneal fluid culture demonstrated no growth. Despite aggressive resuscitative measures, she demonstrated progressively worsening hemodynamics, tissue hypoxia and end-organ dysfunction. She was made DNR. She expired on [**2172-11-7**] following cardiopulmonary arrest. Medications on Admission: Meds at Home Thyroxine 100 mcg daily Atenolol 50 daily Lovastatin 20 daily Prevacid 1 tab daily . Meds on transfer: Octreotide gtt at 50mcg/hr Tylenol prn Unasyn 3gm IV q8h PR Lactulose 40gm q8h Ativan per CIWA Lovastatin 20 daily MVI, Folate, thiamine Ondansetron 4mg IV q4h prn Pantoprazole 40mg PO daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "96.04", "45.23", "45.13", "96.71", "54.91", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

7176, 7185

3795, 6788

326, 484

7236, 7245

3196, 3772

7301, 7311

2516, 2534

7147, 7153

7206, 7215

6814, 6913

7269, 7278

2549, 2563

278, 288

512, 2140

2577, 3177

2162, 2332

2348, 2500

6931, 7124

40,697

144,006

39298

Discharge summary

report

Admission Date: [**2196-8-17**] Discharge Date: [**2196-8-28**] Date of Birth: [**2129-11-8**] Sex: F Service: SURGERY Allergies: Bacitracin Attending:[**First Name3 (LF) 4691**] Chief Complaint: acute onset of shortness of breath Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: 66F who was recently hospitalized on [**2196-8-4**] for right breast hematoma sustained in a MVC who now presents with acute onset shortness of breath secondary to bilateral pulmonary emboli. Her symptoms began on the morning of admission and the patient went immediately to an OSH where the diagnosis of pulmonary embolus was made. The patient has been feeling well otherwise since she was discharged from [**Hospital1 18**] on [**8-12**]. She does recall a slight pain in right calf which began last evening but denies swelling. She is ambulating periodically as an outpatient, but has not yet met her baseline. Past Medical History: PMH: afib, LBBB, hypothyroidism, hypertension, NIDDM, uterine cancer PSH: hysterectomy, cardiac ablation x 2, left total hip replacement x 2 Social History: Patient lives with her husband of 34 years, they have five children, 1 daughter in [**Name (NI) 4754**], 2 daughters in [**Name2 (NI) **], and twin sons who also live in [**Name (NI) **], [**Name (NI) **]. Family History: NC Physical Exam: ON ADMISSION: Physical Exam: 98.6 112 151/75 18 94%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: mild increased work of breathing, Rales bilaterally (~1/2 up), right worse than left. large right breast hematoma/eccymosis with induration ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, diffuse ecchymosis and multiple areas of induration over mid-abdomen Ext: right LE slightly edematous vs left, LE warm and well perfused Pertinent Results: [**2196-8-17**] D-DIMER-[**Numeric Identifier **]* IMAGING: CTA Chest ([**2196-8-17**]) 1. Bilateral extensive pulmonary emboli involving the right and left pulmonary arteries and the segmental branches of all lobes. Findings suggestive of right heart strain. Recommend further evaluation with echocardiogram. 2. Bilateral pleural effusions, left greater than right. Atelectasis and infarction in the left lower lobe. 3. Calcification of the gallbladder wall and cholelithiasis. Gallbladder wall calcification (porcelain gallbladder) significantly increases patient risk of gallbladder malignancy. Bilateral LE Veins ([**2196-8-17**]): IMPRESSION: Extensive bilateral lower extremity DVTs. In the right lower extremity, DVT is seen in the distal right superficial femoral vein, popliteal vein and the proximal calf veins. In the left lower extremity, DVT is seen in the distal superficial femoral vein, and the proximal calf veins. Right Breast Ultrasound ([**2196-8-23**]): IMPRESSION: Large right breast and chest wall hematoma. Some mobile echoes suggesting a liquid component were seen within a portion of the hematoma, although the ultrasound appearance may not necessarily predict ability to aspirate fluid on needle puncture. Brief Hospital Course: ICU course: Mrs. [**Known lastname **] was readmitted to the hospital on [**2196-8-17**] with multiple bilateral LE DVTs and bilateral pulmonary embolism. Her hospital course is summarized below by system: Neuro: Pain and tension in the right breast was controlled with oral pain medication. CV: She was tachycardic on presentation secondary to the bilateral pulmonary emboli. She was admitted to the ICU on [**8-17**] and started on a heparin drip. An IVC filter was placed on [**2196-8-18**] to prevent further embolism to the lungs. Her heparin gtt was adjusted following serial PTTs with a goal of 60-80. A 2D echo was performed on [**8-18**] showing EF 35% which is a precipitous drop from previously. Her labs showed Tp<0.01, and EKG was WNL. A R PICC was also placed for access. On [**8-20**] she developed SVT vs Afib with RVR and was given adenosine 6mg then 12mg without response. She was then given metoprolol IV and restarted on PO metoprolol per cardiology. On [**8-21**], EP was consulted and she was started on a dilt gtt with discontinuation of her po metoprolol, whereupon her HR improved from 120s to 90s. On [**8-22**], the dilt drip was dc'ed but then restarted for HR in 110s. The transition to PO dilt was started. On [**8-23**], her PO diltiazem was increased and she was started on coumadin for long term anticoagulation. Her diltiazem drip was able to be weaned off with increase in the PO diltiazem. On [**8-24**], a TEE was performed without clot detected and she was transferred to the floor. She was noted to flip in and out of Afib from NSR and thus cardioversion, which had been considered previously by EP was no longer thought to be helpful. Pulm: She was given nasal cannula as needed to maintain acceptable saturations in the setting of clinically significant PEs. GI: She tolerated a regular diet. Heme: She was started on a heparin gtt and transitioned to coumadin for her multiple bilateral DVTs and bilateral PEs. She will continue on this regimen after discharge as directed by her primary doctor, likely indefinitely. PT/PTT/INR was checked regularly and dosages adjusted accordingly. Endo: She was on a RISS. Metformin restarted when consistently tolerating a regular diet. Blood sugars were followed and treated appropriately. GU: Urine output was followed and remained adequate throughout her stay. Musculoskeletal/Soft tissue: She complained of right breast pain secondary to its tenseness from the previous bleed. On [**8-23**], she had a breast u/s to assess for hematoma liquification and possible needle drainage. At this point the collection did not appear drainable. Following the ICU course noted above, the patient was admitted to the [**Hospital1 **] under the care of Dr. [**Last Name (STitle) **]. Heparin drip and coumadin anticoagulation were continued until her INR became therapeutic. On [**2196-8-27**] the patient's INR was 2.0 and coumadin was reduced from 3mg daily to 2mg daily. She was discharged [**2196-8-28**] on diltiazem 90 mg QID and coumadin 2 mg daily in addition to her home medications with VNA services for INR checks. The patient was also asked to follow-up with her PCP for management of her cardiac medications and anticoagulation. At this time she was alert and oriented, ambulating independently and tolerating a regular diet. Medications on Admission: asa 81', amiodarone 200', colace 100mg", felodipine 5', levoxyl 100', lisinopril 40', metformin 500", toprol 150', rosuvastatin 20' Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: please follow INR levels closely for dosing changes. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Home Care Discharge Diagnosis: pulmonary embolism deep venous thrombosis of bilateral lower extremities Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. Regular diabetic diet 2. Activity as tolerated Coumadin (Warfarin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [**Name Initial (PRE) **]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin??????/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. 4. Please [**Name8 (MD) 138**] MD or come to ED if you experience any of the following: Fever greater than 101 Chills Shortness of breath Pain with breathing Coughing up blood Wheezing Any other symptoms that concern you Followup Instructions: Please follow up in the Acute Care Surgery Clinic in [**12-19**] weeks, call ([**Telephone/Fax (1) 2537**] to schedule your appointment. Please follow up with your primary care physician this week to discuss anticoagulation and cardiac medications.

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icd9cm

[ [ [] ] ]

[ "88.51", "38.7", "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

7517, 7574

3189, 6510

305, 327

7690, 7690

1927, 3166

11460, 11712

1382, 1386

6693, 7494

7595, 7669

6536, 6670

7841, 11437

1431, 1908

231, 267

355, 975

1416, 1416

7705, 7817

997, 1142

1158, 1366

74,098

198,276

39167

Discharge summary

report

Admission Date: [**2186-4-14**] Discharge Date: [**2186-4-19**] Date of Birth: [**2142-11-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1515**] Chief Complaint: septal ablation for HOCM Major Surgical or Invasive Procedure: ethanol septal ablation placement of temporary pacing wire History of Present Illness: 43 yo M with hypertrophic cardiomyopathy admitted to CCU following septal ablation. He was diagnosed with HOCM in [**Month (only) 116**] [**2185**] following symptoms of dyspnea and dizziness on exertion. His echo has demonstrated hypertrophic cardiomyopathy with a septum of 16mm and an outflow tract gradient that goes up to 125mm Hg with exertion. The patient has been treated with verapamil, and most recently disopyramide. He reports initial improvement with disopyramide, but since then his symptoms recurred. He denies any palpitations, syncope, orthopnea, or peripheral edema. . The patient was taken to the cardiac catheterization lab for septal ablation. In the cath lab, 1.5 mL of ethanol was injection into the first septal artery. The patient was noted to have transient complete heart block. A temporary pacing wire was inserted. Coronary angiography was normal. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Hypertrophic cardiomyopathy Dyslipidemia Social History: Divorced, lives alone. Works in Sales for wine/liquor. -Tobacco history: Former smoker. Smoked for 5-6 years (<1 pack/day), then quit for 20 years. Then smoked <1 pack/day for 2-3 years (<1 pack/day), quitting within past few months. -ETOH: [**3-2**] drinks/day -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. No family h/o HOCM. Physical Exam: VS: T=98.0 BP=128/80 HR=92 RR=10 O2sat=94%/RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple. JVP not elevated. CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Transvenous pacing wire in right groin. No edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ DP 2+ PT 2+ Left: Carotid 2+ Radial 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [**2186-4-14**] 09:26PM BLOOD WBC-9.5 RBC-4.63 Hgb-14.4 Hct-41.0 MCV-89 MCH-31.1 MCHC-35.0 RDW-12.7 Plt Ct-213 [**2186-4-14**] 09:26PM BLOOD Glucose-120* UreaN-17 Creat-1.1 Na-137 K-3.6 Cl-101 HCO3-25 AnGap-15 [**2186-4-14**] 09:26PM BLOOD Calcium-8.9 Phos-4.5 Mg-2.0 . Cardiac enzymes: [**2186-4-16**] 05:33AM BLOOD CK(CPK)-150 CK-MB-9 cTropnT-0.91* [**2186-4-15**] 04:23AM BLOOD CK(CPK)-325* CK-MB-40* MB Indx-12.3* cTropnT-0.67* [**2186-4-14**] 09:26PM BLOOD CK(CPK)-424* CK-MB-51* MB Indx-12.0* cTropnT-0.48* . Discharge labs: [**2186-4-18**] 04:46AM BLOOD WBC-7.5 RBC-4.15* Hgb-12.9* Hct-37.1* MCV-89 MCH-31.1 MCHC-34.8 RDW-12.5 Plt Ct-178 [**2186-4-19**] 04:50AM BLOOD Glucose-92 UreaN-15 Creat-1.1 Na-140 K-4.3 Cl-102 HCO3-29 AnGap-13 [**2186-4-18**] 04:46AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.1 UricAcd-7.5* . Cardiac catheterization [**2186-4-14**]: 1. Selective coronary angiography of this right dominant system demonstrated no angiographically apparent flow limiting coronary artery disease. The LMCA, LAD, LCX and RCA were patent. 2. Successful placement of 5F temporary venous pacing wire in the RV with capture. Pacing was required during the procedure due to complete heart block and slow escape rhythm. 3. Significant LVOT gradient was demonstrated with dobutamine stress test at 10mcg/kg/min with peak gradient of 120mmg. There is a positive Braunwald Brockenbrough sign suggesting a dynamic obstruction. 4. Successful alcohol ablation of the first septal artery. 5. Successful deployment of 6F Angioseal closure device. . FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Significant LVOT gradient of 120mmHg with dobutamine stress at a dose of 10mcg/kg/min and positive Braunwald Brockenbrough sign suggesting a dynamic obstruction. 3. Successful alcohol ablation of the first septal branch. 4. Successful deploment of angioseal closure device. . Echocardiogram, transthoracic [**2186-4-14**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 70%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Midsystolic closure of the aortic valve leaflets is not seen The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Impression: mild resting left ventricular outflow tract obstruction; normal ventricular function. . Echocardiogram, transthoracic [**2186-4-14**]: Septal perforator supplying basal anterior septum including the obstructing segment identified by Definity. Peak outflow tract gradient during dobutamine 10 mcg/kg/min was 80 mmHg, reduced to 36 mmHg post ethanol ablation with dobutamine 10 mcg/kg/min. The LVOT gradient off inotropic stimulation was 12 mmHg prior to ethanol septal ablation. . Echocardiogram, transthoracic [**2186-4-15**]: There is moderate symmetric left ventricular hypertrophy. There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. Compared with the prior study (images reviewed) of [**2186-4-14**], findings are similar. There is mild LVH, moder significant LVH at the basal septum, with a small resting gradient and systolic anterior motion of the mitral valve. Wall thicknesses may have been UNDERestimated on prior. Brief Hospital Course: # Hypertrophic cardiomyopathy s/p septal ablation: On [**2186-4-14**], the patient underwent ethanol septal ablation. This was complicated by complete heart block. The pre-ablation LVOT gradient was 80 mmHg with dobutamine 10 mcg/kg/min. Post-ablation, the LVOT gradient was 36 mmHg with dobutamine 10 mcg/kg/min. Disopyramide was initially held post-ablation but was restarted at the patient's previous dose prior to discharge. Aspirin was also started at 81 mg daily. . # Complete Heart Block: The patient developed complete heart block as a complication of septal ablation. He underwent placement of an ICD on [**2186-4-18**]. He will follow up in the device clinic on [**2186-4-25**]. . # Dyslipidemia: Continued Lipitor at home dose. . # Right knee pain: The patient developed pain in his right knee. This was initially treated with acetaminophen and oxycodone. Indomethacin was added due to concern about gout. The patient was discharged on indomethacin and Percocet. Medications on Admission: Lipitor 10mg QHS disopyramide 300 mg [**Hospital1 **] Discharge Medications: 1. Disopyramide 150 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 5 days. Disp:*15 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:*10 Capsule(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: [**Month (only) 116**] cause drowsiness - do not use when driving. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertrophic cardiomyopathy s/p septal ablation Complete heart block s/p ICD/pacemaker Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [**Hospital1 18**] for ablation of your hypertrophic cardiomyopathy. After the procedure, you developed an abnormal heart conduction requiring a pacemaker/defibrillator, which was placed without complication. You also had some right knee pain that may have been due to gout. Please take all medications as prescribed. We have made the following medication changes: - Started aspiring 81mg daily. - Started cephalexin for 3 days to prevent infection after placing the pacemaker. - Started indomethacin for 5 days to help inflammation for gout. - Prescribed a small amount of oxyxcodone/tylenol (Percocet) for pain control after the pacemaker placement. Followup Instructions: You have an appointment scheduled with the device clinic at [**Hospital 61**] on [**2186-4-25**] at 1:00pm. If you have any questions or want to reschedule this appointment, you should call the clinic at [**Telephone/Fax (1) 62**]. Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 81446**] on [**4-28**] at 3pm at 115 Technology Dr [**Last Name (STitle) 86752**], CT. Phone: [**Telephone/Fax (1) 86753**]. Please call your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] at [**Telephone/Fax (1) 86754**] for a follow up appointment for within the next 3-4 weeks.

[ "E878.8", "530.81", "426.52", "997.1", "426.0", "250.00", "425.1", "274.9", "424.0", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "37.34", "88.52", "37.78", "37.23", "88.56", "37.94" ]

icd9pcs

[ [ [] ] ]

8577, 8583

6827, 7802

340, 400

8723, 8723

2752, 2752

9569, 10210

1878, 1985

7906, 8554

8604, 8702

7828, 7883

4323, 6804

8871, 9238

3299, 4306

2000, 2733

1414, 1487

3055, 3283

9258, 9546

276, 302

428, 1306

2768, 3038

8738, 8847

1518, 1560

1328, 1394

1576, 1862

51,676

178,480

4681

Discharge summary

report

Admission Date: [**2104-1-7**] Discharge Date: [**2104-1-18**] Date of Birth: [**2019-8-14**] Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline / Amoxicillin / Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Transfer from OSH, STEMI Major Surgical or Invasive Procedure: [**2104-1-11**] urgent cabg x3 (LIMA to LAD, SVG to OM, SVG to PDA)/ MV repair (28 mm CE ring)/IABP History of Present Illness: 84 y/o M with a history of diet-controlled diabetes, hypertension presented to [**Hospital **] hospital from PCP's office earlier today with cough productive of yellow sputum, sinus congestion, chest pain with coughing, and shortness of breath for the last several days, no fever. PCP subsequently sent patient to the Emergency room on 2L O2. Patient's initial vitals on arrival to ED were HR 102 BP 116/81 RR 20 92% 2L. CXR done showed "diffuse asymmetric interstitial and alveolar process, worse on the right," pulmonary edema vs. pneumonia. Initial ECG showed NSR, LVH, TWI/STD in Leads V4-V6, Q wave III. He received 40 mg IV Lasix. He then desated to 80% when on the commode and was intubated for hypoxic respiratory failure. ECG showed [**Street Address(2) 1766**] elevation in V3, 1 mm V2, Trop I 10. He was given another 40 mg IV Lasix, started on a heparin gtt, given aspirin 325, plavix 300, and taken urgently to the cath lab. Prior to cath, he was started on a dopamine gtt after SBPs were in the 40s, after recieving multiple doses of propofol/fentanyl during intubation. . Cath showed 90% distal left main disease, 80% mid-LAD, 80% D2, 80% Circumflex, totally occluded distal RCA. Right heart cath was performed (on dopamine and with IABP placed), showing CO 6.38, CI 3.4, SVR 709, PCWP 18, PAP 39/20 (25). Patient was transferred to [**Hospital1 18**] via [**Location (un) 7622**] for evaluation for urgent CABG. . On arrival to [**Hospital1 18**], he had been weaned off dopamine gtt. Initial vitals were HR 69 BP 94/52 RR 24 RR 100% on CMV 500 100% 14 5. IABP was in place. . Remainder of review of systems unobtainable as patient intubated and sedated. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes (diet controlled), Hypertension 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: - allergic rhinitis - anxiety - osteoarthritis - olecranon bursitis [**2103-12-28**] Social History: - Tobacco history: quit [**2066-12-21**] - ETOH: yes Family History: - Mother: died of cervical cancer at 58 yo - Father: died of "old age" at 88 yo -brother has hypertension Physical Exam: VS: HR 69 BP 94/52 RR 24 RR 100% on CMV 500 100% 14 5 79 kg GENERAL: Intubated, sedated. Unresponsive. HEENT: Sclera anicteric. PERRL. NECK: Supple with JVP of 8 cm at 10 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,, occassional premature beat. normal S1, S2, left-sided S3. No murmurs. LUNGS: Coarse breath sounds in ant fields bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness EXTREMITIES: 1+ Distal pulses b/l. No edema. Warm. SKIN: + stasis dermatitis Pertinent Results: ADMISSION LABS: . [**2104-1-7**] 11:55PM BLOOD WBC-12.6* RBC-4.07* Hgb-12.9* Hct-36.6* MCV-90 MCH-31.7 MCHC-35.2* RDW-14.7 Plt Ct-159 [**2104-1-7**] 11:55PM BLOOD PT-14.0* PTT-105.9* INR(PT)-1.2* [**2104-1-7**] 11:55PM BLOOD CK-MB-213* MB Indx-13.2* cTropnT-2.43* [**2104-1-7**] 11:55PM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0 . CARDIAC CATH: 90% distal left main disease, 80% mid-LAD, 80% D2, 80% Circumflex, totally occluded distal RCA. Right heart cath was performed showing CO 6.38, CI 3.4, SVR 709, PCWP 18, PAP 39/20 (25) Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is moderately depressed (LVEF= 25 - 30 %) with preserved basal segments but hypokinetic mid segments and akinesis of the apex. There is moderate global RV hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. There is an IABP 3 cm distal to the left subclavian artery. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. The jet is central and reflects poor co-aptation of the leaflet tips which is worsened by provocation with Trendelenburg position. There is no pericardial effusion. Post-CPB: The patient is AV-Paced on no inotropes. LV systolic fxn is improved to an EF of 35 - 40%. There is a partial mitral ring prosthesis with no leak, no MR and a residual mean gradient of 4 mmHg. AI remains trace - 1+. IABP in good position. Aorta intact. Brief Hospital Course: CAD/Cardiogenic Shock: Cath showing severe 3-vessel disease amenable to CABG. Echo [**1-8**] showing hypokinesis distal anterior/septal segments and the apex (mid-LAD distribution). LVEF = 40%. As he was having ongoing ECG changes, he was started on an integrillin gtt. He was diuresed due to pulmonary edema on CXR and high wedge on PA catheter tracings. Patient was plavix loaded at OSH; Plavix was held prior to CABG. Patient remained on IABP on 1:1, as urine output decreased when pump was weaned. He was weaned of a dopamine drip, started on a beta blocker. # Acute on chronic renal failure: Baseline Cr .9. Likely secondary to renal hypoperfusion from cardiogenic shock/hypotension. Cr 1.6 on arrival, trended down to 1.3 prior to CABG. Taken urgently for surgery on [**1-11**]. Transferred to the CVICU in stable condition. IABP removed on POD #1. PICC placed for access and removed before discharge. Went into A Fib on [**1-12**] also and was started on amiodarone. Remained in ICU for BP and respiratory mgmt. Extubated on POD #2. Amiodarone stopped per cardiology due to conversion pauses and managed with beta blockade.Evaluated for aspiration risk. Chest tubes and pacing wires removed per protocol. Coumadin started for A Fib. Transferred to the floor on POD #5 to begin increasing his activity level. He was gently diuresed toward his perop weight. Continued to make good progress and was cleared for discharge to [**Hospital 19771**] Rehab in [**Location (un) 2624**]. Target INR 2.0-2.5 for A Fib. Medications on Admission: - MVI daily - [**Doctor First Name **] 180mg daily Patanol 0.1% Eye drops- 1 gtt both eyes [**Hospital1 **] Fluticasone 50mcg nasal spray 2 sprays each nostil daily amlodipine 7.5mg daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day. 3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. warfarin 1 mg Tablet Sig: rehab provider to order daily;target INR 2.0-2.5 for AFib Tablets PO DAILY (Daily) as needed for AF: target INR 2.0-2.5; dose for today [**1-18**] only 0.5 mg; all further dosing per rehab provider. 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. insulin fixed dose and sliding scale ( see attached) see attached Discharge Disposition: Extended Care Facility: Hellenic - [**Location (un) 2624**] Discharge Diagnosis: CAD s/p cabg x3/MV repair cardiogenic shock NSTEMI postop A Fib diet-controlled diabetes mellitus hypertension anxiety osteoarthritis olecranon bursitis [**2103-12-28**] 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 - 1+ BLE 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) **] Thursday [**2-7**] @ 1:15 pm Cardiologist:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ( his office will call you with appt) Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 19772**] in [**3-25**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication A Fib Goal INR 2.0-2.5 First draw tomorrow [**1-19**] Please arrange for coumadin/INR f/u prior to discharge from rehab Completed by:[**2104-1-18**]

[ "785.51", "403.90", "428.21", "410.71", "585.9", "518.81", "997.1", "414.01", "250.00", "414.2", "287.49", "428.0", "424.0", "584.9", "427.31", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "36.15", "35.33", "38.97", "39.61", "96.72", "36.12" ]

icd9pcs

[ [ [] ] ]

7504, 7566

4699, 6223

331, 436

7780, 8017

3108, 3108

8941, 9655

2466, 2575

6462, 7481

7587, 7759

6249, 6439

8041, 8918

2590, 3089

2254, 2259

267, 293

464, 2146

3124, 4676

2290, 2378

2168, 2234

2394, 2450

26,763

146,230

22966

Discharge summary

report

Admission Date: [**2186-3-10**] Discharge Date: [**2186-3-14**] Date of Birth: [**2137-3-4**] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Penicillins / Demerol / Ampicillin / Melon Flavor Attending:[**First Name8 (NamePattern2) 1103**] Chief Complaint: Left femur deformity Major Surgical or Invasive Procedure: [**2186-3-10**]: attempted femoral Osteotomy History of Present Illness: The patient is a 49 year old female who had a left femur fracture approximately 25 years ago which was treated with traction. She was left with a left leg deformity. She now presents for treatment. Past Medical History: L femur fracture 25years ago treated by traction Left total knee arthroplasty Social History: art teach; former smoker; rare etoh Family History: NC Physical Exam: Upon discharge AVSS NAD A+O CTA b/l RRR S/NT/ND LLE: incision c/d/i NVI distally Pertinent Results: [**2186-3-10**] 11:13PM CK(CPK)-226* [**2186-3-10**] 11:13PM CK-MB-6 cTropnT-0.21* [**2186-3-10**] 11:13PM HCT-29.2* [**2186-3-10**] 06:10PM HCT-30.2* [**2186-3-10**] 04:41PM CK(CPK)-217* [**2186-3-10**] 04:41PM CK-MB-7 cTropnT-0.44* [**2186-3-10**] 02:15PM TYPE-ART TEMP-36.2 RATES-/17 O2-50 PO2-193* PCO2-47* PH-7.36 TOTAL CO2-28 BASE XS-0 INTUBATED-INTUBATED [**2186-3-10**] 11:30AM GLUCOSE-115* UREA N-17 CREAT-0.7 SODIUM-139 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11 [**2186-3-10**] 11:30AM estGFR-Using this [**2186-3-10**] 11:30AM CK(CPK)-89 [**2186-3-10**] 11:30AM CK-MB-4 cTropnT-0.17* [**2186-3-10**] 11:01AM TYPE-ART PO2-275* PCO2-45 PH-7.39 TOTAL CO2-28 BASE XS-2 [**2186-3-10**] 10:45AM WBC-14.5*# RBC-2.97* HGB-8.4* HCT-24.8* MCV-83 MCH-28.1 MCHC-33.8 RDW-13.7 [**2186-3-10**] 10:45AM NEUTS-96* BANDS-0 LYMPHS-3* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2186-3-10**] 10:45AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL [**2186-3-10**] 10:45AM PLT SMR-NORMAL PLT COUNT-292 [**2186-3-10**] 10:45AM PT-13.5* PTT-23.1 INR(PT)-1.2* [**2186-3-10**] 10:45AM RET AUT-1.3 [**2186-3-10**] 09:20AM TYPE-ART PO2-36* PCO2-44 PH-7.37 TOTAL CO2-26 BASE XS-0 [**2186-3-10**] 09:20AM GLUCOSE-196* LACTATE-4.0* NA+-137 K+-2.9* CL--104 [**2186-3-10**] 09:20AM HGB-10.0* calcHCT-30 [**2186-3-10**] 09:20AM freeCa-1.12 Brief Hospital Course: The patient was brought to the operating room on [**2186-3-14**] for a left femur osteotomy. See operative note for details. Her operation was complicated by desaturation and hypotension and was aborted. The wound was closed and she was transferred to the ICU for further management. A CTA was done that was negative. Differential diagnosis was fat emboli versus acute blood loss. She was stabilized and extubated in the ICU and transferred to the floor to the orthopedic service. Her labs and vital signs remained stable. She was evaluated by physical therapy and progressed well. Her hospital course was otherwise wihout incident. She is being dicharged today in stable condition. Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for hip pain. Disp:*90 Tablet(s)* Refills:*0* 2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30 mg syringe Subcutaneous Q12H (every 12 hours) for 3 weeks. Disp:*42 30 mg syringe* Refills:*0* 6. Outpatient Physical Therapy s/p attempted L femoral osteotomy generalized ROM + strengthening, gait training 2x/wk x 6 wks Discharge Disposition: Home Discharge Diagnosis: Left femur malunion Demand ischemia Discharge Condition: Stable Discharge Instructions: You may continue to bear weight on your left leg. Please keep incision clean and dry. Dry dressing daily as needed. If you notice any increased rednesss, swelling, drainage, temperature >101.4, or difficulty breathing please [**Name8 (MD) 138**] MD or report to the emergency room. Please take all medications as prescribed. You need to take the lovenox injections for 3 weeks to prevent blood clots. You may resume any normal home medications. Please follow up as below. Call with any questions or concerns. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] is 2 weeks. Call [**Telephone/Fax (1) **] to make that appointment. Completed by:[**2186-3-22**]

[ "998.11", "V64.1", "278.01", "518.5", "458.29", "E878.8", "733.81", "997.1", "530.81", "V43.65", "427.5", "493.90" ]

icd9cm

[ [ [] ] ]

[ "93.26", "83.02" ]

icd9pcs

[ [ [] ] ]

3851, 3857

2376, 3070

354, 401

3937, 3946

927, 2353

4511, 4664

801, 805

3093, 3828

3878, 3916

3970, 4488

820, 908

294, 316

429, 630

652, 731

747, 785

45,936

122,903

40634

Discharge summary

report

Admission Date: [**2133-6-29**] Discharge Date: [**2133-7-8**] Date of Birth: [**2077-9-15**] Sex: M Service: MEDICINE Allergies: Titanium Attending:[**First Name3 (LF) 613**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP, biliary stent placed Intubation/Mechanical Ventilation PICC line placement History of Present Illness: 55 yo morbidly obese male with history of DM II, CAD s/p CABG, chronic bilateral lymphedema, and obesity hypoventilation syndrome presented with intermittent LUQ abdominal pain. He initially presented to the OSH with fever to 102.9, and a sharp, intense, stabbing pain awoke him from sleep. It was initially LUQ pain but radiated to the RUQ. He took a double dose of his pain medication and the pain went away. He tried to avoid pain medication later in the day, but the pain came back. He also notes red extremities, but denies cough, SOB, CP, nausea, vomiting, dysuria, or diarrhea. He presented to the OSH for this acute worsening of his abdominal pain. He was found to have a transaminitis with an elevated lipase. His urine was clear after antibiotics. Zosyn was started for empiric coverage of his cellulitic process and for intraabdominal coverage. He was given Dilaudid with subsequent somnolence. ABG at that time revealed 7.28/81/52/38. All narcotics were held and he was placed on BiPap with subsequent improvement. . His hospital course continued with his respiratory status helped some by diuresis. The next morning he was pain free but his bilirubin continued to climb from 2.6 upon admission. Now, his pain has returned in the RUQ though not particularly severe. Bilirubin now 4.5, AlkPhos 185, with a mild transamnitis (60s-80s). GI saw him at [**Location (un) 2251**] and they were unwilling to intervene. Given his persistent pain and transaminitis, RUQ u/s was performed which revealed GB wall inflammation and thickening up to 1cm without any stones visualized. [**Doctor First Name **] there refused to take him for cholecystectomy, so he was transferred to [**Hospital1 18**] for potential intervention. . On the floor, he is sedated and difficult to arouse. He is falling asleep during conversation but notes improved abdominal pain. He denies any other symptoms of CP, SOB, palpitations, N, V, diarrhea, constipation, or leg pain. He reports noncompliance with his BiPap machine noting that he "is an idiot". . Review of systems: (+) Per HPI (-) Denies 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, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: COPD on home oxygen HTN Morbid obesity Chronic respiratory failure with hypoventilation syndrome Asthma DM type II CAD s/p CABG x4 in [**2126**] GERD PTSD Major depression Herpes Zoster OSA using BiPAP at times PFO Chronic stasis dermatitis Hypothyroidism Chronic pain syndrome Social History: Lives alone, greater than 45 pack year smoker, continues to smoke 1 pack per week. Denies EtOH. Has one son [**Name (NI) 382**]. Family History: Father - heart disease, lymphoma; Mother - heart disease. Physical Exam: ICU Admission Exam: Vitals: 97.3 130 109/57 70 21 89% on 6L NC General: Alert, oriented, no acute distress , Bipap mask on HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse wheezes CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: no bruising, +BS, soft, protuberant, non-distended, marked RUQ and LUQ tenderness, no rebound tenderness or guarding, no organomegaly GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, bilateral chronic changes with erythema [**Hospital Unit Name 153**]-->MICU Transfer Exam: VS: T 98.4 HR 94 BP 128/76 RR 23 93%/5LxNC GEN Morbidly obese man, appears uncomfortable in extra-large bed but NAD HEENT: NCAT EOMI PERRLA MMM mild scleral icterus neck supple no JVD CV: Irregularly irregular no murmur PULM: Prominent wheeze throughout respiratory cycle ABD: soft, obese, full but nontympanic or distended, nontender to deep EXT: 2+ pitting edema to knees equal bilaterally superimposed upon stigmata of chronic venous stasis surrounding RLE scar from bypass surgery Foley +dark urine Discharge: Vitals: 99.2/98.8 105/72 102 22 92% 5L General: Alert, oriented, no acute distress, morbidly obese man sitting in bariatic bed HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, nontender Lungs: Wheezes bilaterally CV: Irregular, normal rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: 2+ edema bilaterally with severe chronic venous stasis changes and erythema on R>L. Pertinent Results: [**2133-6-29**] 03:27AM GLUCOSE-96 UREA N-22* CREAT-1.2 SODIUM-140 POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 [**2133-6-29**] 03:27AM ALBUMIN-3.4* CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-2.1 . [**2133-6-29**] 03:27AM ALT(SGPT)-78* AST(SGOT)-67* ALK PHOS-190* TOT BILI-5.3* [**2133-6-29**] 03:27AM LIPASE-43 . [**2133-6-29**] 03:27AM WBC-10.3 RBC-4.94 HGB-12.2* HCT-39.4* MCV-80* MCH-24.6* MCHC-30.9* RDW-15.6* [**2133-6-29**] 03:27AM NEUTS-83.4* LYMPHS-7.8* MONOS-7.2 EOS-1.2 BASOS-0.3 . [**2133-6-29**] 03:27AM PT-14.2* PTT-26.1 INR(PT)-1.2* . [**2133-6-29**] 11:51PM TYPE-ART PO2-67* PCO2-71* PH-7.27* TOTAL CO2-34* BASE XS-2 .[**2133-6-29**] 03:35AM %HbA1c-6.7* Discharge Labs: [**2133-7-8**] 05:43AM BLOOD WBC-8.7 RBC-5.02 Hgb-11.8* Hct-40.5 MCV-81* MCH-23.5* MCHC-29.1* RDW-16.9* Plt Ct-247 [**2133-7-8**] 05:43AM BLOOD PT-16.6* PTT-27.5 INR(PT)-1.5* [**2133-7-8**] 05:43AM BLOOD Glucose-142* UreaN-19 Creat-0.9 Na-137 K-5.2* Cl-91* HCO3-40* AnGap-11 [**2133-7-7**] 06:07AM BLOOD ALT-46* AST-37 AlkPhos-145* TotBili-1.4 [**2133-7-8**] 05:43AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1 Imaging: Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global systolic function. . RUQ U/S: [**2133-6-30**] IMPRESSION: 1. Mildly echogenic liver consistent with fatty infiltration. No intra- or extra-hepatic biliary dilatation. 2. Small gallstone. Limited evaluation of gallbladder does not demonstrate evidence of acute cholecystitis . Gallbladder scan:[**2133-7-1**] IMPRESSION: 1. Cholecystitis, cannot determine whether this is acute versus chronic. . RUQ U/S: [**2133-7-5**] IMPRESSION: 1. Contracted gallbladder with multiple gallstones. No evidence of acute cholecystitis. 2. Mildly echogenic liver, consistent with fatty infiltration. Superimposed fibrosis and cirrhosis cannot be excluded. . Brief Hospital Course: 55 yo morbidly obese male with history of DMII, CAD s/p CABG, chronic bilateral lymphedema, and obesity- hypoventilation syndrome presented with RUQ and LUQ abdominal pain, found to have rising LFTs, fever and evidence of cholecystitis on ultrasound. . # Abdominal Pain: Pt presented to OSH with LUQ and RUQ abdominal pain and elevated LFTs. Transferred to the [**Hospital1 18**] ICU because surgery and ERCP services at the OSH were hesitant to intervene in this morbidly obese patient with multiple comorbidities. His symptoms were thought to be caused by either gallstone pancreatitis, cholangitis, and/or cholecystitis. ERCP performed here showed no gallstones, sludge or obstruction to explain elevated LFTs; CBD stent was placed (will require removal by repeat endoscopy as an outpatient after discharge). Repeat ultrasound 24h after ERCP was nondiagnostic due to pneumobilia, likely secondary to ERCP. HIDA scan did show biliary obstruction and surgery recommended percutaneous cholecystostomy, however patient's exam and LFTs improved after stent placement. Repeat u/s showed a contracted gallblader and did not show evidence of cholecystitis, therefore no further intervention was performed. He completed a 10 day course of unasyn. Prior to discharge his LFTs continued to normalize and notably his total bilirubin normalized to 1.4. # Obesity Hypoventilation Syndrome/COPD: Original reason for ICU admission. Patient on 5L home O2 and bipap. Initial ABG with elevated paCO2 and on initial presentation he was somnolent, poorly ventilating when oversedated which all improved with BiPAP, which he wore at night and during daytime naps and during periods of increased somnolence. He required intubation for ERCP and was difficult to extubate, with high PaCO2 on ABGs. O2 sats remained in the low 90s on his home 5 liters which is his baseline for nearly four days prior to discharge. Of note, he is on high dose opioids at home for chronic pain: 120 mg MS [**First Name (Titles) **] [**Last Name (Titles) **]D + PRN oxycodone; these pain meds were reduced as they were thought to contribute to his somnolence and hypoxia. He remained on the lower dose without complaints. # Atrial fibrillation: Patient on home metoprolol 25 TID but unaware of his atrial fibrillation; unclear whether this is new. Initially required diltiazem gtt for rate control in the ICU, then stabilized on a PO regimen of metoprolol and diltiazem. Continued home aspirin. Echo performed which showed an enlarged left atrium. Started warfarin. He was not at therapeutic levels prior to discharge and this will need to be closely monitored in rehab. Goal INR [**1-15**]. #Chronic pain: Patient on pain meds at home as above. Patient felt his pain was well-controlled on reduced MS contin dose of 60-75 mg TID + 20 mg PRN oxycodone while in the ICU. # Diabetes: Stable on regimen of 50 lantus daily and HISS. # Edema: patient has chronic venous stasis and is on lasix at home. Echo could not demonstrate diastolic dysfunction due to poor image quality. Initially on IV lasix boluses with good response. Transitioned to his home po lasix of 80 mg daily with good effect. # Hyperlipidemia: Held simvastatin while elevated LFTs, restarted prior to discharge. # GERD: Continued home prilosec. # Code: Full Code #Pending items: -Needs follow-up with ERCP for stent removal in 8 weeks (they will arrange) -INR must be monitored closely in rehab to maintain goal of [**1-15**]. Medications on Admission: Toprol XL 50mg daily Lasix 80mg [**Hospital1 **] nitroglycerin SL PRN MS Contin 120mg q8h Oxycodone IR 30mg q6h prn pain Ativan 2mg [**Hospital1 **] ASA 81 Lantus 50qAM and 10 qhs Novolog sliding scale Metolazone Prilosec 40mg daily K 10mEq [**Hospital1 **] Foradil one capsule [**Hospital1 **] Duonebs qid Albuterol q4h prn sob, wheezing Asmanax one puff [**Hospital1 **] Proctofoam prn Senna two tabs daily Metamucil MVI Ocean nasal spray 4-6L home oxygen Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. oxycodone 5 mg Tablet Sig: 2-4 Tablets PO Q6H (every 6 hours) as needed for breakthrough pain. 4. morphine 75 mg Cap, ER Multiphase 24 hr Sig: One (1) Cap, ER Multiphase 24 hr PO Q8H (every 8 hours): hold for sedation. 5. heparin (porcine) 5,000 unit/mL Solution Sig: 7500 (7500) units Injection TID (3 times a day): to be given until patient is ambulating or INR > 2. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. ampicillin-sulbactam 3 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours) for 1 days: Last Day [**2133-7-9**]. 8. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily). 9. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 13. ipratropium bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for wheeze. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation q2H as needed for wheeze. 15. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: Goal INR [**1-15**]. 16. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous QAM. 17. Humulog Please use according to sliding scale 18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 19. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: Oceanside [**Hospital **] Nursing and Rehab Discharge Diagnosis: Primary diagnosis: Possible Gallstone Pancreatitis Cholecystitis . Secondary diagnosis: Atrial fibrillation OSA obesity-hypoventilation syndrome COPD DMII CAD s/p CABG 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 **], it was a pleasure participating in your care while you were an inpatient at the [**Hospital1 18**]. You were transferred from an outside hospital for an episode of severe abdominal pain. It was thought that this was most likely due to a blockage and infection of your gallbladder and bile ducts. You underwent an ERCP here, in which an endoscopic camera was used to look at your small intestine, pancreas, and gallbladder. There did not appear to be a blockage that could be removed, however a stent was placed to keep your gallbladder from becoming obstructed. You also underwent another radiologic study which showed that there was an obstruction of your gallbladder that could not be seen during the ERCP. For this reason, you were evaluated for surgery and placement of a tube that could be used to drain your gallbladder, but after time your abdominal pain and liver enzymes improved. You did not need further intervention. You were given IV antibiotics and will need a total of 10 days. You ate without abdominal pain and liver enzymes approached near normal prior to discharge. . During your time in the hospital, you also developed a heart arrhythmia called atrial fibrillation. You were treated with metoprolol and diltiazem for this condition, and the optimal doses of these medications were determined while you were here. You should follow up with a cardiologist for further evaluation and treatment of this condition. You should continue your medicines with the following important changes. Continue Warfarin 7.5 mg daily and adjust dose based on INR (goal [**1-15**]) Continue Unasyn 3 mg every 6 hours for one more day. Last day: [**2133-7-9**]. Decrease Oxycontin IR to 10-20 mg every 6 hours as needed for breakthrough pain (from 30 mg) Decrease MS Contin to 75 mg PO every eight hours (from 120 mg every 8 hours) Decrease to Glargine 50 units QAM Increase Metoprolol Succinate 150 mg daily Start Diltiazem extended release 240 mg daily Followup Instructions: Department: ENDO SUITES When: THURSDAY [**2133-8-20**] at 12:00 PM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2133-8-20**] at 12:00 PM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "96.04", "51.85", "51.87", "38.97", "96.71" ]

icd9pcs

[ [ [] ] ]

13526, 13596

7586, 11048

282, 364

13808, 13808

5067, 5757

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13705, 13787

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3209, 3340

11,588

158,032

26906

Discharge summary

report

Admission Date: [**2168-3-31**] Discharge Date: [**2168-4-11**] Date of Birth: [**2101-6-26**] Sex: F Service: MEDICINE Allergies: Prednisone / Aspirin / Codeine / Sulfa (Sulfonamides) / Ivp Dye, Iodine Containing / Bactrim / Procardia Attending:[**First Name3 (LF) 2297**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Tracheal stent placment History of Present Illness: Mrs. [**Known lastname 66188**] is a 66 year old woman with a history of COPD who initially presented to [**Hospital 66189**] Hospital ED with COPD exacerbation and after discharge on [**3-16**] had respiratory arrest thought to be secondary to pneumonia/mucus plugging. She was found to have a LLL pneumonia and was transferred to [**Hospital 1727**] Medical Center for management. There a PEG and trach were placed ([**2168-3-21**]) but has had continued respiratory failure due to tracheobronchial malacia (TBM). She completed a 10-day course for klebsiella and MRSA pneumonias. She was put on phenopbarbital and fentanyl for and sedation. She was transferred to [**Hospital1 18**] for rigid bronchoscopy and stenting for this condition. Past Medical History: COPD on home o2 Hypertension Recurrent DVTs on anticoagulation Anemia Recurrent MRSA and klebsiella pneumnonias Steroid-induced myopathy Social History: 20-40 pack years of tobacco, no known etoh use. Family History: Noncontributory Physical Exam: VS: Tc 100.6 Tm 101.1 BP 113/47 (76-166/47-107) HR 93 (78-117) RR 18 (18-51) Sat 96-100% Wt 104kg I/O: (24hrs) 2646/3960 (net: -1314) VENT: SIMV Tv 600 PEEP 8 RR 14 FiO2 0.5; Tv 645, RR 30, PIP40, Plat 33, MAP 14. GEN: Obese woman in bed, trached, sedated. HEENT: sclerae anicteric, moist mucus membranes NECK: Obese, trached CV: Nl s1/s2, RRR PUL: CTA anteriorly ABD: Obese, large midline healed scar, PEG in place. Slight diffuse TTP to deep palpation. BACK: Coccygeal breakdown (per nursing) EXT: LUE 1+ pitting edema, trace bilateral LE edema with venous stasis dermatitis distally. NEURO: sedated, unarousable. Pertinent Results: [**2168-3-31**] 06:21PM WBC-14.7* RBC-2.91* HGB-8.7* HCT-26.4* MCV-91 MCH-29.9 MCHC-33.0 RDW-14.2 [**2168-3-31**] 06:21PM PLT COUNT-398 [**2168-3-31**] 06:21PM PT-13.3* PTT-64.8* INR(PT)-1.2* [**2168-3-31**] 06:21PM GLUCOSE-126* UREA N-16 CREAT-0.7 SODIUM-138 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14 [**2168-3-31**] 06:21PM MAGNESIUM-2.0 . CXR: L hilar mass at AP window (seen on previous cxr's). . CULTURES: [**2168-4-5**] CATHETER TIP-IV NGTD [**2168-4-3**] BLOOD CULTURE AEROBIC: NGTD [**2168-4-3**] BLOOD CULTURE AEROBIC: NGTD ------------ ANAEROBIC BOTTLE (PRELIMINARY): STAPHYLOCOCCUS, COAGULASE NEGATIVE. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ? OF TWO COLONIAL MORPHOLOGIES. BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW. [**2168-4-3**] CATHETER TIP-IV: No growth [**2168-4-2**] RESPIRATORY CULTURE: MRSA STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S [**2168-4-2**] URINE URINE CULTURE: YEAST [**2168-4-2**] BLOOD CULTURE x2: NGTD [**2168-4-2**] BLOOD CULTURE AEROBIC: {ENTEROCOCCUS SP.}; ANAEROBIC BOTTLE-NGTD ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S PENICILLIN------------ 2 S VANCOMYCIN------------ <=1 S [**2168-4-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT . Brief Hospital Course: Since transfer to [**Hospital1 18**] she developed a fever on [**4-3**] so her a-line and central line were replaced. She went to the OR for stenting on [**4-4**]. A Y-stent was placed to her trachea at the carina and the end of the trach was placed into the end of it. On [**4-5**] she [**Hospital **] transferred to the Medical ICU for further management. . # Respiratory failure/Tracheobronchial malacia: s/p y-stenting [**4-5**], although there is some remaining segments proximally and distally that have malacia. She was switched from PCV ventilation to pressure support on [**4-6**]. She tolerated this well and was slowly weaned. On transfer to MICU for patient was on four agents (ativan, phenobarb, fentynyl and propofol) for sedation. Propofol and ativan were discontinued. Fentynyl patch was applied with goal of decreasing the fentynyl gtt. Phenobarb was also decreased with goal of using fentynyl or versed for sedation. Phenobarb was at 60mg IV BID on transfer and was weaned slowly with goal of decreasing 10mg per day. On [**4-9**] however, pt was tachypneic and did not tolerate PS ventilation which was thought to be secondary to too rapid of weaning of sedatives. Pt was placed back on AC and increased fentanyl patch to 100mcg and restarted Versed. On discharge, she was on Fentanly 50mcg and Versed 2mg. Plan was to continue to wean down with addition of Halidol 2.5mg TID for agitation. . # Fevers/bacteremia: Pt had history of MRSA and klebsiella pneumonias. While in the SICU she had temperature spike she was pancultured and central line was changed. One sputum culture with showed MRSA. She also had blood cultures with enterococcus (sensitive to vanc) and coag negative staph. These were thought to be contaminants. She was started on Vancomycin [**2168-4-2**]. She remained afebrile in the medical ICU with ocassional low grade temp. Her Arterial line was discontinued. She should be treated for total 10 days with Vancomycin and the last dose to be on [**4-12**]. She continues to have a left subclavian. . # h/o DVT: on coumadin at home, unclear when the DVT was diagnosed. She had a upper extremity DVT on [**4-6**] which showed no growth. She was continued on heparin gtt and this was maintained with goal PTT 60-85. She should be restarted on coumadin. . # Pulmonary nodules: CXray showed mediastinal mass and so had a Chest CT which showed Right lobe pulm nodules and mediastinal LAD. Needs further w/u with PET/CT, FNAC. PPD placed on [**4-11**] @ 2:30PM - needs follow up. . # Endocrine: Sliding scale insulin. # Access: Left subclavian central line # PPX: PPI, on heparin gtt. # Code: full # Comm: [**Name (NI) 449**] ([**Name2 (NI) 401**]) [**Name (NI) 66188**] - husband [**Telephone/Fax (1) 66190**], cell [**Telephone/Fax (1) 66191**] # Disposition: Being transferred to [**State 1727**] closer to her family for continued call. Medications on Admission: Heparin gtt 1900u/hr 1000 ml LR 75 ml/hr Insulin gtt Tylenol PRN Lidocaine 1% 1-2 ml IH Q1-2H:PRN cough Albuterol [**4-21**] PUFF IH Q4H:PRN WHEN ON VENT Lorazepam 1 mg PO BID Albuterol-Ipratropium [**4-21**] PUFF IH Q4H WHEN ON VENT Miconazole Powder 2% 1 Appl TP [**Hospital1 **] Diltiazem 60 mg PO/NG QID Phenobarbital 60 mg IV Q12H Escitalopram 10 mg PO DAILY Fentanyl Citrate 125 mcg/hr IV DRIP INFUSION Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO sedation Furosemide 40 mg IV BID Vancomycin HCl 1000 mg IV Q18H Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for WHEN ON VENT. 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**4-21**] Puffs Inhalation Q4H (every 4 hours) as needed for WHEN ON VENT. 5. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 6. Vancomycin HCl 1000 mg IV Q18H 7. 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 8. Insulin Sliding scale 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Lidocaine HCl 1 % Solution Sig: One (1) ML Injection Q1-2H () as needed for cough. 11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 12. Fentanyl Citrate @ 50mcg/hr drip rate 13. Versed @ 2mg/hr drip rate 14. Furosemide 40 mg IV BID 15. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1700units/hr Intravenous ASDIR (AS DIRECTED). 16. Vancomycin HCl 1000 mg IV Q 24H 17. Haloperidol 2.5 mg IV TID Discharge Disposition: Extended Care Discharge Diagnosis: Tracheomlacia Respiratory Failure h/o DVT Discharge Condition: Stable Discharge Instructions: Please continue to take all medications as described. If there is any further difficulties with ventilation or difficulties with the tracheal sent please seek further medical care. Followup Instructions: Please follow up with your PCP after discharge from [**Hospital 1727**] hospital. Please call ([**Telephone/Fax (1) 17398**], Interventional Pulmonary at [**Hospital1 18**] to setup an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] after discharge from [**Hospital 1727**] hospital. Completed by:[**2168-4-11**]

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icd9cm

[ [ [] ] ]

[ "38.93", "33.22", "33.21", "96.72", "96.6", "96.05", "38.91" ]

icd9pcs

[ [ [] ] ]

8467, 8482

3725, 6618

385, 410

8568, 8577

2095, 3702

8807, 9144

1426, 1443

7186, 8444

8503, 8547

6644, 7163

8601, 8784

1458, 2076

326, 347

438, 1185

1207, 1345

1361, 1410

48,606

195,757

36778

Discharge summary

report

Admission Date: [**2166-9-2**] Discharge Date: [**2166-9-6**] Date of Birth: [**2102-12-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: cholangitis Major Surgical or Invasive Procedure: ERCP with sphincterotomy, CBD stent replacement, and CBD brushings History of Present Illness: 63M transferred with hypotension from OSH. Per the patient, he has had painless jaundice for 1 month -- and underwent and ERCP with stenting of a biliary stricture. He notes RUQ pain for 3 days that has now resolved. He denies any fevers/chills, nausea/vomiting, [**Male First Name (un) 1658**]-colored stools. He does note 8 pound weight loss over 3 weeks. No history of gallstones. Past Medical History: DM HTN Social History: plumber from [**Location 51056**]; former drinker 5-6 beers/day Family History: non-contributory Physical Exam: Tc 100.0, HR 108, BP 114/45, RR 20, O2sat 96RA Genl: NAD, scleral icterus, jaundice torso CV: RRR Resp: CTA-B Abd: s/nt/nd; negative [**Doctor Last Name 515**] Extr: no c/c/e Pertinent Results: [**2166-9-1**] 10:20PM PT-13.3 PTT-26.9 INR(PT)-1.1 [**2166-9-1**] 10:20PM PLT COUNT-216 [**2166-9-1**] 10:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2166-9-1**] 10:20PM NEUTS-78* BANDS-14* LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2166-9-1**] 10:20PM WBC-19.3* RBC-2.91* HGB-9.4* HCT-28.6* MCV-98 MCH-32.1* MCHC-32.7 RDW-13.4 [**2166-9-1**] 10:20PM LIPASE-39 [**2166-9-1**] 10:20PM ALT(SGPT)-91* AST(SGOT)-94* CK(CPK)-35* ALK PHOS-295* TOT BILI-7.0* [**2166-9-1**] 10:20PM GLUCOSE-301* UREA N-36* CREAT-1.6* SODIUM-134 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-17* ANION GAP-16 [**2166-9-1**] 10:30PM LACTATE-2.7* Brief Hospital Course: On day of admission on [**2166-9-2**], the patient was initially hypotensive in the ER, requiring pressors. He was admitted to the SICU and started on Unasyn. On ERCP, a migrated stent was removed from major papilla, with pus from the CBD. Cytology samples were obtained from CBD stricture. Pus and sludge was seen in the biliary tree, and a new stent was placed. On [**2166-9-3**], the patient was stable and was transferred to the floor. On [**2166-9-4**], pancreatic lesions were seen on CT abdomen. On repeat ERCP on [**2166-9-5**], the CBD stent was replaced, stricture was examined using confocal microscopy, and sphincterotomy was performed. On [**2166-9-6**], he was discharged home with plan for Whipple with Dr. [**Last Name (STitle) **] in the near future. Medications on Admission: 1. Benicar 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Medications: 1. Benicar 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Pancreatic head mass Stricture of common bile duct 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 is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-1**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: Please call ([**Telephone/Fax (1) 2363**] to inquire about the date and time of surgery with Dr. [**Last Name (STitle) **]. Completed by:[**2166-9-6**]

[ "576.1", "576.2", "577.8", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "51.14", "51.85", "38.93", "97.05" ]

icd9pcs

[ [ [] ] ]

2994, 3000

1902, 2678

324, 393

3095, 3102

1166, 1879

4597, 4751

938, 956

2849, 2971

3021, 3074

2704, 2826

3126, 4574

971, 1147

273, 286

421, 811

833, 841

857, 922

1,247

155,555

30808

Discharge summary

report

Admission Date: [**2148-5-26**] Discharge Date: [**2148-6-5**] Date of Birth: [**2067-7-18**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Aspirin Attending:[**First Name3 (LF) 348**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Right ORIF Central line placement (and subsequent removal) History of Present Illness: 80 y/o F w/MMP who was at rehab [**5-24**], noted to have decreased responsiveness and fingerstick was 25. Given glucagon and oral glucose, FS improved only to 30 so was sent to [**Location (un) **]. In ED, was ? hypoxic and had afib with slow ventricular response, so was admitted. Later that day, she was being transferred from the bed to commode and her legs buckled, she slid to the ground, and landed with her legs beneath her. She heard a "snap" and had immediate pain, and xray showed a R intratrochanteric hip fx. She was seen by [**Location (un) 1957**] there, and the plan (after discussion between [**Location (un) 1957**] and her primary cardiologist, Dr. [**Last Name (STitle) 11493**] was to proceed with surgery although it is high risk given her extensive coronary disease.) However, today she was hypotensive in the 80s/40s with a K of 5.8, so her operation was cancelled and she was sent to their ICU. She had a central line placed to monitor CVP, which was 11. She was placed on dopamine with improvement in her bp to 100s-110s. She was then transferred here for further evaluation. . Her hospital course at [**Location (un) **] was also complicated by respiratory depression which occurred after receiving 2 mg IV dilaudid; this responded well to narcan. She also had a UTI being treated with levofloxacin, persistent diarrhea being treated as presumed C diff (although c diff negative), and acute renal failure (creat 1.4 on admission, increased to 2.5 by day of d/c). Past Medical History: # recent hospitalization at [**Location (un) **] for presumed C diff and acute renal failure [**4-6**], was staying at rehab since then # CAD s/p CABG [**2136**] # Paroxysmal afib, on coumadin # Ischemic cardiomyopathy, EF 40% # moderate mitral regurg # Chronic anemia, on epo # DM # HTN # Hyperlipidemia # R foot wound colonized with MRSA Social History: Lived by herself prior to hospitalization in [**Month (only) 547**]. Never smoked or drank. Was a housewife. Has 3 children from whom she is estranged, but is close to her 2 grandsons. Family History: father died of MI at age 86, mother died at age 51 related to complications from DM Physical Exam: T: 98.4 Bp: 119/59 (off dopamine) P: 89 R: 14 100%RA Gen: awake, alert, pleasant female in NAD HEENT: anicteric, MMM Neck: R IJ in place, site c/d/i Lungs: CTA anteriorly, pt unable to sit completely forward CV: RRR, no m/r/g Abd: soft, nt/nd, +bs Ext: 2+ pitting edema on LLE, 2 cm circular ulcer on L foot dorsum without surrounding erythema, decreased sensation to light touch in R foot (pt reports chronic x yrs), 1 cm ulcer on R heel, 1+ dp pulses bilaterally Pertinent Results: Admission Labs: [**2148-5-26**] 11:03PM URINE HOURS-RANDOM CREAT-127 SODIUM-14 [**2148-5-26**] 11:03PM URINE OSMOLAL-464 [**2148-5-26**] 11:03PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2148-5-26**] 11:03PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2148-5-26**] 11:03PM URINE RBC-21-50* WBC->50 BACTERIA-MOD YEAST-MANY EPI-[**3-4**] [**2148-5-26**] 11:03PM URINE GRANULAR-[**3-4**]* [**2148-5-26**] 06:29PM GLUCOSE-207* UREA N-61* CREAT-2.0* SODIUM-136 POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-16* ANION GAP-18 [**2148-5-26**] 06:29PM estGFR-Using this [**2148-5-26**] 06:29PM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-2.3 [**2148-5-26**] 06:29PM WBC-22.8* RBC-3.57* HGB-10.0* HCT-30.7* MCV-86 MCH-28.1 MCHC-32.6 RDW-18.3* [**2148-5-26**] 06:29PM PLT COUNT-282 [**2148-5-26**] 06:29PM PT-15.1* PTT-27.6 INR(PT)-1.4* . IMAGING: [**5-26**] AP CXR: A single AP view of the chest is obtained [**2148-5-26**] at 18:28. No prior films are available for comparison. The heart is likely top normal in size. There is calcification and tortuosity of the aorta and there are median sternotomy wires present. A right-sided IJ line is present and it has its tip projected over the expected location of the SVC. Linear atelectasis or scarring is seen at the left base. There is no evidence of acute consolidation or frank failure. There is deformity of the distal clavicle likely secondary to prior trauma. IMPRESSION: Linear atelectasis or scarring at the left base. Right-sided IJ line in satisfactory position. . [**5-28**] Hip 2 views: There is an intramedullary rod and a gamma nail. . [**5-30**] Port abd: 1)Limited study which is focused around the pelvis rather than abdomen. However, no abnormal looking bowel loop is demonstrated. No obstruction is noted. No pneumoperitoneum is detected. 2) Status post fracture of the right femoral neck with dynamic hip screw placement. Fracture line is still well visualized. . [**2148-6-4**] Colonoscopy: Impression: External hemorrhoids, Internal hemorrhoids; Erythema, friability, congestion and ulceration in the rectum, compatible with possible inflammation from rectal tube trauma; Otherwise normal colonoscopy to cecum. Recommendations: The rectal inflammation was likely due to rectal tube trauma. If rectal bleeding persists, a follow-up flexible sigmoidoscopy should be performed. Brief Hospital Course: Ms. [**Known lastname 9035**] is a 80 year old woman with CAD, CHF, paroxysmal atrial fibrillation, who was admitted with hypotension and a hip fracture. Her brief hospital course, by problem: . # Hypotension: Initially admitted to the MICU for hypotension briefly requiring dopamine but resolved. Her CVP of 11 not suggestive of either sepsis, volume depletion, or cardiogenic shock. Her leukocytosis is concerning, although may be due to stress from her hip fracture. Her blood pressure remained stable on the medicine floor and at the time of discharge, she had been restarted on her antihypertensive medications. . # Bloody bowel movement. Had bloody BM x 2 on [**5-30**], with stable hematocrit. She went for colonoscopy on [**6-4**], which showed internal and external hemorrhoids as well as friable/inflammed rectal mucosa (which was thought likely secondary to rectal tube). If she continues to have rectal bleeding or pain, she should have a flexible sigmoidoscopy in 4 weeks. . # Hip fracture. Underwent ORIF on [**5-28**], without complications. She should continue Lovenox [**Hospital1 **] for a total of 4 weeks, daily dressing changes, and physical therapy. Pain control with Tylenol and oxycodone. . # CAD. Given beta-blocker, ACE-inhibitor, and statin. . # ARF: Renal function continued to improve with fluids, thought pre-renal etiology secondary to third-spacing from the hip fracture. A foley was in place given a coccygeal ulcer, but this should be removed when the patient is able to ambulate. . # UTI: Urinalysis positive on admission. Treated with ciprofloxacin x 3 days. . # Paroxysmal atrial fibrillation: Continued amiodarone. . # Diarrhea: Treated empirically at [**Location (un) **] (OSH) for C. diff, but both C. diff A and B toxins were not detected in assays here. Flagyl and vancomycin were discontinued. All other infectious sources were ruled out. . # Diabetes: Covered with Humalog sliding scale, restarted Lantus on [**2148-5-31**] at half home dose (15 units per AM) She was low FS so this was decreased to 13 units. Once she restarts on a normal diet, lantus should be retitrated up. Medications on Admission: Tylenol 1000mg tid Albuterol nebs prn Amiodarone 200mg qd Ascorbic acid 500mg [**Hospital1 **] Atorvastatin 20mg qd Ciprofloxacin 500mg qd Epo 4000U sc MWF Dilaudid 0.5mg q4h prn Heparin sc Insulin SS Atrovent nebs q6h prn Metoprolol 12.5mg tid Flagyl 500mg IV q8h MVI 1 tab qd Papain-urea to wound Zinc sulfate 200mg qd Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 3. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours) for 3 weeks. 4. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily): to foot ulcer. 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q4-6H (every 4 to 6 hours) as needed. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) inj Injection QMOWEFR (Monday -Wednesday-Friday). 11. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. Insulin Glargine 100 unit/mL Solution Sig: One (1) injection Subcutaneous once a day: 13 units Lantus QAM. 15. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 72922**] Discharge Diagnosis: Right hip fracture Hypotension Secondary: Paroxysmal atrial fibrillation Diabetes mellitus Discharge Condition: Stable Discharge Instructions: You were admitted with a hip fracture and low blood pressure. You had an ORIF procedure to fix your hip. You are being discharged to an extended care facility in [**Hospital1 189**]. . Please take all of your medications as prescribed and follow up with your PCP as instructed. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-6-20**] 12:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-6-20**] 12:40 . Please follow up with Dr. [**Last Name (STitle) **] within 1 week of discharge from rehab. Completed by:[**2148-6-5**]

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icd9cm

[ [ [] ] ]

[ "45.23", "79.35" ]

icd9pcs

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9297, 9345

5501, 7627

301, 362

9480, 9489

3050, 3050

9815, 10204

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7999, 9274

9366, 9459

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9513, 9792

2564, 3031

250, 263

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2262, 2448

62,975

166,032

47890

Discharge summary

report

Admission Date: [**2198-9-8**] Discharge Date: [**2198-9-20**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 633**] Chief Complaint: fatigue and decreased PO Major Surgical or Invasive Procedure: ERCP History of Present Illness: 87M with h/o stage IV pancreatic cancer with liver mets presents with 2 days of generalized weakness, malaise, and poor PO intake. Reports one episode of shaking chills while watching television 3 days ago, did not take temperature and denies other chills or fever. Denies abdominal pain, but does admit to a "tight" feeling in his abdomen. Has chronic intermittent nausea for which he takes meds at home, no recent emesis. Recently when he has the urge to urinate or defecate, he produces only a small volume of dark yellow urine and/or non-bloody stool. Last BM 3 days ago. Normally on laxative and stool softener with daily stools, no melena or hematochezia. Also denies chest pain and SOB. . In the ED, T 98.3 HR 110 irregular BP 72/43 RR 18 O2 99%/RA. Labs showed elevated LFTs with Tbili 7.7 up from baseline 0.9 and alk phos 474 up from 261. ABG 7.35/pCO2 41/pO2 62/HCO3 24. RUQ US showed contracted gallbladder with thickened wall and sludge with possible stones. Blood pressure was low with SBP in the 70s but patient asymptomatic. BP improved with 6L IVF and 0.6 mg/hr levophed, VS at time of ED transfer were HR 108 MAP 89 BP 111/82 O2 96%/RA. Creatinine elevated to 3.8 (past max 4.0, CKD), urine output 20-30 cc/hr. Given 1 dose vancomycin, zosyn, zofran. RIJ triple lumen central line placed. Surgery consulted, requested CT abdomen, deemed pt a non-operable candidate, and suggested ERCP. Of note, ERCP in [**2198-4-17**] in the context of elevated LFTs/nausea showed duodenal bulb stenosis likely [**3-21**] tumor compression. 2cm stricture in lower CBD seen, sphincterotomy was performed with hepatobiliary stent placement. Both LFTs and nausea improved. Today he is admitted directly to the ICU for progressive weakness, decreased po intake, and hypotension with bilirubinemia and neutrophilic leukocytosis. Past Medical History: ONCOLOGIC HISTORY: Stage IV Pancreatic Cancer Originally presented with a one month history of progressive vomiting (1-2 hrs after eating) and the inability to tolerate food, lost approximately 15-20 lbs in a month. He presented to his nephrologist, who was concerned and referred him to the ED for admission and inpatient workup. His labs were notable for a very high alk phos, and CT disclosed multiple lesions in the liver and pancreatic head fullness. An EUS was performed which disclosed a 2cm mass in the head of the pancreas; FNA was performed and returned as adenocarcinoma. His CA-19-9 was 352,000 at presentation. On [**2198-4-26**] he had a biliary stent placed with improvement in his alk phos and nausea symptoms. . Was on regimen of weekly gemcitabine, given 3 weeks in a row with one week off. First dose 3/16; subsequently stopped due to side effects. . Other Past Medical History: Stage IV CKD Hx of nephrolithiasis Renal Osteodystrophy Papillary Urothelial Carcinoma s/p TURBT, receiving BCG treatments Hx of invasive SCC of the head s/p Mohs resection Chronic L pleural effusion (neg for malignant cells on last thoracentesis, [**2197-9-17**]) Moderate Aortic Stenosis (AV area 1 cm2) CAD (prior inferior MI evident on EKG) Hypertension Dyslipidemia Anemia (was on Aranesp) Glaucoma Social History: -Used to work for Polaroid, also a retired WWII veteran -Lives alone in an [**Hospital3 **] facility that provides evening meals. Daughter visits [**3-22**] X a month. -Ambulates without assistance, drives, handles grocery shopping, bills, meds -Prior extensive smoking hx, quit in the [**2157**] -Occasional ETOH use -No illicits Family History: Unable to recall if any family members have had coronary disease or cancer Physical Exam: Admission Exam: VS: T 98.7 HR 134 BP 107/74 RR 17 O2 96%/RA GEN: jaundiced thin elderly man lying in bed watching baseball, NAD HEENT: NCAT EOMI PERRLA +icteric sclera & sublingual jaundice MMM NECK: supple JVP flat +LIJ CV: irregularly irregular +II/VI systolic ejection murmur @LUSB PULM: CTA no rales or wheeze (anterior exam) ABD: thin, soft, mild rebound no guarding, nontender to percussion or palpation, hypoactive bowel sounds, palpable liver edge 3 cm below costal margin, negative [**Doctor Last Name **] sign EXT: warm and dry, +distal pulses, no cyanosis or edema NEURO: AOX3, CNII-XII intact, spontaneously moves all extremities SKIN: no rashes, some ecchymoses on forearms FOLEY: draining clear yellow urine Pertinent Results: [**2198-9-8**] 10:05AM WBC-13.8* RBC-3.22* HGB-10.6* HCT-31.8* MCV-99* MCH-32.8* MCHC-33.2 RDW-15.3 [**2198-9-8**] 10:05AM NEUTS-91* BANDS-0 LYMPHS-1* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2198-9-8**] 10:05AM LIPASE-10 [**2198-9-8**] 10:05AM ALT(SGPT)-50* AST(SGOT)-61* ALK PHOS-474* TOT BILI-7.7* [**2198-9-8**] 10:05AM GLUCOSE-134* UREA N-83* CREAT-3.8* SODIUM-137 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-23 ANION GAP-20 [**2198-9-8**] 10:25AM LACTATE-3.2* [**2198-9-8**] 04:41PM LACTATE-1.5 . . MICRO: . [**2198-9-8**] 2:25 pm BLOOD CULTURE Site: ARM SET#2. Blood Culture, Routine (Preliminary): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2198-9-9**]): Reported to and read back by [**Female First Name (un) **] [**Doctor Last Name 5647**] @ 6PM [**2198-9-9**]. GRAM NEGATIVE ROD(S). [**9-10**] Blood Cx - pending [**9-11**] Blood Cx - pending [**9-8**] Urine Cx negative . IMAGING: . [**9-8**] CXR for ?PNA ONE VIEW OF THE CHEST: The lungs are well inflated in the upper zones with bilateral lower lobe opacities. Bilateral pleural effusion are noted, moderate on left, small on right. The cardiac silhouette is poorly assessed. The mediastinal silhouette and hilar contours are normal. No pneumothorax is present. IMPRESSION: Bilateral effusions and lower lobe opacities may reflect atelectasis and/or pneumonia. . [**9-8**] RUQ US RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates a heterogeneous echotexture with multiple focal nodules, findings consistent with known metastatic pancreatic carcinoma. The main portal vein is patent with hepatopetal flow. Evaluation of the pancreas is limited due to overlying bowel gas. There is a mild amount of perihepatic ascites and a small right pleural effusion. The gallbladder is contracted and demonstrates diffuse wall thickening. Dirty shadowing within the gallbladder is likely secondary to air given the history of known biliary stent. A moderate amount of sludge is also identified within the gallbladder. The common bile duct measures 2 mm and is not dilated. IMPRESSION: 1. Air and fluid filled gallbladder with diffuse wall thickening, likely secondary to third spacing from hepatic dysfunction. 2. Multiple hepatic masses consistent with known metastatic pancreatic carcinoma. 3. Limited evaluation of the pancreas due to overlying bowel gas. 4. Small amount of perihepatic ascites and a small right pleural effusion. . [**9-8**] CT ABD non-contrast CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Moderate bilateral pleural effusions are identified with associated compressive atelectasis. No definite focal mass or nodule identified. The heart size is normal, and there is no pericardial effusion. Complete evaluation of the abdominal viscera is limited due to the non-contrast technique. Multiple hypoattenuating lesions are identified within the liver, findings consistent with known metastatic disease from pancreatic carcinoma. A biliary stent remains in standard position within the distal common bile duct and appears grossly patent. An ill-defined soft tissue mass in the head of the pancreas, appears similar compared to prior, though is incompletely evaluated on this non-contrast examination. No pancreatic ductal dilatation is identified in the body or tail. The local extent of the mass is not well-evaluated on this examination. The spleen and adrenal glands are normal. The gallbladder is air and fluid-filled, likely secondary to a combination of sludge and air from the stented biliary tree. In the midpole of the left kidney, there is a stable 12 mm hyperdense lesion, likely a hemorrhagic cyst (2:32). An exophytic lesion in the lower pole of the left kidney also appears unchanged and measures 2.2 x 2.3 cm, likely a simple cyst (2:42). Bilateral perinephric stranding appears slightly increased compared to prior. There is a large amount of ascites and a significant amount of mesenteric fat stranding, findings consistent with diffuse edema. The abdominal aorta demonstrates mild ectasia, though no frank aneurysmal dilatation. Scattered mesenteric and retroperitoneal lymph nodes are identified, though are difficult to evaluate on this non-contrast examination. BONE WINDOWS: No bone destructive lesion or acute fracture is identified. IMPRESSION: 1. Biliary stent in standard position in the distal common bile duct and grossly patent. 2. New moderate abdominal ascites and significant mesenteric stranding, findings consistent with severe edema. 3. Fluid and air within the gallbladder, likely secondary to ERCP. 4. Large soft tissue density mass in the pancreatic head, though incompletely characterized on this non-contrast examination. . [**2198-9-9**] ERCP Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: A metal stent placed in the biliary duct was found in the major papilla. Cannulation: Cannulation of the biliary duct was successful and deep with a balloon using a free-hand technique. Contrast medium was injected resulting in partial opacification. Biliary Tree: Many small stones / sludge that were causing obstruction were seen at the lower third of the common bile duct and middle third of the common bile duct within the metal stent. Partial opacification of the upper third of the duct and birfucation showed on evidence of obstruction proximal to the stent. Given cholangitis, a high pressure injection into the bile duct was not performed. Procedures: Copious amouts of sludge / small stone fragments were extracted successfully using a balloon. Impression: Stent in the major papilla Obstruction of metal stent by sludge / stone frgaments was noted. No obstruction proximal to the stent was noted. Sludge / stone fragments were removed using a balloon. (cannulation)(stone extraction) Otherwise normal ercp to third part of the duodenum Recommendations: Return to ICU. Continue IV antibiotics and supportive care. Watch for complications - bleeding , perforation, pancreatitis Brief Hospital Course: 87 yo M w/known stage IV pancreatic cancer & liver metastases s/p recent biliary stent placement, CKD, HTN, & CAD p/w acute-onset fatigue, malaise, decreased POs with elevated WBC and t-bili suspicious for septic cholangitis. . #goals of care-Based on the patient's multiple co-morbidities and poor prognosis, discussions were held with him and his family about goals of care. The palliative care service was involved in his care. Ultimately, the decision was made to focus on Mr. [**Known lastname 101052**] comfort per his request. Pt was made officially comfort measures with hospice care on [**2198-9-15**]. All seasons hospice was involved in patient's care, initially pt did not meet inpatient level of hospice care and plan was for discharge to a [**Hospital1 1501**] with hospice care. However, on [**9-19**], pt became hypoxic and was very clear (AAOx3) that he did not want any further medications and wanted to focus solely on comfort care. He did not want any measures that would prolong his life. This was discussed with pt's HCP/dtr and his nephew. [**Name (NI) **] seasons hospice became involved and pt was then made full inpatient hospice care. Social work, Chaplain were involved to help family wiht coping. Pt was given morphine, ativan and antiemetics for comfort care. He died comfortably on the evening of [**2198-9-20**]. [**Name (NI) 1094**] HCP/dtr notified. . #Sepsis. Pt presented with syndrome of malaise/fatigue/decreased POs, found to be jaundiced and hypotensive with elevated LFTs and elevated neutrophilic WBC. RUQ ultrasound suggested acute obstructive cholangitis with cholelithiasis. Obstruction of recently-placed metal CBD stent seen on CT provides a good explanation for elevated bilirubin and acute cholangitis. Patient's hypotension on admission responded well to 5L IVF in the ED but he continued to require levophed at 0.1 mg/hr to maintain SBP >90 and MAP>60 during the first 24h the ICU. IVF was given judiciously for low urine output/hypotension due pt history of moderate aortic stenosis/chronic pleural effusions. Blood cultures sent in the ED grew GNR. He was initially continued on broad-spectrum antibiotics (vancomycin and zosyn), which were narrowed to ceftriaxone once microbiology showed Cftx-sensitive Klebsiella. Ceftriaxone was stopped on [**9-15**] based on discussions surrounding goals of care. #Biliary obstruction/acute cholangitis. Tbili was acutely increased to 7.7, pt with painless jaundice on exam. CBD stent placed in [**2198-4-17**] was seen on CT abdomen to be obstructing biliary flow. Source of possible obstruction include tumor ingrowth within the CBD stent, external compression from stricture proximal to the stent site, or stones/sludge. Surgery was consulted in the ED and recommended ERCP. ERCP team was consulted, procedure performed the morning after admission. During ERCP, CBD stent obstruction with stones and sludge was seen and evacuated. Additional stones/sludge seen within the biliary tree but no flushing done because of current cholangitis. Importantly, no tumor invasion seen during ERCP. Immediately following ERCP LFTs trended upward, tbili max 9.7, and decreased to 7, but then had proceeded to increase to 13.2 with elevated d bili above 11. ERCP team felt that this was likely due to tumor progression in liver. Given goals of care, decision was made to not proceed with further imaging or repeat ERCP. #Atrial fibrillation. No history of atrial fibrillation in [**Hospital 228**] medical record, therefore Afib likely started in context of sepsis. Of note, pt takes 12.5 mg PO metoprolol tartrate [**Hospital1 **] at home for a history of CAD and he did not take any of his home medications on the day of admission. Upon admission to the ICU he was given 1 dose IV metoprolol and an increased PO dose (25 mg). Digoxin was started given need for rate control in this patient with pressor-dependent hypotension but then held given elevated dig level. Lopressor stopped because of relative hypotension on floor (Bps 90s) and heart rates that remain <100. #Malnutrition: cachexia secondary to cancer and hypoalbumenia. Third spacing. POs as tolerated. . #Pancreatic Cancer. Diagnosed 6 months ago, pt is s/p several weeks of chemotherapy which was discontinued as an outpatient given intolerance of side effects in the context of metastatic disease. Tumor growth a likely contributor to his current clinical picture. No intervention for now, as patient, family and PCP have agreed to proceed with comfort care. He was continued on his home midodrine and compazine PRN. Outpatient primary care physician/gastroenterologist Dr. [**Last Name (STitle) 172**] followed the pt while in the ICU and assisted with patient/family communication. #Hx LUE and LLE DVT. Pt not currently on anticoagulation. Heparin gtt was initiated during his [**2198-5-18**] hospitalization when LUE and LLE DVTs were discovered, but it was stopped soon thereafter when he developed hematemesis. No pain or swelling of his extremities noted on exam. Pt denies dyspnea, chest pain, or neurologic symptoms. . #Anticoagulation. Of note, patient not on anticoagulation despite DVT earlier this year because of upper GI bleeding while on heparin gtt and ASA. Now with atrial fibrillation, CHADS scores 2. Team discussed plan for anticoagulation with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 172**] and considered dabigatran vs. aspirin vs. no anticoagulation. None started in ICU. Patient considered to be a poor candidate for coumadin given nutritional status. . #Worsening Chronic Constipation. Pt chronically constipated, on home laxative and stool softener which produce daily BMs. Last BM was three days prior to admission; a stool-filled colon was seen on CT Abd. He was continued on his home bowel regimen w/additional enemas in the ICU PRN. Did have multiple bowel movements but remained constipated. . #Hx and Hypertension: d/c'd lopressor and lasix given volume status and hypotension . #CKD w/renal osteodystrophy. Baseline Cr [**4-20**]. 3.8 in ICU, and began rising on floor to 4.6 as of [**9-15**]. LIkely intra-vascular volume depletion with total volume overload. Not an HD candidate. Supportive care. . #Hx bladder cancer, s/p TURB. Urine output monitered by foley. #BPH. Continued home tamsulosin. #Insomnia. Held home ambien. Gave trazodone as needed. #Glaucoma. Continued home timolol eyedrops. #Code: DNR/DNI (confirmed with patient)/comfort measures. Confirmed with patient, HCP/pt's daughter. Based on the patient's multiple co-morbidities and poor prognosis, discussions were held with him and his family about goals of care. The palliative care service was involved in his care. Ultimately, the decision was made to focus on Mr. [**Known lastname 101052**] comfort. He died comfortably on the evening of [**2198-9-20**]. Medications on Admission: metoprolol 12.5 mg [**Hospital1 **] midodrine 2.5 mg TID omeprazole 40 mg QD calcitriol QOD 0.25 mg sodium bicarbonate 650 mg [**Hospital1 **] furosemide 40 mg QD zolpidem 5 mg qHS sennosides 8.6 mg QD aranesp (on hold) prochlorperazine 5 mg TID PRN nausea sevelamer 800 mg TID w/meals tamsulosin 0.4 mg ER qHS ferrous sulfate 325 mg QD timolol eyedrops QD Discharge Medications: pt expired Discharge Disposition: Expired Discharge Diagnosis: acute on chronic renal failure metastatic pancreatic cancer cholangitis Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

[ [ [] ] ]

[ "51.88", "38.97" ]

icd9pcs

[ [ [] ] ]

18792, 18801

11505, 18349

274, 280

18917, 18926

4666, 5263

18982, 18992

3832, 3908

18757, 18769

18822, 18896

18375, 18734

18950, 18959

3923, 4647

5307, 11482

210, 236

308, 2135

3061, 3466

3482, 3816

5,593

153,855

30075

Discharge summary

report

Admission Date: [**2162-3-27**] Discharge Date: [**2162-4-8**] Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 465**] Chief Complaint: NSTEMI/DIC Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 84 yo Male w/PMH of CAD s/p CABGx3 on [**2162-3-12**] at [**Hospital1 **] Center, CKD, HTN who presented initially to the [**Hospital1 **] center on [**2162-3-27**] with several days of fatigue and decreased appetite. On admission to [**Hospital1 **] Center BUN/CR 80/3.9; PLT 35, H/H 9.4/28.5. There was originally concern for obstruction, a foley was placed with 500 cc UO. UA was notable for trace protein, ketones, bacteria, [**2-10**] wbc, [**4-12**] rbc. Renal US was negative for lesions or hydronephrosis. He was started on D5NS at 75 cc/hour and given one dose of albumin 250 cc. A TTE was done with EF 40-45%. His K was noted to be 6.0 so Kayexylate was given. He was given 500 mg diuril prior to transfer to the [**Hospital1 18**] [**Hospital Unit Name 153**]. . The patient's MICU course was complicated by thrombocytopenia with elevated FDP/D-dimer thought likely to represent DIC, troponin elevation with ? NSTEMI, renal failure, and possible saphenous vein donor site infection. . Past Medical History: Past Medical History: HTN CAD s/p CABG x 3 - LIMA to LAD, RSVG to PLV/OM1) on [**2162-3-12**] - Post-op complicated by atrial fibrillation treated with amiodarone Hyperlipidemia CKD - baseline 1.3-1.7 Prostate Ca - s/p xrt GERD Pulmonary nodule - stable x 2 years . PSH: 1)CABG as above 2)S/P R CEA [**2151**] 3)S/P CCY 4)S/P L TKR 5)S/P Hernia repair Social History: The patient is married and lives with his wife. [**Name (NI) **] has 2 sons. [**Name (NI) **] is a WWII veteran. He lives in [**Location **] RI with his wife currently, retired meat cutter Family History: NC Physical Exam: Vitals: T- 95.5 BP: 122/50 HR: 58 RR: 22 O2: 98% on 2L . General: Patient is an elderly male, appears tired but in NAD, very pleasant HEENT: NCAT, EOMI. + right neck well healed scar s/p previous CEA. Neck: EJ distended. JVP appprox 10cm Chest: Few scattered high pitched expiratory wheezes. Mildly decreased BS at left base but otherwise CTA. No rales appreciated. Healing sternotomy scar with dressing below sternotomy C/D/I. Non-tender Cor: RRR, normal S1/S2. No M/R/G appreciated Abdomen: Soft, non-tender, ND. +BS Extremity: right LE with significant area of erythmea over medial aspect of leg, warm. Non-tender, no area of fluctuance appreciated. + ecchymosis over right foot. 2+ pedal edema bilaterally. DP 1+ bilaterally, feet warm. Pertinent Results: [**2162-3-27**] 11:23PM BLOOD WBC-8.4 RBC-2.99* Hgb-8.9* Hct-26.0* MCV-87 MCH-29.7 MCHC-34.1 RDW-14.3 Plt Ct-50* [**2162-4-4**] 10:05AM BLOOD WBC-7.0 RBC-3.49* Hgb-10.5* Hct-30.9* MCV-88 MCH-30.1 MCHC-34.1 RDW-14.7 Plt Ct-149* [**2162-3-27**] 11:23PM BLOOD Neuts-82.2* Lymphs-6.6* Monos-6.4 Eos-4.6* Baso-0.2 [**2162-3-27**] 11:23PM BLOOD PT-16.0* PTT-35.2* INR(PT)-1.5* [**2162-3-27**] 11:23PM BLOOD Plt Ct-50* [**2162-4-4**] 10:05AM BLOOD Plt Ct-149* [**2162-3-27**] 11:23PM BLOOD Fibrino-65* D-Dimer-6202* [**2162-3-27**] 11:23PM BLOOD FDP-320-640* [**2162-4-3**] 12:00PM BLOOD FDP-40-80 [**2162-3-27**] 11:23PM BLOOD Glucose-106* UreaN-75* Creat-3.6* Na-137 K-4.9 Cl-102 HCO3-25 AnGap-15 [**2162-4-4**] 10:05AM BLOOD Glucose-125* UreaN-29* Creat-1.6* Na-133 K-4.7 Cl-98 HCO3-25 AnGap-15 [**2162-3-27**] 11:23PM BLOOD ALT-41* AST-42* LD(LDH)-399* CK(CPK)-173 AlkPhos-139* TotBili-0.7 [**2162-4-4**] 10:05AM BLOOD ALT-28 AST-24 LD(LDH)-427* AlkPhos-120* TotBili-0.6 [**2162-3-27**] 11:23PM BLOOD CK-MB-22* MB Indx-12.7* cTropnT-1.18* [**2162-3-30**] 07:00AM BLOOD CK-MB-13* MB Indx-8.8* cTropnT-1.88* [**2162-3-31**] 06:45AM BLOOD CK-MB-NotDone cTropnT-3.09* [**2162-4-1**] 07:25AM BLOOD CK-MB-NotDone cTropnT-3.28* [**2162-3-27**] 11:23PM BLOOD Hapto-85 [**2162-4-1**] 07:25AM BLOOD TSH-3.1 [**2162-3-28**] 01:46PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE [**2162-3-27**] 11:23PM BLOOD PSA-<0.1 [**2162-3-28**] 01:46PM BLOOD HCV Ab-NEGATIVE [**2162-3-30**] 10:15AM BLOOD HEPARIN DEPENDENT ANTIBODIES- positive ECG: [**2162-3-29**]: NSR, 60, nml axis. Incomplete RBBB. No acute ST changes. non specific TW changes V1-V6. . Imaging: . [**2162-3-27**]: Portable Chest - IMPRESSION: 1. Cardiomegaly with small left-sided pleural effusion. 2. No signs for focal consolidation or pulmonary edema. . [**2162-3-28**]: Right LENI - negative for DVT, no drainable fluid collection . [**2162-3-30**]: Echocardiogram LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. No LV mass/thrombus. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with prior cardiac surgery. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Minimally increased gradient c/w minimal AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] Normal LV inflow pattern for age. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild to moderate [[**2-9**]+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. . [**2162-4-2**] MRA kidney- FINDINGS: There is no evidence of thrombosis within either the right or left renal vein, or within the IVC. Note is also made of bilateral pleural effusions as well as a fluid- filled duodenal diverticulum arising from the 3rd portion of the duodenum. Multiplanar reformatted images reviewed at the time of interpretation support these findings. IMPRESSION: No evidence of renal vein thrombosis. . [**4-4**] B LENI: No evidence of left lower extremity deep vein thrombosis. Thrombosis of the right greater saphenous vein, not reaching to the junction with the common femoral vein. . Brief Hospital Course: Patient is a n 84 yo Male with CAD s/p CABG on [**2162-3-12**] with course complicated by thrombocytopenia/DIC, ARF, and troponin leak. Issues as follows: . #. Thrombocytopenia/HIT - Pt with persistent thrombocytopenia since immediately post-op, concerning for postbypass thrombocytopenia vs HIT. HIT AB strongly positive. Low fibrinogen and elevated coags consistent with DIC per Hematolgy who followed that patient. Per, Heme, likely combination of HIT (heparin induced thrombocytopenia) and DIC (Disseminated Intravascular Clotting) of unclear etiology (may be secondary to graft site cellulitis). Started on argatroban and coumadin. Once INR within recommended therapeutic range (4-5 per Heme), argatroban was discontinued. An INR 4 hours later was X, which was in therapeutic range for the patient's chronic needs for afib and HIT. Patient will need to be on coumadin for 3 months per Heme. prior to discontinuation of coumadin, will need to have HIT antibodies tested to ensure resolution. If still positive, will need to continue on coumadin and should have hematology follow-up. He should avoid all heparin products in the future. . He received cryoprecipitate, 4U FFP, 2U PRBCs and 1U platelets during his stay in the MICU. . #. CAD - Patient had a troponin leak and was followed by cardiology. Troponin rose from 1.18 to 3.28 throughout course. Initially unclear significance in setting of recent CABG and ARF. However, decision made to treat for NSTEMI for which patient is on Aspirin and Beta-blocker, held ACEI and Heparin given acute renal failure and ? HIT. Echo with preserved EF and no wall motion abnormalities. Plan for medical management for now, ? cath in future with further improvement in Creatinine. Patient had post-op Afib, initially on Amiodarone, but that was discontinued per cardiology since returned to and stayed in sinus rhythm. A TSH was within normal limits. Medically managed with ASA, Beta blocker, Statin, although statin continued at lowered dose given elevated liver function tests. . #. Pump - Echo reveals preserved Ejection Fraction, no Wall Motion Abnormalities. Clinically patient appeared mildly volume overloaded with elevated JVD, peripheral edema and complaints of mild orthopnea. Was gently diuresis with Lasix after renal function returned to what appears to be the patient's baseline with minimal improvement in his symptoms. Still with bilateral pedal edema and may need to be continually diuresis based on clinic appearance. . #. Renal Failure - Initial consideration given to HUS/TTP as above but less likely now. Followed by nephrology: unclear etiology although may be consistent with ATN. This may be [**3-12**] post-op complication although no reported episode of hypotension, but at risk as on pump. No eos in urine or other evidence of cholesterol emboli. Creatinine slowly improved and patient had adequate urine output daily. MRI of kidneys showed no renal vein thrombosis. . #. Hypoxia - initially required 2L and appeared to be appears mildy volume overloaded as explained above. Was weaned off oxygen and then maintained saturations of 95-97 on room air. had no recurrent episodes of hypoxia but did develop some wheezing and feelings of lung congestion 2 days prior to discharge. Wheezing and symptoms improved with albuterol/ipratropium nebs. Placed on standing nebs and eventually transitioned to spiriva and albuterol inhalers with resolution of symptoms. . # LLE edema - new on exam [**4-4**]. Dependent edema vs. heart failure. Again, very mildly clinically volume overloaded on exam. Gently diuresed above with with no resollution of LLE edema. Compression stocking placed on left leg. Had bilateral lower extremity ultrasounds which were negative for deep vein thrombosis on the left with postive clot in the right greater saphenous (graft site for CABG). . #. Atrial fibrillation - episode of afib post-op by report but in sinus throughout this hospital admission. Continued on betablocker. Avoid amiodarone given thrombocytopenia per cardiology. Anticoagulation may not be needed long term if atrial fibrillation was isolated in response to CABG surgery. This will need to be reassessed on an outpatient basis. . #. Cellulitis - patient afebrile throughout admission without significant leukocytosis, however, right medial knee was erythematous and appeared infected clinically. Evaluated by Surgery who drained what they thought was a nonpurulent hematoma. Patient was initially treated with Zosyn and vancomycin but coverage was switched to oral ciprofloxacin when wound cultures returned with pansensitive Serratia. Wound continued to improve. Wound care per surgery recs: ace wrap to right lower extremity and wick placement to graft site wound. . Patient is being discharge to a rehabilitation center for physical therapy and continued post-operative care. Medications on Admission: aspirin 81 mg daily amiodarone 200 mg daily pepcid 20 mg daily colace 100 mg [**Hospital1 **] lopressor 12.5 mg [**Hospital1 **] lovastatin 40 mg daily tylenol #3 prn Discharge Disposition: Extended Care Facility: The Holiday Discharge Diagnosis: Non ST Elevation Myocardial Ischemic Event Disseminated Intravascular Coagulation Heparin Induced Antibiodies Graft Site Cellulitis Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with fatigue and poor appetite and were found to have acute renal (kidney) failure and some changes in your blood counts (low platetelets and red blood cells). You also had elevated cardiac enzymes (lab tests that are markers of heart muscle damage) which may have been related to your recent heart surgery or to additional heart damage from being so ill. You were medically treated as if you had new heart damage and did very well. Your kidney function improved but you will need to discuss this with your primary care physician. However, your platelet level continue to drop after given an anticoagulant medicine called heparin. You were tested and found to have antibodies in your blood to heparin which was making your platelet count fall. You were then switched to a different medicine, argatroban, and are being bridged to coumadin. You will need to be on coumadin for 3 months and should have blood work done prior to discontinuation of coumadin to make sure that those antibodies have resolved. YOU SHOULD AVOID ALL HEPARIN PRODUCTS IN THE FUTURE. Your lab tests have been imroving and are now within the normal range. You also had an infection of the graft site of the inside of your right knee which was opened to allow it to drain by the Surgery service. You were started on an antibiotic, ciprofloxacin, and should continue that for a full 10 day course. You should also continue to keep your right leg in the ace bandage until seen by your Heart Surgeons at [**Hospital1 **] Center in follow-up. You were had some swelling of your lower legs while in the hospital which may be related to not being very physically active or to poor heart function. You were given a diuretic to help get rid of some of the fluid. Discuss the need for future diuretic therapy with your primary care physician. You also complained of some shortness of breath during your admission, which was improved with medications. You are being discharged with Spiriva and albuterol inhalers. Please take them as prescribed. Please take all medications as prescribed. Contact a physician for fever > 101.5, worsening redness, swelling, or pus draining from your incision site, chest pain, palpitations, dificulty breathing, loss of conciousness, lightheadedness, or any other concerns. Followup Instructions: With your primary care physician [**Name Initial (PRE) 176**] 1-2 weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.05", "99.07" ]

icd9pcs

[ [ [] ] ]

11552, 11590

6494, 11334

231, 237

11766, 11775

2660, 6471

14132, 14329

1879, 1883

11611, 11745

11360, 11529

11799, 14109

1898, 2641

181, 193

265, 1280

1324, 1656

1672, 1863

63,750

182,514

54585

Discharge summary

report

Admission Date: [**2177-7-17**] Discharge Date: [**2177-7-20**] Date of Birth: [**2097-3-29**] Sex: F Service: MEDICINE Allergies: Bactrim / Iodine-Iodine Containing / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 425**] Chief Complaint: Pneumothorax Major Surgical or Invasive Procedure: Pacemaker placement Pigtail catheter placement in left lung History of Present Illness: Ms. [**Known lastname 111653**] is an 80 y.o. patient of Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] with atrial fibrillation and Tachy-brady syndrome who was referred for dual chamber pacemaker placement. This procedure was performed this morning. Typically, cephalic vein is used for access; however, patient's vein was somewhat sclerotic and wire could not be passed. The subclavian vein was accessed as an alternative; however, air was drawn back with insertion of the needle. Fluoroscopy during the catheterization revealed pneumothorax. CXR was obtained and the thoracic surgery team was consulted. The patient was then transferred to the CCU for monitoring. . With regard to her tachy-brady syndrome, the patient has had a history of persistent atrial fibrillation since [**Month (only) 404**] for which she has been anticoagulated since [**Month (only) 958**] (following TIA/CVA). Holter monitor in [**Month (only) 116**] revealed sustained atrial fibrillation with HR up to 165 with pauses up to 3.2 seconds; Lifewatch monitor in [**Month (only) **] revealed pauses up to 4 seconds (per notes). She has been treated with metoprolol for rate control (100 mg long acting daily) as well as low-dose digoxin. . On review of systems, she endorses prior history of stroke/TIA (2-minute duration of left arm numbness and aphasia in [**Month (only) 958**] [**2177**]; left parietal infarct noted on imaging) and deep venous thrombosis in [**2175**] (left leg). No known history of pulmonary embolism, bleeding at the time of surgery. No myalgias, joint pains, cough, hemoptysis, black stools or red stools. She has had recent FUO, but no fever since her last admission and no chills or rigors or nightsweats. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. She has occasional swelling in the left ankle only which occurs with standing, present since her DVT in [**2175**]. She does occasionally experience a "flutter" in the chest as well as a sensation of her heart pounding. Past Medical History: - AFib on Coumadin/Tachy-brady syndrome - h/o TIA's/CVA's due to AFib - Mitral regurgitation - Mild COPD. - Hypertension. - DVT in 10/[**2175**]. - H/o hematochezia - h/o nephrolithiasis - h/o tobacco abuse - h/o recurrent UTI's - h/o hypercalcemia - uterine prolapse - left Depuytren - s/p appendectomy - Abdominal hernia (unrepaired) Social History: Widowed mother of seven children. Did not work. Smoked approximately 2 packs per day for 30 years but stopped in her 50s. She drinks 2-3 glasses of wine a night. SOCIAL HISTORY: Lives alone in [**Hospital1 1562**] though has two adult daughters who live nearby. She will stay with one daughter in [**Name (NI) **] following this admission. No current home care services; active at baseline. - Tobacco history: Prior heavy smoker but quit age ~35 - ETOH: [**2-12**] glasses of wine per night - Illicit drugs: None Family History: - Brother: died of massive MI age 62 - Mother: lived to age [**Age over 90 **], died of "old age" - Father: died of complications of metastatic cancer (unknown primary) age 62 Physical Exam: ADMISSION: GENERAL: NAD. Oriented x3. Mood, affect mildly anxious. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple no JVD. Trachea midline. CARDIAC: Dressing over pacemaker site limits exam. Irregular with distant S1/S2. No murmur appreciated though has MR/TR on echo. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles. Slightly diminished breath sounds in left apex, but still audible air entry in all fields. ABDOMEN: Soft, NTND. No HSM or tenderness. Large femoral hernia on right, non-tender to palpation. EXTREMITIES: No edema. Left arm in sling s/p pacemaker placement. Scaring over left palm from Dupuytren's contracture s/p surgery. SKIN: Stasis dermatitis in lower extremtities PULSES: 2+ DP pulses bilaterally . DISCHARGE: Gen: Elderly female appering mildly anxious, alert, oriented, NAD CV: irregularly irregular, s1/s2 no murmurs Chest/Lungs: CTAB, equal air entry BL. Left antrior chest pigtail and pacer site c/d/i, mild TTP. 5cm diameter area of ecchymosis at the pacer site Abd: soft, nontender non distended bowel sounds normoactive Ext: no edema Pertinent Results: ADMISSION LABS: [**2177-7-17**] WBC-4.7 RBC-4.45 Hgb-14.2 Hct-43.1 MCV-97 MCH-32.0 MCHC-33.0 RDW-14.3 Plt Ct-220 Glucose-101* UreaN-14 Creat-0.6 Na-142 K-3.8 Cl-105 HCO3-28 AnGap-13 Calcium-9.0 Phos-3.0 Mg-1.7 DISCHARGE LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2177-7-20**] 05:30 4.9 3.90* 12.8 37.6 96 32.8* 34.0 13.9 166 [**2177-7-19**] 06:06 5.9 4.02* 13.4 39.5 98 33.2* 33.8 14.1 157 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2177-7-20**] 05:30 90 12 0.7 137 4.5 97 34* 11 Calcium Phos Mg [**2177-7-20**] 05:30 8.8 2.5* 2.0 CXR: ([**2177-7-17**]) IMPRESSION: Stable pneumothorax in the left apical region with no significant interval change. ([**2177-7-17**]) Moderate left apical and medial pneumothorax has not changed in volume over four hours, nor is there appreciable atelectasis or pleural effusion. Right lung is grossly clear. Transvenous right atrial and right ventricular pacer defibrillator leads are in standard placements. Subsequent chest radiographs performed over the next four and 13 hours respectively show increase in the volume of the pneumothorax and a small accompanying left pleural effusion. ([**2177-7-19**]) Tiny left apical pneumothorax is less conspicuous than before. There are no other acute interval changes. ECG: Atrial fibrillation with rate in 110s. Normal axis, no evidence of active ischemia. Poor R-wave progression in precordial leads. . - ECHO (TEE) [**2177-6-23**]: 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. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There are filamentous strands on the aortic leaflets, one arising from the ventricular surface (2mm) and one arising from the aortic side (7mm) which are most consistent with Lambl's excresences (normal variant). No paravalar abcess seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**1-12**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: There are two filamentous strands on the aortic leaflets, one arising from the ventricular surface (2mm) and one arising from the aortic side (7mm) which are most consistent with Lambl's excresences (bland non-infectious vegetations). No abcess seen. No aortic regurgitation is seen. Mild to moderate mitral regurgitation. . - HOLTER (45 HOURS, [**2177-5-13**]): IMPRESSIONS: 1. A.Fib throughout recording, rate-controlled (47-165 BPM; average 91 BPM), normal intervals; maximum pause 3.2 seconds. 2. Moderate amount of ventricular ectopy (VPBs, 2 couplets). 3. No ventricular arrhythmia during patient's events. . - LIFEWATCH (REPORT PER NOTES; [**2177-6-18**]): Life Watch monitor which revealed significant sinus pauses up to 4 seconds long. She also had episodes of AF with RVR in the 150's. Brief Hospital Course: ASSESSMENT AND PLAN: Ms. [**Known lastname 111653**] is a 80 F with a history of atrial fibrillation with tachy-brady syndrome documented by Lifewatch monitor who was admitted for pacemake placement; procedure was complicated by pneumothorax following subclavian access. . ACTIVE ISSUES: # PNEUMOTHORAX: Pt admitted for pacemaker placement that was complicated by pneumothorax, initially noted on fluoroscopy following air in syringe with attempted subclavian vein access. Pneumothorax was confirmed on chest xray and though ptient remained asymptomatic, serial xrays revealed that left pneumothorax has increased in volume with substantial atelectasis at the base of the lung as well as a small and increasing left pleural effusion. Pt was attempted on 100% oxygen to assist in resorption of the pneumothorax, however given interval increase in volume, thoracic surgery placed pigtail catheter with interval resolution of pneumothorax within 24 hours. Catheters were removed without incidence and patient was discharged home on room air. . # TACHY-BRADY SYNDROME S/P PACEMAKER: Pacemaker placement was complicated by pneumothorax. Initially pacemaker was programed to DDD setting, with beats alternating between A/V pace and V paced only. Pacer interogration revealed that it was functioning properly, however pt often had episodes of being paced at max rate in response to sensed atrial fibrillation beats. Therefore, the decision was made to change pacer settings to DDI. On DDI she continued to atrial pace while in a-fib, however, there was no elevated ventricular response so no need for additional pace maker setting changes. She was maintained on her home medications metoprolol succ 100 daily and verapamil ER 240mg daily. She will need to take cephalexin 500mg x 5 days for prophylaxis post-procedure. . # ATRIAL FIBRILLATION: Pt has long history of atrial fibrillation complicated by tachy-brady syndrome. Pt suffered TIA/CVA in [**Month (only) 958**] that was atributed to a fib. During hospitalization, pt remained in a fib and was managed on her home medications of verapamil ER 240 mg PO daily, metoprolol succinate 100 mg PO daily, and warfarin 2.5/3.75 mg PO daily. She will be continued on warfarin for one month and then plan on chemical conversion with amiodarone. . CHRONIC ISSUES . # HYPERTENSION: Pt remained normotensive during hospitalization and was maintained on home medications: metoprolol succinate 100 mg PO daily, verapamil ER 240 mg PO daily . # FEVER OF UNKNOWN ORIGIN: Patient has had recurrent fevers for several months, though work-up to date has been unrevealing (negative CT torso, negative TEE, cultures negative, s/p empiric treatment with broad-spectrum antibiotics). Pt remained afebrile during hospitalization with no leukocytosis. . TRANSITIONAL ISSUES: Pt was full code. She will need follow up in device clinic for monitoring of pacemaker, along with close cardiology follow up for eventual attempted conversion with amiodarone. Concerning the care her pacemaker, she should avoid lifting left arm above shoulder height for the next 2 weeks. She also needs to take care to keep incision site clean and dry. She has a 5 day course of antibiotics to complete. Medications on Admission: - Digoxin 0.0625 mg PO daily - Metoprolol succinate 100 mg PO daily - Warfarin 2.5 mg PO M/Tu/W/F/[**Doctor First Name **] and 3.75 mg Th/Sa - Verapamil ER-24 hour 240 mg PO daily (discontinued [**5-/2177**], then resumed [**6-/2177**]) - Trazodone PO QHS PRN for insomnia (has only taken [**2-13**] doses at home since last admission) - Arthro-7 OTC PO daily (sends away for this from CA to help with joint pain) - Biotin OTC PO daily (for fingernail strength) Discharge Medications: 1. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. warfarin 2.5 mg Tablet Sig: 1.5 Tablets PO 2X/WEEK (TH,SA). 4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK ([**Doctor First Name **],MO,TU,WE,FR). 5. verapamil 120 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q24H (every 24 hours). 6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: do not drive or operate heavy machinery while taking this medication . Disp:*21 Tablet(s)* Refills:*0* 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for prn pain. Disp:*30 Tablet(s)* Refills:*0* 11. cephalexin 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 5 days. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis - tachy-brady syndrome - pneumothorax - atrial fibrillation Secondary diagnosis - hypertension - insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 111653**], It was a pleasure caring for you while you were in the hospital. You were admitted after your pacemaker placement because of a pneumothorax (small leakage of air) in your left lung. Thorax surgery was consulted and placed a pigtail catheter to remove the air. Your lung expanded and the catheter was successfully removed. Your pacemaker was adjusted appropriately and you recovered well from the procedure. You will be discharged with a 5 day course of antibiotics and scheduled to follow up with cardiology and device clinic. Concerning the care of your new pacemaker, you should avoid lifting your left arm above shoulder height for the next 2 weeks. Also, you can shower, but keep the incision where the pacemaker was paced dry. The following changes were made to your medication regimen: 1. please start taking cephelexin for 5 days 2. please take oxycodone and/or tylenol as needed for pain 3. please take docusate and/or senna as needed for constipation, which may be a side effect of the oxycodone. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2177-8-5**] at 8:40 AM With: [**Name6 (MD) 7158**] [**Last Name (NamePattern4) 7159**], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2177-7-24**] 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 You are initially scheduled at device clinic on Thursday [**7-24**], however, please change this appointment to Wednesday or Friday with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Dr.[**Name (NI) 1565**] nurse practitioner). Dr. [**Last Name (STitle) **] has clinic on Wednesday [**7-23**] and Friday [**7-25**]. Completed by:[**2177-7-21**]

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icd9cm

[ [ [] ] ]

[ "37.72", "37.83", "34.04" ]

icd9pcs

[ [ [] ] ]

13417, 13423

8434, 8707

341, 403

13591, 13591

5004, 5004

14814, 15734

3563, 3740

12163, 13394

13444, 13570

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13742, 14791

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289, 303

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431, 2658

5021, 5216

13606, 13718

2680, 3017

3211, 3547

19,729

179,519

22725

Discharge summary

report

Admission Date: [**2142-5-18**] Discharge Date: [**2142-6-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6180**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 80M Chinese-speaking with Hepatitis B, hepatoma s/p Radiofrequency ablation on [**2142-5-3**] who presented to ED with abdominal pain that patient thought was constipation (no BM x few days). He was having an annual physical in [**Month (only) 547**] with AFP checked due to history of hepatitis B. This was elevated to 4527. He has a long history of hepatitis B as does his wife and two sons. [**Name (NI) 6**] ultrasound was done on [**2142-3-21**] that showed a five centimeter mass in the left hepatic lobe and two masses in the right hepatic lobe, the largest measuring two centimeters. No biopsy was done, but due to the history and the AFP it is assumed that he has hepatocellular carcinoma. The patient was seen by Dr. [**First Name (STitle) **] on [**2142-4-6**] for treatment options. Patient underwent RFA on [**2142-5-3**]. Patient tolerated this procedure well initally. Pt returned to [**Location **] c/o abd pain and decreased [**Known firstname **] intake over 2 weeks PTA. Denied N/V, diarrhea, BRBPR, or respiratory Sx. . In ED, T100.3, WBC 16.5 w/neutrophilia, lactate 5.4, and became hypotensive to SBP 80s so started on sepsis protocol. Central line placed, given 9L IVF, started on levophed x3hrs, vanco/levo/flagyl for suspected GI vs resp source. . Pt admitted to MICU for sepsis. Past Medical History: -Hepatitis B -Hepatoma: Dx [**2142-3-21**]; s/p radiofreq ablation [**2142-5-3**]; followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -diabetes mellitus, type 2, Dx last yr, no meds just diet & exercise -?glaucoma -hearing loss Social History: He does not smoke or drink. Family History: Significant for father with liver cancer who died at age 85. Physical Exam: GENERAL: Mildly ill appearing male, in no acute distress. VITAL SIGNS: T: 97.6, BP: 147/62, HR: 73-103, O2sat 96% on 2L HEENT: Unremarkable. Sclerae are anicteric, conjunctivae pink. Oropharynx is without lesions or erythema. MMM LYMPHATICS: No cervical, supraclavicular, axillary, or inguinal adenopathy. NECK: Supple, L IJ in place. LUNGS: Bronchial BS on the R, fine rales at L base. No wheezes or rhonchi. HEART: Regular rate and rhythm. PMI nondisplaced. ABDOMEN: Mild distension with normal bowel sounds. Liver edge is palpable one centimeter below the right costal margin. No ascites appreciated. EXTREMITIES: Without clubbing, cyanosis, hands and feet with trace edema. Warm and well perfused. Pertinent Results: CXR [**2142-5-20**]: There is continued mild congestive heart failure with slightly increased moderate-sized right pleural effusion. There is continued opacity in both lower lobes indicating atelectasis. The possibility of superimposed pneumonia cannot be excluded. The right jugular IV catheter remains in place. No pneumothorax is identified. There is diffuse dilatation of the bowel, probably due to ileus. Please correlate clinically. . CT abd [**2142-5-18**]: IMPRESSION: 1) No evidence of hematoma or abscess. 2) Hypodense areas in the liver consistent with post-RF ablation changes. 3) Focus of enhancement adjacent to the right lobe RF ablations site, raising concern for persistent hepatoma. 4) Likely bibasilar atelectasis, although the presence of infection cannot be entirely excluded. . RUQ Ultrasound ([**2142-5-18**]) IMPRESSION: 1) Multiple areas of heterogeneous echotexture consistent with prior RF ablations sites. 2) No intra or extra-hepatic biliary ductal dilatation. 3) Gallstones, with gallbladder wall thickening and edema, which can be seen in cirrhotic states ECHO ([**2142-5-22**]) The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mitral regurgitation is present but cannot be quantified. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: The patient is an 80 yo chinese-speaking male with hepatitis B and hepatoma s/p radiofrequency ablation on [**2142-5-3**] who was admitted to [**Hospital1 18**] on [**2142-5-18**] with enterococcus bacteremia and sepsis admitted to the ICU on the MUST protocol. He found to have adreanl insufficency and started on steroids. He clinically improved and was sent to a regular medicine floor. He was doing well until [**2142-5-24**] when he felt increased SOB. CXR showed a greated increased right pleural effusion. He continued to become tachycardiac and O2 requirements increased from 2L NC to 100% NRB. His BP dropped to the 70's and he was intubated and readmitted to the ICU. The patient was then intubated. A thorocentesis produced 1.8L of bloody fluid from the right lung. The hypotension initially required levophed but was eventaully able to be stabalized with aggressive IV fluids and IV steroids. Antibiotics were taped to ampicillin upon culture sensitivites. After several days of fluid resusitation, the patient became increasingly fluid overloaded. He was diuresed with IV lasix for several days as his BP would tolerate. On [**2142-6-1**] the patient began to be weaned off sedation and was able to breath spontaneously over the ventilatior. He was successfully switched to CPAP and later that day successfully ventilated. Medications on Admission: Pt was taking 600mg Motrin Q4 pfr abs pain prior to admission. No other medications. Discharge Disposition: Expired Facility: [**Hospital1 18**] Discharge Diagnosis: Hepatitis B Hepatoma Respiratory Failure Sepsis Discharge Condition: Death

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icd9cm

[ [ [] ] ]

[ "38.91", "99.04", "96.6", "96.72", "96.04", "34.91", "38.93" ]

icd9pcs

[ [ [] ] ]

6038, 6077

4550, 5903

276, 282

6168, 6176

2774, 4527

1960, 2023

6098, 6147

5929, 6015

2038, 2755

222, 238

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1914, 1944

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124,853

30418

Discharge summary

report

Admission Date: [**2132-2-7**] Discharge Date: [**2132-2-10**] Date of Birth: [**2078-1-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Altered mental status, seizure Major Surgical or Invasive Procedure: none History of Present Illness: 54 M with schizophrenia, inmate at [**Hospital6 **] (history of physical assault, sexual aggressiveness), transferred from [**Hospital **] Hospital for mental status changes and seizures. Patient does not recall why or how he got there. . Patient was reportedly in his usual state of health until Saturday ([**2-2**]), when he was noted to be agitated and acting strangely. He had reportedly been drinking more water than usual and exhibiting odd behaviors such as squatting behind his bed. He was moved to the medical unit at [**Location (un) 1475**], where he became increasingly more agitated. He received a 10mg IM dose of Haldol and subsequently became more lethargic and unresponsive. He was transferred to the emergency department at [**Hospital 1474**] Hospital. A head CT at that time was negative. Laboratory workup was significant for a serum sodium of 126, and a CK of 1605. . He was transferred to the [**Hospital **] Hospital ICU, and en route had a generalized tonic clonic seizure. The seizure lasted approximately 30 seconds and resolved without intervention. On arrival to the [**Hospital1 **], he was noted to have twitching in his legs, and was given 1 mg of IV Ativan with cessation of the twitching. He was aggressively hydrated with IV fluids, and medications held. He was later seen by psychiatry and given 400 mg IV Dilantin. . Plan was initially made to transfer to [**Hospital1 336**] for ICU monitoring and EEG. However, was transferred to [**Hospital1 18**] instead. . At [**Hospital1 18**] ED, temp up to 103.2. Labs again demonstrated hyponatremia, but improved to 130. CK also improved at 819. LP was performed, and pt was given 1 dose of ceftriaxone and vancomycin. Past Medical History: 1. Schizophrenia 2. Hepatitis C 3. Diabetes mellitus 4. Hypertension Social History: Incarcerated at [**Hospital6 **] Family History: non-contributory Physical Exam: Vitals: Tm 101.6, Tc99, BP 138/77, HR 101, RR 16, O2 sat 96% RA; 2.5/5 I/O (-2.5) General: awake, alert, but only intermittently answering questions; oriented to self only. follows most commands. HEENT: PERRL, EOMI, OP clr, MM sl dry Chest: coarse transmitted upper airway sounds, no crackles or wheezes (difficult auscultation secondary to limited compliance) CV: RRR, no M Abdomen: NABS, soft, NT/ND, no g/r Extremities: no edemia, WWP Neuro: Non-focal. difficult secondary to pt mental status. CN III-XII grossly intact. Strength symmetric bilat UE+LE. reflexes not tested. Pertinent Results: [**2132-2-9**] 05:17AM BLOOD WBC-9.8# RBC-3.81* Hgb-10.5* Hct-30.0* MCV-79* MCH-27.5 MCHC-35.0 RDW-15.1 Plt Ct-480* [**2132-2-8**] 01:43AM BLOOD PT-16.2* PTT-37.2* INR(PT)-1.5* [**2132-2-10**] 05:35AM BLOOD Glucose-105 UreaN-10 Creat-0.7 Na-145 K-3.3 Cl-107 HCO3-27 AnGap-14 [**2132-2-7**] 03:30PM BLOOD Glucose-129* UreaN-20 Creat-1.0 Na-131* K-3.7 Cl-88* HCO3-30 AnGap-17 [**2132-2-7**] 03:30PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE [**2132-2-7**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Reports: Head CT: There is no hemorrhage, mass effect, shift of the normally midline structures, or major vascular territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is no hydrocephalus. The osseous structures demonstrate deformity of the right temporomandibular joint, likely involving the head of the condyloid process. The visualized paranasal sinuses and mastoid air cells are well aerated. MPRESSION: 1. No acute hemorrhage or mass effect. 2. Deformity of the right condylar head. Please correlate with prior clinical history to determine if there was a history of prior trauma. In the absence of prior trauma, dedicated CT of the maxillofacial bones is recommended for further evaluation to evaluate for osseous lesion on a non-emergent basis. . EEG [**2-8**]: This is an abnormal EEG due to the rare left temporal sharps, the slow and disorganized background and the bursts of generalized delta slowing. The first abnormality suggests a possible left temporal focus of epileptogenesis. The second and third abnormalities suggest an encephalopathy, which may be seen with infections, toxic metabolic abnormalities, ischemia or medication effect. No electrographic seizures were seen. Brief Hospital Course: Assessment/Plan: 54 y/o M with HCV, schizophrenia, transfer from state hospital for altered mental status, fever to 103, and seizure. 1. # Altered mental status/fever: DDx included multiple medications with sedating side effects vs infection vs NMS. LP was negative for meningitis, and empiric Abx were held (received 1 dose of vanco/levaquin/flagyl in the ED). Urine cx, U/A, CXR, blood cx, CSF cx were all negative for infection. It was felt that his AMS was most likely related to his hyponatremia, seizure, and post-ictal confusion. There was initial concern given his fever to 103 and seizure that he was suffering from neuroleptic malignant syndrome. A Head CT was negative for any intracranial process, and LP was negative as above. Psychiatry was consulted and recommended d/c'ing his Clozaril and his Haldol. He was admitted to the ICU for closer monitoring. Once he was admitted to the ICU, his MS quickly improved and his guards remarked that he was at his baseline mental status. EEG showed generalized slowing c/w an encephalopathy with a possible focus of epileptic areas. Neurology team was consulted who felt that this his confusion was from Haldol use, fever and seizure and did not feel that anti-epileptic therapy was required at this time. Psychiatry recommended that Haldol should not be used and if patient requires medication, to use atypical anti-psychotics (Olanzapine, or Risperdone) or Ativan prn for control of his schizophrenia. No further seizures were documented during this admission. Pt was transferred to the general medical floor on [**2-9**] and was stable for >24 hours prior to his discharge back to [**Location (un) 1475**]. . # Hyponatremia: Likely [**12-28**] hypovolemia or medication changes (was on clozaril) vs psychogenic polydipsia. Was given NS IVF prior to arrival at [**Hospital1 18**] and this was continued. His Na was 131 on admission, but returned to [**Location 213**] on HD#2. No hypertonic saline was required during this admission. This may have contributed to lowering his seizure threshold and this should be monitored periodically at [**Location (un) 1475**] to prevent this complication. . # Diabetes: Metformin was continued during this admission and his FS remained in good control. . # Hepatitis C: Pt with known Hep C, HCV Ab positive here. Unknown if he has had biopsy or undergone treatment; mild elevation of transaminases and coag panel. Hepatitis panel showed a borderline positive HepBsAB; HepBsAg and HepBcAg were negative. Depending on the timing of patient's previous Hep B vaccination, pt could likely benefit from a Hep B booster. Outpatient follow up with Hepatology as needed. . # Deformity of R TMJ: This was found incidentally on pt's Head CT as above. As per radiology report, "In the absence of prior trauma, dedicated CT of the maxillofacial bones is recommended for further evaluation to evaluate for osseous lesion on a non- emergent basis." Please consider outpatient dedicated CT of maxillofacial bones if felt warranted. . DISPO - Pt remained stable, afebrile, without any further seizures. He was transferred back to [**Location (un) 1475**] after speaking with the facility physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Medications on Admission: HCTZ 25 QD Enalapril 20 QD KCl 20 QD Neurontin 100 [**Hospital1 **] Clozaril 150 QAM, 300 QPM Haldol depo 150 Qmo Haldol 5 IM PRN Celexa 40 QD Cogentin 0.5 IM Metformin 250 TID Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Primary Diagnosis: Seizure Hyponatremia Secondary Diagnosis: Schizophrenia Discharge Condition: Stable to be discharged. Discharge Instructions: You were diagnosed with a seizure due to discontinuation of your Clozaril as well as having a low sodium level from drinking too much free water. No infection was found during your admission. . Please take medications as instructed below. . If you develop seizures, blurry vision, headaches, high fevers, or any other worrisome symptom, please contact your facility's doctor or report to the nearest ER. Followup Instructions: As previously scheduled Completed by:[**2132-2-10**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8179, 8222

4686, 7950

344, 351

8342, 8369

2872, 3430

8822, 8877

2239, 2257

8243, 8243

7977, 8156

8393, 8799

2273, 2853

274, 306

380, 2080

8305, 8321

3439, 4663

8262, 8284

2102, 2173

2189, 2223

57,110

169,837

38722

Discharge summary

report

Admission Date: [**2185-3-16**] Discharge Date: [**2185-3-22**] Date of Birth: [**2117-1-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2185-3-17**]: Urgent coronary artery bypass grafting x4: Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch, diagonal branch, posterior descending artery History of Present Illness: 68 year old male with progressive chest pain over last three months and a prior abnormal ETT notable for inferior ischemia, referred for cardiac catheterization to further evaluate. Catherization showed right dominant LVEF 65% LMCA 70% ostial, 50% distal LAD 60% ostial 50% proximal 60% orgin D1 Lcx 60% mid RCA 100% proximal distal fills L>R collaterals. Cardiac Echocardiogram: [**2182**] - EF 50% trace MR. [**First Name (Titles) **] [**Last Name (Titles) 86036**]d [**3-16**]: Rt<40% Lt60-69% He was referred for coronary revascularization. Past Medical History: Coronary artery disease Diabetes mellitus type 2 Hypertension Dyslipidemia Hypertriglycerides Carotid stenosis - Left ICA 50% CLL - diagnosed [**2182**] Colon polyps Past Surgical History Left elbow surgery as child due to fx Social History: Race: caucasian Last Dental Exam: last week Lives with: spouse Occupation: retired assistant principal Tobacco: denies ETOH: denies Family History: non-contributory Physical Exam: Pulse: 66 Resp: 18 O2 sat: B/P Right: 184/74 Left: 183/72 Height: 183 cm Weight: 93 kg General: no acute distress Skin: Dry [x] intact [] bilateral inner albows with petechia - L>R, healed scar left elbow HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] anteriorly Heart: RRR [x] Irregular [] Murmur no Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], Edema none Varicosities: spider veins bilat lower extremities Neuro: alert and oriented x3 non focal Pulses: Femoral Right: cath site Left: +2 DP Right: doppler Left: doppler PT [**Name (NI) 167**]: doppler Left: doppler Radial Right: +1 Left: +1 Carotid Bruit Right: + bruit Left: + bruit Pertinent Results: [**2185-3-17**] Echo PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with posterior mitral leaflet thicknening. There is no mitral valve prolapse. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on Mr. [**Known lastname 5314**]. Post_Bypass: Preserved biventricular systolic function. Intact thoracic aorta. All other findings in relevance to valvular function and wall motions similar to prebypass. LVEF 55% [**2185-3-21**] 10:40AM BLOOD WBC-10.8 RBC-3.64* Hgb-10.6* Hct-31.6* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.3 Plt Ct-181 [**2185-3-16**] 12:00PM WBC-9.1 RBC-3.47* HGB-9.4* HCT-28.5* MCV-82 MCH-26.9* MCHC-32.8 RDW-13.7 [**2185-3-21**] 10:40AM BLOOD Glucose-198* UreaN-22* Creat-1.2 Na-141 K-4.5 Cl-101 HCO3-27 AnGap-18 [**2185-3-16**] 12:00PM BLOOD Glucose-130* UreaN-18 Creat-1.0 Na-138 K-4.0 Cl-108 HCO3-21* AnGap-13 [**2185-3-22**] 06:20AM BLOOD WBC-8.7 RBC-3.41* Hgb-9.6* Hct-28.7* MCV-84 MCH-28.2 MCHC-33.6 RDW-14.0 Plt Ct-166 [**2185-3-21**] 10:40AM BLOOD WBC-10.8 RBC-3.64* Hgb-10.6* Hct-31.6* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.3 Plt Ct-181 [**2185-3-22**] 06:20AM BLOOD PT-13.3 PTT-26.4 INR(PT)-1.1 [**2185-3-22**] 06:20AM BLOOD Glucose-122* UreaN-21* Creat-1.1 Na-138 K-4.7 Cl-103 HCO3-27 AnGap-13 [**2185-3-21**] 10:40AM BLOOD Glucose-198* UreaN-22* Creat-1.2 Na-141 K-4.5 Cl-101 HCO3-27 AnGap-18 Brief Hospital Course: Mr. [**Known lastname 5314**] is a 68-year-old male with worsening anginal symptoms who underwent catheterization that showed severe 3-vessel disease. He presented for urgent revascularization given his unstable symptoms. On [**2185-3-17**] he underwent an urgent coronary artery bypass grafting x4 with a left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch, diagonal branch, posterior descending artery. See operative note for full details. He was extubated on post operative night after Precedex was started for agitation. He was weaned from Neo-Synephrine on post operative night with stable hemodynamics after being volume resuscitated. He initially had low urine output with creatinine bumping 1.0 to 1.3 which resolved by post operative day 2. He also had hyperglycemia with blood glucose in the high 200's post operative day 2 and 3 which improved with resuming home doses of Metformin and Lantus. Chest tubes and pacing wires were removed per cardiac surgery protocols. Ophthalmology was consulted post operative day 1 for the patient's complaints of bilateral floaters. It was determined that there were no signs of hemorrhage or neovascularization bilaterally and it was thought that the floaters were likely debris from PPV prior laser. It was recommended he follow up with Dr. [**First Name (STitle) **] as scheduled after discharge. The patient initially had a first degree AV block coming out of the operating room. On post operative day 2 he went into a rate controlled atrial fibrillation. He was transferred to the step down unit on post operative day 4 after blood sugars were better controlled and he was in a rate controlled atrial fibrillation at this time. His Lopressor was again titrated up and he was bolused with IV amiodarone and started on oral amiodarone as well as Coumadin. He is to be followed by his cardiologist as an outpatient to determine the necessity of continuing these medications. Once on the floor, Mr. [**Known lastname 5314**] continued to progress well. He was working with physical therapy to increase strength and endurance, tolerating a full po diet and his incisions were healing well. He was felt safe for discharge home with visiting nurse services on post operative day 5. His INR goal for atrial fibrillation was [**2-23**] and will be followed by Dr. [**Last Name (STitle) **] for further instructions for Coumadin dosing. All follow up appointments were discussed and arranged. Medications on Admission: NKDA Medications - Prescription ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth twice a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 37 units every evening KETOCONAZOLE - (Prescribed by Other Provider) - 2 % Cream - applied twice a day to arms LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth every morning METFORMIN - (Prescribed by Other Provider) - 850 mg Tablet - 1 Tablet(s) by mouth three times a day. Last dose [**2185-3-14**] evening pre cardiac catheterization per Dr. [**Last Name (STitle) 33746**] SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth every evening TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth every morning TRIAMCINOLONE ACETONIDE - (Prescribed by Other Provider) - 0.1 % Ointment - apply to arms twice a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth every evening CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider) - 1,000 mcg Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth three times a day Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Thirty Seven (37) units Subcutaneous at bedtime. 2. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day: Resume Metformin Saturday morning. 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 7. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fish Oil 1,200-144-216 mg Capsule Sig: One (1) Capsule PO three times a day. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 14. 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* 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 5 days, then 400mg daily x 1 month, then 200mg daily until further instructed. Disp:*120 Tablet(s)* Refills:*2* 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): dose to change daily for goal INR 2-2.5, Dr. [**Last Name (STitle) **] to manage via coumadin clinic. Disp:*30 Tablet(s)* Refills:*2* 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 18. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 19. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 20. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 21. Outpatient Lab Work Serial PT/INR dx: atrial fibrillation results to [**Location (un) 2274**] coumadin clinic [**Telephone/Fax (1) 55854**] (for Dr. [**Last Name (STitle) **] First draw [**2185-3-23**] Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary disease with unstable angina Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**4-21**] at 1:45 PM Primary Care Dr.[**Last Name (STitle) **] in [**1-22**] weeks [**Telephone/Fax (1) 36024**] Cardiologist Dr. [**Last Name (STitle) 33746**] in [**1-22**] weeks [**Telephone/Fax (1) 2258**] Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Dr. [**Last Name (STitle) **] to follow coumadin/INR dosing through [**Location (un) 2274**] coumadin clinic First INR draw [**2185-3-23**] with results to [**Telephone/Fax (1) 55854**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2185-4-21**] 1:45 Completed by:[**2185-3-22**]

[ "V58.67", "600.00", "433.10", "788.5", "414.01", "379.24", "427.31", "204.10", "E878.2", "357.2", "414.2", "411.1", "401.9", "272.1", "458.29", "250.60", "285.9" ]

icd9cm

[ [ [] ] ]

[ "88.55", "37.22", "36.15", "88.53", "36.13", "39.61" ]

icd9pcs

[ [ [] ] ]

10817, 10868

4378, 6894

332, 557

10950, 11046

2418, 4355

11587, 12367

1548, 1566

8347, 10794

10889, 10929

6920, 8324

11070, 11564

1581, 2399

281, 294

585, 1132

1154, 1382

1398, 1532

76,732

140,067

9743

Discharge summary

report

Admission Date: [**2185-8-29**] Discharge Date: [**2185-9-2**] Date of Birth: [**2105-4-15**] Sex: F Service: CARDIOTHORACIC Allergies: Quinolones / Vancomycin Analogues / Levaquin Attending:[**First Name3 (LF) 492**] Chief Complaint: Bronchial stenosis Major Surgical or Invasive Procedure: Flexible bronchoscopy, rigid bronchoscopy with stent removal and balloon dilation of the bronchus intermedius, endobronchial biopsy of the bronchus intermedius. History of Present Illness: Ms.[**Known lastname 32872**] is an 80 year-old woman with lung cancer who has undergone right upper lobectomy and radiation therapy 17 years ago. She presented in [**2185-3-25**] with progressive dyspnea and productive cough. She was ultimately found to have stenosis of the bronchus intermedius and underwent placement of a metal stent [**2185-8-18**]. She continues to complain of cough, mainly over the past 3 days; she reports sputum productive of brownish sputum. She notes her baseline level of dyspnea, which she tells me is 10 -15 feet on level ground. She denies fever, chills, or night sweats. She presents today for bronchoscopy and stent evaluation. Past Medical History: COPD, GERD, CAD with stent placement, breast cancer, s/p l Mastectomy; colon cancer, s/p colectomy; History of syncopes and collapse (not in the last 1.5 years), LLE DVT one year ago Social History: SOCIAL HISTORY: Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:____ 60 pack year smoking history, quit 18 years ago ETOH: [x] No [ ] Yes drinks/day: Drugs: Exposure: [x] No [ ] Yes [ ] Radiation [ ] Asbestos [ ] Other: Occupation: retired, former hairdresser Marital Status: [ ] Married [x] Single Lives: [ ] Alone [ ] w/ family [ ] Other:lives in nursing home since [**2184-3-25**] Family History: nc Physical Exam: AO x 3 PERRL/EOMI RRR Bilateral rhonchi Soft BS+ no rashes; + ecchymoses on arms no cyanosis, clubbing, or edema Pertinent Results: [**8-29**]: CT Chest FINDINGS: The new stent in the bronchus intermedius is fully expanded and contains eccentric intraluminal soft tissue in its distal course. There is residual narrowing just proximal to the tip of the stent in the right main stem bronchus(3.20). The right middle and lower lobe bronchi are patent. Evaluation of the upper mediastinum is limited due to extensive streak artifact from multiple surgical clips however there is no evidence of disease recurrence at the resection site post- right upper lobectomy. The infectious/inflammatory component of the right upper lung consolidation has resolved with residual post-radiotherapy related consolidation in the right apex, unchanged. The small right pleural effusion has slightly increased in size, and marked peribronchial wall thickening in subsegmental and subsegmental bronchi of the right lower lobe persists with centrilobular nodularity throughout the right lung, suggesting superimposed infection or inflammation. There is increased peribronchial thickening which is severe surrounding the segmental course of a right lower lobe bronchus (3.23) which is most likely due to inflammation or infection, attention to this area should be made on followup to exclude disease recurrence. This is best seen on the coronal sequences (400B.36). Atelectasis in the periphery of the right lower lobe (3.37) is new and mild. No new pathological enlargement of mediastinal or axillary lymph nodes by CT size criteria. Centrilobular emphysema in the left upper lobe is mild and unchanged. Discrete sub 2 mm nodules in the left lower lobe (4.150 and 4.176) are stable. Calcification of the aorta is unchanged, the heart size is normal with no pericardial effusion. Pulmonary arteries are normal, calcification of the aortic valve is stable. Limited views of the upper abdomen are unremarkable except to note atrophy of both kidneys and the pancreas. No new destructive or sclerotic bone lesions, post-surgical changes in the right hemithorax are unchanged with extensive degenerative changes throughout the thoracic spine. IMPRESSION: 1) New stent in the bronchus intermedius with residual proximal stenosis in the right main stem bronchus. The distal stent contains intraluminal secretions/granulation tissue 2)New peribronchial wall thickening in a subsegmental bronchus in the right lower lobe, the presence of enlarged small right pleural effusion and multiple centrilobular nodules suggest superimposed infection or inflammation. 3)Stable sub-2-mm left lower lobe nodules. 4)Status post right upper lobectomy with post-surgical changes including radiation fibrosis in the right apex is stable. 5)Calcification of the coronary artery and aortic valve and mitral valve is unchanged. [**2185-8-30**] WBC-47.8* RBC-3.45* Hgb-10.9* Hct-34.9* MCV-101* MCH-31.7 MCHC-31.4 RDW-15.3 Plt Ct-254 [**2185-9-1**] WBC-12.6* RBC-2.67* Hgb-8.6* Hct-25.7* MCV-97 MCH-32.3* MCHC-33.4 RDW-15.5 Plt Ct-143* [**2185-8-30**] Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2185-8-31**]: C diff neg Bcx x2 NGTD, Ucx neg Brief Hospital Course: 80F hx bronchial stenosis admitted evaluation. Flex bronch and chest CT revealed granulation tissue around metal stent placed [**8-3**]. Stent was subsequently removed and the airway was dilated. The patient's WBC [**Known firstname **] to 47.8 and she was started on Linezolid and Zosyn emperically. C. Diff was negative. The following day WBC count decreased to 16.1. The elevated WBC count may be attributed to a reaction to a colonized stent. Following stent removal the patient did well, maintaining original O2 requirements without SOB or complication. A R PICC was placed for abx. At time of discharge, patient's vitals are stable, she is afebrile. She is tolerating a regular diet, ambulating and breathing without difficulty. Medications on Admission: vitamin B12, aspirin, Advair, Synthroid 50 mcg, Lasix, Omeprazole, albuterol neb'''' atenolol 12.5' Keppra, Dilantin, Lipitor, Coumadin, baclofen, oxygen 2L Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for pain. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Phenytoin 50 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 17. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1) Intravenous Q12H (every 12 hours) for 6 days. 18. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 6 days. Discharge Disposition: Extended Care Facility: [**Hospital 5399**] Nursing Home - [**Hospital1 **] Discharge Diagnosis: Bronchus intermedius stenosis s/p stent retrieval dilation and bronchial biopsy, COPD, GERD, CAD with stent placement, breast cancer, s/p l Mastectomy; colon cancer, s/p colectomy; History of syncopes and collapse (not in the last 1.5 years), LLE DVT one year ago Discharge Condition: Fair Discharge Instructions: Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if develops increased shortness of breath, cough or chest pain. Followup Instructions: Follow-up with Dr.[**Name (NI) 5070**] [**Name (STitle) 766**] [**9-12**] at 11:30 in the Chest Disease Center in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I [**Telephone/Fax (1) 7769**] Flexible Bronchoscopy [**2188-9-12**]:30 in the Chest Disease Center NOTHING TO EAT OR DRINK AFTER MIDNIGHT [**2185-9-12**] for flex bronchoscopy [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**] Completed by:[**2185-9-6**]

[ "V58.65", "V15.3", "V10.11", "414.01", "V45.82", "V12.51", "V45.76", "293.0", "V45.71", "V58.61", "V12.04", "V10.05", "519.19", "V45.72", "530.81", "V10.3", "V15.82", "496", "518.5" ]

icd9cm

[ [ [] ] ]

[ "33.23", "38.93", "33.78", "33.91" ]

icd9pcs

[ [ [] ] ]

7803, 7881

5196, 5939

328, 491

8190, 8197

2048, 5173

8375, 8869

1895, 1899

6146, 7780

7902, 8169

5965, 6123

8221, 8352

1914, 2029

270, 290

519, 1188

1210, 1396

1429, 1879

16,695

186,751

744

Discharge summary

report

Admission Date: [**2161-3-7**] Discharge Date: [**2161-3-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Change in MS Major Surgical or Invasive Procedure: femoral line placement, PICC line placement [**3-8**] History of Present Illness: Patient is a [**Age over 90 **] yo vent dependent male with hx of hypothyroid, cad s/p cabg, ef 45%, htn, ge junction lymphoma who presents from [**Hospital 100**] rehab for change for tachypnea and tachycardia while recieving 1 u prbc for hct 24.4. He was given lasix, and found to have new lbbb on ekg. He was also found to be febrile 100.4. He was started on levoflox. . He was febrile in the ED to 102.8, HR 90 and was initially normotensive 129/66 however, a few hours later became hypotensive (of note had rec'd 2mg iv morphine and 40 mg of lasix at that time). Patient was started on the sepsis protocol but in the setting of profound hypotension a femoral line was placed. Blood and urine cultures were obtained and patient was given vanc, levo, flagyl. He was also given hydrocortisone and levophed. Past Medical History: Hypothyroidism, CAD s/p MI [**2142**], EF 45%, HTN, BPH, Depression, High cholesterol, GE Junction lymphoma (s/p 3 months of radiation therapy with tumor size [**1-5**] as before but now no longer candidate for radiation therapy) , peripheral T cell lymphoma Social History: Moved from [**Country 532**] 10 years ago former engineer wife with alzheimer's disease lives alone, walks with cane No ETOH, tobacco his baseline activity - At baseline does not walk. Speaks in full conversations but has lapses of memory at times. Family History: No h/o CAD Physical Exam: Vitals: T BP 100/63 HR 59 afib 100% on AC rr 10 tv 500 Gen: ill appearing male in no app. resp distress HEENT: trach, opens eyes, perrla Lungs: bibasilar crackles Heart: s1 s2 irreg irreg Abd: soft, peg tube in place Ext: 2+pedal edema to sacrum and scrotum Neuro: minimally responsive Pertinent Results: Echo: [**2161-2-13**] LV EF 45% mild LVH mod dilated [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]:a 0.7 "LV inflow pattern c/w impaired relaxation" nl RV size/fxn. TR gradient 29 [**1-5**]+MR, [**1-5**]+TR . Blood cx [**2161-3-4**]- NGTD sputum cx [**2161-3-4**] >25 polys gram - rods staph aureus pseudomonas lactose fermenter . [**3-4**] blood cx- MRSA . cxray [**2161-3-7**]: There are persistent bilateral pleural effusions. The right apical cap is unchanged. There is a right-sided PICC catheter terminating in the SVC. Left-sided pleural catheter is again seen. There is a metallic tracheostomy tube. There is a persistent left basilar opacity. . [**2161-3-7**] 10:15PM PLEURAL WBC-175* RBC-2050* POLYS-28* LYMPHS-72* MONOS-0 [**2161-3-7**] 10:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2161-3-7**] 10:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2161-3-7**] 09:27PM LACTATE-3.1* [**2161-3-7**] 09:15PM GLUCOSE-157* UREA N-45* CREAT-1.0 SODIUM-135 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-20* ANION GAP-17 [**2161-3-7**] 09:15PM CALCIUM-7.6* PHOSPHATE-2.9 MAGNESIUM-1.7 [**2161-3-7**] 09:15PM WBC-7.4 RBC-3.48*# HGB-11.8*# HCT-34.6*# MCV-100* MCH-34.1* MCHC-34.2 RDW-22.1* [**2161-3-7**] 09:15PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-NORMAL SPHEROCYT-1+ SCHISTOCY-OCCASIONAL BURR-OCCASIONAL TEARDROP-1+ BITE-1+ ACANTHOCY-OCCASIONAL [**2161-3-7**] 09:15PM NEUTS-78* BANDS-16* LYMPHS-4* MONOS-1* EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2161-3-7**] 09:15PM PLT COUNT-119* [**2161-3-7**] 09:15PM PT-14.6* PTT-47.3* INR(PT)-1.3* . CXR [**2161-3-9**]: IMPRESSION: 1. No change in position of left chest tube. Slight increase in left pleural effusion. 2. Left PICC line has been advanced and now courses into proximal azygos vein as communicated by telephone to Dr. [**Last Name (STitle) 5443**]. 3. Large mediastinal mass which has been more fully characterized on CT torso of [**2161-2-13**]. . Picc Line stip culture: WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. >15 colonies. BEING ISOLATED FOR SENSITIVITIES. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). >15 colonies. Brief Hospital Course: A/P: [**Age over 90 **] M with end-stage ge junction lymphoma encasing trachea, cad s/p cabg, htn who presented with septic shock. . 1. Cardiogenic / septic shock: The pt was admitted from the ED per sepsis protocol, with an elevated lactate and bp in the 80's systolic. He was aggressively fluid resuscitated and started on Levophed. An arterial bp line was placed in the ICU for better bp monitoring. He was off pressors on the following day with stable bp. In terms of the hydrocort/fludrocort, he was discharged with this after his recent previous admission for sepsis. These were initially started on [**2-21**]. They were continued for possible adrenal insufficiency in the setting of possible sepsis this admission. He can d/c the fludrocort and hydrocort and start a prednisone taper over 6 days. . 2. Line Sepsis: Cx data from [**Hospital 100**] Rehab showed MRSA in bld Cx, MRSA and Psuedomonas in sputum cx. Fever in ED, no WBC count, clear CXR. Came in with 2 PICC lines from rehab and a fem CVC from the ED which were all pulled. Pseudomonas is likely trach colonizer and no signs of PNA, although given the possible septic shock he was treated with zosyn in addition to the vancomycin intially. The zosyn was stopped prior to discharge since there was no sign of PNA. . 3. Lymphoma of GE junction: Dr. [**Last Name (STitle) **],oncologist. Has been getting palliative chemo but is no longer candidate for further radiation.Per oncologist and MICU team, multiple conversations (last admission) had with family informing them of pt's extremely poor prognosis. Per Oncologist, pt has days to weeks left given poor prognosis, metastatic lymphoma now encasing carotids/major vessels in neck as well as affecting/deviating trachea. Family [**Hospital 5439**] hospice/palliative care, however family refused palliative care services on multiple occasion on last admission- will readdress this admission with family. . 4. Atrial fibrillation: Rate remained well controlled off dilt. Dilt was added back at a lower dosage than he came in on since the bp is in the 110's systolic. Anti-coagulation as per below. . 5. h/o PE: Continued anticoaguation with coumadin. 5. hypothyroidism - continued levothyroxine. 6. FEN- restarted tube feeds after hemodynamically stable. Access: PICC placed [**3-8**] Contact: [**Name (NI) **] HCP [**Name (NI) **] [**Name (NI) 4640**] [**Telephone/Fax (2) 5440**]H, [**Telephone/Fax (2) 5441**]CELL Code- CPR not indicated Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 8. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. 9. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours) for 2 days. 10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED) for 2 days. 12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 15. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): continue hep gtt until INR 2.0 while transition to coumadin. 16. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 17. Midazolam 1 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed. 18. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed. 19. 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. PLS HOLD HEP GTT at 4am on [**2-24**] FOR PICC Placement IN AM. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection four times a day: Insulin sliding scale as directed. 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): continue for another 10 days for total 14 day course. 12. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed for pain/agitation. 13. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 2 days: Days #1 and 2 of taper. 14. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: Days#3 and 4 of taper. 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: days #5 and 6 of taper. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: 1. Cath tip culture positive for Coag positive staph aureus. Discharge Condition: Stable. Discharge Instructions: 1. You are being discharged back to [**Hospital 100**] Rehab. 2. Please take your medications as prescribed. 3. Please come to your follow-up appointments (see below). Followup Instructions: Follow-up appointments can be arranged through [**Hospital 100**] Rehab. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "996.62", "V44.0", "038.11", "427.31", "244.9", "V58.61", "785.52", "202.80", "707.03", "V12.51", "995.92", "V46.11" ]

icd9cm

[ [ [] ] ]

[ "00.17", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

10269, 10354

4313, 6774

274, 329

10459, 10469

2070, 4109

10685, 10887

1737, 1749

8777, 10246

10375, 10438

6800, 8754

10493, 10662

1764, 2051

222, 236

4144, 4290

357, 1173

1195, 1455

1471, 1721

75,582

108,993

30009

Discharge summary

report

Admission Date: [**2197-10-16**] Discharge Date: [**2197-10-19**] Date of Birth: [**2128-8-28**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2197-10-18**] Laparoscopic cholecystectomy History of Present Illness: 69M with history of gastric bypass presents with 3 days of RUQ abdominal pain and jaundice. Patient had sudden onset of RUQ pain 3 days ago after a large dinner. His pain has decreased slightly since then, but has not completely resolved. He denies nausea and vomiting but had one episode of diarrhea when his pain started. He has been feeling weak, ill, and had a fever to 101 today. He reports episodes of abdominal pain after meals in the past, but has never been told that he has gallstones. Patient was initially seen at [**Hospital1 18**] [**Location (un) 620**] where he was in new afib with RVR to 120s. He was afebrile at the time, but appeared jaundiced. He was fluid resuscitated and transferred to [**Hospital1 18**] [**Location (un) 86**] for management of possible cholangitis. On arrival to ED, patient was still in afib but down to 100s. He reported persistent RUQ pain but denied nausea, chills, and vomiting. Past Medical History: 1. Morbid obesity - pt has lost 145 lbs 2. hypertension - now improved 3. hyperlipidemia - now improved 4. Obstructive sleep apnea - now improved PSH: 1. Mini-gastric bypass surgery ~10 months ago 2. left thigh tumor excision 3. right inguinal hernia repair Social History: Pt denies tobacco or alcohol use. He has 2 kids and works in sales. Family History: Father had MI. Physical Exam: Temp 100.1 HR 100 BP 144/83 RR 16 O2 sat 94% RA Gen: Appears jaundiced and dehydrated, NAD CV: Irregular Resp: CTAB, no distress Abd: Soft, midly distended, tender in RUQ and mildly tender in epigastrium, midline scar noted with laparoscopic scars as well, no rebound or guarding Ext: Warm, well perfused Pertinent Results: [**2197-10-16**] 11:20PM WBC-12.2*# RBC-4.55* HGB-13.6* HCT-39.1* MCV-86 MCH-29.9 MCHC-34.8 RDW-14.2 [**2197-10-16**] 11:20PM NEUTS-94.7* LYMPHS-3.9* MONOS-1.2* EOS-0.1 BASOS-0.1 [**2197-10-16**] 11:20PM PLT COUNT-133* [**2197-10-16**] 11:20PM PT-16.6* PTT-31.6 INR(PT)-1.5* [**2197-10-16**] 11:20PM ALT(SGPT)-232* AST(SGOT)-97* ALK PHOS-204* TOT BILI-3.8* [**2197-10-16**] 11:20PM GLUCOSE-124* UREA N-27* CREAT-1.2 SODIUM-138 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15 [**2197-10-17**] MRCP : 1. Cholelithiasis with a small amount of pericholecystic fluid. No biliary duct dilatation. 2. Multiple renal cysts with a single hemorrhagic cyst in the upper pole of the left kidney. 3. Stable left adrenal adenoma. 4. Multiple small pancreatic cysts, the largest is an 8-mm cyst in the pancreatic head, given the patient's age, recommend followup with repeat MRCP in one year. Brief Hospital Course: Mr. [**Known lastname 2405**] was evaluated by the Acute Care team in the Emergency Room and based on his symptom, leukocytosis and physical exam he was admitted to the hospital with cholangitis and atrial fibrillation. For that reason he was monitored in the ICU where he was made NPO, hydrated with IV fluids and given broad spectrum antibiotics. He received one dose of lopressor for rate control of his afib and responded well. His initial T Bili was 6 and ERCP was recommended but due to his prior gastric bypass surgery it would be too difficult therefore MRCP was performed that showed cholelithiasis with pericholecystic fluid. All of his LFTs were trending down after 24 hours suggesting that a stone may have passed. His creatinine was 1.5 at the outside hospital but quickly declined with adequate fluid hydration. He was transferred to the floor on [**2197-10-17**] in good condition. Following transfer his LFT's were monitored and his T Bili decreased to 1.5 therefore plans were made for a laparoscopic cholecystectomy . He was taken to the Operating Room on [**2197-10-18**] and underwent a laparoscopic cholecystectomy. He tolerated the procedure well and returned to the PACU in stable condition. He maintained stable hemodynamics and his pain was well controlled. He was transferred back to the Surgical floor and continued to make good progress. His diet was gradually advanced and was tolerated well. He was up and walking without difficulty and his pain was well controlled. His port sites were dry. He remained in rate controlled atrial fibrillation since his admission in the 70-80 range with a blood pressure of 120/80. He has no associated symptoms and preferred to follow up with his Cardiologist Dr. [**First Name (STitle) **] [**Name (STitle) **]. After discussing the situation with Dr. [**Last Name (STitle) **] he recommended starting an aspirin a day and he will see him in his office next week for further work up. He was discharged to home on [**2197-10-19**] with a total bili of 1.1 and a creatinine of 1.2. Medications on Admission: Benicar 40', omeprazole 20' Discharge Disposition: Home Discharge Diagnosis: 1. Acute cholecystitis 2. Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. You also have an irregular heart beat which will need to be followed. You have a visit with Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 766**]. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**10-7**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites Followup Instructions: Dr. [**Last Name (STitle) **] [**Name (STitle) 766**], [**2197-10-23**] at 1:50PM at [**State 71623**]. [**Location (un) 3678**], MA. ( [**Telephone/Fax (1) 18278**]. Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**1-26**] weeks. Call Dr. [**Last Name (STitle) **] for a follow up appointment in [**12-25**] weeks. Completed by:[**2197-10-19**]

[ "V12.71", "V45.86", "782.4", "574.10", "327.23", "427.31", "584.9" ]

icd9cm

[ [ [] ] ]

[ "51.23" ]

icd9pcs

[ [ [] ] ]

5135, 5141

2998, 5056

320, 368

5231, 5231

2076, 2975

7109, 7502

1711, 1727

5162, 5210

5082, 5112

5382, 6740

1742, 2057

266, 282

6752, 7086

396, 1326

5246, 5358

1348, 1608

1624, 1695

78,536

128,271

10784

Discharge summary

report

Admission Date: [**2101-4-17**] Discharge Date: [**2101-4-20**] Date of Birth: [**2073-2-2**] Sex: F Service: MEDICINE Allergies: Zantac / Reglan Attending:[**First Name3 (LF) 3531**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Femoral Central Venous Line History of Present Illness: 28 yo F with a history of DM1 c/b gastroporesis presents with severe abdominal pain. Patient is noncompliant and reportedly only occasionally takes her BP medications and only some of her insulin at baseline. Per report, patient was screaming at the top of her lungs at triage that she had abdominal pain in all 4 quadrants which started upon waking in the morning. This was associated with nausea and vomitting. She did note missing HD for the last 2 sessions. . In the ED, she was found to have an Anion gap of 25, hyperglycemia and ketonuria. She was strarted on an Insulin drip at 7U/hr. She also received 1 L NS, 3 mg of IV Dilaudid, 1mg IV ativan, 8mg IV Zofran, and 10 mg IV compazine. She was also given Calcium gluconate for a K of 5.3 and peaked T waves on EKG. She was hypertensive to ths 190s and was given her PM dose of labetalol 100 mg po x1. 1 EJ and 2 IJs were attempted unsuccessfully, so a femoral line was placed. Per nursing notes, she was noted to be "sleepy but arousable" during the repeated line placements. Repeat FS at 2220 was 71, so Insulin was reduced to 5 u/hr and D51/2 NS with 20 meq K was started after a D50 bolus. On transfer, VS were afebrile, 93, 133/86, 14, 96% RA. . On the floor, she is lethargic and barely arousable to sternal rub. She can tell me she came in with abdominal pain, but then nods back to sleep. She can not answer orientation questions. Past Medical History: # Type 1 diabetes diagnosed at age 12. She has a history of not complying with her diabetes regimen. A1c 9 in [**7-6**] # ESRD on HD (fistula on RUE for access) # Ovarian cyst diagnosed at [**Hospital 47**] Hospital. # History of gonorrhea when she was 16 years old which was treated. # History of Chlamydia s/p treatment # Migraine headaches Social History: (per OMR) She smokes approximately 3 cigarettes per day. She states that she started smoking this way at age 18 and then smoked for 1 year, then quit for 1 year, and recently started again. She denies any alcohol or drug use now or in the past. Family History: (per OMR) Her father has AIDS. Her mother has diabetes and lupus. She also has some sort of liver problem, which [**Name (NI) 35222**] is not sure what it is. There are multiple other people in her family with diabetes. There is no coronary artery disease or cancers that she is aware of. Physical Exam: Vitals: T: 99.5 BP: 172/100 P: 98 R: 18 O2: 99 RA General: Somnolent and barely arousable to verbal stimuli. Able to follow basic commands such as moving fingers and toes. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: RUE with palpable thrill, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Able to MAES to commands. Negative babinksi bilaterally, 2+ patellar reflex bilaterally, pupils 3>2 mm bilaterally Pertinent Results: [**2101-4-17**] 04:20PM WBC-8.6 RBC-4.11* HGB-12.0 HCT-36.7 MCV-89# MCH-29.1# MCHC-32.6 RDW-16.7* [**2101-4-17**] 04:20PM GLUCOSE-301* UREA N-40* CREAT-11.6*# SODIUM-137 POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-17* ANION GAP-30* [**2101-4-17**] 04:20PM ALT(SGPT)-13 AST(SGOT)-28 ALK PHOS-212* TOT BILI-0.2 [**2101-4-17**] 04:20PM LIPASE-44 [**2101-4-17**] 04:20PM ALBUMIN-4.5 Brief Hospital Course: This is a 28 year old female with DM1 and ESRD on HD presenting with abdominal pain and found to be in DKA. . # Diabetic ketoacidosis-- The patient presented with an anion gap acidosis (anion gap of 25), glucose of 301, and ketonuria. The precipitant for the diabetic ketoacidosis was at first unclear, but after discharge the patient's urine culture returned positive for enterococcus. She was called at home and a prescription for Augmentin 500mg daily was called in for her to take after her dialysis session. She was started on IV insulin without a bolus in the ED and continued on an insulin drip at 5U /hr with Q1hr finger sticks. Her anion gap drifted down to 13 and blood sugar to 96. She was also treated with D5 1/2 NS with 20meq K, with frequent electrolyte checks for hyperkalemia given her end stage renal disease. She was transitioned to subcutaneous insulin on hospital day 2. She was followed by [**Last Name (un) **] and discharged on Lantus 12 units at bedtime and a Humalog ISS. . #. UTI: The patient had a benign UA but had >100,000 colonies of enterococcus growing in her urine on a urine culture which was finalized after the patient was discharged. This is the likely cause of her DKA and the patient was called as an outpatient and treated with Augmentin 500mg daily after HD sessions. . # Altered mental status: The patient received benzodiazepines and narcotics in the ED and was noted to be "sleepy" during numerous line attempts, but was apparently awake and oriented at triage. There was concern for cerebral edema in the setting of over-correction of serum osms, but a CT head was negative. . # Abdominal pain: The patient carries the diagnosis of gastroporesis, which may be etiology of her pain as she did present with nausea and vomitting. She responded to dilaudid, ativan, and compazine in the ED. Her lipase was normal and alk phos was elevated, but other LFTs were normal. Her exam was benign. . # ESRD on HD: She had missed several consecutive HD sessions prior to admission. She has a fistula for access and still has good residual UOP. She was continued on sensipar and HD was reinitiated as an inpatient. . #. Hypertension. Her home regimen of clonidine, lisinopril, and labetalol was continued. Medications on Admission: # Prilosec 40mg daily # ? Lantus or NPH 40 units daily # Humalog # Clonidine 0.1 mg/24 hr Weekly Transderm Patch ???? # Sertraline 25 mg Tab # Labetalol 100 mg [**Hospital1 **] vs 600 QID (documentation unclear) # Compazine 10mg TID prn # Phoslo 1334MG po TID # Amlodipine 10 mg daily # Zoloft 25 mg daily # Colchicine 0.6 mg weekly Discharge Medications: 1. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday) as needed for hypertension. 2. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: apply to affected area for 12 hours daily then remove . 5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lorazepam 1 mg IV Q4H:PRN nausea Hold for sedation, RR<12 8. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 11. Lantus 100 unit/mL Solution Sig: Twelve (12) U Subcutaneous at bedtime. 12. Insulin Lispro 100 unit/mL Insulin Pen Sig: as directed Subcutaneous four times a day: as directed by sliding scale. Disp:*5 pen* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: DKA Abdominal Pain Secondary: ESRD on HD HTN Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to the intensive care unit because uncontrolled diabetes. Your blood sugars were controlled as well as your abdominal pain. You also underwent dialysis without complications. You tolerated a regular diet and discharged home. The following changes were made to your medication: 1) Your night time lantus dose was decreased to 12U. 2) A print out of your humolog sliding scale will be give to you at discharge. There were no other changes made to your medications. You should continue as previous. Please follow-up with the appointments below. Followup Instructions: You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35223**], on [**4-25**] at 9am. PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] B [**Telephone/Fax (1) 35224**] Please Call [**Last Name (un) **] Diabetes center to schedule a follow-up appointment regarding your diabetes within 2-4 weeks. [**0-0-**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2101-4-26**] 3:45 Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2101-4-26**] 3:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2101-5-17**] 3:30

[ "403.91", "583.81", "585.6", "285.29", "250.43", "250.53", "V15.81", "346.90", "536.3", "362.01", "250.63", "250.13" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

7712, 7718

3881, 5210

290, 320

7817, 7817

3474, 3858

8626, 9397

2398, 2693

6519, 7689

7739, 7796

6161, 6496

7965, 8603

2708, 3455

236, 252

348, 1745

7832, 7941

1767, 2117

2133, 2382

6,370

172,567

8013

Discharge summary

report

Admission Date: [**2156-8-2**] Discharge Date: [**2156-8-5**] Date of Birth: [**2089-3-8**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: crampy periumbilical and RUQ pain Major Surgical or Invasive Procedure: None History of Present Illness: 67 YO F awoke this morning c crampy periumbilical and RUQ pain. She denies F/C/N/V/D. She was seen by Gen [**Doctor First Name **] and cleared for discharge home c dx of umbilical hernia until her CT C/A/P was read as showing a 5cm infrarenal aortic dissection flap. Past Medical History: Past Medical History: 1. OA 2. s/p TAH 3. HTN 4. Asthma 5. Esophageal stricture s/p dilation 6. hypertensive cardiomyopathy 7. Moderate/severe mitral regurgitation. 8. Moderate/severe systolic and diastolic ventricular dysfunction. Social History: Lives alone in [**Location (un) 686**]. Her only daughter lives nearby. The patient works as a homemaker. She denies any history of tobacco, alcohol, or other drug use. Family History: Hypertension. No history of CAD, cancer, stroke, or sudden death. No history of hemochromatosis, SLE, sarcoidosis. Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2156-8-4**] 11:10AM BLOOD WBC-6.6 RBC-3.89* Hgb-11.0* Hct-31.9* MCV-82 MCH-28.2 MCHC-34.3 RDW-13.7 Plt Ct-146* [**2156-8-4**] 11:10AM BLOOD Glucose-145* UreaN-22* Creat-1.2* Na-140 K-4.3 Cl-99 HCO3-34* AnGap-11 [**2156-8-4**] 11:10AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8 [**2156-8-2**] 8:09:14 AM Sinus rhythm Supraventricular extrasystoles Marked left axis deviation QT interval prolonged for rate RBBB with left anterior fascicular block Lateral T wave changes may be due to myocardial ischemia Since previous tracing,heart rate decreased, atrial premature complexes new Intervals Axes Rate PR QRS QT/QTc P QRS T 79 136 158 [**Telephone/Fax (2) 28676**] -82 59 [**2156-8-2**] 11:02 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST COMPARISON: None. CT ABDOMEN WITH CONTRAST: Small atelectasis is present at the lung bases. In addition, there is marked cardiomegaly and a very small pericardial effusion. The liver enhances homogeneously without focal lesions. The gallbladder, pancreas, spleen, adrenal glands are normal. The kidneys enhance and excrete normally. A hypodense cyst is present within the lower pole of the left kidney. There is a moderate hiatal hernia. No free air, free fluid, or pathologic adenopathy is present in the abdomen. CT PELVIS WITH CONTRAST: There is a large ventral hernia containing omentum and large bowel, without evidence for incarceration. The small bowel loops are normal in caliber. The rectum, sigmoid is remarkable for diverticular disease without evidence for diverticulitis. No free air, free fluid, or pathologic adenopathy is present in the pelvis. The distal ureters and bladder are normal. The uterus is not identified. Dissection flap is present along a 5-cm segment of infrarenal abdominal aorta that terminates before the bifurcation of the iliacs. The [**Female First Name (un) 899**] opacifies clearly. There is no evidence for mesenteric ischemia. Dissection does not involve the adrenals, celiac, or SMA. BONE WINDOWS: Degenerative disease is present throughout the spine, but no suspicious lesions are identified. IMPRESSION: 1. 5-cm infrarenal aortic dissection flap, with characteristics suggesting a chronic etiology. 2. Large ventral hernia without evidence for incarceration. 3. Moderate hiatal hernia. 4. Cardiomegaly. [**2156-8-2**] 11:30 PM CHEST (PA & LAT) PA AND LATERAL CHEST: There is stable severe cardiomegaly. Enlarged right mediastinal contour is again noted. The pulmonary vasculature is within normal limits. There are likely small bilateral pleural effusions. The lungs are otherwise clear. Minimal apical thickening is again seen on the right. Degenerative changes are seen within the thoracic spine. IMPRESSION: 1. Cardiomegaly with probable small bilateral pleural effusions. No overt CHF is identified. 2. Stable prominence of the right perihilar contour, which likely represents mediastinal lymphadenopathy identified on the prior chest CTA of [**2155-7-4**]. Brief Hospital Course: Pt admitted CT C/A/P was read as showing a 5cm infrarenal aortic dissection flap. Pt's BP was 200/94. She was seen by Vascular who recommended labetalol drip but denied any need for surgical intervention. Pt kept for blood pressure control repeat CT Scan - No change Pt stable for Dc taking PO / Ambulating / Urinating / pos bm Medications on Admission: coreg 25", lisinopril 40', hydralazine, protonix 40', lasix 80', aldactone 50', ASA 81', albuterol Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: Type B aortic dissection from celiac to iliacs Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Aortic Aneurysm Symptoms Aneurysms usually do not cause any symptoms until they become very large or rupture. Aneurysms in the abdominal aorta are often found coincidentally when the individual undergoes a medical test or procedure for some other reason. Chest pain and back pain are the 2 most common symptoms of large aneurysms. Almost any unusual sensation or feeling in the upper chest or back, however, may be due to an aneurysm of the aorta. Chest pain is usually the first sign of aortic dissection. Many people describe a tearing or ripping pain in the chest when the aorta enlarges to a critical size and ruptures/dissects. Besides pain, increased sweating, a fast heart rate, rapid breathing, dizziness, and shock may occur. Some people describe the following symptoms of an aortic aneurysm: A pulsating bulge or a strong pulse in the abdomen Feeling of fullness after minimal food intake Nausea Vomiting Where the aorta widens into a bulge, blood clots (thrombi) are more likely to form. If a piece of a blood clot breaks off, it travels through the circulatory system until it lodges somewhere. The clot can cut off blood flow to any area of the body. Symptoms depend on which part of the body is deprived of blood. In the most serious cases, the broken off fragments can cause stroke or heart attack. The fragments can also cause one or more vital body organs, such as the lungs, liver, or kidneys, to stop functioning properly. In less serious cases, it might cause numbness, weakness, tingling, pallor, or coldness in an arm or leg, loss of sensation, light-headedness, or localized pain. Any of these symptoms can also occur with dissection of the aorta. The pain in the chest or pain may be particularly severe, and may mimic a heart attack. In ruptured aneurysm or dissection, internal bleeding will occur. If you have any of these symptoms along with the other symptoms of aortic aneurysm, you could be in danger and must seek emergency medical care right away. Other symptoms include the following: Light-headedness Confusion Weakness Shortness of breath Rapid heart beat Sweating Numbness or tingling Loss of consciousness (fainting) This is a medical emergency. If the bleeding is uncontrolled, your blood pressure will drop dangerously low. Your organs will not receive enough blood to function normally. This is called circulatory collapse, or just "shock." This is a life-threatening condition. You lose consciousness if your brain does not receive enough blood. Your other organs may start to fail. Your heart can stop beating. This is called cardiac arrest and is often fatal. IF YOU HAVE ANY CONCERNS ABOUT THE ABOVE CALL 911 Followup Instructions: please call Dr [**Last Name (STitle) 23782**] office and schedule an appointment for 1 month / You may need a CTA. Mention this to the secretary. If you need one she will order it for you. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2156-9-20**] 2:30 Completed by:[**2156-8-5**]

[ "428.40", "278.01", "441.02", "425.8", "424.0", "553.29", "493.90", "402.91", "428.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5791, 5797

4707, 5041

345, 352

5888, 5897

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5818, 5867

5067, 5167

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1240, 1702

272, 307

380, 648

692, 904

920, 1093

63,496

190,949

37586

Discharge summary

report

Admission Date: [**2156-10-23**] Discharge Date: [**2156-12-13**] Date of Birth: [**2108-12-8**] Sex: M Service: MEDICINE Allergies: Citalopram Attending:[**First Name3 (LF) 2297**] Chief Complaint: Injuries sustained upon falling. Major Surgical or Invasive Procedure: Nasogastric tube Bronchoscopy Tracheostomy Intubation History of Present Illness: This is a 46 year old male with a history of alcohol abuse and end stage liver disease who was admitted to the trauma serivce on [**2156-10-23**] after falling down the stairs in his home and suffering multiple fractures. The patient has received most of his liver care at [**Hospital **] [**Hospital3 26522**] Center. He was found unresponsive by his girlfriend at 4AM on the morning of presentation. He was initially taken to [**Hospital 5450**] Medical center where his initial vitals were BP 72/52, P 73, RR 16, O2 89% with mask ventilation. He was noted to be groaning with some occassional arm movement. He was intubated for airway protection. He was found to have fractures of the C6, C7 left T1 transverse process. Initial head CT there was negative for acute intracranial process. CT abdomen and pelvis was negative for acute intraabdominal trauma. A right femoral line was placed for access. Labs were notable for urine toxicology positive for tylenol, benzodiazepines and opiates. Serum alcohol 162. Urinalysis was negative. Na 131, K 5.0, Cl 95, HCO3 24, BUN 15, Cr 1.3, Glu 96, Ca 8.7, T Bili 16.8, DBili 8.2, ALT 29, AST 60, INR 1.7, WBC 7.24, Hct 32.7, Plts 71. EKG showed normal sinus rhythm, normal axis, normal intervals, no acute ST segment changes, no change for prior. He was transferred here for further management. On arrival to our emergency room, initial vs were: T: 96.4 P: 75 BP: 117/73 R: 14 O2 sat 100% on ventilator. Further imaging demonstrated multiple rib fractures and fractures of C6-T3 transverse processes. Repeat CT head showed a new right frontal subcortical parenchymal hemorrhage with blood-fluid level, He received two units of FFP and two units of PRBCs and was admitted to the trauma ICU for further management. Past Medical History: -End stage liver disease [**1-11**] alcohol. He has not been followed by hepatology for 6 months. He has had ascites in the past as well as a history of encephalopathy. No history of GI bleeding. Recently drinking a few beers every few days. -Peripheral vascular disease with recent toe ulcer on bactrim. -Scheduled bilateral stent placement for this week. -Pancreatitis -s/p appendectomy Social History: Lives with girlfriend. 0.25 ppd x 20 years tobacco use. Still drinking; heavy EtoH in past. Not working. Continuing drinking and no follow-up in recent months despite ESLD. Family History: Non-contributory with respect to heritable illness. Physical Exam: On arrival to MICU: Vitals: T: 99.1 BP: 134/55 P: 91 R: 10 O2: 15L facetent General: Somnolent, makes intermittent groaning noises, doesn't open eyes, no distress HEENT: Sclera icteric, MM dry, mild dried blood in oropharynx Neck: supple, JVP not elevated, no LAD Lungs: Trace crackles at right base, otherwise clear bilaterally CV: Regular rate and rhythm, normal S1 + S2, II/VI HSM at apex, no rubs, gallops Abdomen: soft, non-tender, mildly-distended, bowel sounds present, no rebound tenderness or guarding, liver tip not palpable, no fluid wave GU: foley draining dark urine Ext: warm, well perfused, dopplerable pulses, no clubbing, cyanosis trace edemma, 1 cm healing ulcer with granulation tissue on right great toe Skin: Jaundice Neurologic: Withdraws to pain throughout, moves all extremities, mild asterixis On arrival to floor: Vitals: T: 99.4 BP: 140/9 P: 96 R:16 SaO2: 95 RA General: sleeping, somnolent, jaundiced, not alert but able to follow commands HEENT: PERRL, EOMI, + scleral icterus, dry MM, OP without lesions Neck: supple, no JVD Pulmonary: CTAB, basilar crackles, limited exam due to patient positioning, no wheezes. Cardiac: regular rhythm, tachycardia, II/VI systolic murmur LLSB, no rubs or gallops appreciated Abdomen: soft, mild tenderness on left flank, distended vs obese, +BS Extremities: 2+ pitting edema bilateral, L toe ulcer, clean/dry Skin: large ecchymosis on left shoulder Neurologic: oriented x1 (hospital, [**2048**]), +asterixis Pertinent Results: Labs on admission: [**2156-10-23**] 10:30AM WBC-7.0 RBC-2.24* HGB-8.5* HCT-23.9* MCV-107* MCH-38.2* MCHC-35.7* RDW-19.7* [**2156-10-23**] 10:30AM NEUTS-67 BANDS-6* LYMPHS-22 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2156-10-23**] 10:30AM ASA-NEG ETHANOL-118* ACETMNPHN-13.3 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2156-10-23**] 10:30AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2156-10-23**] 10:30AM AMMONIA-61* [**2156-10-23**] 10:30AM ALBUMIN-2.9* CALCIUM-8.6 [**2156-10-23**] 10:30AM LIPASE-28 [**2156-10-23**] 10:30AM ALT(SGPT)-26 AST(SGOT)-74* ALK PHOS-164* TOT BILI-15.6* [**2156-10-23**] 10:30AM GLUCOSE-105 UREA N-14 CREAT-0.9 SODIUM-134 POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-22 ANION GAP-14 CXR [**2156-10-23**]: Appropriately positioned endotracheal tube. Multiple left rib fractures, no pneumothorax. CXR [**2156-11-6**]: Background pulmonary edema with mild interval improvement in the right mid and left lower zone consolidations. CT Chest w/o contrast [**2156-10-23**]: 1. Small bilateral pleural effusions with underlying consolidation/ atelectasis. 2. Left posterior rib fractures 3, 6, and 10. Left lateral rib fractures 3 through 8. 3. Left transverse process fractures at T1, T2, and T3. 4. NG tube terminates in the proximal stomach, just below the GE junction. CT Abdomen/Pelvis w/o contrast [**2156-10-23**]: 1. No traumatic injury to the abdomen or pelvis. No intra- or retro-peritoneal bleed. 2. Cirrhosis and evidence of portal hypertension. No ascites. 3. Cholelithiasis. 4. Intra- and extrahepatic biliary ductal dilation. 5. Diverticulosis. No evidence of diverticulitis. CT head w/o contrast [**2156-10-23**]: New right frontal subcortical parenchymal hemorrhage with blood-fluid level, which, if occurs at time of presentation, suggests either anti-coagulation or intrinsic coagulopathy. Also new is a subgaleal hematoma over the left parietovertex. CT head w/o contrast [**2156-10-24**]: Again demonstrated is asymmetric prominence of the extra-axial CSF space overlying the left fronto-parietal convexity. This measures 12 mm in maximal thickness from the inner table of the skull (2:28) and 15 [**Doctor Last Name **] in density, and is unchanged over the series of three studies, and may simply represent asymmetric cortical atrophy; a subdural hygroma is not excluded (is there a history of previous trauma?). CT head w/o contrast [**2156-10-25**]: Essentially unchanged size and appearance of right frontal IPH. No new ICH. No developing hydrocephalus. CT head w/o contrast [**2156-10-29**]: 1. Inferior right frontal parenchymal hematoma with peri-hemorrhagic edema, unchanged. 2. No new foci of hemorrhage. 3. No fracture. EKG: normal sinus rhythm, normal axis, borderline prolonged QTc 464, no acute ST segment changes, no change from prior dated [**2156-10-23**]. [**2156-10-26**] RUQ U/S: 1. Irregular nodular liver with a coarse echotexture in keeping with known liver cirrhosis. 2. The portal vein and hepatic veins are patent; however, there is hepatofugal flow in the main portal vein. There is reversed flow also in the splenic vein which would be consistent with the presence of a splenorenal shunt. There is a small amount of ascites and a small right-sided pleural effusion. 3. Single gallstone in the neck of the gallbladder, with a normal gallbladder wall. Two sub-5-mm gallbladder polyps also identified. [**10-26**] CT Head: Unchanged appearance and size of right frontal lobe intraparenchymal hematoma, 2.4x2.0cm. No change since the prior study. While this can be related to trauma, an underlying vascular lesion /mass cannot be excluded and further cworkup can be considered, as clinically indicated. [**11-1**] Abdominal US: Scan trace of ascites in the perihepatic space. [**11-11**] CT Sinus: No fracture. [**11-11**] CT Head: 1. Little change in the right frontal hemorrhage with surrounding edema and mass effect on the right frontal [**Doctor Last Name 534**] and 2-mm leftward shift of midline structures in comparison to five hours prior. 2. Unchanged parafalcine subdural hematoma. 3. Slight increase in the small amount of blood layering in the occpital horns. [**11-14**] CT Head: 1. Unchanged right frontal intracranial hemorrhage with intraventricular extension, surrounding edema and 2 mm leftward shift of midline structures. 2. Unchanged right parafalcine subdural hematoma and left extra-axial CSF attenuation collection. 3. Decreased right maxillary sinus air-fluid level. Unchanged left mastoid air cell partial opacification and right ethmoid air cell mucosal thickening. [**11-15**] Abdominal US: 1. NG tube side port below the gastroesophageal junction and is not coiled. 2. Hepatosplenomegaly. 3. Left lower lung lobe atelectasis. [**11-16**] Xray R foot: There is no plain film evidence of osteomyelitis. [**11-16**] CT Head: 1. Unchanged right frontal intracranial hemorrhage with intraventricular extension. 2. No change in 2 mm leftward shift of midline structures. 3. Unchanged right parafalcine subdural hematoma. 4. Left extra-axial CSF-attenuation collection is unchanged. Chest XP (portable) [**2156-12-12**] FINDINGS: Comparison is made to prior study from [**2156-12-11**]. The tracheostomy tube and feeding tube are again seen and unchanged in position. Patient is rotated on the image and the left lateral chest wall has been cut off from the study. There is again seen complete whiteout of the left lung. Previously a small amount of lung parenchyma was seen in the left upper lobe. There is a large right- sided pleural effusion as well. Brief Hospital Course: Mr [**Known lastname **] was transferred between numerous services (TSICU, [**Doctor Last Name 3271**]-[**Doctor Last Name 679**], MICU, [**Doctor Last Name 3271**]-[**Doctor Last Name 679**], MICU, [**Doctor Last Name 3271**]-[**Doctor Last Name 679**], MICU) and has had a complicated Hospital Course, which will therefore be divided into Summary, and then a narrative description of events. Summary 46M with EtOH cirrhosis and ESLD c/b ascites, varicies, and encephalopathy admitted s/p fall, multiple fractures, intraparenchymal cerebral hemorrhages. Course complicated by ventilator associated pneumonia, hepatic encephalopathy and acute alcoholic hepatitis, coagulopathy and pulmonary and cerebral hemorrhage. Given the patient's serious neurologic injury and end-stage liver disease with coagulopathy and ongoing pulmonary hemorrhage along little prospect of recovery or weaning from a ventilator, it was decided, in discussion with his family, to change to comfort-direct care without other treatments not directed at recovery. He passed away shortly after being extubated. [**Hospital 84345**] Hospital Course While on the trauma SICU service he received 10 mg IV vitamin K, 6 units FFP, 8 units PRBCs, 3 units platelets. He was noted to have guaiac positive stool. OG lavage was negative. He was seen by the hepatology consult service who recommended continuation of lactulose, IV PPI, serial hematocrits, repeat cultures, and potential MRCP when stabilized to evaluate dilated biliary tree. He had a fever to 101.5 degrees on [**2156-10-24**] and had blood and urine cultures taken. Repeat head CTs on [**2156-10-24**] and [**2156-10-25**] were stable. Per neurosurgical team, for management of intracerebral hemorrhage would maintain INR < 1.5, plts > 80. Goal SBP < 160. Given no immediate operative intervention and need for supportive care in context of liver failure and intracerebral hemorrhage, Mr. [**Name13 (STitle) 57920**] was transferred to the Medical ICU. On the MICU service, patient was started on rifaximin and lactulose via NG tube for change in mental status with goal of 3.4 stools per day. A flexiseal was placed after copious stooling. Given intracranial bleeding, agressive coagulopathy control was attempted. He received 1 bag of platelets for a plt count of 72, and 2 bags of FFP for an INR of 1.9. Serial Ct head scans showed that the hemorrhages were unchanged. RUQ u/s did not show any extrahepatic dilatation, and only a small amount of ascities. Blood cultures from [**10-23**] were positive for GPCs on [**10-26**] and he was started on Vanco while awaiting speciation. Patient was continued of ctx/azithromycin for presumed pneumonia and was day 2 of planned 7 day course. While on the floor, patient was switched to Vanc/Zosyn on [**10-23**] and completed 13 days of treatment. By [**11-11**], patient had been accepted by rehabilitation facility. At 4am, he fell on his face on the hospital floor. Plastic Surgery placed 12 stitches for facial/lip lacerations and patient was given two day course of Clindamycin. CT head showed parafalcine subdural hematoma and worsening old intraparenchymal right frontal bleed. Repeat CT 6 hours later showed worsening bleed in the sub-cortical region. NSG saw and recommended specific transfusion goals but no surgical intervention given his coagulopathy. Patient received 1unit pRBC, 2unit platelets, and 1unit FFP. He became progressively more lethargic though his vital signs remained stable. He was transferred to the unit for worsening mental status. In the ICU, he remained on anti-seizure prophylaxis with a stable neuro exam. The day after transfer he had increased work of breathing and was ultimately intubated for hypoxia from presumed aspiration and possible pulmonary edema vs TRALI given massive amount of transfusions. He was treated with Vanc/Zosyn starting [**11-14**] (last dose to be [**11-21**] for total of 7 days of treatment) for aspiration, and diuresed. He was extubated on the evening of [**11-17**] without difficulty. Additionally, during his ICU stay, he was noted to have a new right dorsal hallux ulceration and was evaluated by Podiatry. They felt there was a mild cellulitis covered by the broad-spectrum antibiotics. They recommended Podiatry follow up after discharge. Repeat head CT's on [**11-13**] and [**11-16**] showed no significant change. Cultures grew E. cloacae from the sputum x2 (sparse growth) and R hallux swab grew rare CoNS. While in the ICU, he received a total of 18 units FFP, 12 units of platelets and 6 units of pRBC, most recently 1 unit FFP on [**11-18**]. Was called out to the floor where he was stable for approximately 24-36 hours. Floor course notable for mild abdominal pain briefly treated with flagyl for possible C. Diff. Continued on vanco/zosyn at that time. On [**11-20**] the patient developed respiratory distress with tachypnea to the 30's thought [**1-11**] encephalopathy and inability to protect his airway. ABG at that time was 7.44/55/62 on a non-rebreather. Was urgently transferred to ICU, and on arrival dropped sats to high 80's on NRB and was intubated. In the ICU, impression was for aspiration pneumonia possibly [**1-11**] to known enterobacter w/ possible component of mucous plugging. Patient transitioned from zosyn/flagyl to meropenem on advice from ID (no formal consult) given concern for inducible resistance in enterobacter. Remained intubated for approximately 24-36 hours, and extubated without difficulty. Course notable for persistent anemia refractory to transfusions, but stable for 36 hours prior to call-out from ICU. Stools guaiac negative in ICU. Pan-scan without e/o new or worsening fluid collections, and patient with persistent bleeding from facial/head trauma thought to be source for bleeding. Plastics reluctant to suture head wound and occlusive ace bandages applied for topical hemostasis. Mental status in ICU persistently altered. Noted to be mumbling at times, and occasionally able to Labs notable for significant hypernatremia corrected with free water. Given marked volume overload patient diuresed with initially 40mg IV lasix/spironolactone and later lasix80/spironolactone. Family meeting held in the ICU with goals of care discussion with family. Plan will be to continue current plan of care and await improvement in mental status before readdressing. Upon transfer back to floor, patient was calm but minimally responsive to verbal/noxious stimuli. He was was observed to have foaming at the mouth and decreased responsiveness with upper extremity jerking R>L lasting 5 minutes prior to returning to his encephalopathic baseline. His vitals at the time included HR 80's (baseline), and his Dilantin level was therapeutic at 20 at the time. Neurology was consulted, and an EEG showed diffuse slowing c/w severe encephalopathy and no suggestion of seizures. Neurology recommended continuing to correct metabolic derranagements and consider changing to keppra. However, the patient was found to have a supratherapeutic dilantin level and pharmacy recommended the current dilantin orders in the system. The next Dilantin level should be drawn on Mon [**11-29**]. Overnight on [**11-26**], the patient developed had an episode of desaturation to the 80's, and required suctioning and nebulizer treatments. His PO2 increased to the 90's but the patient had an increased O2 requirement (face tent at FIO2 50%). The morning of [**11-27**], the patient was found to have tachypnea with RR in the low 20's. Respiratory therapy did not wish to suction the patient out of concern for his elevated INR, and he was given 1 unit FFP and diuresed with Lasix 80mg IV x2 over last 24 hours. He responded with good UOP. On the evening of [**11-27**], the patient desaturated again, and respiratory therapy did not feel comfortable suctioning the patient due to his elevated INR. The nurse suctioned the patient and suctioned back blood. The patient was given nebulizers and saturations increased to the low 90's and his RR decreased. The patient was weaned down to 5L NC, but ABG showed 7.45/50/57/36. The patient complained of shortness of breath, and the decision was made to transfer him back to the MICU for respiratory distress and possible need for intubation if respiratory status further declines. The final portion of Mr. [**Last Name (Titles) 84346**] stay was in the MICU from [**2156-11-27**]: Altered Mental Status and Cerebral Hemorrhage Likely multifactorial including primary neurologic process from intraparenchymal hemorrhage, infection and hepatic encephalopathy. He was continued on lactulose and rifaxamin. Intraparenchymal hemorrhage was stable on repeat CT scans. Neurosurgery was involved and has since signed off. He is on phenytoin for seizure prophylaxis and was therapeutic (18). Ventilator associated pneumonia may have also contributed, but the main cause likely remained hepatic encephalopathy. Respiratory Distress Patient's breathing improved with diuresis, but was complicated by large effusions, secondary to hypoalbuminemia, and pulmonary hemorrhage, likely the causes of subsequent complete 'white-out' of left lung. Coagulopathy The patient was severely coagulopathic secondary to liver disease and coagulation was not sustainable without copious repletion of exogenous clotting factors. Previously identified left lingular site was likely repsonsible. Possible contribution by some mucus plugging. Code Status Patient had previously requested aggressive treatement, but Mr. [**Name (NI) 84347**] mother was found to be appropriate next of [**Doctor First Name **] given disrupted relationship with girlfriend, to whom he was not married. Made CMO after discussion with Ethics and patient's mother/family. Made CMO on [**12-13**] with mother and brother in attendance. Saturation had been about 80% all day. Slightly agonal breathing pattern on pressure support. Mr. [**Name13 (STitle) 57920**] passed away shortly after extubation. Medications on Admission: Oxycodone 5 mg Q4H:PRN Aldactone Lactulose Folic Acid Lasix Bactrim DS [**Hospital1 **] Discharge Medications: Not applicable. Discharge Disposition: Expired Discharge Diagnosis: Patient expired secondary to complication of liver failure and coagulopathy. Discharge Condition: Patient expired.

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icd9cm

[ [ [] ] ]

[ "99.15", "33.21", "31.1", "27.51", "96.6", "38.93", "96.72", "86.59", "96.04", "33.24" ]

icd9pcs

[ [ [] ] ]

20194, 20203

10004, 20016

306, 362

20323, 20342

4350, 4355

2787, 2840

20154, 20171

20224, 20302

20042, 20131

2855, 4331

234, 268

390, 2169

9253, 9981

4369, 7801

2191, 2581

2597, 2771

7,427

172,180

13224

Discharge summary

report

Admission Date: [**2141-6-13**] Discharge Date: [**2141-6-19**] Date of Birth: [**2063-3-27**] Sex: F Service: MEDICINE Allergies: Tetracycline Attending:[**First Name3 (LF) 398**] Chief Complaint: MS changes Major Surgical or Invasive Procedure: CVL placement History of Present Illness: HPI: 78 y/o F with obesity, chronic UTIs in the setting of bladder diverticulum, and MMP, presented from her rehab today with mental status changes, hypotension, and concern for urosepsis. Pt has had 4 episodes of urosepsis in the last month, the last 1 week prior. During her hospitalization from [**Date range (1) 36573**] she was found to have an MDR-E.coli, Proteus and VSEnterococcus urosepsis. She was discharged on 1 week of Gentamicin IM and 2 weeks of PO Augmentin. . However, at her rehab today, she was noted to be confused, adn hypotensive to 80/50 similar to her prior episodes of urosepsis. She was brought to [**Hospital1 **] for further evaluation. . In the ED, her VS were: 99.6, HR 80, BP 80/50, RR 20, 94%RA. She received Cefepime 2g IV x1, Vanco 1g IV x1, Decadron 10mg IV x1. She received 4L NS in total during her ED course. Past Medical History: 1) Chronic UTIs; last UTI with E.coli ([**Last Name (un) 36**] imipenem) and VSE and Proteus 2) Hypothyroidism 3) PMR 4) COPD 5) asthma 6) rheumatoid arthritis 7) hypertension 8) DMII 9) morbid obesity 10)bladder diverticulum. 11)anemia 12)History of syncope. 13) Peripheral vascular disease. 14) Coronary artery disease. 15) Status post sigmoidectomy with ileostomy. 16) History of C. difficile. . Social History: She lives at [**Hospital **] Nursing Home. She is bed bound and uses an electric wheelchair. Family History: Noncontributory. Physical Exam: VS: Temp:98.0 BP:115/47 HR:85 RR:16 O2sat: 99% 4L NC GEN: obese, pleasant, comfortable at rest HEENT: PERRL, EOMI, anicteric, MMM. Cannot assess JVD. LIJ in place RESP: CTA b/l anteriorly CV: distant, RR, S1 and S2 wnl, no m/r/g ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ pitting edema bilaterally SKIN: no rashes/no jaundice/no splinters NEURO: AAOx1-2. Follows conversation and answers appropriately. Moves all ext spontaneously. Pertinent Results: Labs: Imaging: CT Head [**6-13**]: 1) No evidence acute intracranial pathology. 2) Possible old neurocysticercosis infection. . CXR [**6-13**]: Evaluation is limited by low lung volumes and patient's oblique positioning. There is no acute cardiopulmonary abnormality. The lungs are clear. Blurred of the left costophrenic angle may be due to a tiny pleural effusion. No pneumothorax. Cardiac, mediastinal, and hilar contours are within normal limits. [**6-16**] CT abdomen 1. Multiple large mid to upper pole right renal calculi without evidence of obstruction or secondary infection. New soft tissue density filling defect within a right upper pole calix may represent a noncalcified stone, however a small soft tissue calyceal neoplasm cannot be excluded. Findings discussed with Dr. [**Last Name (STitle) 14440**]. 2. Multiple splenic cysts, unchaned. 3. Fluid collection inferior to left rectus sheath likely represents a postoperative seroma. 4. Subcutaneous abdominal nodule may represent a site of injection but clinical correlation is required. 5. Diverticulosis without diverticulitis. [**2141-6-13**] 06:48PM COMMENTS-GREEN TOP [**2141-6-13**] 06:48PM LACTATE-1.0 [**2141-6-13**] 06:20PM GLUCOSE-112* UREA N-31* CREAT-1.9*# SODIUM-130* POTASSIUM-5.5* CHLORIDE-92* TOTAL CO2-27 ANION GAP-17 [**2141-6-13**] 06:20PM estGFR-Using this [**2141-6-13**] 06:20PM CK(CPK)-81 [**2141-6-13**] 06:20PM CK-MB-NotDone cTropnT-<0.01 [**2141-6-13**] 06:20PM WBC-21.9*# RBC-3.72* HGB-10.9* HCT-32.4* MCV-87 MCH-29.5 MCHC-33.7 RDW-15.8* [**2141-6-13**] 06:20PM NEUTS-91.0* LYMPHS-5.7* MONOS-2.6 EOS-0.7 BASOS-0 [**2141-6-13**] 06:20PM PLT COUNT-497* [**2141-6-13**] 06:20PM PT-12.5 PTT-24.7 INR(PT)-1.1 [**2141-6-13**] 06:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2141-6-13**] 06:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2141-6-13**] 06:20PM URINE RBC-[**2-27**]* WBC-[**11-14**]* BACTERIA-2 YEAST-NONE EPI-0 Brief Hospital Course: A/P:78 y/o F with obesity, chronic UTIs in the setting of bladder diverticulum, and MMP, presented from her rehab today with mental status changes, hypotension, and concern for urosepsis 1. Sepsis Likely source urine given her frequent episodes of urosepsis over the past month. She was recently admitted at [**Hospital1 **] with an E.Coli, Proteus and Vanco-[**Last Name (un) 36**] Enterococcus UTI. She was discharged on Augmentin and Gentamicin despite E.coli not being sensitive to augmentin nor gentamicin(although [**Last Name (un) 36**] to cephalosporins). Enterococcus and Proteus appeared covered. Was intermittantly hypotensive in the ED requiring fluid resuscitation as well as temporary levophed to maintain MAP >65. Was admitted to the MICU and was stable off pressors in the first 48 hours. She was placed on Imipenem and Vancomycin to cover her empirically. Urology/ID was consulted in the setting of known staghorn calculi and her recurrent urosepsis episodes. Patient will be discharged on ceftazadime for 2 weeks and switched to cefuroxime for suppression per ID. Urology wants to do a procedure once patient finished with IV antibiotics. 2. MS changes Improved with IVF, Abx treatment in ED per daughter. [**Name (NI) 430**] CT negative in ED. Likely toxic-metabolic encephalopathy that is improving given her urosepsis. Patient resolved by discharge. 3.ARF Likely in setting of infection; pre-renal. Baseline Cr normal. Creat on d/c 1.3. 4. PMR Continued prednisone 5mg qD. 5.Chronic LBP cont MS contin at lower doses due to concern for resp suppression. 6.HTN - restarted lisinopril, bblocker once BP was stable. Held Imdur, bblocker 6.CAD - cont ASA. restarted bblocker, acei. . 7.RA - cont Plaquenil 8.DMII - cont NPH [**Hospital1 **], regular ISS Comm: HCP [**Name2 (NI) 40313**] [**Name (NI) **] [**Name (NI) 31429**] (c) [**Telephone/Fax (1) 40314**] (h) [**Telephone/Fax (1) 40315**] Code:DNR/DNI Medications on Admission: Ecotrin 325 mg daily, Lisinopril 5 mg daily Imdur 60 mg daily Metoprolol 37.5 mg [**Hospital1 **] Gemfibrozil 600 mg [**Hospital1 **] Lasix 20 mg daily (except on Monday and Friday, 40 mg p.o. daily on Humulin N 40 units subcu q.a.m. Humulin R 20 units subcu q.a.m. RISS Prednisone 5 mg daily MS Contin 45 mg [**Hospital1 **] 30 mg QHS Lidoderm 5% patch 4 patches daily, 12 hours on, 12 hours off Gabapentin 00 mg TID Cymbalta 60 mg daily Levothyroxine 137 mcg daily Omeprazole 20 mg daily Cardura 20 mEq daily Cranberry 25 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] Senna 2 [**Hospital1 **] Magnesium oxide 400 mg daily Multivitamin 1 daily Iron 325 mg TID Glucerna 1 can daily Hydroxychloroquine 400 mg daily Gentamicin 200 mg IM q.24h. x7 days Augmentin 500/125 mg 1 p.o. b.i.d. x7 days Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 14 days. Disp:*36 1* Refills:*0* 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day): only monday wednesday and friday. 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS OFF (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H (every 4 hours). 15. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 17. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day) as needed for DVT prophylaxis. 19. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical PRN (as needed). 20. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 22. Humalog 100 unit/mL Solution Sig: Sliding Scale units Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Urosepsis Staghorn calculi, chronic UTI Bladder diverticulum Rheumatoid arthritis Polymyalgia rheumatica Chronic obstructive pulmonary disease Hypertension Diabetes Mellitus Type II Anemia Peripheral vascular disease Coronary artery disease Status post sigmoidectomy with ileostomy Morbid obesity Discharge Condition: Patient has been stabilized, and has a PICC line placed for continued antibiotic therapy Discharge Instructions: Please take all medications and make all appointments as listed in the discharge paperwork. Patient was treated for urosepsis and has a history of urinary tract infection with multiresistent bacteria. Please [**Name8 (MD) 138**] MD or come to hospital if fevers, chills, confusion, chest pain, shortness of breath, or other concerning symptoms. Followup Instructions: Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 17753**] in [**12-27**] weeks. Please make appointment to follow with Urology, Dr. [**Last Name (STitle) 3748**] [**Telephone/Fax (1) 40316**] in two weeks.

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icd9cm

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7953

Discharge summary

report

Admission Date: [**2104-8-17**] Discharge Date: [**2104-8-23**] Date of Birth: [**2043-6-8**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**Doctor First Name 5188**] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 7046**] is a 61 year old female with a PMH significant for chronic RUQ abdominal pain and pancreas divisum admitted to the Surgical service and now transferred to the [**Hospital Unit Name 153**] for tachycardia and an increased oxygen requirement. The patient reports that she developed acute onset [**11-15**] epigastric pain on the evening of [**8-17**] described as constant dullness or aching with intermitent sharp/stabbing pain made worse with movement with associated SOB from abdominal pain with inspiration. Onset of pain was preceded by nausea and NBNB emesis. The patient was brought to the OSH ED, where she was found to have a lipase of 6000 and a RUQ U/S that was negative for cholelithiasis or cholecystitis. She also had a CTAP that was suggestive of necrotizing pancreatitis, and she was transeferrred to the [**Hospital1 18**] surgical service for further management this afternoon. . Of note, the patient reports a 30+ year history of RUQ abdominal pain of unclear etiology. Pain is described as intermitent achiness somewhat similar to her current symptoms but in a different location and much lower in intensity. Approximately 10 years ago, she presented to an OSH ED for these symptoms and was diagnosed with pancreas divisum on ERCP. . At [**Hospital1 18**], the patient was placed on a dilaudid PCA with improvement in her pain control. She was noted on the floor, however, to be in sinus tachycardia up to 140 with an SaO2 that decreased to low 90s on RA from mid to high 90s on initial presentation with a venous lactate of 3.7. She was initially treated with ciprofloxacin and flagyl which was held this morning. She was then transferred to the [**Hospital Unit Name 153**] for further management. . Currently, the patient is resting comfortably. Pain is well controlled on PCA. Denies any CP/SOB, f/c/s, n/v, palpitations, orthopnea, PND. . ROS: Last BM 3 days prior to admission. As above, otherwise negative. Past Medical History: Pancreas divisum Hypertension Hyperlipidemia Hypothyroidism Duodenal ulcer Hysterectomy Tonsillectomy Appendectomy Social History: Lives with 2 friends in [**Location (un) 8973**]. Patient is a nurse. Tobacco - quit 20 years ago, 1 ppd x20 yrs. EtOH - 1 drink/month. No IV, illicit, or herbal drug use. Family History: hyperlipidemia, HTN, RA Physical Exam: Gen: Age appropriate female resting comfortably in NAD HEENT: Perrl, eomi, sclerae anicteric, MMM, OP clear without lesions, exudate or erythema. Neck supple. CV: Tachy S1+S2 Pulm: Fine [**Hospital1 **]-basilar rales bilaterally Abd: Mildly distended, TTP throughout worst in epigastrum. No rebound or guarding. Minimal BS Ext: No c/c/e Neuro: AO x3, CN II-XII intact. Pertinent Results: [**2104-8-23**] 02:00PM BLOOD WBC-13.5* [**2104-8-23**] 07:40AM BLOOD WBC-16.4* RBC-3.86* Hgb-11.7* Hct-35.0* MCV-91 MCH-30.2 MCHC-33.4 RDW-13.0 Plt Ct-473* [**2104-8-22**] 06:25AM BLOOD WBC-13.5* RBC-3.91* Hgb-12.0 Hct-36.4 MCV-93 MCH-30.6 MCHC-32.9 RDW-13.1 Plt Ct-394 [**2104-8-21**] 01:20PM BLOOD WBC-15.2* RBC-3.85* Hgb-12.2 Hct-35.2* MCV-92 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-375 [**2104-8-20**] 07:05AM BLOOD WBC-13.6* RBC-3.83* Hgb-11.9* Hct-35.5* MCV-93 MCH-31.2 MCHC-33.7 RDW-13.4 Plt Ct-301 [**2104-8-19**] 04:00AM BLOOD WBC-12.4* RBC-4.58 Hgb-14.1 Hct-42.9 MCV-94 MCH-30.8 MCHC-32.8 RDW-13.4 Plt Ct-327 [**2104-8-18**] 06:20AM BLOOD WBC-11.3* RBC-5.12 Hgb-15.7 Hct-47.7 MCV-93 MCH-30.6 MCHC-32.9 RDW-13.6 Plt Ct-335 [**2104-8-17**] 07:45PM BLOOD WBC-8.8 RBC-5.44*# Hgb-17.4*# Hct-50.1*# MCV-92 MCH-32.1* MCHC-34.8 RDW-13.1 Plt Ct-410 [**2104-8-17**] 07:45PM BLOOD Neuts-67 Bands-14* Lymphs-10* Monos-6 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0 [**2104-8-17**] 07:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2104-8-23**] 07:40AM BLOOD Plt Ct-473* [**2104-8-18**] 06:20AM BLOOD PT-14.7* PTT-27.4 INR(PT)-1.3* [**2104-8-18**] 06:20AM BLOOD Plt Ct-335 [**2104-8-23**] 02:00PM BLOOD Na-135 K-3.3 Cl-99 [**2104-8-17**] 07:45PM BLOOD Glucose-178* UreaN-23* Creat-0.7 Na-134 K-5.1 Cl-100 HCO3-17* AnGap-22 [**2104-8-22**] 06:25AM BLOOD ALT-23 AST-24 AlkPhos-101 Amylase-32 TotBili-0.5 [**2104-8-17**] 07:45PM BLOOD ALT-32 AST-50* AlkPhos-93 Amylase-280* TotBili-0.4 [**2104-8-23**] 07:40AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1 [**2104-8-19**] 04:00AM BLOOD Albumin-3.0* Calcium-8.1* Phos-1.6* Mg-2.0 [**2104-8-22**] 09:27AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 [**2104-8-22**] 09:27AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2104-8-22**] 09:27AM URINE . ABD US [**2104-8-19**] 1.Heterogenous appearance of the pancreas with surrounding fluid, consistent with the history of pancreatitis. There is evidence of gallbladder sludge, but no evidence of chololithiasis. 2. Small right pleural effusion. Brief Hospital Course: Ms. [**Known lastname 7046**] is a 61 year old female with pancreas divisum and acute pancreatitis transferred to the [**Hospital Unit Name 153**] for tachycardia and increasing O2 requirement. . # Acute pancreatitis: Pain much improved with dilaudid PCA. Given elevated venous lactate and UOP ~30 cc/hr, patient was intravascular volume deplete upon admission to ICU. Only risk factor for acute pancreatitis at this time is pancreas divisum. The patient improved overnight in the ICU with 200cc/hr of LR, NPO, dilaudid PCA. She was afebrile, although her WBC increased slightly from previous to 12. Her amylase/lipase were trending down. Currently low suspicion for necrotizing pancreatitis although outside hospital CT could not exclude, so will repeat RUQ ultrasound this AM per surgery recs, and hold prophylactic abx for now. . # Sinus tachycardia: Likely multifactorial in etiology including pain and intravascular volume depletion in setting of third spacing from pancreatitis. Given temporal association with acute pancreatitis, less likely to be hyperthyroid or PE. No indication for AV nodal blockade at this time as tachycardia is likely compensatory and she has no cardiac history, and will follow on telemetry. . # Respiratory: Patient with mildly increased supplemental oxygen requirement now on 3L nc. Likely from large volume IVF in setting of pancreatitis and third spacing, although CXR without significant pulmonary edema at this time. Patient also with small bilateral pleural effusions and rapid shallow breathing from pain may also be leading to some atalectesis. Low suspicion for developing ARDS from pancreatitis at this time. If O2 requirement and tachycardia does not improve can also consider PE, although it less likely clinically at this time. There is also a small likelihood that this could be an inflammatory pancreatic cancer, in which case the patient could be hypercoaguable. Again, at this time we will watch clinically, wean O2 as tolerated, and encourage incentive spirometry. . # HTN: Hold home lisinopril for now as patient is not hypertensive. . # Hypothyroid: Continue home synthroid. . # Hyperlipidemia: Not currently on lipid-lowering regimen. Patient cannot tolerate statin therapy secondary to myalgias. Although it would be a very unlikely cause of her pancreatitis, can consider TriG, chol labs workup as an outpatient as pt states that her mother had values >1000. . # FEN: NPO, IVF, replete as necessary. . # PPx: Heparin SQ, PPI . # Access: PIV . # Code: Full (confirmed) . # Communication: Comments: Patient; PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (in [**Location (un) 9084**]); daughter is in town and will visit today Medications on Admission: Zestril 10qhs, Synthroid 112 Discharge Medications: 1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-8**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: pancreatic divisum and acute pancreatitis . Secondary: pancreas divisum, one episode of pancreatitis 3-4 years ago; hysterectomy, duodenal ulcer, tonsillectomy, appendectomy, hypertension, hyperlipidemia, hypothyroidism Discharge Condition: Stable. Tolerating regular diet. Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. * if you have severe abdominal pain, unable to tolerate liquids, have nausea or vomiting * if you feel your heart racing fast or have irregular heart beats Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 28529**] in [**2-8**] weeks [**Telephone/Fax (1) 1231**] 2. Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week regarding your new beta blocker you were started on while in the hospital. 3. Follow up with Dr. [**Last Name (STitle) **] in one month (cardiology). Please call ([**Telephone/Fax (1) 2037**] to schedule an appointment. [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2104-11-27**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8668, 8674

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3057, 5205

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9288

Discharge summary

report

Admission Date: [**2129-2-15**] Discharge Date: [**2129-3-4**] Date of Birth: [**2051-9-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Location (un) 1279**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Right-sided thoracentesis History of Present Illness: Pt is a 77 y.o. male with h/o rheumatic heart disease s/p mechanical mvr/avr, afib (s/p VVI PPM); CAD s/p x 2 with stenting of RCA and LAD; h/o CHF with preserved EF 55%; 2+MR around [**Location (un) 31820**] leakage around mechanical valve, recently discharged for severe CHF requiring natrecor, lasix and dopamine drips, chronic anemia, MDS, and more recent d/c for fall and ARF admitted to [**Hospital 882**] Hospital on [**2-10**]. * Pt presented to [**Hospital1 882**] with hypoxia and change in mental status from [**Hospital 100**] Rehab. At [**Hospital 100**] Rehab, pt with a 7 lb weight gain over week prior to admission, with attempted increase in Bumex to compensate for weight gain. On day of admission, pt with increasing somnolence and O2 sat 80s on room air --> 92% on 2L. +SOB. Also, in the week prior to admission, pt's Remeron was doubled secondary to depression. Additionally, pt's daughter said that pt had slurred speech week PTA and called her saying nonsensicle things, which is unusual for him (of note remeron doubled around that time). * At [**Name (NI) 882**] Hospital pt found to be in hypercarbic respiratory failure with PCO2 71. Pt placed on BiPAP and transferred to ICU. He was maintained on BIPAP, and diuresed on a natrecor drip, lasix drip, and dopamine for BP support . Pt ruled out by cardiac enzymes and EKG for MI. Repeat echo done to rule out [**Name (NI) 31820**] [**Name (NI) 3564**] showed EF 60% and functioning mechanical valves. On CXR pt with loculated effusion that was tapped on [**2129-2-14**] c/w transudative process per D/C summary. He was started to be treated to a CAP but this was stopped secondary to decreased suspicion with Abx d/cd [**2129-2-14**] (do not know which abx). Pt presented with ARF to 2.4 peak but down to 1.2 upon transfer. Additionally, pt's coumadin was held there as pt got thoracentesis and he was bridged on a heparin gtt. Pt also found to be c. diff positive and started on flagyl [**2129-2-15**]. Pt was transferred to [**Hospital1 **] for further care. * Today, pt feels well. No SOB or CP. Breathing "is pretty good." Pt tells team that he has been compliant with low sodium diet and there have been no recent medication changes. Past Medical History: 1. CAD - s/p cath [**2128-10-20**] with 3VD: 99% distal LAD, 60% LCx at origin of prior PTCA, RCA 50% distal with 70% RPL. Prior LAD and RCA stents widely patent. [**2128-7-30**]:stenting of the RCA with 3 overlapping cypher [**Name Prefix (Prefixes) **] -[**Last Name (Prefixes) **] [**2128-8-11**]: rotational atherectomy, PTCA and stenting of the LAD/LCX. Last stress [**9-27**]--> moderate to severe, fixed perfusion defect of all three segments of the inferior and inferolateral walls extending into the apex (fixed compared to partially reversible in [**7-28**]). 2. MVR/AVR - complicated by [**Date Range 31820**] 2+MR [**Last Name (Titles) 3564**] 3. CHF - EF >55% 2+MR [**Last Name (Titles) 31820**], RV dysfunction, moderate pulmonary HTN 4. PAF s/p VVI pacemaker [**7-28**] 5. CRI baseline Cr 1.5-1.7 6. MDS 7. Chronic mechanical hemolysis 8. Hx. of perirectal abscess s/p surgery 9. Gout 10. Hemorrhoidal bleeding Social History: No EtOH or tobacco. Was living alone at home (widower) prior to recent hospitalizations. Two daughters heavily involved in care. Physical Exam: T: 98.3; BP: 102/48; P: 71; RR: 14; O2: 100 3L Gen: Elderly male speaking in full sentences in NAD. HEENT: PERRLA; EOMI; sclera anicteric. Neck: JVD to earlobe CV: II/VI systolic murmur at apex radiating to axilla. Also with mechanical click S2. Irregularly irregular rhythm. Lungs: Decreased B/S b/l L>R. Rales scattered mid-lower left lung fields. Abd: SOft, mildly distended, LLQ with small few cm hard object (has been there always per pt). Nontender. Ext: [**12-26**]+ pitting edema b/l. Neuro: CN II-XII tested and intact. PERRLA; EOMI; Facial muscles equal and strong. Tongue midline without fasciculation. SCM and shoulder shrug strong. Palate elevation equal and symmetrical. MS [**4-28**] upper and lower. Reflexes: brachio/biceps [**1-26**]. patellar 1 b/l. Brief Hospital Course: 1. CHF- On the floor, he failed to diurese to natrecor and lasix, with dopamine for BP support. He was still fluid overloaded on exam, but was becoming hypotensive to low 70s-upper 60s. He was transferred to the CCU for invasive hemodynamic monitoring. Initially, his PA pressures were 70s/30s, with a wedge of 23. His CO was 7 with an SVR of 469. He was placed on natrecor, vasopressin, lasix, and dopamine. This was changed in the AM to vasopressin, lasix, and levophed, as given his low SVR and low-grade temp it was felt he had some septic physiology. Since he was also clearly volume overloaded, he was given diuril to augment diuresis with Lasix, which was effective. He had a large pleural effusion, which was tapped on [**2-19**] and was c/w transudate. The patient was ultimately controlled with levophed and a lasix drip alone which were both successfully weaned off. His management was optimized with diuril 250 mg daily, lasix 100 mg [**Hospital1 **], digoxin 0.125 mg QOD given his renal dysfunction, and spironolactone 50 mg daily. He was not placed on an ACE-I or beta-blocker given his relative hypotension with systolic blood pressures in the high 80s and 90s - which is his baseline blood pressure. 2. CAD- The patient was continued on a statin, plavix and ASA. The patient ruled out at OSH by enzymes. He was not placed on a beta-blocker given his low blood pressure. * 3. Rhythm- The patient has a history of atrial fibrillation and was monitored on telemetry with no issues. Given his initial rate in the 120s, digoxin was initiated for better rate control and he remained stable thereafter. He was placed on coumadin after his swan was discontinued and a heparin drip to bridge to coumadin. His goal INR is 2.5 to 3.5 as he also has 2 prosthetic valves. * 4. C. diff- The patient was diagnosed with C. diff at the OSH. He was continued on metronidazole 500 tid for 10 days treatment ([**2129-2-15**] 1st dose). He had no further episodes of diarrhea. * 4. CRI- Baseline creatinine 1.5-1.7. His creatinine ranged from 1.7-1.9 during his stay. * 5. Anemia- Secondary to mechanical hemolysis MDS and anemia of chronic disease. He was continue on iron/folate and transfused one unit during his stay. The patient was restarted on epoetin 20,000 MWF. His baseline Hct is 29-30. He is also guaiac negative. Our goal Hct for him is to transfuse for Hct <27 as his hematocrit drops within a few days post transfusion regardless. His hematocrit remained stable otherwise throughout his stay. * 6. Nosocomial pneumonia - The patient was presumed to have a nosocomial pneumonia and placed on Zosyn for a 7 day course. He remained afebrile thereafter. 7. CO2 retention - The patient's CO2 remained in the 40s. Pulmonary followed the patient and believed the patient would benefit from an outpatient sleep study and PFTs to assess for obstructive sleep apnea. He was at first treated with diamox which had little effect on his serum bicarbonate and was thus, discontinued. It is important that his potassium is checked frequently and maintained above 4.0 to ensure his bicarbonate does not rise further. Medications on Admission: ASA 325 qday Bumex 3 mg qam, 2 mg qpm Lovenox sc 30 mg qhs ZOcor 80 mg po qhs Toprol XL 25 mg po qday Coumadin 5 mg po qday Tramadol 25 mg tid Ambien 5 mg qhs prn Arinef 100 mg sc qweek Remeron 30 mg qday Folic acid 1 mg po qday Senna 2 tabs qhs Colace 100 mg [**Hospital1 **] Iron sulfate 325 tid Pepcid 20 [**Hospital1 **] * Medications upon transfer: Diuril 500 [**Hospital1 **] (30 min prior to lasix) Lasix 20 IV bid Coumadin 5 mg qhs Protonix 40 mg qhs ASA 81 mg qday Colace 100 [**Hospital1 **] Heparin drip 700 units/hour Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). 12. Chlorothiazide 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Warfarin Sodium 2 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 15. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Diastolic congestive heart failure Atrial fibrillation h/o rheumatic heart disease with aortic and mitral valve replacement Resolved clostridium difficile diarrhea Discharge Condition: Stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2129-4-8**] 9:30 Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2129-4-8**] 10:00

[ "238.7", "427.31", "458.9", "584.9", "518.81", "398.91", "486", "E878.1", "788.30", "996.02", "578.1", "276.4", "511.9", "416.8" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93", "00.13", "34.91", "93.90" ]

icd9pcs

[ [ [] ] ]

9500, 9572

4509, 7635

331, 359

9780, 9789

9938, 10263

8215, 9477

9593, 9759

7661, 8192

9813, 9915

3716, 4486

272, 293

387, 2603

2625, 3555

3571, 3701

16,516

153,822

19038

Discharge summary

report

Admission Date: [**2129-8-5**] Discharge Date: [**2129-8-16**] Date of Birth: [**2064-10-24**] Sex: M Service: VASCULAR SURGERY CHIEF COMPLAINT: Painful right foot. HISTORY OF PRESENT ILLNESS: Patient is a 64-year-old male with diabetes type 2, borderline hypertension, and 100 pack year smoking history status post endovascular AAA repair in [**2119**] at [**Hospital6 1129**], who is complaining of right foot pain and numbness for the past week. The patient was transferred from [**Hospital 1459**] Hospital for further workup. He had an arteriogram at [**Location (un) 1459**], which showed occluded abdominal ileac endovascular stent graft. It showed 100% patent left external ileac artery and a left common femoral artery which was reconstituted. It also showed that the right external ileac artery was patent. PAST MEDICAL AND SURGICAL HISTORIES: 1. Diabetes type 2. 2. Hypertension. 3. Increased cholesterol. 4. Status post endovascular AAA repair with stent in [**2119**] at [**Hospital6 1129**]. 5. Umbilical hernia repair. MEDICATIONS: 1. Avandia 8 mg q.d. 2. Lipitor 8 mg q.d. 3. Glyburide 10 mg b.i.d. 4. Tricor 54 mg b.i.d. 5. Lisinopril 5 mg q.d. 6. Nicotine patch 21 mg q.d. 7. Glucophage 1 gram twice a day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: His social history includes 100 pack year smoking. PHYSICAL EXAM ON ADMISSION: Temperature of 98.4, blood pressure 124/55, pulse 74, respirations 19, sating 87% on room air, and 95% on 3 liters. Patient's weight on admission is 92.8 kg. In general, the patient is an alert white male. He has bilateral basilar crackles heard in the lung fields. His heart sounds are distant with regular, rate, and rhythm and normal S1, S2. His abdomen is soft, nontender, nondistended. He has no bruits or masses. He has a full range of motion with plantar flexion of the right foot. The right foot is dusky and modeled to the mid calf. He has 2+ carotid pulses bilaterally, 2+ radial pulses bilaterally. Dopplerable femoral pulse on the right and a 2+ femoral pulse on the left. He has no signals in the DP or PT arteries on the right, and the DP and PT arteries are dopplerable on the left. On admission, the patient's hematocrit was 36.7. His BUN and creatinine were 21 and 1.5 respectively. His EKG showed no acute ischemic changes and his chest x-ray showed signs of COPD. His INR on admission was 1.0. Patient was admitted to the [**Hospital **] Hospital to the Vascular ICU, where he was preoped for an aortobifemoral bypass graft, which was performed on [**2129-8-6**] by Dr. [**Last Name (STitle) **]. The patient was transferred upon stabilization in the PACU to the Vascular ICU. Postoperatively, on postoperative day one, the right foot remained cyanotic and cool to the touch. The patient was able to plantar flex and dorsiflex his right foot. No Heparin was administered to the patient at this time as the team was awaiting for the graft to heal before starting anticoagulation. On postoperative day one, the patient's hematocrit increased to 2.8 from 1.7. His BUN was 31. As mentioned, his right foot remained cool, and cyanotic, and painful with no DP or PT signals appreciated on the right. On postoperative day one, the patient was transferred to the Surgical ICU for management of worsening renal function and worsening metabolic acidosis. His creatinine further increased later on postoperative day one to 3.5 and his BUN to 40. His bicarb at this time was 19. An ABG showed that the patient was acidotic, pH of 7.25, pCO2 of 45, pO2 of 76, bicarb of 21, and a base deficit of 7. The patient was started on a Heparin drip in the Surgical ICU, and the Renal service was consulted. The patient was aggressively hydrated. It was felt that his worsening renal function was due to acute tubular necrosis, possibly due to hypovolemia. On postoperative day two, the patient became confused. It was thought that perhaps the patient was going through alcohol withdrawal. He was given 4 mg of Haldol b.i.d., to control these symptoms, Ativan was also given, but the patient had worsening confusion with response to Ativan. On postoperative day two, the patient was intubated for MRI/MRA of the right foot as well as placement of a Swan and radial A-line. A MRA of the right lower extremity was obtained at this time, which showed proximal occlusion of the right superficial femoral artery, which was reconstituted after the anterior tibial artery. The anterior tibial artery was open to the ankle, however, the foot vessels on the right were not visible. The foot remained modeled and cool, although it had capillary refill. The patient was transfused 2 units of packed red blood cells and was then taken to the OR for femoral distal bypass graft. Postoperatively, the patient was taken back to the Trauma Surgical ICU, and remained intubated and sedated. Postoperatively from the second surgery, the right dorsalis pedis and posterior tibial arteries had Doppler signals. At this point, the patient's creatinine began to decrease from 30.3 to 2.8. On postoperative days #4 and one, patient began to be weaned from the ventilator and was extubated on postoperative day five and two. He had dopplerable pulses bilaterally of the DP and PT arteries. His creatinine on postoperative day five and two was 2.4. On postoperative days six and three, the patient was transferred back to the Vascular ICU. Throughout the rest of the hospital course, the patient's creatinine continued to drop and on discharge was 1.7 on [**8-16**], postoperative days 10 and 7. Patient's mental status was felt back to baseline. On postoperative days six and three, the patient was seen for the first time by Physical Therapy, continued to follow the patient throughout the rest of his hospital stay. On postoperative days seven and four, the patient's abdominal wound was open over about 7 cm just inferior to the umbilicus. This wound was packed with wet-to-dry dressings, no pus or exudate was noted. On postoperative days seven and four, the patient was transferred to the floor, where he continued to improve. The patient was started on Coumadin on postoperative days eight and five. His INR on postoperative days nine and six was 2.5. As the patient's right foot remained in plantar flexion, it will be setup for the patient to be fitted for an ankle flexion orthotic at his home upon discharge. CONDITION ON DISCHARGE: Fair with dopplerable signals on the right, posterior tibial and dorsalis pedis arteries with improving color of the right foot. His balance remains below baseline. His mental status is back to baseline. DISCHARGE STATUS: Home with VNA for wound care, 3x weekly INR checks, and Physical Therapy. DISCHARGE MEDICATIONS: 1. Lopressor 100 mg b.i.d. 2. Percocet 5/325 mg as needed for pain. 3. Zantac 150 mg b.i.d. 4. Norvasc 10 mg once a day. 5. Lipitor 80 mg once a day. 6. Glyburide 10 mg twice a day. 7. Avandia 8 mg once a day. 8. Colace 100 mg twice a day. 9. Hydralazine 50 mg 4x a day. 10. Keflex 500 mg 4x a day for seven days. 11. Coumadin 5 mg one tablet once a day. DISCHARGE DIAGNOSES: 1. Ischemic right foot. 2. Peripheral vascular disease. 3. Clotted endovascular abdominal aortic aneurysm stent. 4. Status post aortobifemoral bypass graft. 5. Status post right femoral anterior tibial artery bypass graft. FOLLOW-UP PLANS: 1. Dr. [**Last Name (STitle) **] in one week. The patient should call for appointment. 2. Home visit by [**Location (un) 51992**]Orthotics for fitting of ankle flexion orthotic on the right. Prescription is in the chart. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Name8 (MD) 51993**] MEDQUIST36 D: [**2129-8-16**] 09:06 T: [**2129-8-16**] 09:09 JOB#: [**Job Number 51994**]

[ "584.5", "998.59", "496", "E878.1", "996.74", "401.9", "250.00", "444.22", "276.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "88.48", "96.71", "38.08", "89.64", "39.25", "38.91", "39.29" ]

icd9pcs

[ [ [] ] ]

7176, 7400

6799, 7155

7417, 7910

167, 188

217, 1309

1407, 6450

1326, 1392

6475, 6776

29,464

164,993

33790

Discharge summary

report

Admission Date: [**2115-2-19**] Discharge Date: [**2115-2-26**] Date of Birth: [**2041-2-10**] 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: EGD IVC filter placed History of Present Illness: 74 y.o. male s/p recent TKR was transferred in from [**Hospital 7137**] c/o fatigue and "falling asleep alot". Two days prior to admission, he developed black, tarry stools, 2X/day. On day of admission, BP 98/58 (which is lower than baseline) and he was transferred to [**Hospital1 **] for further evaluation. Of note, he has been on coumadin for afib, Lovenox SQ. Also, he has been taking celebrex [**Hospital1 **] for knee pain. . He denies any CP, SOB, palpitations, abd pain, N/V, dysuria, back pain or any other concerning symptoms. He denies taking any recent antibiotics for medication changes. . In ED, T98, HR 78, BP 101/59, RR 20; 95%RA. EKG with afib, but no ST changes. He received 2UPRBC, 2U FFP, and 1LNS. . Upon arrival to ICU, he reports feeling better. He currently denies any additional complaints. Of note, he had a normal colonoscopy in [**2110**]. . Past Medical History: Atrial Fibrillation Renal Insufficiency (baseline unclear) HTN s/p R TKR obesity ? prior DVT in R popliteal vein Social History: Pt is retired Tractor driver. Currently lives with wife on a farm Smoking: quit in [**2084**], prior had 15 pack years EtOH: 1 beer/day Family History: Father died age [**Age over 90 **] & mother died age [**Age over 90 **] with alzheimers Physical Exam: Vitals: 99.0 107/47 64 16 97%RA GEN: NAD, obese, pleasant HEENT: PERRL, EOM intact CV: RRR, no M/R/G RESP: CTAB ABD: obese, soft, NT/ND, normal bowel sounds EXTR: R with sutures from TKR, chronic venous stasis changes to LE L: mild swelling, DP pulses dopplerable B Pertinent Results: [**2115-2-19**] 06:10PM BLOOD WBC-7.2 RBC-1.67* Hgb-4.9* Hct-15.1* MCV-90 MCH-29.3 MCHC-32.5 RDW-15.0 Plt Ct-310 [**2115-2-19**] 06:10PM BLOOD Neuts-79.1* Bands-0 Lymphs-13.5* Monos-6.0 Eos-1.0 Baso-0.5 [**2115-2-19**] 06:10PM BLOOD PT-30.2* PTT-32.0 INR(PT)-3.1* [**2115-2-19**] 06:10PM BLOOD Glucose-252* UreaN-81* Creat-2.1* Na-136 K-5.6* Cl-103 HCO3-26 AnGap-13 [**2115-2-19**] 06:10PM BLOOD ALT-16 AST-20 CK(CPK)-129 AlkPhos-35* TotBili-0.3 [**2115-2-19**] 06:10PM BLOOD cTropnT-0.03* [**2115-2-19**] 06:10PM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.8 Mg-2.4 [**2115-2-19**] 06:17PM BLOOD Lactate-1.5 Urine Cx pending Brief Hospital Course: 74 y/o M presents with c/o fatigue, melena & hct of 15, on coumadin for A. Fib with an INR of 3. #) GI Bleed: Pt presented with GI bleed, EGD done and visualized ulcer in duodenal bulb. Pt had epi injected for hemostatis and endoclip placed. HCT stable since [**2-24**]. H. Pylori negative. Pt should be on [**Hospital1 **] protonix for at least 4 weeks. He needs an outpt colonoscopy within the next month to be sure there was not a secondary source of bleed. #) Hematoma in right knee: patient had increased swelling of knee and concern of hematoma of knee at surgical site, CT showed fluid. Pt evaluated by orthopedic attending [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], felt there was no evidence of infecion, advised against any needle drainage. Pt should continue continuous motion device and follow up with the surgeon who did the initial operation. #) Bradycardia: Pt having episodes of bradycardia from SSS and AV delay. Improved with treatment of OSA with night time bipap. #) Atrial fibrillation: Coumadin discontinued given multiple bleeding sites. Pt should start full dose aspirin, if hct continues to be stable. #OSA): Patient w/ severe OSA and associated bradycardia/sinus pauses w/ high vagal tone. Did well on BiPap at 10/5 with 2L oxygen. He needs a formal outpt sleep study. #) DVT: LENI showed right popliteal clot, age indeterminate, IVC filter placed Medications on Admission: coumadin ~7.5mg daily bactrim ds 1tab [**Hospital1 **] (unclear start date) celebrex 200mg [**Hospital1 **] lovenox 40mg daily flomax 0.4mg daily, metformin 850 mg [**Hospital1 **] glucotrol 5mg [**Hospital1 **] actos 30 mg QAM glyburide 15 mg daily vicodin lisinopril 20 daily HCTZ 12.5 daily colace, senna prilosec 20mg daily, Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Lovenox 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: duodenal ulcer Discharge Condition: stable Discharge Instructions: Please call the gastroenterologist with any blood in the stool. Please call your orthopedic surgeon with increased knee pain, swelling, or fever. Followup Instructions: Please schedule a colonoscopy within the next few weeks ([**Telephone/Fax (1) 78138**]. Please arrange for outpatient sleep study to evaluate obstructive sleep apnea. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2115-2-26**]

[ "285.1", "327.23", "427.89", "459.81", "403.10", "585.9", "532.40", "584.9", "998.12", "V12.51", "250.02", "427.31", "V43.65", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "44.44", "99.04", "99.07", "38.93", "38.7" ]

icd9pcs

[ [ [] ] ]

5297, 5367

2600, 4021

324, 348

5426, 5435

1954, 2577

5629, 5950

1560, 1649

4401, 5274

5388, 5405

4047, 4378

5459, 5606

1664, 1935

276, 286

376, 1251

1273, 1388

1404, 1544

52,964

149,520

35615

Discharge summary

report

Admission Date: [**2195-4-4**] Discharge Date: [**2195-4-17**] Date of Birth: [**2113-1-25**] Sex: F Service: MEDICINE Allergies: Nsaids Attending:[**First Name3 (LF) 4028**] Chief Complaint: seizure Major Surgical or Invasive Procedure: -Lumbar puncture -Extubation (was intubated at an outside hospital) History of Present Illness: Patient is an 82 year old female with history of CAD, PVD (s/p left AKA), HTN, CHF, Afib with pacemaker, carotid stenosis, and hypothyroidism who initially presented to [**Hospital3 **] with right inguinal pain and right foot pain. In the ED, right foot was initially cold and pale but warmed up by itself. She received dilaudid for pain. . Per discharge summary from [**Hospital3 **], patient was doing well until her second day when she had 2 witnessed seizures (tonic clonic on right side of body) lasting about 10 minutes each. HR 160s, BP 150s at the time. Patient was intubated for airway protection. She was given 2 mg Ativan. Patient had stat head CT which showed old lacunar infarcts. Her EKG showed sinus tachycardia at [**Street Address(2) 81048**] depressions diffusely different from her old EKGs. Initial cardiac enzymes were elevated with troponin of 0.33. Troponin peaked here at 0.55 but trending down to 0.37. Cardiac index normal. She was transferred to [**Hospital1 18**] for management of seizures. . Patient could not have MRI because of pacemaker. She had LP which was negative for meningitis. Per neurology, they think cause of seizures is toxic-metabolic vs. PRES as she was noted to have pressures 190-200 systolic when the propofol was weaned. No history of seizures in her or her family. Patient was extubated at 11 am on [**4-5**] successfully. . Patient denies any headache, dizziness, chest pain, sob, cough, abdominal pain, nausea, vomiting, leg pain or any other symptoms. She asked multiple times when she would be able to leave the hospital. She does not remember the events of her hospitalization at [**Hospital3 **]. Per family, she complains of chest pain at rest intermittently at home. . Cardiology was consulted while she was in the TSICU and felt her troponin rise was due to demand ischemia in setting of seizure and tachycardia. Given her multiple medical problems and since her enzymes were trending down and she was not having any current symptoms, cardiology recommended ongoing medical management of CAD and no interventions. They recommended stopping heparin gtt and holding amiodarone (started in TSICU) and sotalol (takes at home) because of long QT. Also recommended starting her home lopressor dose which was being held. . Given her multiple medical issues and seizure thought to be related to HTN, neurology requested medical transfer. Neurology recommended EEG, carotid ultrasound, and echocardiogram/TTE. She was on Dilantin 100 mg TID at time of transfer. Neurology to follow her on the consult service. Past Medical History: 1. Coronary artery disease; s/p RCA stent at [**Hospital3 2005**] in [**2186**], R coronary artery occlusion [**2187**], and LAD stent '[**92**] at Mt Aubrun, after she had ACS with a trop of 2.5 2. Peripherial Vascular Disease, s/p left below knee amputation; Right leg: aorto-bifemoral bypass and right femoral popliteal bypass 3. Hypertension 4. Hyperlipidemia 5. Afib 6. CHF (diastolic dysfunction, LV function 60% in '[**92**]) 7. Carotid stenosis (not sure of the side) 8. Phantom leg pain in the left leg 9. Hypothyroidism 10. Anixety 11. Osteoporosis 12. Iron deficiency anemia 13. GERD 14. Chronic constipation 15. Possible type 2 DM 16. Pacemaker 17. Psoriasis Social History: Lives in an [**Hospital3 **] facility in [**Hospital1 3494**] MA. An ex-smoker, 40 pack years. Worked in a metal factory. Denies alcohol intake. Her daughter lives in [**Name (NI) 14663**] and she has three adult children. According to her daughter's husband, she is non-compliant with many of her medications. Wheelchair bound at baseline due to her left AKA from severe PVD. Family History: No family history of seizures, premature cardiac disease or cancers per patient. Physical Exam: VS: T 96.7, R 18, BP 150/78, P 71, O2 sat 97% RA. GEN: elederly female, soft voice, A & O, bent over in a ball, sidways on bed, poor eye contact [**Name (NI) 4459**]: [**Name (NI) 12476**], anicteric, no injections, PERRLA, EOMI, OP clear, dry MM, pealing skin on lips Cor: RRR, S1S2, no murmur Lungs: bibasilar crackles b/l, prominent kyphosis Abd: +bowel sounds, soft, nontender, nondistended, + hematomas on abdomin, no hsm Extrem: AKA left leg, no edema of right leg,, pulses faintly paplpapble, cool upto mid calf Skin: multiple ecchymosis Neuro: CN 2-12 intact, strength symmetrical but poor effort, normal sensation Pertinent Results: INITIAL LABS: [**2195-4-4**] 09:33PM BLOOD WBC-16.2* RBC-4.66 Hgb-15.8 Hct-44.5 MCV-95 MCH-34.0* MCHC-35.6* RDW-14.0 Plt Ct-261 [**2195-4-10**] 06:15AM BLOOD WBC-9.7 RBC-3.59* Hgb-12.3 Hct-35.1* MCV-98 MCH-34.1* MCHC-34.9 RDW-14.0 Plt Ct-250 [**2195-4-4**] 09:33PM BLOOD Neuts-84.7* Lymphs-9.7* Monos-5.2 Eos-0.3 Baso-0.1 [**2195-4-4**] 09:33PM BLOOD PT-13.5* PTT-29.9 INR(PT)-1.2* [**2195-4-6**] 06:35AM BLOOD PT-12.4 PTT-26.9 INR(PT)-1.0 [**2195-4-4**] 09:33PM BLOOD Glucose-174* UreaN-23* Creat-0.9 Na-137 K-3.0* Cl-100 HCO3-24 AnGap-16 [**2195-4-4**] 09:33PM BLOOD ALT-21 AST-56* CK(CPK)-374* AlkPhos-68 Amylase-92 TotBili-1.2 [**2195-4-5**] 11:10AM BLOOD Type-ART pO2-174* pCO2-35 pH-7.38 calTCO2-22 Base XS--3 . CARDIAC ENZYMES: [**2195-4-5**] 04:20AM BLOOD CK(CPK)-573* [**2195-4-5**] 09:31AM BLOOD CK(CPK)-562* [**2195-4-6**] 06:35AM BLOOD CK(CPK)-326* [**2195-4-7**] 06:20AM BLOOD CK(CPK)-134 [**2195-4-4**] 09:33PM BLOOD CK-MB-18* MB Indx-4.8 cTropnT-0.55* [**2195-4-5**] 04:20AM BLOOD CK-MB-14* MB Indx-2.4 cTropnT-0.37* [**2195-4-5**] 09:31AM BLOOD CK-MB-12* MB Indx-2.1 cTropnT-0.34* . LIPID PROFILE: [**2195-4-4**] 09:33PM BLOOD Triglyc-187* HDL-83 CHOL/HD-2.1 LDLcalc-58, total Cholest-178 . ENDOCRINE STUDIES: [**2195-4-4**] 09:33PM BLOOD TSH-5.5* [**2195-4-5**] 09:31AM BLOOD Free T4-1.2 . TOXICOLOGY/DRUG MONITORING: [**2195-4-6**] 06:35AM BLOOD Phenyto-12.5 [**2195-4-4**] 09:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE STUDIES : [**2195-4-4**] 09:34PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.039* [**2195-4-4**] 09:34PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2195-4-4**] 09:34PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG MICROBIOLOGY: [**2195-4-5**] 11:28 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2195-4-7**]** GRAM STAIN (Final [**2195-4-5**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2195-4-7**]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. ..... [**2195-4-5**] 12:44 am CSF;SPINAL FLUID Site: LUMBAR PUNCTURE **FINAL REPORT [**2195-4-8**]** GRAM STAIN (Final [**2195-4-5**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2195-4-8**]): NO GROWTH. ..... [**2195-4-13**] 6:30 pm SPUTUM Source: Induced. GRAM STAIN (Final [**2195-4-13**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2195-4-13**]): TEST CANCELLED, PATIENT CREDITED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. ... Source: Catheter. **FINAL REPORT [**2195-4-15**]** URINE CULTURE (Final [**2195-4-15**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <= ...... [**2195-4-13**] Blood Cx x2 negative to date [**2195-4-16**] C.difficile -Negative on stool assay testing ....... ADDITIONAL REPORTS: EKG: Sinus rhythm. Inferolateral ST-T wave changes. Cannot rule out myocardial ischemia. Modestly prolonged QTc interval. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 73 144 104 450/472 74 -24 -27 ============================== [**2195-4-6**] ECHO /TTE: The left atrial volume is markedly increased (>32ml/m2). Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal and mid inferior segments. Diastolic function could not be assessed. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: Mild focal LV systolic dysfunction. Normal right ventricular systolic function. Mild mitral regurgitation. LVEF 55-60% ======================== Arterial ultrasound FINDINGS: Right leg was examined. There is monophasic flow pattern on the femoral, popliteal and dorsalis pedis arteries. The segmental limb pressures are markedly reduced on the calf and over DP. The ankle brachial index at rest 0.59. The patient was not exercised. IMPRESSION: Significant right iliac and SFA disease. Right posterior tibial artery could not be identified. ========================== IMPRESSION: 1. Less than 40% stenosis of the internal carotid arteries bilaterally. 2. Tardus-parvus waveform in the left vertebral artery, suggesting stenosis in the proximal left subclavian artery. ========================== EEG: per neurology attending- demonstrated a few left temporal sharp waves with a mildly encephalopathic pattern, 7 Hz background rhythms DISCHARGE LABS: wbc 6,6, Hct 30.1, Hgb 10.4, plts 335, Na 138, K 4.3, Cl 106, HCO3 25, BUN 8, Cr 0.7, glucose 82 . Brief Hospital Course: In summary, Mrs. [**Known lastname 7111**] is an 82-year-old female with multiple medical problems transferred from [**Name (NI) 3494**] for newly diagnosed seizures status post ICU stay with intubation, then extubated transfered to medical floor. She had some atrial tachycardias and dysrythmias as outlined below and some demand ischemia with enzyme elevations earlier in her hospital course which resolved by time of discharge. For full details by problem list format please see below hospital course summary: . # Demand Ischemia: On initial EKGs [**Date range (1) 47316**] she had widespread lateral ST depressions different from her previous EKGs. These ST changes were felt to be demand ischemia in setting of tachycardia as she had atrial tachycardias up into the 150s-160s at times. Normal CK MB index, and her troponins were slightly elevated [**4-4**] to .55 soon after admission but gradually tapered down on [**4-5**] to .37, .33 and then by [**4-13**] her troponins were in the .06 range. Cardiology was consulted and agreed with medical management given her multiple comorbidities. Stopped heparin drip which was intially started, and sotalol and amiodarone were discontinued. Per reports, she had notable long QT which is why sotolol was abandoned. She was continued on ASA 325mg daily, Plavix 75mg daily, and lopressor [**Hospital1 **] which was titrated up to 62.5mg TID by time of discharge with good rate control in the 60-90 range. Lisinopril also continued. Cardiology followed patient during hospitalization and she was set up for an outpatient follow-up appointment in a few weeks time. . # Dysrhythmias: Ms. [**Known lastname 7111**] had intermittent atrial tachycardias and atrial flutter noted on telemetry monitoring during her hospitalization. Had a rate into the 140s without symptoms early in her admission. Along with cardiology team recommendations, the medical team stopped amiodarone and sotolol and gradually uptitrated her beta blocker. She responded well and HRs improved with better rate control. Electrophysiology team was consulted for PCM interogation, patient has St. [**Male First Name (un) 923**] pacemaker which appeared to be functioning. She was only noted to have these newer atrial tachycardia episodes post seizure.From [**Date range (1) 15037**] she was slightly refractory and had increased ectopy with atrial flutter and atrial tachycardias becoming more frequent on telemetry. She also had a several runs of asymptomatic NSVT ([**4-20**] beat runs)which were short lived. During this timeframe she spiked fevers and underwent an infectious workup which revealed an E.Coli UTI and questionable LLL infiltrate on CXR which was later felt to be atelectasis on better 2-View CXR. These rapid heart rates were attributed to her dehydration from infection along with her sensitivity to fluid changes given her known diastolic dysfunction. Cardiology was re-consulted. Tachycardias improved once she was transitioned to TID beta blocker regimen and after she was replenished with IVFs over 2 days time. . # Seizures: Unclear precipitant. Neurology evaluated patient and was not sure of the exact cause but felt the most likely etiology of seizures was toxic-metabolic vs. PRES as she was noted to have pressures 190-200 systolic when the propofol was weaned at outside hospital. No history of seizures in her or her family. She had an EEG that showed a temporal spike, that could be source of seizure, although this is not definitive. She also had a carotid ultrasound with <40 stenosis noted. Electrolytes were predominantly stable. Head CT showed old lacunar infarcts. LP negative for infectious etiology. Could not get MRI because of pacemaker, and she has no focal deficits on exam making stroke unlikely. Kidney and liver function normal. Toxicology screens negative. Placed on initial Dilantin load and then Dilantin 100mg TID which was discontinued as she was transitioned to Trileptal which was adjusted to ensure she had no dizziness. However, she still had some fleeting complaints of dizziness and nausea likely in setting of starting these medications; all resolved now. Trileptal was downtitrated to 300mg [**Hospital1 **] with good results and this is her current dose. Will have neurology follow up as outpatient. . # Hypertension: Patient had labile blood pressures initially. Blood pressure poorly controlled at admission with SBPs into 170-180s range. Over the course of her first week her medications were increased. Then she had several scattered hypotensive bouts with SBPs as low as 80s range with occasional complaints of lightheadedness. This was attributed to poor PO intake and dehydration and aggressive medication adjustments. I/Os balance typically corroborated this with negative balance tendency. Eventally re-established normotensive BP on home dose of lopressor, and addition of lisinopril. Then metoprolol tartrate uptitrated for tighter rate control (now 62.5mg TID). Currently well controlled with lisinopril 10 mg qd, Imdur ER 30mg, beta blocker and 10mg daily lasix. Lasix had been decreased from her usual 20mg daily dose to 10mg daily dose now as her pressures have been in the 98-130/50-70s range and her PO intake is still not optimal. She has been given several small IVF boluses in setting of her UTI/dehydration which have helped to stabilize her hemodynamics. Intially she was also on hydralazine for BP control, but this was discontinued as it is no longer needed, and since it can contribute to her tachycardias. . # PVD: Patient had initial outside hospital presentation for leg pain. On admission leg cool with dopplerable pulses. Then within hours overnight her leg rewarmed and pulses easier to palpate per reports. It stayed warm with faint pulses. Skin tone normal, no apparent ischemia or cyanotic features. Had ABI of 0.59 of right leg. She has been set up for an outpatient follow-up in vascular surgery. . # CHF: Patient now appears euvolemic to low volume on daily exams. Chronic diastolic CHF is likely from long-term HTN. TTE/Echo done on [**4-6**] showed preserved LVEF of 55-60% and mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal and mid inferior segments. She was continued on lasix, lopressor, Imdur, and lisinopril with careful holding parameters given her shifting blood pressures as noted above. She will follow-up as an outpatient with cardiology in a few weeks. . # Hyperlipidemia: For her entire hospital course she was continued on her usual atorvastatin 80mg daily alongside a daily aspirin. # UTI: Urinalysis revealed increased bacteria and WBCs and follow-up urine culture showed >100,000 E.Coli. She had several fevers in 100-101 range which resolved several days ago after she was started on antibiotics. Initially she was placed on broad antibiotics as source of her fevers unknown, and CXR had initial read of a questionable LLL so she was on combination of Vancomycin and Zosyn for 4 days and then this was switched to PO Bactrim for a complicated UTI, she now has 3 days of Bactrim DS [**Hospital1 **] to continue and she will complete course on [**2195-4-20**]. Foley catheter has been removed. Currently afebrile and denies suprapubic pain. . #PNA: Patient with LLL very questionable infiltrate on a portable CXR done after she spiked some fevers on [**5-7**]. Follow-up 2 view CXR showed only atelectasis however and she had no productive sputum and no increased cough from baseline, no URI symptoms. Therefore, antibiotic regimen tailored to her UTI and she was not given additional PNA directed antibiotics at discharge as she is clinically stable. . # Hypothyroidism: TSH elevated at 5.5, but normal free T4 soon after admission. She was continued on levoxyl 112 mcg qdaily. However, a re-check on [**4-16**] still showed a TSH of 7.9 and FT4 was .70. Hypothyroidism poorly controlled. Therefore her dose of levoxyl was increased to 125mcg daily dose, and she will need her TSH and FT4 followed closely in the days after admission. This may have some bearing on her recent low blood pressures. Moreover, poorly controlled hypothyroidism can contribute to diastolic HTN as well. . # Phantom leg pain in the left leg: Continued on neurontin and fentanyl patch for her AKA left leg pains. Also has chronic right hip pain for which she was continued on Percocet q6hrs PRN. . #Diabetes type II - Patient has mainly diet controlled mild type II diabetes, noted as questionable and borderline DM in records. During her hospitalization her FSGs were checked and daily glucose levels mainly within normal ranges, well controlled. She should continue on a diabetic/cardiac healthy diet on discharge. . # Anxiety: Appeared very well controlled on her current medication. She was continued on usual home dose of Celexa 10mg daily. . # Osteoporosis: After discharge she should continue on Calcium/with vitamin D supplementation and she should discuss the option of starting a bisphosphonate as outpatient with her PCP at [**Name9 (PRE) 702**]. . # Iron deficiency anemia: She was continued on ferrous sulfate 325 mg [**Hospital1 **], and a bowel regimen was provided to avoid constipation. . # GERD: Contined on daily protonix, no symptomatic complaints. . #Diet, fluid and electrolytes: As above, additional IVFs provided for intermittent dehydration in setting of infection and fevers. Given a cardiac healthy/diabetic PO diet and daily electrolytes were checked and repleted as needed. . #Code Status: Patient was maintained as a full code status and this was confirmed with patient. Medications on Admission: 1. Sotalol 80 mg po bid 2. Levoxyl 112 mcg po daily 3. Lopressor 50 mg [**Hospital1 **] 4. ASA 325 mg daily 5. Lipitor 80 mg daily 6. Calcium and Vitamin D 500 mg po tid 7. Celexa 10 mg daily 8. Plavix 75 mg daily 9. Colace 10. Fentanyl patch 100 mcg every 48 h 11. Ferrous sulfate 325 mg [**Hospital1 **] 12. Advair 500/50, one puff [**Hospital1 **] 13. Lasix 20 mg daily 14. Percocet 1 tablet q6h prn 15. Protonix 40 mg daily 16. Senna 17. Spriva 18. zestril 10 mg qd 19. neurontin 300 mg qhs, 100 mg qam Discharge Medications: 1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q48 HOURS (). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO In the morning. 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Furosemide 20 mg Tablet Sig: [**1-16**] Tablet PO DAILY (Daily). 14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): for blood pressure. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 18. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 20. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. 21. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital 3137**] Care Center Discharge Diagnosis: Primary- -Seizure, focus in temporal lobe -Cardiac Ischemia -Atrial tachycardia -Hypertension Secondary- -Diabetes, type II -Peripherial vascular disease Discharge Condition: Hemodynamically stable, afebrile, able to use wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 7111**], It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted to [**Hospital1 18**] due to a new diagnosis of seizures at another hospital. You had no seizures after being transferred here to [**Hospital1 18**]. You required a ventilator due to difficulty breathing on your own but you are now breathing well on room air without difficulty. The seizure put stress on your heart and caused an irregular rhythm and may have injured some of your heart tissue. You had an ultrasound of the heart called an echocardiogram showing slightly less effective pumping of your heart. It is important to control your blood pressure to protect your heart. You were started on a new medication to prevent seizures called trileptal. The dose was adjusted to limit ant dizziness and nausea, but these may be some side effects experienced. If you experience these symptoms they should improve over time. There is also concern about the blood flow in your legs, as it is slightly reduced with poor distal pulses. This issue will need further evaluation as an outpatient by the vascular doctor. Please keep your listed follow-up appointments. You will need to see your PCP, [**Name10 (NameIs) **] neurologist, the cardiologist, and a vascular doctor for your leg as outlined below in more detail. We spoke with your cardiologist, and he agrees to discontinue your Sotalol, until you are seen by him and be reevaluated. MEDICATION INSTRUCTIONS/CHANGES: Several changes were made to your medications. 1) Your sotolol was stopped 2)Hydralizine was stopped 3) You were started on a new antiseizure medication called oxcarbazine (trileptal). 4)Neurontin adjusted to once daily dosing at 300mg nightly 5) levoxyl was increased for poorly controlled thyroid disease 6)Metoprolol tartrate was increased to 62.5mg three times a day 7)please take 3 more days of Bactrim antibiotic for urinary tract infection 8)Percocet was restarted at prior home dose for your lower extremity pains 9)lasix was decreased to 10mg daily * Otherwise, please continue your other usual medications as prescribed, full list attached. . Lastly, if you have chest pain, palpitations, shortness of breath, fainting, loss of bowel or bladder, pain and coldness in your leg, or other concerning symptoms please seek medical attention or go to the ER. Followup Instructions: APPOINTMENTS: 1) MD: Dr. [**First Name8 (NamePattern2) 13544**] [**Last Name (NamePattern1) 81049**] Specialty: PCP Phone number: [**Telephone/Fax (1) 81050**] Special instructions: Dr. [**Last Name (STitle) 81049**] was unavailable to schedule a follow up appointment today. The office will work on setting up an appointment for next week and that they will call with the date and time. Please contact Dr.[**Name (NI) 81051**] office after discharge if you have not been contact[**Name (NI) **] with this appointment. 2) MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 81052**] Specialty: Neurology Date and time: [**2195-4-22**] 1:00pm Location: [**Hospital Ward Name 516**] [**Hospital Ward Name 860**] Building Room # 457 Phone number: [**Telephone/Fax (1) 3506**] 3) MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62081**] Specialty: Cardiology Date and time: [**2195-5-29**] 2:00pm Location: [**Hospital1 81053**], [**Hospital1 8**] Phone number: [**Telephone/Fax (1) 62865**] 4) MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3407**] Date/Time:[**2195-5-5**] 9:30am Specialty: Vascular Sugery, appointment to evaluate the right lower leg Phone:[**Telephone/Fax (1) 1237**] Completed by:[**2195-4-19**]

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Discharge summary

report

Admission Date: [**2141-11-20**] Discharge Date: [**2141-11-22**] Date of Birth: [**2092-11-24**] Sex: F Service: MEDICINE CHIEF COMPLAINT: Unresponsive. HISTORY OF THE PRESENT ILLNESS: This is a 48-year-old woman with a long history of type 1 diabetes mellitus and multiple complication, status post recent admission in [**2141-9-28**] for myocardial infarction, as well as an admission on [**2141-10-29**] for cholelithiasis treated medially. She was sent to rehabilitation on a stable regimen of NPH. Per her husband, she was doing well since [**Name (NI) 2974**], with a good appetite without fever or other complaints. She was eating and drinking at baseline. She had a mild cough, which was nonproductive. He saw her yesterday and she was very confused and disoriented. He questioned the nursing staff regarding her insulin dosing and she had gotten 32 units of NPH in the am. It is unclear what her blood glucose fingersticks were at that time. During the evening, she got 8 units of NPH again. It was unclear what the fingerstick blood glucose was at that time. This morning, at 5 am, she was no arousable. Fingerstick blood glucose was low per report, and she was given some p.o. glucose treatment. She was not able to tolerated it, so 911 was called. She was brought to [**Hospital **] [**Hospital 1459**] Hospital, and she was intubated for airway protection secondary to poor mental status. Fingerstick blood sugar, at the time, was 90 with a bicarbonate normal. Chest x-ray and head CT were unremarkable. The EKG was significant for an old left bundle branch block. Transfer was arranged for the patient to the [**Hospital1 346**]. Prior to transfer, a repeat fingerstick blood sugar was 20, and the patient received one ampule of D50 with improvement in her mental status. A D5 drip was begun and Unasyn was given. Upon arrival to the [**Hospital1 69**], the patient was in some discomfort from the intubation tube. But, she was awake and oriented followed commands. The patient denied any other complaints. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus diagnosed in [**2103**] with multiple complications including the following: Retinopathy, nephropathy, peripheral vascular disease, and coronary artery disease. 2. Coronary artery disease, status post coronary artery bypass graft in [**2132**]; status post myocardial infarction on [**9-/2141**]; congestive heart failure with diffuse hypokinesis and decreased ejection fraction and 3+ mitral regurgitation. 3. Blindness, secondary to complications from diabetes mellitus. 4. End-stage renal disease, currently on hemodialysis, status post a renal transplant in [**2126**] and treated with immunosuppression including Cyclosporin, Imuran, and Prednisone. This was discontinued in [**2137**], secondary to the development of multiple squamous cell cancers. 5. Hepatitis C in 4/[**2140**]. 6. MRSA bacteremia. 7. Multiple squamous cell carcinomas. 8. VRE in the urine, but asymptomatic. MEDICATIONS: 1. NPH insulin 32 units subcutaneously, q.a.m.; 8 units q p.m. 2. Aspirin 81 mg p.o.q.d. 3. Prilosec 20 mg p.o.q.d. 4. Prednisone 2.5 mg p.o.q.d. 5. Pravachol 10 mg p.o.q.d. 6. Reglan 10 mg p.o.q.i.d. 7. Lopressor 25 mg p.o.b.i.d. 8. Percocet p.r.n. ALLERGIES: The patient is allergic to DEMEROL and a question of IV CIPRO; the patient can tolerate p.o. CIPRO. SOCIAL HISTORY: This is a disabled registered nurse, who lives with her husband, who is also blind and a recent amputee. She denies ethanol use and tobacco use. PHYSICAL EXAMINATION: Examination revealed the following: VITAL SIGNS: Temperature 93.1; heart rate 70; blood pressure 132/70; respiratory rate 14; pO2 100% on room air. GENERAL: The patient was awake, opens eyes to voice and follows commands. HEENT: Right eye prosthesis; left eye blind. Mucous membranes dry. Intubation tube in place. NG tube in place. NECK: No lymphadenopathy or masses. CHEST: Chest was clear to auscultation bilaterally with some upper airway sounds. CARDIOVASCULAR: Regular rhythm, normal rate, no murmurs. ABDOMEN: Right lower quadrant surgical scar, no masses, soft, nontender, with bowel sounds. EXTREMITIES: No edema; bilateral old surgical scars. Upper extremity: Left upper extremity fistula with a positive thrill. RECTAL: Guaiac negative brown stool. LABORATORY DATA: Studies revealed the following: White count 10.2; hematocrit 41.6, platelet count 112; INR of less than 1.0; PTT 28; troponin of 0.23; sodium 129; potassium 4.2; chloride 93; bicarbonate 23; BUN 26; creatinine 4.5; glucose 90; albumin 2.9; total protein 6.4; calcium 9.0; bilirubin 0.8; alkaline phosphatase 242; ALT 35; AST 30; CKs 47. CHEST X-RAY: Without infiltrates. Endotracheal tube in good position. EKG: Left bundle branch block at a rate of 80, without change from prior, except an upright QRS in V5. HOSPITAL COURSE: The patient was admitted for observation overnight in the medical Intensive Care Unit at [**Hospital1 346**]. She continued to do well, throughout the night, and the following morning, she was extubated without complications. She was continued on her glucose drip and blood glucose was followed closely. Subsequently, she was transferred to the Medical [**Hospital1 **], where her IV fluid was discontinued, and the patient was given p.o. food to eat and drink. She was restarted on a regimen of NPH insulin starting at 28 units q.a.m. and 6 units q.p.m. the patient is a knowledgeable registered nurse and can aid in the management of her glycemic control. Therefore, we instructed the nursing staff to check with the patient and allow her to take two units more or less depending upon what she anticipated eating on that day. A regular insulin sliding scale was used to main euglycemia when the NPH was inadequate. Four time a day, fingerstick blood glucose was done to include q.a.c. and q.h.s. From a renal perspective, the patient has been doing well and continues her hemodialysis. On the date of discharge, the patient was hemodialyzed without problem. Given the patient's problems with the previous nursing home facility, the patient was screened and accepted for acute rehabilitation at [**Hospital **] Hospital. At the time of this dictation, the patient was awake, alert, and oriented. All medical issues have resolved and she was stable for transfer. DISCHARGE CONDITION: The patient was markedly improved. DISCHARGE STATUS: The patient was discharge to [**Hospital **] Rehabilitation Facility. DISCHARGE MEDICATIONS: 1. Prilosec 20 mg p.o.q.d. 2. Lopressor 25 mg p.o.b.i.d. 3. Aspirin 81 mg p.o.q.d. 4. Reglan 10 mg p.o.q.i.d. 5. Pravachol 10 p.o. q.d. 6. Prednisone 2.5 mg p.o.q.d. 7. Tums, two tablets p.o.t.i.d. with meals. 8. NPH insulin 28 units q.a.m. and 6 units q.p.m.; the patient may request two more or two less depending upon the blood glucose. 9. Insulin sliding scale: 0 to 60, give one ampule D50; 61 to 200, do nothing; 201 to 250, two units; 250 to 300, four units; 301 to 350, six units; 351 to 400, eight units. Greater than 401, ten units. Please check fingerstick blood sugar q.a.c. and q.h.s. Please also given ?????? dose of NPH when the patient is NPO. 10. Percocet 1 tablet p.o.q.4h.p.r.n. DISCHARGE FOLLOWUP: The patient is to followup with Dr. [**First Name (STitle) 805**] after discharge from [**Location **]. She is also to followup with her primary care physician. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2141-11-22**] 13:24 T: [**2141-11-22**] 13:48 JOB#: [**Job Number **]

[ "428.0", "362.01", "250.43", "585", "250.83", "583.81", "518.81", "424.0", "250.53" ]

icd9cm

[ [ [] ] ]

[ "96.71", "39.95", "96.04" ]

icd9pcs

[ [ [] ] ]

6417, 6543

6566, 7278

4919, 6395

3586, 4901

162, 2068

7299, 7723

2090, 3399

3416, 3563

47,747

173,347

11899

Discharge summary

report

Admission Date: [**2195-1-19**] Discharge Date: [**2195-2-2**] Date of Birth: [**2128-12-25**] Sex: M Service: MEDICINE Allergies: Primidone / Bactrim Attending:[**First Name3 (LF) 5606**] Chief Complaint: Neck pain with left arm numbness Major Surgical or Invasive Procedure: Anterior/posterior cervical fusion C3-6 History of Present Illness: 66 year-old man with past medical history of GERD, tobacco use, COPD, hypothyroidism, cauda equina syndrome, and cervical spondylosis with stenosis, who was admitted 2.13 for C3-C6 diskectomy and fusion, found to have elevated troponin (peak 0.22) and new wall motion abnormality and 2+MR [**First Name (Titles) **] [**Last Name (Titles) 113**] checked after episode of acute resp distress 2.17. Resp distress thought to be aspiration and multifocal pneumonia. His daughter states that all this was precipitated by him receiving a sleeping pill the night that this aspiration event occured. He was intubated for airway protection considering he had a significant amount of neck swelling (post-cervical surgery). He successfully extubated and transfered to the floor. He is now sat'ing in the mid 90s on room air. He has a persistent productive cough. He has been afebrile since coming to the floor and denies any chest pain. Per his daughter [**Name (NI) **] he also has been more confused since his ICU stay and has had difficulty sleeping over the last several days. She also states that he has been more anxious lately as well something that is not usual for him. ROS: (+) 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: - COPD: mild-moderate; FEV1 66% predicted, FEV1/FVC 80% predicted - Cauda equina syndrome: dx [**8-8**], s/p L2-laminectomy in [**11-7**], with baseline BLE paresis, neuropathic pain, and neurogenic bladder/bowel - Abdominal pain / Dyspepsia - H. pylori gastritis, s/p treatment; ?hiatal hernia on CXR today - Hyperthyroidism [**1-8**] [**Doctor Last Name 933**] disease s/p radioi-active iodine ablation [**10/2191**], now on replacement therapy - Erectile dysfunction - h/o Pneumonia, [**2186**] - L hip sebaceous cyst - chronic groin pain, on Ultram Social History: 60 pk-yr smoker, quit 5 yrs ago. Denies EtOH use, no IVDA. He is divorced and lives alone in [**Location 4288**]. He went on disability after the surgery for the cauda equina syndrome. Semi-retired, previously worked in administration for construction company. Family History: Denies any major family illnesses. Father died age [**Age over 90 **], mother died age [**Age over 90 **]. Sister w/breast cancer. No premature heart disease or other cancers. Physical Exam: Admision Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND RUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; + [**Doctor Last Name 937**], hyperreflexic at biceps, triceps and brachioradialis LUE- strength and sensation decreased throughout; hyperreflexic; + [**Doctor Last Name 937**] BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles . DC Physical exam VS: Tm/c 98.2 112/62 (112-132/62-91) 76 (76-80) 20 (16-20) 94%RA (94-96) 16-hr I/O: 940/925 Gen: frail, chronically ill appearing, lying in bed, comfortably HEENT: EOMI, PERRL, MMM, OP clear, cervical collar in place, slight conjuctival pallor Neck: posterior and anterior surgical scars healing well, no purulent discharge CV: regular rate and rhythm, no MRG, normal S1/S2 Resp: harsh inspiratory sounds diffusely, decreased breath sounds at left lung base GI: soft NTND, no HSM, +BS Ext: thin extremities, multiple ecchymosis present, no c/c/e Neuro: Right sided weakness with dorsiflexion ([**3-12**]), otherwise strength in UE/LE [**4-11**] bilaterally. Decreased sensation in right leg from knee down through toes. Pertinent Results: ADMISSION LABS ============== [**2195-1-22**] 05:10AM BLOOD WBC-8.2 RBC-4.28* Hgb-11.7* Hct-36.1* MCV-84 MCH-27.3 MCHC-32.3 RDW-14.2 Plt Ct-162 [**2195-1-20**] 06:23AM BLOOD WBC-9.3# RBC-4.60 Hgb-12.6* Hct-39.7* MCV-86 MCH-27.4 MCHC-31.7 RDW-14.3 Plt Ct-183 [**2195-1-20**] 06:23AM BLOOD Glucose-145* UreaN-13 Creat-0.6 Na-136 K-4.5 Cl-103 HCO3-25 AnGap-13 [**2195-1-27**] 11:00AM BLOOD WBC-5.5 RBC-3.90* Hgb-10.8* Hct-32.4* MCV-83 MCH-27.7 MCHC-33.3 RDW-14.0 Plt Ct-253 [**2195-1-25**] 01:18AM BLOOD WBC-8.5 RBC-3.97* Hgb-11.0* Hct-32.6* MCV-82 MCH-27.8 MCHC-33.9 RDW-14.3 Plt Ct-167 [**2195-1-27**] 11:00AM BLOOD Glucose-107* UreaN-15 Creat-0.4* Na-135 K-3.8 Cl-100 HCO3-26 AnGap-13 [**2195-1-26**] 01:21AM BLOOD Glucose-88 UreaN-14 Creat-0.4* Na-139 K-3.6 Cl-104 HCO3-23 AnGap-16 [**2195-1-24**] 04:52AM BLOOD Glucose-147* UreaN-10 Creat-0.5 Na-136 K-4.2 Cl-102 HCO3-25 AnGap-13 . CARDIAC ENZYMES =============== [**2195-1-25**] 01:18AM BLOOD CK-MB-18* cTropnT-0.13* [**2195-1-24**] 09:05PM BLOOD CK-MB-20* MB Indx-3.1 cTropnT-0.16* [**2195-1-24**] 04:00PM BLOOD CK-MB-13* MB Indx-3.2 cTropnT-0.21* [**2195-1-24**] 04:52AM BLOOD CK-MB-10 MB Indx-2.4 cTropnT-0.22* . DISCHARGE LABS ============== [**2195-2-2**] 02:49PM BLOOD WBC-5.9 RBC-3.66* Hgb-10.8* Hct-31.5* MCV-86 MCH-29.3 MCHC-34.1 RDW-15.7* Plt Ct-307 [**2195-1-31**] 03:56AM BLOOD PT-14.0* PTT-27.5 INR(PT)-1.3* [**2195-2-1**] 05:34AM BLOOD Glucose-85 UreaN-14 Creat-0.5 Na-136 K-3.4 Cl-104 HCO3-19* AnGap-16 . IMAGING ======= CXR [**2195-1-22**]: There remains marked elevation of the left hemidiaphragm. New increased opacity in the left retrocardiac region adjacent to an increasingly elevated left hemidiaphragm could reflect atelectasis or aspiration given the clinical suspicion for the latter entity. A subcentimeter nodular opacity in the level of the right third anterior rib is again demonstrated and previously carried a recommendation for followup chest radiographs. Linear opacities at right lung base are consistent with atelectasis. Cardiomediastinal contours are unchanged. IMPRESSION: Left lower lobe atelectasis or aspiration. Persistent nodular opacity right 3rd anterior rib level. PA and lateral CXR are recommended for more complete evaluation of these findings when the patient's condition permits. . TTE [**2195-1-24**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is an inferoposterobasal left ventricular aneurysm. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to basal inferior and posterior wall akinesis. 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) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: inferior posterior myocardial infarct of indeterminate age; due to the technically suboptimal nature of this study, the mitral and tricuspid regurgitation may have been significantly underestimated by color-flow imaging . CXR [**2195-1-24**]: Interval appearance of diffuse airspace process, most likely representing mild-to-moderate pulmonary edema, less likely diffuse pneumonia. There is persistent elevation of the left hemidiaphragm with adjacent more confluent airspace opacity, which could reflect confluent pulmonary edema or an area of atelectasis. There is some overlying motion artifact on the study as well. Cardiac and mediastinal contours are difficult to assess but likely unchanged. Portion of the spinal fusion hardware is seen overlying the lower cervical spine. The described right upper lobe nodular opacity is not well appreciated on the current study due to the diffuse airspace process. . CXR [**2195-1-24**]: Interval intubation with the tip of the endotracheal tube 5.5 cm above the carina. Improved aeration of both lungs, particularly on the left side. There is diffuse airspace process in the right lung as well as more patchy focal process at the left lung base. These findings could reflect asymmetric pulmonary edema, although bilateral pneumonia should also be considered. Overall, cardiac and mediastinal contours are stable. Previously reported more focal nodular opacity in the right upper lobe again is not well appreciated on the current study due to the diffuse airspace process. Spinal fusion hardware overlying the lower cervical spine is incompletely visualized. . CTA CHEST WITH & WITHOUT CONTRAST [**2195-1-24**]: The pulmonary arterial tree is well opacified and no filling defect to suggest pulmonary embolism is seen. The aorta is normal in caliber and configuration without evidence of acute aortic syndrome. Within the lungs, there is bilateral basilar atelectasis with consolidation. An area of additional consolidation is noted within the posterior right upper lobe with areas of peribronchial opacification, bronchial wall thickening and ground-glass opacity. Patchy opacities are also seen in the lingula. No significant pleural effusion is seen. No pneumothorax. The heart and great vessels are grossly unremarkable. There appears to be some distal impaction of bronchi possibly due to aspiration or mucoid impaction in the areas of atelectasis and consolidation. There are coronary artery calcifications. The patient is intubated with endotracheal tube in standard position. Limited views of the upper abdomen are grossly unremarkable. No concerning osseous lesion is seen. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Findings consistent with multifocal pneumonia. . CXR [**2195-1-25**]: In comparison with the study of [**1-24**], there is some increased patchy opacification at the left base. This suggests the possibility of aspiration or pneumonia superimposed upon atelectasis and pleural effusion. Indistinctness of the right hemidiaphragm could reflect small effusion and atelectasis as well. Patchy area in the right mid zone could also represent a focus of consolidation. Engorgement of the pulmonary vessels suggests some elevated pulmonary venous pressure. . CXR [**2195-1-26**]: Endotracheal tube continues to lie 5.5 cm above the carina. There is a persistent opacification and consolidation at the left lung base which may represent an area of pneumonia, although it is possible that this could also reflect worsening lobar atelectasis in the setting of a layering effusion as the pulmonary vasculature is now more ill defined consistent with superimposed pulmonary edema. Cardiac and mediastinal contours are stable. No pneumothorax is seen. . DIPYRAMIDOLE-MIBI [**2195-1-28**]: Stress: INTERPRETATION: This 66 year old man with a history of hypertension, hyperlipidemia, COPD, cervical disc disease with recent operation complicated by peri-operative myocardial infarction, new cardiomyopathy and heart failure was referred to the lab to evaluate his new heart failure. The patient was infused with 0.142mg/kg/min of dipyrimadole over 4 minutes. The patient reported no chest, back, arm, or neck discomfort during the study. There were no ST segment changes during the infusion. The rhythm was sinus with rare VPBs. The hemodynamic response to the infusion was appropriate. At 4 minutes into recover the dipyrimadole was reversed with 125mg of aminophylline. IMPRESSION: No symptoms or ST segment changes with pharmacologic stress. Nuclear report sent separately. . Nuclear Perfusion: INTERPRETATION: Left ventricular cavity size is mildly enlarged, with a calculated end diastolic volume of 113ml. Rest and stress perfusion images reveal a moderate fixed perfusion defect in the base of the inferoseptal wall. No reversible ischemic perfusion defect is identified. Gated images reveal hypokinesis in the basal aspect of the inferoseptal wall. The calculated left ventricular ejection fraction is 46%. Compared with the study of [**2188-1-24**], these findings are new. IMPRESSION: 1. No reversible ischemic perfusion defect. 2. Moderate fixed perfusion defect in the base of the inferoseptal wall with associated hypokinesis. . VIDEO SWALLOW [**2195-1-28**]: An oral and pharyngeal swallowing videofluoroscopy was performed in collaboration with the speech pathology service. During the oral phase, there was mild impairment of bolus formation. Epiglottic deflection was incomplete. There was intermittent, trace penetration with thin and nectar-thick liquids and no aspiration. IMPRESSION: No aspiration. Trace penetration with liquids as above. For further details, please consult the speech pathology note in the medical record dated [**0-0-0**]. Brief Hospital Course: Mr. [**Known lastname **] is a 66 yo M w/ for cauda equina syndrome s/p L2 laminectomy c/b persistent LE neuropathy, now s/p Cervical laminectomy for cervical spondylosis with post surgical course complicated by pneumonia, acute hypoxic event requiring TICU admission, and melena concerning for GI bleed. . . ACTIVE ISSUES: #. C-spine Decompression/Fusion: The patient underwent C3-6 discectomy with posterior decompression and fusion on [**1-21**]. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 he returned to the operating room for a scheduled C3-6 decompression and fusion as part of a staged 2-part procedure. Post-operatively he developed orophyrngeal swelling which caused difficulty swallowing. He was made NPO and speech and swallow was consulted. His diet was advanced slowly. . # Upper Gastrointestinal Bleed- Patient suddenly developed melena with mixed bright red blood and hypotension. He was emergently transfered to the MICU. An EGD was performed which showed multiple duodenal ulcers one with clot present. He was transfused 2 units unmatched pRBC and another unit of matched pRBC. The ulcers were injected epinephrine and no further bleeding resulted. He was started on PPI gtt initially then transitioned to omeprazole 40mg [**Hospital1 **]. Serum H. pylori antigen was positive however he has a history of h. pylori gastritis, the antigen may remain positive after the infection has cleared. . #. Hypoxemic respiratory failure: The evening of [**1-23**] he became hypoxic to the 70's on room air. A code blue was called for respiratory distress, he was not pulseless and CPR was not performed. He was transfered to the T/SICU and intubated for airway protection. It was thought he developed an aspiration pneumonia and he was started on vancomycin and cefepime. Chest x-ray showed multifocal pneumonia. . #. Health Care Acquired Pneumonia: We continued Vancomycin/Cefepime for a total of a 10 day course for HCAP. He remained afebrile and w/o a leukocytosis. He had one positive sputum culture obtained while intubated grew GPCs in pairs and clusters. the rest of his cultures have remained negative. . # Upper GI Bleed: On [**1-30**], patient was noted to have large melenic stool concerning for upper GI bleed. Bleed was accompanied by a Hct drop of 10 points over the course of 24 hours and blood pressures in the 90s (baseline pressure in the 120s). Patient was transferred to the MICU where he was intubated for airway protection given his recent cervical spine surgery and underwent emergent endoscopy. He was noted to have five kissing stress ulcers in the duodenum, one of which had a large adherent clot but none of which were actively bleeding. They injected epi into the largest clot. Cause of stress ulcers felt to be discontinuation of patient's home dose omeprazole during this hospitalization and the stress of surgery, infection, and hospitalization leading to increased acid secretion. He was transfused 3 units of blood and started on a PPI drip. Patient briefly required peripheral pressor support with phenylephrine while intubated but was successfully extubated and off pressors several hours post-endoscopy. He had a few episodes of resolving melena but his hematocrit and blood pressures remained stable requiring no further transfusions. . #. Left Ventricular Dysfunction: At the time of hypoxemic respiratory failure, elevated cardiac biomarkers were noted (peaking at troponin 0.2). [**Month/Year (2) **] showed The patient has a newly found LV aneurysm and new inferior and posterior wall motion abnormalities as well as new MR [**First Name (Titles) **] [**Last Name (Titles) **] compared to his prior TTE in [**2187**]. Most likely these new findings were related to an old MI of indeterminant age. Cardiology recommened anticoagulation for the LV aneurysm but considering his recent spine surgery this was not initiated. Nuclear stress showed fixed defect representing an old MI as well. Started pt on Metoprolol 12.5mg [**Hospital1 **], ASA 325mg and Atorvastatin 80mg daily. Aspirin 81mg was discontinued in the setting of acute gastrointestinal bleed, it should be resumed [**2195-2-8**]. . . CHRONIC ISSUES: #. Neuropathic pain- Pt was taking 800mg of Gabapentin q4 at home for neuropathic pain resulting from prior cauda equina syndrome. This medication was abruptly stopped after acute respiratory failure. He started complaining of increasing neuropathic pain. Gabapentin was restarted at 300mg TID which can be up titrated as tolerated. . #Hypothyroidism- S/P radio ablation for [**Doctor Last Name **], we continued levothyroxine 175mcg . #COPD- stable we continued the following medications at home doses: Fluticasone, albuterol prn, tiotroprium . . TRANSITIONAL ISSUES: - Patient should be continued on a PPI indefinitely given his history of gastritis and this current episode of serious upper GI bleed due to stress ulceration - Patient should have h. pylori stool antigen or breath test performed following discharge. If positive, he should be treated and h. pylori eradication confirmed. - Further consideration into anticoagulation or cardiology consultation for further management of his LV aneurysm will be deferred to his PCP. Medications on Admission: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Neurontin 400mg TID Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) 50 mg/5 mL Liquid PO BID (2 times a day). 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 7. doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day. 8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 12. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO three times a day. 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Cervical stenosis and spondylosis Aspiration pneumonia Demand Myocardial ischemia Acute gastrointestinal bleed Discharge Condition: Good Discharge Instructions: Mr [**Known lastname **], it was a pleasure taking care of you in your stay at [**Hospital1 18**]. As you know, you were admitted for cervical spine surgery. Your hospitalization was complicated by respiratory failure and pneumonia. You were intubated and treated with antibiotics, when your breathing improved, we removed the breathing tube. Your hospital course was complicated by an acute gastrointestinal bleed, we placed a small camera into your stomach and found two bleeding ulcers. We stabalized the bleeding and transfused blood to replace the blood that you lost. START Atorvastatin START Metoprolol INCREASE Omeprazole DECREASE Gabapentin STOP Ibuprofen Followup Instructions: Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] Appointment: Monday [**2195-2-9**] 9:00am Department: CARDIAC SERVICES When: FRIDAY [**2195-2-27**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "80.51", "81.63", "44.43", "77.69", "81.02", "77.79", "96.71", "96.04", "81.03" ]

icd9pcs

[ [ [] ] ]

20399, 20469

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313, 355

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53728

Discharge summary

report

Admission Date: [**2189-1-2**] Discharge Date: [**2189-1-9**] Date of Birth: [**2128-5-7**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old white female with an extensive past medical history including interstitial lung disease, breast cancer, chronic obstructive pulmonary disease, obstructive sleep apnea and congestive heart failure who presents with complaints of shortness of breath and dyspnea on exertion times two days. The patient states that she was experiencing her baseline status of dyspnea on exertion until two days prior to admission she noticed an acute exacerbation. The patient also experienced chills, but denies any frank fevers, sweats, chest pain, sputum, cough, myalgias or chronic change in her orthopnea, pedal edema, paroxysmal nocturnal dyspnea. Due to persistent symptoms the patient presented to the Emergency Department where she was found to have a room air sat in the 80s, systolic blood pressure in the 70s. The patient was fluid resuscitated with 3 liters intravenous fluid, but persisted to have systolic blood pressure in the 70s. A left subclavian line was placed and Dopamine was started. The patient was given one dose of Levofloxacin. O2 saturation of 100% on 100% nonrebreather in the Emergency Department. The patient otherwise denies any symptoms of changes in weight, decreased appetite, nausea, vomiting, diarrhea, dysuria. The patient reports some sinus congestion. The patient denies any changes in vision, abdominal pain, numbness, tingling or weakness. The patient was last admitted in [**2188-6-21**] for shortness of breath. A BAL was performed by Dr. [**Last Name (STitle) 575**], which was unremarkable for PCP, [**Name10 (NameIs) **] or organisms. The patient was felt to be in congestive heart failure and was diuresed. PAST MEDICAL HISTORY: 1. Interstitial pulmonary fibrosis, UIP on immunosuppression. 2. Invasive breast cancer status post lumpectomy. 3. Chronic obstructive pulmonary disease. Last pulmonary function tests, FVC 1.32, SV1 0.9, ratio of 92% with improvement with Albuterol. 4. Obstructive sleep apnea, question if the patient is on BiPAP. 5. PMR/fibromyalgia. 6. Hypertension. 7. Congestive heart failure. Echocardiogram in [**2188-5-21**] revealed an EF of 45 to 50% with posterior hypokinesis. 8. Diabetes mellitus type 2. 9. Coronary catheterization in [**11/2186**] revealed no coronary artery disease. 10. Gastroesophageal reflux disease. 11. History of pseudomonal pneumonia in [**2188-1-22**]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Prednisone 10 mg po q.d. 2. Albuterol. 3. Lipitor 30 mg po q.d. 4. Azathioprine 150 mg po q.d. 5. Beclomethasone four times a day. 6. Celebrex 200 mg po q.d. 7. Klonopin .5 mg po t.i.d. 8. Estrogen .625 mg po q.d. 9. Effexor 37.5 mg po b.i.d. 10. Flovent. 11. Neurontin 600 mg po q.i.d. 12. Lasix 80 mg po q.d. 13. Provera 25 mg po q.d. 14. Metformin 500 mg po b.i.d. 15. Ultram. 17. NPH. 18. Prilosec. 19. Bactrim one tab po q.d. 20. Zestril 5 mg po q.d. 21. Mexiletine 150 mg po b.i.d. SOCIAL HISTORY: The patient quit cigarette smoking in [**2181**]. She has an approximate thirty pack year history. The patient reports occasional alcohol use. The patient is married and lives with her husband. FAMILY HISTORY: There is no significant contributing family history. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.2. Heart rate 98. Blood pressure 109/45. Respirations 29. The patient had a saturation of 99% on 100% nonrebreather. In general the patient was lying in bed and was plethoric and in mild respiratory distress. HEENT examination was within normal limits. Cardiac examination revealed normal S1 and S2. The patient is tachycardic. Pulmonary examination revealed diffuse inspiratory and expiratory wheezes associated with crackles. Abdominal examination was benign. Extremities revealed no clubbing, cyanosis or edema. The patient was guaiac negative per the Emergency Department. LABORATORY: White blood cell count of 10.3, hematocrit 26.3 platelets of 306, 92% neutrophils, 6% lymphocytes, 6% bands and 2% monocytes. Chem 7 revealed a sodium of 136, potassium 6, which is hemolyzed, chloride of 96, bicarb of 25, BUN 35, creatinine 2.7, elevated from the patient's baseline of 1.4, glucose of 76 and a CK of 243 with admission CKMB and troponin not recorded. Urinalysis revealed rare bacteria. Chest x-ray revealed diffuse air space disease with relative sparing of the left base. ASSESSMENT: The patient is a 60 year-old woman with an extensive past medical history presenting with hypoxemia, cough, hypotension, acute renal failure. The patient was admitted to the Medical Intensive Care Unit for closer monitoring. In the Emergency Department the patient was given Levofloxacin and the patient also was started on Vancomycin broad spectrum antibiotics given the likelihood of an infectious etiology at the time of admission. Upon admission to the MICU the patient was also given Vancomycin, Ceptaz and Cipro. The patient was also continued on admission on a Dopamine drip. The patient was also transfused packed red blood cells. Attempts at a right A line was placed upon admission to the unit, however, an A line was not able to be ascertained. HOSPITAL COURSE: 1. Hypoxia: Upon admission it was thought that the patient's hypoxia was secondary to a multilobar pneumonia. However, with improving status and complicated pulmonary history it was felt by the Pulmonary Service that her this recent decompensation was not necessarily due to that of an infectious process, but more likely a combination of her asthma, bronchiectasis, interstitial lung disease and perhaps a congestive heart failure. It was felt that her examination was more consistent of a flare of her airway disease then a pneumonia given lack of fever or production of sputum. Of note the patient also has had multiple exacerbations in the past that have been diagnosed and treated as pneumonia, but for which her outpatient pulmonologist had felt otherwise. It was felt unlikely in addition to lack of fever and sputum production that she was also currently being treated on Levofloxacin for sinusitis and the development of a community acquired pneumonia would be unlikely. Given this history and negative culture data including sputum, Legionella and blood cultures, antibiotic therapy except for Bactrim was discontinued prior to discharge. The patient was also gradually tapered on her steroids. The patient had a dramatic improvement in her oxygen saturation throughout this admission. At the time of discharge the patient's oxygenation still remained below her baseline as she was at 83% on room air and 95% on 2 liters nasal cannula. Chest x-ray on the day prior to discharge revealed resolution of patchy multifocal air space consolidations leaving a background of diffuse interstitial markings. Given the patient's clinical improvement and extensive pulmonary history and the patient's unwillingness to go to an in house pulmonary rehabilitation center the patient was discharged to home with VNA for chest physical therapy. The patient is to follow up with Dr. [**Last Name (STitle) 575**]. The patient was also continued on Prednisone therapy and Bactrim. 2. Hypotension: The patient was continued on a Dopamine drip at the time of admission. Dopamine was discontinued within two days of admission. The patient also was fluid resuscitated with intravenous fluids and packed red blood cells. The patient's blood pressure remained stable throughout the remainder of the hospital stay. 3. Congestive heart failure: Given the patient's history of congestive heart failure she underwent a TTE that revealed a normal EF with a decreased E to A ratio suggestive of a diastolic dysfunction. The patient was reinitiated on her Lasix therapy with resolution of her hypotension. The patient was continued on Lasix therapy at the time of discharge though regimen was decreased to 40 mg po q.d. in the setting of recent hypotension. Of note the patient also had cardiac enzymes cycled and remained negative for any sign of ischemia. 4. Hematology: The patient was repleted with packed red blood cells at the time of admission. Her hematocrit increased appropriately with stabilization throughout remainder of hospital admission. 5. Oncology: The patient with a history of invasive breast cancer and she remained on her Arimidex throughout this hospital stay. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Exacerbation of reactive airway disease. 2. Interstitial lung disease. 3. Hypotension. 4. Anemia. 5. Congestive heart failure. 6. Acute renal failure. 7. Breast cancer. DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr. [**Last Name (STitle) 575**] upon discharge. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 18207**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 110291**] MEDQUIST36 D: [**2189-7-28**] 08:46 T: [**2189-7-31**] 09:40 JOB#: [**Job Number 110292**]

[ "276.5", "255.4", "780.57", "428.0", "285.9", "515", "401.9", "491.21", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

8550, 8588

3339, 3414

8609, 8789

5333, 8528

8814, 9180

153, 1832

3429, 5315

1854, 3108

3125, 3322

8,606

110,187

23809

Discharge summary

report

Admission Date: [**2115-2-24**] Discharge Date: [**2115-3-13**] Date of Birth: [**2043-3-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Bright Red Blood Per Rectum, unstable Major Surgical or Invasive Procedure: Intubation Angiography Endoscopy and Colonoscopy History of Present Illness: 71 yo with Afib on anticoagulation, CAd s/p MI, and HTN, Hyperlipiedmia presents with gas pain followed by bloody BM associated with dizziness, but no n/v, no hx of GI bleeding in past. Has been on coumadin for many years, but dose constantly being adjusted. At [**Last Name (un) 4068**] where he presented, found to initially Hct of 37, but with 4Liters hydration for BP support, Hct 29 and patient with 2bloody BMs at [**Last Name (un) 4068**] as well. He notes he cannot control BMs with all the blood. At [**Last Name (un) 4068**] he received FFP, Vitamin K and 1uPRBC and was transferred here for eval. DEnies any hx of GIbleeding in past and notes that has had sigmoidoscopy in past which was esssentially nl except [**First Name8 (NamePattern2) **] [**Last Name (un) 4068**] report for possible diverticuli. Over last few weeks had prolonged course with sore throat and congestion. Past Medical History: PMHx: HTN Afib on anticoag CAD s/p MI, but no intervention per pt Hyperlipidemia NIDDM Gout s/p TURP [**2111**] Social History: lives alone at home. Occ ETOH, quit tobacco 3y ago (prior smoked for 50y) Family History: Noncontributary Physical Exam: axo NAD CTA B/L S-NT-ND, S1,S2, no M/R/G EXT, WNL, Guiac + Pertinent Results: [**2115-2-25**] 12:00AM TYPE-ART TEMP-37.7 RATES-14/ TIDAL VOL-750 PEEP-5 O2-40 PO2-82* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2115-2-25**] 12:00AM TYPE-ART TEMP-37.7 RATES-14/ TIDAL VOL-750 PEEP-5 O2-40 PO2-82* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2115-2-24**] 08:14PM TYPE-ART RATES-16/ TIDAL VOL-750 PEEP-5 O2-50 PO2-118* PCO2-31* PH-7.45 TOTAL CO2-22 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2115-2-25**] 12:00AM TYPE-ART TEMP-37.7 RATES-14/ TIDAL VOL-750 PEEP-5 O2-40 PO2-82* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2115-2-24**] 01:15PM WBC-11.5*# RBC-4.01* HGB-11.8* HCT-34.4* MCV-86 MCH-29.4 MCHC-34.3 RDW-15.4 [**2115-2-24**] 12:09PM HGB-11.2* calcHCT-34 [**2115-2-24**] 11:04AM HGB-11.0* calcHCT-33 O2 SAT-98 [**2115-2-24**] 09:04AM HGB-11.0* calcHCT-33 [**2115-2-24**] 08:00AM WBC-5.3# RBC-3.29* HGB-9.7* HCT-29.6* MCV-90 MCH-29.4 MCHC-32.7 RDW-14.8 [**2115-2-24**] 06:16AM WBC-13.0* RBC-3.30* HGB-9.4* HCT-29.7* MCV-90 MCH-28.4 MCHC-31.6 RDW-14.2 Brief Hospital Course: [**Known firstname 9241**] was markedly unstable in the ER, invasive monitoring was placed and angiography was emergently performed. He had no obvious bleeding site. He was intubated prior to the procedure for airway protection secondary to large volume support. His bleeding resolved with coagulation correction and he was supported in the ICU while intubated. Post procedure he developed fevers and failed extubation twice. Sputum cultures yielded MRSA. He as treated for the pneumonia and was extubated successfully on the third attempt. He was transfered to the floor. Upper endoscopy and colonoscopy revealed only severe diverticulosis. He was discharged to rehab. to complete his vancomycins for the MRSA pneumonia. Medications on Admission: Meds / Labs / Radiology: Meds: Heparin, Insulin, metoprolol Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 9. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 10 days: Please complete 10 days. Disp:*28 Recon Soln(s)* Refills:*0* 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 511**] [**Hospital 4094**] Hospital Discharge Diagnosis: GI bleed Discharge Condition: stable Discharge Instructions: Please wait one week prior to starting coumadin Followup Instructions: F/U in 1- 2 weeks, please F/U with primary care physisicn regarind GI bleed and colonascopy results and need to F/U with Gastroenterology Completed by:[**2115-3-13**]

[ "562.12", "427.31", "401.9", "211.3", "250.00", "427.1", "274.9", "286.9", "518.82", "455.0" ]

icd9cm

[ [ [] ] ]

[ "88.47", "45.42", "45.13", "96.04", "45.23", "38.93", "96.72", "99.15", "99.04" ]

icd9pcs

[ [ [] ] ]

4738, 4817

2807, 3538

353, 404

4870, 4878

1676, 2784

4974, 5143

1565, 1582

3649, 4715

4838, 4849

3564, 3626

4902, 4951

1597, 1657

275, 315

432, 1323

1345, 1458

1474, 1549

16,042

188,180

14633+56561+56562

Discharge summary

report+addendum+addendum

Admission Date: [**2156-8-19**] Discharge Date: [**2156-9-3**] Service: Blue Surgery CHIEF COMPLAINT: Decrease in appetite over a couple of months. HISTORY OF PRESENT ILLNESS: An 81-year-old male status post ERCP and metallic stent placement for treatment of pancreatic cancer. The patient had another ERCP in [**2156-6-18**], and Dr. [**Last Name (STitle) **] found migration of the common bile duct stent into the duodenum. The ERCP showed the pancreatic mass found to have mass effect on the stent and a new stent was placed to the proximal migrated previous stent. Currently, patient presents with two months history of decreasing appetite. Patient has been eating and drinking, but in decreasing amounts. No fever or chills, nausea, vomiting, or diarrhea, no shortness of breath, no chest pain. Patient reports normal flatus and normal urinary habits and present, but decreased bowel movements. Patient states that the last bowel movement was the day prior to admission. PAST MEDICAL HISTORY: 1. Pancreatic cancer diagnosed in [**2155-3-19**]. 2. Pacer. 3. Coronary artery disease. 4. Gout. MEDICATIONS AT HOME: 1. Toprol 25 mg p.o. q.d. 2. Pancrease one tablet q.8. 3. Furosemide 20 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. ALLERGIES: Levofloxacin leads to arm swelling. SOCIAL HISTORY: Occasional alcohol, quit smoking approximately 45 years ago. Patient lives at home with his wife. PHYSICAL EXAMINATION: Temperature 97.4, 74, 20, 90/60. General: The patient was alert, oriented, thin in no apparent distress. Examination of the head, eyes, ears, nose, and throat showed normocephalic and symmetric. Pupils are equal, round, and reactive to light. Extraocular movements are intact and oral mucosa was moist. Examination of the chest revealed clear to auscultation, no wheezes, rales, rhonchi, or rubs were appreciated. Examination of the heart revealed regular, rate, and rhythm without any murmurs or gallops, positive S1, S2. Examination of the abdomen revealed moderate-to-severe distention of the upper left quadrant without any pain to palpation or position, and the abdomen was soft without any palpable masses. Examination of the extremities revealed DP and PT pulses were nonpalpable bilaterally. DP and PT were Dopplerable biphasic. There were no gross deformities. The patient was admitted to the GI service originally with assessment of patient having pancreatic mass and two stents present for ERCP by Dr. [**Last Name (STitle) **]. HOSPITAL COURSE: On hospital day #2, patient had the ERCP which showed a large amount of food in the stomach and showed that there is gastric outlet obstruction due to the mass effect from the pancreatic mass. Surgery was consulted at this time and the patient was transferred to Dr.[**Name (NI) 1369**] service on hospital day #3. Patient complained of vomiting without tenderness with distended abdomen. Patient was recommended to be NPO, to start TPN, and placement of nasogastric tube, and planned for gastrojejunostomy to bypass the outlet obstruction. On hospital day #4, obtained a Cardiology consult to prepare for the gastrojejunostomy. From the cardiac standpoint, the patient is to start on aspirin, but it was not because of the perioperative bleeding risk concerns. The patient was continued on beta blockers and continued on Lasix, and to maintain euvolemia. The concern with the patient was his ejection fraction of approximately 20% from the CAD cardiomyopathy. Patient was continued on TPN, patient's cardiac medications, placement of nasogastric tube and kept NPO. Patient had the operation on hospital day #5. Patient had gastrojejunostomy without any events. Patient was intubated after the operation, and was transferred to the cardiac unit. Patient had good urinary output and hemodynamically stable after the operation. The patient was weaned to extubate. The patient was kept NPO and with nasogastric tube to suction and to continue to check laboratories. After postoperative, the patient required some crystalloids and intermittent Neo-Synephrine for low blood pressure. Patient continued to have good urine output. On postoperative day #1, patient was weaned off the Neo-Synephrine. Patient was extubated. Continued to be NPO with nasogastric tube to suction and to start TPN. Patient continued to have the Foley in place and patient received perioperative dose of Unasyn. Continued to check laboratories and patient was beta blocked. On postoperative day #2, patient's pain was controlled with prn morphine sulfate. Patient continued to have pulmonary toilet. Patient was maintained NPO with nasogastric tube in place. The patient continued to have adequate urinary output and patient was on no antibiotics, and continued the current management. On postoperative day #3, the patient was on prn pain medications. Patient was weaned off the Neo-Synephrine and used beta blockers. Patient was able to tolerate it. Continued pulmonary toilet. Continued TPN and continued the nasogastric tube. The patient had adequate urine output, and the patient remained afebrile. On postoperative day #4, patient's pain was well controlled. Patient was started on aspirin and continued beta blocker, which patient tolerated. Patient's blood pressure was stable. Continued pulmonary toilet. The patient remained NPO with nasogastric tube, and continued TPN. Patient's pain was well controlled. Patient was started on beta blockers. If blood pressures were stable, continue on aspirin. Continue the pulmonary toilet. Continued NPO. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 3118**] MEDQUIST36 D: [**2156-9-2**] 10:25 T: [**2156-9-3**] 08:20 JOB#: [**Job Number 43128**] Name: [**Known lastname 1511**], [**Known firstname 1424**] Unit No: [**Numeric Identifier 7859**] Admission Date: [**2156-8-19**] Discharge Date: [**2156-9-15**] Date of Birth: [**2075-1-23**] Sex: M Service: BLUE SURGERY ADDENDUM: This is a continuation of the previously dictated discharge summary. On postoperative day number five, the patient continued to do well. The patient was continued on TPN and continued to be monitored. On postoperative day number six, the patient's abdomen was slightly distended but still soft. The patient's NG tube was removed and continued on TPN. Cardiology recommended to start the patient on Captopril 12.5 mg t.i.d. in addition to the IV Lopressor for his low ejection fraction. On postoperative day number seven, the patient was continued on TPN. The patient's abdomen was soft, nontender and the patient was encouraged to be out of bed and to ambulate. On postoperative day number eight, the patient's diet was advanced to clears and the patient's Foley was removed. However, the patient was unable to void. Therefore, the Foley was placed back. On postoperative day number nine, the patient's abdomen was slightly distended and the patient was continued on TPN. The patient's diet was advanced to a regular diet. On postoperative day number ten, the patient continued to be afebrile with stable vital signs. The patient was started on calorie counts. On postoperative day number 11, the patient had large emesis. The NG tube was placed back which produced 800 cc of gastric content. The patient was kept n.p.o. and continued on TPN. The NG tube was placed under fluoroscopy. On postoperative day number 12, the patient was continued on TPN and continued with the NG tube. The patient continued to have high NG output. On postoperative day number 13, the patient was passing gas and had bowel movements but the abdomen was still distended and still continued to have high NG tube output. On postoperative day number 14, the patient's abdomen continued to be distended and the patient had an upper GI and small bowel follow through which showed that there was patent gastrojejunostomy anastomosis and no obstruction. The patient was started on 4:1 NG tube clamp on postoperative day number 15 and the patient was also started on erythromycin and Reglan was increased. On postoperative day number 16, the patient spiked temperature to 101.2. Urine culture was sent which showed a U/A which was positive and urine culture which ended up growing out Klebsiella pneumoniae. The patient was started on Bactrim for which the organism was sensitive too and was continued on Bactrim. There was a trial of removal of the Foley; however, the patient did not tolerate this and the Foley was put back in with postvoid residual of 600 cc. Urology was consulted and they recommended that the patient go home with Foley and to follow-up with the [**Hospital 1976**] Clinic. The patient also had a KUB which showed a nondistended stomach and the patient's NG tube was removed. On postoperative day number 17, the patient was continued on Bactrim and the patient was encouraged to be out of bed and to ambulate. The patient also continued the TPN and was kept n.p.o. On postoperative day number 18, the patient remained afebrile with stable vital signs. The abdomen was slightly distended, no nausea or vomiting and was advanced to clears and was tolerating it without any difficulties. There were some drainage from the medial and lateral aspect of the wound. Staples were removed. The wound edges were opened and the findings were consistent with fat necrosis. The wound, however, was closed without any difficulties. On postoperative day number 19, the patient was continued on TPN, continued on Bactrim, and continued on a clear liquid diet and was tolerating it without any difficulties. On postoperative day number 20, the patient continued to remain afebrile with stable vital signs, slightly distended abdomen; however, no nausea or vomiting. The patient was started on calorie counts on a regular diet and continued TPN. On postoperative day number 21, the patient continued to do well. The patient's diet was changed to a post gastrectomy diet, six small meals per day. On that day, the patient's intake was 50% estimated caloric needs and 45% of protein needs. On postoperative day number 22, the patient had met 81% of caloric needs and 91% of protein needs. The TPN remained at half the rate. The patient continued on postgastrectomy diet. The patient continued to do well. On postoperative day number 23, the patient continued to remain afebrile with stable vital signs. The patient was continued on 1 liter and half the rate of TPN as previously and continued calorie counts, encouraged to be out of bed and ambulate. On postoperative day number 24, the patient continued to do well without any difficulties. The patient was discharged to rehabilitation to continue the recovery process. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Rehabilitation. DISCHARGE DIAGNOSIS: 1. Status post gastrojejunostomy. 2. Gastric outlet obstruction. 3. Pancreatic cancer. 4. Pacer. 5. Coronary artery disease. 6. Gout. FOLLOW-UP PLANS: Please follow-up with Dr. [**Last Name (STitle) **]. Please call his office for an appointment. Please follow-up with the PCP. [**Name10 (NameIs) 2947**] call his office for an appointment. Please follow-up with Dr. .................... Please call his office for an appointment. DISCHARGE MEDICATIONS: 1. Furosemide 20 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Pancrease one tablet t.i.d. 4. Reglan 20 mg p.o. q. six hours. 5. Bactrim one tablet q.d. 6. Aspirin 81 mg p.o. q.d. 7. Captopril 12.5 mg p.o. b.i.d. 8. Erythromycin 250 mg p.o. q. six hours. 9. Colace 100 mg p.o. b.i.d. 10. Ursodiol 300 mg p.o. b.i.d. 11. Nystatin powder as needed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 360**] MEDQUIST36 D: [**2156-9-15**] 11:33 T: [**2156-9-15**] 12:33 JOB#: [**Job Number 7860**] Name: [**Known lastname 1511**], [**Known firstname 1424**] Unit No: [**Numeric Identifier 7859**] Admission Date: [**2156-8-19**] Discharge Date: [**2156-9-19**] Date of Birth: [**2075-1-23**] Sex: M Service: HEPATOBILIARY SURGERY SERVICE ADDENDUM CONTINUATION: On postoperative day twenty-four, the patient was seen by case management. No beds were available at any short term nursing facilities. The patient search for rehabilitation placement was expanded and case management was currently searching for suitable facility for the patient. On postoperative day twenty-five, the patient was afebrile and vital signs were stable. The patient was on Bactrim. Discharge planning was continued. The patient was awaiting a bed at short term nursing facility. Nutrition had seen the patient and calorie count were ensuing. The patient was tolerating a regular diet and was supplementing with Boost shakes. On postoperative day twenty-five, case management alerted team that a bed had been available in [**Location (un) 176**] in [**Last Name (un) 7861**], [**State 1145**]. The patient was scheduled for discharge on Sunday. The patient's family is made aware. On postoperative day number twenty-six, the patient was afebrile and vital signs were stable. The patient's fingerstick levels were all within normal limits. The patient was tolerating a diet. Plans for rehabilitation were continued. On postoperative day number twenty-seven, the patient was afebrile and vital signs were stable. Laboratory values were within normal limits. The patient's physical examination was unchanged. The patient was discharged to rehabilitation. DISCHARGE DIAGNOSES: 1. Status post gastrojejunostomy. 2. Gastric outlet obstruction. 3. Pancreatic cancer. 4. Cardiac pacer. 5. Coronary artery disease. 6. Gout. FOLLOW-UP PLANS: The patient is to follow-up with Dr. [**Last Name (STitle) **] in [**Hospital 7862**] Clinic. The patient is to call office for appointment. The patient will also follow-up with his primary care physician and will call for an appointment. MEDICATIONS ON DISCHARGE: 1. Furosemide 20 mg p.o. once daily. 2. Protonix 40 mg p.o. once daily. 3. Pancrease one tablet three times a day. 4. Reglan 20 mg p.o. q6hours. 5. Bactrim one tablet p.o. once daily. 6. Aspirin 81 mg p.o. once daily. 7. Captopril 12.5 mg p.o. twice a day. 8. Erythromycin 250 mg p.o. q6hours. 9. Colace 100 mg p.o. twice a day. 10. Ursodiol 300 mg tablet p.o. twice a day. 11. Nystatin Powder applied to area as needed. The patient is discharge to rehabilitation facility in stable condition. The patient is tolerating regular diet with nutritional supplements. The patient is ambulating with help of physical therapy. The patient will resume physical therapy care at rehabilitation facility. CONDITION ON DISCHARGE: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 7863**] MEDQUIST36 D: [**2156-12-8**] 10:23 T: [**2156-12-8**] 19:10 JOB#: [**Job Number 7864**]

[ "428.22", "458.29", "157.0", "428.0", "041.3", "425.4", "V45.01", "537.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.07", "44.13", "44.39", "99.15" ]

icd9pcs

[ [ [] ] ]

13751, 13900

11413, 13730

10945, 11086

14185, 14893

2511, 10856

1138, 1301

1441, 2493

13918, 14159

113, 160

189, 996

1018, 1117

1318, 1418

14918, 15189

24,652

179,769

25028

Discharge summary

report

Admission Date: [**2186-10-14**] Discharge Date: [**2186-10-17**] Date of Birth: [**2109-11-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest and back pain Major Surgical or Invasive Procedure: [**2186-10-15**] Endovascular repair of thoracic aneurysm with Endograft History of Present Illness: Mr. [**Known lastname **] is a 76 year old male with known saccular thoracic aneurysm. On the morning of admission, he awoke with 4/10 back pain which radiated to his sternum. The pain last approximately 2 hours - it was exacerbated by lying down and improved upon standing. He denied SOB, syncope, presyncope, palpitations, and orthpnea. He initially presented to [**Location (un) **] for evaluation(details unknown)and was eventually transferred to the [**Hospital1 18**] for surgical intervention. Past Medical History: Hypertension Hypercholesterolemia Diabetes Mellitus Coronary Artery Disease s/p Myocardial Infarction x 2 and PCI x 2 Chronic Renal Insufficiency Social History: Quit tobacco 25 years ago. Denies ETOH and recreational drugs. Family History: Non-contributory Physical Exam: VS: T 98.7, BP 109/24, HR 108, RR 16, Sat 97% RA General: Well developed elderly male in no acute distress HEENT: Oropharynx [**Last Name (un) 17066**] Neck: Supple, no JVD Heart: Regular rate, normal s1s2, no murmur Lungs: Clear bilaterally Abd: Pulsatile mass noted paraumbilical area. Soft, nontender, nondistended. Ext: Warm, no edema Neuro: Nonfocal Pulses: 2+ distally Pertinent Results: ECG [**10-14**]: Sinus tachycardia 107. Old inferior myocardial infarction. Poor R wave progression. CTA [**10-14**]: 1. Saccular aneurysm of the descending thoracic aorta and fusiform aneurysm of the infrarenal abdominal aorta. Aneurysms of the common iliac arteries bilaterally. No evidence of aortic dissection. No evidence of periaortic fluid collection. 2. 1-cm hyperenhancing nodule within the pancreatic neck and questionable area of hyperenhancement in pancreatic head. The findings could be consistent with hyperenhancing neoplasm such as islet cell tumor. 3. Pleural calcifications consistent with prior asbestos exposure. 4. 2-mm nodule in the right upper lobe. If there is no prior history of malignancy, one year followup with CT is recommended to assess stability. If there is a history of prior malignancy, three-month followup is recommended. 5. Diverticulosis without evidence of surrounding inflammation. [**2186-10-14**] 08:05PM BLOOD WBC-9.3 RBC-4.68 Hgb-14.1 Hct-41.4 MCV-88 MCH-30.0 MCHC-34.0 RDW-13.4 Plt Ct-200 [**2186-10-17**] 05:20AM BLOOD WBC-8.8 RBC-3.34* Hgb-10.0* Hct-30.2* MCV-90 MCH-30.0 MCHC-33.2 RDW-13.5 Plt Ct-123* [**2186-10-14**] 08:05PM BLOOD PT-12.5 PTT-26.3 INR(PT)-1.0 [**2186-10-16**] 02:39AM BLOOD PT-13.2 PTT-32.8 INR(PT)-1.2 [**2186-10-14**] 08:05PM BLOOD Glucose-169* UreaN-27* Creat-1.6* Na-138 K-3.4 Cl-99 HCO3-26 AnGap-16 [**2186-10-17**] 05:20AM BLOOD Glucose-97 UreaN-19 Creat-1.4* Na-141 K-4.2 Cl-102 HCO3-31 AnGap-12 [**2186-10-16**] 02:39AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.3 [**2186-10-14**] 10:23PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.034 [**2186-10-14**] 10:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Brief Hospital Course: Mr. [**Known lastname **] was evaluated in the Emergency Room. A CT angiogram was notable for a saccular aneurysm of the descending thoracic aorta with peripheral mural thrombus. The saccular aneurysmal dilatation along the right side which measured 4.7 cm in total transverse diameter x 4.1 cm AP x up to approximately 5 cm in maximal sagittal dimension. No aortic dissection was identified within the thoracic aorta. There was also a fusiform infrarenal abdominal aortic aneurysm measuring 4.3 x 5.3 cm in greatest transaxial diameter. There was additional aneurysmal dilatation of the right and left iliac arteries. The right iliac artery measures up to 2.1 cm and the left iliac artery measures up to 3.4 cm in greatest transaxial diameter. There was mural thrombus within the left iliac aneurysm. Based on the above results, he was admitted to the ICU. He was maintained on Esmolol for tight BP and HR control. The following day, he was urgently taken to the operating room for stent graft repair of his thoracic aortic aneurysm. Surgery was uneventful - for further details, see operative note. After the operation, he was brought to the CSRU. Within 24 hours, he awoke neurologically intact and was extubated. He maintained good hemodynamics and transferred to the SDU on POD#1. He remained in a normal sinus rhythm. His postoperative course was uncomplicated and he was discharged to home on POD#2. He will need to follow up with Dr. [**Last Name (STitle) 26770**](vascular surgery) regarding his infrarenal abdominal aortic aneurysm. T 98.0 HR 73 106/44 RR 18 94% RA sat Medications on Admission: Aspirin, Crestor, Effexor, Zetia, Metformin, Lasix, Duragesic Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Metformin 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Thoracic Aortic Aneursym s/p Endovascular repair of thoracic aneurysm Hypertension Hypercholesterolemia Diabetes Mellitus Coronary Artery Disease s/p Myocardial Infarction x 2 and PCI x 2 Chronic Renal Insufficiency Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incisions, or weight gainmore than 2 pounds in one week or five in one day. [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks Follow-up with Dr. [**Last Name (STitle) 1391**]/[**Doctor Last Name **] for infrarenal AAA Follow-up with PCP [**Last Name (NamePattern4) **] 2 weeks Completed by:[**2186-11-13**]

[ "424.1", "414.01", "412", "441.2", "V45.82", "401.9", "442.2", "272.0", "585.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.73" ]

icd9pcs

[ [ [] ] ]

6243, 6311

3414, 4998

344, 419

6571, 6578

1642, 3391

1214, 1232

5110, 6220

6332, 6550

5024, 5087

6602, 6723

6774, 7016

1247, 1623

285, 306

447, 949

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1134, 1198

32,713

140,055

34269

Discharge summary

report

Admission Date: [**2156-4-13**] Discharge Date: [**2156-4-23**] Date of Birth: [**2103-1-29**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: ICH Major Surgical or Invasive Procedure: None History of Present Illness: 53 RHM no sign [**Hospital **] transferred from OSH after being found down outside of his house with right hemiparesis and aphasia found to have a left thalamus and semiovale hemorrhage. Per patient who appears to understand questions but has difficulty answering, pt has had the right hemiparesis x1 wk but does not remember the details of its onset. He reports remembering sitting in a chair at the table Thursday evening when he suddenly passed out and came to 15 minutes later. EMS and OSH reports, describe finding pt down, crawling outside of his house with right sided weakness, incontinence, slurred speech and equal pupils. Noted to have a swollen right arm w/ecchymosis but reportedly AOx3. Taken to OSH where VS 97.4 230/110 100 16 99RA FS 125. HCT mod left ICH centered on left centrum semi ovale with surrounding edema, assoc mass effect with compression of the left lat ventricle and sl midline displacement of the right. No IV spread or extra-axial fluid. EKG NSR 91 without comparison. PCXR and pelvis xray. UA neg for infxn. Utox (incl etoh) neg. K 2.7, BUN/Cr 22/0.9 and INR 1.16, PTT 27.4. WBC 13.5, Hct 35.4. Plt 285, no bands, 78N, 13L. Given Cerebrex 1g IV and Labetolol 20mg IV. ROS: Currently, denies HA, trauma, hearing changes, dysphagia, dysarthria, urine or bowel incontinence. Hasn't walked since onset of hemiparesis. Past Medical History: Denies HTN, hyperchol, DM or seizures. Social History: Lives alone in [**Location (un) 14663**]. Unable to explain his job. Drinks ~3x/day usu beer but states that he hasn't drunk in one week. Denies smoking or drugs. Family History: Denies neurologic illnesses or HTN Physical Exam: T- 97.5 BP- [**Numeric Identifier 74920**] HR- 68 RR- 16 100 O2Sat Gen: Lying in bed, NAD HEENT: NC/AT, dry oral mucosa Neck: supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: [**12-10**]+ edema on the right side arm and leg Neurologic examination: MS: General: alert, awake, normal affect Orientation: oriented to person, "health facility", [**2139**] Attention: follows simple commands. Unable to recite MOYbws. Speech/[**Doctor Last Name **]: nonfluent; intact repetition (only [**12-10**] words not sentences), [**Location (un) 1131**] (short phrases) and comprehension. But unable to naming ("rabbit" chair and "[**Last Name (un) 78889**]" for glove). Memory: registers [**12-11**] at 30 seconds despite given clues & multiple choices L/R confusion: some difficulty with L/R confusion Praxis: able to brush teeth w/left hand CN: I: not tested II,III: right inferior quadranopsia, right pupil 5mm -> 3mm and left pupil 4mm -> 2mm III,IV,V: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: right UMN facial weakness VIII: hears finger rub bilaterally IX,X: voice nl, palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**4-12**] on the left XII: tongue protrudes to the left (?[**1-10**] facial weakness) without atrophy or fasciculation, mild dysarthria Motor: Normal bulk. Decr'd tone on right. Mild postural tremor. No asterixis, myoclonus or pronator drift on left. Full [**4-12**] on left and flaccid paralysis on right. Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2+ 2+ 2+ 2+ 2 Extensor R 3+ 3+ 3+ 4+ 3+ Extensor Sensation: Decr'd light touch, cold, vibration and proprioception on right side, decr'd vibration to ankles and stocking distribution to cold to mid-shin on left leg. Coordination: finger-nose-finger and RAMs normal on the left. Gait/Romberg: deferred Pertinent Results: BILAT LOWER EXT VEINS [**2156-4-13**] 2:15 PM No evidence of bilateral lower extremity deep vein thrombosis. CT/CTA 5/6/8: 1. Large, 5.0 x 4.1 cm intraparenchymal hematoma, involving the left thalamus, posterior limb of the left internal capsule and the left frontotemporal lobe including the centrum semiovale along with some extension into the left lateral ventricle (body and occipital [**Doctor Last Name 534**]). Comparison with prior studies will be helpful to assess interval change. 2. Moderate vasogenic edema, mild-to-moderate mass effect on the left lateral ventricle, and mild shift of the midline structures to the right side. 3. Patent major intracranial arteries. No focal flow-limiting stenosis, occlusion, or aneurysm on the present study. However, an underlying vascular lesion in the hematoma cannot be assessed. To consider getting the CT angiogram after resolution of the hematoma as well as neurosurgical consultation (if no intervention is contemplated). The presence of tumor is less likely but cannot be completely excluded and can be further evaluated with MR of the head without and with IV contrast, preferably after resolution of the hematoma Repeat CT 5/8/8: 1. Overall stable appearance to large left parenchymal hemorrhage with similar mass effect when compared to prior. 2. Slight enlargement of the right ventricle. R Elbow 5/8/8: Three radiographs of the right elbow demonstrate a small elbow joint effusion. No fracture is identified. There is prominence of the soft tissues posterior to olecranon. The regional soft tissues are otherwise unremarkable. U/S both arms 5/10/8: No evidence of DVT within the upper extremities bilaterally. The right basilic vein was not visualized due to limited patient positioning. Unilateral LEFT arm U/S [**2156-4-21**]: 1. No evidence of abscess. 2. Thrombus within the left cephalic vein as well as a superficial vein in the dorsum of the left hand EKG: Sinus rhythm. Consider left ventricular hypertrophy. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 148 84 [**Telephone/Fax (2) 78890**] 10 ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with normal global and regional biventricular systolic function. No diastolic dysfunction, pulmonary hypertension or significant valvular disease seen. Dilated aorta. Brief Hospital Course: Brief ICU course: Admitted to the Neuro ICU for close monitoring and blood pressure control. His symptoms remained generally stable although he had a mild worsening of his aphasia on HD 3. A repeat head CT was unchanged. Blood pressure control with a goal of MAP < 130 and SBP < 160 was attained initially with a nicardipine gtt through the first 36 hours. He was then controlled with increasing doses of PO metoprolol and eventually PO captopril was added. IV hydralazine was used PRN. Etiology of the hemorrhage was presumed to be hypertensive, although the location and appearance are somewhat unusual. He may benefit from an MRI as an outpatient in [**3-14**] weeks (after the hemorrhage has cleared) to characterize the area more fully and exclude an underlying mass lesion. A plain film was obtained at the area of ecchymosis on his right UE. No fracture was seen. He was placed on a CIWA scale to monitor for alcohol withdrawal, but showed no evidence of this. Brief FLOOR course [**4-17**] - [**4-23**]: NEURO: He continued to slowly improve with fragented, non-fluent aphasia more expressive than receptive. He still has a limited attention span. His R hemiplegia started to develop an increased tone leg > arm so a podus boot was given. He was seen by PT, OT, and Speech Therapy. He was cleared for a regular diet with nectar-thickened liquids and whole pills in thick liquids. He was continued on Thiamine, FA and MVI. CARDIO: His oral antihypertensive medication was titrated upwards - at time of discharge he was on Metoprolol 100 TID, Captopril 50 TID and was started on Norvasc 5 mg on [**4-21**]. This will need further titration. His EKG showed mild LVH, this was confirmed by ECHO - results are outlined in the "results" section. ACCESS: A central line (R IJ) was placed on [**2156-4-18**]. This line was placed during bacteremia and at the recommendation of ID, it was taken out and a PICC line was placed on [**2156-4-23**] (under U/S and fluoroscopic guidance). PULM: No issues on the floor. ID: On arrival to the floor noted to have a temp to 101.6. UA was significant for 36 WBC, dip otherwise negative, and the patient was started on Bactrim. He was persistently febrile to 103 on [**4-18**], was noted to have LUE thrombophlebitis with cord and pus drainage secondary to an L antecubital and later also L dorsum IV site, a right IJ TLC was placed on that day for access. His Bactrim was intially switched to Ceftriaxone on [**4-18**], then when Cx came back with Staph aureus, to Vancomycin on [**4-19**]. He was evaluated by Vascular Surgery, surgical intervention was planned but cancelled due to clinical improvement. He was ACE bandaged. ID was consulted, and he was advised to have serial BCx, and U/S of the L arm to r/o abscess (negative), and a TTE to r/o seeding to the valves (negative). He was switched to Cefazolin 2 grams q4 hrs for 4 - 6 weeks (see D/C instructions). The ID attending spoke to the vascular surgery attending on [**4-22**] and no surgery was pursued. The ABx will be on for at least FOUR WEEKS, and it is requested to send WEEKLY CBC, CHEM 7 and LFTs and fax the results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of the [**Hospital1 18**], fax number [**Telephone/Fax (1) 23413**]. She will also follow-up with him, please see discharge instructions for that. FEN: On the floor he had a low potassium 3.5 on a single occasion [**2156-4-17**], not warranting repletion. He passed his swallowing evaluation. GI: He was started on a bowel regimen, and BM were monitored. Medications on Admission: Advil OTC Discharge Disposition: Extended Care Facility: [**Hospital6 **] Hospital Discharge Diagnosis: 1. Hypertension 2. Alcohol abuse 3. Staphyloccus aureus superfical septic thrombophlebitis. 4. Left ventricular hypertrophy Discharge Condition: Stable. Neuro exam notable for disorientation to date, non-fluent anomic aphasia with moderately impaired comprehension, right face and body hemiplegia, right hemianesthesia. Discharge Instructions: You have been evaluated for a stroke caused by bleeding in your brain. This is thought to be due to uncontrolled high blood pressure. You have been started on blood pressure medications. Please take all medications as directed and keep all follow-up appointments. If you have worsening of your speech, weakness, or sensory loss, or experience new symptoms on your left side, or if you become more drowsy than usual, or if you have any new symptoms that are concerning to you, please call your PCP or your neurologist or go to the nearest hospital emergency department. Followup Instructions: Please call [**Telephone/Fax (1) 2574**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) **] within 4 weeks of returning home from rehab. Please call your PCP to be seen in 1 week after returning home from rehab. If you need a new PCP, [**Name10 (NameIs) **] may call [**Telephone/Fax (1) 250**] to schedule a new patient appointment in [**Hospital6 733**]. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2156-4-23**]

[ "038.11", "995.91", "401.9", "276.8", "599.0", "305.01", "996.62", "451.82", "707.13", "431" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10832, 10884

7208, 10772

320, 326

11051, 11228

4064, 7185

11846, 12347

1983, 2020

10905, 11030

10798, 10809

11252, 11823

2035, 2370

276, 282

354, 1721

2394, 4045

1743, 1784

1800, 1967

14,607

168,786

7363

Discharge summary

report

Admission Date: [**2200-2-13**] Discharge Date: [**2200-2-22**] Date of Birth: [**2155-3-12**] Sex: F Service: Medicine CHIEF COMPLAINT: Fevers, nausea, and vomiting. HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old female with chronic hepatitis C secondary to transfusion, status post liver-related liver transplant with hyperacute rejection, status post retransplant with cadaveric liver 24 hours later, who presents with progressive nausea, vomiting, and fevers. She had a recent admission on [**2-1**] to [**2-4**] for cholangitis. Originally admitted on [**2199-12-9**] for a biliary obstruction and underwent endoscopic retrograde cholangiopancreatography with sphincterotomy and stenting of right and left hepatic ducts. A repeat endoscopic retrograde cholangiopancreatography on [**2-3**] showed bilateral stent occlusion with postobstructive dilation. The patient's stents were removed and replaced. She completed a course of Unasyn and subsequently ciprofloxacin as an outpatient. She was discharged home. She subsequently went on a trip to Porta [**Country **] over the seven days prior to admission. On the morning before admission, she had an episode of emesis which was nonbloody and was bilious. Also with intermittent nausea. She had progressive fevers and chills; however, did not take her temperature. No chest pain or shortness of breath or diarrhea. She had no change in her bowel or bladder function. She did note some darkening of her stool over the past two months; however, no frank blood was noted. PAST MEDICAL HISTORY: 1. Living-related liver transplant, status post hyperacute rejection; status post cadaveric liver transplant in [**2199-10-9**], complicated by sepsis, stroke, and biliary stricture. 2. Hepatitis C. 3. Hypertension. 4. Tubal ligation. 5. Anemia, not otherwise specified. 6. Diabetes mellitus. 7. Hepatitis A positive. ALLERGIES: DILAUDID. MEDICATIONS ON ADMISSION: Neoral 50 mg p.o. b.i.d., prednisone 7.5 mg p.o. q.d., Rapamune 2 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Actigall 300 mg p.o. t.i.d., Lopressor 100 mg p.o. b.i.d., magnesium oxide 400 mg p.o. b.i.d., NPH insulin 45 units q.a.m., regular insulin sliding-scale, ganciclovir 500 mg p.o. t.i.d. SOCIAL HISTORY: Born in Porta [**Country **], now lives in [**Location 86**]. No history of tobacco, ethanol or IV drug use. FAMILY HISTORY: No liver disease. PHYSICAL EXAMINATION ON ADMISSION: Admission vitals were stable. Generally, was an ill-appearing female in no acute distress. HEENT revealed normocephalic/atraumatic. Pupils were equal, round and reactive to light and accommodation. Sclerae were icteric. Moist mucous membranes. No pharyngeal erythema. Neck had no masses or bruits. It was supple. Heart had a regular rate and rhythm without murmur, rubs or gallops. Lungs had bibasilar crackles with decreased breath sounds at the right base plus egophony. Abdomen was protuberant, redundant skin folds, minimal striae. No caput, normal active bowel sounds, and nontender. Liver was palpable below costal margin. Spleen was not palpable, and no fluid wave noted. Extremities revealed mild pedal edema. Pulses were 2+ distally. Neurologically, alert and oriented times three. Cranial nerves II through XII were intact. She moved all of her extremities well. Reflexes were 2+. Sensation was intact to light touch in all extremities. LABORATORY: White blood cell count 6.8 (baseline 4.4), hematocrit 32.5, platelets 212, MCV 87. PT 12.5, INR 1. Sodium 132, potassium 4.2, chloride 98, bicarbonate 20, BUN 19, creatinine 1.2, glucose 185; 89% polys, 5% bands, 4% lymphocytes. Urinalysis revealed small bilirubin, 388 red blood cells, no white blood cells, 3 epithelials. ALT 164 (down from 400), AST 173 (down from 530), alkaline phosphatase 631 (down from 831), total bilirubin 5.4, amylase 61, lipase 40. Calcium 8.3, magnesium 1.5. TSH 1.6. T4 0.8. Cyclosporin level from [**2-4**] was 385. Rapamycin level from [**2-4**] was 13.1. Liver biopsy in [**2200-1-9**] revealed recurrent hepatitis C cholestasis. No evidence of acute rejection. No bile duct proliferation. Chest x-ray revealed right lower lobe opacity, small right pleural effusion. No enteral change. ASSESSMENT: A 44-year-old female who is hepatitis C positive, status post revised cadaveric liver transplant, status post biliary stent with revision, who presented with symptoms suggestive of cholangitis. HOSPITAL COURSE: 1. HEPATOBILIARY: The patient's bilateral hepatic stents were removed and dilated via endoscopic retrograde cholangiopancreatography. She had good biliary drainage after this. She was maintained initially and empirically on intravenous ampicillin, levofloxacin, and Flagyl. She was kept n.p.o. initially, and her diet was subsequently advanced, which she tolerated. Her liver function tests, transaminases, and electrolytes were checked on a daily basis. Her transaminases were noted to improve daily and were noted to be near her baseline at the time of discharge. She had intermittent temperature spikes which were of unclear significance. She had no further focal abdominal findings throughout the course of her admission. On [**2-14**], the patient became febrile to 101 and hypotensive to the 80s. Her blood pressure was unresponsive to fluids, and she was transferred to the surgical intensive care unit on the [**Hospital Ward Name **]. Chest x-ray showed pulmonary edema and persistent right pleural effusion. The patient was maintained on 4 liters nasal cannula. Blood pressure improved, and the patient's respiratory status generally improved. Episode of hypotension was felt to be due to the post endoscopic retrograde cholangiopancreatography period and transient sepsis syndrome secondary to bile duct manipulation. She had no further episodes of hypotension throughout her stay. 2. PULMONARY: The patient generally weaned very readily off of her nasal cannula back on to room air and maintained her saturations. She did remain dyspneic on exertion throughout her hospital stay. This was thought to be due to deconditioning and to mild congestive heart failure secondary to volume overload. The patient underwent a CT scan of her chest which showed diffuse ground glass opacities. Could not rule out edema versus infiltrate. She also had a moderate sized right pleural effusion. Given the patient's intermittent temperature spikes and pleural effusion, it was decided to perform diagnostic thoracentesis which was done on [**2200-2-16**]. The results were consistent with an exudate; however, the Gram stain and culture were negative. The source of this pleural effusion remained unclear. She was maintained on her intravenous antibiotics empirically. Clinically, the patient's respiratory status remained good; however, given her continued intermittent temperature spikes, repeat thoracentesis was performed on [**2200-2-19**]. The patient was sent to the radiology department and a spot was marked via ultrasound. Attempt was made to perform therapeutic as well as diagnostic thoracentesis; however, only approximately 50 cc of fluid could be removed from her pleural effusion. The fluid analysis was consistent with an exudate; however, again, her Gram stain and culture were negative. Laboratories were sent to rule out pancreatitis, and amylase content was found to be low. Infectious disease team was consulted early and had followed throughout these events. They recommended placing a PPD as well as sending the pleural fluid for AFB. CMV antigenemia was also a consideration, and CMV antigen was sent. These studies were pending at the time of discharge. For the 72 hours prior to discharge, the patient was noted to afebrile and hemodynamically. It was felt that it would be prudent to repeat the chest CT to evaluate for progression of infiltrates. A CT was performed on [**2-21**] and showed partial resolution of the diffuse ground glass opacities which were felt to be related to resolving pulmonary edema. Her right-sided pleural effusion was also noted to be smaller than previous studies. Given the patient's clinical stability and resolving infiltrates on chest CT, no further diagnostic workup was performed for her pulmonary infiltrate, and she will be managed as an outpatient by the transplant service. 3. ORTHOTOPIC LIVER TRANSPLANT: The patient was maintained on her outpatient immunosuppressive regimen throughout her hospital stay. She was noted not to have complications from this regimen and will be discharged on her current regimen. She will follow up with the liver transplant service early next week for further modifications. 4. DIABETES MELLITUS: The patient was maintained on regular insulin sliding-scale and b.i.d. fingersticks throughout her stay. Her morning dose of NPH was reduced to 10 units given her initial poor p.o. intake. However, as her p.o. intake increased, her evening blood sugars were found to be in the low to mid 200 range. Therefore, her a.m. NPH was increased to 20 units. She will need close outpatient followup for her hyperglycemia. The patient's IV antibiotics were discontinued on [**2200-2-21**], and she was placed on Augmentin 500 mg p.o. t.i.d. to complete a 2-week course. She was felt to be stable for discharge on [**2-22**], [**Numeric Identifier 13462**]. DISCHARGE STATUS: She will be discharged to home with services. CONDITION AT DISCHARGE: Good. MEDICATIONS ON DISCHARGE: 1. Neoral 50 mg p.o. b.i.d. 2. Prednisone 7.5 mg p.o. q.d. 3. Rapamune 2 mg p.o. q.d. 4. Augmentin 500 mg p.o. t.i.d. (stop on [**2200-3-8**]). 5. Zantac 150 mg p.o. b.i.d. 6. K-Dur 40 mEq p.o. q.a.m. 7. NPH 20 units subcutaneous q.a.m. 8. Magnesium oxide 400 mg p.o. b.i.d. 9. Actigall 300 mg p.o. t.i.d. 10. Insulin sliding-scale as before. DISCHARGE DIAGNOSES: 1. Orthotopic liver transplant. 2. Cholangitis. 3. Congestive heart failure with pulmonary edema. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 5708**] Dictated By:[**Last Name (NamePattern1) 1768**] MEDQUIST36 D: [**2200-2-22**] 09:24 T: [**2200-2-23**] 08:08 JOB#: [**Job Number 3165**]

[ "070.54", "576.2", "576.1", "V42.7", "584.5", "997.5", "E879.8", "571.5", "402.91" ]

icd9cm

[ [ [] ] ]

[ "97.55", "34.91", "51.84" ]

icd9pcs

[ [ [] ] ]

2404, 2444

9897, 10237

9514, 9876

1965, 2259

4494, 9465

9480, 9487

155, 186

215, 1566

2459, 4476

1588, 1938

2276, 2387

9,942

191,199

54519

Discharge summary

report

Admission Date: [**2108-9-17**] Discharge Date: [**2108-9-20**] Date of Birth: [**2037-3-3**] Sex: F Service: MEDICINE Allergies: Penicillins / Ampicillin / Sulfonamides / Tramadol Hcl / Tetracycline / Risperidone / Aspirin / Ibuprofen,Micronized Attending:[**First Name3 (LF) 783**] Chief Complaint: Call-out from MICU Major Surgical or Invasive Procedure: non-invasive positive pressure ventilation History of Present Illness: 71 y/o female with hx CVA, ESRD on HD, HTN, hypercholesterolemia, Bipolar d/o, ?DI from lithium, etoh and drug abuse, hypothyroidism, secondary hyperparathyroidism who was found by VNA [**9-17**] at home with decreased MS and O2sat 82%; w/u in MICU found to have hypercarbic resp failure, thought [**3-1**] opiate overdose on top of chronic CO2 retention, now stable and transferred to the floor for medical stabilization. . Past Medical History: ESRD, HTN, hypercholesterolemia, CVA-[**2101**], Hypothyroidism, secondary hyperparathyroidism, spinal stenosis, Alcoholism, Drug abuse, Bipolar Disorder, ? DI from Lithium, Left Nephrectomy [**2058**], Lumpectomy, TAH, Appendectomy Social History: Lives with Husband, History of Drug and ETOH abuse Family History: NC Physical Exam: PE: VS: 98.1, 136/64, 52, 20, 97% 3L Gen: Obese, drowsy, arrouses to voice. Oriented to person, place, year and situation. HEENT: EOMI, PERRL, Mild Rt sided facial droop although smile symmetric and edentulous CV: RRR no MRG Chest: CTA anteriorly Abd: soft, NT, large bowel with redundant fat, BS+ Ext: No c/c/e or rash . Physical exam on discharge had improved mental status with oxygen saturation >92% on RA. . Pertinent Results: [**2108-9-17**] 03:53PM GLUCOSE-73 UREA N-57* CREAT-6.3* SODIUM-138 POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-28 ANION GAP-18 [**2108-9-17**] 06:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2108-9-17**] 06:15PM TSH-2.8 [**2108-9-17**] 07:33PM WBC-13.3* RBC-3.51* HGB-11.7* HCT-36.0 MCV-103* MCH-33.4* MCHC-32.6 RDW-13.5 [**2108-9-17**] 07:33PM NEUTS-71.3* LYMPHS-16.3* MONOS-7.5 EOS-3.4 BASOS-1.5 [**2108-9-17**] 08:46PM PT-31.8* PTT-42.5* INR(PT)-3.4* [**2108-9-17**] 10:27PM TYPE-ART PO2-67* PCO2-65* PH-7.26* TOTAL CO2-31* BASE XS-0 . Brief Hospital Course: 71 y/o female with hx CVA, ESRD on HD, HTN, hypercholesterolemia, Bipolar d/o, ?DI from lithium, etoh and drug abuse, hypothyroidism, secondary hyperparathyroidism who was found by VNA [**9-17**] at home with decreased MS and O2sat 82%; w/u in MICU found to have hypercarbic resp failure, thought [**3-1**] opiate overdose on top of chronic CO2 retention. . Brief MICU course: Pt ABG remained hypercarbic with 0.2 mg naloxone, felt to be chronic CO2 retainer, given BiPap, and pt's MS improved, more alert, and received HD on [**2108-9-18**]. . On the floor, pt was A&Ox3 answering questions appropriately, no pain at rest, +pain in R hip with movement. Only major c/o is of sticking in her throat when she drinks liquids. reports some constipation. no cp/dyspnea/diarrhea. . Hypercarbic respiratory failure: [**3-1**] medication effect. Held all sedating medications; serum ETOH and Benzos neg, but Utox + for opiates and benzos. MRI/MRA negative for acute stroke. Recommended sleep study as outpt for probable OSA. . ?CVA: No acute stroke on MRI/MRA, but old stroke with vertebral stenosis evident. Continued warfarin per neuro recs for probable vertebro-embolic source of old stroke as seen on MRI/MRA; targeted INR [**3-2**]. Maintained appropriate oxygenation and blood pressure. . HTN: continued home meds . Hypothyroidism: TSH wnl, continued home dose of levoxyl . Bipolar d/o/psych: Continued Haldol, but held benzos. . FEN: S&S done - recommended soft solids, nectar-thickened liquids, lytes prn, euvolemic . Pt was discharged home with VNA services . Medications on Admission: -coumadin since her stroke 5/2.5 alternating -prilosec -vicodin -ativan -haldol 1mg TID -levoxyl 175mcg daily -neurontin dose not known -lipitor -inderal 80 -"renal" medications Discharge Medications: 1. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Propranolol 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 4. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed) as needed for rash. Disp:*qsx1 month * Refills:*0* 9. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 10. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hypercarbia Discharge Condition: stable, saturating well on room air, awake/alert Discharge Instructions: You were admitted to the hospital because you were very sleepy, and we think this was due to taking too much of your pain medication. Please follow the prescription instructions carefully, and do not take extra pain medication. . There is also a concern that you have sleep apnea, because the carbon dioxide level in your blood was somewhat high. You should talk to your primary care doctor about having a sleep study, to see if you have problems breathing when you fall asleep. . Please call your doctor or return to the emergency room if you experience fevers, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or any other concerns. Followup Instructions: Follow up with your primary care doctor in the next week. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2108-10-1**]

[ "244.9", "E854.3", "970.1", "588.81", "518.81", "327.23", "585.6", "110.5", "403.91", "272.0", "296.7" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5198, 5255

2295, 3859

394, 439

5311, 5362

1687, 2272

6073, 6292

1235, 1239

4087, 5175

5276, 5290

3885, 4064

5386, 6050

1254, 1668

336, 356

467, 894

916, 1150

1166, 1219

26,350

113,194

51364

Discharge summary

report

Admission Date: [**2134-6-12**] [**Month/Day/Year **] Date: [**2134-6-18**] Date of Birth: [**2051-7-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2134-6-12**] Placement of pigtail chest catheter History of Present Illness: 82 yo male s/p fall at home in garage on, no LOC able to recall whole event. He reports that he tripped and thinks he fell and hit his back, he did not hit his head. He went to see his PCP on following day and he was taking tylenol for the pain. He then presented to [**Hospital1 **] [**Location (un) 620**] two days following the fall because he had difficulty sleeping and complaints of left flank/back pain. He was evaluated there, found to have a negative head CT, left rib [**9-30**] fractures and hemothorax with INR 3.2 and was then transferred to [**Hospital1 18**] for further care. Past Medical History: Atrial fibrillation, s/p pacemaker placement, on coumadin Hypertension Prostate cancer status post XRT Benign prostatic hypertrophy Osteoarthritis h/o rectal bleeding in [**2128**] Mild dementia Depression Hypothyroidism Retinitis pigmentosa. Social History: Lives with wife, is a retired computer salesman, denies tobacco, alcohol, or IVDU. normal colonoscopy <10 y ago. Family History: Non-contributory. Physical Exam: Upon admission: Temp (F): 95.9 Heart Rate: 71 Blood Pressure: 142/71 Resp Rate: 15 O2 Sat(%): 99% Room Air/O2: 3L NC Pertinent Results: [**2134-6-12**] 10:39PM PT-18.0* INR(PT)-1.6* [**2134-6-12**] 08:09PM HCT-29.1* [**2134-6-12**] 08:09PM PT-20.9* PTT-31.8 INR(PT)-2.0* [**2134-6-12**] 12:15PM GLUCOSE-95 UREA N-24* CREAT-0.9 SODIUM-137 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-29 ANION GAP-9 [**2134-6-12**] 12:15PM WBC-6.7 RBC-3.60* HGB-11.8* HCT-34.6* MCV-96 MCH-32.8* MCHC-34.2 RDW-14.2 [**2134-6-12**] 12:15PM NEUTS-69.2 LYMPHS-25.0 MONOS-4.0 EOS-1.6 BASOS-0.2 [**2134-6-12**] 12:15PM PLT COUNT-130* Reason: reassess Field of view: 36 Final Report (Revised) CT CHEST [**2134-6-12**] FINDINGS: There is a pacemaker with leads in the right atrium and the right ventricle. The heart is enlarged. There is no pericardial effusion. The aorta and pulmonary arteries are normal in caliber. There are multiple small mediastinal lymph nodes that measure less than 1 cm in short axis and do not meet CT criteria for malignancy. The tracheobronchial tree is patent. There is a small left pleural effusion the measures up to 40 [**Doctor Last Name **] in density and is compatible with hemothorax. There is subsegmental atelectasis in the left lower lobe. Otherwise, the lungs are clear. The right pleural effusion that was seen in [**2130**] has resolved. There is no pneumothorax. BONE WINDOWS: The there is an acute nondisplaced fracture of the left 9th rib at midaxillary line. The rest of the fractures seen on an ouside CT are not included on this study. There are multilevel degenerative changes in the thoracic spine. No compression fracutres are identified. Limited images through the abdomen demonstrate a 3 cm cyst in the right kidney. IMPRESSION: 1. Small left hemothorax. No evidence of pneumothorax. 2. Non-displaced fracture of the left 9th rib. CXR [**2134-6-17**] FINDINGS: Portable upright chest radiograph is reviewed and compared to [**2134-6-17**] 8:23. Left pigtail catheter has been removed. There is no pneumothorax. There has been no significant interval change in appearance of the chest, with relatively low lung volumes, elevated hemidiaphragms, and slight apparent widening of the cardiac silhouette. IMPRESSION: No pneumothorax status post pigtail catheter removal. Brief Hospital Course: He was admitted to the Trauma service and transferred to the Trauma SICU for reversal of his INR, pain control and close monitoring. Thoracic surgery was consulted for placement of chest pigtail catheter because of the hemothorax. This remained in place for several days and was eventually removed. Follow up chest film showed no pneumothorax and persistent retrocardiac atelectasis with small bilateral pleural effusions. He was encouraged to use the incentive spirometer and to cough and deep breathe; he was able to do this with lots of encouragement and reinforcement. He was evaluated by Physical and Occupational therapy and they have recommended rehab after acute hospital stay. The screening process was initiated by case management and he was discharged to a rehab facility on [**2134-6-18**]. Medications on Admission: Detrol LA 4', Coumadin 4' (Wed 2), Amiodarone 200', Celexa 40', Synthroid 88', Namenda 10", Toprol 37.5', Exelin 6" [**Date Range **] Medications: 1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Rivastigmine 3 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-25**] hours as needed for pain. 11. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. [**Month/Day (3) **] Disposition: Extended Care Facility: [**Last Name (un) 1687**] - [**Location (un) 745**] [**Location (un) **] Diagnosis: s/p Fall Rib fractures left [**9-30**] Left hemothorax [**Month/Year (2) **] Condition: Good Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in Clinic in [**2-21**] weeks, call [**Telephone/Fax (1) 600**] for an appointment. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab. Completed by:[**2134-6-23**]

[ "362.74", "V10.46", "427.31", "401.9", "V58.61", "V45.81", "V45.01", "E885.9", "E849.0", "311", "294.8", "807.03", "715.90", "244.9", "860.2" ]

icd9cm

[ [ [] ] ]

[ "99.05", "34.04" ]

icd9pcs

[ [ [] ] ]

3841, 4647

335, 389

1631, 3818

5980, 6246

1429, 1448

4673, 5828

1463, 1465

5860, 5957

287, 297

417, 1015

1484, 1612

1037, 1281

1297, 1413

29,770

197,088

23867

Discharge summary

report

Admission Date: [**2176-4-16**] Discharge Date: [**2176-4-27**] Date of Birth: [**2099-5-18**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2176-4-19**] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to Diag1, SVG to Diag2 to OM, SVG to RCA) History of Present Illness: Mrs. [**Known lastname 60889**] is a 76 y/o female with known CAD s/p MI with unstable angina referred for outpatient. cardiac cath. Cath revealed severe three vessel coronary disease. She has been medically managed until now and is being evaluated for surgical intervention. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction [**2147**], Hypertension, Hyperlipidemia, Hypothyroid, Scleroderma, Uterine Cancer s/p Hysterectomy [**2145**], Ischemic Cardiomyopathy, s/p Parathyroid tumor removal Social History: Denies tobacco use. Admits to 2 alcoholic beverages/wk. Family History: Father died from MI at age 62 s/p 1 month from CABG. Physical Exam: VS: 60 SR 133/60 5'2" 75 kg Gen: Comfortable in NAD Skin: Unremarkable HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD Chest: decreased breath sounds 1/3 up bilaterally w/faint crackles Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused trace edema, -varicosities Incision: sternal clean/dry/intact, left lower extremity clean/dry/intact ecchymotic Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**4-16**] Cardiac Cath: 1. Coronary angiography of this right dominant system revealed three vessel coronary disease. The LMCA had no angiographically apparent CAD. The LAD had proximal calcification. There was a 70% stenosis in the mid vessel distal to the aneurysmal dilatation at the bifurcation of the D1. The D1 had serial 90,80 and 70% stenoses. The LCX had a long proximal and mid 60% stenosis into a large OM. The RCA had a [**Doctor Last Name **] crook deformity with moderate calcification. There was a 70% stenosis in the mid vessel and a proximal 50% stenosis as well. 2. Resting hemodynamics revealed normal systemic arterial pressure with an SBP of 119 mm Hg. 3. Left ventriculography was not performed. [**4-19**] Echo: PRE-BYPASS: The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No left ventricular aneurysm is seen. There is moderate regional left ventricular systolic dysfunction with hypokinesis notable in the LAD distribution. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-31**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known lastname 60889**] at 8AM on [**2176-4-19**]. POST_BYPASS: LVEF 45% on no inotropic support. Mild AI, Mild MR and Mild TR. Normal RV systolic function. Ascending aortic contour is intact. LAD terriotry WMA is the same. Brief Hospital Course: As mentioned in the HPI, Mrs. [**Known lastname 60889**] was admitted for cardiac cath which showed severe coronary disease. She was evaluated for bypass surgery and appropriately worked up. She remained medically managed for several days awaiting Plavix washout. On [**4-19**] she was brought to the operating room where she underwent a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She remained intubated until post-op day two when she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on IV Lasix and gently diuresed towards her pre-op weight. On post-op day two she had episodes of atrial fibrillation and she was started on Amiodarone. On post-op day three her chest tubes were removed. She remained in the CVICU until post-op day five when she was transferred to the telemetry floor for further care. On post-op day six her epicardial pacing wires were removed. She worked with physical therapy during her post-op course for strength and mobility. On post-op day eight she was discharged to home with the appropriate medications and follow-up appointments. Medications on Admission: Synthroid 0.05mg qd, Atenolol 100mg qd, Asirin 325mg qd, Diltiazem 240mg qd, Imdur 30mg qd, Celexa 40mg qd, MVI, Ferrous Sulfate qd, Plavix 600mg [**4-16**] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days: take with lasix. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 Post-operative Atrial Fibrillation PMH: Hypertension, Hyperlipidemia, Myocardial Infarction [**2147**], Hypothyroid, Scleroderma, Uterine Cancer s/p Hysterectomy [**2145**], Ischemic Cardiomyopathy, s/p Parathyroid tumor removal 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 for 10 weeks. No driving until follow up with surgeon. Followup Instructions: [**Hospital Ward Name 121**] 6 for wound check in 2 weeks Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) **] in [**3-3**] weeks Dr. [**Last Name (STitle) **] in [**1-31**] weeeks Completed by:[**2176-4-27**]

[ "997.1", "276.6", "244.9", "414.01", "710.1", "414.8", "E879.9", "285.9", "272.4", "V10.44", "412", "411.1", "401.9", "458.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.22", "99.04", "39.63", "36.15", "36.14", "39.61", "88.56" ]

icd9pcs

[ [ [] ] ]

5800, 5858

3311, 4563

288, 398

6191, 6197

1517, 3288

6510, 6742

1032, 1086

4770, 5777

5879, 6170

4589, 4747

6221, 6487

1101, 1498

238, 250

426, 703

725, 943

959, 1016

54,311

179,790

14000

Discharge summary

report

Admission Date: [**2122-8-31**] Discharge Date: [**2122-9-8**] Date of Birth: [**2058-2-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Respiratory failure following seizure Major Surgical or Invasive Procedure: Intubation, extubation Bronchoscopy with resection of lung mass Bronchoalveolar lavage History of Present Illness: 64 year old male with COPD, CAD s/p CABG, AICD, and unexplained spells of unresponsiveness (? hypoxia, vs arrythmia, vs seizure) who presented to [**Hospital 1562**] Hospital on the 16th with dyspnea. The patient apparently drove to [**Hospital1 1562**] himself and presented to the ED where he complained of shortness of breath. He became responsive shortly thereafter without dropping his sats and was intubated electively for airway protection. He then was noted to have a tonic-clonic seizure. He was admitted to the MICU with neurology following and cardiology. EEG was pending. He remained stable and today was bronched with the plan to help with pulmonary toilet prior to extubation. During this procedure patient found to have left lower lobe obstructing, friable mass. Therefore, after discussion with the IP service here the patient was transferred here for definitive management. Of note, prior to decision to tx patient for bronch the patient had been allowed to wake up and was communicating appropriately off sedation. At arrival the patient was intubated and sedated. ROS unobtainable. Bronchoscopy here revealed similar tumor in left lower bronchus. Past Medical History: -COPD on home O2 -HTN -HL -CAD s/p CABG -s/p ICD -? Seizure disorder (>1 yr work-up for intermittent unresponsiveness spells) -chronic shoulder/ back pain Social History: Stopped smoking [**11-15**] yrs ago. Independent for ADL's, widowed, otherwise unknown Family History: Non-contributory Physical Exam: VS: Temp:100.1 BP:86/43 HR:90 , 95% on 15/7 CPAP GEN: Obese, NAD, intubated HEENT: Sclerae anicteric. OP clear. RESP: Inspiratory and expiratory wheezing bilaterally, diminshed air movement CV: difficult to hear, but grossly RRR Abd: Obese, soft, NT, ND, BS+ EXT: 1+ [**Month/Day (2) **] edema w/ visible graft harvest scar SKIN: erythema and induration over skins of hands w/ multiple blood blisters noted NEURO: Intubated, sedated, moving all extremities, intermittently waking up and responding to voice . On discharge: VS: 98.6 104/81-121/78 57-67 24 92% 4L GEN: Obese, NAD, AOx3, comfortable HEENT: Sclerae anicteric, MMM RESP: Diminished air movement bilaterally, coarse breath sounds, no rales, faint end-expiratory wheezing CV: distant heart sounds, grossly RRR, S1/S2 Abd: Obese, soft, NT, ND, BS+ EXT: 1+ [**Month/Day (2) **] edema, no LE edema, visible graft harvest scar, erythema on dorsum of shins, non-tender SKIN: erythema and induration over skins of hands w/ multiple blood blisters NEURO: alert and oriented x 3, 5/5 strength in UE and LE b/l, no sensory deficits Pertinent Results: Initial Labs: [**2122-8-31**] 08:52PM WBC-14.4* RBC-3.45* HGB-11.6* HCT-33.7* MCV-98 MCH-33.6* MCHC-34.4 RDW-13.7 [**2122-8-31**] 08:52PM NEUTS-83* BANDS-9* LYMPHS-2* MONOS-5 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-8-31**] 08:52PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL STIPPLED-OCCASIONAL [**2122-8-31**] 08:52PM PLT COUNT-182 [**2122-8-31**] 08:52PM PT-14.7* PTT-36.1* INR(PT)-1.3* [**2122-8-31**] 08:52PM GLUCOSE-80 UREA N-13 CREAT-1.0 SODIUM-134 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-11 [**2122-8-31**] 08:52PM ALT(SGPT)-15 AST(SGOT)-22 LD(LDH)-239 CK(CPK)-171 ALK PHOS-72 TOT BILI-0.6 [**2122-8-31**] 08:52PM CK-MB-3 cTropnT-0.09* [**2122-8-31**] 08:52PM CALCIUM-8.3* PHOSPHATE-2.9 MAGNESIUM-2.0 [**2122-8-31**] 08:52PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2122-8-31**] 08:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [**2122-8-31**] 08:52PM URINE RBC-[**4-23**]* WBC-[**4-23**]* BACTERIA-FEW YEAST-NONE EPI-0 [**2122-8-31**] 08:52PM URINE GRANULAR-0-2 CELL-0-2 Imaging: [**2122-9-1**]: Echo Poor image quality. The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. 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 probably mildly depressed (LVEF= 45 %). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. . . CXR [**9-6**]: As compared to the previous radiograph, the image is again technically limited. Moderate cardiomegaly, no signs of overt pulmonary edema. Unchanged retrocardiac and right basal atelectasis. The presence of small-to-moderate pleural effusions cannot be excluded. Unchanged moderate cardiomegaly. Unchanged left pectoral pacemaker. . [**Name (NI) **] sono - [**Name2 (NI) **] evidence of DVT. . Brief Hospital Course: 64 year old male w/ severe COPD, seizure disorder?, CAD, presenting with respiratory distress and with unresponsive spell then found to have new left lower carina mass. . 1) Hypoxic respiratory failure: The patient was initially intubated for airway protection in the setting of apnea due to a likely neurological event. Nevertheless, upon his arrival he required significant respiratory support with high FiO2's and pressures. Given patient had a fever early in the day was initially treated for presumed pneumonia with cefepime/vancomycin and given bronchodilators for COPD. He also required a signficant amount of IVF on the night of admission due to hypotension so then developed an exacerbation of his chronic systolic CHF. He was diuresed successfully with doses of IV furosemide and extubated on [**2122-9-4**]. Following some respiratory distress on the night of [**9-4**] he was restarted on oral prednisone with plan for a five day burst. At time of transfer from unit on [**9-6**] he was satting well on 3L O2 by nasal cannula. On the floor, pt was weaned down to 3L O2 with goal O2 sats 88-92% given underlying COPD. Pt was breathing with minimal laboring, on exam had crackles and wheezing, crackles resolved after lasix challenge. Respiratory came to assess pt for CPAP but pt refused this. Pt's respiratory status was combination of obstruction by mass, post-obstructive PNA, COPD exacerbation with slight element of CHF. He completed 7-day course of vanco, will copmlete 7-day course of levofloxacin (last day [**9-11**]) and 5-day course of prednisone (last day [**9-9**]). Nebulizer treatments, inhaled steroids, and inhaled albuterol should be continued at rehab. . 2) Acute on Chronic Systolic CHF: Patient known to have depressed EF but received multiple fluid boluses on night of presentation in the setting of hypotension. He then developed chest radiograph findings consistent with volume overload and presumed exacerbation of his chronic systolic CHF. He diuresed well with 60 mg doses of IV furosemide and was eventually negative for length of stay. Echo showed improved EF from previous reports (EF of 45%) with no obvious wall motion abnormalities. Pt was hypervolemic on exam with rales and lower ext edema, given lasix daily (from 80mg IV to 160mg PO) with net negative output of 1L/day. Pt's exam prior to discharge was euvolemic and lasix was put back to home dose of 30mg [**Hospital1 **]. All other home medications were continued. . 3) Post-obstructive Pneumonia: The patient had a CT scan of his chest on [**2122-8-29**] at presentation to the outside hospital which revealed no infiltrate. On the day of transfer, however, he had a fever and given no other likely source and abnormal chest radiograph he was started on cefepime/ vancomycin for possible health care associated pneumonia. Given initially negative BAL results without gram positive organisms and then just with streptococcus pneumonia he was narrowed to simply levofloxacin on [**9-4**]. On [**9-5**], however, due to concern for a worsening appearance to his lower extremity and cellulitis his vancomycin was restarted and then cultures revealed MRSA growing on a BAL specimen from the lung as well as strep pneumoniae and Haemophilus influenza. He was continued on vancomycin and levofloxacin for total of 7-day course of each. . 4) Intrabronchial Mass: Patient was found to have a very vascular appearing mass on a bronchoscopy on day of transfer in his left lower lobe. On the day following transfer [**2122-9-1**] he had resection of the mass with a rigid bronchoscope and imaging revealed a chondroid hamartoma. . #) Acute renal insufficiency - Cr rose up to 1.5 from baseline 0.8-1. Likely pre-renal from poor forward flow due to third spacing vs hypovolemia. Lasix challenge was given and net output 1L obtained, but Cr continued to remain elevated. Prior to discharge, returned to home dose lasix 30mg [**Hospital1 **], should have Cr rechecked at rehab. Compression stockings given, ambulation encouraged. Cr will likely begin to improve with continued gentle diuresis and adequate PO intake once fluid remobilizes intravascularly. No evidence of intrinsic or post-renal etiology. . 5) Unresponsiveness/ Seizure: Patient has a history of nonresponsive spells status post extensive work up. His initial presentation was marked by a similar spell followed by a tonic-clonic seizure. EEG at the OSH showed no epileptiform focus but overall presentation consistent with underlying seizure disorder. He was phenytoin loaded at the outside hospital and this was continued on presentation here. Levels inpatient were 13-17 and he was discharged on 200mg q8hr, should have levels checked at rehab. He should follow up with a neurologist after discharge. . 6)Hypertension: Within a few days of admission patient had become hypertensive, which is his baseline. Eventually he was restarted on his home blood pressure regimen with lisinopril and metoprolol. Nifedipine continued to be held. . 7) Hyperlipidemia: He was continued on his home statin. . 8) CAD s/p CABG: The patient had an elevated troponin at presentation but signs/ symptoms not consistent with ACS and likely due to element of heart failure. Cycled enzymes were stable. Not consistent with ACS. He was restarted on his home BB and aspirin. Medications on Admission: Home Medications: -Oxycodone 5 mg Q6hrs PRN -Theophylline SR 400 mg PO BID -Furosemide 30 mg PO BID -Metolazone 5 mg Q MF -Nifedipine SR 60 mg daily -Fluticasone/Salmeterol 500/50- 1 puff [**Hospital1 **] -Metoprolol 75 mg PO QAM and 50 mg PO QHS -Atorva 20 mg daily -Amiodarone 200 mg daily -Lisinopril 20 mg daily -Tiotroprium daily -Xoponex 2 puff Q4 hrs PRN Transfer Medications: Furosemide Lisinopril Metoprolol Enoxaparin ASA Lorazpeam Amiodarone Phenytoin Duoneb Fentanyl Cefepime Vanc Oxycodone Pantoprazole Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 6. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] PRN () as needed for lower extrem rash. 7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Lasix 20 mg Tablet Sig: 1.5 Tablets PO twice a day. 9. ipratropium bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days: last day [**9-11**]. 11. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 5 days: 5 days total, last day on [**9-9**]. 12. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 14. phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg PO Q8H (every 8 hours): please have your levels checked daily, goal [**9-2**]. 15. furosemide 20 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Chondroid hamartoma in lung COPD exacerbation CHF exacerbation Post-obstructive pneumonia . Secondary: seizure disorder CAD s/p CABG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [**Hospital1 18**] with respiratory distress, you were found to have a mass in your left lung which was a benign tumor called a chondroid hamartoma. Because this mass was obstructing a part of the lung, you developed a small infection behind the obstruction which was treated with antibiotics. You have underlying COPD and heart failure, both of which were controlled with steroids, inhalers, nebulizers, and water pills. Your breathing improved throughout the admission and you were able to go down to needing about 3L of oxygen (you use 2L at home). Your kidney function worsened a little bit, which is likely due to poor intake causing dehydration and extra fluid in your body from heart failure. You should work on becoming more active at the rehab facility and to build your strength up. Because there was concern that your unresponsive episode was due to a seizure, you were started on an anti-seizure medication called Phenytoin. You should follow up with a neurologist after you leave rehab to address this. . We have made the following changes to your medications: Continue levoquin 750mg once a day until [**9-11**] Continue prednisone 40mg once a day until [**9-9**] Take Dilantin 200mg every 8 hrs to prevent seizures, have your levels checked daily at rehab Continue your home dose of lasix at 30mg twice a day Take miralax daily to help prevent constipation . Please have your creatinine checked at rehab to ensure it is decreasing and have your Phenytoin level checked (goal [**9-2**]) Followup Instructions: Please follow up at rehab. Call your PCP for an appointment within 2 weeks after discharge. . Call the [**Hospital1 18**] neurology office at [**Telephone/Fax (1) 3294**] to schedule an appointment to follow up about your possible seizures. Completed by:[**2122-9-9**]

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icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "96.71", "32.01", "33.22" ]

icd9pcs

[ [ [] ] ]

12774, 12846

5504, 10834

351, 440

13032, 13032

3072, 5481

14732, 15003

1935, 1953

11402, 12751

12867, 13011

10860, 10860

13183, 14252

1968, 2477

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2491, 3053

14281, 14709

274, 313

11245, 11379

468, 1636

13047, 13159

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1831, 1919

18,186

191,330

18426

Discharge summary

report

Admission Date: [**2205-8-26**] Discharge Date: [**2205-8-28**] Date of Birth: [**2140-11-21**] Sex: F Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 2704**] Chief Complaint: Scheduled Carotid Artery Stent Placement Major Surgical or Invasive Procedure: Left Carotid Artery Stent Placement History of Present Illness: The patient is a 64yo woman with a past medical history notable for CAD s/p RCA stent [**2200**], with occluded R-ICA and 80% narrowing of L-ICA, admitted for monitoring post L-carotid artery stenting. . The patient underwent angiography in [**2204-1-2**] which showed L-ICA stenosis 40-50% 1/[**2204**]. Carotid u/s at [**Hospital1 **]-[**Location (un) **] on [**2204-02-29**] showed [**Doctor First Name 3098**] pk velocities of 391/83cm/s and a ratio of 5. In [**2204-9-1**], these velocities were noted to be 231/75 cm/sec, ratio 2.5. On [**7-4**] of this year, CTA neck chronically occluded R-ICA at origin, L-ICA 80% narrowing. At that time, she was referred for L-carotid angioplasty and stenting. The patient was evaluated by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] from neurology 10am prior to procedure. She successfully underwent stenting in PM of [**2205-8-26**], with a Protege stent placed without difficulty. transferred to CCU. On arrival, the patient was noted to have a BP 109/60, HR 60, RR14, 98% ra. She was alert and oriented x 3, with no complaints. . On ROS, the patient denied CP, SOB, motor or sensory changes, amaurosis fugax. The patient endorced L-calf cramping w/walking 10 mins and L-thigh discomfort at night. Past Medical History: 1. CAD s/p MI, [**2200**] RCA cypher stenting 2. Hypertension 3. Hyperlipidemia 4. Lower extremity claudication/PVD 5. PVD - s/p atherectomy L distal common fem artery and profunda fem artery [**10-8**], R SFA stenting [**4-9**] 6. PUD - [**2202**] - bleeding ulcer reportedly found by endoscopy 7. abdominal aortic aneurysm - 3.8cm 8. sleep apnea - cannot tolerate CPAP 9. tobacco use Social History: Married with 3 adult children, retired, prior to retiring she worked for an oil company. Husband [**Name (NI) 401**] [**Name (NI) **]. +tobacco use, smoked 1ppd for 40+ years. Denies etoh or recreational drugs. Family History: see results Physical Exam: PE: VS: T 98, BP 109/60, HR 60, RR 14, 98%ra Gen: middle aged female, NAD, a/o x3, mood, affect appropriate. HEENT: sclera anicteric, PERRL, EOMI. No pallor or cyanosis of the oral mucosa. Supple with JVP of cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. R femoral site dry and intact, small sq swelling, but no identified hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2205-8-26**] 09:17PM GLUCOSE-110* UREA N-12 CREAT-0.8 SODIUM-134 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-24 ANION GAP-11 [**2205-8-26**] 09:17PM estGFR-Using this [**2205-8-26**] 09:17PM CK(CPK)-34 [**2205-8-26**] 09:17PM CK-MB-NotDone [**2205-8-26**] 09:17PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-1.8 Brief Hospital Course: The patient is a 64 year old woman with a history of CAD s/p RCA stent [**2200**], hypertension, hyperlipidemia, with occluded R-ICA and 80% narrowing of L-ICA, now s/p L-carotid artery stenting, transferred to CCU for monitoring. . # CAD/PVD/ischemia - The patient presented post stenting of L-ICA as above. She denied any discomfort post procedure. Initially, systolic blood pressures were >100 when the patient was lying flat, but dropped precipitously to the 60's with a heart rate in the 40's with head elevation. The patient was given fluid boluses and Neo-Synephrine to increase pressures and over the course of 24 hours, the patient was weaned from the Neo-Synephrine. While the patient mostly denied any symptoms from her low blood pressure, she at one point reported transient blurry vision while in the upright position. Systolic blood pressure at that time were again in the 60's. The patient's symptoms resolved with a change in position and the remainder of her neurological exam was intact. The morning of discharge, the patient was ambulating without assistance and was able to maintain blood pressures >100 without pressure support. She was encouraged to ambulate and was discharged with instructions to call her doctor if she noticed any symptoms of hypoperfusion. She was instructed to discontinue her home beta blocker and was scheduled for post procedure follow-up with Dr. [**First Name (STitle) **]. Medications on Admission: 1. toprol XL 25mg qam 2. plavix 75mg daily qam 3. crestor 10mg qpm 4. tricor 145mg qam 5. zetia 10mg qam 6. protonix 40mg qd 7. nitroglycerin 0.3mg SL prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO qam (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: Left Carotid Artery Occlusion Discharge Condition: Stable. BP: 101/40 HR: 50 Discharge Instructions: You were admitted for the placement of a carotid artery stent. After the procedure, you required observation for low blood pressures. We have stopped your normal home blood pressure medication (metoprolol) because of your low blood pressure. . You can restart this medication after discussion with Dr. [**First Name (STitle) **]. We have scheduled you for a follow-up appointment this Friday at 9am. Please attend this appointment as scheduled, or call ahead if you cannot attend. . Except for the metoprolol, you should continue to take all of your previously prescribed medications. . Please call your doctor or seek medical attention if you develop any blurry vision, feelings of weekness or loss of muscle strength, difficulty speaking, feelings of confusion or any other symptoms of concern. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2205-8-30**] 9:00 . Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2206-1-14**] 2:00 Completed by:[**2205-8-28**]

[ "272.4", "327.23", "V45.82", "414.01", "401.9", "440.21", "433.10", "305.1", "441.4", "458.29" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.63", "00.45", "00.61", "88.41" ]

icd9pcs

[ [ [] ] ]

5689, 5695

3500, 4929

310, 347

5769, 5797

3167, 3477

6645, 6934

2301, 2314

5134, 5666

5716, 5748

4955, 5111

5821, 6622

2329, 3148

230, 272

375, 1647

1669, 2057

2073, 2285

81,763

153,679

35745

Discharge summary

report

Admission Date: [**2131-2-6**] Discharge Date: [**2131-4-5**] Date of Birth: [**2078-9-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Confusion, falls Major Surgical or Invasive Procedure: Lumbar Puncture Portal Vein Thrombolysis Blood Transfusion Endoscopy Placement of a Feeding Tube Liver [**First Name3 (LF) **] replaced post pyloric feeding tube c.diff + History of Present Illness: 52 y/o M with h/o of Hep C and alcoholic cirrhosis, complicated by ascites, encephalopathy, and thrombocytopenia, and chronic low back pain p/w confusion and multiple falls. Patient was admitted [**2036-1-17**] for hepatic encephalopathy, presumed to be caused by med non-compliance, and discharged with rifaximin 400 mg TID in addition to his lactulose. On [**2130-11-22**] he was admitted for hyponatremia [**1-9**] cirrhosis. Patient, who uses a cane, fell at least twice yesterday when going to the bathroom, as witnessed by girlfriend. [**Name (NI) **] struck his head but had no LOC. Patient then presented to [**Hospital **] Med Center ED, called Dr.[**Name (NI) 948**] service, and was told to come to the [**Hospital1 **]. Patient has been increasingly unsteady on his feet and, even in his confused state, realizes that he's not doing well and is much more confused than usual. He states that he had run out of some med but was unable to state which one. Endorses mild diffuse abdominal pain, but denies feeling malaise or fatigue, just confusion and imbalance. Has a mild, dry cough of unknown duration. Denies sick contacts, increased eating of meat, or blood in his stool. . In the ED, initial vs were: T 97.7 P 52 BP 116/60 R O2 98%. . On the floor, 98.9, 109/52, 76, 16, 99% on 2L Past Medical History: Hepatitis C (genotype 2, never treated) + alcoholic Cirrhosis - c/b hyponatremia, treated with tolvaptan, ascites, encephalopathy, and thrombocytopenia (56 on [**2131-2-6**]). - grade 1 esophageal varices - heterozygote for hemochromatosis (H63D) - on [**Date Range **] list Back surgery in [**2108**] Chronic Low Back Pain Vit D deficiency Restless leg syndrome Social History: He is a smoker and has decreased the amount of cigarettes he is smoking from 3 packs per day, down to about 7 cigarettes a day. He has had no alcohol since [**2129-12-8**]. Family History: Mother is still alive. Father died five years ago of complications related to CVA. Sister has hyperthyroidism. Physical Exam: Vitals: lying down T: 98.9 BP: 108/65 P: 72 R: 18 O2: 99% on 2L sitting up BP: 95/60 P: 78 General: jaundiced, tangential, awake but not alert, ox2 (needs prompts for date) HEENT: Sclera icteric, MMM, no teeth Neck: supple, JVP not elevated, no LAD Chest: Clear to auscultation bilaterally, no wheezes, rales, ronchi, no gynecomastia CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur Abdomen: yellow hue, soft, non-distended, slightly tender in all four quadrants, bowel sounds present, no rebound tenderness, ?palpable spleen GU: no foley Ext: 2+ edema in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], no palmar erythema, no dupytron's contracture Pertinent Results: [**2131-4-5**] 05:35AM BLOOD WBC-3.4* RBC-2.90* Hgb-9.6* Hct-27.9* MCV-96 MCH-33.2* MCHC-34.6 RDW-18.9* Plt Ct-190 [**2131-3-21**] 05:45AM BLOOD PT-11.6 PTT-28.0 INR(PT)-1.0 [**2131-4-5**] 05:35AM BLOOD Glucose-110* UreaN-29* Creat-1.4* Na-137 K-5.0 Cl-103 HCO3-28 AnGap-11 [**2131-4-5**] 05:35AM BLOOD ALT-27 AST-17 AlkPhos-80 TotBili-0.5 [**2131-4-5**] 05:35AM BLOOD Calcium-8.7 Phos-4.9* Mg-1.5* [**2131-2-13**] 06:30AM BLOOD TSH-1.8 [**2131-2-23**] 05:50AM BLOOD Free T4-1.1 [**2131-2-13**] 06:30AM BLOOD T4-3.8* [**2131-4-5**] 05:35AM BLOOD tacroFK-10.4 Brief Hospital Course: Mr. [**Known lastname **] is a 52 year old man with a history of hepatitis C and alcoholic cirrhosis complicated by hepatic encephalopathy, ascites, and hyponatremia. He was hospitalized on the medical service with persistent confusion. On admission he was not able to speak a full sentence. An initial infectious workup of blood and urine cultures along with head CT were all negative. He had an abdominal ultrasound which showed flow in the portal vein. He was treated for presumed hepatic encephalopathy with lactulose (q 2 hour), rifaximin, and a vegetarian diet. All of his medications that could be contributing to altered mental status were discontinued. He failed to show significant improvement. He had an MRI of the brain which failed to show any acute changes. An abdominal CT was obtained which showed a non-occlusive portal vein thrombus. He was started on a heparin gtt with the goal pTT was 55-70. An LP was performed looking for any infectious causes of altered mental status. This was also negative. A metabolic workup of thyroid function, B12, folate, and RPR among others was essentially negative. He was hyponatremic upon admission. Tolvaptan was continued for hyponatremia. Sodium gradually rose after diuretics were stopped. Tolvaptan was discontinued. A small amount of half normal saline was administered for a couple of days. This was discontinued and sodium remained within the normal range. An infectious workup was repeated. It was significant for a urine culture with 6000 organisms/mL of enterococcus. This was treated with a one week coures of ampicillin. Neurology was consulted. An EEG showed diffuse slowing consistent with hepatic encephalopathy. On admission he was guaiac positive. His hematocrit decreased from admission. However, after heparin was initiated, it decreased more rapidly. His mental status appeared to worsen. There was concern that a slow GI blood loss may be worsening his encephalopathy. Therefore, his heparin gtt was stopped. An EGD was performed which showed portal hypertensive gastropathy and grade I varices. An additional abdominal ultrasound was performed to re-examine the thrombus in the portal vein. This ultrasound showed that there was a progression of the thrombus. It fully occluded the portal vein. He underwent a portal vein thrombolysis (percutaneous approach with TPA). A balloon dilation of a stricture in the portal vein was also performed. Following the procedure there was no significant change in his mental status. Following the portal vein thrombolysis, his creatinine again began to rise, exponentially over a few days. This was likely due to contrast, but hepatorenal syndrome was amongst the differential diagnoses. A bridled Dobhoff was placed to initiate tube feeds. Less than 12 hours following the placement of this Mr [**Known lastname **] partially pulled out the Dobhoff. He had a nose bleed which resolved with compression. The stitches were removed and the Dobhoff was taken out after the incident. ENT saw the patient and felt that basic monitoring and precautions were suitable, with no intervention recommended; they recommended follow-up in 3 weeks in the outpatient setting. Patient was then transferred from the medicine to the surgical team for liver [**Known lastname **] on [**2131-3-10**]. He was taken to the OR by Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] for Orthotopic deceased donor (brain dead)liver [**Last Name (NamePattern4) **], piggyback, portal vein-to-portal vein anastomosis, common bile duct-to-common bile duct, no T-tube, donor superior mesenteric artery (with replaced left hepatic artery and replaced right hepatic artery) to proper hepatic artery (recipient). A right femoral dialysis catheter was placed. Postop, he was transferred to the SICU for management where he remained intubated for many days. Liver function improved as well as renal function. He was extubated, but remained very sedated and appeared to be encephalopathic with agitation. A clonidine patch was used for agitation. Head CT and MRI were unremarkable. Neurology was consulted. CVVHD was required postop through postop day 6. Once CVVHD was stopped, creatinine gradually trended down and urine output increased to 1.5 liters per day with creatinine dropping to 1.2-1.4. Tube feedings continued, but he experienced diarrhea. Stool was sent for C.diff and was found to be positive. Flagyl was started on [**3-19**] and continued until [**3-31**]. Repeat stool specimens after Flagyl cessation were negative. Liver function was excellent and liver duplexes done immediately postop and on postop day 13 were normal. Portal vein was patent. Two JP drains were placed at time of OR. Outputs from drains were non-bilious. Drains were removed on postop day 6 and 17. Incision remained intact without signs of infection. He was transferred out of the SICU to the med-[**Doctor First Name **] unit on [**3-20**] where he continued to receive maximum assist from nursing, PT and nutrition. Mental status improved very slowly each day. He became more verbal and oriented to person, place and time. He becomes easily fatigued, but re-orients. A bedside swallow eval was conducted clearing him for diet advancement. Gradually dietary intake increased allowing for cycled tube feeds. A repeat swallow eval conducted on [**4-2**]. Per report, "patient was observed with thin liquids (straw, consecutive) and apackage of crackers. Mastication was mildly prolonged, but was functional with only a trace to mild coating of residue that was cleared with sips of liquid. He was without overt coughing, throat clearing or changes in vocal quality and denied the sensation of aspiration or residue." Recommendations were to advance to thin liquids and soft, moist solids ensuring that his dentures were in place for all PO intake with 1:1 supervision. Physical therapy worked with him intially hoyering him out of bed. Strength/endurance improved to the point where he was ambulating with assist of 2 with a walker. Rehab was recommended. Immunosuppression consisted of steroids which were tapered per protocol. Cellcept 1 gram [**Hospital1 **] was well tolerated. Prograf was started on postop 1 and adjusted daily per trough levels. Goal level was 10. Dose was adjusted to 2mg [**Hospital1 **]. A bed at [**Hospital3 **] in [**Hospital1 8**] became available on [**4-5**] and he was transferred there. Labs will be drawn every Monday and Thursday with results fax'd to [**Hospital1 1388**] [**Hospital1 **] office for monitoring and adjustments per the [**Hospital1 1326**] Team. Medications on Admission: Clotrimazole 10 mg Troche 5 lozenges/day Folic Acid 1 mg Tablet PO QD Furosemide 40 mg Tablet, 3 Tablet(s) by mouth daily 2 tabs in the morning 1 tab at noon time Lactulose 10 g/15 mL Solution, 30 ml [**Hospital1 **] Midodrine 5 mg Tablet, 2 Tablet(s) PO TID Pramipexole [Mirapex] 0.125 mg PO HS Rifaximin 400 mg Tablet PO TID Spironolactone 200 mg PO QD Tolvaptan 30 mg Tablet, 2 Tablet(s) PO QD [**2130-12-13**] Tramadol 50 mg Tablet PO Q4h PRN pain * OTCs * Calcium Carbonate-Vitamin D3 600 mg-400 unit PO QD Cyanocobalamin 1,000 mcg Tablet Sustained Release 0.5 (One half) Tablet(s) PO QD Docusate Sodium 100 mg PO BID Ferrous Sulfate 325 mg PO QD Magnesium Oxide 400 mg PO BID Multivitamin Tablet PO QD Thiamine HCl 100 mg PO QD Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Sulfamethoxazole-Trimethoprim 200-40 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 3. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: Five (5) ml PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 7. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO once a day: started [**3-30**]. continue thru [**4-8**] then decrease to 15mg [**4-9**] thru [**4-18**]. Decrease to 12.5mg on [**4-19**]. 8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 9. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting 10. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous twice a day. 12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous once a day. 14. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous 6pm. 15. Insulin Regular Human 100 unit/mL Solution Sig: follow printed sliding scale Injection four times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Hepatic encephalopathy Alcoholic and Hepatits C Cirrhosis Acute Renal Failure Portal Vein Thrombus Bacteremia malnutrition Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Max assist of 2 to ambulate fall risk Discharge Instructions: You will be transferred to [**Hospital3 **] in [**Hospital1 8**] Please call the [**Hospital1 18**] [**Hospital1 1326**] Office [**Telephone/Fax (1) 673**] if you have any of the warning signs listed below. You will have labs drawn every Monday and Thursday with results sent to the [**Telephone/Fax (1) 1326**] Office for review Tube feedings will continue Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2131-4-11**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2131-4-11**] 2:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2131-4-5**]

[ "303.93", "537.89", "456.21", "276.1", "572.4", "276.7", "287.5", "452", "789.59", "572.3", "V15.81", "070.71", "333.94", "305.1", "275.3", "263.9", "008.45", "782.3", "571.2", "584.9", "459.2", "286.9", "790.7", "268.9", "724.2", "599.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "03.31", "99.10", "39.79", "96.71", "00.40", "96.04", "38.95", "00.93", "96.07", "96.6", "88.64", "99.05", "39.95", "99.07", "39.50", "45.13", "50.59" ]

icd9pcs

[ [ [] ] ]

12695, 12766

3841, 10469

328, 501

12952, 12952

3258, 3818

13551, 14004

2425, 2537

11254, 12672

12787, 12787

10495, 11231

13168, 13528

2552, 3239

272, 290

529, 1828

12806, 12931

12967, 13144

1850, 2218

2234, 2409

14,990

199,589

25083

Discharge summary

report

Admission Date: [**2146-9-28**] Discharge Date: [**2146-10-15**] Date of Birth: [**2086-2-5**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 1491**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: TIPS procedure. [**Last Name (un) **] tube. History of Present Illness: 60y/o F with alcoholic cirrhosis presented on [**2146-9-9**] with hematemesis and melena x1 day. Pt underwent EGD at that time, where varices were cauterized. Pt was discharged on [**9-20**]. She came back for followup EGD on [**9-26**] to assess for possible sclerotherapy. She was found to have grade [**4-1**] varices, more numerous than a few years prior. No active bleeding, bright red blood noted in stomach. No intervention performed at that time. Pt then rec'd 1.5L paracentesis as outpatient on [**9-27**]. . Afterwards, at home, she developed nausea and had another episode of hematemesis, which she describes as clumpy and dark red. Felt lightheaded, but no chest pressure or SOB. + dark stools. No other episodes of hematemesis. Pt was admitted to OSH, and she was started on octreotide and transfused with 3 units PRBCs - Hct from [**9-27**] was 20. Last Hct prior to transfer was 24. She was then transferred to [**Hospital1 18**] for evaluation for TIPS. . Here, pt denies chest pain/pressure, SOB, or dizziness. Feels thirsty. No further episodes of hematemesis. Still with + dark, watery BMs, but no BRBPR. Pt had 6 BM yesterday, none thus far today. Past Medical History: 1. alcoholic cirrhosis 2. h/o variceal bleed 3. Type 2 DM 4. GERD 5. h/o carpal tunnel surgery Social History: Lives with youngest son, daughter-in-law, and grandson. [**Name (NI) **] tobacco, no IVDU. H/o EtOH x10 years - 1 bottle hard liquor per week, quit 7 years ago. Works as a home health aide. Family History: no liver disease no GI bleeding Physical Exam: VS: 96.8 93/24 64 15 100% RA I/O: 400/650 Gen: somewhat pale-appearing, obese, NAD Neuro: no asterixis, A&O x3, appropriate HEENT: PERRL, EOMI, MM dry, OP clear Neck: no cervical LAD, flat neck veins CV: RRR, nl S1/S2, no murmurs appreciated Pulm: CTAB, good air movement Abd: soft, distended, nontender, liver edge not palpable, no masses Ext: [**1-30**]+ pretibial edema, somewhat cool, 2+ DP pulses Skin: no rashes, no caput medusae, no spider angiomata visualized Pertinent Results: OSH: WBC 7.4, Hct 24, plt 94 Na 135, K 4.2, Cl 101, HCO3 27, BUN 32, Cr 0.9, glc 116, Ca 7.7, alb 2.0 t bili 2.8, direct 0.4, AST 45, ALT 33, LDH 479, alk phose 103, PT 33.5 INR 1.46 CK < 20, trop < 0.038 Admission labs: CBC: WBC-2.7* RBC-3.13* HGB-10.1* HCT-30.1* MCV-96 MCH-32.4* MCHC-33.8 RDW-18.3* NEUTS-62.7 BANDS-0 LYMPHS-26.9 MONOS-8.5 EOS-1.6 BASOS-0.3 PLT COUNT-44* electrolytes: GLUCOSE-128* UREA N-24* CREAT-1.0 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12 ALBUMIN-2.3* CALCIUM-8.0* PHOSPHATE-2.8 MAGNESIUM-1.5* LFTs: ALT(SGPT)-21 AST(SGOT)-65* LD(LDH)-173 CK(CPK)-31 ALK PHOS-89 TOT BILI-5.4* LACTATE-2.2* coags: PT-15.0* PTT-34.0 INR(PT)-1.5 enzymes: CK 31 CK-MB-NotDone cTropnT-<0.01 EKG: NSR 61bpm, nl intervals, nl axis, early R wave progression, no ST/T wave changes suggestive of ischemia ....... Floor: [**2146-10-15**] 06:10AM BLOOD WBC-7.6 RBC-3.02* Hgb-9.9* Hct-30.3* MCV-100* MCH-32.7* MCHC-32.7 RDW-21.3* Plt Ct-37* [**2146-10-15**] 06:10AM BLOOD Plt Ct-37* [**2146-10-15**] 06:10AM BLOOD Glucose-182* UreaN-23* Creat-0.5 Na-144 K-4.1 Cl-102 HCO3-37* AnGap-9 [**2146-10-14**] 12:39PM BLOOD ALT-26 AST-41* AlkPhos-137* TotBili-4.8* [**2146-10-15**] 06:10AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0 Brief Hospital Course: Patient is 60 y/o F with alcoholic cirrhosis s/p variceal hemorrhage who presents for evaluation for TIPS. 1. Upper GI bleed - Initially patient did not appear to be actively bleeding, with no hematemesis. Plan was to have EGD in ICU and then transfer to floor. EGD performed and Grade III varices were noted starting at 24 cm from GE junction and extending to GE junction. An active variceal bleed was found which was banded x 1 and 3 other varices were banded in the process. Approximately one hour s/p EGD and banding, patient developed large volume hemetemesis requiring intubation for airway protection and placement of [**Last Name (un) **] to tamponade bleeding. The following day patient went for successful TIPS procedure in IR (only time patient was exposed to heparin). Bleeding slowed and [**Last Name (un) 10045**] left in place with gastric balloon inflated for ~2 days. Once the risk of rebleed was low, the [**Last Name (un) 10045**] was removed. No further episodes of hemetemesis. Continued melena. Hct was checked frequently and patient initially transfused for <30, but once no active bleed, was transfused <25. Octreotide gtt was started on admission and continued until [**Last Name (un) 10045**] tube was removed. Levofloxacin given for 6 days for GI prophylaxis against sepsis but was stopped on [**10-4**] d/t worry that it was contributing to thrombocytopenia. Patient's BetaBlocker held initially but added propranolol then nadolol when BP stabilized. Pt transferred to the floor, did well. She was generally weak, though without focal findings. She tolerated NG tube feedings though could not take adequate PO due to sore throat and large caliber NG tube she reported. The NG was d/c'd. She did not take adequate PO after that, and a Dobhoff feeding tube was placed post pyloric by fluoro. She restarted her tube feeds and was transferred to acute rehab with follow up. The pt was maintained on rifamixin and lactulose during her hospital course and afterwards. . 2. Respiratory failure - Initially intubated for airway protection and placement of [**Last Name (un) 10045**] during bleed. Once bleeding resolved, extubated without complications. GPC in pairs and clusters, but c/w oropharyngeal flora, no fever, no white count, unlikely PNA. Was treated with Vanc initially but this was stopped after 3 days when suspicion of PNA was low and thought was it was contributing to thrombocytopenia. HOB >40 degrees. Pt had good o2 sats on the floor with minimal o2 by nasal cannula (1-2L). . 3. Thrombocytopenia - Potential meds d/c'd and hematology consulted. A platelet autoantibody was discovered. The pt was transfused a few times with platelets and prednisone was started at 1mg/kg per hepatology. A tapering dose was given at/after acute rehab. . 4. Coagulopathy - In setting of liver disease patient is coagulopathic with poor production of factors and low plts d/t splenic sequestration and medication effect INR maintained <1.5, plts >20, fibrinogen >120 - check Q12. Pt did well and had stable INR. . 5. Cirrhosis/Liver Transpant - Cause most likely alcoholic cirrhosis. No evidence for autoimmune hepatitis, hemochromatosis, viral etiologies, SPEP normal, AFP elevated. Pt had a mild encephalopathy during her stay on the floor. She was logical and sequential in her thinking and understood what was going on though she would occasionally have difficulty recalling the name of the hospital. She always knew her name and the season and month. Paracentesis from OSH showed no growth of cultures. Lasix and spironolactone initially held in setting of hypotension, but restarted when more stable and tolerated well. Lactulose was continued to prevent encephalopathy. F/U Liver transplant workup labs: large work up started to be followed as outpt (cscope, mammography, etc). . 6. Anemia - Due to variceal bleed, but also was on iron therapy as outpatient, indicating an underlying iron deficiency. Iron studies normal but may be confounded by multiple transfusions. Pt transfused on occasion for low hct, though stable toward the end of admission. . 7. Diabetes mellitus - Metformin held. Start metformin once taking adequate. QID fingersticks, RISS. Pt had increasing blood glucose levels with the beginning of steroids. The pt was started on NPH 20 qam and 10 qpm which she tolerated well. . 8. FEN/GI - NPO while intubated, TF's while bridging patient to full diet. The pt was not able to have enough PO intake and a dobhoff was restarted and pt was d/c'd to acute rehab with tube feeds per nutrition. Medications on Admission: metformin 500mg po daily protonix 40mg po daily levofloxacin 500mg po daily spironolactone 50mg po bid lasix 40mg po daily inderal 10mg po bid Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for ENCEPHALOPATHY. 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for systolic bp<100 or heart rate <55. 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for systolic bp <100. 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 13 days: for UTI. 7. Sodium Chloride 0.9 % Parenteral Solution Sig: 1-2 MLs Intravenous DAILY (Daily) as needed: for picc line flush. 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous Daily and PRN as needed: flush picc line to ensure patency. 9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 10. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H:PRN as needed. 11. Prednisone 10 mg Tablet Sig: See below mg PO once a day for 18 days: 70 mg on [**10-16**] and [**10-17**]; then 60 mg from [**Date range (1) 62923**]; then 50 mg from [**Date range (1) 62924**]; then 40 mg from [**Date range (1) 62925**]; then 30 from [**Date range (1) 62926**]; then 20 mg from [**Date range (1) 62927**]; then 10 mg from [**Date range (1) 62928**]; then off. 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous QAM. 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous QPM with dinner. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Cape & Islands Discharge Diagnosis: Esophageal varices. Alcoholic cirrhosis. Discharge Condition: Stable (plt ct >40, hct >30, generalized weakness w/o focal findings, with mild encephalopathy). Discharge Instructions: Monitor daily platelets and contact primary physician if platelets <20. . Monitor hematocrit daily and contact physician [**Last Name (NamePattern4) **] < 25 or symptomatic. . Continue steroids until tapering dose is finished. . Take Rifaximin as indicated in ongoing fashion (the hepatologist want you on this medication). . Change from tube feeds to po feeds as tolerated. The Dobhoff feeding tube may be removed once adequate PO intake is achieved (>75% of a normal diet). Followup Instructions: You have many appointments. Please see below for the list. . Call Dr. [**First Name (STitle) 10733**] at [**Telephone/Fax (1) 13266**] for a follow up appointment within 1 month. . Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2146-10-18**] 4:30 . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2146-10-18**] 4:30 . The hepatologists will call you with your liver ultrasounds follow up appointment, which will be just before your appointment with Dr. [**Last Name (STitle) 497**] on [**11-7**] (see below). . Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-11-7**] 9:00 . You will also have an appointment on [**2146-11-7**] with Dr. [**First Name (STitle) **] of the transplant surgery service. The schedulers did not have an exact time before the weekend, so please call them at [**Telephone/Fax (1) 673**] to confirm the time, date, and location of your appointment.

[ "530.81", "789.5", "572.3", "518.81", "250.00", "276.0", "456.0", "578.0", "286.9", "599.0", "041.04", "287.5", "276.2", "571.2", "458.9", "285.1", "401.9", "280.9", "572.2" ]

icd9cm

[ [ [] ] ]

[ "99.07", "39.1", "96.04", "96.6", "96.06", "96.72", "38.93", "99.04", "99.05", "42.33" ]

icd9pcs

[ [ [] ] ]

10053, 10111

3708, 8266

280, 326

10196, 10295

2438, 2645

10819, 12050

1890, 1923

8460, 10030

10132, 10175

8292, 8437

10319, 10796

1938, 2419

229, 242

354, 1540

2662, 3685

1562, 1664

1680, 1874

24,827

161,715

26242

Discharge summary

report

Admission Date: [**2181-10-31**] Discharge Date: [**2181-11-21**] Date of Birth: [**2102-3-22**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions, resection of recurrent gastric cancer and gastrojejunostomy. Roux-en-Y gastrojejunostomy and jejunojejunostomy. Feeding jejunostomy. History of Present Illness: 79 yo M history gastric cancer s/p partial gastrectomy w/ Bilroth II reconstruction in [**4-29**] who presents with intolerance to solid foods for 4-6 weeks. Pt vomits one hour after eating solid foods. Pt has lost 20 pounds over 4-6 weeks. Endoscopy x2 has showed stricture at GJ junction and attempts to dilate have failed. Past Medical History: Carcinoma of stomach, Stage IV (T2B PN3 PM0) Upper Endoscopy w/ PEG [**7-30**] Hemigastrectomy w. Billroth II anastomosis- [**2181-5-9**] Witzel jejunostomy Upper endoscopy- [**2181-5-22**] BPH s/p TURP ([**3-29**]) s/p Disc Surgery x2 in [**2125**]'s Osteoarthritis Social History: Pt is retired. Worked as a civilian in procurement for the Air Force. Pt has a 60 pack year tobacco history, and quit 30 years ago. Denies EtOH and drug use. Pt is widowed, wife died 1.5 years ago of Multiple Sclerosis. He has no children. Family History: Father died at age 84 of "natural causes" Mother died in her 60's of an MI Brothers died of lung ca and alcoholism, both at age 51 Physical Exam: On admission: Thin, dry. Alert, oriented. Sclera anicteric No enlarged nodes. Chest clear Heart RRR, no murmur No carotid bruit Abd soft, flat, + BS. no masses. no incisional hernia. no groin hernia. no edema. J-tube in place. Pertinent Results: [**2181-10-31**] 10:00PM BLOOD WBC-5.6 RBC-4.65 Hgb-12.4* Hct-36.7* MCV-79* MCH-26.8* MCHC-33.9 RDW-16.2* Plt Ct-283 [**2181-11-19**] 11:50AM BLOOD WBC-9.9 RBC-3.92* Hgb-12.0* Hct-35.5* MCV-91 MCH-30.5 MCHC-33.6 RDW-16.5* Plt Ct-413 [**2181-10-31**] 10:00PM BLOOD PT-13.6* PTT-28.7 INR(PT)-1.2 [**2181-11-5**] 04:00PM BLOOD PT-14.2* PTT-30.3 INR(PT)-1.4 [**2181-11-5**] 04:00PM BLOOD Plt Ct-251 [**2181-11-19**] 11:50AM BLOOD Plt Ct-413 [**2181-10-31**] 10:00PM BLOOD Glucose-81 UreaN-16 Creat-0.7 Na-141 K-3.6 Cl-107 HCO3-25 AnGap-13 [**2181-11-20**] 04:19AM BLOOD Glucose-101 UreaN-23* Creat-0.5 Na-139 K-4.1 Cl-111* HCO3-21* AnGap-11 [**2181-10-31**] 10:00PM BLOOD ALT-25 AST-19 AlkPhos-111 Amylase-83 TotBili-0.5 [**2181-11-18**] 07:00AM BLOOD ALT-54* AST-39 AlkPhos-237* TotBili-2.1* Cardiology Report ECHO Study Date of [**2181-11-20**] Conclusions: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric and may be underestimated. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Of note: this discahrge summary written from the patient chart. This MD did not assume care until the last week of hospitalization. Pt transferred from [**Hospital3 **] for definitive treatment. Pt arrived with NG tube in place which was not changed. Nutritional status checked and tube feedings were optimized to prepare for surgery in order to replace the 20lbs lost prior to presentation. Pt was ambulating and afebrile. On HD9, [**2181-11-8**] the patient was taken to the operating room by Dr. [**Last Name (STitle) 957**] for the following: 1. Exploratory laparotomy, 2. lysis of adhesions, 3. resection of recurrent gastric cancer and gastrojejunostomy, 4. Roux-en-Y gastrojejunostomy, 5. jejunojejunostomy, 6. Feeding jejunostomy, and 7. Catheterization and placement of a Coude catheter because of benign prostatic hypertrophy. There were no complications and the patient was transfered to floor from the PACU. Tube feeds were restarted on POD 1. On [**2181-11-11**] the patient was noted to have a drop in hematocrit from 30 to 24 with an INR of 1.7 on Lovenox. JP drain output was more serosangenous than previously. Also patient had an episode of emesis. He was transfered to the ICU, transfused 1 unit PRC's & FFP, and monitored closely. There was no source of bleeding, and he was transfused several more units over the next 2 days for a hematocrit which continued to trend down. On [**2181-11-15**] the patient had a brief episode of narrow complex tachycardia. Cardiology did not see the need for an antiarrythmic as the irregular heart beats were in the immediate post-operative period. Daily aspirin was started later per their recommendations. An Echo was later essentially normal. On [**2181-11-16**] the patient was transfered back to the floor. He continued to be stable and sips were started on [**2181-11-17**]; diet was slowly advanced. TPN was given [**2102-11-12**] to improve nutional status. On [**2181-11-21**] the patient was tolerating a regular diet, the JP drain was removed, and the patient was transfered to rehab. He is to continue on tube feeds at night in addition to taking a regular diet. Medications on Admission: Reglan Protonix 40 [**Hospital1 **] Celexa 20 QD Ambien 5 QHS Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*55 Tablet(s)* Refills:*0* 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 unit Injection [**Hospital1 **] (2 times a day). 5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 6. Glycerin (Adult) 3 g Suppository Sig: One (1) Suppository Rectal DAILY (Daily). Disp:*30 Suppository(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:*60 Capsule(s)* Refills:*2* 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 12. Loperamide 1 mg/5 mL Liquid Sig: 7.5 MLs PO bid (). Disp:*450 ML(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**] Discharge Diagnosis: Gastric outlet obstruction, chronic and recurrent gastric cancer. Discharge Condition: Good Discharge Instructions: Please resume your home medications. Take all new medications as prescribed. Do not drive while taking narcotic pain medications. You may eat a regular diet. You may resume your regular activities. Keep the dressing intact. You may shower and pat the dressing. No tub soaks until otherwise told by Dr. [**Last Name (STitle) 957**]. Please refrain from heavy lifting for 4 weeks, unless otherwise directed. Please call your physician or return to the hospital if you experience: - Fever (>101.5) - Vomiting or Inability to eat or drink - Redness or discharge from your wound - Increasing pain - Other symptoms concerning to you Followup Instructions: 1. Please call Dr.[**Name (NI) 6275**] office for a follow-up appointment for 2-3 weeks after discharge. ([**Telephone/Fax (1) 376**] 2. Please call Dr.[**Name (NI) 13919**] office (Urology) for a follow-up appointment for 2-3 weeks after discharge. ([**Telephone/Fax (1) 4230**]

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icd9cm

[ [ [] ] ]

[ "40.3", "46.39", "99.15", "43.7", "99.04", "54.59", "45.62", "38.93", "99.07", "96.6", "57.94" ]

icd9pcs

[ [ [] ] ]

6941, 7048

3449, 5600

334, 513

7158, 7165

1833, 3426

7845, 8129

1439, 1571

5712, 6918

7069, 7137

5626, 5689

7189, 7822

1586, 1586

277, 296

541, 871

1600, 1814

893, 1161

1177, 1423

58,514

183,071

39844

Discharge summary

report

Admission Date: [**2147-12-31**] Discharge Date: [**2148-1-10**] Date of Birth: [**2098-7-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5810**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 48 yo male with history of HTN, Diabetes, GERD, obestiy who presents with worsening dyspnea on extertion. Found to have a pulmonary saddle embolus. . Patient states that around [**Holiday **] had general sense of feeling unwell. Nothing specific. While hanging [**Holiday **] lights after [**Holiday 1451**] patient developed left calf and later thigh pain which was extremely painful. This pain resolved and was not associated with any noticeable lower extremity swelling or rashes. Since that time the patient endorses slowly worsening shortness of breath with exertion and an episode of chest burning. Patient finally decided to come to the emergency department when walking up the stairs to his home was exhausting. No history of blood clots. No family history of clots though sister with lupus. No history of recent plain flights or long trips. No smoking or other hormone use. No fevers, rashes, recent weightloss, or blood in stool. . In ED an EKG was performed with S1QT3 and deep T-wave inversions anteriorly concerning for right heart strain. CTA with large saddle embolus with bowing of RV wall. CXR without acute process. Patient was given Nitro x1, Aspirin 325mg, Heparin gtt started. Vitals prior to transfer: 81 115/72 18 100 2L . In the ICU the patient conversant without complaints. Past Medical History: HTN T2 DM on metformin GERD Obesity Obstructive Sleep Apnea on home CPAP OA knees . Previous operations Vasectomy No GA problems Social History: Lives with wife and [**2-23**] children. Works as a Sports Editor for the [**Location (un) 86**] Herald. No mobility problems. [**Name (NI) 4084**] smoked Occasional rare alcohol 1 beer every 1-2 months Pets - 1 cat, well No recent foreign travel or recent trips to the countryside Family History: Mother died following complications of AAA surgery also had stroke Father died age 48 of MI with no other health prpoblmes Maternal grandmother also had AAA Sister with SLE Sister with aneurysmal SAH Nephew with [**Name2 (NI) 87681**] [**Doctor First Name 87682**] sarcoma Physical Exam: VS: Temp: Afebrile BP: 131/66 HR:72 RR:16 O2sat: 100% on 2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: Fixed split P2, No M/R/G, No RV heave ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: Admission labs: [**2147-12-31**] 03:30PM BLOOD WBC-8.1 RBC-5.21 Hgb-15.5 Hct-46.0 MCV-88 MCH-29.8 MCHC-33.7 RDW-14.1 Plt Ct-211 [**2147-12-31**] 03:30PM BLOOD PT-12.8 PTT-23.3 INR(PT)-1.1 [**2147-12-31**] 03:30PM BLOOD Glucose-108* UreaN-24* Creat-1.3* Na-138 K-6.6* Cl-102 HCO3-23 AnGap-20 [**2148-1-1**] 03:46AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.1 . Other labs: [**2148-1-1**] 12:15PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**2148-1-1**] 12:15PM BLOOD ACA IgG-2.8 ACA IgM-8.0 [**2147-12-31**] 04:58PM BLOOD D-Dimer-4616* [**2147-12-31**] 03:30PM BLOOD proBNP-4720* [**2147-12-31**] 03:30PM BLOOD cTropnT-<0.01 [**2148-1-1**] 03:46AM BLOOD CK-MB-3 cTropnT-<0.01 [**2148-1-1**] 12:15PM BLOOD proBNP-2192* [**2148-1-2**] 04:14AM BLOOD CK-MB-3 cTropnT-<0.01 [**2148-1-1**] 03:46AM BLOOD CK(CPK)-77 [**2148-1-2**] 04:14AM BLOOD CK(CPK)-61 . INR trend [**2147-12-31**] 03:30PM BLOOD PT-12.8 PTT-23.3 INR(PT)-1.1 [**2148-1-3**] 06:25AM BLOOD PT-14.3* PTT-91.2* INR(PT)-1.2* [**2148-1-4**] 06:50AM BLOOD PT-13.9* PTT-89.2* INR(PT)-1.2* [**2148-1-5**] 06:50AM BLOOD PT-14.9* PTT-79.1* INR(PT)-1.3* [**2148-1-6**] 06:45AM BLOOD PT-15.7* PTT-98.2* INR(PT)-1.4* [**2148-1-7**] 07:30AM BLOOD PT-17.7* PTT-121.8* INR(PT)-1.6* [**2148-1-7**] 04:55PM BLOOD PT-17.4* PTT-50.5* INR(PT)-1.6* [**2148-1-8**] 12:58AM BLOOD PT-18.1* PTT-83.4* INR(PT)-1.6* [**2148-1-8**] 07:25AM BLOOD PT-19.1* PTT-98.5* INR(PT)-1.7* [**2148-1-9**] 06:40AM BLOOD PT-21.1* PTT-108.3* INR(PT)-2.0* [**2148-1-10**] 07:45AM BLOOD PT-23.7* PTT-81.8* INR(PT)-2.2* . Discharge labs: [**2148-1-10**] 07:45AM BLOOD PT-23.7* PTT-81.8* INR(PT)-2.2* [**2148-1-10**] 07:45AM BLOOD WBC-5.2 RBC-5.07 Hgb-14.6 Hct-43.8 MCV-86 MCH-28.8 MCHC-33.3 RDW-14.2 Plt Ct-155 [**2148-1-6**] 06:45AM BLOOD Glucose-137* UreaN-22* Creat-1.1 Na-139 K-4.4 Cl-101 HCO3-27 AnGap-15 [**2148-1-6**] 06:45AM BLOOD Calcium-9.8 Phos-4.7* Mg-2.2 . . Microbiology: . [**2148-1-1**] 12:02 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2148-1-3**]** MRSA SCREEN (Final [**2148-1-3**]): No MRSA isolated. . . Radiology: . XR CHEST (PORTABLE AP) Study Date of [**2147-12-31**] 4:22 PM FINDINGS: Please note the extreme costophrenic angles have been excluded from view. The lungs are clear without consolidation or edema. The mediastinum is unremarkable. The cardiac silhouette is top normal for size accounting for patient and technical factors. No effusion or pneumothorax is noted within limitations. The osseous structures are grossly unremarkable. IMPRESSION: No acute pulmonary process. . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2147-12-31**] 5:45 PM CT CHEST: The aorta is normal in caliber without acute pathology. There is a large saddle pulmonary embolus, extending bilaterally into lobar, segmental, and subsegmental pulmonary arteries. The main pulmonary artery measures 3.6 cm, suggestive of pulmonary arterial hypertension. There is intraventricular septal bowing into the left ventricle, indicating right heart strain (3, 44). The heart is otherwise top normal in size without pericardial effusion. There is no mediastinal, hilar, or axillary lymphadenopathy. The lungs are clear, without evidence of pulmonary infarct or pleural effusion. Central airways are patent. Limited subdiaphragmatic evaluation demonstrates diffuse hepatosteatosis. A small hiatal hernia is present. BONE WINDOW: No focal concerning lesion. IMPRESSION: 1. Large saddle pulmonary embolus extending into bilateral lobar, segmental, and subsegmental pulmonary arteries, with signs of right heart strain. No pulmonary infarct. 2. Small hiatal hernia. 3. Hepatosteatosis. . BILAT LOWER EXT VEINS Study Date of [**2148-1-1**] 2:55 PM FINDINGS: RIGHT LOWER EXTREMITY: The right common femoral vein, superficial femoral vein and popliteal vein appear normally compressible with preserved wall-to-wall flow. Cardiorespiratory variation and augmentation are preserved. Limited evaluation of the calf veins on the right. The partially seen right posterior tibial vein appears normally compressible. The peroneal vein was not well seen on this exam. LEFT LOWER EXTREMITY: Partial nonocclusive thrombus within a segment of the popliteal vein below the knee is demonstrated. This does not extend proximally into the superficial femoral vein or common femoral vein. The common femoral vein and superficial femoral veins are normally compressible with preserved wall-to-wall flow and response to augmentation. Limited evaluation of the calf veins demonstrating normal compressibility of the posterior tibial veins. IMPRESSION: Nonocclusive thrombus in the popliteal vein below the knee in the the left lower extremity. Limited evaluation of bilateral calf veins. . . Cardiology: . ECG Study Date of [**2147-12-31**] 3:10:28 PM Baseline artifact. Sinus rhythm. T wave inversions in leads V1-V4 but not in leads I and aVL. Suspect right ventricular pathology. Clinical correlation is suggested. No previous tracing available for comparison. TRACING #1 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 214 92 [**Telephone/Fax (2) 87683**] -3 . ECG Study Date of [**2147-12-31**] 4:12:10 PM Sinus rhythm. Multiple aforementioned abnormalities suggest right ventricular pathology. Clinical correlation is suggested. Compared to the previous tracing there is no change. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 138 92 [**Telephone/Fax (2) 87684**] 0 . Portable TTE (Congenital, complete) Done [**2148-1-1**] at 3:22:50 PM Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. 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 mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Right ventricular cavity dilation with free wall hypokinesis. No intracardiac shunt identified. . ECG Study Date of [**2148-1-1**] 3:49:32 AM Sinus rhythm. T wave inversions in leads V1-V5 but not in leads I and aVL suggesting right ventricular pathology. Compared to the previous tracing there is no change. Clinical correlation is suggested. TRACING #3 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. Intervals Axes Rate PR QRS QT/QTc P QRS T 81 138 96 [**Telephone/Fax (2) 87685**] 7 . ECG Study Date of [**2148-1-2**] 10:46:36 AM Sinus rhythm. Marked anterior and anterolateral ST-T wave changes. Compared to the previous tracing of [**2148-1-1**] there is no significant change. Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 142 94 [**Telephone/Fax (2) 87686**] 31 Brief Hospital Course: 48 yo male with history of HTN, Diabetes, GERD, obestiy who presents with worsening dyspnea on extertion. Found to have a pulmonary saddle embolus on CT-PA without pulmonary infarct in addition to evidence of right heart strain on ECG and RV dilation on echo. FH of SLE and he was found to be [**Doctor First Name **] positive with low titre and anticardiolipin Ab was negative. He was initially monitored in the ICU and given that he remained stable and was saturating well on only 2L O2 and comfortable with this, there was no indicaton for TPA. He was treated with an IV heparin infusion and concomitant warfarin as it was felt that hi body weight precluded the use of enoxaparin. A lower extremity non-invasive ultrasound showed a small nonocclusive thrombus in the popliteal vein below the knee in the the left lower extremity which did not extend proximally into the superficial femoral vein or common femoral vein. As there was no significant proximal extension, it was felt that IVC filter would not be beneficial. He was transferred to the [**Hospital1 **] on [**1-2**] and he remained stable although ambulatory sats were 85-90% on RA but this improved as he was anti-coagulated. INR was increasing and by [**1-9**], this was therapeutic. By [**1-10**], his INR was stable at 2.2, heparin was discontinued and he was discharged home with close INR follow-up. Given that his PE was unprovoked, his PCP should undertake [**Name Initial (PRE) **]/P cancer screening and have thrombophilia screen sent when appropriate. He should also have his anti-hypertensives restarted by his PCP in the community. . # Saddle Pulmonary Embolism: He had no risk factors for PE and is independently mobile with no recent surgery or pertinent family history of clotting disorders. On admission, CT-PA demonstrated a large saddle PE extending into bilateral lobar, segmental, and subsegmental pulmonary arteries, with signs of right heart strain but no pulmonary infarct. There was evidence of RV strain on ECG and moderate RV dilation with mild global free wall hypokinesis on echocardiogram. Troponin was not elevated. He was monitored in the ICU and given that he remained stable and was saturating well on only 2L O2 and comfortable with this, there was no indicaton for TPA. He was treated with an IV heparin infusion and concomitant warfarin as it was felt that hi body weight precluded the use of enoxaparin. A lower extremity non-invasive ultrasound showed a small nonocclusive thrombus in the popliteal vein below the knee in the the left lower extremity which did not extend proximally into the superficial femoral vein or common femoral vein. As there was no significant proximal extension, it was felt that IVC filter would not be beneficial. Given that his sister has SLE, he was investigated with [**Doctor First Name **] which revealed a low Positive titre 1:80 and he was Anticardiolipin Ab negative. He was transferred to the [**Hospital1 **] on [**1-2**] and he remained stable although ambulatory sats were 85-90% on RA but this improved as he was anti-coagulated. His warfarin dose was cautiously increased and he was therapeutic on 7.5mg by [**1-9**]. He was also treated with TEDs. This remained stable by [**1-10**] at which point heparin was discontinued and he was discharged home with close INR follow-up. Given that his PE was unprovoked, his PCP should undertake [**Name Initial (PRE) **]/P cancer screening and have a thrombophilia screen sent when appropriate. He should also have his anti-hypertensives restarted by his PCP in the community as these were held while in house due to concerns of hypotension given his sizeable clot load. . # Chest pain: Patient complained of CP on [**1-1**] and [**1-2**] that was thought to be possibly due to his PE, given that his PE extended into bilateral lobar, segmental and subsegmental pulmonary arteries on CT-PA. There was no evidence of pulmonary infect however. Cardiac enzymes were negative, symptoms improved by [**1-4**] and after this, his symptoms resolved. . # Low Plt: On admission, Plt were 211 and dropped to 150 on [**1-3**]. Given IV heparin, the concern was for possible developing HIT. Plt 141 on [**1-4**] and rose after this to settle at 150s. Platelets remained stable thereafter. . # HTN: BP was controlled without meds. Given large saddle PE, it was felt reasonable to withhold his home anti-hypertensives while in house out of concern for possible hypotension given his considerable clot burden. These should be restarted in the community by his PCP. . # Type 2 Diabetes: We held home metformin/glipizide and he received a HISS while in house. Blood glucoses were controlled. His Metformin/Glipizide was restarted on discharge. . # OSA: Continued CPAP . # GERD: Continued PPI. Medications on Admission: Omeprazole 20mg Daily Atenolol 25mg Daily Lisinopril 5mg Daily Simvastatin 40mg Daily Glipizide-Metformin 2.5mg-500mg Twice Daily Discharge Medications: 1. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: Please chaneg your warfarin dose as appropriate after your repeat INR on [**1-11**]. Disp:*120 Tablet(s)* Refills:*0* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. glipizide-metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Outpatient Lab Work Please check INR on [**1-11**] and fax this to Dr [**Last Name (STitle) **] on [**Telephone/Fax (1) 6808**]. Discharge Disposition: Home Discharge Diagnosis: Primary disgnoses: Saddle pulmonary embolism Left popliteal Deep Vein Thrombosis . Secondary diagnoses: Type 2 Diabetes Mellitus Hypertension Gastro-Esophageal Reflux Disease Obstructive Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure looking after you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented following a history of worsening shortness of breath, chest ache and an episode of pain in your left leg. You were markedly short of breath when you were seen and a heart tracing (ECG) showed concerning changes and thus you were sent to the ED. In the ED you had a scan of the chest (a CT pulmonary angiogram which looks at the blood vessesl supplying the lungs) and this found a large blood clot in the blood vessels to the lungs called a pulmonary embolism. As a result of the large clot there was also evidence of back pressure into the right side of the heart which caused strain and dilation of the right side of the heart. Due to the extensive clot (called a saddle pulmonary embolism due to it sitting at the branch point of the pulmonary artery and when seen pathologically in specimen resembling a "saddle"), you were closely observed in the ICU and started on IV heparin which helps to break down the blood clot and stop it from becoming larger. You were treated with oxygen and you remained stable in the ICU with good blood pressures. You had chest pains which were likely associated with your pulmonary embolism and these resolved early in your hospital course. You were transferred to the [**Hospital1 **] on [**1-2**]. On the [**Hospital1 **] you intermittently had episodes of shortness of breath on walking and it was noted that on walking your oxygen levels were lower. We continued you on IV heparin and started warfarin. Your INR (warfarin level) was in the therapeutic range on [**1-10**] and you were discharged with close PCP [**Name9 (PRE) 702**] on [**1-15**] and to have your INR checked on [**1-11**]. You had your high blood pressure medications held while in house as we wanted to keep your blood pressure higher to allow better blood flow through your lungs. . Medication changes: We started warfarin and this should be continued at a dose of 7.5mg at the moment and you will be directed by your PCP [**Last Name (NamePattern4) **] [**1-11**] regarding what dose to take over the festive period prior to your PCP review on [**1-15**]. We stopped atenolol and lisinopril and these should be restarted in the community by your PCP. [**Name10 (NameIs) **] should continue your home medications. . Patient instructions: Please attend all your appointments and if you start feeling more short of breath or develop chest pain you should seek urgent medical attention Followup Instructions: Dr.[**Name (NI) 87687**] office will draw an INR blood test Thursday morning, [**2148-1-11**]. You should just drop by at your covenience in the morning. They will then help direct your coumadin dosage. Name: [**Last Name (LF) 10779**],[**First Name3 (LF) 10778**] Location: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 87688**] Appointment: Monday [**2148-1-15**] 8:00am

[ "415.19", "327.23", "250.00", "786.59", "278.00", "715.36", "453.41", "530.81", "401.9", "287.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15863, 15869

10317, 15079

313, 319

16112, 16112

3078, 3078

18876, 19352

2131, 2405

15261, 15840

15890, 15973

15106, 15238

16263, 18252

4632, 10294

2421, 3059

15994, 16091

18272, 18853

266, 275

348, 1663

3095, 3430

16127, 16239

1685, 1816

1832, 2115

3442, 4616

72,436

151,223

49539

Discharge summary

report

Admission Date: [**2171-2-5**] Discharge Date: [**2171-2-16**] Date of Birth: [**2117-5-21**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 99**] Chief Complaint: transfer for MRSA bacteremia/?endocarditis Major Surgical or Invasive Procedure: Left internal jugular central venous line placement ([**2171-2-6**]) History of Present Illness: 53 year old male with past medical history significant for marginal zone non Hodgkin's lymphoma s/p splenectomy [**2169-12-28**] and rituximab with post-op course complicated by gastric perforation. He was recently admitted to [**Hospital3 **] hospital in Novemember [**2170**] for generalize weakness and discharge without any cause of his weakness. . He recently moved to Massachussets from [**State 2748**] so his sister could take care of him. He was admitted to [**Hospital1 18**] [**Location (un) 620**] on [**2171-2-3**] after five days of worsening fatigue, moaning, agitation and fall with a head trauma on [**2171-2-3**]. On admission, VS noted to have a T of 100.3, Cre of 2 (baseline 1.8-1.9), WBC of 32, Hct of 30, Trop-I of 0.052, BNP of 15,000. Tox screen positive for opiates. . He was noted to have MRSA in his blood cultures with concern for aortic valve endocarditis. He was initially started on Vancomycin and oxacillin which was switched to Vancomycin 1500 mg IV BID and rifampin once it was confirmed to be MRSA. He had a CT torso/head that did not show any clear abscesses. His hospital course was notable for acute kidney injury which was initally oliguric but improved with intravenous hydration. He was intubated on [**2171-2-5**] for worsening mental status and agitation. CT head without contrast did not show any acute intracranial pathology. ABG was 7.48/32/74/24 on 2 L NC prior to intubation. . ABG on transfer was AC 500 x 16 40% FiO2 PEEP 5 = 7.39/32/149/19. Hct 20.6 prior to transfer and received 1 U PRBCs. . On the floor, patient was intubated and sedated. Past Medical History: 1. Splenic marginal zone lymphoma - s/p splenectomy in [**12/2169**] - post-op course complicated by atrial fibrillation/sick sinus syndrome/reentral atrial tachycardia, gastric tear requiring re-exploration and repair of gastric perforation, post-operative pancreatitis and autoimmune hemolytic anemia requiring prednisone. 2. CAD s/p MI - s/p cardiac cath with no abnormalities - TTE [**3-/2170**]: EF 60%, normal systolic function, mild TR, borderline PAH, mild MR, trivial pericardial effusion 3. Rheumatoid arthritis controlled with prednisone 4. Antiphospholipid antibody syndrome c/b DVT in [**2158**] - was on coumadin, currently on aspirin 5. GER 6. Sleep apnea 7. Hepatitis C 8. h/o loculate pleural effusion 9. s/p pancreatic stent [**70**].Vitamin B12 deficiency 11. Chronic kidney disease (baseline creatinine 1.5) 12. ?HIT Social History: The patient still lives at home. Divorced and has been depending on his care by his ex-wife and son. Recently moved to [**State 350**] so his sister could take care of him. Ambulates with a walker but has become more dependent on others for care recently. He recently started smoking. No clear history of increased alcohol abuse and no drug history. Family History: Positive for a father who died from colon cancer at the age of 55. His mother died from head and neck cancer at age 59. Multiple other siblings with cancers and a sister with splenectomy also after a non-Hodgkin lymphoma. Physical Exam: VS: 98.6 92 121/70 96% 40%FiO2 PEEP 5 cm GEN: Intubated. Sedated. HEENT: Normocephalic. Normotraumatic. Anicteric. NECK: Supple neck PULM: Clear to auscultation bilaterally. No crackles or wheezing appreciated. CARD: [**3-3**] holosystolic murmur best heard at apex but could not appreciate it radiating to the axilla. No gallops ABD: Soft, nontender and nondistended. NABS EXT: No edema SKIN: B/l stasis dermatitis. Chronic skin changes at b/l UE. No osler nodes or janeaway lesions noted NEURO: Sedated. Not following commands. PERRLA Pertinent Results: ([**Location (un) 620**]) Na 136 Cre 2 WBC 32 Hct 30 (20.6 prior to transfer, received 1 U PRBCs) INR 1.3 PTT 53 NH4 18 Albumin 1.6 AP 207 ALT 43-> 70 AST 36-> 87; Lipase 46 Trop-I 0.052, 0.056 BNP: 15,000; HgA1c 7.4 TSH: 0.849 B12: 610 Folate > 20 . IMAGING: CT head showed no acute intracranial pathology but this was the motion degraded study. CT of the cervical spine: No cervical spine fracture, subluxation or prevertebral soft tissue swelling; however, the DJD changes at C5-C6 place the patient at a greater risk for cord injury and if needed an MRI could be obtained. . Chest x-ray: There is a right upper lobe opacity that potentially may represent an area of aspiration versus contusion, although definitive developing infectious process cannot be entirely excluded. . hip x-ray showed no fracture. . Pelvic x-ray: No pelvic fractures. . CT torso showed infiltrates and effusions at both lung bases, small amount of ascites. He is status post splenectomy. No obvious intra-abdominal abnormality. . TTE ([**2171-2-5**]): LVEF of 50%. Moderate vegetation at aortic valve. . Urine Culture ([**2171-2-3**]): No growth todate . Blood Culture ([**2171-2-3**]): 1. METH RESISTANT STAPH AUREUS Target Route Dose RX AB Cost M.I.C. IQ ------ ----- ------------------ ------ -- ------ --------- ------ CEFAZOLIN R CIPROFLOXACIN R >=8 CLINDAMYCIN R <=0.25 ERYTHROMYCIN R >=8 GENTAMICIN S <=0.5 INDUCIBLE CLIND + POS LEVOFLOXACIN R >=8 LINEZOLID S 2 BENZYLPENICILLI R >=0.5 OXACILLIN R >=4 TETRACYCLINE S <=1 TRIM/SULFA S <=10 VANCOMYCIN S <=0.5 . Blood culture ([**2171-2-4**]): Positive surveillance culture . Blood culture ([**2171-2-5**]): No growth todate . CXR ([**2171-2-5**]): Cardiomegaly. ET tube 4 cm above carina. B/l infiltrate @ RLL and LLL . EKG ([**2171-2-5**]): NSR. Normal axis. Normal intravals. No ST-T changes.. . Pertinent Labs [**2171-2-6**] 07:50PM BLOOD Hct-25.8* [**2171-2-9**] 04:15AM BLOOD WBC-22.1* RBC-3.12* Hgb-9.1* Hct-28.6* MCV-92 MCH-29.4 MCHC-32.0 RDW-16.4* Plt Ct-58* [**2171-2-11**] 03:37PM BLOOD WBC-23.4* RBC-2.55* Hgb-7.8* Hct-23.7* MCV-93 MCH-30.5 MCHC-32.8 RDW-16.1* Plt Ct-100* [**2171-2-13**] 04:33AM BLOOD WBC-21.6* RBC-2.76* Hgb-8.6* Hct-25.4* MCV-92 MCH-31.0 MCHC-33.7 RDW-16.3* Plt Ct-128* [**2171-2-5**] 10:25AM BLOOD Inh Scr-POS Lupus-POS [**2171-2-6**] 04:47AM BLOOD Glucose-258* UreaN-54* Creat-1.9* Na-147* K-3.8 Cl-116* HCO3-21* AnGap-14 [**2171-2-9**] 03:54PM BLOOD Glucose-145* UreaN-62* Creat-2.0* Na-148* K-4.1 Cl-117* HCO3-21* AnGap-14 [**2171-2-11**] 02:50AM BLOOD Glucose-150* UreaN-59* Creat-2.0* Na-148* K-3.9 Cl-121* HCO3-19* AnGap-12 [**2171-2-13**] 04:33AM BLOOD Glucose-138* UreaN-69* Creat-2.8* Na-148* K-4.5 Cl-120* HCO3-16* AnGap-17 [**2171-2-6**] 04:47AM BLOOD ALT-49* AST-32 AlkPhos-176* TotBili-0.6 [**2171-2-13**] 04:33AM BLOOD ALT-23 AST-46* LD(LDH)-374* AlkPhos-266* TotBili-0.6 [**2171-2-5**] 09:13PM BLOOD calTIBC-147* Hapto-533* Ferritn-1128* TRF-113* [**2171-2-5**] 09:13PM BLOOD TSH-0.55 [**2171-2-6**] 04:47AM BLOOD Cortsol-44.2* [**2171-2-6**] 04:47AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE . Heparin Dependent Antibody positive ([**2171-2-10**]) . Pertinent Imaging TTE ([**2171-2-6**]): Moderate sized mass on the right coronary cusp of the aortic valve which is consistent with vegetation, tumor, or thrombus. Moderate to severe aortic regurgitation. Mild to moderate mitral regurgitation. Moderate pulmonary hypertension. . ECG ([**2171-2-10**]): Atrial fibrillation with rapid ventricular response. Compared to the previous tracing of [**2171-2-6**] no diagnostic interval change. . MRI ([**2171-2-10**]): Multiple foci of restricted diffusion, distributed in both cerebral hemispheres as described above, the possibility of septic emboli and thromboembolic ischemic events are considerations. Few of these lesions demonstrate magnetic susceptibility at the frontal lobes and punctate enhancement in the left parietal lobe. Bilateral mucosal thickening is identified at the mastoid air cells and sphenoid sinus. Subtle high signal intensity foci are demonstrated in the pons on T2 and FLAIR, possibly reflecting chronic microvascular ischemic disease. . TTE ([**2171-2-12**]): Aortic valve vegetation with moderate associated regurgitation. Mildly dilated right ventricle with normal global and regional biventricular systolic function. Moderate pulmonary hypertension. Limited study. . CXR ([**2171-2-13**]): In comparison with the study of [**2-12**], the tip of the endotracheal tube now lies approximately 4 cm above the carina. The other monitoring and support devices are unchanged. Diffuse bilateral pulmonary opacifications persist. Multiple nodules are again consistent with the clinical diagnosis of septic emboli. . Brief Hospital Course: 53 year old male with past medical history significant for marginal zone non Hodgkin's lymphoma s/p splenectomy [**2169-12-28**] and rituximab, rheumatoid arthritis on chronic prednisone, ?HIT, autoimmune hemolytic anemia transfer to [**Hospital1 18**] MICU for further management of MRSA bacteremia. . 1. MRSA bacteremia: Positive blood cultures on [**2171-2-3**] @ [**Hospital1 18**] [**Location (un) 620**] with positive surveilllance culture on [**2171-2-4**] and no growth on blood cultures since [**2171-2-5**]. TTE showed moderate vegetation and 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **] of 50% which has stayed stable on TTE on [**2171-2-12**]. MRI head significant for > 20 foci concerning for septic emboli to brain which might have caused his acute agitation leading to his intubation at [**Hospital1 18**] [**Location (un) 620**]. Has been continued on IV Vancomycin throughout his hospital stay. Cardiac surgery was consulted early but have decided not to intervene surgical due to multiple comorbidities along with septic emboli to his brain which would not be able to handle heparin load during open heart surgery. CT abdomen/pelvis done on [**2171-2-13**] showed no intra-abdominal abscess, although study was limited without IV contrast. Was started on zosyn on [**2-8**] for continued leukocytosis and fever; these initially improved but have remained elevated. . 2. Respiratory failure: Intubated in the setting of agitation which could be due to septic emboli vs nonpulmonary ARDS from sepsis vs toxic/metabolic injury. His respiratory status did improve over the course of his stay, however he remained intubated due to sedation and poor neurologic exam. . 3. Acute kidney injury: pt has chronic kidney disease, with baseline creatinine around 1.5. His creatinine has continually increased to max of 3.5, concerning for septic emboli to kidney versus ATN vs volume depletion (though urine lytes not consistent with prerenal state). . 4. Anemia: Iron studies consistent with anemia of chronic disease. Stool guiaic has been negative along with hemolysis labs. Pt received one blood transfusion on [**2-6**], and a second on [**2-13**]. Crit has remained stable since that time. . 5. Elevated LFTs: History of hepatitis C Ab with negative viral load in the past along with abnormal LFTs. Differential also includes emboli to the liver but CT abdomen without contrast did not show any abscess vs amiodarone toxicity. . 6. ?HIT: ? of HIT from records obtained from OSH (only in one note though). Contact[**Name (NI) **] primary oncologist who could not give any further information. Optical density came back minimally positive. Heme consulted, who felt that this was likely not HIT, but recommended no heparin x24 hours. . 7. R foot discoloration: concern for arterial septic embolization. Vascular consulted, felt that no intervention indicated until amputation needed. Family discussion held on [**2171-2-16**]. Family aware that pt very sick, and feel that he would not want amputation, trach, or to be in a nursing home for the rest of his life. Given his poor pre-hospital functional status, it was felt that all of these things were very likely to happen. The family decided to make the patient CMO. He passed away at 1858 on [**2171-2-16**]. Medications on Admission: MEDICATIONS (on transfer) 1. Versed gtt 2. Fentanyl gtt 3. Vancomycin 1500 mg IV q12 with trough of 15.8 4. Rifampin 300 mg po BID 5. Metoprolol 12.5 mg po TID . MEDICATIONS (Prior to admission to [**Hospital1 18**] [**Location (un) 620**]) 1. Amiodarone 200 mg twice a day 2. Cymbalta 60 mg twice a day 3. Folate 1 mg po qdaily 4. Lyrica 75 mg once a day 5. Lisinopril 20 mg a day 6. Metoprolol 100 mg twice daily 7. Oxycodone/APAP every 4 hours as needed 8. Pravastatin 80 mg at bedtime 9. Prednisone 20 mg 3 times daily 10. Lantus insulin 11. Vitamin A 12. Stool softener 13. MVA . Discharge Medications: pt passed away Discharge Disposition: Expired Discharge Diagnosis: pt passed away Discharge Condition: pt passed away Discharge Instructions: pt passed away Followup Instructions: pt passed away Completed by:[**2171-2-16**]

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icd9cm

[ [ [] ] ]

[ "03.31", "38.97", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

13500, 13509

9526, 12826

315, 385

13567, 13583

4065, 9503

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2886, 3240

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131,141

12659

Discharge summary

report

Admission Date: [**2105-6-1**] Discharge Date: [**2105-6-3**] Date of Birth: [**2042-4-4**] Sex: F Service: MEDICINE Allergies: Keflex / Penicillins / Erythromycin Base / Demerol / Ceclor Attending:[**First Name3 (LF) 783**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: 63 yo female with history of schizoaffective disorder with SI, UC s/p sigmoidectomy, COPD who was recently admitted [**Date range (1) 39099**] for pneumonia and suicidal ideation. Patient presented on [**2105-6-1**] s/p fall at her group home and found to be hypotensive secondary to dehydration and atenolol intake. . Of note, she has had multiple admissions in the past for lightheadness and was admitted to [**Hospital1 112**] for the same complaint from [**Date range (1) 39100**]. At that time the patient fell in the bathroom and hit the back of her head on her bath tub. She recalls having a head CT which was negative. Up to and throughout that hospitalization she had nausea and vomiting which only resolved on her day prior to discharge. After discharge she was feeling well and tolerating PO's. She had occassional feelings of diziness, but thought it was due to the psychosocial stress over the murder of her grandson's girlfriend. . She continued to eat and drink well with no diarrhea, melena, hematochezia. She denied headache but has been taking Motrin 600mg qid for left hip pain. She decided to take her Atenolol which she had taken in the past but was no longer taking on the morning of admission. The diziness progressed and she felt presyncopal and fell onto her backside with her left foot underneath her. She had no fecal or urinary incontinence. In ED, her SBP was in the 70's and she was given 1 liter fluid with good response. It was initially thought to be due to atenolol ovedose and she was given glucagon and calcium gluconate with no further improvement. Pt complained of foot pain and had negative plain x-ray of her foot, but after she was given 1mg of morphine her SBP's decreased to to 60's which didn't respond to Narcan so decision was made for ICU admission. Patient responded well to IVF in the ICU and thought that her symptoms were a combination of Atenolol overdose along with dehydration from decrease po intake. Past Medical History: PMHx: 1. COPD 2. Schizoaffective Disorder 3. Ulcerative Colitis s/p sigmoidectomy [**2098**] 4. Suicidal Ideation (Psychiatrist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39101**] [**Telephone/Fax (1) 39102**]) 5. s/p diverticular rupture with colostomy and reversal of colostomy 6. Osteoarthritis 7. h/o of rheumatic fever with Sydenham's chorea 8. Duodenal ulcer 9. Orthostatic Hypotension Social History: She smokes 1 pack of cigarettes per day and has been doing so for that past 50 years. She denies any alcohol and illicit drug use. She lives in [**Location 39098**] house in [**Location (un) **] and is on disability. She has one daughter who is on disability for multiple psychiatric illnesses. One son died secondary to drug overdose. Family History: Daughter - "psychiatric illnesses", No family hx of CAD Physical Exam: VS: Temp 98.2, BP 126/68, Pulse 64, RR 18, O2 sat 98% room air GEN: comfortable, NAD HEENT: PERRLA, EOMI LUNGS: CTA bilateral, no wheezes HEART: S1, S2, RRR, no murmurs, rubs, gallops appreciated ABD: soft, ND, NT, no HSM, + bowel sounds EXTREM: no edema, cyanosis, clubbing; 2+ pulses symmetrical Pertinent Results: [**2105-6-1**] 10:48PM LACTATE-2.4* [**2105-6-1**] 10:45PM GLUCOSE-107* UREA N-20 CREAT-1.1 SODIUM-137 POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-27 ANION GAP-11 [**2105-6-1**] 10:45PM TSH-2.9 [**2105-6-1**] 10:45PM CORTISOL-2.1 [**2105-6-2**] 04:12PM BLOOD Cortsol-29.6* [**2105-6-2**] 05:27AM BLOOD calTIBC-226* Ferritn-35 TRF-174* [**2105-6-2**] 05:27AM BLOOD Albumin-2.7* Calcium-7.6* Phos-3.9 Mg-1.8 Iron-32 [**2105-6-3**] 05:18AM BLOOD Glucose-85 UreaN-11 Creat-0.6 Na-137 K-4.1 Cl-108 HCO3-23 AnGap-10 [**2105-6-3**] 05:18AM BLOOD WBC-4.2 RBC-3.19* Hgb-9.9* Hct-27.8* MCV-87 MCH-31.1 MCHC-35.7* RDW-12.8 Plt Ct-184 Left Foot X-Ray: No fracture or dislocation Brief Hospital Course: 63 yo female with multiple medical problems who presented s/p fall and found to be hypotensive secondary to dehydration and ingestion of atenolol that seemed to have resolved with IVF. . 1. Hypotension: - likely secondary to dehydration as responded well to IVF and did have some acute renal failure that resolved with fluids - could have been superimposed with atenolol overdose although patient denies taking multiple pills. BP and HR have returned to [**Location 213**] by HD#2. Will continue to hold Atenolol until reevaluation of BP as an outpatient. Suggest restarting at a lower dose and titrating up gradually. - has had multiple workups in the past including a pMIBI in [**9-9**] which was unremarkable. Echo done [**2105-6-2**] showed EF 55-60% with mild to moderate AR and mild MR; no evidence of any wall motion abnormalities - was ruled out with 3 sets of cardiac enzymes - medications adjusted as per Psych team; avoid narcotics . 2. Heme: - HCT drop likely secondary to volume resuscitation - iron studies consistent with deficiency of chronic disease likely from her ulcerative colitis with inappropriately low Retic Index. Guaiac neg on exam. Instructed to f/u with PCP for further monitoring. . 3. COPD: - not wheezy at this time and so will continue on outpatient Combivent and Advair MDI's. - smoking cessation; is on Wellbutrin which will facilitate this; cont nicotine patch to prevent withdrawal . 4. Foot pain: - findings not suggestive of severe trauma and plain films show no fracture - continue to treat with Ibuprofen around the clock, and Tylenol prn, and be gentle with narcotics for risk of hypotension -PT evaluation. Is safe to go to home with cane. Will arrange VNA home PT to work on strength and use of cane. . 5. Schizoaffective D/O: - denies SI at this time and denies taking overdose of atenolol - seen by the Psychiatry team who recommended to d/c buspirone, reduce trazodone, and reduce risperidone and move it to QHS Did not need sitter at any point. No SI/AH. . 6. Ulcerative colitis: - denies diarrhea as precipitant for dehydration and labs show no low bicarb - cont on her output mesalamine dose. Is guaiac Neg. . 7. Renal: - initially presented with acute renal insufficiency secondary to dehydration as resolved with IVF from 1.7 to 0.7 Medications on Admission: 1. Fluoxetine HCl 30mg qd 2. Bupropion HCl 150 mg [**Hospital1 **] 4. Clonazepam 0.5 mg tid 5. TraZODONE HCl 150 mg qhs 6. Risperidone 3mg qhs 7. Buspirone HCl 15mg tid 8. Mesalamine 800mg tid 9. Ranitidine HCl 150 mg tid 10. Fluticasone-Salmeterol 100-50 mcg [**Hospital1 **] 11. Pantoprazole Sodium 40 mg qd 12. Nicotine patch 13. Combivent 103-18 MDI qid prn 14. Tiotropium Bromide 18 mcg qd Discharge Medications: 1. Fluoxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO bid () as needed for depression. 6. Clonazepam 0.5 mg Tablet Sig: As Directed Tablet PO As Directed as needed: 0.5 mg by mouth every morning 0.5 mg by mouth every afternoon 1 mg by mouth every evening. Disp:*120 Tablet(s)* Refills:*0* 7. Risperidone 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 8. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 9. Physical Therapy Sig: as directed as directed : Evaluation and treatment. 10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Puff Inhalation once a day. 11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1) Dizziness 2) Hypotension Discharge Condition: Stable, improved condition from the time of admission Discharge Instructions: Please call your doctor or return to the ER if you experience significant dizziness, blurry vision, fainting, chest pain, difficulty with breathing, or falling down. . Take your medications as prescribed with the following changes: - You should stop taking Atenolol and Buspar. - Your Trazodone has been decreased from 150mg --> 100mg at bedtime. - You should continue taking Risperdal 3mg, but take this medication at bedtime instead of taking it in the morning - Your Klonopin prescription has changed, you will now take 0.5mg in the morning and afternoon, and 1 mg at night. . Follow up as scheduled below. Followup Instructions: An appointment has been made for you to follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on WEDNESDAY, [**6-10**] AT 1:45 PM. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "972.9", "E858.3", "428.0", "496", "556.9", "584.9", "276.5", "285.9", "458.29", "295.70" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8171, 8229

4205, 6492

324, 330

8301, 8356

3512, 4182

9015, 9330

3122, 3179

6937, 8148

8250, 8280

6518, 6914

8380, 8992

3194, 3493

277, 286

358, 2315

2337, 2753

2769, 3106

20,643

140,597

4422

Discharge summary

report

Admission Date: [**2105-8-11**] Discharge Date: [**2105-8-13**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: None. History of Present Illness: 66yM with COPD on home O2 and chronic steroids, CAD, VRE UTIs and chronic back pain admitted for SOB. He missed his daily Prednisone today and was at the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] clinic getting an injection for LBP, on his stomach when he became SOB. They sat him up and finished the procedure but his SOB persisted and he was recommended to go to the ED. Similar episodes of SOB during lower back injections have occurred in the past. He denied chest pain, but does have a chronic cough. He is dyspnic at baseline but ambulates with limitations due to chronic pain. . Of note, recent ED discharge for lower back pain/incontinence with MR L spine done which revealed no significant change since [**2101-11-30**] with no evidence of canal stenosis or compression of the conus or the cauda equina and and L5/S1 disc bulge causing moderate left foraminal stenosis with impingement of the exiting nerve root. . ROS: (+)productive cough, lower back pain. (-)fever, chills, orthopnea, PND, chest pain, palpitations, edema, N/V, diarrhea, constipation, no bladder or bowel incontinence . ED course: CXR revealed large lung volumes without infiltrate or evidence of CHF. He received IV Solumedrol 125, Levofloxacin and was sating 93% on nasal cannula. He was started on Bipap briefly but pulled this off. His O2 sats were 95% on 4L N/C (baseline O2). Past Medical History: 1. COPD on 4 L O2 at home and s/p multiple admissions and intubations for flares-FEV1 .47(19%) FEV1/FVC 36% on 4L home 02, and BiPap QHS. 2. h/o VRE UTI, formerly had indwelling catheter 3. hx of MRSA 4. CAD s/p NSTEMI ([**2101**]) [**4-9**] with cath normal, TTE with preserved biventricular function. 5. Steroid induced hyperglycemia 6. Hypertension 7. Hyperlipidemia 8. Chronic low back pain L1-2 laminectomy from accident at work 9. Left shoulder pain for several months 10. Cataract 11. GERD 12. BPH Social History: SH: Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint. Married with six children. Lives at home in [**Location (un) 16174**] with wife and step-son. His step-son is a drug dealer, in and out of jail and has guns and is physically threatening to the patient. Mr. [**Known lastname 19017**] does not feel he is safe at home. He would like to get a warrent vs his step son but mobility makes it hard for him to go to court. Minimally active at baseline. Substances: 20 p-y smoking, quit 25 years ago. Occassional EtOH. Quit marijuana 3 years ago. Denies IVDA. Family History: Mother with asthma and [**Name (NI) 2481**]. Father with [**Name2 (NI) 499**] cancer. Physical Exam: PE: 97.8 97/67 74 28 94% O2 Sats 4L NC Gen: Awake, alert, NAD. HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: CTAB with increased exp phase, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-6**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Lymphatics: No cervical, supraclavicular lymphadenopathy noted Skin: no rashes or lesions noted. Pertinent Results: [**2105-8-11**] 10:35AM BLOOD WBC-21.8*# RBC-4.66 Hgb-13.0* Hct-41.1 MCV-88 MCH-28.0 MCHC-31.7 RDW-14.7 Plt Ct-523*# [**2105-8-11**] 10:35AM BLOOD Neuts-69.7 Lymphs-22.7 Monos-4.7 Eos-2.2 Baso-0.7 [**2105-8-11**] 10:35AM BLOOD Plt Ct-523*# [**2105-8-11**] 10:35AM BLOOD Glucose-133* UreaN-16 Creat-0.7 Na-141 K-4.1 Cl-98 HCO3-33* AnGap-14 [**2105-8-11**] 10:35AM BLOOD CK-MB-4 cTropnT-<0.01 [**2105-8-11**] 10:35AM BLOOD Calcium-10.1 Phos-4.6* Mg-2.0 [**2105-8-12**] 11:11AM BLOOD %HbA1c-5.7 [**2105-8-11**] 12:02PM BLOOD Type-ART pO2-105 pCO2-68* pH-7.32* calTCO2-37* Base XS-6 [**2105-8-11**] 10:54AM BLOOD Lactate-2.4* CXR ([**2105-8-11**]): The lungs are hyperexpanded consistent with underlying obstructive lung disease. No consolidation or superimposed edema noted. There is a tortuous atherosclerotic aorta. The pulmonary arteries are enlarged likely due to underlying pulmonary arterial hypertension. The cardiac silhouette size is within normal limits. No definite effusion or pneumothorax is seen. The visualized osseous structures are unremarkable. IMPRESSION: COPD with no superimposed acute pulmonary process. Brief Hospital Course: IMPR/PLAN: The patient is a 66 year old man with COPD on home O2 and chronic steroids, CAD, VRE UTIs, and chronic back pain admitted for COPD exacerbation that occurred while he was being positioned prone in the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center. . #1 COPD. Chronic Stage IV COPD with worsened FVC per PFTs in [**3-11**]. He had remained on home prednisone 20mg per instructions from last discharge in [**Month (only) 547**]. In the hospital he was initially placed on Bipap and monitored in the MICU. He was given IV Solumedrol and then switched to prednisone 40 mg. He improved on nebs with prednisone. He uses 4L of O2 at home and he required the same amount on the floor. He was discharged on 40 mg Prednisone for 5 days with plan to go back to his home dose of 20 mg. He was also given a 5 day course of Azithromycin, and Bactrim as PCP [**Name Initial (PRE) 1102**]. His home COPD medications were otherwise continued. . #2 Lower back pain. Chronic. He had been treated at the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) **] the day of admission with injection to L4-5 area but injections had not been completed when SOB occurred. His left-sided back/rib pain was controlled with q4h Percoset and prior to discharge he was given an injection near the left costal margin. . #3 CAD. No active issues. NSTEMI ([**2101**]) [**4-9**] with cath normal, TTE with preserved biventricular function. Continued ASA, Statin, Ace-i, CCB at home doses. . #4 Steroid induced hyperglycemia. FSBG on day of discharge was 104/120/150/170. He should follow-up with Dr. [**Last Name (STitle) 8499**] for hyperglycemia. . #5 Hypertension. No acute issues. Continued home CCB and Ace-i. . #6 Hyperlipidemia: No acute issues. Continued home statin. . #7 GERD: No acute issues. Continued PPI. . #8 Domestic violence. Unsafe at home as described above. Consulted SW who gave the patient a home safety plan. There is no evidence that the patient is in any immediate danger. Medications on Admission: 1. Hexavitamin Tablet One (1) Cap PO DAILY 2. Sertraline 50 mg Tablet One (1) PO DAILY 3. Pantoprazole 40 mg Tablet PO Q24H 4. Finasteride 5 mg Tablet One Tablet PO DAILY 5. Ferrous Sulfate 325 (65) mg Tablet One PO DAILY 6. Aspirin 81 mg Tablet One Tablet PO DAILY 7. Verapamil 240 mg Tablet SR PO Q24H 8. Lisinopril 5 mg Tablet One Tab PO DAILY 9. Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4-6H 10. Prednisone 20 mg Tablet Daily 11. Nitroglycerin 0.4 mg Tablet, PRN 12. Atorvastatin 10 mg Tablet PO DAILY 13. Calcium 1200 mg qd 14. Alendronate 70 mg qwk 15. Albuterol Sulfate 0.083 % Nebs Q6H 16. Ipratropium Bromide 0.02 % Nebs Q6H 17. Lorazepam 1 mg [**Hospital1 **] 18. Boost shake 1 can qd Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation every four (4) hours. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO once a day for 3 days. Disp:*3 Capsule(s)* Refills:*0* 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO Take Monday, Wednesday, and Friday: Take one pill Monday, Wednesday, and Friday only. Disp:*30 Tablet(s)* Refills:*0* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Take two daily until [**8-17**] and on [**8-17**] and thereafter take one daily. Disp:*30 Tablet(s)* Refills:*2* 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 19. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual twice a day as needed for chest pain. 20. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day. 21. Lactulose 10 g/15 mL Solution Sig: Two (2) PO at bedtime as needed for constipation. 22. Boost Plus Liquid Sig: One (1) PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: COPD exacerbation. Discharge Condition: Stable. Discharge Instructions: You have been given new medicines: . 1) Bactrim DS, to protect you against infections in your lungs while you are taking steroids. Take one pill a day only on Monday, Wednesday, and Friday. 2) Azithromycin, an antibiotic. Take one pill a day as instructed. 3) Prednisone (old medicine, new dose). Take 40 mg per day until [**8-17**] (when you see Dr. [**Last Name (STitle) 8499**]. You should discuss this when you see Dr. [**Last Name (STitle) 8499**]. Also, you should take 1200 mg Calcium and 400U Vitamin D daily if you were not doing so previously. . Otherwise, please take your medications as you did previously. . Call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 8499**] at [**Telephone/Fax (1) 7976**] or come the the ER if you have any symptoms that concern you such as shortness of breath, increased oxygen or inhaler requirements, chest pain, or unresolving abdominal or back pain. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2105-8-17**] 2:15 . Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2105-10-2**] 8:20 . [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2105-8-14**]

[ "V15.82", "V10.11", "E932.0", "600.00", "414.01", "724.2", "412", "V46.2", "530.81", "V10.46", "251.8", "491.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9697, 9755

4839, 6877

324, 332

9818, 9828

3689, 4816

10835, 11290

2904, 2992

7630, 9674

9776, 9797

6903, 7607

9852, 10812

3007, 3670

276, 286

360, 1757

1779, 2286

2302, 2888

49,840

140,436

50886

Discharge summary

report

Admission Date: [**2164-7-11**] Discharge Date: [**2164-7-17**] Date of Birth: [**2110-10-11**] Sex: M Service: SURGERY Allergies: Adhesive Tape / Ibuprofen Attending:[**First Name3 (LF) 598**] Chief Complaint: Left flank pain Major Surgical or Invasive Procedure: none History of Present Illness: 53M morbidly obese male s/p fall on Monday [**7-9**] presents for evaluation of increasing left hip and flank pain. As per patient he feel after his right knee gave out while going to the bathroom. He did not hit his head or neck, but sustained the impact to his left flank and hip. He denies LOC, remembers all events and states that he has no pain anywhere else in his body except his left side. HE has had repeated falls in the past due to weakness/ giving out of right knee that is chronically affected by lymphedema. In Ed patient was initially normotensive but then BP dropped to mid 80s without tachycardia. A left IJ was placed. He was receiving his first liter of fluid at the time of this evaluation. Past Medical History: PMH 1. Hypertension 2. Obesity 3. Depression 4. MVA - remote, with fracture right upper extremity, s/p ORIF 5. Cellulitis 6. Chronic right lower extremity cellulitis and lymphedema Atrial fibrillation, on Coumadin PSH 1. Gastric Bypass surgery in [**2152**] [**Doctor First Name 30929**] followed by Dr. [**Last Name (STitle) **] currently. 2. Right elbow surgery Social History: Non-smoker. Denies EtOH or drug use. Patient is on disability. Lives by himself in an apartment in [**Location (un) 86**]. Family History: Lung CA in mother and father, both were smokers, and both died of this, his mother at age 39. His sister has ovarian ca. His father also had gout. Physical Exam: Temp 97 HR 73 BP 114/64 RR 18 O2 sat 100% RA GEN: Morbidly obese male in NAD. Neuro: CNII-IV intact. GCS 15 HEENT: Atraumatic/ NC, pupils 3>2 bilaterally, EOMI. C spine nontender and atraumatic. CVS: RRR but decreased limited evaluation because of body habitus Stable sternum, no pain along ribs. PUlM: CTAB but decreased [**1-25**] body habitus Abdomen obese, midline incision mildly tender without evidence of hernia ( unable to stand so examined in supine position only). Left inferior abdomen and flank with ecchymosis and tenderness throughout, no skin breakdown. Pelvis stable. GU: Externally WNL. Ext: WWP with significant lymphedema of the right leg, no lymphedema of the left leg. No evidence of trauma to extremities. Pertinent Results: [**2164-7-11**] 11:50AM WBC-7.8 RBC-2.79*# HGB-7.9*# HCT-23.9*# MCV-86 MCH-28.3 MCHC-33.1 RDW-17.8* [**2164-7-11**] 11:50AM NEUTS-69.4 BANDS-0 LYMPHS-20.2 MONOS-6.4 EOS-3.4 BASOS-0.5 [**2164-7-11**] 11:50AM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO [**2164-7-11**] 11:50AM PT-37.8* PTT-35.2* INR(PT)-3.8* [**2164-7-11**] 11:50AM GLUCOSE-72 UREA N-20 CREAT-1.0 SODIUM-137 POTASSIUM-3.4 CHLORIDE-110* TOTAL CO2-20* ANION GAP-10 [**2164-7-11**] CT Abd/pelvis : 1. 37-cm obliquely oriented fluid collection in the left lateral body wall, likely a hematoma. 2. No thigh hematoma. 3. No acute intra-abdominal process. 4. Seroma along anterior abdominal wall adjacent to mesh, slightly decreased in size from [**2161**] CT. Brief Hospital Course: The patient was admitted to the ICU on [**2164-7-11**] from the ED. Initially in the emergency room the patient was normotensive, however he quickly dropped his pressures to SBP 80s without tachycardia. A LIJ was placed and patient was given 10 units VitK, 2u FFP, 2u pRBC. The patient received 4 additional units of blood in the ICU, and his HCT improved to 32.1. The patient's INR improved to 1.4 from 3.8 on admission. CT scan on [**7-11**] showed a 37cm hematoma in the left lateral body wall. On [**7-12**], the patient was hemodynamically stable. He was off pressors, and did not require further transfusions. He was transferred to the floor in stable condition. Following transfer to the Trauma floor he had problems with pain control and mobility. He has a history of leg pains and prior to admission was on Gabapentin with some effect. Currently he is taking a combination of Tizanidine, Tylenol, Morphine IR and Ultram and generally is getting more pain control daily. He worked with the Physical Therapy service to help him mobilize and a short term rehab was recommended prior to his return home. His hematocrit has been stable for > 72 hours and remains in the 32-35 range. He was 23 on admission and stabilized after transfusions. He also has remained off Coumadin. He had some brief rapid atrial fibrillation 4 days ago which resolved after resuming his beta blocker. He has had long standing hypertension treated with Lisinopril 20 daily and Toprol 200 daily. Due to his hypotension on admission his medication was held. Now that he is euvolemic his blood pressure is 126/85 and his heart rate is 77 which reflects Lopressor 25 mg [**Hospital1 **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP is aware that we are keeping him off of Coumadin and he will be re evaluated at his appointment with Dr. [**Last Name (STitle) 30375**] in early [**Month (only) 216**]. He had some complaints of left calf pain on [**2164-7-16**] and had venous studies which were negative for DVT.. He remains on DVT prophylaxis with Heparin 5000 units SC TID. Currently he is tolerating a regular diet in modest amounts and is able to stay well hydrated. He was discharged on [**2164-7-17**] to rehab and will follow up in the [**Hospital 2536**] Clinic in [**1-26**] weeks. Medications on Admission: Calcium Citrate + 315 mg-200u 2 Tabs ", Vitamin B-12 1,000 mcg Tab,Cholecalciferol (Vitamin D3) 1,000 unit, triamcinolone acetonide 0.1 % Topical", Lasix 20 mg Tab, lisinopril 20 mg, Omeprazole 20 mg, tramadol 50 mg, Docusate Sodium 100 mg", trazodone 50 mg Tab, ferrous sulfate 325 mg", warfarin 5 mg (need to verify dose, Gabapentin 800 mg Tab"', MVI, metoprolol succinate ER 200 mg,Miralax 17 gram' Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP < 100, HR < 60. 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 6. tizanidine 2 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 9. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day. 10. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: S/P Fall 1. Hematoma left flank and hip 2. Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital after falling with a large hematoma on your left flank and hip area. Your INR was elevated and was reversed with blood products. Your bleeding stopped and your blood count has been stable. You have had problems with pain control and mobility. * You did not sustain any broken bones but sometimes the generalized pain from falling can be debilitating. For that reason we are sendiong you to a rehab to try to gradually increase your mobility so that you may return home. * Due to your frequent episodes of falling at home we are keeping you off Coumadin for now. You will be able to discuss this more when you see Dr. [**Last Name (STitle) 30375**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**1-26**] weeks. Provider: [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2164-7-27**] 1:45 Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2164-8-1**] 1:00 Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2164-11-14**] 8:30 [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2164-7-17**]

[ "E885.9", "338.29", "427.31", "V58.61", "V85.42", "790.92", "E849.0", "458.9", "924.01", "V45.86", "719.7", "457.1", "922.2", "278.01", "285.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

7117, 7187

3275, 5583

301, 307

7298, 7298

2525, 3252

8256, 8958

1600, 1749

6035, 7094

7208, 7277

5609, 6012

7474, 8233

1764, 2506

246, 263

335, 1054

7313, 7450

1076, 1443

1459, 1584

109

172,335

14797

Discharge summary

report

Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]

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icd9cm

[ [ [] ] ]

[ "54.98" ]

icd9pcs

[ [ [] ] ]

16076, 16133

7981, 14717

291, 298

16328, 16421

3600, 7958

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243, 253

326, 1347

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29,278

144,113

54520

Discharge summary

report

Admission Date: [**2139-9-8**] [**Month/Day/Year **] Date: [**2139-9-11**] Date of Birth: [**2072-5-9**] Sex: M Service: MEDICINE Allergies: Ampicillin / Ciprofloxacin / Neomycin Sulfate/Colist Sul/Hc / Afrin Saline Nasal Mist / Clindamycin Attending:[**First Name3 (LF) 5893**] Chief Complaint: syncope Major Surgical or Invasive Procedure: Intubation/Extubation History of Present Illness: 67 y/o M with a PMHx of CAD s/p 5v CABG and multple PCI, sCHF EF 20%, HTN, DM2, CKD (bl Cr 2.0), ITP, hx of GIB, OSA on home o2 who was found unconscious by neighbor. Pt without recollection of event; currently intubated. Per EMS, was apneic in respiratory distress and an attempt to intubate in the field was made unsuccessfully. He was brought to [**Hospital3 **] Hospital, found to be hypoxic to 80% on RA and in respiratory distress per report. He was given Etomidate 16mg & Succinylcholine 150mg x1 and intubated. Had CXR that showed stable opacity in L mid-zone, and had a Head/neck CT that was negative for bleed or fracture. An ABG at 9pm after intubation was 7.19 35 372. Was transferred to [**Hospital1 **] for further w/u. . In the ED, his VS on transfer were: HR 70, BP 105/56, RR 16, 100% on the vent. His BP remained in the 100/50 range and he was started on a dobutamine gtt @ 5mcg/hr. This was eventually titrated up to 10mcg/hr. He was given 3L IVF hydration and Levaquin 500mg IV x1, Flagyl 500mg IV x1, Decadron 10mg IV x1, CTX 1gm x1, and Versed 2mg x1. He was given a bag of platelets and admitted to the MICU for further management. . On arrival, pt denies any CP, SOB, air hunger, abd pain. He continued to have persistent BMs here in the ICU. Past Medical History: 1)CAD: - s/p MI [**2114**] - 5 vessel CABG [**2119**], LIMA to LAD and SVGs to D1, OM1 and OM2, and PDA. - NSTEMI with LCX stent [**2-23**]. PTCA of proximal circumflex in-stent and peri-stent restenosis [**4-25**]. - POBA of the proximal LCX and distal LCX/OM lesions [**1-27**] - Stent to LCx and RCA (bare metal) in [**9-29**]. MIBI [**2137**]: Moderate fixed defects in basal anterior wall and lateral wall, previously partially reversible. Similarly poor LV function (LVEF 20%). Dilated cavity (LVEDV 206 mL). 2)Congestive heart failure: EF 20-25% per echo in [**2-27**]; pMIBI in [**10-29**] 3)Hypertension 4)Type 2 diabetes complicated by neuropathy and nephropathy 5)Hyperlipidemia 6)CKD (baseline creatinine low 2's, followed by Dr. [**Last Name (STitle) **] 7)Remote tobacco abuse 8)Peripheral vascular disease 9)Thrombocytopenia, followed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 5565**], thought to be [**12-26**] to chronic ITP 10)History of GI bleed with recent EGDs for ulcers 11)Pulmonary fibrosis: HRCT with honeycombing with upper lobe predominance - PFTs [**2138-12-12**] FEV1 1.89, FVC 2.44, FEV1/FVC 77 on 3L O2 since [**1-28**] 12)Pulmonary arterial hypertension 13)OSA on home O2 . Cardiac Risk Factors: Diabetes, Dyslipidemia and Hypertension . Cardiac History: CABG 5 vessel in [**2119**], LIMA to LAD and SVGs to D1, OM1 and OM2, and PDA. . Percutaneous coronary intervention, [**2-23**] with LCX stent. PTCA of proximal circumflex in-stent and peri-stent restenosis [**4-25**]. POBA of the proximal LCX and distal LCX/OM lesions [**1-27**] Stent to LCx and RCA (bare metal) in [**9-29**]. . ICD SJM single lead placed via cephalic vein on [**2139-6-1**] . Social History: Absence of current tobacco use (quit in [**2114**]). Drinks [**11-25**] alcoholic beverages/week. The patient has never been married, and does not have any children. He lives with roommate in [**Location (un) 21541**]. Retired communications engineer. Smoked 3ppd for 15 yrs, quit in [**2114**]. Family History: Father died of cerebral hemorrhage. Mother died of heart disease. Heart disease also in sister and brother. Physical Exam: PEX on day of [**Year (4 digits) **]: VS: Tc: 99.2 BP:111/57 HR:87 RR:16 O2sat: 100% on 3L NC GEN: Comfortable. Awake, alert. HEENT: PERRL, EOMI. RESP: Stable dry crackles bilaterally L > R. Moving air bilaterally. No rales CV: RR, S1 and S2 wnl. +III/VI holosystolic murmur best over apex ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e. Pertinent Results: [**2139-9-11**] 07:25AM BLOOD WBC-6.6 RBC-3.62* Hgb-11.8* Hct-35.5* MCV-98 MCH-32.7* MCHC-33.4 RDW-16.8* Plt Ct-86* [**2139-9-10**] 05:08AM BLOOD PT-12.2 PTT-25.5 INR(PT)-1.0 [**2139-9-11**] 07:25AM BLOOD Glucose-100 UreaN-40* Creat-1.8* Na-143 K-3.9 Cl-103 HCO3-29 AnGap-15 [**2139-9-9**] 03:38AM BLOOD CK-MB-NotDone cTropnT-0.68* [**2139-9-8**] 09:28PM BLOOD CK-MB-10 MB Indx-7.2* cTropnT-0.87* [**2139-9-8**] 11:07AM BLOOD CK-MB-18* MB Indx-9.6* cTropnT-1.55* [**2139-9-8**] 01:15AM BLOOD cTropnT-0.76* proBNP-[**Numeric Identifier 43524**]* [**2139-9-8**] 01:15AM BLOOD CK-MB-18* MB Indx-11.5* . Radiology: CXR [**9-8**]: 1. Limited study due to lack of IV contrast. 2. No secondary signs of bowel ischemia. 3. Mild CHF. 4. Nonspecific perihepatic fluid. 5. Extensive abdominal vascular calcifications including at the right renal artery ostium with a resultant chronic ischemic atrophic right kidney. . CXR [**9-10**]: A pacer device is seen with the lead in the right ventricle. The sternotomy wires intact. There is a left lower lobe and left lingular hazy opacity concerning for consolidation versus atelectasis. This is relatively unchanged since previous examination. The cardiomediastinal silhouette is enlarged but stable. There is no pneumothorax. Brief Hospital Course: 67 y/o M with a PMHx of CAD s/p 5v CABG and multple PCI, sCHF EF 20%, HTN, DM2, CKD (bl Cr 2.0), ITP, hx of GIB, OSA on home o2 initially admitted here with syncope of unclear etiology, mild hypoxia, hypotension. . 1. Respiratory Failure Found in respiratory distress per EMS report, with unclear etiology. CXR does not show overwhelming CHF or PNA. No fever, sputum or WBC noted. Intubated at OSH on [**9-8**] and was subsequently extubated at [**Hospital1 18**] on [**9-9**]. He was quickly weaned down to his baseline o2 requirement of 3L NC with minimal diuresis. On [**Month/Year (2) **], appeared euvolemic, and he was instructed to follow up with his cardiologist and pulmonary doctor [**First Name (Titles) **] [**Last Name (Titles) **]. . 2. Hypotension/Syncope Initially admitted to the MICU with hypotension of unclear etiology - no infection/sepsis was ever identified. Had syncopal event of unclear etiology that may have contributed to hypotension it may have even been a mechanical fall. Unclear. His pacer was interrogated on admission by the EP service with no events found. He initially on peripheral dobutamine temporarily but this was quickly weaned off on his arrival to the MICU. His home BP meds were initially held, and reintroduced slowly. He was discharged on Lisinopril 5mg daily, and Toprol XL 50mg daily. He was instructed to discuss with his cardiologist regarding titrating his Toprol XL back to his previous level of 125mg daily. He was advised not to take so many sedating medications such as vicodin, ambien, and lorazepam. . 3. CHF Pt with hx of sCHF with EF 20%. Initially in respiratory disterss with ? mild CHF that responded to his home level of diuretics. Weaned down to his baseline o2 requirement of 3L NC satting 96-99% on day of [**Last Name (Titles) **]. His ASA, bblocker, ACE and home lasix dose were continued during his hospitalization. He was instructed to follow up with his cardiologist/PCP to titrate back up his Bblocker as his BP tolerates. . 4. Diarrhea Pt presented with syncope in setting of 1 episode of diarrhea. Had c.dif x1 that was negative. Resolved on admission. . 5. CAD/NSTEMI Here with diarrhea with guiaic + stools. EKG unchanged, with mildly elev troponin/CK-MB in setting of ARF. Troponins peaked at 1.55 and now are trending down. Cards consulted - diagnosed with NSTEMI. Cards agreed with continuing ASA/Plavix, holding on Hep gtt given hx of GIB and mildly guiaic (+) stool. His BBlocker, statin and ACE were continued. He was discharged on his home meds and given a prescription for nitroglycerin for angina as needed. . 6. DM2 Covered with RISS while inpt, back to oral Glipizide XL on [**Last Name (Titles) **]. . 7. Thrombocytopenia At baseline plt count (in the 80's), was given plt transfusion in ED. He did not require any further transfusions during his hospitalization. . 8. Health maintanence Patient received the flu shot while in the hospital on [**2139-9-11**] . Code: Full Code. DISPO: Discharged in stable condition home from the ICU. To follow up with Dr. [**Last Name (STitle) 120**] (cardiology), Dr. [**Last Name (STitle) **] (renal) and his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] after [**Last Name (STitle) **]. Medications on Admission: Plavix 75' ASA 325' Toprol XL 125' Glipizide 10' Niacin SR 500" Digoxin 0.125mcg qOD Lasix 40" PPI [**Hospital1 **] Vit E qD Imdur 30 Clorazepate 6.5 [**Hospital1 **] Vit D 400 Aldactone 25' Lisinopril 5' Zocor 40' citalopram 40mg [**Hospital1 **] Medications: 1. NitroQuick 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain. Disp:*30 tablets* Refills:*0* 2. 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* 3. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO twice a day. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Vitamin E Oral 14. Clorazepate Dipotassium 7.5 mg Tablet Sig: One (1) Tablet PO three times a day. 15. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a day. 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 17. oxygen please use home oxygen at 3L continuously to keep oxygen saturation above 90% 18. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 19. Acetylcysteine 600 mg Capsule Sig: One (1) Capsule PO three times a day. 20. Multivitamin Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **] Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] [**Hospital3 **] Diagnosis: Primary Etiology: Syncope of unclear etiology Respiratory Arrest s/p intubation and extubation Congestive Heart Failure Non-ST elevation MI Cardiogenic Hypotension on pressors that resolved [**Hospital3 **] Condition: Stable to be discharged home. [**Hospital3 **] Instructions: We are discharging you on 50mg daily of Toprol XL (this is changed from your previous home dose of 100mg daily). Please discuss with your cardiologist regarding increasing this back to your home dose of Toprol XL. You were also given a new prescription for Nitroglycerin to be used for chest pain. Your lisinopril was changed to 5mg daily because of your low/normal blood pressure. You should not take so many sedating medications such as the vicodin, ambien and benzos. All of your other medications are unchanged. Please take your medications as listed below. If you develop chest pain, shortness of breath, sensation of passing out, fainting or any other concerning symptoms, please contact your doctor or report to the nearest ER. You were given the flu shot on [**2139-9-11**] while in the hospital. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 1500mL Followup Instructions: Please call your primary care doctor when you are discharged to schedule close follow up in the next week. Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 56107**]. Cardiology: Dr. [**Last Name (STitle) 120**] [**Telephone/Fax (1) 127**]. Appointment made Friday, [**9-18**] at 4pm. [**Location (un) 8661**] [**Location (un) 436**] Reminder: Renal doctor appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2139-9-22**] 1:00 Completed by:[**2139-9-11**]

[ "414.00", "287.5", "780.2", "584.9", "428.0", "250.00", "V45.81", "410.71", "585.9", "518.81", "403.90" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5554, 8803

378, 402

4269, 5531

12157, 12697

3759, 3869

8829, 9061

3884, 4250

331, 340

10820, 12134

9091, 10790

430, 1699

1721, 3429

3445, 3743

25,815

160,628

6167

Discharge summary

report

Admission Date: [**2191-1-4**] Discharge Date: [**2191-1-12**] Service: MEDICINE Allergies: Penicillins / Demerol / Heparin Agents Attending:[**First Name3 (LF) 1377**] Chief Complaint: Tracheal stenosis Major Surgical or Invasive Procedure: Flexible bronchoscopy Rigid bronchoscopy Intubation CRP History of Present Illness: 80 year old woman with severe upper cervical myelopathy s/p cervical spine surgery and trach and PEG placement in [**10-14**] presents from rehab after bronchoscopy revealed a question of tracheal stenosis. . Her problems began in [**2190-6-10**] when she presented with bilateral paresthesias. She had an MRI done which showed a large mass perhaps arising from the clivus impinging on the ventral medulla, and extending all the way down to the dens and arch of C1, encroaching on the ventral cord, with posterior thecal sac and cord impingement, and abnormal cord signal. It also showed evidence of C3-C4 cord impingement due to a herniated disk also contributing to her myelopathy. . From [**2191-11-17**] - [**2191-11-22**] she was admitted for hypotension, fevers and mental status change presumably secondary to an aspiration pneumonia. She spend her first 2 days in the MICU and was then transferred to the floor. She was treated with levaquin and flagyl for a 14 day course, and was discharged back to rehab on [**11-22**]. She reports a recent cough but denies any fevers, chills, abdominal pain, nausea, vomiting, headache. Past Medical History: 1. s/p C-spine operation (as above) for subluxation with pannus around odontoid 2. Tracheostomy [**2190-11-2**] 3. PEG placement [**2190-11-1**] 4. HIT, diagnosed [**10-14**] 5. IVC filter placement [**2190-10-28**] 6. Bipolar d/o, on lithium 7. c-section x3 8. cervical myelopathy [**1-12**] rhematoid arthritis since [**2186**] 9. hx or bowel obstruction Social History: Came from rehab, married, husband is also sick at times per daughters, has 2 daughters and 1 son, children very involved.Communication: Husband/daughter at ([**Telephone/Fax (2) 23974**]Son at ([**Telephone/Fax (1) 23975**] Family History: Parents with CAD Physical Exam: VS- T= 98.4 BP= 126/67 P= 86 RR= 18 O2= 100% on 35% TM HEENT- NC/AT. EOMI. Unable to move neck. Chest- referred sounds from upper airway heard throughout anterior and posterior fields. Equal bilaterally. No wheezes, crackles. CV- normal rate, regular rhythm. Normal S1, S2. No M/R/G Abd- PEG in place, dressing C/D/I. BS present. Soft, nontender, nondistended. Ext- no edema. DP pulses 2+ bilaterally. nontender. Right arm in brace. Neuro- AAOx3. Motor: LLE- [**1-15**], RLE- [**12-15**]. Pertinent Results: Admission labs: [**2191-1-4**] 11:46PM GLUCOSE-94 UREA N-30* CREAT-0.6 SODIUM-144 POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-31* ANION GAP-8 [**2191-1-4**] 11:46PM CALCIUM-9.7 PHOSPHATE-4.2 MAGNESIUM-2.4 [**2191-1-4**] 11:46PM WBC-15.0* RBC-3.82* HGB-11.8* HCT-36.3 MCV-95 MCH-30.8 MCHC-32.4 RDW-15.7* [**2191-1-4**] 11:46PM PLT COUNT-289 [**2191-1-4**] 11:46PM PT-12.6 PTT-22.7 INR(PT)-1.0 Brief Hospital Course: A/P: 80 yo F with cervical myelopathy s/p tracheostomy who presents from rehab for evaluation of tracheal stenosis. . #Tracheal stenosis / Respiratory - On [**2191-1-5**] a flexible bronchoscopy showed subglottic/tracheal stenosis with 100% collapse of the trachea and mainstem bronchi with mild suctioning consistent with severe tracheal bronchomalacia. No endobronchial lesions were seen and the vocal cords could not be observed. On [**2191-1-6**] a CT neck showed high-grade narrowing of the subglottic airway above tracheostomy, 4 mm in greatest diameter. Focus of opacity between the superior segmental LLL bronchus and aorta which could represent focal atelectasis. Nonspecific opacities within both upper lobes. On [**2191-1-7**] the patient sufferred cardiac arrest likely due to respiratory arrest from a mucus plugging. She required CPR x 5-10 min and aggressive suctioning. She was maintained on a ventilator overnight and weaned in the AM. She was ruled out for MI and monitored on telemetry. She remained stable after this event and on [**2191-1-10**] a rigid bronchoscopy showed subglottic stenosis. Due to severe stiffness of her cervical spine and extension of her cervical spine could not be obtained for adequate rigid intubation and, therefore, the vocal cords or the epiglottis could not be visualized. After the rigid bronchoscopy, no further testing was recommended by interventional pulmonology. She was transferred from the MICU to the floor on [**2191-1-11**] and remained stable for the rest of hospital stay. #ID: On [**2191-1-7**] the patient patient had a positive blood cluture which grew MRSA, and a positive sputum culture which grew MRSA, pseudomonas, gram negative rods. She was started on cefipime and vancomycin on [**2191-1-9**] with the plan of completing a 14 day course of antibiotics. She had a cardiac echo on [**2191-1-12**] which did not show any vegetations. . Bipolar disorder: The patient was continued on her home dose of lithium 150 mg [**Hospital1 **] . HTN: The patient was continued on her home dose of lopressor and her hydralazine was discontinued. Medications on Admission: Colace Senna Hydralizine 10 Q6 Prevacid Lithium 150 [**Hospital1 **] MOM Lopressor 50 [**Hospital1 **] Nystatin S&S Tylenol Discharge Medications: 1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for daily. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 5. Lithium Citrate 8 mEq/5 mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO BID (2 times a day). mg 6. Cefepime HCl 1 g Recon Soln Sig: 1000 (1000) mg Intravenous Q12H (every 12 hours) as needed for pseudomonal pneumonia resistant to other medications. Last dose on [**2191-1-15**] PM. 7. Vancomycin HCl 10 g Recon Soln Sig: 1000 (1000) mg Intravenous Q12H (every 12 hours). Last dose on [**2191-1-22**]. 8. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed. 10. Sodium Chloride 0.9 % Solution Sig: Three (3) ML Injection DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Tracheal stenosis Secondary: -cervical myelopathy [**1-12**] rhematoid arthritis since [**2186**] -bipolar disorder -hx of HIT -hx or bowel obstruction -s/p c-spine operation -s/p trach and PEG -s/p IVC filter placement Discharge Condition: Stable Discharge Instructions: Take all your medications as prescribed. Call your doctor or come to the ER if you are having shortness of breath, fevers, chest pain, trouble clearing your secretions, or any other worrisome symptoms. Followup Instructions: After discharge from [**Hospital1 13199**], please call Dr [**First Name (STitle) 679**] to make a follow up appointment: [**Telephone/Fax (1) 682**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "E849.7", "285.9", "V44.1", "790.7", "401.9", "V09.0", "041.11", "296.80", "714.0", "E878.3", "427.5", "519.02" ]

icd9cm

[ [ [] ] ]

[ "33.21", "38.93", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

6502, 6574

3088, 5208

263, 321

6839, 6847

2667, 2667

7099, 7374

2125, 2143

5383, 6479

6595, 6818

5234, 5360

6871, 7076

2158, 2648

206, 225

349, 1486

2684, 3065

1508, 1867

1883, 2109

74,740

144,396

31063

Discharge summary

report

Admission Date: [**2129-12-20**] Discharge Date: [**2129-12-21**] Date of Birth: [**2058-10-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: upper GI bleeding Major Surgical or Invasive Procedure: intubation on arrival to ED History of Present Illness: 71 M h/o pancreatic cancer, portal vein thrombosis on coumadin, hypertension p/w syncopal episode at home. Seizures x 2 tonight, no history of seizures in past. Vomiting blood. On coumadin for portal vein thrombosis. BP 58/33. Type O blood about to begin. Full code. PICC and working on another line. . In ED, patient received 8 u prbc at osh, and 1 u prbc at [**Hospital1 18**] ED. Also received 3 u FFP, vitamin K, 4 vials prop. 9 Ca gluconate, IVF. On dopamine, neo and levophed in ED. Intubated, 2 central lines placed and transferred to floor. En route patient vomited BRB and on arriving to ICU developed epistaxis. Past Medical History: PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Recent hospitalization in [**4-/2128**] for pneumonia Borderline diabetes mellitus Pancreatic cancer- unresectable disease, followed by Dr. [**Last Name (STitle) **], on palliative gemcitabine chemotherapy. PAST SURGICAL HISTORY: Status post subtotal thyroidectomy for hypothyroidism in [**2088**] Status post total hip replacement in [**2118**] Status post umbilical hernia repair in [**2117**] Social History: The patient works as a bookkeeper in [**Location 4288**]. He lives in [**Hospital1 3494**] with his wife, [**Name (NI) **]. [**Name2 (NI) **] is a former smoker. He smoked for 25 years and quit in [**2096**]. He does not drink alcohol at present, but drank ETOH heavily at times in the past Family History: The patient states that his father died from lung cancer. He had an aunt with a cancer of an unknown primary. He had an uncle who died form prostate cancer at age 84. He has 3 children who are in good health. Physical Exam: patient brought up from ER on 3 pressors, unresponsive, intubated large amount of bloody sputum per ET tube, epistaxis on arrival to ICU extremities mottled, thready pulses Pertinent Results: [**2129-12-20**] 10:10PM PT-44.7* PTT-77.3* INR(PT)-5.0* [**2129-12-20**] 10:10PM PLT COUNT-116*# [**2129-12-20**] 10:10PM NEUTS-76.9* LYMPHS-16.2* MONOS-6.0 EOS-0.6 BASOS-0.2 [**2129-12-20**] 10:10PM WBC-9.0# RBC-4.00* HGB-11.9* HCT-34.5* MCV-86# MCH-29.7# MCHC-34.5 RDW-16.0* [**2129-12-20**] 10:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2129-12-20**] 10:10PM ALBUMIN-1.1* CALCIUM-5.3* PHOSPHATE-5.4*# MAGNESIUM-1.3* [**2129-12-20**] 10:10PM CK-MB-NotDone [**2129-12-20**] 10:10PM cTropnT-<0.01 [**2129-12-20**] 10:10PM LIPASE-6 [**2129-12-20**] 10:10PM ALT(SGPT)-10 AST(SGOT)-28 CK(CPK)-53 ALK PHOS-100 TOT BILI-0.2 [**2129-12-20**] 10:10PM estGFR-Using this [**2129-12-20**] 10:10PM GLUCOSE-225* UREA N-12 CREAT-0.9 SODIUM-138 POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-16* ANION GAP-13 [**2129-12-20**] 10:21PM HGB-12.5* calcHCT-38 O2 SAT-92 CARBOXYHB-3 MET HGB-0.3 [**2129-12-20**] 10:21PM GLUCOSE-208* LACTATE-5.3* NA+-135 CL--111 [**2129-12-20**] 10:21PM PO2-69* PCO2-36 PH-7.25* TOTAL CO2-17* BASE XS--10 COMMENTS-GREEN TOP Brief Hospital Course: On arrival to ICU, patient was unresponsive, intubated and on 3 pressors. Per nursing, patient had bloody emesis prior to transport. Upon arrival to ICU, sodium bicarb in D5 1/2NS IVF were initiated along with continuation of pressors and drips started in ED. Within minutes of arrival the patient had large amounts of epistaxis. ENT was called to pack the nasal passage and slow bleeding. The patient's family arrived in the ICU and upon discussing goals of care decided on comfort measures only. Invasive measures were stopped per family's wishes. At approximately 3:30am the patient expired. His family was at his bedside. Discharge Disposition: Expired Discharge Diagnosis: massive GI hemorrhage, ?DIC vs secondary to arterial infiltration by known pancreatic tumor Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "272.4", "276.2", "V58.61", "784.7", "286.6", "250.00", "578.9", "518.81", "780.39", "157.8", "785.50", "V43.64", "V12.51", "401.9" ]

icd9cm

[ [ [] ] ]

[ "00.17", "99.04", "99.07", "96.71" ]

icd9pcs

[ [ [] ] ]

4015, 4024

3365, 3992

343, 372

4159, 4168

2243, 3342

4221, 4364

1821, 2034

4045, 4138

4192, 4198

1329, 1496

2049, 2224

286, 305

400, 1026

1070, 1306

1512, 1805

65,227

108,079

49874

Discharge summary

report

Admission Date: [**2121-10-20**] Discharge Date: [**2121-10-27**] Date of Birth: [**2055-8-21**] Sex: M Service: CARDIOTHORACIC Allergies: Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain with activity Major Surgical or Invasive Procedure: coronary rtery bypass grafts x3(LIMA-LAD,SVG-OM,DVG-DG) [**2121-10-23**] Reoperation for bleeding [**2121-10-23**] closed right thoracostomy [**2121-10-24**] History of Present Illness: 66 year old male has a history of carotid artery disease s/p left endarterectomy in [**2117**]. He is normally very active with karate three times a week but recently he has noticed episodes of exertional chest aching with moderate levels of activity. He has even had one episode that woke him from sleep, described as a mild chest pain that radiated to the back, resolving with one SL nitroglycerin. He is now referred for cardiac catheterization to further evaluate. He is now referred to cardiac surgery for revascularization. Past Medical History: Hyperlipidemia Hypertension Hx of TIA's Carotid stenosis s/p left endarterectomy in [**2118-4-19**] Asthma Cyclothymic Disorder, patient reports this is not currently an active issue Sleep apnea- CPAP BPH per outside records (patient denies) Bilateral rotator cuff repair Right hand trigger finger, s/p cortisone injection Right arm fracture s/p surgery Social History: Lives with:wife Occupation: [**Name2 (NI) **] Tobacco:quit 36 years ago ETOH:[**12-21**] glasses of wine/night Family History: Mother CABG Physical Exam: Pulse:67 Resp:16 O2 sat:100&/RA B/P Right:142/80 Left:135/88 Height: 6' Weight:255 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] L CEA incision Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: dressing Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 incision Pertinent Results: [**2121-10-26**] 04:18AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.1* Hct-25.7* MCV-88 MCH-31.5 MCHC-35.6* RDW-14.4 Plt Ct-114* [**2121-10-25**] 08:30PM BLOOD WBC-7.8 RBC-2.93* Hgb-9.2* Hct-25.8* MCV-88 MCH-31.3 MCHC-35.6* RDW-14.4 Plt Ct-103* [**2121-10-23**] 11:19PM BLOOD PT-15.0* PTT-30.0 INR(PT)-1.3* [**2121-10-27**] 05:50AM BLOOD Na-136 K-4.1 Cl-99 [**2121-10-26**] 04:18AM BLOOD Glucose-101* UreaN-20 Creat-0.8 Na-133 K-3.6 Cl-96 HCO3-30 AnGap-11 [**2121-10-25**] 03:34AM BLOOD Glucose-109* UreaN-19 Creat-0.8 Na-132* K-4.0 Cl-99 HCO3-28 AnGap-9 Intra-op echo [**2121-10-23**] PREBYPASS No atrial septal defect is seen by 2D or color Doppler. 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 simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Turbulence on color flow Doppler and an increased velocity (`2 m/sec) by Doppler were demonstrated in the pulmonary artery however a PDA was NOT visualized by TEE or epi-aortic scanning. POSTBYPASS There is preserved biventricular systolic function. The study is otherwise unchanged from prebypass. Elevated PA velocities remain. Brief Hospital Course: The patient was brought to the operating room on [**2121-10-23**] where the patient underwent CABG x 3. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He did return to the operating room within hours of arrival to the CVICU for re-exploration for bleeding. He was loaded with Plavix 3 days preop. Hemostasis was achieved and the patient returned to [**Location 42137**]. Vancomycin was used for surgical antibiotic prophylaxis, given his preoperative length of stay of greater than 24 hours. 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. His chest tubes were discontinued and he did develop right sided pneumothorax. Bedside tube thoracostomy was performed, and the right lung re-expanded. 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. He had a tiny right sided pneumothorax on CXR, which was stable at the time of discharge. He also developed a brief burst of atrial fibrillation which converted to sinus rhythm with lopressor. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 1 puff as needed FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - Dosage uncertain HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth every morning ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth every morning LISINOPRIL - (Prescribed by Other Provider) - 30 mg Tablet - 1 Tablet(s) by mouth every morning LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth as needed for anxiety NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually every five minutes for chest discomfort. Call 911 if pain persists longer than 15 minutes ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth every morning ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth every morning MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain ZINC-PUMPKIN SEED OIL-SAW PALM [SAW [**Location (un) **] COMPLEX(PUMK& ZN)] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO TID (3 times a day) for 1 weeks. Disp:*21 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: **Resume [**2121-11-4**], after lasix is finished**. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Corornary artery disease s/p coronary artery bypass grafts hypertension obstructive sleep apnea obesity hyperlipidemia s/p left carotid endarterectomy asthma Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema: 2+ bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] on Date/Time:[**2121-11-18**] 2:00 [**Telephone/Fax (1) 170**] Cardiologist: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-12-18**] 3:40 Please call to schedule appointments with: Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35852**] ([**Telephone/Fax (1) 34088**]) in [**3-24**] 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:[**2121-10-27**]

[ "493.90", "E878.2", "512.1", "401.9", "411.1", "458.21", "327.23", "427.31", "300.00", "414.01", "272.4", "998.11" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "38.93", "36.12", "34.03", "37.22", "34.04", "88.56" ]

icd9pcs

[ [ [] ] ]

8013, 8084

3732, 5458

329, 489

8286, 8524

2274, 3709

9364, 10081

1572, 1586

6815, 7990

8105, 8265

5484, 6792

8548, 9341

1601, 2255

264, 291

517, 1049

1071, 1427

1443, 1556

79,252

197,591

3823

Discharge summary

report

Admission Date: [**2177-12-3**] Discharge Date: [**2177-12-10**] Date of Birth: [**2108-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**12-3**] Repair of Type A Aortic Dissection with Replacment of Ascending Aorta and Hemiarch and Resuspension of Aortic Valve History of Present Illness: Mr. [**Known lastname 17147**] presented to [**Hospital1 **]-[**Location (un) 620**] ED complaining of chest pain. The work-up ultimately revealed an aortic dissection and he was transferred to [**Hospital1 18**] for emergent surgical management. Past Medical History: Glaucoma, Peripheral Neuropathy, Abdominal aortic aneurysm, s/p right knee athroscopy Social History: non-smoker Family History: non-contributory Physical Exam: At discharge: Vitals: 118/73 67 18 General: No acute distress, HEENT: Extraoccular movements intact, Pupils reactive Neck: Supple, full range of motion Chest: Clear bilaterally Heart: regular rate and rhythm, -murmur Abd: Soft, non-tender, non-distended, +bowel sounds Ext: Warm, trace edema Neuro: Non-focal, Alert and oriented x 3 Pertinent Results: [**2177-12-3**] Echo: PRE-BYPASS: 1. The interatrial septum is aneurysmal. No atrial septal defect or PFO is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF= 65%). Right ventricular chamber size and free wall motion are normal. 3. The aortic root is moderately dilated at the sinus, ascending aorta, and descending thoracic aorta levels. A mobile density is seen in the ascending, arch, and descending aorta consistent with an intimal flap/aortic dissection. There is flow in the false lumen. 4. There are three aortic valve leaflets. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. 6. There is no pericardial effusion or echo findings of tamponade. 7. Dr. [**Last Name (STitle) **] was notified in person of the results during the surgery. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. The LVEF remains similar at 65%. 2. An ascending aortic tube graft is noted. 3. The aortic regurgitations is similar and graded mild 4. Mitral regurgitation also remains mild. [**2177-12-9**] CXR: Again noted is the small right apical pneumothorax, unchanged in size since prior study. Left lower lobe opacification remains similar in appearance most likely a combination of atelectasis and pleural effusion. The remainder of the lungs appear clear. Midline sternotomy wires remain intact. The cardiomediastinal silhouette is unchanged. [**2177-12-3**] 10:02PM BLOOD WBC-3.7* RBC-2.55*# Hgb-8.7*# Hct-23.9*# MCV-94 MCH-34.1* MCHC-36.4*# RDW-14.0 Plt Ct-85*# [**2177-12-9**] 05:35AM BLOOD WBC-7.0 RBC-3.21* Hgb-10.5* Hct-29.3* MCV-91 MCH-32.7* MCHC-35.9* RDW-15.1 Plt Ct-211 [**2177-12-7**] 04:50AM BLOOD PT-13.4 PTT-30.6 INR(PT)-1.1 [**2177-12-8**] 07:40AM BLOOD PT-14.3* PTT-31.3 INR(PT)-1.2* [**2177-12-9**] 05:35AM BLOOD PT-16.3* INR(PT)-1.5* [**2177-12-10**] 05:15AM BLOOD PT-20.0* INR(PT)-1.9* [**2177-12-3**] 11:16PM BLOOD UreaN-17 Creat-0.7 Cl-110* HCO3-22 [**2177-12-4**] 04:45AM BLOOD Glucose-81 UreaN-17 Creat-0.8 Na-139 K-4.2 Cl-112* HCO3-24 AnGap-7* [**2177-12-9**] 05:35AM BLOOD Glucose-91 UreaN-18 Creat-0.8 Na-131* K-4.1 Cl-98 HCO3-26 AnGap-11 [**2177-12-10**] 05:15AM BLOOD Na-133 [**2177-12-9**] 05:35AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.1 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 17147**] presented to OSH with chest pain and was diagnosed with a Type A Aortic Dissection. He was transferred to [**Hospital1 18**] and emergently taken to the operating room where he underwent an Ascending Aorta and Hemiarch replacement with aortic valve resuspension. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Over next several days he remained in the CVICU while BP medications were titrated for maximum hemodynamics. Post-operatively he had episodes of atrial fibrillation and was started on Amiodarone and Coumadin. Chest tubes and epicardial pacing wires were removed per protocol. After removal of chest tubes chest x-rays revealed a small apical pneumothorax. On post-op day five he was transferred to the telemetry floor for further care. He appeared to be doing well while working with physical therapy for strength and mobility. He complained of a hoarse voice on post-op day six and ENT was consulted. ENT exam revealed left vocal cord immobility with residual gap and full motion of right vocal cord. He will follow-up with ENT as an outpatient. He appeared to be ready for discharge on post-op day seven and was discharged home with VNA services. Dr. [**Last Name (STitle) **] will follow INR and adjust Coumadin. Her office was contact[**Name (NI) **] ([**Name (NI) 17148**] [**Name (NI) 10794**]) and stated they would follow it. Contact #[**Telephone/Fax (1) 3393**]. VNA will draw blood on [**12-12**] with future dosing and blood draws per Dr. [**Last Name (STitle) **]. Medications on Admission: At home: Xalatan 0.005% 1gtt OD QD Protonix 40mg QD Fluticasone 50mcg 2 sprays QD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*1* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 * Refills:*2* 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take two 200mg tablets for 5 days. Then one 200mg tablets [**Hospital1 **]. Finally one 200mg tablet QD until stopped by cardiologist. Disp:*60 Tablet(s)* Refills:*2* 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: You already received your Coumadin dose for [**12-10**]. Please skip your dose on [**12-11**]. VNA will draw your INR on [**12-12**] with results sent to Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] will advise you about future Coumadin instructions. Disp:*30 Tablet(s)* Refills:*0* 14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): You already received your Coumadin dose for [**12-10**]. Please skip your dose on [**12-11**]. VNA will draw your INR on [**12-12**] with results sent to Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] will advise you about future Coumadin instructions. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic Dissection s/p Repair of Type A Aortic Dissection with Replacment of Ascending Aorta and Hemiarch and Resuspension of Aortic Valve Post-op Atrial Fibrillation PMH: Glaucoma, Peripheral Neuropathy, Abdominal aortic aneurysm, s/p right knee athroscopy Discharge Condition: Good Discharge Instructions: No driving for 4 weeks. No lifting more than 10 pounds for 10 weeks. Shower daily, no baths. Report any temperature greater than 100.5. Report any weight gain greater than 2 pounds a day or 5 pounds a week. Report any redness of, or drainage from incisions. No lotions, creams or powders to incisions. Coumadin dosing will be followed by Dr. [**Last Name (STitle) **] at [**Hospital1 **]. Goal INR should be between 2-2.5. VNA should contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3393**] with INR results. You already received your Coumadin dose for [**12-10**]. Please skip your dose on [**12-11**]. VNA will draw your INR on [**12-12**] with results sent to Dr. [**Last Name (STitle) **]. As already mentioned, Dr. [**Last Name (STitle) **] will advise you about future Coumadin instructions. Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2177-12-22**] at 2:45PM (Appointment has already been made) Dr. [**Last Name (STitle) **] will follow your INR and adjust Coumadin accordingly. Dr. [**Last Name (STitle) 3878**] (Otolaryngology) at [**Telephone/Fax (1) 41**]. [**Hospital 409**] clinic in 2 weeks Please call for appointments. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2177-12-10**]

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Discharge summary

report

Admission Date: [**2170-12-13**] Discharge Date: [**2170-12-29**] Date of Birth: [**2106-4-8**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 7591**] Chief Complaint: Pancytopenia (sent from [**First Name3 (LF) 3390**] [**Name Initial (PRE) 3726**]) Major Surgical or Invasive Procedure: Right IJ line History of Present Illness: 64 y/o M with history of MS presenting from [**Name Initial (PRE) 3390**] with progressive lower extremity edema and new systolic murmur. Patient reports subacute deterioration from his baseline. In the 2-3 weeks, he has been feeling more fatigued, weak, with one episode of severe weakness when he had trouble getting out of bed. He also has experienced increasing shortness of breath at rest. In addition, he started having bilateral lower extremity swelling 2-3 days ago (has had a remote history of this, but not as severe). ROS notable for constipation, remote history of bloody stools and urine, constipation and LE pinpoint rash. Denies F/C, orthopnea, PND, cough. This AM, his VNA visited and thought he was pale, concerned about anemia, so sent him to [**Name Initial (PRE) 3390**]. [**Name10 (NameIs) 3390**] office exam notable for new murmur and palpable liver edge with some jaundice, concern for valvular insufficency and hepatic congestion, and labs showing pancytopenia. In the ED inital vitals were, 98.1 92 114/53 20 98% 4L Nasal Cannula. Exam was notable for bilateral lower extremity edema, elevated jugular venous pressure, and a systolic murmur, in addition to scleral icterus and jaundice. Labs were notable for WBC 1.9, hemoglobin 3.0 and hematocrit 9.6, with platelets of 12. He had a transaminitis with elevated LDH and normal total bili. Automated smear was negative for schistocytes. Troponin was negative x 2 and EKG was sinus tachycardia at [**Street Address(2) 7592**] elevations or depressions. BNP was elevated to 3543. He was transfused 2U PRBC. Urinalysis was concerning for urinary tract infection, so patient was started levaquin. CXR concerning for RLL infiltrate, and patient given levaquin and azithromycin. Bedside ECHO in ED concerning for ?RV mass, vegetation? On arrival to the ICU, patient comfortable, hemodynamically stable. 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, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: Multiple Sclerosis - Diagnosed in [**2154**]. Multiple resolving flares. Multiple lesions detected on [**Year (4 digits) 4338**]. Has been treated with alternative medications and acupuncture after having a bad experience with amantadine. Osteoporosis Vitamin D deficiency Social History: On disability. Was VP of publishing company and travelled extensively many years ago. Lives alone, rarely goes outside, has groceries delivered to him and has a housekeeper. - Tobacco: Currently uses tobacco and marijuana - Alcohol: Denies - Illicits: medical marijuana Family History: Mother: Ovarian [**Name (NI) 3730**] - Died at age 60 Father: Died in accident at age 50. Siblings: No siblings. Denies diabetes or hypertension. Physical Exam: Admission exam: Vitals: 97.2, 70, 123/61, 23, 90% on high [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP elevated to angle of the jaw at 70 deg angle, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [**2-18**] holosystolic murmur at LLSB, no rubs or gallops Abdomen: +BS, soft, RUQ tenderness, no hepatosplenomegaly, no rebound tenderness or guarding GU: foley draining red-tinged blood Ext: 2+ edema in the b/l LE, R>L up to mid leg. petechiae on b/l LE. warm, well perfused, 2+ pulses, no clubbing, cyanosis Neuro: CNII-VII intact, motor strength 5/5 in LUE, [**4-17**] in RUE, [**4-17**] in LLE, [**3-17**] in RLE Pertinent Results: Admission labs: WBC-2.4*# RBC-1.23*# Hgb-3.3*# Hct-9.9*# MCV-80*# MCH-26.5*# MCHC-31.2 RDW-30.5* Plt Ct-14*# Neuts-43* Bands-0 Lymphs-39 Monos-6 Eos-0 Baso-0 Atyps-11* Metas-0 Myelos-0 NRBC-10* Plasma-1* PT-16.9* PTT-33.4 INR(PT)-1.6* Fibrino-495* ESR-50* Ret Aut-7.5* Glucose-100 UreaN-40* Creat-1.8*# Na-135 K-4.3 Cl-94* HCO3-29 AnGap-16 ALT-146* AST-185* LD(LDH)-584* AlkPhos-106 TotBili-1.0 Lipase-20 proBNP-3543* cTropnT-<0.01 Albumin-3.4* Calcium-8.2* Mg-2.5 D-Dimer-1223* Hapto-102 Ferritn-663* calTIBC-244* VitB12-602 Folate-15.2 Ferritn-584* TRF-188* Triglyc-78 Cortsol-17.1 HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE HIV Ab-NEGATIVE HCV Ab-NEGATIVE HSV, parvo B19, EBV, CMV negative . DISCHARGE LABS [**2170-12-29**] 12:00AM BLOOD WBC-3.8* RBC-2.38* Hgb-7.0* Hct-20.8* MCV-87 MCH-29.4 MCHC-33.8 RDW-16.5* Plt Ct-39* [**2170-12-29**] 12:00AM BLOOD Neuts-73* Bands-0 Lymphs-19 Monos-1* Eos-2 Baso-2 Atyps-0 Metas-0 Myelos-1* NRBC-1* Other-2* [**2170-12-29**] 12:00AM BLOOD PT-16.7* PTT-36.2 INR(PT)-1.6* [**2170-12-29**] 12:00AM BLOOD Glucose-78 UreaN-15 Creat-0.6 Na-138 K-3.8 Cl-105 HCO3-27 AnGap-10 [**2170-12-29**] 12:00AM BLOOD ALT-21 AST-16 LD(LDH)-160 AlkPhos-81 TotBili-0.5 [**2170-12-29**] 12:00AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.7 UricAcd-2.6* . MICROBIOLOGY: [**2170-12-13**] 5:55 pm URINE Site: CATHETER URINE CULTURE (Final [**2170-12-16**]): CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | CITROBACTER FREUNDII COMPLEX | | CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I 32 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Pleural fluid ([**2170-12-21**])- GRAM STAIN (Final [**2170-12-21**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. Sputum endotracheal ([**2170-12-21**])- contaminated, culture not performed GRAM STAIN (Final [**2170-12-21**]): [**11-6**] PMNs and >10 epithelial cells/100X field. Sputum ([**2170-12-19**])- contaminated, culture not performed, no legionella Blood culture ([**2170-12-18**])- NGTD, pending final Blood culture ([**2170-12-17**])- NGTD, pending final Blood culture ([**2170-12-13**])- NGTD, pending Sputum ([**2170-12-17**])- GRAM STAIN (Final [**2170-12-17**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final [**2170-12-19**]): RARE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. CMV IgG POSITIVE, IgM NEGATIVE, no CMV DNA detected [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2170-12-17**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2170-12-17**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2170-12-17**]): NEGATIVE <1:10 BY IFA. Hepatitis serologies ([**2170-12-13**])- HBsAg negative, HBs Ab negative, HBc Ab negative, HAV Ab negative, IgM HAV negative IMAGING: CXR [**2170-12-13**]: IMPRESSION: Subtle minimal ill-defined opacity within the right lung base may reflect an area of developing infection. No evidence for pulmonary edema. ECHO [**2170-12-14**]: The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. 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. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. RUQ U/S [**2170-12-14**]: IMPRESSION: 1. Small liver hemangioma. Otherwise, normal-appearing liver. 2. Fullness of the bilateral renal pelvises without hydronephrosis. 3. Gallbladder wall edema without significant distention of the gallbladder likely relates to third spacing. Sludge within the dependent portion of the gallbladder. 4. Splenomegaly. 5. Bilateral pleural effusions. 6. Trace ascites. 7. Left renal cyst. BLE U/S [**2170-12-14**]: IMPRESSION: 1. Partially occlusive thrombus within a left posterior tibial vein with possible occlusive thrombus in a second left posterior tibial vein versus superficial vein. 2. No additional deep venous thrombosis within the bilateral lower extremities. CXR [**2170-12-15**]: IMPRESSION: 1. Interval placement of an endotracheal tube which has its tip approximately 10 cm above the carina. The tube should be advanced approximately 4 cm. The patient's nurse, [**Doctor First Name 7279**], was notified by phone on [**2170-12-16**] at 8:42 a.m. the need for repositioning. 2. Both costophrenic angles are not included on this study. There is a bilateral diffuse airspace process which again appears slightly improved favoring that this represents some moderate-to-severe pulmonary edema rather than diffuse pneumonia. However, clinical correlation is advised. Overall cardiac and mediastinal contours are stable. No large pneumothorax appreciated. [**Year (4 digits) 4338**] Brain, C-spine [**2170-12-21**]: Scattered areas of high signal intensity in the subcortical and periventricular white matter, extending to the callosal septal region, consistent with demyelination and related with a history of multiple sclerosis. The plaques are more numerous since [**2163**], there is no evidence of abnormal enhancement. No mass effect or shifting of the normally midline structures is present. The alignment of the cervical vertebral bodies appears maintained, disc degenerative changes are identified, consistent with disc desiccation, mild posterior disc bulge is noted at C4-C5, causing anterior thecal sac deformity and impinging the thecal sac (image 13, series 19). There is no evidence of neural foraminal narrowing or significant spinal canal stenosis. Disc degenerative changes are also present at C6-C7 level with narrowing of the intervertebral disc space, Schmorl's node and endplate changes are visualized at this level, consistent with bone marrow replacement for fat (image 8, series 16). The spinal cord demonstrates areas of high signal intensity on the fat suppression sequence, more evident at C2, C3 and C5 levels, likely consistent with demyelinating plaques. There is no evidence of abnormal enhancement in this area. . Head CT [**2170-12-25**] Final Report INDICATION: 64-year-old male with MS presents with coagulopathy, respiratory distress and mental status change. Rule out ICH. COMPARISON: [**Month/Day/Year 4338**] of [**2170-12-21**]. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. CT HEAD WITHOUT IV CONTRAST: A tiny amount of hyperdense material is seen in a right frontal sulcus (2:20) and a right temporal sulcus (2:14) concerning for subarachnoid hemorrhage. In addition, there is a small amount of hyperdense material layering in the posterior [**Doctor Last Name 534**] of the left lateral ventricle concerning for intraventricular hemorrhage (2:17). There is no intraparenchymal hemorrhage or extra-axial collection. There is no major vascular territory infarction, mass effect, or edema. [**Doctor Last Name **]-white matter differentiation is preserved. There is age-appropriate prominence of ventricles and sulci compatible with diffuse parenchymal volume loss. Globes and lenses are intact. Mucosal thickening in the left maxillary and sphenoid sinuses is noted, but the remainder of visualized paranasal sinuses and mastoid air cells are well aerated. There is no suspicious lytic or sclerotic bone lesion. IMPRESSION: 1. Findings concerning for subarachnoid hemorrhage in the right frontal and temporal lobes and a tiny amount of intraventricular hemorrhage in the left lateral ventricle. Close interval follow up recommended to exclude progression. 2. Left maxillary and sphenoid sinus inflammatory disease. COMMENT: Findings discussed by phone with Dr. [**First Name8 (NamePattern2) 1255**] [**Name (STitle) 1256**] at 10 PM on [**2170-12-25**]. NOTE ADDED IN ATTENDING REVIEW: In retrospect, the diffusely abnormal hyperintensity on the FLAIR sequences from the MR examination of [**2170-12-21**] was in the subarachnoid space, rather than cortically-based (as reported). This likely represented diffuse subarachnoid hemorrhage in cortical sulci, and there was a "sedimentation layer" in the trigone and occipital [**Doctor Last Name 534**] of the left lateral ventricle at that time (8,12:[**10-23**]). No pathologic leptomeningeal or dural enhancement was demonstrated on that exam. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Approved: WED [**2170-12-26**] 10:51 AM . HEAD CT [**2170-12-26**] CLINICAL INFORMATION: 64-year-old male with MDS and MS, found to have intracranial hemorrhage and altered mental status, for followup. COMPARISON: [**2170-12-25**] CT, [**2170-12-21**] MR. TECHNIQUE: Axial MDCT images were acquired of the head without contrast and reformatted into coronal and sagittal planes. FINDINGS: Hyperdense material is again seen layering within the occipital [**Doctor Last Name 534**] of the left lateral ventricle. There has been interval development of hyperdense material layering within the occipital [**Doctor Last Name 534**] of the right lateral ventricle, increasing the probability that this does in fact represent hemorrhage. While the ventricles are mildly prominent, there is no dilatation of the temporal horns to suggest hydrocephalus. The sulci also are prominent. The [**Doctor Last Name 352**] matter/white matter differentiation remains preserved. Hypodensity in the frontal white matter, extending superiorly from the corpus callosum is consistent with the known demyelinating lesions seen better on [**Doctor Last Name 4338**]. Hyperdense foci are also seen within frontal sulci (image 26), which is nonspecific and could represent subarachnoid hemorrhage or calcification. There is minimal mucosal change of the left maxillary sinus, and there is partial opacification of left mastoid air cells. Additionally, there is an air-fluid level seen within the left sphenoid sinus with mucosal thickening. IMPRESSION: 1. Redistribution of intraventricular hemorrhage, now seen within the occipital horns of the lateral ventricles, bilaterally. 2. Subtle hyperdensity within multiple sulci, likely reflecting resorption and redistribution of the diffuse subarachnoid blood seen on the MR study of [**2170-12-21**] is unchanged from the NECT obtained only 10 hours earlier. 3. There has been further ventricular dilatation since the remote MR study of [**2163-2-12**], but this more likely reflects progressive global, including central atrophy, rather than developing hydrocephalus. . BONE MARROW BIOPSY Cell culture was established to provide metaphase cells for chromosome analysis. No metaphases were available from this specimen, therefore the cytogenetic analysis could not be performed. -------------------INTERPHASE FISH ANALYSIS, 100-300 CELLS------------------- nuc ish(D7Z1,D7S522)x1[43/100], (EGR1x1,D5S23/D5S721x2)[30/100],(D8Z1x2),(D20S108x2)[100] FISH evaluation for a 7q deletion was performed with the Vysis LSI D7S522/CEP7 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for D7S522 at 7q31 and CEP7 (D7Z1) (chromosome 7 alpha satellite DNA) at 7p11.1-q11.1 and is interpreted as ABNORMAL. A single D7S522/D7Z1 hybridization signal was observed in 43/100 nuclei, which exceeds the normal range (up to 3% MONOSOMY 7) established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. FISH evaluation for a 5q deletion was performed with the Vysis LSI EGR1/D5S23, D5S721 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for EGR1 at 5q31 and D5S721/D5S23 at 5p15.2 and is interpreted as ABNORMAL. A single hybridization signal was observed in 30/100 nuclei examined, which exceeds the normal range (up to 3% EGR1 deletion) established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. FISH evaluation for a chromosome 8 aneuploidy was performed with the D8Z2 DNA Probe (chromosome 8 alpha satellite DNA) ([**Doctor Last Name 7594**] Molecular) at 8p11.1- q11.1 and is interpreted as NORMAL. Two hybridization signals were detected in 94/100 nuclei examined, which is within the normal range established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 6% of cells in normal samples can show apparent trisomy 8 using this probe set. A normal chromosome 8 FISH finding can result from absence of trisomy for chromosome 8 or from an insufficient number of neoplastic cells in the specimen. FISH evaluation for a 20q deletion was performed with the Vysis LSI D20S108 Probe ([**Doctor Last Name 7594**] Molecular) at 20q12 and is interpreted as NORMAL. Two hybridization signals were observed in 97/100 nuclei examined, which is within the normal range established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 8% of cells in normal samples can show apparent 20q deletion using this probe set. A normal 20q FISH finding can result from absence of a 20q deletion, from a 20q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. . SPECIMEN SUBMITTED: BON E MARROW CORE BX ILIAC CREST (1 JAR) Procedure date Tissue received Report Date Diagnosed by [**2170-12-14**] [**2170-12-14**] [**2170-12-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/mn???????????? ============== DIAGNOSIS ============ SPECIMEN: BONE MARROW CORE BIOPSY. DIAGNOSIS: HYPERCELLULAR MARROW WITH EXTENSIVE FIBROSIS, TRILINEAGE DYSPLASIA, AND INCREASED MYELOBLASTS. SEE NOTE. Note: The findings are highly suspicious for a myelodysplastic disorder best classified as refractory anemia with excess blasts (RAEB-2) based on the number of myeloblasts in the peripheral blood (a marrow aspirate could not be obtained) and the core biopsy immunostained with CD34. However, given the clinical presentation of the patient with severe anemia and acute high output cardiac failure the findings in this marrow need to be interpreted with caution and a follow up biopsy is highly recommended, unless cytogenetic studies confirm myelodysplastic syndrome or other related myeloproloferative disorder. Please correlate with cytogenetic findings and clinical evolution. MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The peripheral blood smear is adequate for evaluation. Erythrocytes exhibit anisopoikilocytosis, targets, bite cells, elliptocytes, dacrocytes, and show polychromasia and basophilic stippling. The white cell count is decreased. Neutrophils are decreased and exhibit dysplastic features including hyposegmentation. Pseudo Pelger-[**Doctor Last Name **]??????t forms are present as well as hypogranular forms. Monocytes are normal in number and exhibit mild dysplasia. Lymphocytes are decreased in number and include some large granular lymphocytes. Platelets are decreased in number and many are hypogranular and large. Multiple nucleated red blood cells are seen (50% of nucleated cells) and exhibit significant dyspoiesis including asymmetric nuclear budding, nuclear fragments and cytoplasmic nuclear dy synchrony. Differential shows 54% neutrophils, 2% bands, 18% lymphocytes, 7% monocytes, 2% eosinophils, 4% basophils; 12% blasts and 1% myelocytes. Aspirate Smear: An aspirate smear was not submitted. Biopsy and clot sections: Two cores are received both measuring 9mm in length. One core consists almost entirely of fibrotic marrow with variable cellularity, which ranges from 5% to 20%. The second core is cellular with an overall cellularity of 70-80%. The M:E ratio appears decreased. Erythroid precursors are increased and exhibit dyspoietic maturation. Myeloid precursors are decreased in number and exhibit dysplastic maturation. Megakaryocytes are increased and exhibit dysplastic maturation. Special Stains: A CD34 stain highlights blasts comprising 10-20% of the marrow cellularity. CD33 is immunoreactive in approximately one third of the marrow cells. E-Cadherin and glycophorin-A highlight erythroblasts. There is a greater percentage of cells staining for glycophorin-A than E-cadherin which is immunoreactive in about one third of the cells, indicating that the majority of the erythroblasts are undergoing maturation. CD42 reveals numerous megakaryocytes. MPO staining is dim and stains approximately 20% or less in the cells. CD68 stains most myeloid precursors as well as increased marrow histiocytes. CD117 (CKit) has strong staining in the mast cells and reveals an increased number. Dimly stained cell with CD117 correspond to increased megakaryocytes. Cytogenetic Studies: See separate report. Flow Cytometry Studies: See separate report. Clinical: Anemia, leukopenia and thrombocytopenia. 64 year old male with progressive MS [**First Name (Titles) **] [**Last Name (Titles) 7595**] associated with pancytopenia concerning for aplastic process. . SPECIMEN SUBMITTED: Immunophenotyping - PB Procedure date Tissue received Report Date Diagnosed by [**2170-12-17**] [**2170-12-17**] [**2170-12-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/dsj?????? Previous biopsies: [**-1/5104**] BON E MARROW CORE BX ILIAC CREST (1 JAR) FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, Glycophorin A, Kappa, Lambda, and CD antigens 2, 3, 4, 5, 7, 8, 10, 11c, 13, 14, 15, 19, 20, 33, 34, 41, 56, 64, 71, 117. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize blast yield. There are two dominant populations in the blast gate. One population is slightly dimmer than lymphocytes for CD45 and exhibits a phenotype consistent with myeloblasts (positive for CD45, CD34, CD33, CD11c, CD117 (dim), CD15, CD13 and are negative for CD14, CD41, CD56, CD64, and glycophorin. A second population which express only low levels of CD45 lacks all lymphoid and myeloid markers but is positive for CD71 and glycophorin-a and represent erythroblasts. INTERPRETATION Immunophentopyic findings consistent with an increased population of myelodysplastic and erythroblasts, and suggest a myelodysplastic syndrome with increased blasts or acute leukemia. Please correlate with the morphologic findings in the marrow biopsy and a blast count. Please see concurrent bone marrow report S11-[**Numeric Identifier 7596**]. Note: This test was performed using analyte specific reagents (ASRs). These ASRs have not been cleared or approved by the US Food and Drug Administration (FDA). However, the FDA has determined that such clearance or approval is not necessary . This test was developed and its performance characteristics determined by the Flow Cytometry Laboratory at [**Hospital1 771**], which is licensed by CLIA to perform high complexity tests. This test was used for clinical purposes; it should not be regarded as for research. Clinical: Multiple sclerosis and new pancytopenia. Gross: Bone marrow for immunophenotyping. Brief Hospital Course: 64 yo M with advanced progressive multiple sclerosis presenting with increasing fatigue/weakness, b/l LE swelling, and pancytopenia, bone marrow consistent with MDS, course complicated by hypoxic respiratory failure, DVT/PE, Pneumonia, ICH. . # Hypoxic Respiratory Failure: Patient initially presented with increasing fatigue. Developed hypoxic respiratory failure requiring intubation. Differential included PE (patient with DVT found on LE ultrasound), transfusion associated circulatory overload [**2-14**] to rapid multiple transfusions, and less likely pneumonia. CXR revealed a diffuse bilateral pattern. Initially covered with Vanc/Cefepime, but then discontinued Vanc/Cefepime after 2 days when likelihood of pneumonia low. Patient treated for DVT (potential PE) with heparin drip. Extubation was performed on HD 5, however patient was extremely tachypnic and required re-intubation. Antibiotics were restarted with vancomycin, cefepime, and levofloxacin and patient completed a ten day course. He was diuresed over the next several days with IV lasix (bolus and drip) for treatment of transfusion associated circulatory overload. In addition, patient had a large left sided effusion, largely related to volume overload/pulmonary edema, which was drained by thoracentesis. Fluid was consistent with transudate and culture was negative. Difficulty extubating was also thought to be related to underlying multiple sclerosis causing neuromuscular weakness. Negative inspiratory force was low, but gradually improved and on HD 10, patient was successfully extubated. His respiratory status continued to improve and he had saturations in the mid to high 90s on room air at the time of discharge. # Deep vein thrombosis: Patient had bilateral swelling of lower extremities on presentation. Doppler ultrasound showed a partially occlusive clot in the left lower extremity. Patient was placed on heparin drip with goal PTT 60-80 given patient's high risk of bleeding given his pancytopenia. He was kept on heparin drip while intubated, and upon extubation and clearance by speech and swallow he was transitioned to lovenox and given one dose of warfarin. Lovenox was however discontinued due to thrombocytopenia. The patient therefore underwent successful placement of an IVC filter by IR. A CTA was deferred given patient's initial acute kidney injury. # Hypotension: Concern of sepsis from urinary and pulmonary sources. Sedation may also have contributed to hypotension. Adrenal insufficiency ruled out by normal cortisol AM level and cortisol stim test. Right IJ placed, but patient did not require pressor support. Blood pressures remained low normal throughout his hospitalization. His systolic blood pressures were in the 100-110s at the time of discharge. . # Myelodysplastic syndrome: Patient presented with pancytopenia. Bone marrow biopsy showed MDS with erythroblasts without evidence of leukemia. Viral studies negative for CMV, HSV, HIV, EBV, and parvovirus. Patient treated with supportive blood products, transfusion threshold Hct<21 and Plt<30. Patient required a total of 12 units of pRBC and 14 units of platelets throughout hospitalization. He was started on neupogen 480mcg daily per BMT recommendations, this was discontinued on discharge as he was no longer acutely infected. Once patient's respiratory status was stabilized, he was transferred to BMT floor for further management. Given the patients current deconditioned status he is not a good candidate for therapy at this time. He will follow-up with Hematology/Oncology as an outpatient to determine further management of his MDS. For now he will be managed with transfusion support. . # Multiple sclerosis: Patient has progressive MS, with recent deteriorations. Per conversation with outpatient neurologist, [**Month/Day (2) 7595**] was not a necessary medication and was discontinued. Oxacarbazepam was initially held as concern for cause of pancytopenia, however it was restarted once bone marrow showed MDS. An [**Month/Day (2) 4338**] was performed which showed increased numbers of plaques compared to [**Month/Day (2) 4338**] from [**2163**]. Patient complained of worsening right greater than left upper and lower extremity weakness, which improved following extubation, but was still quite debilitating. In addition, difficulty extubating was attributed to MS [**First Name (Titles) 3**] [**Last Name (Titles) 4338**] showed plaques in C3-C5 concerning for involvement of the phrenic nerve. However, as above, following extubation, patient had no signs of neuromuscular weakness effecting his ability to breath independently. The patient was evaluated by PT who felt the patient would benefit from intensive rehab. . # Supraventricular tachycardia: Patient was noted to have 2 episodes of tachycardia to the 150s after transfer to the BMT service. EKG showed an SVT (most likely AVNRT). During theses episodes his blood pressure decreased to SBP of high 80s. He also became mildly confused during the first episode. Each time he was given adenosine 6 mg once with return of sinus rhythm and improvement in his blood pressure. Following the second episode he was started on metoprolol tartrate which was titrated upward to 25 mg [**Hospital1 **]. He remained in sinus rhythm for the remainder of his hospitalization. He will need to follow-up with his [**Hospital1 3390**] [**Last Name (NamePattern4) **]. [**First Name (STitle) **] regarding need for outpatient cardiology referral. . # Intracranial hemorrhage: On [**12-25**] patient was noted to be confused. Given his low platelet count there was concern for an intracranial hemorrhage. A head CT did show a small focus of intraventricular hemorrhage in the left lateral ventricle and small foci of possible SAH. The patient was given vitamin K to reverse the coumadin he had received that day, FFP and platelets. Repeat head CT 7 8 hours later was unchanged and the patients neuro exam was stable. Neurosurgery was consulted and recommended keeping platelets > 80 for 7 days and follow up in 1 month. . # Acute mental status changes: Patient was noted to be confused on transfer from the ICU. This was felt to be multi-factorial in nature. ICU delirium was likely a factor as mental status improved with better sleep hygiene. Additionally, as above the patient was noted to have a small intracranial hemorrhage. Infectious work-up including blood cultures and urine cultures were negative though the patient was undergoing treatment of pneumonia. Chemistry panel was unremarkable. The patients mental status continued to improve and was at baseline at the time of discharge. . # Urinary retention- Patient noted to be retaining urine after removal of a foly catheter. Catheter was replaced. He will need repeat voiding trial in [**3-16**] days ([**1-1**], [**1-2**]) . # Elevated INR - Patient noted to have INR elevated to 1.3-1.6. He was given vitamin K 5 mg x 2. He was started on PO vitamin K 5 mg weekly. This medication should be continued on discharge. His INR should be monitored at rehab with discontinuation of medication when INR is within normal limits. . # Urinary tract infection: Urine culture was positive for pansensitive citrobacter from the urine. Patient completed a 7-day course of ciprofloxacin. Subsequent urine cultures were negative as were several blood cultures. . # Hypernatremia: Patient's sodium was high during admission. This was treated with free water flushes via OG tube while patient was intubated. Hypernatremia resolved and did not return. . # Transaminitis: Initially elevated, then trended down. RUQ showed no signs of hepatic congestion or infiltrative disease. No venous thrombosis. Hepatitis serologies negative, CMV negative, EBV, HIV negative. [**Month (only) 116**] still be medication induced. This resolved prior to discharge. . # Acute kidney injury: Cr initially elevated, likely [**2-14**] severe hypovolemia in the setting of severe anemia. Trended back to baseline with transfusions and remained stable throughout hospitalization. . # Hyperuricemia: Uric acid was 11.0. Potassium and phosphate were not consistent wtih tumor lysis syndrome. Patient was started on allopurinol to decrease uric acid level as there was concern that high level may be contributing to acute kidney injury. His allopurinol dose was decreased to 100 mg daily prior to discharge. . # Overall goals of care: Established friend, [**Name (NI) 6739**], to be health care proxy. Following extubation, patient expressed his wishes to be DNR/DNI. Paperwork for code status and health care proxy were completed with the assistance of social work. # Transitional issues: - Patient is DNR/DNI - Patient will follow-up with Dr. [**Last Name (STitle) 3759**] (Heme/Onc), Dr. [**Last Name (STitle) 739**] (Neuro [**Doctor First Name **]), Dr. [**Last Name (STitle) **] (Neurology), he should also call to make an appointment with Dr. [**First Name (STitle) **] ([**First Name (STitle) 3390**]) after being discharged from rehab - Blood cultures were pending at the time of discharge - Patient was discharged to [**Hospital3 **] facility in [**Hospital1 8**] - Patient will need monitoring of his INR, CBC and Chem-10 Medications on Admission: Alendronate 70mg po qweek [**Hospital1 **] 20mg subcutaneous daily Provigil 200mg po qAM, 100mg po qPM Naltrexone 1.5mg po TID Oxcarbazepine 150mg po BID/TID Lorazepam 0.5mg po qHS prn Calcium carbonate-Vit D3 800mg-400U tab po BID Vitamin C 1000mg po daily MVI Discharge Medications: 1. modafinil 100 mg Tablet Sig: 1-2 Tablets PO qAM (). 2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 3. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO twice a day. 4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP < 90 HR < 60 . Tablet(s) 6. calcium carbonate-vit D3-min 600 mg calcium- 400 unit Tablet Sig: One (1) Tablet PO twice a day. 7. ascorbic acid 500 mg/5 mL Syrup Sig: One (1) PO DAILY (Daily). 8. therapeutic multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. docusate sodium 50 mg/5 mL Liquid Sig: [**5-22**] mL PO BID (2 times a day) as needed for constipation. 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 12. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for anxiety/insomnia. 13. phytonadione 5 mg Tablet Sig: One (1) Tablet PO once a week. 14. ketoconazole 1 % Shampoo Sig: One (1) application Topical every other day. 15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: [**1-16**] Tablet, ER Particles/Crystalss PO once a day as needed for hypokalemia : Please administer Potassium 3.8 - 3.6: 40 mEq PRN Potassium 3.5 - 3.3: 60 mEq PRN Potassium 3.2 - 3.0: 80 mEq PRN . Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: PRIMARY Multiple sclerosis Myelodysplastic Syndrome Intraventricular hemorrhage Deep venous thrombosis Supraventricular Tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr [**Known lastname 7597**] It was a pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know you were admitted because you had swelling in you legs. You were found to have a clot in your left leg. You were also found to have very low blood counts due to your bone marrow not working properly. You were given blood and platelets. Since your blood counts are low we cannot give you blood thinners to treat the clot so a filter was placed in one of your blood vessels to prevent it from traveling to your lungs. You also had trouble breathing while in the hospital and required placement of a breathing tube. This was successfully taken out and you are now breathing on your own. Your heart was noted to have an irregular rhythm that was very fast. We started you on medication to help control your rate. You were also noted to have a small bleed in your brain. This has been stable. There is nothing that needs to be done for this currently however you will need to follow-up with the neurosurgeons in 1 month. We made the following changes to your medications 1. STOP [**Hospital1 **] 2. STOP Naltrexone 3. DECREASE Provigil to 200 mg in the morning and stop taking it at night 4. DECREASE Ativan to [**1-14**] pill as needed at night 5. START Metoprolol tartrate 25 mg twice a day 6. START allopurinol 100 mg daily 7. START senna, colace as needed for constipation 8. START tylenol as needed for pain 9. START vitamin K 5 mg every week 10. START ketoconazole shampoo every other day . Please feel free to call if you have any questions or concerns Followup Instructions: Department: NEUROLOGY When: FRIDAY [**2171-1-18**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: TUESDAY [**2171-1-29**] at 10:00 AM With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2171-1-29**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage * The office of Dr. [**Last Name (STitle) 739**] in neurosurgey will contact you regarding a follow-up appointment in 1 month if the rehab does not hear from them they should call ([**Telephone/Fax (1) 88**] . * After discharge from rehab you will need to follow-up with Dr. [**First Name (STitle) **] his number is [**Telephone/Fax (1) 7477**]

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icd9cm

[ [ [] ] ]

[ "88.51", "38.7", "96.6", "41.31", "96.72", "38.97", "96.04", "96.71", "34.91" ]

icd9pcs

[ [ [] ] ]

36164, 36235

25185, 33843

356, 371

36411, 36411

4315, 4315

38211, 39532

3315, 3463

34722, 36141

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4331, 7030

36426, 36563

33866, 34409

2733, 3007

3023, 3299

7062, 25162

25,492

127,354

49524

Discharge summary

report

Admission Date: [**2189-9-20**] Discharge Date: [**2189-9-29**] Date of Birth: [**2111-6-23**] Sex: M Service: SURGERY Allergies: Azithromycin / Nsaids Attending:[**Known firstname 148**] Chief Complaint: Acute epigastric abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 78yo [**Male First Name (un) 4746**] that after eating seafood the night prior to admission at home developed sharp, stabbing, non-radiating epigastric pain with associated nausea and vomiting 6 hours after initial food consumption. Patient had normal urine and stool color/consistency. Pt denies prior episodes and denies fevers/chills Past Medical History: HTN Prostate Ca Vertigo Hypercholesterolemia Normal EGD '[**85**] Colonoscopy [**2184**] showed polpys with adenomas and hyperplasia PSHx: Penile prosthesis Radical Prostatectomy [**2172**] Lap appy [**2185**] Social History: Denies tobacco use. Has one vodka drink/day Family History: No GI malignancy Physical Exam: VS: 97.6, 80, 146/76, 16 GEN: NAD, anicteric CV: RRR LUNGS: CTAB ABD: soft, tender diffusely/mildly distended, decreased BS, with well-healed old scar RECTAL: Normal tone, guiac negative, no pain Pertinent Results: [**2189-9-20**] 03:17AM GLUCOSE-182* UREA N-25* CREAT-1.1 SODIUM-142 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-22 [**2189-9-20**] 03:17AM ALT(SGPT)-82* AST(SGOT)-107* LD(LDH)-315* ALK PHOS-82 AMYLASE-4258* TOT BILI-2.0* [**2189-9-20**] 03:17AM LIPASE-7055* [**2189-9-20**] 03:17AM ALBUMIN-4.6 CALCIUM-9.5 PHOSPHATE-2.5* MAGNESIUM-1.9 [**2189-9-20**] 03:17AM WBC-19.5*# RBC-5.39 HGB-16.7 HCT-45.6 MCV-85 MCH-31.1 MCHC-36.7* RDW-12.3 [**2189-9-20**] 03:17AM NEUTS-82.6* BANDS-0 LYMPHS-12.5* MONOS-4.1 EOS-0.5 BASOS-0.3 [**2189-9-20**] 03:17AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-1+ [**2189-9-20**] 03:17AM PLT COUNT-293 [**2189-9-20**] 03:17AM PT-13.0 PTT-18.5* INR(PT)-1.1 [**9-20**] RUQ US - Cholelithiasis without son[**Name (NI) 493**] evidence of acute cholecystitis. 2. Heterogeneously echogenic liver consistent with focal fatty infiltration. Other forms of liver disease, including more significant hepatic fibrosis or cirrhosis, cannot be excluded on the basis of this examination [**9-23**] CT A/P - Extensive peripancreatic stranding and fluid consistent with pancreatitis. No evidence of pancreatic necrosis. Tiny fluid collection anterior to the pancreatic body could represent a tiny pancreatic pseudocyst. Additional unorganized fluid collections tracking within the retroperitoneal space. 2. Bilateral pleural effusions and bibasilar atelectasis. 3. Gallstones. No definite CT evidence of cholecystitis. 4. Hypodense lesion in left lobe of the liver is too small to accurately characterize. 5. Right renal cyst Brief Hospital Course: 78yo [**Male First Name (un) 4746**] who after eating seafood at his home the night prior to admission, had an acute onset of sharp/stabbing, non-radiating epigastric pain associated with nausea and vomiting approximately six hours after eating. Patient described having normal urine color and stool consistency. Patient was admitted on [**2189-9-20**] and RUQ US showed cholelithiasis without evidence of cholecystitis. Patient was placed NPO, with IVF hydration, Abx, and had repeat labs sent. With labs that showed a trending downward of amylase, lipase, and bilirubin, patient was serially monitored on HD2, despite WBC increase to 24. Patient did have one episode of desaturation to 88% that responded to oxygen administration. With improved, but continued abdominal pain, patient had CT A/P performed that showed radiographic evidence of pancreatitis and cholethiasis but not cholecystitis. For fear of continued pulmonary complications as a result of pancreatitis, the patient was transferred to the ICU for observation and CVL placement for CVP monitoring. Aggressive hydration was performed and GI was consulted for severe [**Last Name (un) 5063**] criteria (age, WBC, pO2, serum Ca, and Hct) for possible ERCP but it was discouraged after patient normalized his LFT's and was shown to have non-dilated biliary ducts on CT. A bit of lasix in the ICU improved his respiratory system, with improvement in bilateral pleural effusions. Patient did have episode of altered personality following administration of ativan in the ICU, with improper statements and actions directed at the nurses, requiring patient's four point leather/soft restraints. Patient was then continued on supportive care and improved steadily with transfer back to surgical floor on HD6. Once stabilized, the patient was still in need of elective cholecystectomy; because of his respiratory complications and cardiac history, operative clearance was sought. Cardiology felt patient was low-risk candidate and recommended perioperative beta-blockade for his CCY. Patient was discharged to home on [**9-29**] with intended f/u with Dr. [**Last Name (STitle) **] for outpatient elective CCY on [**2189-10-7**] Medications on Admission: Lisinopril 20', ASA 81', Atorvastatin 10', Nasacort ''puffs Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Phenergan 12.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Gallstone Pancreatitis Discharge Condition: Stable Discharge Instructions: Please resume all of your home medications Please return to the hospital ER for fever in excess of 101 degrees, worsening abdominal pain, increasing nausea/vomiting, or changes in bowel movements such as blood, or thick tarry stools Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in this Friday. Please call [**Telephone/Fax (1) 1231**] to schedule an appointment. You are tentatively scheduled for an operation to remove your gallbladder on [**2189-10-7**]. Completed by:[**2189-9-29**]

[ "577.0", "272.0", "511.9", "401.9", "V10.46", "574.20" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5845, 5851

2891, 5085

311, 318

5918, 5927

1245, 2868

6209, 6473

996, 1014

5195, 5822

5872, 5897

5111, 5172

5951, 6186

1029, 1226

240, 273

346, 685

707, 919

935, 980

82,520

132,612

79

Discharge summary

report

Admission Date: [**2179-5-24**] Discharge Date: [**2179-5-31**] Date of Birth: [**2116-7-18**] Sex: F Service: MEDICINE Allergies: Percocet / Penicillins / Aspirin / Ibuprofen / Codeine / Reglan / Morphine Sulfate / Dilaudid / Demerol / Darvocet-N 100 / Erythromycin Base / Tetracycline / Oxycodone Attending:[**First Name3 (LF) 759**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: Anterior/posterior lumbar fusion with instrumentation L2-S1 History of Present Illness: 62 year old female with chronic low back pain s/p multiple lumbar surgeries presents for elective anterior/posterior decompression laminectomy on [**2179-5-25**]. Past Medical History: h/o depression and ?PTSD Chronic low back pain s/p multiple lumbar surgeries Multiple sclerosis hypertension pancreatic atropy (secondary to recurrent pancreatitis), low fecal elastase in [**11-22**] migraine headaches . Past Surgical History: Amblyopia correction, cesarean section, two dilation and curettages, tonsillectomy, endometriosis and lysis of adhesions, hysterectomy with bilateral oophorectomy, bilateral knee arthroscopies, bilateral breast reduction, vocal cord laser cauterization node excision, four lumbar laminectomies from L3-L5 from the years [**2159**], [**2164**], as well as a C4-C7 anterior cervical fusion in the year [**2166**]. She has also had left shoulder surgery, biceps tendon release, and bilateral carpal tunnel surgery performed [**2172**] and [**2173**] Social History: - Grew up in [**Location (un) 936**]. Verbally and physically abusive father. - No EtOH - No illicits - No tobacco Family History: Father had h/o EtOH abuse Physical Exam: ADMISSION EXAM: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; + lumbar radiculopathy DISCHARGE EXAM: PHYSICAL EXAMINATION VITALS - T 98.5 Tm 99.7 HR 80 RR 20 BP 132/70 SaO2 100% on RA GENERAL - Obese woman resting in bed, taking meds from RN. Awake and conversant. NECK - Obese neck, unable to assess for JVD. CARDIOVASCULAR - RRR, heart sounds distant. II/VI SEM. No rubs or gallops. PULMONARY - Diffuse wheezing present in anterior lung fields. Crackles present in bilateral dependent flanks. No dullness to percussion. Breathing is unlabored. NEUROLOGICAL - Alert & oriented x3. Neuro exam is unchanged. WOUND - Dressing not removed but no surrounding erythema, no tenderness to palpation. Pertinent Results: Admission Labs: [**2179-5-24**] 12:00PM BLOOD WBC-25.4*# RBC-2.85*# Hgb-8.3*# Hct-25.8*# MCV-91 MCH-29.1 MCHC-32.2 RDW-15.1 Plt Ct-227 [**2179-5-24**] 03:16PM BLOOD PT-11.2 PTT-28.9 INR(PT)-1.0 [**2179-5-24**] 12:00PM BLOOD Glucose-121* UreaN-19 Creat-0.9 Na-143 K-4.2 Cl-115* HCO3-22 AnGap-10 [**2179-5-24**] 12:00PM BLOOD Calcium-7.5* Phos-4.0 Mg-1.7 Discharge Labs: [**2179-5-31**] 06:26AM BLOOD WBC-9.9 RBC-3.28* Hgb-9.6* Hct-29.7* MCV-91 MCH-29.3 MCHC-32.3 RDW-15.0 Plt Ct-308 [**2179-5-31**] 06:26AM BLOOD Glucose-104* UreaN-15 Creat-0.7 Na-142 K-3.8 Cl-110* HCO3-22 AnGap-14 [**2179-5-31**] 06:26AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9 [**2179-5-30**] 06:25AM BLOOD ALT-14 AST-36 AlkPhos-80 TotBili-0.9 CHEST (PA & LAT) - [**2179-5-30**] As compared to the previous radiograph, there is unchanged evidence of mild bilateral hilar enlargement, potentially due to hilar lymphadenopathy or enlarged pulmonary arteries. Minimal atelectasis at the left lung base and along the minor fissure. No evidence of pneumonia, no pulmonary edema. No pleural effusions. Brief Hospital Course: Ms. [**Known lastname 939**] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2179-5-24**] and taken to the Operating Room for L2-S1 interbody fusion through an anterior approach. # Lumbar spondylosis, scoliosis, and stenosis. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pneumoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 she returned to the operating room for a scheduled L2-S1 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the T/SICU in a stable condition. Postoperative HCT was 25 and she was given 2 units PRBCs. She was maintained on strict supine bedrest for 48 hours given the small dural tear that was noted. She was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#3 from the second procedure. She was fitted with a lumbar warm-n-form brace for comfort. Physical therapy was consulted for mobilization OOB to ambulate. #) Delirium: During her post-operative course, the patient was noted to be confused and disoriented, prompting transfer to medicine for further management of her delirium. This was felt to be possibly as secondary to narcotic medication and lingering effects of anesthesia. Infectious etiologies were ruled out and the patient underwent an ABG which did not reveal evidence of hypoventilation. Her mental status improved significantly and she was awake, alert, oriented x3 and long longer confused prior to discharge. #) Pain control: The patient was intially maintained on a fentanyl PCA and this was transitioned to oral pain medications with good control prior to discharge. She was followed by the chronic pain service given her history of multiple medication allergies. She is to be discharged on tramadol, topiramate, and aceaminophen. #) Anemia Patient's baselined hematocrit was felt to be approximately 40 (from [**2179-4-24**]). She required PRBC transfusions given intraoperative blood [**Last Name (un) 940**]. Her hematocrit remained stable upon discharge (28-29). CHRONIC PROBLEMS ================ #) DEPRESSION: Continued venlafaxine, buproprion. #) ANXIETY: Continued alprazolam. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 2. BuPROPion 150 mg PO BID 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Topiramate (Topamax) 50 mg PO BID 5. Venlafaxine XR 75 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital 941**] - [**Location 942**] Discharge Diagnosis: Lumbar stenosis and spondylosis Acute post-op blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Lumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: As tolerated Treatments Frequency: Please change the dressing daily. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days

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icd9cm

[ [ [] ] ]

[ "77.79", "80.51", "81.63", "81.06", "81.07", "84.52", "84.51", "03.59" ]

icd9pcs

[ [ [] ] ]

6795, 6861

3866, 6466

437, 499

6969, 6976

2777, 2777

9054, 9106

1654, 1681

6882, 6948

6492, 6772

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388, 399

7364, 7831

7843, 8943

527, 691

2793, 3131

713, 934

1521, 1638

16,429

149,904

18059

Discharge summary

report

Admission Date: [**2123-2-17**] Discharge Date: [**2123-2-19**] Date of Birth: [**2046-8-6**] Sex: F Service: CCU HISTORY OF THE PRESENT ILLNESS: This is a 76-year-old female with a past medical history remarkable for coronary artery disease, status post a four vessel coronary artery bypass graft approximately ten years ago in which the LIMA to the LAD, saphenous vein graft to the D1, saphenous vein graft to the RCA, and a saphenous vein graft to the OM. A catheterization in [**2122-6-25**] revealed complete occlusion in her native coronaries along with a total occlusion of her OM and RCA saphenous vein graft. The LIMA along with the saphenous vein graft to the D1 remained patent. She had been medically managed since that time. Approximately two weeks ago, she started to develop severe back pain, shortness of breath, along with intermittent episodes of dizziness. She also complained of paroxysmal nocturnal dyspnea and increased dyspnea upon exertion. She initially went to an outside hospital on [**2123-2-12**] with these complaints but left against medical advice after not being able to be served in a timely manner. She continued to have episodes of chest pain, at which time she went to another outside hospital on [**2123-2-15**] and was admitted. While in the hospital, her cardiac enzymes were drawn. She was negative times three sets. An EKG there, however, showed approximately [**Street Address(2) 49973**] depressions during her three episodes of chest pain. She was transferred to [**Hospital3 **] for further evaluation. A catheterization revealed known totally occluded native vessels, along with a mild proximal disease of the LIMA to the LAD. She also had two lesions in her saphenous vein graft to her SVG to D1, proximal 90% occluded, and the distal being 70% occluded. It was found that this graft filled the left circumflex and distal RCA. At that time, it was determined to place a stent in the SVG to D1 graft. The procedure was complicated by a transient angiographic focal aortic dissection with the left main ejection, and an iliac dissection during the initial wire catheter insertion. The patient also became hypotensive and bradycardiac for which she received one dose of Atropine. She was then transferred to the CCU for overnight observation. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post a four vessel CABG approximately ten years ago. 2. Aortic valve replacement. 3. Gastroesophageal reflux disease. 4. Hypertension. MEDICATIONS AT-HOME: 1. Lopressor 50 mg b.i.d. 2. Pepcid 20 mg q.d. 3. Aspirin 325 mg q.d. 4. Imdur 60 mg q.d. 5. Plavix 75 mg q.d. 6. Lasix 20 mg q.d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: She lives at home. She is a retired factory worker with Ratheon. She denied any smoking or alcohol use. She is widowed with four children. FAMILY HISTORY: Her father passed away from a drowning accident. Her mother passed away in her 70s from coronary artery disease. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Her initial blood pressure was 106/39 with a heart rate of 76, 02 saturation 95% on 2 liters, respiratory rate 20. General: This is an elderly pleasant female in no apparent distress. She was alert and oriented to person, place, and time. Neck: She had approximately 9 cm JVP. Her neck was supple without lymphadenopathy. Lungs: Clear to auscultation bilaterally. Heart: There was a regular rate and rhythm, S1 with a loud S2. She had a grade II/VI holosystolic murmur heard best on the left sternal border. Abdomen: Soft, nontender, nondistended, with normal bowel sounds. Extremities: There was +1 DP pulses in the lower extremities. Neurologic: Both short and long-term memory were intact. Cranial nerves II through XII grossly intact. There were no motor or sensory deficits. LABORATORY DATA: The laboratories from the outside hospital showed a total cholesterol of 518, LDL 397, HDL 28, triglycerides 182. Her Chem-10 showed a sodium of 139, potassium 4.9, chloride 105, bicarbonate 29, BUN 11, creatinine 0.8. Her glucose was 105. PTT 78. EKG showed a heart with a normal sinus rhythm with a rate of approximately 70 beats per minute. It had normal axis with normal intervals. There were [**Street Address(2) 1766**] depressions in lead II, V4 through V6. She also had downsloping ST depressions in lead I and aVL. HOSPITAL COURSE: This is a 76-year-old female with severe coronary artery disease who presented to an outside hospital complaining of chest pain. She was referred to [**Hospital3 **] for a catheterization and further evaluation. Her catheterization revealed that a large majority of her heart was being supplied by an SVG to D1 graft that had two serial lesions. She underwent PCI with stent placement. The procedure was complicated by a retrograde iliac dissection as well as post balloon inflation hypotension/bradycardia which resolved with Atropine. She was transferred to the CCU in stable condition for overnight monitoring. 1. CARDIAC: For her coronary artery disease, the patient was placed on aspirin, Plavix (for her lifetime), Pravastatin, a low-dose beta blocker and an ACE inhibitor. She also remained on Integrelin for approximately 18 hours following the procedure. During her stay, she experienced no further episodes of chest pain, shortness of breath, upper extremity or jaw pain. An echocardiogram was performed which revealed that the patient had an left ventricular ejection fraction of approximately 60% with symmetrical hypertrophy. She had a TR gradient of 43, she had +2 mitral regurgitation, and mild tricuspid regurgitation. She remained in sinus rhythm throughout her stay. 2. DYSLIPIDEMIA: The patient was with an LDL of 397 and a total cholesterol of 518. She states that these numbers are actually much better than in the past for her. She had been on Lipitor in the past but had discontinued it for unclear reasons. The patient was started on a high-dose of pravastatin and a follow-up appointment was scheduled for the [**Hospital **] Clinic for further evaluation of her dyslipidemia. DISPOSITION: The patient was discharged home in stable condition. DISCHARGE INSTRUCTIONS: 1. Follow-up with the lipid clinic-information will be sent to her concerning her appointment. 2. Follow-up with her primary cardiologist to discuss when a recatheterization will be performed to ensure that the graft remains open. 3. The patient should return to the Emergency Room if she develops any chest pain, back pain, upper extremity pain, jaw pain, or shortness of breath. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg b.i.d. 2. Pepcid 20 mg q.d. 3. Aspirin 325 mg q.d. 4. Plavix 75 mg q.d. 5. Lasix 20 mg q.d. 6. Pravastatin 80 mg q.d. 7. Lisinopril 5 mg q.d. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**] Dictated By:[**Name8 (MD) 6284**] MEDQUIST36 D: [**2123-2-19**] 12:54 T: [**2123-2-20**] 19:43 JOB#: [**Job Number 49974**]

[ "458.2", "427.89", "411.1", "V43.3", "414.02", "401.9", "414.01", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.01", "88.56", "36.06", "99.20", "37.22" ]

icd9pcs

[ [ [] ] ]

2909, 3045

6659, 7090

4438, 6227

6251, 6636

3060, 4420

2345, 2733

2750, 2892

15,843

165,761

54370+59597

Discharge summary

report+addendum

Admission Date: [**2102-7-2**] Discharge Date: [**2102-7-17**] Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 2972**] Chief Complaint: CC: slurred speech and left arm weakness after a nap Major Surgical or Invasive Procedure: Right internal carotid stent, [**2102-7-5**] History of Present Illness: The pt. is an 85 year-old right-handed man with a history of CAD s/p CABG and placement of 3 stents, pacer/defibrillator, and severe chronic sensorimotor polyneuropathy, who was in his usual state of health when he fell asleep for a nap on the day of admission, then awakened a number of hours later with slurred speech, left facial droop (witnessed by pt's son), and inability to raise left arm (also witnessed by patient's son). These symptoms improved over the course of the 90 minutes between first noticing the symptoms and presentation. He had not been ill recently, has had no headache, dizziness, chest pain, or fever. No known seizures. As at baseline he has occasional tremors of arms and legs when he sits up from bed and complains of numbness in the first three fingers of his left hand, which has been going on for years. The numbness is worse when he has his elbow resting on the dinner table. He states that he has been taking all his medications. He does complain of urinary urgency, so that he has to use the bathroom about a half hour after he drinks anything. Sometimes he doesn't actually void, but when he does there is [**Last Name **] problem initiating and completing urination. Per OMR, he was neurology service in [**10-3**] for evaluation of a similar episode, involving dysarthria and truncal ataxia. He was also noted to have glove and stocking distribution sensorimotor neuropathy, steppage gait, and bilateral foot drop. He was diagnosed with Vitamin B12 deficiency (for which he continues treatment) and a probable midline cerebellar stroke, although MRI imaging could not be obtained due to the pacemaker. At the time of my encounter, the pt. stated that he felt that his speech difficulties and weakness have disappeared. He offered no complaints other than frustration that he was confined to bed. He denied any further episodes of dysarthria, weakness, headache. Past Medical History: *CABG (quadruple bypass) in [**2083**] *Stents placed in 3 coronary arteries *Pacer/Defibrillator Implant Most recent echo [**2101-10-4**]: Ejection Fraction 25-30% The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the basal half of the inferior and inferolateral walls, distal septum and apex. The remaining walls are mildly hypokinetic. No masses or thrombi are seen in the left ventricle (does not exclude due to suboptimal apical image quality). The aortic root is moderately dilated. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-1**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No definite cardiac source of embolism identified. Compared with the prior study (tape reviewed) of [**2101-5-31**], septal motion is less vigorous and the distal septum and apical dysfunction are now apparent c/w interim ischemia. *Gout *Glaucoma, Cataracts, Blind in Right Eye *B/l hearing loss *Chronic severe sensorimotor polyneuropathy Report of EMG/NCS from [**2102-6-13**]: Abnormal, complex study. There is electrophysiologic evidence for a severe, chronic and ongoing, generalized, sensorimotor polyneuropathy with both axonal and demyelinating features. There is evidence for superimposed, severe, median neuropathies at both wrists (as in bilateral carpal tunnel syndrome); the left is chronic and ongoing. There is also evidence for superimposed, severe, ulnar neuropathies at both elbows; the left is chronic and ongoing. The underlying neuropathy prevents determination of whether there are superimposed ulnar neuropathies at both wrists. Medications on admission: -Cyanocobalamin 100 mcg PO DAILY -Aspirin (Buffered) 325 mg PO DAILY -Metoprolol XL 75 mg PO DAILY -Lisinopril 20 mg PO DAILY -Clopidogrel Bisulfate 75 mg PO DAILY -Furosemide 40 mg PO DAILY -Atorvastatin 20 mg PO DAILY -Latanoprost 0.005% Ophth. Soln. 1 DROP OD HS glaucoma -Docusate Sodium 100 mg PO DAILY -Folic Acid 1 mg PO DAILY -Nitroglycerin SL 0.3 mg SL PRN chest pain can give one every 5 minutes x 3 Allergies: shrimp; reaction to indomethicin (confusion) CAD s/p MI '[**95**], '[**98**], s/p CABG '[**83**], s/p SVG->ramus in '[**98**], s/p svg to OM stent in '[**95**] with thrombectomy, PTCA of prox RCA '[**00**] CHF with EF 30-35%, s/p BIV-ICD [**1-3**] CVA Hx of NSVT Glaucoma/cataracts Social History: The pt. lives alone, son lives down the street and is with him most of the time. He uses a walker at baseline. Has used alcohol and tobacco in the remote past, none now. Family History: 57 yo son with CAD Brother with DM. Physical Exam: Vitals: T: 97 P: 70 BP: 130/67 R: 18 SaO2: 99% RA General appearance: alert elderly male in NAD Cardiac: regular rate and rhythm without murmurs, rubs or gallops; pacemaker palpable on chest wall Pulmonary: Lungs clear to auscultation bilaterally. Abdomen: soft, nontender Extremities: no clubbing, cyanosis or edema; hypertrophy of multiple MTP joints on feet b/l without warmth or swelling. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. Able to name [**Doctor Last Name 1841**] forward and backward without difficulty. Language is fluent with intact repitition and comprehension. There were no paraphrasic errors. Able to follow commands across midline. Pt. was able to register 3 objects and recall [**3-2**] at 5 minutes. -cranial nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. VFF to confrontation in left eye, right eye is blind. There is no ptosis bilaterally. EOMI without nystagmus. Sensation intact to light touch over face. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically in midline. [**5-4**] strength in trapezii and SCM bilaterally. Tongue protrudes in midline; no fasciculations. -motor: Distal muscle atrophy bilaterally, normal tone throughout. Fine resting tremor (roughly 4 Hz) noted in bilateral UE. Delt Bic Tri WrF WrE FFl FE IP Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] L 4+ 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: Loss of light touch, pinprick, vibratory sense, proprioception in a stocking and glove distribution. No extinction to DSS. Graphesthesia and sterognosis intact. -coordination: FNF and HKS WNL bilaterally. -DTRs: 1+ biceps, triceps, brachioradialis, patellar and ankle jerks bilaterally. Plantar response was flexor bilaterally. -gait: Narrow-based, normal arm swing. Mental Status: The patient is attentive, registered and repeated three objects. Good knowledge for current events. Language is intact with fluent speech. There is no apraxia or agnosia. There is no left/right agnosia. He was able to do serial 7's x 2. Rest of exam was limited due to his difficulty hearing. Cranial Nerves: The left eye visual fields are full (right eye is blind, with cataract visible). The left optic disc is normal in appearance. Eye movements are normal, the left pupil reacts normally to light 4>2, right eye 3>2. Sensation on the face is intact to light touch, pin prick. There is a mild left facial droop with very mild flattening of left nasolabial fold. Forehead wrinkling is symmetric. Hearing is intact to loud finger rub. There is no nystagmus. The palate elevates in the midline. The tongue protrudes in the midline and is of normal appearance. The patient is not wearing his upper denture. Motor System: There is muscle wasting of extremities distal>proximal, especially involving the interdigital muscles b/l, the thenar emininence on the right, and the tibialis anterior/gastrocnemius bilaterally. Grip strength is [**5-4**] on right and 4+/5 on left. Patient is not able to dorsiflex feet and plantarflexion is [**3-4**] bilaterally. Remainder of strength exam was [**5-4**]. There is a fine low-amplitude tremor of hands and feet which is exacerbated by exertion (e.g. sitting up). Fasciculations were seen in both hands and thighs. Reflexes: The tendon reflexes are absent in the lower extremities and present but very hypoactive in the upper. The plantar reflex is extensor on the right and equivocal on the left. Sensory: Sensation is difficult to assess in this patient, but there appears to be diminished sensation to light touch, temperature, and pin prick in the distal hands and feet. Coordination: There is mild end-point dysmetria with finger-nose test bilaterally. There is no titubation or truncal ataxia. Gait and stance: Did not assess. Pertinent Results: Imaging: [**2102-7-2**] TECHNIQUE: CT of the brain without IV contrast. COMPARISON: [**2101-5-28**]. FINDINGS: There is no acute intracranial hemorrhage, shift of normally midline structures or hydrocephalus. A lacunar infarct is again identified within the left basal ganglia and within the right anterior limb of the caudate. Hypodensity is seen in the periventricular white matter adjacent to the right lateral ventricle, which is more prominent than on the prior study, and also likely represents small vessel ischemic changes. [**Doctor Last Name **]- white matter differentiation appears preserved. The middle cerebral arteries are normal bilaterally. Soft tissues and osseous structures are unremarkable. The visualized paranasal sinuses are clear. Incidental note is made of a cavum septum pellucidum. IMPRESSION: No acute intracranial hemorrhage or evidence of major acute territorial infarction. [**2102-7-2**] 03:05PM UREA N-34* CREAT-1.5* SODIUM-141 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-27 ANION GAP-16 [**2102-7-2**] 03:05PM WBC-7.3 RBC-4.24* HGB-14.0 HCT-39.9* MCV-94 MCH-33.0* MCHC-35.0 RDW-13.0 [**2102-7-2**] 03:05PM NEUTS-58.8 LYMPHS-33.8 MONOS-5.2 EOS-1.6 BASOS-0.5 [**2102-7-2**] 03:05PM PLT COUNT-158 [**2102-7-2**] 03:05PM PT-12.2 PTT-25.5 INR(PT)-1.0 Brief Hospital Course: The pt is an 85 year old male with multiple medical problems including significant cardiac disease and severe polyneuropathy who presented with L facial droop, and L arm weakness, resolved at this point arguing for TIA. MRI was not possible due to presence of pacemaker, and the CT was not definitive for stroke. He underwent a Right ICA stent on [**2102-7-5**], with complications of hypotension and confusion/delerium. He was transferred to the CCU, where his course improved and pressure improved on pressors. He was then transfered to [**Hospital Unit Name 196**], stable. His goal SBP> 120 to prevent hypoperfusion to the CNS, so he was taken off all antihypertensives during his stay. His pressures stabilized off the medications and ran from SBP 110-130's. He was kept on aspirin and plavix s/p TIA and for his CAD. During his stay, he intermittently had low-grade spikes in his temperature and confusion. He was seen by Neurology, who recommended a work-up for infection vs. metabolic vs. hypoperfusion causes. His work-up for infection (U/A, urine cx, blood cx, CXR) was negative, and his WBC count always remained normal. The patient also stopped having temperature spikes, and became completely afebrile around [**2102-7-10**] and has stayed that way since. His mental status improved by the [**2102-7-11**], at which point the patient was alert and oriented x 3, and back to his baseline according to his son. [**Name (NI) **] was no longer agitated and was off the 1:1 sitter for >24 hours. He was then screened for placement to rehab. However, starting the 13th, his mental status once again began to decline and the patient became confused, with hallucinations and agiation. Neurology and Psychiatry were consulted, and their recommendations included r/o infection, d/c Zyprexa and Seroquel (use Haldol for agitation), and possibly repeat a head CT if his confusion continues. The patient was r/o again for any infection (also pt was afebrile, no WBC count), and d/c'd off the Zyprexa and Seroquel. Over the last five days, from the 13th to the 18th, the patient has improved in mental status. He is alert, cooperative, and oriented to person and situation. He responds to questions appropriately. He occasionally requires Ativan or Haldol at night for sleep. On [**2102-7-16**], the patient reported some mild chest pain for [**5-9**] minutes, unlike his previous angina. An EKG was checked which showed no acute changes and 2 sets of CE's were negative. Since then, the patient had no further chest pain. Most likely his confusion is a result of many factors, including his lengthy hospital stay, hypoperfusion injury, possibly underlying dementia, and his medications (primarily Zyprexa and Seroquel, which were d/c'd). He is medically stable to be sent to rehabilition. Secondary issues: 1. HTN: holding antihypertensives for now in context of low bp - Restart B-blocker and ACE as able. 2. CHF: EF 25%, avoid large fluid boluses 3. CAD - Continue Lipitor - Restart beta-blocker and ACE-I as able - Continue ASA Medications on Admission: Medications on admission: -Cyanocobalamin 100 mcg PO DAILY -Aspirin (Buffered) 325 mg PO DAILY -Metoprolol XL 75 mg PO DAILY -Lisinopril 20 mg PO DAILY -Clopidogrel Bisulfate 75 mg PO DAILY -Furosemide 40 mg PO DAILY -Atorvastatin 20 mg PO DAILY -Latanoprost 0.005% Ophth. Soln. 1 DROP OD HS glaucoma -Docusate Sodium 100 mg PO DAILY -Folic Acid 1 mg PO DAILY -Nitroglycerin SL 0.3 mg SL PRN chest pain can give one every 5 minutes x 3 Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: s/p [**Country **] stent Secondary: s/p stroke/TIA, HTN, CHF, confusion/delerium, CAD, constipation Discharge Condition: Good Discharge Instructions: Continue medications discharged with. Follow through with rehab, if any concerning symptoms arise, please return to the ED. Followup Instructions: Follow through with rehab and primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Completed by:[**2102-7-17**] Name: [**Known lastname 18265**],[**Known firstname **] Unit No: [**Numeric Identifier 18266**] Admission Date: [**2102-7-2**] Discharge Date: [**2102-7-17**] Date of Birth: [**2016-10-22**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 2838**] Addendum: Rechecked Hct prior to discharge - [**2102-7-17**] (at 0700): Hct 33.6 [**2102-7-17**] (at 1300): Hct 34.8 Pertinent Results: [**2102-7-17**] (at 0700): Hct 33.6 [**2102-7-17**] (at 1300): Hct 34.8 Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 2839**] MD [**MD Number(1) 2840**] Completed by:[**2102-7-17**]

[ "428.0", "433.10", "V45.02", "356.9", "414.8", "424.0", "401.9", "434.91", "V45.81", "266.2" ]

icd9cm

[ [ [] ] ]

[ "00.63", "00.61" ]

icd9pcs

[ [ [] ] ]

15084, 15314

10442, 13477

269, 316

14189, 14195

14985, 15061

14367, 14966

5109, 5146

14056, 14168

13529, 13942

14219, 14344

5957, 7108

5161, 5568

177, 231

344, 2250

7436, 9108

7123, 7420

2272, 4174

4921, 5093

9,982

107,153

23604

Discharge summary

report

Admission Date: [**2124-5-29**] Discharge Date: [**2124-6-2**] Service: MEDICINE Allergies: Ace Inhibitors / Nitroglycerin Transdermal Attending:[**First Name3 (LF) 106**] Chief Complaint: admit from home for elective peripheral procedure Major Surgical or Invasive Procedure: Cath and renal artery stenting History of Present Illness: 80 year old woman with DM, HTN, choles, prior CVA, carotid disease, PVD s/p failed ? left leg bypass, moderate AS, CAD< s/p CABG in [**2116**] (LIMA-->LAD,SVG-->OM2, OM1-->diagonal), Prior PCI, admitted in [**2124-4-28**] (d/c'd [**5-13**]) with NSTEMI, had Cx stented with Cypher. Also noted to have severe right RAS. Direct admit from home today to have MRA of left leg, hydration overnight and then Peripheral procedure with Dr [**Last Name (STitle) **] as a 1st case tomorrow. Since d/c, notes progressive cooling of left foot. Notes an aching, cramping pain, along her left buttock and lateral thigh, occuring consistently after several steps. Her left foot will ensuingly becomes numb and painful. Symptoms remit with rest. Does not have consistent rest pain, though has had some trouble on occasion sleeping [**3-1**] pain. Hanging feet over edge of bed does not help. Denies leg, or calf cramping or pain. Qulatity of pain is not burning, numbness, or tingling On detailed review of symtpoms, she mentions an episode of SSCP lasting several minutes, releived with Sl NTG. Had no associated N/V, diaph, SOB. This pain was not as intense as the crushing pain with which she presentted in [**5-2**]. Notes [**5-2**] transient episodes of chest pain w/ either rest or exertion since discharge [**5-13**]. Has uses prn Sl NTG for these episodes with resolution of symptoms. She also complains of pain along the site of her hernia. Does not note a buldge in her inguinum, nor necorosis. Has been evaluated by her surgeon who plans to operate following cardiovascular work up. Past Medical History: CAD s/p CABG in [**2116**] LIMA-->LAD, SVG-->OM1, OM2-->diag Left CEA [**2116**] shunt and patch from Left carotid to ascending aorta [**2116**] [**2121**] NSTEMI in setting of SVT, stent for 80% LMA blockage CHF with EF of 45-50% with moderate TR/MR RFA for AV nodal tachycardia--successful COPD on home O2 at night 2L Hypothyroidism HTN CRI, baseline Cr 1.4 PVD Left Iliofem bypass and aorto-fem bypass [**2111**] Ant tibial bypass CVA x 2 with some residual right-sided weakness osteoporosis ventral hernia repair x 4 s/p TAH s/p left ORIF of hip anemia of CD Diabetes Hyperlipidemia Social History: widowed, lives alone, no EtOH, quit tobacco 15 yrs ago Family History: non-contributory Physical Exam: Gen: Pleasant. NAD. PSeaking in complete sentences VS: 98.3, 116/64, 61, 18, 98%RA HEENT NCAT, PERRL NECK: no JVD Chest: CTA CV: rrr, [**3-5**] HSM ABD: s, nt, nd, Right lower ventral budge w/ strain, easily reduceable, no incarceration, no necrosis EXT: -bilateral femoral bruits -popliteal pulses 1+ B/L -trace RIGHT DP, cannot palpate PT pulse. Pedals palpable on right -no dependant rubor -unable to assess capillary refill given baseline onychomycotic changes to nails -skin in b/l feet moderately cool L>R, skin atrophic, hairless -moderate tenderness to palpation diffusely along left thigh and as well as dorsum and lateral left foot. most tender along hallux, no point tenderness at dorsum. -no erythema, warmth -no sensation loss to light touch NEURO: CN 2-12 intact Brief Hospital Course: ##Arterial occlusive disease: Pt has claudication by history. No evidence of acute arterial thrombotic/occlusion that would threaten this limb acutely. Had hypotension following procedure, brief CCU stay, BP improved quickly. ##Unilateral Severe RAS: Pt has chronic kidney disease. Creatine improved after hydration. She had a unilateral renal artery stent placed during this admission, pt tolerated procedure without difficulties. ##CAD: s/p CABG, recent stenting. With several epoisodes of CP at home (last while travelling here) relieved with NTG. OMR note of several episodes of rest pain of unclear etiology (? vasospasm) post cath and prior to d/c on last admit. Pt has not had any further episodes of chest pain in-house. Cardiac enzymes are negative x3 ##ENDO: DM II and hypothyroid. No issues while here. ##COPD: nightly home 02. No issues while here Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Atacand 32 mg Tablet Sig: One (1) Tablet PO once a day. 9. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Regular Human 100 unit/mL Solution Sig: as dir Injection ASDIR (AS DIRECTED): as dir. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Atacand 32 mg Tablet Sig: One (1) Tablet PO once a day. 9. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Regular Human 100 unit/mL Solution Sig: as dir Injection ASDIR (AS DIRECTED): as dir. Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: renal artery stenosis DM II CAD COPD Discharge Condition: stable Discharge Instructions: Resume previous activity Followup Instructions: PCP [**Last Name (NamePattern4) **] [**1-30**] weeks

[ "496", "244.9", "412", "440.21", "401.9", "250.00", "440.1", "414.00", "272.0", "V45.81", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.48", "39.50", "39.90" ]

icd9pcs

[ [ [] ] ]

6094, 6190

3476, 4344

298, 331

6271, 6279

6352, 6408

2639, 2657

5232, 6071

6211, 6250

4370, 5209

6303, 6329

2672, 3452

209, 260

359, 1939

1961, 2550

2566, 2623

71,825

193,810

46612

Discharge summary

report

Admission Date: [**2108-1-27**] Discharge Date: [**2108-2-1**] Service: HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old female with recent admission on [**2107-12-19**] for embolic mesenteric ischemia. Angio diagnosed occlusion of the ileocolic branch of the SMA and occlusion of smaller distal jejunal branches at that time. The patient was started on anticoagulation. She subsequently was readmitted for short term secondary to C-difficile colitis. She was treated with fourteen days of metronidazole. She now represents with a one day history of bloody stool times one, chronic low grade abdominal pain since [**Month (only) 956**], which has since unchanged. No nausea or vomiting. No changes in bowel status. The patient did note some bright red blood per rectum. She noted that the pain was worse with eating. No complaint of palpitations. Previous echocardiogram on [**2107-12-21**] showed an EF of 35 to 40% with mild left ventricular hypertrophy and moderate mitral regurgitation. No atrial fibrillation was noted at that time. PAST MEDICAL HISTORY: Notable for inferior posterior myocardial infarction, hyperthyroidism, hypertension, gout and embolic mesenteric ischemia, C-diff colitis. PAST SURGICAL HISTORY: Appendectomy. MEDICATIONS AT HOME: Coumadin 4 mg po q.d., Cardizem 240 mg po q.d., Allopurinol 300 mg po q.d., Atenolol 25 mg po q.d., Synthroid 100 mg po q.d. ALLERGIES: Percocet and morphine. SOCIAL HISTORY: The patient quit smoking twelve years ago. No alcohol use. PHYSICAL EXAMINATION: On examination she was noted to have a temperature of 97.8. Vital signs were stable. No orthostatic signs. Heart was regular. Lungs were clear. Her abdomen showed a well healed appendectomy scar with bowel sounds, soft, minimal diffuse tenderness. LABORATORY: White count 10.5, hematocrit 41.4. Electrolytes were normal. Liver function tests were normal. She underwent CT of the abdomen, which showed gallstones. No large or small bowel obstruction. Celiac and SMA were patent. Positive renal cyst. No fluid collections. Positive diverticuli. No diverticulitis. She was admitted to the Intensive Care Unit where serial hematocrits were checked and found to be stable. she remained hemodynamically stable with A line monitoring for several days in the Intensive Care Unit. Dr. [**Last Name (STitle) 1476**] of vascular surgery was consulted since he was a previous consultant and he did not think that the patient's situation appeared to be mesenteric ischemia. GI was consulted. Her Coumadin was held. She was made NPO. IV antibiotics were started Ancef, Ceftriaxone and Flagyl. GI saw the patient on the 17th. On the 18 a Golytely prep was initiated. On the 18th she was transferred to a regular floor since she remained hemodynamically stable and hematocrits remained stable. On the 19th the patient underwent colonoscopy. A C-diff colitis test was noted to be positive. Colonoscopy was unremarkable with several benign appearing polyps and several areas of polyposis that appeared abnormal. These were biopsied by Dr. [**Last Name (STitle) **]. Diverticulosis was noted. No ischemic colitis or colitis was noted. No active bleeding was noted on that scan. Her diet was advanced on [**2108-2-1**]. She is now hospital day number five on Flagyl day number five and tolerating a regular diet. Minimal abdominal pain at baseline. She remains afebrile at 98.6. Her vital signs are stable. Her last known white count was 9.2. Her INR is 2.0 today. Her examination remains unchanged. She is alert. Her lungs are clear. Heart is regular. Her abdomen is soft and nontender. The patient is to be discharged to home. DISCHARGE PLAN: To home. DISCHARGE CONDITION: Stable. FOLLOW UP: Follow up will be with primary care physician to titrate Coumadin to achieve an INR of 2.0. Continue with ten day course of Flagyl. DISCHARGE MEDICATIONS: Flagyl 500 mg po t.i.d. for ten more days, Coumadin 2 mg po q.d. to be titrated by the patient's primary care physician to keep INR 2 to 2.5. DISCHARGE DIAGNOSES: 1. C-difficile colitis. 2. Diverticulosis, possible diverticular bleed. 3. Lower GI bleed with insignificant blood loss. 4. Hypertension. 5. Previous myocardial infarction. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Name8 (MD) 98985**] MEDQUIST36 D: [**2108-2-1**] 16:11 T: [**2108-2-2**] 09:25 JOB#: [**Job Number 36240**]

[ "008.45", "412", "562.12", "562.10", "414.01", "574.20", "211.3", "557.0", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "45.25" ]

icd9pcs

[ [ [] ] ]

3758, 3767

4101, 4540

3937, 4080

1293, 1455

1256, 1271

3779, 3913

1555, 3709

110, 1069

3726, 3736

1092, 1232

1472, 1532

20,560

109,008

44743

Discharge summary

report

Admission Date: [**2188-4-7**] Discharge Date: [**2188-4-10**] Date of Birth: [**2104-3-26**] Sex: F Service: MEDICINE Allergies: Motrin / Ultram / Vicodin Attending:[**First Name3 (LF) 1936**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [**Known firstname 13842**] [**Known lastname **] is a 84 yo woman with history of CAD, Afib (not on coumadin), HTN, DM2, spinal stenosis, diverticulosis and diverticulitis who presented to an OSH from her nursing home after having 2 bloody bowel movements on [**2188-4-5**]. Her hematocrit on day of admission had fallen from mid 30s to 28. She received IVF and 1 u pRBC. She underwent abdominal CT which suggested sigmoid diverticulitis. Due to this finding GI did not want to pursue endoscopy. She was started on cipro/flagyl. She underwent red blood cell scan which was negative. She continued to have bloody bowel movements over the next day and had a hematocrit drop from 30.9 to 23.8. She received an additional 2 u pRBC with an appropriate hematocrit response. Since the this transfusion on the evening of [**2188-4-6**] her hematocrit has remained stable at Per the family's request the patient was transferred to [**Hospital1 18**] ICU for further monitoring and management. On arrival to the ICU she is drowsy and disoriented but easily arousable. She is inattentive but denies pain, sob, chest pain, or any other complaints. Per family, she has does not have any history of abdominal surgeries, liver disease, or recent GI illness. She did have a single episode of hematemesis on [**2188-4-5**] when she first experienced BRBPR. She reports only cramping abdominal discomfort prior to bowel movements. Denied other abdominal pain, nausea, fevers or chills. Family witnessed a bowel movement earlier today that appeared black and tarry. Past Medical History: Dementia CAD s/p CABG [**2178**] Afib (not on coumadin) HTN DM2 Depression Spinal Stenosis Diverticulosis/Diverticulitis Social History: Patient lives at [**Location **] Immaculate Nursing Center. She has no history of tobacco, etoh or drug use. She is ambulatory with a walker. She has several family members who are involved in her care. Family History: noncontributory Physical Exam: VS: T 98.9 HR 61 BP 132/61 RR 17 SpO2 98% 2 L NC GEN: The patient is in no distress and appears comfortable SKIN:No rashes, scattered echymoses on forarms HEENT:No JVD, neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. EOMI, pupils small reactive CHEST: Lungs are clear anteriorly, rales, or rhonchi. CARDIAC: RRR, 2/6 systolic murmur at RUSB ABDOMEN: No apparent scars. Non-distended, and soft without tenderness EXTREMITIES:no peripheral edema, warm without cyanosis, 2+ distal pulses NEUROLOGIC: Drowsy, easily arousable to verbal stimuli, oriented to person, inattentive, moving all four extremities Pertinent Results: [**2188-4-5**] GI bleeding scan: Initial dynamic and 24-hour delayed images do not show any significant focal areas of increased uptake. [**2188-4-5**] CT Abdomen/Pelvis w/o IV contrast: Uncomplicated sigmoid diverticulitis. Brief Hospital Course: 84 yo female with history of dementia, CAD, Afib (not on coumadin), diverticulosis and diverticulitis who presents from OSH with BRBPR and hematemesis. She was initially admitted to the MICU and then transferred to the floor on hospital day 2. Hospital course will be reviewed by problem. GIB: Her GI bleed was likely lower in origin secondary to diverticulosis given significant diverticulosis on CT scan. In addition the patient has diverticulitis noted on imaging. Initially she received 4 units of PRBCs (3 at the OSH and 1 at [**Hospital1 18**]) to keep her hematocrit above 25%. HCT was then stable and she was hemodynamically stable. She was continued on a PPI twice daily for a history of possible hematemesis. GI was consult (Dr. [**Last Name (STitle) 349**] and had thought the risk of endoscopy/colonoscopy would outweigh the benefit given the current diverticulitis. She and her family will follow-up with her primary care physician to discuss whether a colonoscopy is desired. GI recommended a colonoscopy only if the family desires screening for and treatment of potential colon cancer. They did not feel endoscopy was necessary. She will continue on a PPI twice daily for one month and then transition to once daily. At the time of discharge, her stools were maroon and guaiac positive but per GI this was to be expected following her GI bleed. Diverticulitis: She was initially started on IV Cipro and flagyl with the intention of a 14 day course. She was then transitioned to a po course of levofloxacin and flagyl (renally dosed). Cough: Per the patient's daughter, Ms. [**Known lastname **] had a new cough. She had a CXR concerning for LLL PNA versus atelectasis, however, she had a clear lung exam and good oxygen saturations on room air. PNA was felt to be unlikely and she was not treated for these symptoms. Cipro was switched to levo for better lung penetration in case there was an aspiration event. Atrial Fibrillation: Patient was rate controlled on metoprolol and amiodarone. These were continued while aspirin was held given GI bleed. On discharge she was instructed to restart her aspirin 81 mg in one week. Type 2 diabetes: She was kept NPO while bleeding and started a po diet on [**4-9**]. She was initially put on a sliding scale and then on [**4-10**] put on her home dose oral hypoglycemics. She was discharged to her nursing home on [**4-10**] in stable condition. Medications on Admission: Aspirin 81 mg amiodarone 100 mg daily Lisinopril 40 mg daily Metoprolol 75 mg po bid Glyburide 2.5 mg daily Prilosec 20 mg daily Aricept 10 mg daily Citalopram 30 mg daily Mulitvitamin daily Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. 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:*0* 8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: Restart in one week. 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for until [**2188-4-19**] days. Disp:*5 Tablet(s)* Refills:*0* 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Start in one month. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 13. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Immaculate [**Hospital **] Nursing Home Discharge Diagnosis: Primary: Diverticulitis GI bleed . Secondary: Dementia CAD s/p CABG [**2178**] Afib (not on coumadin) HTN DM2 Depression Spinal Stenosis Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: Dear Mrs. [**Known lastname **], You were transferred to [**Hospital1 69**] Medical Intensive Care Unit for evaluation of your diverticiulitis and GI bleed. You were given four units of blood (including those at the original hospital) and your blood levels remained stable after this. You were seen by gastroenterology, who recommended a colonoscopy as an out-patient if you desire screening and treating a possible cancer. You were treated with antibiotics for your diverticulitis and remained afebrile. The following medication changes were made: Levofloxacin 750 mg every other day was ADDED until [**2188-4-19**] Flagyl 500 mg three times daily was ADDED until [**2188-4-19**] Pantoprozole 40mg twice daily was ADDED for one month, then switch to once daily. RESTART aspirin 81 mg in one week Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week. Please discuss whether you want a colonoscopy to screen for cancer. This colonoscopy should not be done for at least one month.

[ "585.9", "V45.81", "294.10", "331.0", "414.00", "562.13", "403.10", "290.43", "250.00", "427.31", "437.0", "311" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7246, 7312

3222, 5650

291, 297

7493, 7493

2971, 3199

8493, 8713

2275, 2292

5891, 7223

7333, 7472

5676, 5868

7668, 8470

2307, 2952

246, 253

325, 1891

7508, 7644

1913, 2035

2051, 2259

18,459

116,484

23050

Discharge summary

report

Admission Date: [**2169-11-1**] Discharge Date: [**2169-11-20**] Date of Birth: [**2100-4-20**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5547**] Chief Complaint: black stools Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Anterior gastrotomy. 3. Submucosal resection of gastric neoplasm, likely lipoma. 4. Two-layer gastrorrhaphy. History of Present Illness: The patient is a 69-year-old gentleman who was admitted to the medical service on [**11-1**] with anemia and melena. He has a history of end-stage renal disease secondary to complications from diabetes and is on hemodialysis. He reported 2 prior significant episodes of GI bleeding, one in [**2168-10-17**] for which he received 5 units and no source was found, and another in [**Month (only) 956**] of this year in which no source was found. At the time of this GI bleed, upper endoscopy was performed, and this revealed evidence of a 6 cm submucosal mass in the antrum of the stomach with central ulceration and stigmata of recent bleeding. This was felt to be consistent with a GI stromal tumor or leiomyoma and was felt to be the source of bleeding. No other abnormality was noted in the esophagus, stomach or first 2 portions of the duodenum. Preoperative CT scans of the chest, abdomen and pelvis showed a well-defined mass in the antrum with attenuation consistent with fat. On further questioning, the patient does note a recent history of early satiety without weight loss. He states that this has progressed over the last several months Past Medical History: 1. ESRD on HD 2. HTN 3. Hypercholesterolemia 4. DM 5. Diastolic CHF, EF >55% 6. COPD 7. h/o GI bleeding 8. unilateral kidney 9. s/p cataract surgery Social History: Pt is a retired medical record coder at the VA. He is widowed with 4 children and 5 grandchildren. Quit smoking 14 years ago. Smoke [**2-17**] ppd for 40+ years. No EtOh. No drug use. Pt was in the army from [**2118**]-[**2142**]. Family History: Family History: M: Died at 64 of MI; DM F: Died at 41 of MI Aunts maternal and paternal with DM. Physical Exam: At admission, Mr. [**Known lastname **] was pale, but non-diaphoretic, and non-distressed. There was no JVD. His heart was regular rate rhythm with a [**1-22**] holosystolic murmur, best heard at the apex. His abdomen was soft, non-tender, non-distended with normal bowel sounds. He was guaiac positive. There was no edema in his extremities. Distal pulses were diminished. The left upper extremity fistula had good thrill and bruit. Pertinent Results: [**2169-11-1**] 12:35PM BLOOD WBC-11.1* RBC-2.35*# Hgb-7.6*# Hct-20.9*# MCV-89 MCH-32.3* MCHC-36.3* RDW-15.9* Plt Ct-149* [**2169-11-8**] PATHOLOGY REPORT: Submucosal gastric lipoma. Brief Hospital Course: Upon admission, the patient was made NPO and given IV fluids. He was then transfused several units of pRBC's to maintain his hematocrit to be near 30. A CT scan of this abdomen revealed a 48 x 38 mm rounded, well-defined mass in the antrum of the stomach. He was then taken to the operating room to have the mass removed, which was confirmed to be mucosal lipoma by pathology. He tolerated the surgery, but post-operatively, he had several bouts of nausea and vomiting. An upper GI with small-bowel follow through showed no obstruction up to the mid-portion of the jejunum. It was decided that the study was sufficient because inorder to study up to the terminal ileum, the patient had to swallow a much greater amount of barium at the risk of aspiration. Although slow, the patient's nausea and vomiting did eventually resolved and he was able to tolerate a regular, low salt diet. While in hospital, he maintained his hemodialysis schedule of M/W/F. At time of discharge, he was in stable/good condition. Medications on Admission: ASA 81mg Calcium acetate 667mg po TID docusate 100 [**Hospital1 **] nephrocaps qD omeprazole 20 qD NPH Insulin 22U HS lovastatin 20mg HS - d/c'd by PCP metoprolol [**Name9 (PRE) **] 25 diltiazem 180 qD (on M,W,F,Sa only) sevelamer 800 2 tabs TID flovent ambien monopril 20mg vit E 400qD Pred-forte gtt OD qid Advair Spiriva Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed. Disp:*100 Tablet(s)* Refills:*0* 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4-6HRS () as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Insulin per outpatient regiment Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Gastric Lipoma Discharge Condition: Stable Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1924**] in his office in 2 weeks. Please call the office ahead of time to make an appointment ([**Telephone/Fax (1) 55864**] Completed by:[**2169-11-23**]

[ "250.40", "578.9", "V58.67", "496", "428.30", "427.89", "280.0", "997.4", "787.01", "403.91", "214.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "45.13", "99.04", "43.42", "96.34" ]

icd9pcs

[ [ [] ] ]

5734, 5791

2870, 3885

328, 469

5850, 5859

2661, 2847

6677, 6882

2102, 2185

4260, 5711

5812, 5829

3911, 4237

5883, 6654

2200, 2642

276, 290

497, 1646

1668, 1819

1835, 2070

16,112

100,460

50605

Discharge summary

report

Admission Date: [**2171-2-27**] Discharge Date: [**2171-3-29**] Date of Birth: [**2093-12-30**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Heparin Agents Attending:[**First Name3 (LF) 613**] Chief Complaint: transferred from [**Hospital3 **] with abnormal labs--worsening renal failure and metabolic acidosis Major Surgical or Invasive Procedure: placement and removal of central venous access swan-ganz catheter History of Present Illness: Mr. [**Known lastname 74377**] is a 77 year-old man with multiple medical problems including CAD, left ventricular systolic dysfunction with EF of 20%, diabetes mellitus, chronic renal insufficiency with baseline creatinine of 2.2-2.4, hypertension, admitted now from [**Hospital3 **] after labs there demonstrated worsening renal failure and metabolic acidosis. ABG there was 7.25/64/37. The patient reports being bored there. He also reports non-productive cough. Denies chest pain, shortness of breath, pnd, orthopnea, palpitations. He says he was brought to [**Hospital1 18**] because he has a urinary tract infection. As per notes, patient has had recent fevers, which he denies. Additionally at [**Hospital1 **], the was patient being treated for c. diff infection, although no definitive C. diff positivity as per records from [**Hospital1 1319**]. Patient was discharged from [**Hospital1 18**] on [**2-1**]. At that time, lisinopril and lasix had been added to medication regimen. Unclear when these meds were stopped, but at least on day of admission, patient did not receive these. He denies uremic complaints. No dysuria, hesitancy, increased frequency as per patient. Past Medical History: 1. Type 2 DM c/b neuropathy, 2. CAD s/p cath [**4-24**] and [**12-26**]: PTCA LAD and LCX, course complicated by ischemic CM with EF 20%, hemothorax secondary to chest compression 3. CHF: [**1-23**] ischemic CM w/ EF 20% 4. CRI: [**1-23**] diabetic nephropathy, baseline CR 2.2-2.4 5. Anemia of chronic disease, baseline HCT 30 6. h/o VTach s/p DCCV 7. Hypertension 8. stroke: Left posterior deep white matter CVA [**7-25**] 9. Seizures: [**4-24**] on dilantin 10. Urinary retention 11. s/p OS catract, s/p OD catract [**2166**] 12. s/p thoroscopic, parietal decrotication for hemo thorax [**4-24**] 13. s/p tracheostomy [**4-24**] 14. s/p EGD with percutaneous gastrostomy [**4-24**] 15. s/p CCY [**7-25**] 16. s/p appendectomy Social History: Patient is married. He has been between hospital and [**Hospital1 **] since [**4-24**]. He is a retired court officer and state representative. Denies any history of tobacco, alcohol, or illicit drug use. Family History: mother died at 92, had diabetes and breast cancer sisters ages 70 and 80 - one has CAD and had MI, other with MR, thyroid problems brother died at 52 of cancer of unknown type Physical Exam: VS: temp: 97.9 hr: 83 bp: 101/42 rr: 22 95% room air general: somewhat lethargic, elderly appearing gentleman in no apparent distress, "bored" HEENT: PERLLA, EOMI, MMM, op without lesions, no jvd, no carotid bruits, no cervical or supraclavicular lymphadenopathy lung: scattered rhonchi heart: RR, S1 and S2 wnl, no murmurs rubs, gallops abd: +b/s, soft, nt, nd extr: no cyanosis, clubbing or edema, has b/l boots, left heel ulcer with erythema and tenderness neuro: AAOx3, somewhat lethargic, 5/5 strength throughout, good sensation throughout, cn ii-xii intact, no pass pointing, [**1-25**] patellar reflex, gait not assessed Pertinent Results: Admit labs: [**2171-2-27**] 12:00PM WBC-7.8 RBC-2.91* HGB-8.9* HCT-27.9* MCV-96 MCH-30.7 MCHC-32.0 RDW-15.7* [**2171-2-27**] 12:00PM NEUTS-85.8* LYMPHS-10.7* MONOS-2.2 EOS-1.2 BASOS-0.1 [**2171-2-27**] 12:00PM PLT COUNT-160 [**2171-2-27**] 12:00PM PT-18.8* PTT-35.7* INR(PT)-2.2 [**2171-2-27**] 12:00PM GLUCOSE-135* UREA N-81* CREAT-3.2*# SODIUM-137 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-20* ANION GAP-14 Urinalysis: [**2171-2-27**] 12:35PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2171-2-27**] 12:35PM URINE RBC-0-2 WBC->50 BACTERIA-NONE YEAST-NONE EPI-0 Cardiac Enzymes: [**2171-2-27**] 07:40PM CK(CPK)-63 [**2171-2-27**] 07:40PM cTropnT-0.12* [**2171-2-27**] 07:40PM CK-MB-NotDone EKG: NSR, LBBB, no changes [**2171-3-14**] renal U/S: IMPRESSION: Left-sided simple renal cysts. No evidence of hydronephrosis. Chest x-ray: PA and lateral views of the chest: There is stable cardiomegaly. The aorta is tortuous. There is perihilar haziness, upper zone vascular redistribution, and vascular indistinctness, findings all consistent with mild congestive heart failure, which is improved since the prior examination. There is persistent retrocardiac opacity present, which may represent a collapsed/consolidation. Additionally, there is a small bilateral pleural effusions, which appears slightly improved since the prior examination. Degenerative changes are noted within the thoracic spine. IMPRESSION: 1. Mild congestive heart failure, improved since the prior examination. 2. Persistent retrocardiac opacity, which may represent collapse/consolidation. 3. Small bilateral pleural effusions, decreased since the prior examination. Head CT [**2171-3-14**]: IMPRESSION: No evidence of intracranial hemorrhage or edema. Of note, an MRI with diffusion-weighted imaging is most sensitive for acute infarction. Left heel [**2171-3-14**]: IMPRESSION: No focal bone destruction to confirm the presence of osteomyelitis. CT Chest/Abd/Pelvis [**2171-3-27**]: IMPRESSION: 1. Unchanged appearance of the abdomen compared to [**Month (only) 956**] [**2170**]. There is persistence of the nonspecific [**Doctor First Name 9189**] mesentery, without associated lymphadenopathy or bowel abnormalities. There is no evidence of abscess or ascites. There is no CT evidence of pancreatitis. 2. Bilateral pleural effusions have slightly improved but persist. 3. Marked vascular calcifications. Right knee x-ray [**2171-3-26**]: degenerative changes. no fracture or dislocation On discharge: [**2171-3-28**] 06:08AM BLOOD WBC-8.2 RBC-3.04* Hgb-9.4* Hct-28.1* MCV-92 MCH-30.9 MCHC-33.5 RDW-16.6* Plt Ct-163 [**2171-3-29**] 09:00AM BLOOD PT-18.4* PTT-33.8 INR(PT)-2.1 [**2171-3-29**] 05:29AM BLOOD Glucose-78 UreaN-103* Creat-4.4* Na-133 K-4.9 Cl-102 HCO3-18* AnGap-18 Brief Hospital Course: 77 year-old man with history of CAD, left ventriuclar systolic dysfunction with EF 20-25%, type II diabetes mellitus, hypertension, anemia, history of v-tach, chronic renal insufficiency admitted with worsening renal failure, metabolic acidosis, undocumented fevers, and concern for UTI or pneumonia. During his hospitalization the following problems were addressed: 1. Worsening renal failure: the patient's baseline creatinine was 2.2-2.4, and he presented with creatinine of 3.2. Previously he had been discharged to rehab on n lisinopril and lasix, and his creatinine worsened since that time. Renal failure was likely multifactorial related to his poor cardiac function, prerenal azotemia leading to ATN, and complicated by ACE inbitor and lasix use, obstruction due to prostatic hypertrophy as he was noted to have urine residuals of 350cc when catheter was inserted, and continued periods of hypotension. Renal service consulted. Despite efforts to closely monitor his fluid status, to increase his blood pressure to SBP >120 to maintain renal perfusion, to relieve obstruction by placing a foley, and to treat his funguria aggressively, his creatinine continued to rise. Hemodialysis was discussed at length with the patient by both the primary medical and renal teams. He fluctuated in his willingness to start dialysis, but would not commit to it. He developed subtle metabolic acidosis, K+ rose but not above the normal level, and he continued to make urine and maintain a euvolemic fluid balance. There was no an indication for acute initiation of hemodialysis. Creatinine stabilized at around 4.2 by the time of discharge. 2. Funguria: the patient had a fever and a delirium. The only source of infection identified was yeast in his urine, and it was felt this warrented treatment. Two species of yeast were identified; [**Female First Name (un) **] albicans and galabrate. He was treated with a two week course of fluconazole 200mg daily. Infectious disease service was consulted and saw no indication for amphotericin bladder washes. They recommended continuing the two week course of fluconazole. 3. Conjestive heart failure: With treatment for his renal failure the patient developed acute worsening of his conjestive heart failure. He became hypoxic and was admitted to the CCU. There a Swan-Ganz catheter was placed for tailored diuresis. He was diuresed and placed on afterload reduction with hydralazine. He was transferred back to the floor on metoprolol, hydralazine, and lasix. His renal failure continued to worsen on this regimen, and he became hypotensive with SBP 80-90. The metoprolol dose was reduced, the hydralazine initially held, then restarted at a reduced dose, and lasix discontinued. His respiratory status remained stable. He did not complain of shortness of breath. He continued to saturate well on room air. He did have elevated JVP suggestive of fluid overload. This improved but did not resolve entirely by the time of discharge. He was discharged on continued metoprolol, hydralazine, and statin, for secondary prevention of CHF exacerbation. 4. Fevers: The patient presented initially with fevers, with concern for UTI and pneumonia. CXR here showed a possible pneumonia, and he was treated with levofloxacin. Additionally he was treated with flagyl for c.diff infection. He completed both courses. He also ruled out for influenza by nasal aspirate. Additionally, there was concern for osteomyelitis given his chronic left heal ulcer. X-ray; however, did not show any signs of osteomyelitis. 5. h/o DVT: pt had a DVT diagnosed in [**12-26**]. He was continued on anticoagulation. INR became surpratherapeutic while on concurrent antibiotics, and coumadin was held. It remained elevated, thought to be due to nutritional Vit K deficiency, but eventually trended down. He should be treated for an additional 3months. Coumadin should be resumed at 2mg qHS, and held for INR >2 (goal INR [**1-24**]). 6. Anemia: the patient has a history of anemia and guiaic positive stools. He continued to have guiaic positive stools, but his Hct remained stable. He had a colonoscopy in [**12-26**] that showed benign adenomatous polyps. He should likely consider repeat colonoscopy as part of his outpatient. He was treated with Epogen injections, and Hct remained stable. 7. Type II diabetes mellitus: [**Last Name (un) **] services were consulted. The patient was initially treated with a regular insulin sliding scale. He was then on tubefeeds for about three weeks, and lantus was added. When the tubefeeds were discontinued, hte lantus dose was reduced. He was discharged to rehab on 26units Lantus in the mornings, and a regular insulin sliding scale. 8. Dispo: he was discharged back to [**Hospital3 **]. His renal failure may progress, and he may require hemodialysis at some time in the future. For now, he continues to be euvolemic and stable. He should be encouraged to improve his po diet to sustain nutrition for healing of his pressure ulcers. He will follow up with Drs. [**Last Name (STitle) **] in the primary care clinic, Dr. [**Last Name (STitle) 1366**] in nephrology, and Dr. [**Last Name (STitle) 284**] in cardiology. Medications on Admission: plavix 75mg daily aspirin 325mg daily toprol 50mg daily imdur 30mg daily hydral 10 q6hrs glargine 20 qhs zinc vit c vit d vit a calcitriol zocor 40mg daily coumadin 5mg daily protonix 40mg daily tamsulosin 0.4mg daily Discharge Medications: 1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-23**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily): hold for loose stool. 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Hydralazine HCl 10 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for gas. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 17. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleeplessness. 18. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Thirty (30) ML PO QD (). 19. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Four (24) units Subcutaneous QAM. 20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 21. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours). 22. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 23. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold for INR >2. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: renal failure conjestive heart failure (EF 20%) deep venous thrombosis funguria type II diabetes mellitus anemia s/p stroke coronary artery disease pressure ulcers Discharge Condition: stable Discharge Instructions: If you develop fever >101.3, chest pain, shortness of breath, or decreased urine output, please contact your primary care physician [**Name Initial (PRE) **]/or return to the emergency department. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 33346**], MD Where: [**Hospital6 29**] [**Hospital6 **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2171-4-8**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-4-15**] 3:00 Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2171-4-11**] 2:30 You also have an appointment with Dr. [**First Name4 (NamePattern1) 105334**] [**Last Name (NamePattern1) 284**], your cardiologist, for [**2171-4-29**]. Please call [**Telephone/Fax (1) 285**] for the time. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "00.13", "89.64", "89.68", "38.93", "87.61", "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

14019, 14089

6397, 11636

393, 461

14306, 14314

3516, 4154

14560, 15487

2675, 2852

11905, 13996

14110, 14285

11662, 11882

14338, 14537

2867, 3497

6097, 6374

4172, 6083

253, 355

489, 1682

1704, 2435

2451, 2659

13,835

127,890

51669

Discharge summary

report

Admission Date: [**2160-3-13**] Discharge Date: [**2160-3-19**] Date of Birth: [**2096-12-17**] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Sulfonamides / Percocet / Latex Attending:[**First Name3 (LF) 3151**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 63W h/o diverticulitis s/p colectomy, PUD p/w n/v and bloody diarrhea. Recently discharged from [**Hospital1 18**] ([**2160-3-12**]) for n/v/diarrhea. Since discharge, worsening abd pain, vomitting and diarrhea w/blood. Decreased PO. . Last admission, thorough w/u by GI incl colonscopy w/bx and MRI/MRA. MRI/MRA -> stenosis celiac artery. Pt started on ursodiol, cholestyramine and cont on anti-diarrhea meds, PPI and other bowel meds. . In ED, tachycardic, NGT placed and NG lavage was negative. Pt rec'd ativan, morphine, and protonix in the ED. Also rec'd baracath to prepare for CT scan but then had a large episode of BRBPR. A right femoral line was placed, given 1L NS. Repeat HCT was 21.2 from 33. Rec'd 1U PRBCs in ED and transferred to MICU for further monitoring. . In MICU, she complained of pain in her throat, continued nausea, diarrhea. Denied abd pain, CP or SOB. Past Medical History: 1. PUD 2. Diverticulitis s/p partial colectomy '[**56**] 3. Depression 4. HTN 5. Hypothyroidism 6. Raynaud's syndrome 7. Fibroids 8. Asthma 9. H/o hepatitis 10. H/o TIA 11. [**Year (2 digits) 12588**] seizures 12. H/o internal carotid artery dissection 13. presumed infectious colitis [**2-14**] 14. History of necrotizing fasciitis Social History: Retired [**Hospital1 18**] pathologist (on disability); lives with her husband Denies [**Name2 (NI) **], EtOH, illicit drug usage. Family History: non-contributory Physical Exam: 97.7 125/84 89 27 100RA -570 24hrs/+2.5L LOS Gen alert, orientedx3, NAD HEENT PERRL, MM dry, OP clear Neck left EJ in place, no lymphadenopathy, no thyromegally Lungs Clear to auscultation bilaterally CV RRR, nl S1S2, no murmers Abd soft, non-tender, hyperactive BS Ext no edema, well healed wound on right leg Pertinent Results: EKG: sinus tachycardia at 100, no ST T wave changes, compared to prior. . COLONOSCOPY [**2159-2-15**]: showed normal mucosa in the colon, diverticulosis of the ascending colon and descending colon, previous end to end [**Last Name (un) **]-colonic anastomosis of the descending colon. Otherwise normal colonoscopy to cecum to terminal ileum. . COLONOSCOPY [**2160-3-11**]: Tortuous colon. Liquid prep in the colon. Normal mucosa in the colon. . EGD on [**2160-2-15**] showed small hiatal hernia, small cyst was seen on the epiglottis, vocal cord appeared mildly edematous, normal mucosa in the duodenum, mild erythema in the antrum compatible with gastritis, erythema and erosion in the stomach body, otherwise normal egd to second part of the duodenum. . MRI/MRA Abdomen: [**2160-3-3**]: Moderate stenosis at the origin of the celiac artery, with mild post-stenotic dilatation. The superior mesenteric artery and inferior mesenteric artery are of normal caliber. Brief Hospital Course: 63 yo W with extensive medical history including diverticulitis, PUD, presents to the ED with nausea/vomiting/diarrhea found to have BRBPR. s/p 6U PRBCs. Now stable and being transferred to floor [**2160-3-16**]. . 1. GI bleed - Having new onset BRBPR could be from biopsy site vs. diverticulitis (although recent negative colonoscopy) vs. anastomosis site vs ischemic colitis.. - [**3-14**]: had 2 tagged RBC scans - no clear source of lbeeding Treated initially with IV ppi, transitioned to PO. BLeeding resolved without further intervention. . 2. Chronic diarrhea/abdominal pain - previous infectious work-up negative, imaging negative, diarrhea osm c/w with osmotic diarrhea. Mod celiac artery stenosis thought to be unrelated. Non-specific focal active colitis thought to be [**3-13**] diarrhea, non-specific. Unable to measure stool output to confirm diarrhea as patient not fully complying with saving stools. . 3. Thromobocytopenia - platelets improved to 240s from nadir in low 100s, now off of any heparin products. HIT antibody negative. . 4. Asthma- stable. continue singulair and [**Doctor First Name 130**]. Albuterol INH PRN. . 5. HTN - held all anti hypertensive medications while having active GI bleed. Restarted prior to discharge. . 6. Hypothyroidism - continue levoxyl at current dose . 7. Depression- will continue home meds for now. . 8. Elevated INR - Unclear why elevated INR on repeat lab draw, will continue to follow. . 11. Prophylaxis - pt maintained on PPI, pneumoboots Medications on Admission: 1. Duloxetine DR 60mg QD 2. Fexofenadine 60mg PO BID 3. Albuterol INH 1-2 Puffs Q6H PRN 4. Triamterene-Hydrochlorothiazide 37.5-25 mg PO DAILY 5. Fluticasone-Salmeterol INH [**Hospital1 **] 6. Levothyroxine 150 mcg PO DAILY 7. Gabapentin 200mg PO TID 8. Montelukast 10mg PO HS 9. Metaxalone 400mg PO BID 10. Pantoprazole 40 mg DR PO BID 11. Hyoscyamine Sulfate 0.250mg SL QID 12. Calcium Carbonate 500mg PO TID 13. Amphetamine-Dextroamphetamine SR 80mg PO daily 14. Cholestyramine-Sucrose 4g PO BID 15. Ursodiol 300 mg PO BID 16. Aspirin 81 mg Chewable PO DAILY 17. Lidocaine HCl 2 % Solution to Mucous membrane TID 18. Tramadol 50mg PO QD 19. Atenolol 25mg PO QD 20. Opium Tincture Ten (10) Drops PO Q6H 21. Loperamide 2mg PO QID 22. Bismuth Subsalicylate 786mg Chewable PO TID 23. Diphenoxylate-Atropine 2.5-0.025 mg PO Q6H 24. Adderall XR 60 mg PO daily Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: Two (2) Tablet, Sublingual Sublingual QID (4 times a day). 7. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 9. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 10. 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* 11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day: only take if persistent diarrhea. Disp:*60 Capsule, Sustained Release(s)* Refills:*0* 13. Outpatient Lab Work Please check eletrolyte panel (chem 7) sometime between [**3-21**] and [**3-24**], send results to Dr. [**Last Name (STitle) 107054**], [**First Name3 (LF) **] tel # [**Telephone/Fax (1) 250**]. Discharge Disposition: Expired Discharge Diagnosis: diarrhea Discharge Condition: stable Discharge Instructions: Please follow-up with your doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**], you have a [**Last Name (Titles) 1988**] appointment in clinic next week with Dr. [**Last Name (STitle) **]. Call Dr. [**Last Name (STitle) 665**] if you have worsening of you current symptoms including diarrhea, nausea/vomiting, abdominal pain. Please have your labs checked in the next few days to make sure that your electrolytes are stable. Call or report to the hospital for fever, chills, worsenining abdominal pain, especially if more localized, bloody diarrhea, or any other concerning symptoms. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2160-3-26**] 2:30 Provider: [**Name10 (NameIs) **] FIELD SCREENING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2160-4-2**] 2:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2160-4-2**] 2:30 Completed by:[**2162-7-19**]

[ "V12.59", "287.5", "443.0", "443.9", "311", "244.9", "998.11", "401.9", "E879.9", "493.90" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

7101, 7110

3157, 4661

341, 347

7163, 7172

2167, 3134

7819, 8240

1785, 1803

5569, 7078

7131, 7142

4687, 5546

7196, 7796

1818, 2148

296, 303

375, 1265

1287, 1621

1637, 1769

64,383

163,114

1008

Discharge summary

report

Admission Date: [**2185-9-27**] Discharge Date: [**2185-9-28**] Service: NEUROSURGERY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2724**] Chief Complaint: collapse Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 85 M found down today. Was brought to the ED, then decompensated acutely and was intubated. Pt had CT of the head showing a large left subdural hematoma. Past Medical History: PMH: 1. Hypertension 2. Hyperlipidemia 3. CAD s/p CABG ('[**70**]) 4. OA- left knee 5. OSA Social History: Reportedly no tobacco, EtOH. He is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6630**] of the [**Hospital **] Hospital in [**Location 1268**]. Family History: unk Physical Exam: 97.8 F 74 157/77 20 100 vented Intubated, sedated Emaciated male RRR CTA soft, nontender LE- warm, no edema Corneal reflexes intact No gag reflex Pupils- 5mm equal, non-reactive small extensor response to painful stimuli toes upgoing on Babinski Pertinent Results: Labs 5.7 >-----< 193 36.0 N:70.9 L:22.7 M:4.1 E:1.9 Bas:0.4 143 / 106 / 21 --------------< 111 4.4 / 29 / 0.8 CK: 53 MB: Notdone Trop-T: <0.01 PT: 13.6 PTT: 37.7 INR: 1.2 Imaging: CT head: 1) Large left subdural hematoma with rightward subfalcine herniation and uncal herniation. 2) Right frontoparietal intraparenchymal hematomas likely represent hemorrhagic contusions, with associated subarachnoid hemorrhage. Brief Hospital Course: Pt was admitted to the ICU for monitoring. His neurologic exam remained poor with fixed and dilated pupils. The grave prognosis was dicussed with the pt's brother [**Name (NI) 6631**] his health care proxy who stated patient would not want to live like this and he was made comfort measures only. Morphine drip was initiated. He was extubated. Medications on Admission: unk Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Left SDH and R IPH Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2185-9-29**]

[ "432.1", "715.90", "401.9", "V45.81", "414.00", "272.4" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

1960, 1969

1529, 1877

256, 263

2032, 2042

1074, 1270

2095, 2131

778, 783

1931, 1937

1990, 2011

1903, 1908

2066, 2072

798, 1055

208, 218

291, 453

1279, 1506

475, 567

583, 762

18,738

154,724

44009

Discharge summary

report

Admission Date: [**2166-7-7**] Discharge Date: [**2166-7-13**] Date of Birth: [**2110-10-2**] Sex: F Service: MICU/GREEN CHIEF COMPLAINT: Lethargy and hypotension. HISTORY OF PRESENT ILLNESS: This is a 55 year old female with multiple medical problems including diabetes mellitus type 1, coronary artery disease, end stage renal disease with calciphylaxis, who had been recently discharged from [**Hospital1 1444**] after a four week hospitalization for Methicillin resistant Staphylococcus aureus bacteremia/line sepsis/pseudomonal wound infection. This hospital course had been complicated by change in mental status, hypoglycemia, discovery of a right atrial clot. The patient had been discharged on Estrianem and Vancomycin and Flagyl after placement of a tunnel right groin catheter on [**2166-6-27**], and was also on Lovenox for the right atrial clot. The patient was transferred to [**Hospital3 **] facility on [**2166-7-3**], and there became progressively confused and delirious in the 24 hours prior to readmission to [**Hospital1 1444**]. The patient had been dropping blood pressure to 50/palpable at the time of transfer and was noted on blood cultures there to have one out of two bottles growing gram positive cocci in pairs and clusters from [**2166-7-1**]. In the Emergency Department, the patient's blood pressure was 67/17 and the pulse was 66, respiratory rate 16, oxygen saturation 88% in room air. The patient received fluid bolus with a transient increase in blood pressure and electrocardiogram was obtained and found to be in atrial fibrillation at 75 beats per minute. Chest x-ray showed no infiltrate or congestive heart failure. The left internal jugular was placed and the patient was started on Dobutamine drip. Blood cultures were drawn and the patient was transferred to the Intensive Care Unit. PAST MEDICAL HISTORY: 1. End stage renal disease with calciphylaxis. 2. Diabetes mellitus type 1. 3. Congestive heart failure with a left ventricular ejection fraction of 14% and 3+ mitral regurgitation. 4. Chronic atrial fibrillation. 5. Coronary artery disease. 6. Peripheral vascular disease. 7. History of Methicillin resistant Staphylococcus aureus bacteremia. 8. History of VRE. 9. Chronic sacral decubitus ulcer with pseudomonal infection. MEDICATIONS ON ADMISSION TO MEDICAL INTENSIVE CARE UNIT: [**Unit Number **]. Digoxin. 2. Aspirin. 3. Fregmin. 4. Simvastatin. 5. Metoprolol. 6. Vancomycin. 7. Flagyl. 8. Estrianem. 9. Hydroxyzine. 10. Colace. 11. Senna. 12. Tramadol. 13. Nephrocaps. 14. Folate. 15. Epogen. 16. Sorbitol. 17. Fentanyl. 18. Oxycontin. 19. Regular insulin sliding scale. 20. Bacitracin. 21. Colecalcifin. ALLERGIES: Codeine, Vicodin, Penicillin, Keflex, Cephalosporin, Dicloxacillin, Gentamicin. SOCIAL HISTORY: The patient had been in rehabilitation hospital since [**2166-2-15**], had been widowed in [**2163**], did not drink or smoke. The [**Hospital 228**] health care proxy was [**Name (NI) **] [**Name (NI) 4281**]. PHYSICAL EXAMINATION: On admission, in general, the patient is lethargic but oriented times three. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are dry. Cardiovascular is irregularly irregular with II/VI systolic murmur at the apex. The abdomen is soft, bowel sounds present, soft with multiple healing wounds and striae. Extremities showed necrotic digits on the lower extremities bilaterally, undressed wounds on the lower extremity heels bilaterally, the hips with deep wounds open to muscle and fascia and several wounds with eschar. LABORATORY DATA: On admission, the white blood cell count was 10.5, hematocrit 29.3. INR was 2.4. Sodium 140, potassium 5.0, chloride 105, bicarbonate 25, blood urea nitrogen 13, creatinine 7.5, glucose 50. HOSPITAL COURSE: This is a 55 year old female with multiple medical problems including end stage renal disease complicated by calciphylaxis and deep infected ulcers in multiple places on her body, coronary artery disease, and congestive heart failure, recent history of Methicillin resistant Staphylococcus aureus and pseudomonal infections, who is readmitted from the [**Hospital3 **] facility with hypotension and possible sepsis. 1. Hypotension - The patient was admitted with blood pressure of 67/17, initially requiring pressor support with Dobutamine. Fluid boluses were attempted but the patient was never able to support her blood pressure on her own. The patient's pressor requirement increased over the several days of her stay. She eventually was requiring three pressors for support; Neo-Synephrine at 6, Dopamine at 16, Vasopressin at 0.04, even after she had been fluid resuscitated. This refractory hypotension was likely due to gram negative sepsis which the patient and her antibiotics were not able to fight off. 2. Sepsis - The patient was found to have Klebsiella bacteremia from blood cultures drawn both at the [**Hospital3 6373**] facility and here at [**Hospital1 190**] and this Klebsiella was sensitive only to Meropenem and Piperacillin/Tazobactam. Actually, it was a wound culture from the outside hospital that grew the Klebsiella initially. The patient was eventually placed on Meropenem without any apparent improvement in her clinical status. Antibiotics were continued until the decision was eventually made to focus on the patient's comfort. These antibiotics also included Vancomycin. 3. End stage renal disease - The patient was felt to have also an infected dialysis catheter and the catheter was removed shortly after her admission. From that point forward, she had no access for dialysis and it was felt by the renal team who was consulted to be unstable for dialysis and so she was not dialyzed during this admission. 4. Respiratory - The patient was breathing and oxygenating well, however, given her acidosis and the feeling that we may need to give her additional fluids to support her blood pressure, after discussion with the patient and her proxy, she was electively intubated at that time. The patient remained intubated with no real improvement in her clinical status until such time that it was decided to focus on comfort measures. 5. Decision making - The patient was initially quite adamant about her desire that everything be done to try and improve her clinical situation even though the team was quite certain that she had a very, very poor prognosis. Extensive discussions were had with the patient and her health care proxy in which the patient conveyed her feelings to the health care proxy. As can be seen from the above, initially very aggressive measures were taken, multiple pressors and multiple antibiotics. The patient's clinical condition, these measures not withstanding, continued to deteriorate over the course of her stay. She became unable to respond to questions and after extensive discussions with the team and the [**Hospital 228**] health care proxy, all were in agreement that the prognosis for meaningful comfortable survival was zero as especially given that the patient's ulcerated extremities had become gangrenous. All were in agreement that it was no longer humane to prolong the patient's current pain and postpone her notable passing with heroic measures. At this time, with the patient's proxy's permission, the patient was made "comfort measures only". Pressors, antibiotics, and blood draws were stopped. Fentanyl was continued for comfort. The team was called to see the patient at 3:00 on [**2166-7-13**], when she stopped breathing. The patient was found to be asystole by monitor. Her pupils were fixed. There was no response to sternal rub. There were no breath sounds or heart sounds after two minutes of auscultation. The patient was pronounced dead at 3:17 p.m. on [**2166-7-13**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 6006**] MEDQUIST36 D: [**2166-9-26**] 11:04 T: [**2166-9-28**] 14:40 JOB#: [**Job Number 94514**]

[ "585", "424.0", "785.59", "428.0", "518.81", "785.4", "996.62", "427.31", "038.49" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3920, 8158

3057, 3902

156, 183

212, 1857

1879, 2803

2820, 3034

3,268

115,960

6523

Discharge summary

report

Admission Date: [**2167-3-2**] Discharge Date: [**2167-3-15**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: SOB Major Surgical or Invasive Procedure: VATS, talc pleuradesis Bronchoscopy Pleurax cath placement History of Present Illness: 82 F s/p RULobectomy for stage IIIA [**4-7**] Lung Ca now c/b malignant effusion s/p thoracentesis week prior to this now with SOB and recurrent effusion Past Medical History: Coronary artery disease s/p cardiac catheterization '[**61**], aortic stenosis, Abdmoninal aortic aneurysm s/p aortobifememoral graft '[**61**] ([**Doctor Last Name **]), Hypertension, hypercholesterolemia, s/p sigmoid colectomy for Cancer s/p chemotherapy/radiation therapy and anastamotic recurrence, nephrectomy (benign dz), Right internal carotid stenosis, Left knee neuropathy, Ejection fraction 76% Social History: 55 ppy smoking hx, quit 7 years ago previously married x2, 1st husband died of accident, 2nd died age 42- MI. 7 children, 9 grandchildren, 4 great grandchildren Family History: Father - died at 92- old age Mother -died at 92- old age brother died 60's- MI sister died [**2163**] of cerebreal aneurysm Physical Exam: per readmission note IRIRR decreased BS and crackles on R soft NT/ND no c/c/e Pertinent Results: [**2167-3-14**] 04:57AM BLOOD WBC-13.2* RBC-3.25* Hgb-8.8* Hct-27.6* MCV-85 MCH-27.1 MCHC-32.0 RDW-16.8* Plt Ct-288 [**2167-3-13**] 02:00AM BLOOD WBC-11.2* RBC-3.05* Hgb-8.4* Hct-26.0* MCV-85 MCH-27.5 MCHC-32.3 RDW-16.8* Plt Ct-288 [**2167-3-4**] 03:58PM BLOOD WBC-21.0* RBC-3.77* Hgb-10.0* Hct-32.3* MCV-86 MCH-26.5* MCHC-30.9* RDW-15.8* Plt Ct-504* [**2167-3-4**] 09:15AM BLOOD WBC-21.6*# RBC-3.68* Hgb-9.7* Hct-31.4* MCV-85 MCH-26.3* MCHC-30.8* RDW-15.7* Plt Ct-514* [**2167-3-3**] 11:14AM BLOOD WBC-13.2* RBC-3.96* Hgb-10.4* Hct-32.7* MCV-83 MCH-26.3* MCHC-31.8 RDW-15.9* Plt Ct-608* [**2167-3-2**] 09:25PM BLOOD WBC-11.7* RBC-4.00* Hgb-10.9* Hct-31.9* MCV-80*# MCH-27.2 MCHC-34.1 RDW-15.9* Plt Ct-565* [**2167-3-14**] 04:57AM BLOOD Glucose-142* UreaN-22* Creat-1.0 Na-140 K-4.1 Cl-94* HCO3-39* AnGap-11 [**2167-3-13**] 02:00AM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-144 K-3.8 Cl-103 HCO3-34* AnGap-11 [**2167-3-2**] 09:25PM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-135 K-4.3 Cl-95* HCO3-28 AnGap-16 [**2167-3-4**] 01:10PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2167-3-4**] 09:40PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2167-3-5**] 06:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2167-3-14**] 02:51PM BLOOD Type-ART pO2-78* pCO2-69* pH-7.40 calTCO2-44* Base XS-13 [**2167-3-14**] 05:21AM BLOOD Type-ART pO2-118* pCO2-54* pH-7.47* calTCO2-40* Base XS-14 [**2167-3-13**] 06:32PM BLOOD Type-ART pO2-83* pCO2-51* pH-7.45 calTCO2-37* Base XS-9 [**2167-3-13**] 01:27PM BLOOD Type-ART pO2-168* pCO2-56* pH-7.42 calTCO2-38* Base XS-10 [**2167-3-12**] 06:53AM BLOOD Type-ART PEEP-5 FiO2-50 pO2-126* pCO2-44 pH-7.47* calTCO2-33* Base XS-8 Vent-SPONTANEOU Comment-PSV 12 [**2167-3-5**] 02:05PM BLOOD Type-ART Temp-36.2 pO2-266* pCO2-56* pH-7.22* calTCO2-24 Base XS--5 Intubat-NOT INTUBA [**3-2**] CXR - IMPRESSION: Large right-sided pleural effusion, which may mask a pneumonia or mass. [**3-5**] CTA - IMPRESSION: 1. Bilateral pleural effusions and sclerosis in the right pleural space consistent with prior pleurodesis. 2. Loculated fluid collection in the anterior right pleural space as well as multiple foci of gas which may be secondary to recent VATS procedure. 3. Pulmonary edema. 4. No evidence of pulmonary embolism. 5. Patchy airspace disease predominantly at the right lung base, which may represent aspiration or infection, clinical correlation is recommended. 6. Emphysema. Brief Hospital Course: She was readmitted on [**3-2**], made NPO, given lopressor for her A_fib, on [**3-3**] she had a R vats, talc pleurodesisShe was stable immediately post op, but did have low UOP requirng boluses. CT was left to suction post op. On [**3-5**] she desated on the floor and was solmnent - transferred to CSRU and intubated. CTA neg for PE. She was started on an amio gtt in the CSRU for A-fib control and Cipro for a UTI. CT was placed to waterseal and removed on [**3-6**]. She extubated on [**3-6**]. She had labored breathing post extubation and remained in the CSRU and was converted to PO Amio and lopressor. IV access was consulted for PICC line placement. IP was consulted and they did a bronch which showed thick secretion swere seen in the RML. on [**3-11**] in the early morning she was reitnubated for resp failure and required levophed. On [**3-12**] she had a CT guided pleurax cath placed - ~60 cc drained immediately. She also had been started on Vanc/Zosyn for ? VAP. She was diuresed with a hop of getting her pressure support down. She was extubated on [**3-14**] to see if she would make it - plan was she would be DNI after this. She extubated successfully that morning. Her respiratory situtation worsened and she decided she wanted to be comofrt measures only and was started on a morphine gtt for comfort. She had respiratory failure on [**3-15**] and went into asystole and was evaluated by the TICU resident who pronounced her as diseased on [**2167-3-15**] at 210PM. Medications on Admission: Toprol Norvsc Zocor Plavix Prilosec Folic acid ativan Zoloft Colace albuterol Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Respiratory failure and death secondary to malignant effusion secondary to lung cancer Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "599.0", "486", "196.1", "272.0", "492.8", "518.81", "162.8", "427.31", "197.2", "999.9", "V10.05", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.92", "96.71", "33.24", "34.24", "34.21", "34.09", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

5445, 5451

3780, 5287

271, 332

5581, 5590

1377, 3757

5643, 5650

1139, 1264

5415, 5422

5472, 5560

5313, 5392

5614, 5620

1279, 1358

228, 233

360, 515

537, 944

960, 1123

5,036

179,385

16021

Discharge summary

report

Admission Date: [**2128-3-22**] Discharge Date: [**2128-3-24**] Date of Birth: [**2107-6-13**] Sex: M Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old male who fell off a second story balcony while drinking and had positive loss of consciousness. He landed with his head first on a dirt surface. The patient was awake but combative on transfer. He was hemodynamically stable on arrival to the hospital. Upon arrival, the patient had no complaints. PAST MEDICAL HISTORY: History of schizophrenia with psychiatric hospitalizations. Bipolar disorder. MEDICATIONS: Depakote. ALLERGIES: NO KNOWN DRUG ALLERGIES. PHYSICAL EXAMINATION: Vital signs: On arrival pulse was 110, blood pressure 134/70, oxygen saturation 92% on 2 L. General: The patient was combative and intoxicated. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements full. Tympanic membranes were clear. The patient's trachea was midline. Neck: The patient's neck was in a hard collar. He complained of no midline neck tenderness. Chest: Lungs clear to auscultation bilaterally. Cardiovascular: Regular, rate and rhythm. Abdomen: Soft, nontender, nondistended. Good bowel sounds. Back: No step-offs or tenderness. Rectal: Normal tone. Heme negative. Extremities: Without deformity. LABORATORY DATA: Sodium 147, potassium 4.1; white count 4.2, hematocrit 37.6; INR 1.1; amylase 51; serum ethanol 277. Initial radiologic studies showed no fracture on chest or pelvic x-ray. The patient's head CT was negative for intracerebral hemorrhage, and his cervical spine CT with a also negative for fracture. Abdominal and pelvic CT was negative. HOSPITAL COURSE: For agitation in the Emergency Room, the patient was intubated. Additionally, he was vomiting. Following intubation and his initial resuscitation, the patient was transferred to the Trauma Intensive Care Unit. He was transferred intubated and was sedated on Propofol. Over night from hospital day 1 to hospital day 2, the patient did well. He remained hemodynamically stable. His alcohol level was allowed to decline. On the morning of hospital day #2, the patient was extubated without difficulty. He tolerated the wean without difficulty. Following extubation, the patient's cervical spine was cleared clinically. The hard collar was removed. Additionally on hospital day #2, the patient was transferred from the Intensive Care Unit to the regular floor. Given the patient had a past medical history of bipolar disorder and known suicide attempts, the Psychiatry Service was consulted. In their work-up, it was felt that this current episode was not an attempt by the patient to hurt himself in the context of ethanol intoxication. Psychiatric Service recommended a voluntary hospitalization to a psychiatric facility for alcohol treatment, given the patient's recent drinking history and inability to hold a job. For full details, refer to the psychiatric CCC ........... record. Over night from hospital day #2 to hospital day #3, the patient did well. He was able to tolerate a regular diet and ambulate without difficulty. On hospital day #3, the patient only complained of some mild right scapular pain, and at that time x-ray demonstrated no fracture. On hospital day #3, after discussion with the family, the patient agreed to a voluntary inpatient psychiatric hospital stay. At this time, the Psychiatric case manager arranged for the patient to be transferred to a psychiatric facility. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: 1. Alcohol intoxication. 2. Fall from second story. SECONDARY DIAGNOSIS: In past medical history as listed above. DISCHARGE MEDICATIONS: Tylenol 350-650 p.o. q.4-6 hours p.r.n. pain, Vicodin [**1-8**] tab p.o. q.4-6 hours p.r.n. pain for a total dose of Tylenol not to exceed 4 g q.d., the patient should be placed on a CIWA scale for alcohol withdraw at the discretion of the patient's psychiatric facility. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Name8 (MD) 16207**] MEDQUIST36 D: [**2128-3-24**] 13:16 T: [**2128-3-24**] 13:19 JOB#: [**Job Number 45850**]

[ "305.00", "295.90", "E884.9", "296.7", "854.02" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

3754, 4290

3611, 3666

1743, 3558

696, 1725

176, 507

3688, 3730

530, 673

3583, 3590

11,506

123,936

43707

Discharge summary

report

Admission Date: [**2166-3-26**] Discharge Date: [**2166-4-1**] Date of Birth: [**2095-8-1**] Sex: F Service: CHIEF COMPLAINT: This 70-year-old female presented with a chief complaint of acute renal failure, digoxin toxicity, anemia, urosepsis, and hypotension to the Fenard Intensive Care Unit. HISTORY OF PRESENT ILLNESS: A 70-year-old female with a past medical history of congestive heart failure, biventricular failure, ejection fraction of 30%, MAT, status post left knee replacement in [**2158**], perforated duodenal ulcer in [**2164**], psoriasis, eczema, depression, chronic lower extremity edema, obesity, recurrent lower extremity cellulitis, rheumatoid arthritis, interstitial lung disease on 3 liters of home O2, hypothyroidism, steroid-induced hyperglycemia, presents with being chronically ill and bedbound secondary to pain over the past month, decreasing po intake and increasing fatigue and weakness. She fell the night prior to admission on her left elbow and right foot with both with large hematomas. She had no evidence of seizure, no chest pain, no shortness of breath, no loss of consciousness, and no head trauma. Her daughter was there and witnessed it. She denied any fevers, chills, or sweats. No nausea, vomiting, diarrhea, no dysuria, no headache, no melena, no bright red blood per rectum. She continues to complain of severe buttock pain. In the Emergency Room, her vital signs were a temperature of 96.4, pulse of 54, blood pressure 139/60, respiratory rate 18, and sating 96% on 3 liters. Her systolic blood pressures dropped to the 50s and was given 1 liter of IV fluid. Her sats also decreased and improved with 5 liters of O2. She bradied down and was given 1 mg of atropine and 10 mg of dopamine to help her blood pressure. She was started on levofloxacin and Flagyl. She received 100 mEq of potassium chloride and 20 mEq of potassium chloride. In the Emergency Department, she received a total of 1200 cc of normal saline. ALLERGIES: Keflex, Ambien, lorazepam, diclox. OUTSIDE HOME MEDICATIONS: 1. Fosamax once a week. 2. Prevacid. 3. Simethicone. 4. Insulin. 5. Lopressor. 6. Lasix. 7. Prednisone. 8. Synthroid. 9. Digoxin. 10. Potassium chloride. 11. Arava. 12. Leucovorin. 13. Methotrexate. SOCIAL HISTORY: Wheelchair bound, family very involved. PHYSICAL EXAMINATION: On admission, she was febrile at 101.0, blood pressure of 119/68, heart rate 95-105, respiratory rate 20, and sating 96% on room air. Anxious and uncomfortable. Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Equal ocular eye movements. Dry mucous membranes. Tachycardic S1, S2, irregularly, irregular. Lungs are clear to auscultation bilaterally. No wheezes. Abdomen is soft and nontender, bowel sounds present, guaiac negative. Extremities: No clubbing or cyanosis, 1+ bilateral pitting edema. Derm: Diffuse ecchymosis. Neurologic: Cranial nerves II through XII are grossly intact. Oriented x2. INITIAL PRESENTATION LABORATORIES: Pertinent for a sodium of 126, potassium 2.7, creatinine of 1.5, baseline of 0.5. Digoxin is 3.7, and a complete blood count with a white count of 10.8 with a differential of 91 neutrophils, 5 bands, 32 for hematocrit, and platelet count of 57. LENI was negative. Chest x-ray showed chronic interstitial disease. Hip and knee films were negative for fracture. Patient was admitted for Intensive Care Unit. Her hypertension did not really improve with continued IV fluids, stress dosed steroids as she was on chronic steroids and continued on dopamine. Urosepsis was treated with levofloxacin. Acute renal failure improved somewhat. Digoxin toxicity resolved with holding her medications. Her hyponatremia and hypokalemia improved. The patient remained in the Intensive Care Unit until the 22nd, and at that point on the evening prior to being called back to the floor, the patient had a family meeting with the team and her family members, and at that point the family and the patient decided they would like to switch her code status to comfort measures only. Patient was called out to the floor on [**2166-4-1**] at about 2 in the afternoon and was pronounced at 3:15 pm. The patient's family was notified as was the attending. CAUSE OF DEATH: Urosepsis. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Doctor First Name 93938**] MEDQUIST36 D: [**2166-4-1**] 17:35 T: [**2166-4-4**] 06:26 JOB#: [**Job Number 93939**]

[ "515", "038.9", "584.9", "287.5", "599.0", "428.0", "425.4", "276.1", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2069, 2269

2350, 4549

143, 313

342, 2051

2286, 2327

61,661

101,517

43085

Discharge summary

report

Admission Date: [**2171-8-12**] Discharge Date: [**2171-8-16**] Date of Birth: [**2131-12-6**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Increasing dyspnea on exertion Major Surgical or Invasive Procedure: [**2171-8-12**] MV repair (30 mm [**Company 1543**] CG Future ring) History of Present Illness: This is a 39 year old man who has been followed here for 10+ years for mitral valve prolapse and moderate-to-severe mitral regurgitation. He has undergone routine echocardiograms and presents now with probable valve related symptoms (dyspnea on exertion) and worsening of MR [**First Name (Titles) **] [**Last Name (Titles) **]. After appropriate evaluation, he was cleared to proceed with cardiac surgical intervention. Past Medical History: Mitral valve prolapse, Mitral Regurgitation Seizure disorder Osteoporosis Social History: Last Dental Exam: [**2171-7-3**] Lives with: Mother - currently staying with sister and will continue to stay with sister post op until return to [**Name (NI) 108**] Occupation: unemployed Tobacco: none ETOH: none Family History: Non-contributory Physical Exam: Pulse: 98 Resp: 16 O2 sat: 98% B/P Right: 133/85 Left: 136/80 71" 65.7 kg General: no acute distress Skin: Dry [x] intact [x] small scab on forehead and right side of necking healing no erythema HEENT: NCAT [x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no lymphadenopathy Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**2-23**] holo-diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none 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: no bruit Left: murmur Pertinent Results: [**2171-8-12**] Intraop [**Month/Day/Year **] PREBYPASS The left atrium is elongated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed however given degree of MR LV intrinsic function may be worse. (LVEF= 50%). Right ventricular chamber size is normal with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is partial posterior mitral leaflet flail likely at the junction of P1 and P2. Torn mitral chordae are present. Moderate to Severe (3+) mitral regurgitation is seen. There is no pericardial effusion. POSTBYPASS LV systolic function now appears normal. RV systolic function remains normal. There is a ring prosthesis in the mitral position. No MR [**First Name (Titles) **] [**Last Name (Titles) 48613**]. There is no mitral stenosis. However [**Male First Name (un) **] of the MV leaflets is present. The [**Male First Name (un) **] is mild however changes (worsens or improves SBP <90 vs SBP >130 respectively) depending on loading conditions. MR appears when [**Male First Name (un) **] becomes significant. The remaining study is otherwise unchanged from prebypass. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2171-8-12**] where the patient underwent mitral valve repair with resection of the middle scallop of the posterior leaflet and a mitral valve annuloplasty with a 30-mm Future CG annuloplasty ring. 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 on no inotropic or vasopressor support. Beta blocker was initiated. No diuresis was initiated due to [**Male First Name (un) **] seen on intraop echocardiogram. Echo was repeated to further evaluate this on the day of discharge and the report was pending. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with VNA services and appropriate follow up instructions. Medications on Admission: ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 (One) Tablet(s) by mouth weekly. - No Substitution DIGOXIN - (Prescribed by Other Provider) - Dosage uncertain LAMOTRIGINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALTRATE-600 PLUS VITAMIN D3] - (OTC) - 600 mg-400 unit Tablet - 1 (One) Tablet(s) by mouth twice a day FOLIC ACID - 0.8MG Tablet - TAKE ONE TABLET PER DAY MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 6. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Mitral regurgitation s/p MV repair Seizure disorder Osteoporosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage 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 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** Completed by:[**2171-8-16**]

[ "E936.1", "E849.8", "733.09", "429.5", "424.0", "345.90" ]

icd9cm

[ [ [] ] ]

[ "35.12", "39.61" ]

icd9pcs

[ [ [] ] ]

6900, 6975

3568, 4902

352, 422

7084, 7241

2060, 3545

1217, 1235

5542, 6877

6996, 7063

4928, 5519

7265, 8001

1250, 2041

282, 314

450, 872

894, 969

985, 1201

30,424

178,605

4709

Discharge summary

report

Admission Date: [**2175-10-5**] Discharge Date: [**2175-10-20**] Date of Birth: [**2093-12-17**] Sex: M Service: CARDIOTHORACIC Allergies: Spironolactone Attending:[**First Name3 (LF) 1505**] Chief Complaint: worsening DOE over the past 2 days Major Surgical or Invasive Procedure: Cardiac catheterization AVR(25m CE tissue) [**10-16**] History of Present Illness: 81 yo M with AS([**Location (un) 109**] 1.0, 68/40 mmHg as of [**4-3**],), hypertension, DM, CAD s/p multiple coronary interventions, A fib on amiodarone admitted with worsening DOE. The patient states that for the past 2-3 days he is unable to walk more than 200 feet without getting significantly short of breath. Prior to [**12-31**] days ago he could walk up to 400-500 feet with minimal shortness of breath. He describes a significant weight gain based upon his admission weight (up 32 lbs from his last weight measured several weeks ago on a different scale). He denies any new edema, orthopnea, PND, CP, SOB at rest, cough or productive sputum. He describes medication and low-salt dietary compliance. . ED: 97.6 53-55 150-160/50-70 20 97% 3L NC, 94% RA. The patient had one set of negative cardiac enzymes and was admitted for further work-up. . Past Medical History: AS ([**Location (un) 109**] 1.0, 68/40 mmHg as of [**4-3**]) Acxute on chronic diastolic heart failure CAD s/p multiple coronary interventions (PCI to LAD and RCA) A fib s/p successful DC CV [**8-4**] and [**2169**] Hypertension DM Spinal stenosis BPH Basal cell cancer, s/p resection Glaucoma Bilateral Cataracts, s/p lens replacements Social History: He lives alone. He does not smoke but has one glass of wine or beer per day. He is retired from the Navy as an airplane mechanic and then drove an automobile carrier till he retired in [**2153**]. Family History: Father deceased from MI at 66 Physical Exam: PHYSICAL EXAMINATION: 97.4 59 190/80 20 98% 2L FS 228 102.3kg Gen: Comfortable. NAD. HEENT: PERRL. JVP 10. CV: AS murmur. RRR. Pulm: Decreased breath sounds in the left lung base. Abd: Soft, nontender. Ext: No edema. Neuro: A&Ox3. Pertinent Results: CXR ([**2175-10-5**]): Small bilateral pleural effusions. No evidence of focal consolidation. . EKG ([**2175-10-5**]) NSR, rate of 54, normal axis and intervals. Downgoing T waves in V4-6. Unchanged from prior in [**2-/2175**] Brief Hospital Course: During work-up Mr. [**Known lastname 19841**] dyspnea on exertion, PFTs were performed secondary to amiodarone use. He underwent cardiac catheterization which showed no significant coronary disease and confirmed severe AS. Dental consult recommended that some teeth be extracted. He awaited decrease in INR and creatinine, and dental extractions which were performed on [**10-12**]. He was taken to the operating room on [**10-16**] where he underwent an AVR (tissue). He was transferred to the ICU in critical but stable condition. He was extubated later that same day. He was given 48 hours of perioperative vancomycin as prophylaxis given that he was in the hospital preoperatively. His pressors were weaned and he was transferred to the floor. Mr. [**Known lastname 19841**] wires and chest tubes were removed. By post-operative day four he was ready for discharge to home. Medications on Admission: Amio 200', Norvasc 7.5, ASA 81', Lipitor 10', DDAVP 0.2', Doxazosin 8', Finasteride 5', HCTZ 25', Benicar 40', NPH 19U qAM, NPH 22U qhs, Labetolol 400", MVI, Coum Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Desmopressin 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*0* 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Nineteen (19) units Subcutaneous before breakfast. Disp:*qs units* Refills:*0* 11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Two (22) units Subcutaneous at bedtime. Disp:*qs units* Refills:*0* 12. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO daily (). Disp:*60 Tablet(s)* Refills:*0* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 14. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:*14 Packet(s)* Refills:*0* 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 16. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Please take 1 pill (2.5mg) every TThSS and 2 pills (5mg) every MWF or as directed by the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 9486**] . Disp:*30 Tablet(s)* Refills:*20* 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 18. Outpatient Lab Work INR to be drawn Sunday and sent to the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. phone [**Telephone/Fax (1) 9486**] fax [**Telephone/Fax (1) 19842**]. Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: severe AS now s/p AVR glaucoma, HTN, IDDM, CAD-s/p PCI to LAD, RCA [**2164**], Afib, CRI ( baseline creat. 1.3), BPH, anemia, Bell's palsy, T+A, s/p cataract surgery, skin ca 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 daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Please see Dr. [**Last Name (STitle) **] 4 weeks ([**Telephone/Fax (1) 11763**]. Already scheduled appointments: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] INTERNAL MEDICINE (NHB) Date/Time:[**2175-11-29**] 10:45 Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2175-11-30**] 4:00 INR to be drawn Sunday and sent to the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. phone [**Telephone/Fax (1) 9486**] fax [**Telephone/Fax (1) 19842**]. Completed by:[**2175-10-20**]

[ "585.9", "250.80", "403.90", "424.1", "600.00", "414.01", "365.9", "272.4", "V58.67", "584.9", "521.00", "428.32", "428.0", "285.21", "433.30", "427.31" ]

icd9cm

[ [ [] ] ]

[ "35.21", "88.56", "23.19", "37.22", "39.63", "88.53" ]

icd9pcs

[ [ [] ] ]

5818, 5877

2400, 3283

319, 376

6096, 6104

2148, 2377

6409, 7010

1851, 1882

3496, 5795

5898, 6075

3309, 3473

6128, 6386

1897, 1897

1919, 2129

244, 281

404, 1261

1283, 1621

1637, 1835

83,235

197,984

36915

Discharge summary

report

Admission Date: [**2191-7-17**] Discharge Date: [**2191-7-25**] Date of Birth: [**2125-4-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2191-7-18**] ERCP with stent placement [**2191-7-21**] Laparoscopic converted to open cholecystectomy History of Present Illness: Pt is a 66 yo F with PMHx sig. for GERD who presents to [**Hospital3 **] Hospital for 2 weeks of epigastric pain and transferred here for emergent ERCP. Pt reported that for the past 2 weeks she has had worsening GERD symptoms, describing intermittent [**11-19**] sharp epigastric pain, no radiation, improved with prevacid. This acutely on Friday. She also reports 1 episode of N/V, nonbloody 2 weeks ago. She reports that she has always alternated between diarrhea and constipation; no changes in bowel habits. She denies BRBPR and melena. She also reports shaking chills the past week. Pt reports she has been feeling very weak as well. She had fallen last night. She feel again this morning while waking to the bathroom. She reports that she suddenly became very weak and slumped to the ground. She was there from about 3 AM to 8AM until her sister-in-law came to help. She denied LOC, but reports hitting her head. . At [**Hospital3 **] Hospital, initial VS were: T98, 94/59, 72, 16, 96% on RA. Her VS trended toward sepsis with tachycardia to 112, BP to 90/51. A Rt femoral line was placed and pt was started on levophed. Labs were sig. for WBC 18 (33% bands), HCT 38, plt 239, Cr 1, K 2.5, SGO 67, SGP 132, TB 8.4, DB 5.1, alk phos 408, CK 503, CKMB 7.3, Trop I 0.26 (<0.10). US showed thickened GB wtih multiple stones and biliary dilitation wtih CBD of 14 mm. CT abd showed dialted intrahepatic biliary ducts, CBD of 14 mm, a soft tissue density at the intrahepatic biliary duct bifurcation of the R and L main CBD, thickened gb with stones, nonspecific mesenteric LAD. CXR showed mild bibasilar atelectasis. Pt received zosyn and ?3 L of NS. Pt was transferred for emergent ERCP. . On the [**Location (un) **], SBPs dipped to 70s transiently. . In the ED, initial vs were: 97.5, 111/54 on 0.30 mcg/kg levophed, 115, 96% on 4L. Exam was sig. for coolness. Labs were sig. for lactate 3.8, WBC 26 (37% bands), HCT 28.9, TB 5.9, [**Doctor First Name **] 438, lip , ap 310, alt 112, ast 103. Pt was continued on levophed. ERCP has been consulted and perform the procedure tonight. Surgery had no further recs. Current vs are: 95/47 on Levophed 0.28, 113, 39, 98% on 4L. mcg/kg. No UOP. Past Medical History: Depression, Hyperlipidemia, GERD, Osteoarthritis, s/p TAH Social History: Lives alone, works as a secretary. Denies tobacco use, usually drinks a glass of wine per evening. Has not had any alcohol in 1 week. Denies illicit substance use. Family History: Father died of colon cancer at age 78; mother had dementia, died at age 84. Has one brother whose health is unknown. Has no children. Physical Exam: On Admission: . 97.4 111-117 102/50-111/59 16-26 97% 4lNC Gen: dyspneic female, appears younger than stated age, NAD, mild scleral icterus, diaphoretic HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD Cor: RRR without m/g/r, no JVD, no bruits Lungs: CTA bilat. [**Last Name (un) **]: +BS, soft, ND, no masses, no hernias, tender at RUQ with [**Doctor Last Name **] sign Ext: warm feet, no edema On discharge: AF/AVSS Gen: NAD, A/O x3 Cardiac: RRR, no MRG Lungs: CTA bilaterally Abd: soft, minimally tnder, [**Doctor Last Name 19973**] Wound: C/D/I Extr: no CCE Pertinent Results: LABS ON ADMISSION: [**2191-7-17**] 09:20PM BLOOD WBC-26.0* RBC-3.34* Hgb-9.9* Hct-28.9* MCV-87 MCH-29.7 MCHC-34.3 RDW-15.0 Plt Ct-166 [**2191-7-17**] 09:20PM BLOOD Neuts-49* Bands-37* Lymphs-4* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-4* Myelos-4* [**2191-7-17**] 09:20PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-2+ Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Burr-2+ Acantho-OCCASIONAL [**2191-7-17**] 09:20PM BLOOD PT-17.2* PTT-34.2 INR(PT)-1.6* [**2191-7-17**] 09:20PM BLOOD Glucose-66* UreaN-17 Creat-1.0 Na-143 K-3.3 Cl-113* HCO3-17* AnGap-16 [**2191-7-17**] 09:20PM BLOOD ALT-112* AST-103* LD(LDH)-262* CK(CPK)-589* AlkPhos-310* Amylase-438* TotBili-5.9* [**2191-7-17**] 09:20PM BLOOD Lipase-467* [**2191-7-17**] 09:20PM BLOOD CK-MB-14* MB Indx-2.4 [**2191-7-17**] 09:20PM BLOOD Albumin-2.5* Calcium-6.9* Phos-0.8* Mg-2.2 [**2191-7-17**] 09:20PM BLOOD Hapto-288* [**2191-7-18**] 04:16AM BLOOD Type-ART Temp-37.1 pO2-150* pCO2-30* pH-7.30* calTCO2-15* Base XS--9 . MICROBIO: pending . RADIOLOGY: [**2191-7-18**] CT A/P: 1. Marked CBD dilatation, with moderate intrahepatic biliary ductal dilatation, but no pancreatic ductal dilatation. No radiopaque obstructing stone is identified, but findings are concerning for obstruction. ERCP or MRCP recommended. 2. Inflammatory changes surrounding the head of the pancreas concerning for acute pancreatitis. 3. Gallbladder wall thickening and pericholecystic stranding, with relatively [**Name2 (NI) 19973**] gallbladder. This may be reactive, associated with biliary obstruction. If there is concern for acute cholecystitis, a nuclear medicine hepatobiliary scan may be helpful. . GI [**2191-7-18**] ERCP: Pus was seen in the stomach. There was pus discharge in the major papilla. There was an impacted stone stone in the major papilla. There was a filling defect that appeared like sludge/stone in the lower third of the common bile duct.Minimal amount of contrast was injected considering risk of bacteremia. 4 ml pus material has been suctioned from the bile duct and sent for culture. A 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully in the lower third of the common bile duct using a Microvasive 10FR stent introducer kit. Sphincterotomy was not perfromed considering her underlying coagulopathy. . Brief Hospital Course: Ms. [**Known lastname **] is a 66F who was transferred to [**Hospital1 18**] from [**Hospital3 **] hospital with a diagnosis of cholangitis. When she arrived she was in septic shock and requiring a Levophed drip to maintain adequate perfusion pressures. She was transferred to the ICU and electively intubated and underwent an emergent ERCP on [**2191-7-18**]. The ERCP showed purulent material in the stomach and coming from the major papilla. There was an impacted stone in the major papilla and another stone in the lower third of the CBD. A stent was placed in the distal CBD. She was placed on empiric Vanc, Zosyn, and Flagyl. Blood cultures from [**Hospital3 **] hospital grew E.coli that was pan sensitive. Bile cultures also grew E.coli that was pan sensitive. Repeat blood cultures drawn here at [**Hospital1 18**] were negative. She recovered from her initial septic episode after decompression of her biliary tree and Levophed was quickly weaned off. Once stable she was transferred to the surgical floor. On [**2191-7-21**] she was taken to the operating room for cholecystectomy. A laparoscopic attempt was made, but due to extensive adhesions a conversion to open cholecystectomy was made for the safety of the patient. Post-operatively she did quite well. She was given a PCA for pain control and started on her home medications. Her diet was slowly advanced and she was converted to oral pain medications. A PICC line was placed early in her hospital stay due to difficult access and the need for multiple antibiotics and IVF but was removed prior to discharge. Physical therapy evaluated her and recommended rehabilitation for improving ambulation therefore she was transferred to rehab for a less than 30 day stay. Medications on Admission: Abilify 5 mg daily , Pristiq ?100 mg daily , Liptor 20 mg daily, Prevacid 30mg PO daily, Motrin 800 mg [**Hospital1 **] Discharge Medications: 1. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare - [**Location (un) 23638**] Discharge Diagnosis: Cholangitis Choledocholithiasis Cholecystitis Discharge Condition: Good Discharge Instructions: Call your surgeon if you develop: - fever > 101 or chills - inability to eat or drink - persistent abdominal pain not relieved by your medication - persistent nausea or vomiting - increasing redness or drainage from your incision - or any other concerns you may have . You may shower. Do not take a tub bath or submerge your incision in water for the next 3-4 weeks. . Resume all of your home medications. You will be given a prescription for narcotic pain medication. Do not drive while taking this medication as it may make you drowsy. You will also be given a prescription for a stool softener. Followup Instructions: The Gastroenterologist will contact you and schedule an appointment for a repeat ERCP to remove the stent that they placed on the first ERCP. Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2191-8-8**] 10:15 Call Dr. [**Last Name (STitle) 47654**] ([**Telephone/Fax (1) 83324**]) for an appointment in 2 weeks Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2191-8-8**] 10:15 Call Dr. [**Last Name (STitle) 47654**] ([**Telephone/Fax (1) 83324**]) for an appointment in 2 weeks Completed by:[**2191-7-25**]

[ "518.81", "574.01", "574.11", "995.92", "576.1", "785.52", "038.42", "V64.41", "577.0" ]

icd9cm

[ [ [] ] ]

[ "51.87", "96.71", "38.93", "96.04", "51.22" ]

icd9pcs

[ [ [] ] ]

8654, 8743

6039, 7792

328, 435

8833, 8840

3684, 3689

9490, 10149

2936, 3072

7962, 8631

8764, 8812

7818, 7939

8864, 9467

3087, 3087

3512, 3665

274, 290

463, 2656

3703, 6016

2678, 2738

2754, 2920

63,966

169,161

50970

Discharge summary

report

Admission Date: [**2159-9-6**] Discharge Date: [**2159-9-8**] Date of Birth: [**2106-5-7**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Bacitracin/Polymyxin B Sulfate / Zoloft Attending:[**First Name3 (LF) 6473**] Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 53-year-old woman with a PMH of lupus, fibromyalgia and migraines transferred from BIDNH after presenting with methadone overdose and intubated for airway protection. Per nedham report and coversation with the patient's husband, the patient has been depressed in recent past with history of tylenol ingestion with suicidal intent within the past week. She was seen by a therapist after this episode but it does not seem as though she recieved any medical intervention. Around 7:30pm this evening, the patient was taking a nap and was minimally responsive with gurgling breath sounds. Her husband called EMS and initiated CPR although the patient was never [**Doctor Last Name **] apneic or pulseless. She arrived to [**Location (un) **] at approx 9pm. She was given narcan with unknown response. Received carchol. Given Cefrtriaxone and flagyl for question of aspiration PNA. . On arrival to [**Hospital1 18**], the patient was evaluated by the Toxicology team. Serum tox positive for barbiturates and methadone. QTC 472. No interventions made. She was weaned off propofol in ED with response, moving all extremities. Past Medical History: SLE Fibromyalgia Depression Migraines Osteoporosis R Hip fracture post-traumatic s/p closed reduction, internal fixation on [**2147-1-30**] Social History: Unable to obtain - per [**Date Range **] no tobacco or EtOH Family History: Unable to obtain - per [**Name (NI) **] Mother: Glaucoma. Father: Prostate cancer. Paternal grandfather: [**Name (NI) **] cancer. Brother: [**Name (NI) 4522**] Physical Exam: VS: 97.8 74-88 112-118/80-76 84 18 98% on 2L General Appearance: Well nourished, No acute distress, Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube Cardiovascular: PMI Normal, S1 and S2: Normal Peripheral Vascular: (Right, Left radial, Right, Left DP pulse: Present Respiratory / Chest: Expansion: Symmetric, Breath Sounds: Clear Abdominal: Soft, Non-tender, Bowel sounds present, Not Distended Extremities: Right: Absent, Left: Absent, Not Cyanosis or Clubbing Skin: Not assessed, Not Rash: , Not Jaundice Neurologic: Attentive, Follows simple commands Pertinent Results: Lab Results: [**2159-9-6**] 01:10AM BLOOD WBC-13.2*# RBC-3.51* Hgb-10.7* Hct-32.2* MCV-92 MCH-30.6 MCHC-33.4 RDW-12.9 Plt Ct-196 [**2159-9-7**] 04:40AM BLOOD WBC-7.4 RBC-3.42* Hgb-10.7* Hct-30.7* MCV-90 MCH-31.4 MCHC-35.0 RDW-12.9 Plt Ct-182 [**2159-9-8**] 05:20AM BLOOD WBC-6.2 RBC-3.10* Hgb-9.8* Hct-27.1* MCV-87 MCH-31.5 MCHC-36.1* RDW-12.8 Plt Ct-155 . [**2159-9-6**] 01:10AM BLOOD Neuts-85.4* Lymphs-9.7* Monos-4.3 Eos-0.4 Baso-0.1 . [**2159-9-6**] 01:10AM BLOOD PT-13.0 PTT-24.8 INR(PT)-1.1 . [**2159-9-6**] 01:10AM BLOOD Glucose-81 UreaN-10 Creat-1.0 Na-139 K-3.9 Cl-107 HCO3-25 AnGap-11 [**2159-9-7**] 04:40AM BLOOD Glucose-120* UreaN-8 Creat-0.7 Na-137 K-3.8 Cl-103 HCO3-28 AnGap-100 [**2159-9-8**] 05:20AM BLOOD Glucose-119* UreaN-7 Creat-0.6 Na-134 K-3.4 Cl-100 HCO3-24 AnGap-13 . [**2159-9-6**] 01:10AM BLOOD ALT-24 AST-28 AlkPhos-58 TotBili-0.2 [**2159-9-7**] 04:40AM BLOOD ALT-20 AST-25 LD(LDH)-222 AlkPhos-65 TotBili-0.4 . [**2159-9-6**] 01:10AM BLOOD Calcium-7.4* Phos-1.9*# Mg-1.9 [**2159-9-7**] 04:40AM BLOOD Albumin-3.7 Calcium-7.5* Phos-2.8 Mg-2.0 [**2159-9-8**] 05:20AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.0 . Serum Barb Pos Serum ASA, EtOH, Acetmnphn, Benzo, Tricyc Negative . TSH:2.9 . ABG: pH 7.46 pCO2 33 pO2 370 HCO3 24 BaseXS 1 Type:Art; Intubated; FiO2%:100; AADO2:340; Req:59; Rate:12/; TV:550; Mode:Assist/Control . Urine Barbs Pos Urine Mthdne Pos Urine Benzos, Opiates, Cocaine, Amphet Negative . Color Straw Appear Clear SpecGr 1.006 pH 6.5 Urobil Neg Bili Neg Leuk Neg Bld Neg Nitr Neg Prot Neg Glu 50 Ket Neg Brief Hospital Course: 53 y.o. female with a history of lupus, fibromyalgia, depression, osteoporosis, and migraines transferred from BIDNH after presenting with methadone overdose and intubated for airway protection, transfered to the floor after successful extubation. . # Methadone Overdose: Suicide attempt patient admitted to true attempt. She has history of prior suicide attempt three days prior with tylenol. Patient received charchoal at BIDNH, no indication to repeat charcoal per toxicology. Patient received narcan at BIDNH as well. Intubated for airway protection and weaned successfully in the MICU. Psychiatry and Toxicology consulted and follwed. As patient has a history of tylenol ingestion, checked serial LFT's which were all within normal limits. As LFT's not abnomal did not administer mucomyst. Monitored on telemetry and got daily EKG's to monitor QTc, stable at 475 prior to discharge. No prior recent EKG to compare to. Maintained with a 1:1 sitter. She was kept under section 12 for her safety. Now that she is medically stable, she will be transfered to an inpatient psychiatric facility for evaluation and treatment. . # Leukocytosis: resolved. Per OSH reports there was a question of aspiration. CXR was negative for evidence of infiltrate. Patient able to be extubated without difficulty. Did not initiate antibiotic therapy as leukocytosis resolved, patient afebrile and not requiring 02 prior to discharge. . # SLE: Discussed plan with Dr. [**Last Name (STitle) 3057**]. Patient should continue on hydroxychloroquine while inpatient, alternating 200mg QD with [**Hospital1 **]. . # Chronic Pain: History of chronic headaches, neck pain, and bilateral upper extremity pain with some relief in the past with nerve blocks. Continued indomethacin only for pain control with some relief. [**Month (only) 116**] have to go back on other narcotics in the future, however held methadone while inpatient considering overdose. Toxicology did not think that she would go into withdrawls from holding methadone, but monitored closely for signs of withdrawls, with none noted. . # Migraines: Continued indomethacin. Also used PRN Ativan for nausea, initially IV, then switched to PO as zofran has concern of effecting QT length. Therapeutic exchange for maxalt as not on formulary, gave imitrex. Will switch back to maxalt on discharge. . # Anemia: Patient's Hct dropped from 32 on admission to 27 on discharge to psychiatric facility. Most likely patient has dilutional changes from aggressive IV fluids, however will have facility check Hct on Monday to confirm this has remained stable or increased. If Hct continues to decrease, patient will need further workup regarding anemia, including possible GI etiology as patient has taken many NSAIDs in the past. . # FEN: advanced diet to regular, repleted lytes and fluids PRN . # Prophy: Heparin SC, H2 blocker . # Code: Full Code Medications on Admission: CELECOXIB - 200 mg po [**12-13**] daily DECADRON - 0.5MG/5ML Elixir - 5CC TID SWISH AND SPIT FLUCONAZOLE - 150 mg Tablet - up to 2x/week FLUOXETINE - 40mg po daily IBANDRONATE INDOCIN - 50MG Capsule TID PRN LORAZEPAM - 0.5 mg Tablet - up to tid MAXALT MLT - 10MG Tablet, Rapid Dissolve [**Hospital1 **] PRN METHADONE HCL - 10 mg [**Hospital1 **] PRN OMEPRAZOLE - 20 mg Capsule daily PREMPRO - 0.625-2.5 Tablet - daily VITAMIN D - 400 UNIT Capsule - daily 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. Indomethacin 25 mg Capsule Sig: [**12-13**] Capsules PO TID (3 times a day) as needed for headache. 4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea: Hold for excess sedation, RR < 10. 5. Maxalt-MLT 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day as needed for migraine. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Prempro 0.625-5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID, EVERY OTHER DAY (). 9. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Alternating with [**Hospital1 **] every other day. 10. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 11. Celecoxib 200 mg Capsule Sig: [**12-13**] Capsules PO DAILY (Daily) as needed for pain. 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: Primary Diagnosis: Overdose . Secondary Diagnoses: SLE Migraines Fibromyalgia Osteoporosis Discharge Condition: medically stable. Discharge Instructions: You were [**Hospital1 18**] for an overdose of your medications. You admitted that this was a suicide attempt. You were treated with narcan and charcoal to reverse the effects of the medications. You were seen in the ICU and then when stable transfered to the floor. You were determined to be medically stable prior to your discharge. . Methadone was held during your stay. You will need to discuss with the psychiatrists and your pain management physician when and if to restart this medication. You should not take you ibandronate until you are released from the psychiatric facility. Your mouthwashes were also held, if you become symptomatic they can be added in the future. Senna and dulcolax were added for constipation to be used as needed. . You will be released to a psychiatric facility with 1:1 supervision. If you have worsening pain or headaches, or any other worrisome symptoms please alert medical personnel. Followup Instructions: Provider: [**First Name4 (NamePattern1) 3049**] [**Last Name (NamePattern1) 8155**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1652**] Date/Time:[**2159-9-27**] 1:00 . Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2159-10-3**] 3:00 . Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2159-11-1**] 2:30 Completed by:[**2159-9-9**]

[ "311", "733.00", "E950.0", "346.90", "729.1", "710.0", "518.81", "965.02", "285.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

8775, 8820

4143, 7053

334, 340

8956, 8976

2564, 4120

9956, 10420

1762, 1923

7558, 8752

8841, 8841

7079, 7535

9000, 9933

1938, 2545

8893, 8935

286, 296

368, 1505

8861, 8872

1527, 1669

1685, 1746

6,447

189,502

1203

Discharge summary

report

Admission Date: [**2107-4-27**] Discharge Date: [**2107-4-30**] Date of Birth: [**2061-10-20**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 3561**] Chief Complaint: transfer from micu for altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: This is a 45 year-old male with history of HIV/AIDS([**4-12**] CD4 53, VL < 50), HCC (w/ cirrhosis) who was found to have mental status changes after taking tincture of opium. The patient says he has had diarrhea for 2 years, but has been worse over past couple of days. Usually this is relieved with loperamide, though over last 2 days diarrhea worse and took opium. The morning of the admission the patient took an unknown amount of opium and mother noted patient was somnolent and difficult to arouse. The patient said with the recent diarrhea he had some abdominal pain, nausea, fever to 101 and some streaks of blood in his stool. Based on his somnolence he was brought to ED. . In the ED, patient received naloxone 0.8mg with intermittent improvement in mental status followed by relapse to original state. He also complained of headache at this time. Due to headache and concern for meningitis, patient received head CT and also 1 dose of acyclovir, ceftriaxone, and vancomycin. Blood cultures were sent prior to this. He was also given lactulose for possible hepatic encephalopathy. Due to concern for naloxone requirement and periods of apnea, patient was transferred to MICU for further respiratory monitoring. . His micu course was uncomplicated, he had some meds (trazodone, mirtazapine, percocet and clonazepam) held to prevent further somnolene and he was given lactulose for high ammonia. Initially treated for presumed meningitis given fevers, given ceftriaxone, azithromycin and vancomycin His mental status improved and he was transferred to medicine. . Currently patient feels well, had formed, non-bloody stool today. . Past Medical History: 1. AIDS by CD4 (CD4 128, HIV VL<50, [**7-30**], on abacavir, atazanavir, lamivudine, reports missing 1 dose/week typically) 2. HCV (Genotype [**2-8**] hybrid) not currently treated due to his polysubstance abuse and depression. No Biopsy done yet. 3. Invasive Anal Carcinoma treated with chemo/XRT; recent high grade lesion found and treated; followed in Anal dysplasia clinic 4. Substance abuse, cocaine and ETOH 5. L arm amputee secondary to compression injury and ischemia after drug overdose, [**2096**] 6. Depression with multiple suicide attempts 7. Bone marrow toxicity secondary to Bactrim/AZT 8. Chronic Thrombocytopenia 9. MRSA scrotal abscess x2 [**10**]. h/o testicular cellulitis, [**6-11**] 11. COPD (FEV1 83% of predicted on [**4-9**]) 12. erosive gastritis on EGD, [**2103-2-14**] 14. s/p multiple sexual and physical trauma Social History: lives alone, social support from mother in [**Name (NI) 2251**]. h/o polysubstance abuse, although denies current drug use or EtOH use, 10 pack year smoking hx, Pt has been in multiple fights, where he has been severely beaten and injured. Abused as a child. The patient dropped out of [**Location (un) 3786**] high school while in the tenth grade secondary to being bullied on the basis of being gay. He later obtained his GED. Family History: -His family psychiatric history is significant for his mother diagnosed with depression and alcoholism, currently in remission, -His biological father has a history of depression. -His sister died at the age of 24 in a fire while intoxicated with alcohol. -His brother was addicted to heroin and prescription opioids and he had died from an overdose. Physical Exam: Vitals: BP: 103/59, P 94, T 98.6, 98%RA, RR 15 GEN: sitting in bed, NAD, pleasant male HEENT: EOMI, sclera anicteric, no mucosal ulcerations of thrush, MM slightly dry COR: regular rhythm, no M/G/R PULM: slight crackles at bases bilateral ABD: Soft, mildly distended, non-tender, +BS EXT: No cyanosis, clubbing or edema, warm, well-perfused, +2 DP pulses, LUE amputation at forearm. NEURO: aaox3, conversant, appropriate, cn intact, strength intact, non-focal exam Pertinent Results: [**2107-4-27**] 11:43PM GLUCOSE-123* UREA N-25* CREAT-1.3* SODIUM-133 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-13 [**2107-4-27**] 06:12PM AMMONIA-83* [**2107-4-27**] 05:25PM GLUCOSE-125* UREA N-26* CREAT-1.3* SODIUM-136 POTASSIUM-5.6* CHLORIDE-109* TOTAL CO2-20* ANION GAP-13 [**2107-4-27**] 05:25PM WBC-5.4 RBC-3.78* HGB-13.5* HCT-41.4 MCV-110*# MCH-35.7* MCHC-32.6 RDW-16.2* . [**4-27**] ct head: IMPRESSION: No acute intracranial pathology, including no sign of intracranial hemorrhage . [**4-27**] cxr: FINDINGS: Single frontal view of the chest demonstrates normal heart size and mediastinal contours. There are linear markings at the left base consistent with scar or small areas of atelectasis. The right lung is clear. There is no parenchymal consolidation, pleural effusion, or pneumothorax. The bones are unremarkable. IMPRESSION: Left basilar atelectasis or scar . [**4-28**] doppler abd: IMPRESSION: 1) Heterogeneous cirrhotic appearing liver normal Doppler waveforms and no focal lesions. 2) Splenomegaly. 3) Trace amount of ascites insufficient for paracentesis. Brief Hospital Course: 45 y.o. male with history of AIDS, HCV cirrhosis, polysubstance abuse, diarrhea, admitted for mental status changes and respiratory monitoring. . His micu course was uncomplicated, he had some meds (trazodone, mirtazapine, percocet and clonazepam) held to prevent further somnolence and he was given lactulose for high ammonia. Initially treated for presumed meningitis given fevers, he was given ceftriaxone, azithromycin and vancomycin. His mental status improved and he was transferred to medicine. . Floor course: . #) Mental status changes - The patient's mental status changes were likely related to his overdose of opium, as his mental status improved through his course. Given his elevated ammonia a concern for encephalopathy was raised, but this was unlikely. Given this concern the patient was initially treated with lactulose, and rifaximin. With the history of fever and headache in ED, he was initially treated for meningitis, though on the floor he was afebrile with no meningismus, so concern for meningitis was low and he was not treated any further. On the floor, his mental status improved and this was again related to opium overdose. Given this his lactulose and rifaximin were stopped. He was doing well prior to discharge, and as blood cultures were sent in the ED, and should be followed as an outpatient. . #) Cirrhosis: The patient had improved mental status on the floor, and while he had elevated ammonia it was unlikley he had encephalopathy, so his lactulose and rifaximin (given in the ED and MICU) were stopped. He did not appear to have a large amount of ascites, though given his delicate fluid balance he had an US which showed minimal ascites. As he had Acute renal failure, his lasix and spironolactone were held, and his fluid balance was closely followed. His renal function improved prior to discharge, so to prevent fluid overload his diuretics were restarted at a lower dose, and he will be followed closely by ID and the coinfection clinic as an outpatient, so he is maintained on the appropriate dose of diuretics to prevent reacummulation of ascites. . #) HIV - The patient is followed by Dr. [**Last Name (STitle) 3394**], and he is on appropriate medications. He was followed by ID and was continued on PCP and MAC prophylaxis with [**Last Name (STitle) 7615**] and azithromycin respectively, and also continued on his antiretroviral regimen (Emtricitabine, tenofovir, abacavir, ritonavir, atazanavir). He will be closely followed by ID and the coinfection clinic as an outpatient. . #) Diarrhea - The patient has chronic diarrhea, and the acute worsening was likely due to the lactulose he was given. ID did not feel this was infectious, though stool cultures were sent and should be followed as an outpatient. With the discontinuation of his lactulose and rifaximin, and with starting imodium, the patient's diarrhea improved and he was at baseline for discharge. . #) Chronic thrombocytopenia: The patient has a history of bone marrow toxicity secondary to Bactrim/AZT. His thrombocytopenia appears stable during this admission and was not an active issue. . #) Acute renal failure - The patient has a baseline creatinine that appears to be around 0.9-1.0, and this was elevated to 1.3. This was likely due to dehydration in setting of diarrhea for this patient. His lasix and spironolactone were held and with IVF his renal function returned to baseline. He was restarted on a lower dose of his diuretics prior to discharge, and will need his dose of diuretics readjusted as an outpatient and should have his creatinine closely monitored as well. Medications on Admission: Transfer meds: Sarna Lotion 1 Appl TP QID:PRN Clonazepam 1 mg PO QHS traZODONE HCl 100 mg PO HS:PRN Mirtazapine 30 mg PO HS Oxycodone-Acetaminophen 1 TAB PO Q4-6H:PRN Emtricitabine 200 mg PO Q24H Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Rifaximin 200 mg PO TID Lactulose 15 ml PO BID Multivitamins 1 CAP PO DAILY Azithromycin 1200 mg PO 1X/WEEK (TH) [**Last Name (STitle) **] Suspension 1500 mg PO DAILY Heparin 5000 UNIT SC TID Ritonavir 100 mg PO DAILY Tenofovir Disoproxil Fum. 300 mg PO DAILY Atazanavir 300 mg PO DAILY Abacavir *NF* 20 mg/mL Oral 10mL [**Hospital1 **] . Medications on admission: 1. Oxycodone/Acetaminophen 5-325mg 1 tablet PO Q4-6H PRN 2. Furosemide 80 mg PO DAILY 3. Spironolactone 200 mg PO DAILY 4. Mirtazapine 30 mg PO QHS 5. Trazodone 100 mg PO HS 6. [**Hospital1 **] 1500mg PO DAILY 7. Clonazepam 1 mg PO QHS 8. Azithromycin 1200mg PO 1X/WEEK (TH). 9. Abacavir 200mg PO BID 10. Atazanavir 300mg PO DAILY 11. Truvada 1 pill daily 12. Ritonavir 100 mg PO DAILY 13. Hexavitamin PO DAILY Discharge Medications: 1. Abacavir 20 mg/mL Solution Sig: Ten (10) ML PO 10mL [**Hospital1 **] (): 200 mg [**Hospital1 **]. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 5. [**Hospital1 **] 750 mg/5 mL Suspension Sig: 1500 mg PO DAILY (Daily): 10 ml daily. 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (TH). 8. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. Disp:*120 Capsule(s)* Refills:*0* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 14. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Altered mental status related to drug overdose 2. Cirrhosis 3. HIV 4. Diarrhea 5. Acute renal failure Discharge Condition: stable, tolerating medications Discharge Instructions: 1. You were admitted with altered mental status, likely due to opium use. You should avoid opium in the future. All of your medications are the same, except we are decreasing your lasix and spironolactone. You should have these readjusted by Dr. [**First Name (STitle) 3640**]. . 2. Return for fevers, chills, weight gain, shortness of breath, vomiting, worsened diarrhea and inability to take medications. . 3. Please attend all follow-up appointments. . 4. Follow new medication list Followup Instructions: 1. You need to attend your infectious disease appointment as follows: Provider: [**First Name8 (NamePattern2) 7620**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2107-5-2**] 1:00. This is the urgent care [**Hospital **] clinic . 2. Please attend the following appointment: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 7621**] CLINIC Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2107-5-10**] 1:00 . 3. Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2107-5-10**] 2:15

[ "155.0", "V10.06", "584.9", "496", "287.5", "276.51", "E850.2", "042", "571.5", "965.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11185, 11191

5292, 8905

314, 321

11340, 11373

4173, 4580

11910, 12469

3319, 3672

10012, 11162

11212, 11319

9576, 9989

11397, 11887

3687, 4154

230, 276

349, 1991

4589, 5269

2013, 2856

2872, 3303

30,708

149,371

32508

Discharge summary

report

Admission Date: [**2106-1-18**] Discharge Date: [**2106-1-24**] Date of Birth: [**2059-6-13**] Sex: F Service: CARDIOTHORACIC Allergies: Peach / Cherry Flavor / Pollen/Hayfever / Ragweed Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2106-1-18**] Minimal Invasive Mitral Valve Repair w/ 30mm CE [**Doctor Last Name 405**] Band History of Present Illness: 46 y/o female with known mitral valve prolapse, we recent development of dypnea on exertion. TEE revealed severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 75827**]y depressed systolic LV function. Now present ofr mitral valve surgery. Past Medical History: Mitral Valve Regurgitation/Mitral Prolapse, Hypercholesterolemia, Dysthymia, s/p Tonsillectomy Social History: Denies tobacco use. Admits to ETOH use. Family History: NC Physical Exam: WDWN female in NAD Skin: mild acne HEENT: EOMI, PERRL, NCAT, OP benign Neck: Supple, FROM -JVD Chest: CTAB -w/r/r Heart: RRR +murmur Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema Neuro: A&O x 3, non-focal Pertinent Results: [**1-18**] Echo: 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 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%) Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is moderate/severe mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] was notified in person of the results on the entire study results. Post_Bypass: There is no residual MR. There is a ring which is stable in the mitral position. Thoracic aortic contour is intact. Normal biventricular systolic function. [**1-21**] CXR: In comparison with study of [**1-19**], the small right apical pneumothorax is slightly smaller. There is a moderate right pleural effusion, best seen on the lateral view. Minimal blunting of the left costophrenic angle is noted. [**2106-1-18**] 11:10AM BLOOD WBC-6.9 RBC-3.05*# Hgb-9.2*# Hct-25.5*# MCV-84 MCH-30.3 MCHC-36.2* RDW-12.4 Plt Ct-204 [**2106-1-22**] 06:25AM BLOOD WBC-8.0 RBC-2.66* Hgb-7.9* Hct-22.6* MCV-85 MCH-29.8 MCHC-35.0 RDW-12.6 Plt Ct-163 [**2106-1-18**] 11:10AM BLOOD PT-15.2* PTT-30.5 INR(PT)-1.3* [**2106-1-18**] 12:25PM BLOOD Glucose-40* UreaN-12 Creat-0.5 Na-142 K-4.2 Cl-111* HCO3-24 AnGap-11 [**2106-1-22**] 06:25AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-140 K-4.0 Cl-105 HCO3-28 AnGap-11 Brief Hospital Course: Mrs. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission she was brought to the operating room where she underwent a minimal invasive mitral valve repair. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one her chest tube was removed. Post-op chest x-ray revealed small pneumothorax. She was started on beta-blockers and diuretics this day and autodiuresed towards her pre-op weight. Later on this day she was transferred to the telemetry floor for further care. Her electrolytes were repleted over the next several days. She has a mild fever on post-op day three without increase in white count. On post-op day four she had a run of NSVT. Beta blockers were titrated. She was also quite anemic (HCT 22.6) and was transfused 2 units of PRBC. She otherwise recovered well post-operatively and was discharged home on post-op day 5. Medications on Admission: lisinopril 10mg qd, Lexapro 5mg qd, Lasix 20mg qd, Xanax prn, Ambien prn, Abx prophylaxis Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 months. Disp:*90 Tablet(s)* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray Nasal 5X/DAY (5 Times a Day) as needed. Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 75828**] health care Discharge Diagnosis: Mitral Valve Regurgitation s/p Minimal Invasive Mitral Valve Repair PMH: Hypercholesterolemia, Dysthymia, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving when taking narcotics Please call with any questions or concerns [**Telephone/Fax (1) 170**] [**Last Name (NamePattern4) 2138**]p Instructions: [**Hospital Ward Name 121**] 6 for wound check in 2 weeks Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**12-27**] weeks Dr. [**Last Name (STitle) 75829**] in [**11-25**] weeks Completed by:[**2106-1-25**]

[ "512.1", "511.9", "272.0", "E878.1", "780.6", "424.0", "285.9", "427.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5239, 5302

3033, 4137

336, 433

5469, 5475

1153, 3010

902, 906

4277, 5216

5323, 5448

4163, 4254

5499, 5913

5964, 6202

921, 1134

277, 298

461, 710

732, 829

845, 886

62,346

115,951

3995

Discharge summary

report

Admission Date: [**2171-3-18**] Discharge Date: [**2171-3-26**] Date of Birth: [**2105-5-31**] Sex: M Service: MEDICINE Allergies: Pravastatin / Shellfish Derived Attending:[**First Name3 (LF) 7281**] Chief Complaint: presented for left total knee replacement Major Surgical or Invasive Procedure: [**2171-3-18**]: s/p Left total knee replacement History of Present Illness: 65M with history of ESRD s/p renal transplant [**2165**] c/b graft failure, on immunosuppression, HIV/AIDS on HAART, HBV, DM, HTN, currently POD #2 s/p L TKR, whose course has been complicated by [**Last Name (un) **], hyperkalemia, anemia, thrombocytopenia, fevers, and altered mental status. Mr. [**Known lastname **] was admitted to the Ortho service after undergoing L TKR on [**2171-3-18**]. He tolerated the procedure well, with about 300cc EBL. However, over the last several days he has become increasing more somnolent. This morning, was difficult to arouse, not following commands, and unable to answer questions. He has been febrile (Tmax 101.9 on [**3-19**], 101.4 today), though has not had a clear infectious source. His UA was unremarkable, blood cultures sent [**3-19**] are negative to date, and CXR earlier today was not suggestive of infection. Of note, he received Ancef peri-operatively, but otherwise has not been on antibiotics. He was initially on a dilaudid PCA, and has since been transitioned to oral oxycodone. Hct has trended down from 35.8 on [**2171-3-5**] to 25.8 on POD#1 to 21.7 today (POD #2). He was ordered for 2 units pRBCs but has not yet been transfused given his fevers. . Of note, his Cr has been trending up from 2.9 on admission to 4.2 this afternoon. Renal transplant team is following. Over the past 2 days he has also had worsening hyperkalemia, and K was 7.1 this morning. For his hyperkalemia, he was given kayexalate 30 once, calcium gluconate 2gm IV, albuterol neb, 10 units insulin, 40 mg IV lasix, 25 gm IV dextrose 50%, sodium bicarb 50 mEq IV. K has since trended down to 5.5, which is close to his recent baseline. Platelet count has also been decreasing, and is down to 85 today. Heme/onc also consulted, and feel this is likely thrombocytopenia secondary to sepsis. Was some concern for TTP, though labs not suggestive of this. Given worsening mental status, increased nursing requirements, and above medical issues, he is being transferred now the ICU for further evaluation and management. VS prior to transfer were 101.4, 152/62, 78, 20, 96% RA. On arrival to the ICU, patient arousable, can state name, and can follow some commands. He cannot state where he is, what the date is, or answer most questions. . Review of systems: Unable to obtain secondary to patient's mental status. On later questioning, elicited history of bilateral ankle pain, R > L. Past Medical History: * ESRD: s/p renal transplant [**12/2165**], c/b chronic graft failure; just recently started tacrolimus; on prednisone 5 mg daily * HIV: CD4 of 38 and viral load of 65 in [**2169-12-16**]. * HTN * DM: poorly controlled; recent A1c 10.8 * MGUS: UPEP and SPEP in [**12/2166**] showed no evidence of monoclonal protein. * Osteoarthritis * Medication noncompliance * Diastolic HF, EF 55% Social History: Lives alone. No tobacco or illicit drug use per notes. Per records, does have history of prior heavy alcohol use, but his daughter reports rare/minimal EtOH use at present. States he may have had a drink in [**Month (only) 404**] (Superbowl Sunday), but no other EtOH intake she is aware of. works as a chef. Has HIV but daughter who is also his healthcare proxy is unaware. Family History: Per daughter, no family history of heart or renal disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 100.6 BP: 135/50 P: 85 R: 18 O2: 93% on 2L General: intermittently lethargic and difficult to arouse, at other times awake, oriented to person only, able to follow some commands, not able to answer questions HEENT: pupils contricted and minimally reactive, EOMI, sclera anicteric, slightly dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: CTAB in anterior and lateral lung fields, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, mumur heard throughout precordium likely radiating from fistula Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, renal graft present in RLQ GU: no foley Ext: warm, well perfused, 2+ pulses, no lower extremity pitting edema, left knee dressing C/D/I, LUE with AV fistula with palpable thrill, right ankle with small effusion but no warmth/erythema, RUE with mild edema Neuro: EOMI, face symmetric, shrug strength 5/5, moving all four extremities, unable to cooperate with full exam, intermittent jerking/twitching movements, + asterixis . DISCHARGE PHYSICAL EXAM: VS 98.1 (98.7) 142/31 (132-155/31-39) 66 (65-72) 18 98RA (98-100RA) I/O: 1360/1550 BMx2 FSBS: 174-374 Weight: 89.6 kg GENERAL: very pleasant, comfortably lying in bed, appropriate HEENT: EOMI, PERRL, clear oropharynx NECK: Supple with low JVP, no cervical LAD CARDIAC: RRR, normal S1/S2, continuous murmur from fistula heard at sternal border LUNGS: Resp were unlabored, no accessory muscle use, moving air well and symmetrically on anterior auscultation. +Minimal rales at the bases bilaterally. ABDOMEN: Soft, non-tender to palpation. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. DP/PT dopplerable bilaterally. Right knee with some swelling, surgical site intact, slight erythema, no exudate. Left arm with old AV graft (not used since [**2165**]). NEURO: Awake, alert and oriented x3, CNs II-XII intact, moving extremities Pertinent Results: ADMISSION LABS: [**2171-3-19**] 06:24AM BLOOD WBC-7.8# RBC-2.84*# Hgb-8.1*# Hct-25.8*# MCV-91 MCH-28.3 MCHC-31.3 RDW-14.5 Plt Ct-98* [**2171-3-20**] 06:50AM BLOOD Neuts-87* Bands-0 Lymphs-6* Monos-6 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2171-3-20**] 01:40PM BLOOD PT-12.6* PTT-33.1 INR(PT)-1.2* [**2171-3-18**] 04:30PM BLOOD Glucose-201* UreaN-64* Creat-2.9* Na-143 K-5.6* Cl-113* HCO3-23 AnGap-13 [**2171-3-20**] 06:50AM BLOOD LD(LDH)-172 CK(CPK)-215 TotBili-0.2 [**2171-3-20**] 01:40PM BLOOD ALT-3 AST-15 AlkPhos-33* . RELEVANT LABS: [**2171-3-20**] 05:39PM BLOOD Type-ART pO2-69* pCO2-33* pH-7.40 calTCO2-21 Base XS--2 [**2171-3-20**] 01:40PM BLOOD Creat-4.2* Na-137 K-6.1* Cl-107 [**2171-3-20**] 01:40PM BLOOD WBC-7.5 RBC-2.35* Hgb-6.4* Hct-21.7* MCV-92 MCH-27.4 MCHC-29.6* RDW-14.8 Plt Ct-85* [**2171-3-21**] 04:29AM BLOOD WBC-8.0 RBC-2.41* Hgb-6.7* Hct-21.6* MCV-89 MCH-27.7 MCHC-31.0 RDW-14.9 Plt Ct-102* [**2171-3-23**] 06:48AM BLOOD VitB12-432 [**2171-3-23**] 06:48AM BLOOD Ammonia-17 . PERTINENT LABS: [**2171-3-24**] 06:50AM BLOOD tacroFK-7.2 . DISCHARGE LABS: [**2171-3-26**] 06:00AM BLOOD WBC-6.8 RBC-2.91* Hgb-7.9* Hct-25.9* MCV-89 MCH-27.1 MCHC-30.4* RDW-18.0* Plt Ct-245 [**2171-3-26**] 06:00AM BLOOD PT-15.2* PTT-35.1 INR(PT)-1.4* [**2171-3-26**] 06:00AM BLOOD Glucose-284* UreaN-75* Creat-3.0* Na-138 K-4.8 Cl-109* HCO3-19* AnGap-15 [**2171-3-26**] 06:00AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.5 [**2171-3-26**] Tacrolimus level: pending . MICROBIOLOGY: [**2171-3-19**] Urine culture: no growth [**2171-3-19**] Blood cultures x2: no growth [**2171-3-20**] MRSA Screen: negative [**2171-3-20**] Blood culture: no growth to date . PATHOLOGY: [**2171-3-20**]: left femoral tissue diagnosis: Consistent with osteoarthritis. . IMAGING: [**2171-3-18**] L knee x-ray: FINDINGS: In comparison with study of [**2170-9-12**], there has been placement of a left TKA that appears to be well seated without evidence of hardware-related complication. Standard post-surgical changes are seen. . CXR [**2171-3-20**]: In comparison with study of [**2-15**], there are slightly lower lung volumes. There is enlargement of the cardiac silhouette with engorgement of indistinct pulmonary vessels consistent with some elevated pulmonary venous pressure. The left hemidiaphragm is not as well seen, suggesting volume loss in the left lower lobe and possible left effusion. . [**2171-3-21**] unilateral RU extremity u/s FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] of the bilateral subclavian veins and the right internal jugular, axillary, brachial and basilic veins were performed. There was normal compressibility, flow, and augmentation. The right cephalic vein was not visualized. IMPRESSION: No right upper extremity DVT. . [**2171-3-22**] CXR FINDINGS: Portable AP chest radiograph demonstrates a new right PICC terminating in the mid-to-low SVC. There are persistent left basilar opacities that probably represent atelectasis. There is no pneumothorax or pleural effusion. The heart size is within normal limits. IMPRESSION: Right PICC terminates in the mid-to-low SVC Brief Hospital Course: Mr. [**Known lastname **] is a 65M with history of ESRD s/p renal transplant [**2165**] c/b graft failure, on immunosuppression, HIV/AIDS on HAART, HBV, DM, HTN, currently s/p L TKR, whose course has been complicated by [**Last Name (un) **], hyperkalemia, anemia, thrombocytopenia, fevers, and altered mental status requiring ICU transfer. . HOSPITAL COURSE: . #TOTAL KNEE REPLACEMENT: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Patient will require 3 weeks of anticoagulation with warfarin after this hospitalization for post-op DVT prophylaxis. Subcutaneous heparin should be continued at rehab. . Postop course was remarkable for the following: 1. Nephrology Transplant consult for co-management 2. Hyperkalemia 3. Heme consult for thrombocytopenia 4. Medicine consult for co-management 5. Post-op anemia due to bloos loss - Hct 21.6 . Given the above, when pt developed altered mental status [**2171-3-20**] he was transferred to the Medical ICU, and once stablized, transferred to the medicine floor. . POST-OPERATIVE COURSE: On [**2171-3-20**], patient was transferred to the ICU for increased lethargy/AMS and further evaluation and management of his hyperkalemia, [**Last Name (un) **], anemia, thrombocytopenia, and fevers. . . ACTIVE ISSUES: # Encephalopathy: Was felt to be secondary to delirium in setting of toxic-metabolic encephalopathy (post-op pain, narcotic pain medication administration, fevers, possible infection, electrolyte abnormalities, and renal impairment). His sedating medications and narcotics were initially held, though restarted at lower dosing as his mental status improved. His fever was evaluated and treated as below. While in the ICU, he became less lethargic, and while occasionally oriented to person/place/time he was intermittently confused and paranoid. Considered EtOH withdrawal, but patient's daughter did not believe he is actively drinking. . # Fevers: No clear source of infection. Patient was initially started on vanc/zosyn for possible PNA given fevers and new oxygen requirement, but these were stopped after CXR negative. UA unremarkable, and blood cultures remained negative. LFTs not suggestive of hepatitis or biliary process. Considered menigitis, especially given immunosuppression, though patient's exam and overall clinical presentation not suggestive of this infection. Also considered post-op fevers, thrombus. . # Right ankle/heel pain: Differential included gout, pressure sore, peripheral neuropathy. Evaluated by Ortho. Uric acid level was elevated at 9, however pain resolved the following day and was no longer concerning. . # RUE edema: RU extremity u/s was performed which showed no evidence of DVT. Most likely dependent edema. . # Hypoxia: Likely secondary to atalectasis, and quickly resolved. CXR negative for PNA. Also considered aspiration, and kept patient NPO until mental status improved. . # Anemia: Hct dropped to 21.6 on POD#2. Per Ortho team, this degree of anemia can be expected post-operatively. Patient had 300cc EBL in OR, and also had vac on knee that drained about 265cc per chart. Labs not suggestive of hemolysis, and direct Coombs was negative. Transfused 4 units pRBCs, intitially without appropriate HCT bump but with the 4th unit he demonstrated appropriate response. No obvious source of bleeding. Hematocrit rose to the mid-20s, and remained stable there for the rest of his hospital course. Discharge Hct was 25.9. . # [**Last Name (un) **]: Patient with ESRD s/p renal transplant [**2165**] c/b graft failure, on immunosuppression. Recent baseline has been 2.7-3.2. Cr was 2.9 on admission [**2171-3-18**], rose to 4.2 on [**2171-3-20**]. Acute rise in creatinine was most likely secondary to allograft nephropathy in the setting of decreased renal perfusion (decreased PO intake post-op, increased insensible losses w/fevers). Over the course of admission, creatinine trended down to 3.0 at the time of discharge (within his previous baseline). His home medications were restarted. . # Hyperkalemia: Improved after administration of kayexalate, insulin, dextrose, calcium gluconate, albuterol, and bicarb earlier. Likely secondary to worsening renal function. Elevation secondary to cell lysis less likely as labs not suggestive of hemolysis. . # Thrombocytopenia: Was initially concern for TTP given concurrent anemia and AMS, though labs not c/w this diagnosis. [**Month (only) 116**] be secondary to decreased production in setting of fevers/sepsis and recent surgery. Heme consulted and felt also possible that tacro toxicity contributing. Would also need to consider medication effect, as patient has been on HAART and immunosuppressive agents with worsening renal function, as well as thrombocytopenia related to his underlying HIV. HIT seems less likely given timing. No known history of liver disease, and no palpable splenomegaly on exam. Platelets improved to 200 at the time of discharge. . . CHRONIC ISSUES: # HIV on HAART: Most recent CD4 count on [**2171-3-5**] was 327, with HIV VL undetected. Per outpt ID provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 724**], initially held antiretrovirals for now as these may be contributing to AMS. Renal transplant team felt that HAART could be restarted and this was done on [**2171-3-21**]. Tacrolimus levels were followed throughout adjustment of HAART regimen. Of note, pt's daughter, who is his healthcare proxy, is unaware of his HIV status. . # Tremor: Per notes, tremor has been present for weeks. Etiology unclear, not consistent with asterixis. . # ESRD s/p transplant c/b graft failure, on immunosuppresssion. He continued weekly tacrolimus 0.5 mg and prednisone 5 mg daily. Continued bactrim ppx. . . # Osteopenia: Patient restarted his home calcitriol and Vitamin D . # HTN: BP currently well controlled. He was restarted on his home metoprolol, clonidine, Lasix and terazosin. . # DM: Most recent A1c 8.7 [**2171-2-7**]. [**Last Name (un) **] following, appreciate input. Continued lantus plus insulin sliding scale. He was discharged on 28 units of Lantus in the morning (which was his dose prior to admission). . . TRANSITIONAL ISSUES: # Please call back to follow up tacrolimus level on [**2171-3-26**] (pending at the time of discharge. Level should be checked weekly, 30 minutes prior to administration of medication. **IF TACROLIMUS LEVEL IS NOT WITHIN RANGE 5.0-7.0, please call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 673**] for further instructions.** # Please continue anticoagulation with warfarin for 3 weeks, with goal INR 2-2.5. Patient should be established with [**Hospital 191**] [**Hospital **] Clinic after discharge from rehab. # Please check INR daily until INR is therapeutic (2-2.5) and stable. Then weekly checks are adequate. # Patient's daughter/HCP does not know about his positive HIV status. She should not be informed of this. # Code: full (confirmed) # HCP: Daughter [**Name (NI) 1743**] [**Name (NI) **] [**Telephone/Fax (1) 17673**] Medications on Admission: ASA 81mg qd, bactrim ss qod, terazosin 3mg qhs, novolog SS and lantus 28u qam, lasix 40mg [**Hospital1 **], metoprolol 25mg [**Hospital1 **], omeprazole 40mg [**Hospital1 **], viread 300mg twice weekly, lamivudine 100mg qd, Ritonavir 100mg [**Hospital1 **], prezista 600mg [**Hospital1 **], Etravirine 200mg [**Hospital1 **], tacrolimus 0.5mg qweek, prednisone 5mg qd, clonidine 0.1mg tid, gabapentin 300mg qhs (not taking) Discharge Medications: 1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take with ritonavir. 4. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. insulin aspart 100 unit/mL Solution Sig: One (1) unit Subcutaneous three times a day: per sliding scale, with meals. 7. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous once a day: in the morning. 8. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual q5 minutes as needed for chest pain. 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. ritonavir 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take with darunavir . 14. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 15. tacrolimus (bulk) 100 % Powder Sig: 0.5 mg Miscellaneous once a week: on Tuesdays. 16. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO TWICE A WEEK ON SATURDAY AND WEDNESDAY (). 17. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 18. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 19. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 20. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): while at rehab. 22. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM for 3 weeks: Goal INR 2-2.5, for post-op DVT prophylaxis. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Left knee osteoarthritis . Secondary diagnoses: Acute on chronic kidney disease Hyperkalemia Post-op anemia due to blood loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). 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 **], It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted for an elective left total knee replacement. Your post-operative course was complicated by decrease in your kidney function, low blood counts, and high potassium. We adjusted your medications to treat these problems, and you improved. Please note, the following changes have been made to your medications: - START warfarin 5 mg by mouth daily at 4 pm. This dose will be adjusted based on your labs (INR) at rehab. Then, your dosing should be followed closely by the [**Hospital1 18**] [**Hospital 191**] [**Hospital **] Clinic. You should continue warfarin for 3 weeks (until [**4-13**]), with a goal INR of [**1-17**].5. - CONTINUE heparin injections three times per day while at rehab. Continue all of your other medications as you had prior to this hospitalization. The following are your post-operative instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. You may not drive a car until cleared to do so by your surgeon. 3. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out at your follow-up visit in three (3) weeks after your surgery. 4. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 5. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 6. ANTICOAGULATION: Please continue your heparin while at rehab, then warfarin for three (3) weeks to help prevent deep vein thrombosis (blood clots). You may continue your Aspirin 81mg daily. [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 7. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up visit in three (3) weeks. 8. VNA (once at home): Home PT/OT, dressing changes as instructed, and wound checks. 9. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. 10. Weigh yourself every morning, call your doctor if weight goes up more than three pounds. Please see below for your follow-up appointments. Wishing you all the best! Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [**2171-4-9**] at 1:40 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PA [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: WEDNESDAY [**2171-4-10**] at 8:20 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT When: TUESDAY [**2171-4-16**] at 9:00 AM With: TRANSPLANT ID [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: MONDAY [**2171-5-20**] at 11:00 AM With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 7284**]

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icd9cm

[ [ [] ] ]

[ "81.54", "38.97" ]

icd9pcs

[ [ [] ] ]

19565, 19635

8821, 9164

334, 385

19824, 19824

5709, 5709

23294, 24667

3669, 3730

17491, 19542

19656, 19656

17042, 17468

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5725, 6708

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19997, 20141

6724, 6768

14971, 16155

2870, 3256

3272, 3653

4824, 5690

31,454

149,133

34335

Discharge summary

report

Admission Date: [**2144-8-16**] Discharge Date: [**2144-8-19**] Date of Birth: [**2073-4-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Chief complaint: hypotension Major Surgical or Invasive Procedure: femoral line placement History of Present Illness: Mr. [**Known lastname **] is a 71 year old male with ESRD on HD, dialysis, HTN, CAD, PVD, who presented to [**Hospital1 **] yesterday from [**Hospital **] rehab with altered mental status and hypotension. He was given vanco/gent/cipro at [**Hospital1 **] for Foot infection vs. PNA vs. Line infection, though no cultures were positive. He was noted to be hypotensive, so a femoral line was place and patient was put on dopamine and then transiently on neo and was transferred on levophed. He was initially hypoglycemic on arrival to [**Hospital1 **] as well. . Upon arrival to [**Hospital1 18**], he is moaning in pain. Conversation through the interpreter was unsucessful as patient is making incomprehensible words. . Of note, patient was seen in the [**Location (un) **] [**Location (un) 1459**] ED on [**2144-8-13**] for surgical evaluation of right gangrenous foot. At that time, he was felt to have dry gangrene which did not require urgent intervention. He returned to rehab (unclear if he was placed on antiobiotics - vanco/imi or not) and was awaiting work-up for right BKA or right transmetatarsal amputation. . Also of note, patient recently was seen at [**Hospital3 7362**] from [**2144-7-13**] to [**2144-7-24**] for ACS. During this stay he was found to have a dramatic decrease in his cardiac function. He had anterolateral ischemia, but was not felt to be a cardiac cath candidate so was managed medically. During this visit, he was found to have a left elbow MRSA bursitis for which he was treated with vancomycin q hd. He had AMS thought to be secondary to delerium in the setting of infection which resolved with treatment of the infection. Past Medical History: Type 2 Diabetes End stage renal disease on HD Hypertension Coronary Artery Diseases s/p NSTEMI - underwent balloon angioplasty to RCA in [**2143**] Peripheral [**Year (4 digits) 1106**] disease Legally Blind Atrial flutter s/p ablation [**11-22**] PFO BPH GERD Social History: He has a 60-pack-year smoking history but quit five years ago. He is married, but has been living at a rehab facility. He is a nondrinker. He is a retired officer from [**Country 3992**]. He has three children. Family History: There is no family history of premature coronary artery disease, unexplained heart failure, or sudden death. . Physical Exam: Patient unresponsive to vouce or tactile stimuli. Unable to auscultate cardiac tones or breath sounds. Pupils fixed and dilated. Pertinent Results: . Admission Labs [**2144-8-16**]: . 142 | 99 | 40 / -------------- 253 4.6 | 28 | 5.1 \ . CK 79 Trop 0.24 . Ca 8.9 Mg 2.3 Phos 7.3 . ALT 38 AST 26 AP 178 LDH 177 T. bili 0.8 Alb 3.0 Dilantin < 0.6 Vanco 15 . .. \ 10.2 / 14.0 ---- 261 .. / 33.9 \ . Diff 91.4%N, 3.7%L, 3.6%M, 1.0%E, 0.2%B . Micro - blood cultures x 4 - no growth to dat . Echo [**2144-8-16**]. The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe global left ventricular hypokinesis (LVEF = 20-25 %). 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 is normal with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-17**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2143-8-23**], biventricular systolic function is now more depressed with increased PCWP. The aortic and mitral leaflets now appear more thickened (diffuse) without discrete vegetation. Trace aortic regurgitation and increased mitral regurgitationare now seen. . [**2144-8-16**]. Bilateral Foot films. Findings are concerning for osteomyelitis bilaterally, with most pronounced findings at the level of the right 1st metatarsal bone. A wet read was provided stating "lucency at the distal margin of the right 1st metatarsal and dorsum foot, concerning for infection. Cortical irregularity of the distal 1st metatarsal, of uncertain chronicity, lucency or soft tissue defect at distal margin 2nd metatarsal, osseous fusion of left mid foot, bilateral [**Month/Day/Year 1106**] calcification, status post multiple amputations in bilateral feet." . [**2144-8-16**]. Right hand film. CONCLUSION: Prior amputation as described. Evidence of end-stage renal disease. No definitive evidence of osteomyelitis. . [**2144-8-17**]. Chest X-ray. IMPRESSION: Improving left lower lobe atelectasis. No consolidation. Brief Hospital Course: In summary, Mr. [**Known lastname **] is a 71 year old male with ESRD on HD, PVD, CAD s/p NSTEMI, admitted with altered mental status and sepsis requiring pressors likely secondary to osteo of feet bilaterally associated with gangrous feet. After a family meeting, decision to transition toward [**Known lastname **] care was made. . Sepsis. Patient presented with septic shock likely secondary to osteomyelitis. He has sifnificant portions of gangrene on his right foot, but also smaller sites of gangrene on left foot and right hand. Feet films showed multiple sites of osteo on feet bilaterally. He was treated with levophed to maintain is blood pressure in addition to gentle fluid boluses. He was evaluated by [**Known lastname 1106**] surgery who felt he did not need an urgent amputation. He was treated with broad spectrum antiobiotics. His cultures were all negative. However, after a family meeting was held, the decision to transition to [**Known lastname **] measures only was held. All antibiotics were stopped. . Gangrenous feet/ Severe peripheral [**Known lastname 1106**] disease. Patient has bilateral gangrenous feet which have significantly worsened over the last year. Foot films showed bilateral osteomyelitis. He was evaluated by [**Known lastname 1106**] who felt he did not need urgent amputation, but should ultimately get amputations. However, after a family meeting, the goals of care were changed towards [**Known lastname **] measures. He was given morphine for pain control. . Altered mental status. Even with vietnamese translator, patient was confused and only occasionally responded appropriately to questions. He was felt to have delerium secondary to sepsis, infection, prolonged hospital stay. . Type 2 Diabetes. Patient presented to the outside hospital with hypoglycemia at OSH. He alternated between hypoglycemia and hyperglycemia while in the MICU, likely secondary to his infection. He was initially managed with an insulin drip, but this was discontinued when the goals of care were changed towards [**Known lastname **] measures only. . End stage renal disease on HD. Patient is dialysis depended and typically gets HD on Mondays, Wednesday, and Fridays. Renal was notified of his arrival, but given that he had no urgent dialysis needs, he did not receive dialysis. Goals of care were changed to transition towards [**Last Name (LF) **], [**First Name3 (LF) **] he did nto receive dialysis. . Coronary Artery Disease. Patient has ischemic cardiomyopathy and significantly reduced EF over the course of 1 year (from 45% to 20%). He had been told that he needed revascularization but was not felt to be a cath candidate. . Current wife and health care proxy - [**Telephone/Fax (1) 79009**] (h), cell is [**Telephone/Fax (1) 79010**]. Daughter [**Telephone/Fax (1) 79011**], Another daughter - [**Telephone/Fax (1) 79012**]. . Goals of Care. Patient had repeatedly stated that he wanted to be DNR/DNI prior to arrival to [**Hospital1 18**]. A family meeting was held during which the family decided to change his goals of care to [**Hospital1 **] measures only. Upon transfer to the medical floor the patient was made comfortable with continued morphine and a scopalamine patch. He passed away at 0252 on [**8-19**] approximately 3 hours after transfer. Medications on Admission: Aspirin 81 mg Celexa 20 mg daily [**Month/Day (1) **] 75 mg daily Aranesp 60 mcg qweek colace prevacid 30 mg PO QD Lisinopril 2.5 mg PO QD Miralax 75 mg PO qday Seroquel 12.5 mg PO BID, 25 mg PO QHS Coumadin for goal INR [**2-18**] Multivitamin Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: end stage renal disease bacteremia gangrenous limbs Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9018, 9027

5366, 8691

343, 368

9122, 9131

2879, 5343

9187, 9197

2602, 2714

8986, 8995

9048, 9101

8717, 8963

9155, 9164

2729, 2860

292, 305

396, 2069

2091, 2354

2370, 2586

13,558

145,852

23596

Discharge summary

report

Admission Date: [**2141-2-15**] Discharge Date: [**2141-5-2**] Date of Birth: [**2066-11-26**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: 74 year old female admit to [**Hospital1 18**] MICU [**2141-2-15**] in resp distress, pna, UTI, mild CHF initially on NRB, but then intubated on [**2141-2-17**] (extubated [**2141-2-22**]). Hosp course noted for bradycardia (AV block) during swan placement, CHF. PMH: recent MI, CHF, a fib, CVA, GERD, gastritis, TIAs, Bell's palsy, lower GI polyps. Major Surgical or Invasive Procedure: Cardiac Catheterization [**2141-3-29**] Aortic Valve Replacement (21mmm [**Last Name (un) **] [**Doctor Last Name **] pericardial valve) History of Present Illness: 74 year old female transfered from outside hospital status post embolecotomy for R brachial emboli with history of severe aortic stenosis and anemia for cardiac work-up. Patient of Dr. [**Last Name (STitle) 957**], found to have colonic polyps on colonoscopy for anemia work-up at OSH. Pt admitted to receive medical clearance for future procedure. Found to have a urinary tract infection with signs of sepsis severe respiratory difficulty and severe aortic stenosis. Past Medical History: CHF TIA HTN GERD CVA AS AI Anemia ^Chol s/p CCY, laminectomy, appy Social History: Lives alone in [**Location (un) 18825**], MA Has 10 children. Family History: Unremarkable. Physical Exam: GEN: Intubated , sedated LUNGS: Clear to auscultation HEART: RRR, III-IV/VI systolic murmur ABD: Soft, nontender, nondistended, normoactive bowel sounds EXT: Surgically absent bilateral greater saphenous veins, 1+ edema. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-4-26**] 05:40AM 12.7* 4.31 11.1* 35.9* 83 25.7* 30.8* 18.2* 305 BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2141-4-26**] 05:40AM 305 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-4-26**] 05:40AM 89 37* 1.2* 138 5.3* 105 21* 17 Cardiology Report ECHO Study Date of [**2141-3-6**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.6 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.3 cm (nl <= 5.0 cm) Left Ventricle - Ejection Fraction: 30% (nl >=55%) Aortic Valve - Peak Velocity: *4.2 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 69 mm Hg Aortic Valve - Mean Gradient: 45 mm Hg Aortic Valve - LVOT Peak Vel: 0.80 m/sec Aortic Valve - LVOT Diam: 2.1 cm Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2) Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.3 m/sec Mitral Valve - E/A Ratio: 0.77 Mitral Valve - E Wave Deceleration Time: 210 msec INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Moderate global LV hypokinesis. No resting LVOT gradient. No LV mass/thrombus. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS. Moderate (2+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Moderate (2+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[**11-27**]+] TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or electrodes. Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. There is moderate-to-severe global left ventricular hypokinesis (ejection fraction 30 percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Compared with the findings of the prior study (tape reviewed) of [**2141-2-16**], no major change is evident. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2141-3-6**] 13:59. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**2141-3-7**] Cardiac Catheterization 1. Coronary angiography of this co-dominant system revealed two vessel coronary artery disease. The left main coronary artery was very short in length and had a 30% stenosis in the proximal vessel. The LAD had a 40-50% stenosis in the proximal vessel involving the origin of a large D1 while the D1 had a 50-60% stenosis. The LCX had no angiographically apparent flow limiting stenoses. The RCA had a 70% stenosis in the proximal vessel. 2. Limited resting hemodynamics were performed secondary to the incidence of complete heart block with a previous attempt at pulmonary artery catheterization. The tricuspid valve was not crossed. Right sided filling pressures were normal (mean RA pressure was 5 mm Hg). Left sided filling pressures were mildly elevated (LVEDP was 16 mm Hg). Cardiac index was normal (at 3.2 L/min/m2) (calculated using an RA oxygen saturation, assuming no intracardiac shunt). 3. The aortic valve was evaluated and had a mean gradient of 49 mm Hg and an aortic valve area of 0.8 cm2. Brief Hospital Course: 74F transfer from OSH s/p embolectomy for R brachial emboli, h/o severe AS and anemia for cardiac work-up. Pt of Dr. [**Last Name (STitle) 957**], found to have colonic polyps on colonoscopy for anemia work-up at OSH. Pt admitted to receive medical clearance for future procedure. Found to have UTI, with signs of sepsis severe respiratory difficulty and severe aortic stenosis. Admitted to MI CU 3/23/5 for respiratory distress intubated on [**2141-2-17**]. Found to have UTI with VRE, and e coli multiresistant. At that point ID consult was called and recommendations were followed. Received full course of antibiotic treatment until bc and UC were cleared. Patient was extubated on [**2-22**]/5. Since then patient was persistently disoriented, seen by psychiatry multiple times diagnosis of delirium was made. We minimized pain medications and pt was placed on Haldol for a couple of days. On max dose of Haldol he mental status did not improved nor sedation was archived so Pt was placed on Ativan that met her sedation requirements. Patient since extubation was placed on TF to meet her caloric requirements impact with five 3.4 strength.Pt underwent CATH ON [**2141-2-27**] ABORTED FOR AGITATION OF PATIENT ECHO DONE ON 4 11 05 SHOWING;The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. There is moderate-to-severe global left ventricular hypokinesis (ejection fraction 30 percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly Underestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion CATH REPEATED ON [**3-7**]/5 SHOWING:1. Two vessel coronary artery disease. 2. Severe aortic stenosis. We keep pt in ICU monitoring for optimization of her cardiac, and nutritional status before surgery aVR. During this period of time c Diff was send ed several times found to be negative. Her mental status remained uncharged, having to restrain her and requiring a sitter at all times. Pt pulled her feeding tube multiple times. Finally antibiotic course with Linezolid was archived and negative blood and urine cul tires were found to be negative. Her nutritional status was improved with transferrin of 174 albumin of 2.7. On [**2141-3-29**], Ms. [**Known lastname 60395**] was taken to the operating room where she underwent an aortic valve replacement utilizing a 21mm [**Last Name (un) **] [**Doctor Last Name **] pericardial bioprosthesis. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Ms. [**Known lastname 60395**] [**Last Name (Titles) 5058**] and was extubated. She was transfused for postoperative anemia. Beta blockade was started and titrated for optimal heart rate and blood pressure support. She developed atrial fibrillation and underwent cardioversion on [**2141-4-1**]. Ms. [**Known lastname 60395**] was only able to hold a normal sinus rhythm for less then two minutes and amiodarone was started. Heparin and coumadin were started for anticoagulation with the plan for a repeat cardioversion in a month. Tube feeds were started for nutritional support and calorie counts were started. On postoperative day seven, Ms. [**Known lastname 60395**] was transferred to the cardiac surgical step down unit for further recovery. Se continued to be gently diuresed towards her preoperative weight. The physical therapy service was consulted for asssistance with her postoperative strength and mobility. Ms. [**Known lastname 60395**] remained in a rate controlled atrial fibrillation and was anticoagulated on heparin. On POD#18 she developed BRBPR, her heparin was d/c'd and it resolved. She continued to make steady progress, but had some agitation at night. She was followed closely by the geriatric medicine service and her medications were adjusted. She was discharged to rehab on POD#34. She will follow-up with Dr. [**Last Name (STitle) 1290**], Dr. [**Last Name (STitle) 957**], her cardiologist and her primary care physician as an outpatient. Medications on Admission: 1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine Besylate 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 7. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. 9. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 8. Olanzapine 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for agitation. 9. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation Q6H (every 6 hours) as needed. 10. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed. 11. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q8A/4P/10P (). 12. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO Q4PM (). 13. Prednisone 1 mg Tablet Sig: Six (6) Tablet PO QAM (once a day (in the morning)). 14. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO 8 PM (). 15. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**] Discharge Diagnosis: Aortic stenosis status post AVR. Discharge Condition: Good Discharge Instructions: Monitor wounds for signs of infection. These include redness, drainage or increased pain. Monitor vital signs. Report any fever greater then 100.5. Report any weight gain of more the 2 pounds in 24 hours. Follow medications on discharge instructions. Shower regularly and pat wounds with a towel. Do not use lotions, creams, or powders on wounds. [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks after discharge. Follow-up with Dr. [**Last Name (STitle) 957**] as instructed. Follow-up with you cardiologist in 2 weeks Follow up with Dr. [**First Name (STitle) 10733**] in [**11-27**] weeks. Completed by:[**2141-5-2**]

[ "038.9", "486", "518.81", "293.0", "401.9", "995.92", "599.0", "398.91", "410.71", "427.31", "396.2", "110.1", "440.0", "426.0", "521.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.61", "23.09", "38.91", "99.04", "35.21", "89.64", "96.72", "00.14", "86.27", "88.72", "37.23", "96.04", "96.6", "99.62", "37.78" ]

icd9pcs

[ [ [] ] ]

12894, 13001

6242, 10793

671, 810

13078, 13084

1764, 5054

1493, 1508

11613, 12871

13022, 13057

10819, 11590

13108, 13456

13507, 13791

1523, 1745

282, 633

838, 1308

5086, 6219

1330, 1398

1414, 1477

55,357

151,470

328

Discharge summary

report

Admission Date: [**2198-4-22**] Discharge Date: [**2198-5-4**] Date of Birth: [**2160-7-23**] Sex: F Service: MEDICINE Allergies: Bactrim / Vioxx / Penicillins / CellCept / Ceftriaxone / Ferrlecit / Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: HEMOPTYSIS Major Surgical or Invasive Procedure: LEFT BRONCHIAL ARTERY EMBOLIZATION UNDER FLUOROSCOPY RIGHT INTERNAL JUGULAR LINE PLACEMENT, REPOSITIONING, AND REMOVAL IVC FILTER PLACEMENT INTUBATION AND MECHANICAL VENTILATION History of Present Illness: 37F with history of lupus, lupus nephritis with ESRD on peritoneal dialysis on transplant list, hx of PE/Antiphopholipid antibody on coumadin, mitral regurg, presents with 4-6 month history of cough, worse in the morning, one week of trace blood, now producing bright red blood over last couple days. Patient states that the amount of blood she has been coughing has been increasing and is now almost hourly, aprroximately 1 teaspoon bright red blood. Patient states that the cough produced primarily yellow sputum until it turned to blood. Patient denies any other symptoms such as dizziness or lightheadedness. She denies any changes in her BMs, including consistency, frequency, and color. Patient visited PCP on [**Name9 (PRE) 2974**], and a CXR was negative. Her was also noted to be subtherapeutic and she took an extra day of 10 mg warfarin as instructed. . Initial vitals in the ED were: 108 138/95 18 100% RA. Her HCT was 29.6, her baseline is unclear but appears to be low 30s. INR was 4.4. A CTA was done for concern of PE which showed: 1. Left lower lobe consolidation with large amount of secretions/fluid within the left lower lobe segmental bronchi. 2. Centrilobular nodules and ground glass opacities throughout both lungs, compatible with chronic collagen vascular disease, progressed since [**2191**]. Ground glass opacities could also represent hemorrhage. 3. Chronic left lower segmental pulmonary arterial PE, unchanged since [**2191**]. No new acute PE detected to the subsegmental levels. She was initially admitted to medicine but then transferred to the ICU. . On arrival to the MICU initial vitals were: 110 163/96 20 95%RA. She is breathing comfortably but complains of pain in her chest. Her EKG was reviewed which did not show changes from her prior. She also complains of a HA that she says she occasionally recieves toradol. She has had emesis in the ED that looked dark/possibly coffee ground but currently denies nausea. Past Medical History: # Lupus rash # Herpes Simplex I - [**12-2**], white lesions on the tongue and buccal mucosa # Axillary Adenopathy - [**10-2**], biopsied -> reactive lymph node # Osteopenia - [**7-2**], L spine Tscore -2.40, Fem neck -1.91, Tot Hip -1.41 # Hypercholesterolemia - [**8-1**] # Lung abscess - [**8-1**] # Pulmonary emboli (PE) - [**6-1**] # Angioedema vs Anasarca - [**6-1**], associated with 2 grand mal seizures, required intubation for massive facial/laryngeal swelling # Pleural Effusions - s/p pleurodesis in [**6-11**] nephrotic syndrome # Lupus nephritis / Nephrotic syndrome - [**5-1**], renal bx showed focal proliferative class III # GERD / Gastric ulcer - [**1-31**], seen on barium swallow # Recurrent pneumonia - [**2185**], possibly from aspirations, most recent [**2191-10-1**] # Antiphospholipid antibody syndrome (APS) - [**2184**], requiring anticoagulation to INR of 2 to 3 # Breast Masses - [**8-/2182**], bilateral, largest right upper outer quadrant 4/3 cm # Thrombotic thrombocytopenic purpura (TTP) - [**10/2182**], s/p plasmapheresis # Inflammatory eye mass - [**11/2180**], s/p excision of mass, [**2-1**] lupus # Gonorrhea - [**7-/2180**], disseminated gonococcus # Abnormal pap smear - [**2180**], subsequent paps x 2 normal # Systemic lupus erythematosus (SLE) - [**2179**], followed by Dr. [**Last Name (STitle) **] # Raynaud's syndrome # Stroke - hemiparalysis # Asthma - no problems for several years Social History: Married with three children, born in [**2184**], [**2185**], and [**2188**]. Lives in [**Hospital1 8**]. Went to [**University/College 3036**]. Worked as an accountant until health declined in early [**2187**]. No tobacco, ethanol or drug use. Family History: Mother with MS [**Name13 (STitle) 3054**] with sarcoid [**Name (NI) 3055**] discoid lupus Physical Exam: ADMISSION EXAM Vital signs: 110 163/96 20 95%RA. Gen: Uncomfortable appearing but no acute distress. HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP clear. Neck: Supple. Resp: Absent breath sounds entire L Lung fields, R lung firels CTA CV: Tachycardic, regular rhythym. Normal s1 and s2. [**2-5**] SM at apexNo M/G/R. Abd: +BS. Soft. NT/ND. No rebound or guarding. No hepatosplenomegaly. Ext: Warm and well-perfused. Radial and DP pulses 2+ bilaterally. Neuro: A+Ox3. PERRL. EOMI, with no nystagmus. Face symmetric. . DISCHARGE EXAM VS T 98.0 HR 128 (regular) BP 102/76 RR 22 O2 100/RA GEN thin young woman resting in bed, somnolence but easily roused, NAD NCAT MMM EOMI OP clear Lungs CTAB, prominent breath sounds, no wheeze no L dullness CV tachycardic at regular rate, nl S1 S2 no mumur Abd full but nondistended and nontender, soft Ext no edema, warm and dry Pertinent Results: ADMISSION LABS [**2198-4-22**] 07:30AM WBC-7.9# RBC-3.19* HGB-9.2* HCT-29.6* MCV-93 MCH-28.8 MCHC-31.0 RDW-16.9* [**2198-4-22**] 07:30AM NEUTS-64.1 LYMPHS-24.2 MONOS-4.4 EOS-6.4* BASOS-0.8 [**2198-4-22**] 07:30AM PLT COUNT-376# [**2198-4-22**] 07:30AM GLUCOSE-96 UREA N-58* CREAT-13.0*# SODIUM-142 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-24 ANION GAP-23* [**2198-4-22**] 07:30AM PT-45.1* PTT-46.9* INR(PT)-4.4* . OTHER PERTINENT LABS [**2198-4-22**] 05:04PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:160 dsDNA-POSITIVE * [**2198-4-26**] 04:57AM BLOOD dsDNA-NEGATIVE [**2198-4-23**] 11:44AM BLOOD SM ANTIBODY-3.6 POS (<1.0 NEG AI) [**2198-4-22**] 05:04PM BLOOD ANCA-NEGATIVE B [**2198-4-26**] 04:57AM BLOOD dsDNA-NEGATIVE [**2198-5-1**] 07:00PM BLOOD Lupus ANTICOAGULANT-POS [**2198-5-1**] 05:13AM ANTICARDIOLIPIN IgG-5.5(NEG) ANTICARDIOLIPIN IgM-5.6(NEG) [**2198-4-22**] 05:04PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:160 dsDNA-POSITIVE (1:10) [**2198-5-1**] 05:13AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-PND [**2198-4-22**] 07:30AM BLOOD C3-109 C4-44* [**2198-4-26**] 04:57AM BLOOD C3-87* C4-29 [**2198-4-29**] 03:36AM BLOOD C3-104 C4-30 . DISCHARGE LABS [**2198-5-4**] 03:12AM BLOOD WBC-14.2* RBC-3.89* Hgb-11.5* Hct-35.9* MCV-92 MCH-29.5 MCHC-31.9 RDW-15.9* Plt Ct-488* [**2198-5-4**] 03:12AM BLOOD PT-13.2* PTT-31.8 INR(PT)-1.2* [**2198-5-4**] 03:12AM BLOOD Glucose-90 UreaN-77* Creat-12.1* Na-136 K-4.1 Cl-94* HCO3-25 AnGap-21* [**2198-5-4**] 03:12AM BLOOD Calcium-10.1 Phos-6.4* Mg-2.4 . MICRO [**2198-5-1**] BLOOD CULTURE -PENDING [**2198-5-1**] BLOOD CULTURE -PENDING [**2198-4-30**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL [**2198-4-30**] URINE CULTURE-FINAL [**2198-4-30**] BLOOD CULTURE -PENDING [**2198-4-30**] BLOOD CULTURE -PENDING [**2198-4-30**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY [**2198-4-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL [**2198-4-28**] DIALYSIS FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL [**2198-4-28**] STOOL C. difficile DNA amplification assay-FINAL [**2198-4-28**] BLOOD CULTURE -FINAL [**2198-4-28**] BLOOD CULTURE -FINAL [**2198-4-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2198-4-25**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL . [**4-22**] CTA CHEST The lung apices are excluded from this examination, which was optimized for assessment of the pulmonary vasculature. Coarse calcifications within the breasts are new on the left (2:33), and slightly increased in size on the right (2:24), in comparison to the [**2191-3-11**] examination. No distinct mass is seen, although the breast tissue is diffusely dense. There is no axillary or mediastinal lymphadenopathy. The heart size is top normal. There is no pericardial effusion. The aorta is normal in caliber and patent. There is no dissection. The main pulmonary arteries are normal in caliber. There is a chronic pulmonary embolus within the left lower segmental pulmonary artery (3:57), which is present since the [**2191**] CT examination. No superimposed acute pulmonary embolus is detected to the subsegmental levels. Endobronchial secretions are seen within the left lower lobe segmental bronchus (3:54), extending into the left lower lobe, where there is a moderate-sized consolidation (3:86) filling a previously-seen large air collection from [**2191-3-11**]. There are neighboring areas of tree-in-[**Male First Name (un) 239**] and ground-glass opacities (3:72). Ground-glass and tree-in-[**Male First Name (un) 239**] opacities are also seen throughout both lungs, slightly worse at the lower zones (right lower lobe 3:104, right middle lobe 3:109, right upper lobe 3:49, lingula 3:95), distributed along a centrilobular pattern, with associated mild bronchiectasis, all progressed since [**2191**]. There is no pleural effusion. Mild pleural thickening along the left lower lobe (3:78) has slightly progressed since [**2191**]. Moderate intraabdominal ascites is present. OSSEOUS STRUCTURES: There is no bony lesion concerning for infection or neoplasm. IMPRESSION: 1. Left lower lobe consolidation with large amount of secretions/fluid within the left lower lobe segmental bronchi. A small air-filled space within the left lower lobe seen on the [**2191**] CT examination is now filled with fluid and/or blood. Findings could represent hemorrhage secondary to collagen vascular disease. Infection and abscess also have the same appearance on CT. 2. Centrilobular nodules and ground glass opacities throughout both lungs, with a basilar predominance, with associated mild bronchiectasis, compatible with chronic collagen vascular disease, progressed since [**2191**]. There is no advanced fibrosis. Superimposed infection cannot be excluded by imaging alone. Ground glass opacities could also represent hemorrhage. 3. Chronic left lower segmental pulmonary arterial PE, unchanged since [**2191**]. No new acute PE detected to the subsegmental levels. . [**4-22**] CXR CHEST, SINGLE AP PORTABLE VIEW Suspect background hyperinflation. Superimposed on this, the heart is not enlarged. The left hemidiaphragm is elevated. There is patchy dense opacity at the left base, increased compared with [**2198-4-19**]. Blunting of the left costophrenic angle suggests a small effusion. Smudgy densities scattered in the right and ? left upper lung are compatible with ground glass oapcities seen on chest CTA obtained earlier the same day. There is minimal biapical pleural scarring. Note is made of calcification along the bronchial walls, an unusual finding in an individual of this age. A large (13 mm) coarse calcification overlying the right lung lies within the right breast. Minimal superior endplate scalloping is noted in several mid/upper thoracic vertebral bodies. IMPRESSION: Irregular dense opacity at left base, increased compared with [**2198-4-19**], associated with an elevated left hemidiaphragm. Differential diagnosis includes alveolar processes such as infection and hemorrhage. . [**4-22**] CT ABD/PELVIS ABDOMEN: There is atelectasis at the left base with a small left pleural effusion. Centrilobular nodules and ground-glass opacities at the right base remain unchanged from CTA chest performed yesterday. Lack of intravenous contrast limits evaluation of the solid abdominal viscera. The liver, spleen, adrenal glands and pancreas demonstrate a grossly unremarkable unenhanced appearance. The kidneys are small in size. There is vicarious excretion of contrast within the gallbladder from contrast CT performed yesterday. Nonenlarged retroperitoneal lymph nodes are visualized. There is no adenopathy. The abdominal aorta is normal in caliber with atherosclerotic calcifications noted predominantly infrarenally. A peritoneal dialysis catheter is present, looped in the right mid abdomen entering from the left. There is a moderate amount of ascites, which measures higher than simple fluid in Hounsfield units. There is no evidence of retroperitoneal hematoma. PELVIS: The bladder, uterus and rectum are within normal limits. Ascites is redemonstrated within the pelvis. There are no dilated or thick-walled loops of bowEl. There is no inguinal or pelvic adenopathy. OSSEOUS STRUCTURES: Mild degenerative changes are present in the right hip and sacroiliac joints. A sclerotic 9-mm lesion in the left iliac bone appears nonaggressive and is essentially unchanged from [**2187**] suggesting a benign lesion. IMPRESSION: 1. Moderate ascites. Given the fluid withdrawn from the peritoneal dialysis catheter is nonhemorrhagic, and the patient underwent a contrast-enhanced CT yesterday, this is likely increased in density from the contrast administration. No evidence of retroperitoneal hematoma. 2. Vicarious excretion of contrast in the gallbladder consistent with stated history of chronic kidney disease. 3. Left basilar disease is poorly evaluated on this examination. Centrilobular nodules and ground-glass opacities are redemonstrated consistent with known chronic collagen vascular disease. Again, superimposed infection cannot be excluded by imaging. . [**4-23**] FLUOROSCOPIC-GUIDED EMBOLIZATION L BRONCHIAL ARTERY FINDINGS: 1. Existing right IJ temporary triple-lumen catheter was seen with the tip in the axillary vein. This was successfully repositioned/replaced with the new catheter tip positioned in the distal SVC. 2. Angiography demonstrated dilated tortuous left bronchial artery, supplying the left lung and specifically, the left lower lobe. Some filling of an adjacent pulmonary artery was seen at the end of the angiography suggesting microvascular shunting. 3. No contributor was identified from the left bronchial artery anywhere in its course to an anterior spinal artery. 4. During selective microcatheterization of the left bronchial artery, a small amount of contrast extravasation was noted in the mediastinum from the proximal portion of the artery. Subsequent aortic angiography demonstrated no contrast extravasation from the aorta or evidence of aortic dissection. 5. Following this, 5 French [**Last Name (un) 3056**] was again used to select the ostium of the left bronchial artery. From this location, particle embolization with 300-500 micron Embospheres was performed to good slowing of flow and angiographic result. IMPRESSION: 1. Successful particle embolization in the left bronchial artery, as described above. 2. Successful replacement and repositioning of non-tunneled right internal jugular vein triple lumen catheter, with the tip now in distal SVC. The line is ready to use. . [**4-26**] CT CHEST FINDINGS: AIRWAYS AND LUNGS: Since [**2198-4-22**], high-density consolidation in the left lower lobe sparing only a portion of the superior segment has increased and new in posterior basal segment of the right lower lobe. Preexisting left lower lobe cavity is obscured by this large consolidation. In addition, diffuse ground-glass opacities without septal thickening in both lungs (left side more than right), are also new since [**Month (only) 547**] [**2197**]. Keeping with clinical history, these are highly suggestive of multifocal pulmonary hemorrhage, most pronounced in the left lower lobe. Thin rim of hyperdensity along the posterior pleural space in the left lower lobe is probably due to the dissection of the blood from the consolidation. MEDIASTINUM: Thyroid gland is normal. Endotracheal tube tip lies 3 cm above the carina. There are no pathologically enlarged, mediastinal, supraclavicular or axillary lymph nodes. Heart is normal size, and thin rim of pericardial fluid is likely reactive. Coronary artery calcification is minimal. ABDOMEN: The study is not designed for assessment of subdiaphragmatic pathology; however, limited views were remarkable for moderate ascites with an attenuation value ranging between 19 to 35, suggesting complex fluid, unchanged since [**2198-4-22**]. BONES: There is no bone lesion concerning for malignancy or infection. IMPRESSION: 1. CT featuRes are concerning for progressive multifocal pulmonary hemorrhage, most pronounced in left lower lobe. 2. Left lower lobe bronchial tree occlusion is likely from aspirated blood. 3. Moderate ascites with attenuation ranging between 19 to 35 is probably complex fluid, unchanged since [**2198-4-22**]. . [**5-1**] CXR FINDINGS: As compared to the previous radiograph, there is substantial improvement with substantially improved ventilation of the left lung. Only at the left lung base, areas of atelectasis with subsequent elevation of the left hemidiaphragm persists. Two new tubular structures project over the left hemithorax. There is no evidence of pneumothorax. The monitoring and support devices are overall constant. Constant appearance of the right lung. . [**5-2**] LENIS FINDINGS: There is normal phasicity within the common femoral veins bilaterally. The visualized vessels are patent and compressible with normal waveforms and augmentation. No thrombus identified. IMPRESSION: No evidence of DVT within the lower extremities bilaterally. . [**5-2**] TTE Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are elongated. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Poor image quality (patient difficult to position and unable to cooperate). Preserved regional and global left ventricular systolic function. Based on limited views, right ventricular cavity size and function are probably normal. Pulmonary pressures were undetermined. Compared with the prior study dated [**2198-4-17**] (images reviewed), left ventricular function is more vigorous. Other findings are probably similar although current suboptimal image quality precludes definite comparison. Brief Hospital Course: 37F with SLE c/b lupus nephritis, w/ESRD on PD & bilateral PE on chronic coumadin p/w hemoptysis & hypoxic respiratory failure, found to have L bronchial artery bleed. # HEMOPTYSIS On admission pt was HD stable, not hypoxia, and without airway compromise. She did have significant Hct drop, from 29.6 to 20.8 within 24h of admission. Pt is on chonic coumadin for hx bilateral PE 11y ago; INR was elevated to 4.4 on admission. Explanation for acute bleed not entirely clear - initial ddx included infection (PNA vs abscess) in setting of elevated INR most likely; diffuse alveolar hemorrhage also possible, & rheumatology consult also suggested possible pulmonary vasculitis. No new PE seen on CTA. She initially received antibiotics for possible pulmonary infection (vanc/levo/flagyl, subsequently narrowed to levo/flagyl). On HD3, underwent CT-guided pulmonary angiography for question source of bleed and possible bleeding into mediastinum. Bleed localized to L bronchial artery, which was embolized. Solumedrol started for possible vasculitis. Hct stabilized and uptrended thereafter. There was discussion of possible pulmonary wedge biopsy for purpose of solidifying a tissue diagnosis to guide possible immunosuppression but this was decided against after risk/benefit analysis. Discharge Hct 35.9. Sent home w/steroid taper to be further managed in rheumatology follow-up next week. . # HYPOXIC RESPIRATORY FAILURE Pt developed respiratory failure while in the ICU, w/increasing O2 requirement. CXR showed significant left-sided infiltrate, most likely from L bronchial arterial bleed (as discussed above). Pt developed progressive respiratory distress requiring supplemental O2. She was intubated on HD4 for rigid bronchoscopy and was difficult to extubate, first because of persistent L-sided infiltrate (blood) and volume overload (retained >5L over 3-4d from PD), then because she developed ventilator associated pneumonia (VAP). She was already on levo/flagyl at the time (coverage for possible pulmonary infection as precipitant for hemoptysis, discussed above); aztreonam/vancomycin added briefly for VAP coverage. On repeat bronchoscopy on HD9, large mucous plug removed from LUL bronchus. Pt's respiratory status improved quickly thereafter, and she was successfully extubated the following morning. Weaned to RA within several hours, O2 sat in high 90s/RA for >48h thereafter. . #CHRONIC PE/ANTICOAGULATION Hx indication for anticoagulation was revisited during this admission given hemoptysis and supratherapeutic INR on admission. No acute PE on CTA. [**Year (4 digits) **] was consulted and agreed w/continuing to hold anticoagulation. IVC filter placed. Review of OMR records revealed that anticoagulation was started in [**6-/2187**] during hospitalization for lung abscess; large bilateral PEs were revealed on CTA done for unexplained persistent sinus tachycardia. She has been on anticoagulation since. OMR also include diagnosis of antiphospholipid antibody syndrome in OB/GYN notes (based upon 3 miscarriages and hx CVA age 14) but rheumatology notes/records show autoantibody panel not c/w this diagnosis ([**Doctor First Name **] positive 1:320, anti-Ro/La positive, lupus anticoagulant negative x2, *anticardiolipin negative*. Rheumatology and hematology were consulted here for assistance with re-evaluation of pt's indication for chronic anticoagulation and plan to resume anticoagulation. Repeat serologies sent - lupus anticoagulation now *positive*, anticardiolipin again negative, b2glycoprotein Ab pending at time of discharge. Discharge anticoagulation plan as follows: - IVC filter to be removed in ~1 week (IR aware, procedure scheduled for [**2198-5-11**]) - Resume warfarin after IVC filter removed, with f/u INR checks at [**Hospital 191**] clinic overseen by PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. [**Month (only) 116**] require re-hospitalization to restart warfarin, TBD by PCP and [**Month (only) **]/pulm in outpatient follow-up - PCP, [**Name10 (NameIs) **], Rheum and Pulmonary follow-up appointments arranged - situation discussed with Rheumatologist Dr. [**Last Name (STitle) 3057**] who will review paper records for any OSH coagulopathy studies sent prior to initiation of coumadin in [**2187**] and share info w/Dr. [**First Name (STitle) **] . # SINUS TACHYCARDIA Pt's HR was 100 on admission and trended 100-140 during her hospital status. Always sinus tachycardia on EKG and telemetry. Given hx PE, she had bilateral LENIs and a TTE to evaluate any right heart strain. Both were wnl. No CTA was obtained because a) pt had an IVC filter placed on admission so low-likelihood and b) no anticoagulation would have been restarted as an inpatient given recent life-threatening bleed. # Hx ESRD on PD Renal failure chronic, lupus nephritis. Underwent PD throughout hospital stay. Initially there was some difficulty evacuating entire content of PD dwells, and pt became volume overloaded. Renal consult service followed closely and guided modifications to PD solution. Pt was euvolemic on PD for 4 days prior to discharge. . # Hx SLE Diagnosed in [**2180**] and followed by Dr. [**Last Name (STitle) 3057**]. Complicated by nephritis, & recurrent pleural effusions, w/additional ocular and skin manifestations. Plaquenil was continued while pt able to take POs; held while intubated & restarted thereafter. Rheumatology consult service followed, suggested possibility that lupus vasculitis or other vasculitis might have contributed to her hemoptysis (see above) and recommended initiation of IV steroids. Steroid taper to be further managed by rheumatologist in follow-up. . # Hx HTN Recently stopped lisinopril for concern of exacerbation of her cough. BP meds held on admission given concern for bleeding. Used PRN IV labetolol to control BPs while intubated. After extubation, pt's BP ran . # Hx MIGRAINE HEADACHES Takes amitriptyline at home at night. Amitriptyline + PRN tylenol while here. . # Hx GERD Continued ranitidine. Pt did have some nausea and PO intolerance but was able to take small-volume POs prior to discharge. . TRANSITIONAL ISSUES 1. ANTICOAGULATION Discharge anticoagulation plan as follows: - IVC filter to be removed in ~1 week (IR aware, procedure scheduled for [**2198-5-11**]) - Resume warfarin after IVC filter removed, with f/u INR checks at [**Hospital 191**] clinic overseen by PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. [**Month (only) 116**] require re-hospitalization to restart warfarin, TBD by PCP and [**Month (only) **]/pulm in outpatient follow-up - PCP, [**Name10 (NameIs) **], Rheum and Pulmonary follow-up appointments arranged - situation discussed with Rheumatologist Dr. [**Last Name (STitle) 3057**] who will review paper records for any OSH coagulopathy studies sent prior to initiation of coumadin in [**2187**] and share info w/Dr. [**First Name (STitle) **] - Warning signs for CVA and DVT/PE reviewed with pt and family prior to discharge, recommend careful follow-up neuro and pulmonary exams. 2. STEROID TAPER - to be managed by outpatient rheumatologist 3. Need for ongoing home physical therapy - pt thought to need intense rehabilitation but refused PT, will need follow-up evaluation by PCP and likely ongoing home PT Medications on Admission: AMITRIPTYLINE - 25 mg Tablet QHS B COMPLEX-VITAMIN C-FOLIC ACID CALCITRIOL 0.25 mcg Capsule six times weekly CODEINE-GUAIFENESIN [**1-1**] tsp(s) prn cough DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - 60 mcg/0.3 mL Syringe -Q2weeks GENTAMICIN - 0.1 % Cream - apply to exit site as directed HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg Tablet - 1 Tablet(s) by mouth ONE BY MOUTH EVERY DAY, TWO BY MOUTH EVERY OTHER DAY LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day -recently stopped for concern of contributing to chroninc cough RANITIDINE HCL - 150 mg Tablet - [**Hospital1 **] SEVELAMER CARBONATE [RENVELA] 800 mg Tablet - 3 Tablet TID VALACYCLOVIR - 500 mg Tablet - one Tablet(s) by mouth x 1 dose as needed for cold sore outbreak as soon as you have symptoms WARFARIN - Alternating 7.5 mg and 10 mg Discharge Medications: 1. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 6x/week. 4. Aranesp (polysorbate) 60 mcg/0.3 mL Syringe Sig: One (1) injection Injection q2weeks. 5. gentamicin 0.1 % Cream Sig: One (1) Topical once a day: apply to exit site as directed. 6. hydroxychloroquine 200 mg Tablet Sig: AS DIRECTED Tablet PO once a day: 200 MG (1 TAB) AND 400 MG (2 TABS) ON ALTERNATING DAYS. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 8. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO x1: take 1 tablet immediately as needed for cold sore outbreak as soon as you have symptoms. 10. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q6H (every 6 hours) as needed for throat pain. Disp:*QS * Refills:*0* 11. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: take 4 tabs (40 mg) Saturday morning, then 3 tabs (30 mg) every morning until further instructions from your rheumatologist. Disp:*50 Tablet(s)* Refills:*1* 12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety or nausea for 30 doses. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: LEFT BRONCHIAL ARTERY BLEED VENTILATOR-ASSOCIATED PNEUMONIA END-STAGE RENAL DISEASE, PERITONEAL DIALYSIS-DEPENDENT HISTORY OF PULMONARY EMBOLISM 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 Mrs. [**Known lastname **], You were admitted to the hospital with a life-threatening bleed into your left lung. Your INR was >4 so we stopped coumadin. You underwent a procedure to localize and cauterize the source of the bleed: a left bronchial artery. You required intubation to help you breathe as the blood in your left lung resolved. You had multiple bronchoscopies to remove blood clots and mucous plugs. You were followed closely by rheumatologists who recommended steroids to dampen any possible lupus vasculitis, which could have caused the bleed. You also developed ventilator-associated pneumonia and were treated with antibiotics. Your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] will continue to manage your coumadin. For now, do not take coumadin. We will recommend restarting coumadin in approximately 1 week, after IVC filter removal, but the final decision will be made by Dr. [**First Name (STitle) **] in cooperation with your hematologist and rheumatologist. Please see below for a list of warning signs. Please pay special attention to any difficulty breathing, chest pain including discomfort with breathing, leg or calf pain or swelling. Also be aware of warning signs for stroke including sudden weakness or numbness, difficulty speaking, and change in vision. We recommended [**Hospital 3058**] rehabilitation because you were very weak after 10 days in bed in the hospital. Physical therapy did not think you were safe to go home. However, you refused to go to rehab. We made the following changes to your medications: STOP COUMADIN STOP LISINOPRIL (RECENTLY DISCONTINUED BY YOUR PCP) STOP GUAIFENESIN STOP LOSARTAN, please discuss resuming this medication with your PCP and Nephrologist START CHLOROSEPTIC SPRAY FOR THROAT DISCOMFORT, EVERY 6 HOURS AS-NEEDED START PREDNISONE TAPER, 40 MG SATURDAY THEN 30 MG DAILY UNTIL YOU SEE YOUR RHEUMATOLOGIST, WHO WILL GIVE FURTHER TAPERING INSTRUCTIONS. START ATIVAN 0.5 mg UP TO EVERY 8 HOURS FOR ANXIETY OR NAUSEA FOR 10 DAYS. PLEASE DO NOT DRINK [**Street Address(1) 3059**] WHILE TAKING THIS MEDICATION. Followup Instructions: Please arrive 1 hour early for this [**Street Address(1) 648**] to get your blood drawn: Department: [**Hospital3 249**] When: [**Hospital3 **] [**2198-5-7**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RHEUMATOLOGY When: WEDNESDAY [**2198-5-9**] at 4:30 PM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2198-5-10**] at 11:30 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage This is your [**Street Address(1) 648**] to remove your IVC filter. It is very important that you keep this [**Street Address(1) 648**] and arrive early. Department: RADIOLOGY CARE UNIT When: FRIDAY [**2198-5-11**] at 7:00 AM [**Telephone/Fax (1) 446**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: Hematology Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] When: Dr. [**Last Name (STitle) 3061**] office is working on a follow up [**Last Name (STitle) 648**] for 9-15 days after your hospital discharge. If you have not heard from the office in 2 business days please call the office number listed below. Location: DIVISION OF HEMOSTASIS AND THROMBOSIS Address: [**Location (un) **], E/TCC-9, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3062**] Department: PULMONARY FUNCTION LAB When: THURSDAY [**2198-5-31**] at 1:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2198-5-31**] at 2:00 PM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Pulmonology Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9pcs

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4456

Discharge summary

report

Admission Date: [**2166-11-12**] Discharge Date: [**2166-11-18**] Date of Birth: [**2089-10-2**] Sex: M Service: NEUROLOGY Allergies: Shellfish Derived Attending:[**First Name3 (LF) 5018**] Chief Complaint: language difficulty and right weakness Major Surgical or Invasive Procedure: none History of Present Illness: Per admitting resident: 77 yo RHM with a history of prostate ca, HTN, who went to bed in his usual state of health at 9 pm, but when he woke up at 6 am, he had right sided weakness and a right facial droop. He went to work anyway, and according to what the ER stated, his work place contact[**Name (NI) **] his "son" who brought him to the ER. Unfortunately, his son was no longer present when I arrived. The patient is only really able to give "yes" or "no" answers, and finds it difficult to enunciate words. I contact[**Name (NI) **] his [**Name (NI) 6435**] (Dr [**Last Name (STitle) 19111**] office on [**Telephone/Fax (1) 12807**], but unfortunately, they did not have a record of any of his family members names. At about 3:15 pm, his nephew (not son) arrived, and the history is as follows, his uncle works with him in his office, and his uncle arrived at 11:45 am. His nephew, [**Name (NI) **] noted that he could not speak properly, had a right facial droop, and had right sided weakness, thus called the EMS, who brought him to the [**Hospital1 **]. ROS: Patient states "no" to all of the following: vertigo, headache, nausea, palpitations, dyspnea, chest pain, fevers, chills, new GI or GU symptoms. Past Medical History: Prostate cancer (adenoca) - diagnosed in [**2150**] at [**Hospital1 3278**], radiotherapy treatment initiated in [**2154**] (as per OMR records) HTN sigmoid polyp Fixation of femur age 16 Social History: The patient is single and continues to work and is trained as an interior designer. He exercises regularly and performs yoga on a regular basis. He previously smoked cigarettes, stopped 30 years ago and will drink two glasses of wine occasionally with meals. No use of recreational drugs. Nephew - [**Name (NI) **] [**Name (NI) 19112**] [**Telephone/Fax (1) 19113**] Family History: As per OMR rad-onc records: family history is notable for a sister who was treated for breast cancer and is alive, well and another sister who was recently diagnosed with breast cancer. Physical Exam: Exam on admission: T-98 HR-63 (30s) BP-160/64 RR-18 SpO2-99 Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, Right carotid bruit, cannot hear any flow on the left, but no vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, thinks that he is in NEB, and states that the date is 18/19. Unable to spell "WORLD" backwards. Speech is non-fluent with normal comprehension and he has problems in repeating longer sentences; naming intact. Dysarthria noted, and saliva dribbling out of the right corner of his mouth. He cannot read a sentence and writing could not be checked. Registers [**2-25**], recalls [**1-28**] in 5 minutes (but the words are difficult to understand). No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light (senile arcus bilaterally), 3 to 2 mm bilaterally. Fundoscopy is normal. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Right facial droop noted. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue appears to be deviated due to the extent of the facial weakness, but movements are intact. Motor: Normal bulk bilaterally. Tone increased in the right arm. No observed myoclonus or tremor could not check pronator drift due to R arm weakness [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 3 +4 5 2 2 2 2 +4 +4 5 5 5 5 5 Sensation: Intact to light touch. No extinction to DSS. However, due to his language deficits, it is difficult to do this accurately Reflexes: B T S P A Pl R +2 +2 +2 3 2 up L 2 2 2 2 - down Coordination: finger-nose-finger normal on the left, could not do this on the right, heel to shin normal on the left only, slower on the right, RAMs normal on the left only. Gait: not assessed due to his bradyarrhythmia Exam at time of discharge: Pertinent Results: Labs on admission: [**2166-11-12**] 12:30PM BLOOD WBC-7.2 RBC-5.48 Hgb-17.6 Hct-50.0 MCV-91 MCH-32.2* MCHC-35.3* RDW-14.4 Plt Ct-146* [**2166-11-12**] 12:30PM BLOOD Neuts-86.2* Lymphs-9.4* Monos-3.7 Eos-0.5 Baso-0.2 [**2166-11-12**] 12:30PM BLOOD PT-13.2 PTT-25.6 INR(PT)-1.1 [**2166-11-12**] 12:30PM BLOOD Glucose-141* UreaN-15 Creat-0.9 Na-139 K-3.7 Cl-101 HCO3-26 AnGap-16 [**2166-11-13**] 03:23AM BLOOD ALT-11 AST-19 AlkPhos-54 [**2166-11-12**] 12:30PM BLOOD CK(CPK)-159 [**2166-11-13**] 03:23AM BLOOD CK-MB-3 cTropnT-<0.01 [**2166-11-12**] 08:25PM BLOOD CK-MB-4 cTropnT-<0.01 [**2166-11-12**] 12:30PM BLOOD cTropnT-<0.01 [**2166-11-12**] 12:30PM BLOOD Calcium-9.4 Phos-2.5* Mg-1.9 [**2166-11-13**] 03:23AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.5 Cholest-200* [**2166-11-13**] 03:23AM BLOOD Triglyc-94 HDL-66 CHOL/HD-3.0 LDLcalc-115 [**2166-11-13**] 03:23AM BLOOD %HbA1c-5.3 [**2166-11-12**] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine studies: [**2166-11-12**] 01:15PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG [**2166-11-12**] 01:15PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 RenalEp-0-2. Imaging: CT head on admission: IMPRESSION: No acute intracranial process. MRI/A brain/neck: IMPRESSION: 1. Acute infarct involving the left striatum, with other punctate foci of involvement in the left centrum semiovale and possibly left superior temporal gyrus. Given the lack of involvement of the more distal portion of the left middle cerebral artery territory, there is likely collateral flow. However, on the MRA of the neck images, there is no evidence of enhancement of the left middle cerebral artery. Dedicated MRA of the head is recommended. 2. Occlusion of the left internal carotid artery from the carotid bulb extending intracranially, although there may be some residual flow within the distal cavernous and supraclinoid segments. IMPRESSION: 1. Near-complete occlusion of the left internal carotid artery, with propagation since the earlier study and further diminished flow in the cavernous and supraclinoid segments. 2. There is also complete occlusion of the left middle cerebral artery, with no evidence of flow-related enhancement throughout its visualized extent. ECHO: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Carotid dopplers: IMPRESSION: 1. No significant right ICA stenosis. 2. Occluded left ICA. 3. Moderate to high-grade left external carotid artery stenosis. CT head [**11-15**]: IMPRESSION: Evolution of left MCA infarct with slightly increased mass effect on the left lateral ventricle without midline shift. No hemorrhage seen. XR L shoulder/elbow [**2166-11-16**]: RIGHT SHOULDER: There is a possible non-displaced fracture of the lateral acromion. A well-corticated fragment within the right shoulder is consistent with calcific tendinopathy of the supraspinatus tendon and is chronic in nature. There is mild osteoarthritis of the AC and glenohumeral joints. No dislocations are seen. No focal lytic or sclerotic lesions identified. No radiopaque foreign body is seen. RIGHT ELBOW AND FOREARM: No fracture or dislocation is seen. There is osteoarthritis of the ulnar trochlear joint as well as calcific tendinopathy of the common extensor tendon. No focal lytic or sclerotic lesions identified. No radiopaque foreign body is seen. IMPRESSION: 1. Possible nondisplaced fracture of the lateral acromion. 2. Osteoarthritis of the right shoulder and elbow. Brief Hospital Course: 77 yo with a history of prostate cancer, HTN, who woke up with a right facial droop and a right hemiparesis. At work, he was noted not to speak properly and was brought to [**Hospital1 18**]. On initial examination he was he had intact comprehension, motor aphasia, R face/arm weakness >> R leg weakness. CT head showed a hyperdense MCA sign. ED course was complicated by sinus bradycardia to 30s. He was admitted to neuromedicine service for further evaluation. NEURO. Patient was treated per stroke protocl of HOB < 30, IVF, SBP autoregulation, ASA, statin and normoglycemia/normothermia maintenance. MRI head showed a new large LEFT basal ganglia and left caudate and putamen as well as the anterior limb of the internal capsule. In additin, there were scattered strokes in left centrum semiovale, all of this suggesting an embolic etiology. MRA showed complete occlusion of the L MCA as well as near complete occlusion of [**Doctor First Name 3098**]. Patient was started on heparin gtt and carotid US obtained to assess degree of [**Doctor First Name 3098**] stenosis, which confirmed complete occlusion. ECHO showed no source of embolism and no afib was noted on Telemetry. His examination progressed by HD2 to global aphasia and R side plegia. Given this, no surgical intervention was indicated. Patient was started on Plavix. He underwent a S&S evaluation that resulted in requiring ground solids and nectar thick liquids. He underwent calorie counts showing consumption of 850kCal on [**11-17**]. This will require follow up in skilled nursing facility setting. At time of discharge his examination was remarkable for global, but motor predominant aphasia and R sided hemiplegia. CV. Patient was noted to have sinus bradycardia while in the ED. EKG was remarkable only for above finding. He completed ROMI. Cardiology was consulted and it was felt that this was due to increased vagal tone. Patient continued to have episodes of asymptomatic bradycardia while asleep. He will require adjustment of his medications to a BP goal of SBP 120-140s. His antihypertensive regimen was held during the acute post stroke phase. He was restarted at 5mg of Lisinopril at time of discharge and amlodipine and HCTZ were held. Medications can be titrated to goal listed above by increasing Lisinopril first, followed by addition of the either amlodipine or hydrochlorothiazide. GU. After disposition from ICU, patient underwent a voiding trial which he failed with retention of 750cc of urine. This was felt to be multifactorial, from increased prostatic size and possible impairment of frontal lobes due to edema from the stroke. The latter is expected to improve within one to two months. Foley catheter was replaced. He has follow up with his urologist, Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Phone:[**Telephone/Fax (1) 22**]. ORTHO: Unfortunately on [**11-16**] patient experience a fall from a chair, despite being on fall precautions and chair alarm trying to sit up from a chair. Follow up neurological examination was unchaned and head CT showed evolution of of the MCA infarction. Unfortunately patient was c/o of R shoulder pain and was found to have a R acromion mildly displaced fracture. He was evaluated by orthopedics and was deemed to be best treated with a brace, no surgical intervention was recommended. Follow up was arranged with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name6 (MD) **] orthopedics NP. Patient is non weight bearing (e.g. Ok for ROM, feeding, combing hair, glass of water etc., but no heavy weights) and will require OT. Should you have further questions about limitation, please contact the orthopedics office. Code status: DNR/I confirmed with family Medications on Admission: AMLODIPINE [NORVASC] - 10mg HYDROCHLOROTHIAZIDE - 12.5mg daily LISINOPRIL - 10mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 3. Insulin Regular Human 100 unit/mL Solution Sig: per SS Injection ASDIR (AS DIRECTED). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 9. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day. 10. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection every six (6) hours as needed for SBP>160: goal SBP 120-140;. 11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Left MCA infarct and ICA occlusion Secondary: Hypertension, prostate cancer. Discharge Condition: Hemodynamically stable. Neurological exam remarkable for: Aphasia (global), R hemiplegia in upper and lower extremity Discharge Instructions: You were admitted to the hospital with difficulty with speech and right sided weakness. You were found to have a large stroke. You underwent an evaluation for this and you were found to have a blockage in one of your neck arteries that caused your stroke. You were started on new medications. You required temporary nasogastric tube placement for feeding, however, you were able to take over 50% of your calories and tube was removed. The following changes were made to your medications: - Started on Plavix - Started on Simvastatin Please make the follow up appointments with your doctors. You were discharged to a rehabilitation facility. Should you experience any symptoms concerning to you, please call your doctor or go to the emergency room. Followup Instructions: Please follow up with the following appointments: Please make a follow up appointment with [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 12807**], your PCP. NEUROLOGY: Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2166-12-17**] 2:00 In [**Hospital Ward Name 23**] Clinical Center on the [**Location (un) **], [**Hospital1 18**] [**Hospital Ward Name **] UROLOGY: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2166-11-27**] 9:30 ORTHOPEDICS: Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2166-12-16**] 9:00 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "427.89", "811.01", "401.9", "V58.67", "250.00", "E849.7", "433.11", "507.0", "E884.2", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "96.07" ]

icd9pcs

[ [ [] ] ]

13985, 14055

9054, 12845

320, 326

14185, 14306

4801, 4806

15110, 16077

2186, 2375

12983, 13962

14076, 14164

12871, 12960

14330, 15087

2390, 2395

242, 282

354, 1571

3442, 4782

6052, 9031

2842, 3426

2827, 2827

1593, 1783

1799, 2170

17,949

103,247

3709

Discharge summary

report

Unit No: [**Numeric Identifier 16726**] Admission Date: [**2185-6-27**] Discharge Date: [**2185-6-29**] Date of Birth: [**2120-9-24**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 54-year-old black male had a type B aortic dissection in [**2184-8-22**] from the left subclavian at the level of the pulmonary vein. He was treated medically for hypertension, and he has a penetrating ulcer in his descending aorta of 3.2 cm which increased from 2.3 cm. The diameter of his aorta is 6.7 cm. He was admitted for thoracoabdominal repair. He had a cardiac cath on [**2185-5-30**] which revealed an ejection fraction of 56% and clean coronary arteries. An echocardiogram on [**2184-9-17**] revealed no MR and no AS. PAST MEDICAL HISTORY: Significant for a history of non- insulin-dependent diabetes, hypertension, obesity, and chronic renal insufficiency. MEDICATIONS ON ADMISSION: Avandia 2 mg p.o. daily, labetalol 800 mg p.o. t.i.d., Lipitor 10 mg p.o. daily, lisinopril 20 mg p.o. b.i.d., nifedipine 90 mg p.o. daily, Protonix 40 mg p.o. daily, isosorbide 30 mg p.o. daily, hydrochlorothiazide/triamterene 37.5/25 one daily, and iron. ALLERGIES: He has no known allergies. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: Occupation: He is retired from Fed Ex. He does not smoke cigarettes. He does not drink alcohol. He lives with his wife. [**Name (NI) **] does not use drugs. REVIEW OF SYSTEMS: Significant for BPH. PHYSICAL EXAMINATION: He is a well-developed and well- nourished black male in no apparent distress. Vital signs are stable. Afebrile. HEENT exam reveals normocephalic and atraumatic. Extraocular movements are intact. The oropharynx is benign. The neck is supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids are 2+ and equal bilaterally without bruits. The lungs are clear to auscultation and percussion. Cardiovascular exam reveals a regular rate and rhythm. Normal S1 and S2 with no rubs, murmurs, or gallops. The abdomen is soft, nontender, with positive bowel sounds. No masses or hepatosplenomegaly. The extremities are without clubbing, cyanosis, or edema. Neurologic exam is nonfocal. Pulses are 1+ and equal bilaterally throughout. HOSPITAL COURSE: He was admitted to the OR. He was intubated and then an intrathecal catheter was attempted, and the patient had spinal stenosis, and the anesthesiologists were unable to advance into the CSF space. The procedure was aborted, and the patient was transferred to the CSRU in stable condition. Of note, they were also unable to place a Foley catheter, and he needed a coude catheter which was placed. He was extubated in the CSRU the same day, and the following day was transferred to [**Hospital Ward Name 121**] Two. DISCHARGE STATUS: He had his bladder catheter discontinued and was able to void and was discharged to home on [**6-29**] in stable condition. His hematocrit was 28.9, white count was 8600, platelets were 168,000. PTT was 31.5. INR was 1.2. Sodium of 140, chloride of 106, CO2 of 24, BUN of 31, creatinine of 2, potassium of 4.1. MEDICATIONS ON DISCHARGE: Same as preoperatively. DI[**Last Name (STitle) 408**]E FOLLOWUP: He will follow up with Dr. [**Last Name (Prefixes) **] on [**7-7**] to reschedule his surgery. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2185-6-29**] 13:34:21 T: [**2185-6-29**] 14:31:22 Job#: [**Job Number 16727**]

[ "593.9", "V64.1", "600.01", "250.00", "721.3", "441.01", "278.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "57.94", "96.04", "88.72" ]

icd9pcs

[ [ [] ] ]

1209, 1224

3097, 3516

894, 1192

2223, 3070

1464, 2205

1419, 1441

190, 725

748, 867

1241, 1399

74,680

141,651

10038

Discharge summary

report

Admission Date: [**2195-4-20**] Discharge Date: [**2195-5-4**] Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: numbness of lips and jaw pain Major Surgical or Invasive Procedure: Coronary Artery Bypass Grafting x3 (Left internal mammary to left anterior descending artery, reverse saphenous vein graft to diagonal artery, reverse saphenous vein graft to posterior left ventricular branch artery History of Present Illness: 88yo woman admitted to [**Hospital6 **] with lip numbness and jaw pain. Initial troponins were negative for infarction but she did have T wave inversions. She underwent cardiac catheterization which revealed 3 vessel disease. She was then transferred to [**Hospital1 18**] for coronary artery bypass grafting. Past Medical History: Gastric Esophogeal Reflux Disease Hypertension Paroxysmal atrial fibrillation Atherosclerotic cerebral vascular accident Ileal conduit/urostomy right hip fracture s/p surgical repair Social History: lives alone. has a son and daughter Denies alcohol or tobacco use Family History: noncontributory Physical Exam: 5'2" 121 lbs VS T97.9 HR68 BP145/61 RR20 O2sat 97%-RA Gen NAD Skin unremarkable HEENT unremarkable Neck supple/full ROM Chest CTA-bilat Heart RRR Abdm soft, NT/ND/+BS Ext warm, well perfused. no varicosities Pulses fem 3+bilat, DP 2+bilat, PT 2+bilat, Rad 2+bilat Pertinent Results: [**2195-4-20**] 11:45PM GLUCOSE-103 UREA N-17 CREAT-0.6 SODIUM-139 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [**2195-4-20**] 11:45PM WBC-7.2 RBC-3.75* HGB-11.7* HCT-33.4* MCV-89 MCH-31.1 MCHC-34.9 RDW-13.4 [**2195-4-20**] 11:45PM PLT COUNT-223 [**2195-4-20**] 11:45PM PT-13.7* PTT-28.6 INR(PT)-1.2* [**2195-4-20**] 10:27PM URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025 [**2195-4-20**] 10:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2195-4-30**] 05:10AM BLOOD WBC-8.8 RBC-3.11* Hgb-9.8* Hct-28.1* MCV-91 MCH-31.7 MCHC-35.0 RDW-13.3 Plt Ct-167 [**2195-4-30**] 05:10AM BLOOD Plt Ct-167 [**2195-4-28**] 03:13AM BLOOD PT-14.1* PTT-30.8 INR(PT)-1.2* [**2195-4-30**] 05:10AM BLOOD Glucose-143* UreaN-22* Creat-0.9 Na-138 K-3.9 Cl-104 HCO3-24 AnGap-14 [**2195-4-21**] 10:25AM BLOOD CK-MB-2 cTropnT-<0.01 [**2195-4-21**] 10:25AM BLOOD %HbA1c-5.2 ....................................... [**Known lastname 33571**],[**Known firstname **] M [**Medical Record Number 33572**] F 88 [**2106-10-8**] [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2195-5-1**] 9:22 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 33573**] [**Hospital 93**] MEDICAL CONDITION: 88 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions Final Report HISTORY: Status post CABG. FINDINGS: In comparison with study of [**4-29**], the right IJ sheath has been removed. The degree of atelectasis at the left base appears to be decreasing. Probably little change in the small left effusion. Minimal blunting of the right costophrenic angle. Sternal sutures remain intact after CABG procedure. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: FRI [**2195-5-1**] 11:09 AM ........................................... [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 33571**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 33574**]Portable TEE (Complete) Done [**2195-4-27**] at 2:44:13 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-10-8**] Age (years): 88 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG. Coronary artery disease. Left ventricular function. Right ventricular function. Valvular heart disease. Abnormal ECG. ICD-9 Codes: 440.0, 413.9, 424.1, 745.5 Test Information Date/Time: [**2195-4-27**] at 14:44 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: Portable TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2009AW4-: Machine: AW4 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 65% >= 55% Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Arch: 2.4 cm <= 3.0 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Suboptimal image quality - poor echo windows. The patient appears to be in sinus rhythm. Frequent atrial premature beats. Results were personally Conclusions PRE BYPASS Mild spontaneous echo contrast is seen in the body of the left atrium. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. 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 was initially AV paced and then A paced. There is normal biventricular systolic function. Valvular function remains unchanged from the pre bypass study. Left to right flow through a patent foramen ovale remains. The thoracic aorta appears intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2195-4-27**] 17:19 .................................................... Brief Hospital Course: Ms [**Known lastname **] was admitted to [**Hospital1 18**] for coronary artery bypass grafting on [**4-20**]. She had received PLavix during her cardiac catheterization and it was decided to hold surgery while the Plavix had a chance to clear her system. She was started on nitrates and heparin infusion during this time. She was also treated for a urinary tract infection prior to surgery. On [**4-27**] she was brought to the operating room where she had coronary bypass grafting times three with left internal mammary to left anterior decending artery, reverse saphenous vein graft to diagonal and reverse saphenous vein graft to posterior lateral ventriclular artery. Bypass time was 67 minutes with a crossclamp of 50 minutes. Please see operative note for details. She tolerated the surgery well and was transferred from the operating rooom to the cardiac surgery ICU in stable condition. The patient did well in the immediate post-operative period, she remained hemodynamically stable and was extubated on POD1. Following extubation her pulmonary artery catheter and chest tubes were removed. On POD2 she was transferred to the stepdown floor for further care and recuperation. She was started on betablockers and diuresis. It should be noted that the patient had intermittent periods of atrial fibrillation in the immediate post operative period which persisted and were refractory to IV amiodarone and lopressor. She responded very well to diltiazem and lopressor. She was started on coumadin for afib - her most recent INR was 1.2 on [**2195-5-3**]. She continued to progress and was discharged to rehab on POD#7. All follow up appointments were advised. Medications on Admission: Plavix Prilosec Xanax 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection TID (3 times a day). 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed. 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: while on lasix. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: has been rec'ing 2mg coumadin daily for afib. Goal INR 2-2.5. 12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Doctor First Name **] Immaculate - [**Hospital1 487**] Discharge Diagnosis: s/p coronary artery bypass grafting x3 intermittent post-op atrial fibrilation PMH: Hypertension, Anxiety, Gastric esophogeal reflux disease, right hip surgery, urostomy/ileal conduit Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever(Temp>100.5), redness or drainage from sternal wound No lifting greater than 10 pounds for 6 weeks No driving for 6 weeks No lotion, powder, cream or ointment on wounds **Daily INR draws for INR goal>2.0 for AFib/MD order for Coumadin Followup Instructions: Dr [**Last Name (STitle) 33575**] in [**1-30**] weeks or upon discharge from rehab Dr [**Last Name (STitle) 5017**] in [**3-3**] weeks or upon discharge from rehab Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] patient to call to arrange all appointments Completed by:[**2195-5-4**]

[ "427.31", "V58.66", "599.0", "E879.0", "300.00", "041.3", "V58.61", "414.01", "438.89", "E849.7", "998.12", "530.81", "411.1", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11444, 11528

8332, 9999

254, 472

11756, 11763

1435, 2683

12165, 12471

1116, 1133

10071, 11421

2723, 2750

11549, 11735

10025, 10048

11787, 12142

1148, 1416

185, 216

2782, 8309

500, 811

833, 1017

1033, 1100

53,758

121,036

36831

Discharge summary

report

Admission Date: [**2181-9-28**] Discharge Date: [**2181-10-4**] Date of Birth: [**2114-4-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: status post pulmonary vein isolation for a-fib now with cardiac tamponade Major Surgical or Invasive Procedure: Pulmonary vein isolation History of Present Illness: 67 year old female with a history of atrial fibrillation, asthma/COPD, HLD, osteoporosis, glaucoma presented with cardiac tamponade s/p pulmonary vein isolation procedure. The pt has had drug refractory a-fib which has been progressive over the past few years despite failed attempts at cardioversion and rate control (intolerance to beta blockers due to asthma/COPD). She complains of fatigue and dyspnea with exertion and intermittent palpitations that resolve with rest. . A pulmonary vein isolation procedure was performed on [**2181-9-28**] which was complicated by perforation. BP dropped and an emergent pericardiocentesis was performed and drain was put in place. 250cc of fluid was drained. Pt was given Protamine and started on Phenylephrine. Transferred to CCU intubated. Hct dropped from 45 --> 34.7 after the procedure. Preop INR was 2.6. No recent fever, cough, sputum, back pain, arthralgias, myalgias or rash. The rest of the review of systems is negative in detail. Past Medical History: 1. CARDIAC RISK FACTORS: dyslipidemia 2. CARDIAC HISTORY: paroxysmal afib s/p failed cardioversion 3. OTHER PAST MEDICAL HISTORY: Asthma COPD Glaucoma Macular degeneration Tonsillectomy [**2120**] Rhinoplasty [**2134**] Hysterectomy [**2160**] Exc. Benign left breast lump [**2172**] Cataract [**Doctor First Name **] [**2179**] Social History: Patient is a retired bank Administrator and lives with her husband and has two grown children. -Tobacco history: smoked [**1-12**] pack per day for 7 years. Quit 30yrs ago. -ETOH: none. -Illicit drugs: none. Family History: Father had a CHF in his 80's, mother had [**Name (NI) 27349**] in her 80's. Physical Exam: VS: T=36.2 BP= 92/66 HR= 77 RR=16 O2= 100% intubated General Appearance: Sedated. No acute distress. Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral [**Name (NI) **]: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t) Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender. Ecchymosis over L groin site tracking to mid thigh. Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm Pertinent Results: On Admission: [**2181-9-28**] 06:45AM WBC-6.8 RBC-4.75 HGB-14.8 HCT-45.0 MCV-95 MCH-31.2 MCHC-33.0 RDW-14.1 [**2181-9-28**] 06:45AM NEUTS-57.8 LYMPHS-33.3 MONOS-5.7 EOS-2.0 BASOS-1.2 [**2181-9-28**] 06:45AM PLT COUNT-224 [**2181-9-28**] 06:45AM PT-26.3* INR(PT)-2.6* [**2181-9-28**] 06:45AM GLUCOSE-98 UREA N-21* CREAT-0.8 SODIUM-143 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-31 ANION GAP-11 [**2181-9-28**] 02:20PM WBC-14.7*# RBC-3.68* HGB-11.3*# HCT-34.7*# MCV-94 MCH-30.7 MCHC-32.6 RDW-14.1 [**2181-9-28**] 02:20PM NEUTS-78.3* LYMPHS-17.7* MONOS-3.2 EOS-0.6 BASOS-0.2 [**2181-9-28**] 02:20PM PLT COUNT-176 . FEMORAL ULTRASOUND [**2181-9-29**]: IMPRESSION: Findings concerning for a pseudoaneurysm in the left groin, that is predominantly thrombosed. . CT CHEST/ABD/PELVIS [**2181-9-29**]: IMPRESSION: 1. No retroperitoneal hematoma. 2. No pericardial effusion with catheter in the pericardial space wrapping around the heart. 3. A few ground-glass opacities throughout the lungs bilaterally, as described above. While these may represent focal areas of atelectasis, a six-month followup CT thorax is recommended to ensure stability or resolution. 4. Unremarkable CT of the abdomen and pelvis. . ECHO [**2181-10-1**]: There is a bidirectional shunt across the interatrial septum at rest. A secundum type atrial septal defect is present. Overall left ventricular systolic function is normal (LVEF>55%). with mild global RV free wall hypokinesis. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2181-10-1**] at 1430hours. Post removal of the drain there was no accumulation of fluid in the pericardial space. . On Discharge: [**2181-10-4**] 06:20AM BLOOD WBC-12.7* RBC-3.16* Hgb-10.0* Hct-30.8* MCV-98 MCH-31.7 MCHC-32.5 RDW-14.2 Plt Ct-283 [**2181-10-4**] 06:20AM BLOOD Plt Ct-283 [**2181-10-4**] 06:20AM BLOOD Glucose-132* UreaN-21* Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-29 AnGap-11 [**2181-10-4**] 06:20AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9 Brief Hospital Course: 67 year old female with a history of atrial fibrillation, COPD/asthma, osteoporosis, glaucoma, hyperlipidemia presented with cardiac tamponade s/p pulmonary vein isolation procedure. . # CARDIAC TAMPONADE: Developed during EP procedure. Paracardiocentesis was performed and drain was put in place. 250cc fluid was drained. Hypotension developed and the patient was supported with phenylephrine. Hematocrit dropped 45-->34.7. Followup Hct??????s were stable. The patient was then extubated and sedation and phenylephrine were weaned. An attempt was made on [**9-30**] to pull peridcardiocentesis drain which was unsuccessful as the drain appeared to be adhesed to pericardium. The drain was then removed [**10-1**] under fluoroscopy in the cath lab, as there was concern that drain had adhered to pericardium. TTE after drain removal showed no reaccumulation of fluid in the pericardial space. The patient's hematocrit continued to be stable and there was no evidence of retroperitoneal bleed. . # RHYTHM: The patient has a history of a-fib refractory to cardioversion and rate control. There is evidence of left atrial tachycardia intermittently. After the pulmonary vein isolation procedure she continued to be tachycardic with variable rate. Amiodarone was loaded and converted to PO. Electrical cardioversion was unsuccessful. She was discharged on Metoprolol 150mg po bid, Amiodarone 600 po qday until [**10-9**] and then 400mg po daily thereafter, Warfarin 2.5mg po qday. She was scheduled to follow up as an outpatient with Dr. [**Last Name (STitle) 52498**] in 2 weeks. . # UTI: positive U/A on [**2095-10-1**] with a low grade temperature but the patient was asymptomatic. E. Coli was found on urine culture. Her Foley catheter was removed. Bactrim was started and will be continued for a 7 day course. . # Left CFA pseudoaneurusm: Found on femoral ultrasound. [**Date Range **] surgery evaluated the patient and an appointment was set up with Dr. [**Last Name (STitle) 3407**] in 2 weeks where a repeat ultrasound will evaluate progression. If the pseudoaneurysm increases to >2 cm, the patient may need a thrombin injection. . # HYPERLIPIDEMIA: Home Simvastatin 20 po qday was continued. . # COPD/Asthma: Home spiriva and albuterol inh were continued. . # Osteoporosis: Home Vitamin D was continued. . # Glaucoma: Home eye drops were continued. . # Conditioning: PT was consulted. The patient progressed to ambulating upon discharge. FEN: Senna, colace and miralax prn were given during admission. . ACCESS: PIV's . CODE: Full . COMM: patient. Medications on Admission: Coumadin 5mg one day and 2.5mg the next day Simvastatin 20mg daily Verapamil 120mg one tablet two times a day Spiriva INH once daily Albuterol INH Q6 hrs PRN Citrical D (Calcium Citrate with Vitamin D) two tablets daily Omega 3 fatty acids one pill four times a day Alendronate 70mg one a week Alphagan one drops in OU twice a day Lumigan eye one drops in each eye every night Cosopt one drops in OU twice a day Eye Cap vitamins two tablets two times a day Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Take 3 tabs daily until [**10-9**], then decrease to 2 tabs daily. Disp:*70 Tablet(s)* Refills:*2* 2. Outpatient Lab Work Please check your INR on Friday [**10-5**] and call results to Dr. [**Last Name (STitle) 13177**] at ([**2181**] 3. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for asthma. 6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic HS (at bedtime). 10. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. packet 12. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal PRN (as needed) as needed for pain. 13. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* 14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Pericardial Effusion Atrial Fibrillation Asthma COPD Discharge Condition: stable Discharge Instructions: You had a pulmonary vein isolation to treat atrial fibrillation and some blood collected around your heart after the procedure requiring a drain. The drain was removed and there is no evidence for reaccumulation of the blood. You were started on amiodarone to control your heart rate and rhythm. You will see Dr. [**Last Name (STitle) 13177**] in 2 weeks to re-evaluate your heart rhythm. Medication changes: 1. START Amiodarone to help your heart rhythm. You will need to have your lungs, thyroid and liver function checked at regular intervals while on this medicine. Your liver function was normal during your hospitalization here. 2. START Metoprolol to lower your heart rate. 3. STOP taking Verapamil 4. START Trimethoprim-Sulfamethoxazole for your urinary tract infection. You will be on this for 6 days. 5. Hold your couamdin until Dr. [**Last Name (STitle) 13177**] tells you to start taking it again. Your INR was 3.4 on [**10-3**]. The amiodarone will make you need less coumadin daily. . Please call Dr. [**Last Name (STitle) 82205**] if you notice any bleeding at the groin sites, any chest pain or trouble breathing, dark stools or vomiting blood, fevers or chills, or any other unusual symptoms. . Your CT scan of your lungs showed some changes that are likely because of decreased lung volumes. You should have another CT scan in 6 months. Followup Instructions: Cardiology: Alexi [**Last Name (STitle) 52498**] [**Street Address(2) 52499**] [**Location (un) 936**], [**Numeric Identifier 78949**] Phone: ([**2181**] Date/time: Thursday [**10-18**] 1:00pm [**Month (only) **]: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2181-10-16**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2181-10-16**] 2:00 Primary Care: [**Last Name (LF) **],[**First Name3 (LF) 177**] Phone: [**Telephone/Fax (1) 79851**] Date/Time: Please keep your previously scheduled appt. . Needs F/[**Location 83208**] opacities throughout the lungs bilaterally, reccomended f/u in 6 months to evalutate

[ "423.0", "041.4", "997.2", "458.29", "599.0", "V58.61", "493.20", "V12.54", "427.31", "998.2", "E879.0", "733.00", "442.3", "423.3", "272.4" ]

icd9cm

[ [ [] ] ]

[ "88.72", "37.27", "37.28", "99.62", "37.0", "97.49", "37.34" ]

icd9pcs

[ [ [] ] ]

9702, 9753

5113, 7669

389, 416

9850, 9859

2939, 2939

11264, 12010

2022, 2099

8176, 9679

9774, 9829

7695, 8153

9883, 10272

2114, 2920

1509, 1550

4774, 5090

10292, 11241

276, 351

444, 1429

2953, 4760

1581, 1781

1451, 1489

1797, 2006

21,187

118,827

45500+45501+45502

Discharge summary

report+report+report

Admission Date: [**2107-10-8**] Discharge Date: [**2107-11-2**] Service: MED ICU Please note that this is a discharge summary for patient [**Known firstname 42907**] [**Known lastname **] from date of admission on [**2107-10-8**], until today, [**2107-10-26**]. The Discharge Summary will be continued by the Team that will be following Ms. [**Known lastname **] after today. CHIEF COMPLAINT: Status post fall, unresponsiveness, seizure times one. HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known firstname 42907**] [**Known lastname **] is a pleasant 88 year old female with a past medical history significant for polio and hypertension and is status post multiple falls, who was found on the floor of her nursing home around 07:15 on [**2107-10-8**]. She was found by the nursing home staff and EMS was called right away who came and placed a cervical collar to stabilize her spine. At that time, the patient was somewhat awake and responsive to verbal stimuli and en route to the hospital, the patient developed a seizure that lasted for about 40 seconds. It was described as a general tonic/clonic seizure and she was given 2 mg of Ativan. In addition, at that time, the fingerstick blood sugar was 140. When the patient arrived to the Emergency Room, the patient was intubated for airway protection. The patient received Etomotide and Succinylcholine to help with the intubation. The patient was admitted to the Medical Intensive Care Unit for further evaluation and work-up. PAST MEDICAL HISTORY: 1. Hypertension. 2. Depression. 3. Polio. 4. Status post multiple falls. 5. Urinary tract infection. 6. Pancreatitis. 7. Chronic anemia. 8. Right lower extremity cellulitis. MEDICATIONS ON ADMISSION: 1. Zestril 10 mg p.o. q. day. 2. Lopressor 12.5 mg p.o. q. day. 3. Prevacid 30 mg p.o. q. day. 4. Multivitamin one tablet p.o. q. day. 5. Tylenol as needed. 6. Maalox. 7. Subcutaneous heparin 5000 units twice a day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has no known history of alcohol or tobacco use. The patient is currently a nursing home resident. PHYSICAL EXAMINATION: On admission, in general, the patient is intubated and sedated; responds to noxious stimuli, elderly, fragile. HEENT: Pupils 3 to 4 mm; minimally responsive to light. Dry mucous membranes. Neck supple; no lymphadenopathy; no jugular venous distention noted. Lungs clear to auscultation bilaterally. Heart: S1, S2, tachycardic, Grade II/VI mid-systolic murmur heard at the apex, radiating towards the axilla. Abdomen soft, nondistended, nontender; decreased bowel sounds. Extremities: One to two plus pitting edema, right lower extremity. Neurologic: Intubated and sedated. LABORATORY: On admission, sodium 125, potassium 5.3, chloride 89, bicarbonate 16, BUN 22, creatinine 0.8, glucose 140, white count 17.7, hematocrit 40.4, hemoglobin 14.3, platelets 328. CK 163, CK MB 12, MBI 7.4, troponin I less than 0.3. ALT 29, AST 47, alkaline phosphatase 423, amylase 244, lipase 54, albumin 4.1, total bilirubin 0.9. PT 13.0, PTT 34.6, INR 1.3. Blood cultures and urine cultures were obtained which were both pending. Urinalysis with small blood, no nitrites, no ketones, no leukocyte esterase, protein 300, glucose negative, bilirubin negative, 3 to 5 epithelial cells, 3 to 5 white blood cells, zero to 2 red blood cells and many bacteria. EKG on admission is sinus tachycardia at 100 to 110s, normal sinus rhythm, normal axis and intervals. Left ventricular hypertrophy by voltage criteria; no ST changes. No changes when compared to the previous EKG. CT scan of the head without contrast is no intracranial hemorrhage; slight asymmetry in white matter but unable to compare because of motion artifact in prior CT scan. Increased density of left middle cerebral artery. MRI/MRA, no signs of hemorrhage or stroke. HOSPITAL COURSE: Please note that this hospital course is from [**10-8**] until [**10-26**]. It will be continued by the next team who is picking up Ms. [**Known firstname 42907**] [**Known lastname **]. 1. PULMONARY/RESPIRATORY: The patient was initially intubated for airway protection status post generalized tonic/clonic seizure. There was no other indication for her to remain intubated and so the patient was extubated on [**2107-10-10**]. She did well for the first few hours, but then became tachypneic, tachycardic, and her O2 saturation fell to the mid to low 80%, and so she was intubated again secondary to respiratory distress/failure. On her initial intubation, the patient was set at assist control but then it was later switched to pressure support and the patient tolerated pressure support of 15 and 12 along with PEEP of 5, FIO2 of 30 to 35%, however, would not tolerate pressure support of 10 for more than two to three hours. Multiple attempts were made to try to wean her from her mechanical ventilation and her RSBI were actually found to be over 200. At that time it was concluded that the failure for us to wean her mechanical ventilation or extubate was probably secondary to a combination of volume overload and post-polio syndrome. Since nothing much could be done about the post-polio syndrome, we thought we would aggressively diurese the patient to help reduce the volume overload and maybe help her in her extubation. Multiple RSBI were obtained from [**10-10**] until [**10-26**], and she had failed all of them. At that time, the option was brought up with the two nieces, [**Doctor First Name **] and [**Doctor First Name **] ([**Doctor First Name **] is the health care proxy), that if the patient was to be extubated and would fail extubation what would be the two possible options: One option would be for the patient to undergo a tracheostomy and a PEG, and the other option would be if patient failed extubation, whether we are going to reintubate her or not or whether we would just make her comfortable. At that time, it was decided by the family that the patient will be "DO NOT RESUSCITATE" "DO NOT INTUBATE" and we were going to extubate the patient. If the patient was to fail extubation, we would not reintubate her and that they would not go ahead and do the tracheostomy or the PEG. If the patient was to fail extubation then the patient will be made comfortable. The patient was extubated on [**2107-10-26**], at 10 in the morning as per the family's request. The patient tolerated extubation well. At the time of this dictation, the patient's O2 saturation is running anywhere between 96 to 99% on two liters of oxygen through nasal cannula and the patient is breathing at a rate of anywhere between 20 to 28. 2. CARDIOLOGY: 1) Rate/Rhythm: The patient had an episode of atrial fibrillation and atrial flutter in the Medical Intensive Care Unit and failed to respond to Lopressor 5 mg times two intravenously. As a result, the patient was given 10 mg of Diltiazem and the patient's rate was well controlled with that calcium channel blocker. In the next day or two, the patient came back into sinus rhythm on her own. An echocardiogram was also obtained which showed an ejection fraction between 50 to 55% and a moderate to severe mitral regurgitation but no thrombus was noted. Given the fact that the patient has a history of multiple risks of falls and the age of the patient, it was then decided that the best way to anti-coagulate her would probably be to start her on aspirin. As a result, aspirin 325 mg p.o. q. day was started and the patient was restarted back on the Lopressor at 12.5 mg p.o. twice a day as per her outpatient dose. This was later titrated upwards to 50 mg three times a day at the time of this dictation. In addition, we also decided to start the patient on Captopril. The patient was initially started off at 6.25 mg p.o. three times a day and this was titrated up and the patient is currently getting 25 mg p.o. three times a day. The patient would occasionally have premature atrial contractions and premature ventricular contractions but would be asymptomatic and not hypotensive, so we will be checking and repeating the electrolytes as needed. In addition, the patient had a couple of episodes in which her blood pressure was in the 200s. She would receive either Lopressor intravenous 5 mg or she received a one time dose of Hydralazine 10 mg and that would help stabilize her blood pressure. 2) Ischemia - no ischemic signs of changes noted on EKG. 3) Pump - no signs of congestive heart failure. 2. NEUROLOGIC: The patient is status post a generalized tonic/clonic seizure. Neurology was consulted who recommended that the patient be started on Dilantin. The patient was initially started on 300 mg p.o. q. day but after three doses a Dilantin level was obtained which was found to be elevated. As per Neurology recommendation, her Dilantin dose was decreased to 250 mg p.o. q. day. After three doses, another Dilantin level was checked which also was elevated and so her Dilantin level is currently at 150 mg p.o. q. day. Her free Dilantin level is 2.0, normal range being 1.0 to 2.0 and her regular Dilantin level is 6.8, and for someone who is this small, it is considered to be relatively normal. The patient is to continue the Dilantin 150 mg p.o. q. day for 30 days as per Neurology recommendation. 3. INFECTIOUS DISEASE: Since the patient had a seizure and was intubated for airway protection, the patient was started on Levofloxacin and Flagyl for aspiration pneumonia for ten days. In addition, the patient also received Ampicillin 500 mg q. six hours for seven days for growing enterococcus in her urine. On [**10-25**], the patient was also started on Vancomycin one gram q. 24 for Methicillin resistant Staphylococcus aureus in her sputum culture. 4. HEMATOLOGY: The patient's hematocrit had been gradually declining. On [**10-18**], the patient received 2 units of packed red blood cells and her hematocrit had increased to 44. Since then it has been declining once again and on the day of this discharge, her hematocrit was 37.8. Guaiac stool was obtained which was found to be positive. Gastrointestinal was curbside who noted that there was no need to do any further work-up at this point since patient is intubated and in Intensive Care Unit. If the patient is to be transferred to the Floor, then GI would work her up. 5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was initially hyponatremic which was thought to be a possible cause of her seizure. The patient was started on intravenous fluids of normal saline at 75 cc per hour as it was found that the patient was hyperosmolar, hypovolemic, hyponatremic. Her sodium had gradually improved in the next two to three days. Over time, the patient would occasionally become hypotensive and cross-cover would give her intravenous fluid boluses, and the patient because significantly volume overloaded with as much as positive nine liters. Hence, the patient was started on a Lasix drip to diurese the patient which was also thought to help her with her volume overload and possibly help her with her extubation. In addition, the patient was also receiving tube feeds through her OG tube, as per Nutrition recommendations, and the patient's electrolytes were usually checked twice a day since she was on a Lasix drip and her electrolytes were repleted as needed. 6. TUBES, LINES AND DRAINS: The patient has a PICC line; the patient has a Foley catheter. 7. CONTACT: [**Name (NI) **] Health Care Proxy is [**Name2 (NI) **], phone number [**Telephone/Fax (1) 97081**] home, [**Telephone/Fax (1) 97082**] cell. 8. PROPHYLAXIS: The patient is on subcutaneous heparin and proton pump inhibitor. 9. CODE: The patient is "DO NOT RESUSCITATE" "DO NOT INTUBATE". MEDICATIONS AT THE TIME OF DICTATION: 1. Protonix 40 mg intravenous q. day. 2. Heparin 5000 units subcutaneously twice a day. 3. Captopril 25 mg p.o. three times a day. 4. Aspirin 325 mg p.o. q. day. 5. Dilantin 150 mg p.o. q. day. 6. Metoprolol 50 mg p.o. three times a day. 7. Vancomycin one gram intravenous q. 24. 8. Miconazole Powder 2%, apply four times a day p.r.n. to affected area. This Discharge Summary describes the hospital course of [**First Name8 (NamePattern2) **] [**Known firstname 42907**] [**Known lastname **] from [**10-8**] until [**10-26**]. The rest of the Discharge Summary will be completed by the team that will be continuing the care of [**First Name8 (NamePattern2) **] [**Known firstname 42907**] [**Known lastname **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2107-10-26**] 14:13 T: [**2107-10-26**] 16:52 JOB#: [**Job Number **] Admission Date: [**2107-10-8**] Discharge Date: [**2107-11-2**] Service: DISCHARGE DIAGNOSES: 1. Seizure disorder. 2. Pneumonia. 3. Hypertension. 4. Depression. 5. Polio. 6. Urinary tract infection. 7. Chronic anemia. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Discharged to nursing home, [**Hospital 100**] Rehab Facility. FOLLOW UP: Patient will follow up with her primary doctor. Most recent labs on [**11-1**] at 4:37 PM showed a white count of 10.8, hematocrit 36.9, platelets 287,000. Her Chem-7 was within normal limits. She will need a Dilantin level taken upon arrival or tomorrow. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 6834**] MEDQUIST36 D: [**2107-11-2**] 12:39 T: [**2107-11-2**] 12:59 JOB#: [**Job Number 97083**] Admission Date: [**2107-10-8**] Discharge Date: [**2107-11-2**] Service: Medicine ADDENDUM: 1. Pulmonary/respiratory: The patient was admitted to the floor and completed a course of vancomycin for pneumonia with Methicillin resistant Staphylococcus aureus positive swabs in her nares. On discharge, she was saturating 95% to 98% in room air. She is tachypneic at baseline due to her kyphotic lung restriction. 2. Cardiovascular: The patient was periodically tachycardiac on the floor, which was fluid responsive. She was not tachycardia in the final days of her admission. She was hypertensive at times during her admission and her atenolol was increased to 25 mg with good blood pressure control. 3. Neurologic: The patient was status post generalized tonic-clonic seizure. The plan was to have her on Dilantin until [**2107-11-7**] at 150 mg daily, although she was subtherapeutic on this dose and, on the day prior to discharge, the dose was upped to 200 mg daily. The patient will need a free Dilantin level taken tomorrow since her albumin is low. 4. Infectious disease: The patient has completed a ten day course of vancomycin for pneumonia with Methicillin resistant Staphylococcus aureus in sputum culture. 5. Hematology: The patient's hematocrit was stable when she left the floor. 6. Fluids, electrolytes and nutrition: The patient initially failed her swallow evaluation after her extubation. Upon re-evaluation, the patient was found to aspirate thin but to be safe for thickened liquids. The patient should get thickened pureed foods and should get a one-to-one sitter, but she was taking orals at the time of discharge. 7. Tubes, lines and drains: The patient had a left midline placed which was discontinued two days prior to discharge since she had erythema in the area and her right peripheral was taken. 8. Prophylaxis: The patient was continued on subcutaneous heparin and proton pump inhibitor. 9. Code status: The patient remained "Do Not Resuscitate", "Do Not Intubate". DISCHARGE MEDICATIONS: Atenolol 25 mg p.o.q.d. Dilantin 200 mg p.o.q.d. Lisinopril 10 mg p.o.q.d. Prevacid 30 mg p.o.q.d. Multivitamins one p.o.q.d. Tylenol 650 mg p.o.q.4-6h.p.r.n. Heparin 5,000 units s.c.b.i.d. Miconazole powder 2% apply b.i.d.p.r.n. to affected areas. DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766 Dictated By:[**Last Name (NamePattern1) 6834**] MEDQUIST36 D: [**2107-11-2**] 12:36 T: [**2107-11-2**] 12:49 JOB#: [**Job Number 36960**]

[ "138", "427.31", "518.82", "276.1", "276.6", "599.0", "482.41", "780.39", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "38.93", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

12945, 13077

15801, 16289

1758, 2021

3927, 12924

13204, 15778

2173, 3909

408, 464

493, 1527

1549, 1732

2038, 2150

13102, 13192

13,948

133,127

15430

Discharge summary

report

Admission Date: [**2121-9-19**] Discharge Date: [**2121-9-25**] Date of Birth: [**2089-2-18**] Sex: M Service: MEDICINE Allergies: Amiodarone Attending:[**First Name3 (LF) 425**] Chief Complaint: Atrial fibrillation w/ RVR, VT s/p ICD firing, SDH Major Surgical or Invasive Procedure: None History of Present Illness: 32yoM with h/o dilated cardiomyopathy (EF 20%) s/p ICD placement [**3-/2119**], chronic a. fib on coumadin who initially presented to [**Hospital **] hospital on [**2121-9-12**] after having had a syncopal event. He does not remember much about the event, he has had presyncopal episodes associated with postural change in the past, but has never actually fallen until now. He does not remember if their was a prodrome associated with this event. He was found to have a SDH secondary to hitting his head with this syncopal event, he was then transferred to [**Hospital1 112**] for further care. His ICD was interrogated and revealed VT as etiology of his syncope. During his hospitalization at [**Hospital1 112**], he had two generalized ?tonic clonic seizures and was started on dilantin. His neuro status remained stable without furher seizures and he was discharged directly to Dr.[**Name (NI) 1565**] device clinic on [**2121-9-19**]. There, he was noted to be in a. fib with RVR. He additionally was complaining of headache at that time so he was referred to our ED for head imaging and improved rate control for his a. fib. . Initial imaging upon presentation to our ED revealed a right-sided subdural hematoma measuring up to 8 mm causing effacement of right cerebral sulci, right lateral ventricle, with 5-mm shift of midline structures, right inferior frontal lobe parenchymal hemorrhage with surrounding edema, and left occipital lobe encephalomalacia, compatible with prior infarct. He was admitted to the CCU with neurosurgery as the primary team. Imaging was obtained from [**Hospital1 112**] and CT head is stable in appearance from his admission there. Additionally, repeat head CT yesterday ([**2121-9-20**]) is stable. His head pain is currently improving but somewhat variable. . Of note, he was recently admitted at this facility for a CHF exacerbation ([**2121-9-3**]) in setting of medication non-adherence and increased fluid intake and was d/c'd on [**2121-9-4**] following diuresis. . He was then called out to the cardiology service for uptitration of his rate control for atrial fibrillation. He is occassionally symptomatic from his atrial fibrillation and feels fast heart rate/palpitations. He has not noted that these sensations have worsened or gotten more frequent over the past few weeks. Past Medical History: 1. Severe idiopathic cardiomyopathy - s/p ICD placement [**3-/2119**] - Echo ([**8-1**]) showed EF 20% 2. Atrial fibrillation on coumadin s/p CVA 3. Amiodarone-induced hyperthyroidism s/p prednisone and methimazole-->hypothyroidism 4. CVA [**3-29**]: Presented with mild right hemiparesis and mild ataxia. MRI at OSH shows left PCA stroke. Per pt still has residual Right sided weakness (patient is somewhat unclear about this) 5. Osteoporosis 6. S/P knee surgery . Social History: Portuguese speaker, moved from [**Country 4194**] in [**2113**]. Lives with wife and two young children. Pt does NOT work. Used to have job as dishwasher but was only employed one day per week and the restaurant closed so currently unemployed. Wife works at [**Company 44769**] and this is the only income source for the family. Pt is primary child caretaker. Denies tobacco, occ EtOH. Family History: Father with "[**Last Name **] problem" at age 52; mother with "[**Last Name **] problem" at age 25. Physical Exam: VS - 98.9 104/63(98-116/57-73) 108(78-108) 18 96%RA Gen: WDWN young male lying in bed 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 of 5 cm. 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. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. Ext: No c/c/e. Skin: + mild stasis dermatitis but no ulcers, scars, or xanthomas. Neuro: A+Ox3. CNII-XII intact, muscle strength 5/5 in biceps, triceps, grip, hip flexors, foot dorsi/plantar flexors, toe dorsi/plantar flexors. 1+ DTR at [**Name2 (NI) 15219**] on right, unable to elicit on left. toes downgoing bilaterally. Pertinent Results: [**2121-9-19**] 05:00PM BLOOD WBC-11.5* RBC-5.12 Hgb-15.2 Hct-44.8 MCV-87 MCH-29.7 MCHC-34.0 RDW-17.2* Plt Ct-284 [**2121-9-22**] 05:30AM BLOOD WBC-8.7 RBC-4.55* Hgb-13.4* Hct-39.8* MCV-88 MCH-29.4 MCHC-33.6 RDW-17.0* Plt Ct-307 [**2121-9-24**] 06:05AM BLOOD WBC-9.2 RBC-4.57* Hgb-13.7* Hct-40.6 MCV-89 MCH-30.0 MCHC-33.8 RDW-16.8* Plt Ct-302 [**2121-9-19**] 05:00PM BLOOD Neuts-76.4* Lymphs-16.9* Monos-3.9 Eos-2.7 Baso-0.2 [**2121-9-20**] 05:55AM BLOOD PT-13.4* PTT-27.2 INR(PT)-1.2* [**2121-9-20**] 05:55AM BLOOD Calcium-9.6 Phos-4.4# Mg-2.5 [**2121-9-21**] 06:47AM BLOOD Digoxin-0.5* [**2121-9-22**] 05:30AM BLOOD Digoxin-0.6* [**2121-9-23**] 05:35AM BLOOD Digoxin-0.6* [**2121-9-20**] 05:55AM BLOOD Phenyto-1.7* [**2121-9-21**] 07:07PM BLOOD Phenyto-7.4* [**2121-9-22**] 05:30AM BLOOD Phenyto-5.4* [**2121-9-23**] 05:35AM BLOOD Phenyto-3.3* [**2121-9-24**] 12:45PM BLOOD Phenyto-10.1 [**2121-9-20**] 05:55AM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-136 K-4.6 Cl-98 HCO3-30 AnGap-13 [**2121-9-24**] 06:05AM BLOOD Glucose-101 UreaN-16 Creat-0.9 Na-139 K-4.6 Cl-102 HCO3-25 AnGap-17 . PA AND LATERAL RADIOGRAPHS OF THE CHEST: Single chamber pacemaker is in unchanged position, with lead projecting over the right ventricle. Moderate to severe cardiomegaly is unchanged. The lungs remain clear, with no focal consolidation or edema. There is no effusion or pneumothorax. Old right rib fractures are noted. IMPRESSION: Persistent moderate to severe cardiomegaly. No acute cardiopulmonary process . .Non-contrast head CT ([**9-19**]). There is a 1.9 x 1.8 cm intraparenchymal hemorrhage in the right inferior frontal lobe with surrounding edema. Additionally, there is a subdural hematoma (maximally 8mm) along the right cerebral hemisphere with resultant effacement of the right cerebral sulci and effacement of the right lateral ventricle causing subfalcine herniation and approximately 5 mm of shift of midline structures. There is no evidence of uncal herniation. Basilar cisterns are patent. Encephalomalacia in the left occipital lobe is noted, which is related to prior infarct which was demonstrated on prior CTs. The calvarium appears intact. The mastoid air cells, middle ear cavities, and paranasal sinuses are clear. Orbits appear unremarkable, though incompletely imaged. IMPRESSION: 1. Right-sided subdural hematoma measuring up to 8 mm causing effacement of right cerebral sulci, right lateral ventricle, with 5-mm shift of midline structures. 2. Right inferior frontal lobe parenchymal hemorrhage with surrounding edema. 3. Left occipital lobe encephalomalacia, compatible with prior infarct. 4. Motion limits evaluation. . Repeat head CT [**9-20**]: IMPRESSION: Unchanged appearance of right frontal intraparenchymal hemorrhage and subdural hematoma along the right convexity. The extent of mass effect and sulcal effacement is unchanged from [**2121-9-19**]. . Lower extremity non-invasives [**2121-9-25**] FINDINGS: Doppler waveform analysis reveals a triphasic waveform at the right common femoral artery. There are monophasic waveforms at the right popliteal and posterior tibial. The right dorsalis pedis is absent. The right ABI is 0.76. The right toe pressure is 43 with a toe brachial index of 0.43. On the left there are triphasic waveforms at the common femoral, popliteal, posterior tibial and dorsalis pedis. The ABI is 1.0, the toe pressure is 68 with a toe brachial index of 0.68. Pulse volume recordings show significantly dampened waveform in the right thigh. There is additional dampening at the level of the metatarsal and less than 5 mm of deflection at the metatarsal and digital level. In the left lower extremity there are essentially normal waveforms throughout. IMPRESSION: Normal left lower extremity arterial study at rest. Significant right SFA and tibial disease. Brief Hospital Course: A/P 32yoM with idiopathic chronic systolic CHF (EF20%), type II amiodarone-induced thyroid toxicity (now hypothyroid), s/p AICD placement for ventricular arrhythmia and atrial fibrilation with h/o CVA previously on coumadin now stopped for SAH s/p fall, who presented with afib with RVR. . #. Pump systolic CHF with EF20%. as an outpatient, Mr. [**Known lastname **] was on 120mg of furosemide [**Hospital1 **], however he was discharged from [**Hospital1 **] on 40mg [**Hospital1 **]. He seemed euvolemic on this regimen, however given recent admission to [**Hospital1 18**] for CHF exacerbation and possibility of dietary noncompliance (patient's wife reports he eats salty foods) his lasix dose was increased to 80mg [**Hospital1 **] with close followup with his [**Hospital1 3390**] and with Dr. [**First Name (STitle) 437**] his heart failure specialist. He was continued on a good heart failure medical regimen including a beta-blocker, ace-inhibitor, furosemide, and spironolactone. . #. Rhythm Patient has chronic atrial fibrillation which has been difficult to rate control now on three agents (metoprolol, diltiazem, and digoxin). He remained in atrial fibrillation throughout hospitalization. He was admitted on 200mg of Toprol XL TID, a dose which was confirmed with his cardiologist. This was continued. Diltiazem increased from 180mg to 240mg extended release. Digoxin continued. On discharge, his heart rate generally <100bpm, but did increase with activity. Once amiodarone is restarted he will hopefully achieve better rate control. . Coumadin held given recent SDH, patient discharged with followup at [**Hospital1 112**] to discuss when he may restart coumadin. We communicated with the office of Dr. [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) **] to advise of the need for good coordination of anticoagulation for Mr. [**Known lastname **]. . For ventricular arrhythmia which likely caused syncope, patient needs to be restarted on amiodarone. He has had amiodarone-induced hyperthyroidism in past, however and repeat episode causing tachycardia would be deleterious for this patient with tenuous cardiac function. Endocrinology was consulted to comment on risk of recurrent hyperthyroidism. They were unable to rule out the possibility of recurrent hyperthyroidism. They did feel he could be monitored closely should amiodarone need to be restarted. Alternatively he could have chemical ablation or surgical removal of the thyroid. Final decision regarding management of thyroid dysfunction was left to the outpatient setting and patient was scheduled for endocrinology followup. Given need for possibly thyroidectomy, general surgery was consulted during hospitalization. If his outpatient doctors feel [**Name5 (PTitle) **] [**Name5 (PTitle) **] thyroidectomy he will be sent to see Dr. [**Last Name (STitle) **] who saw him as an inpatient. . #. SDH: Patient sustained SDH post-syncope per [**Hospital1 112**] reports. He was discharged by the [**Hospital1 112**] neurosurgical service on phenytoin. At [**Hospital1 18**], phenytoin level was subtherapeutic. Phenytoin loaded intravenously on two occassions to help achieve therapeutic level. Per discussion with [**Hospital1 18**] neurosurgery he should receive phenytoin for a total of 10 days. Neurologic exam remained non-focal throughout admission. Patient seemed intermittently sleepy which was concerning, however neurosurgery felt this was to be expected. Patient also had increasing head pain which did not have any concerning CNS findings. Neurosurgery felt that pain in the absence of new neurologic deficits was to be excpected post-fall. Given headache and SDH, monitored closely for neurologic deficits - although oat one point seemed more sleepy, pateient denied this and neuro exam remained nonfocal. Phenytoin loaded may account for sleepiness and cognitive slowing and will hopefully improve once dilantin discontinued. Coumadin held at least until followup with Dr. [**Last Name (STitle) **] at [**Hospital1 112**] Mental status was worse than patient's baseline, although wife reveals that he was somnolent during day even before bleed. one possibility is OSA causing daytime somnolence as patient's wife notes that he snores. SDH also likely impairing cognitive function as is phenytoin. When phenytoin is stopped, hopefully mental status will improve. Patient provided short course of oral morphine for head pain if needed. Have contact[**Name (NI) **] patient's [**Name (NI) 3390**] to consider OSA evaluation if sleepiness does not improve off phenytoin. . #. Hypothyroidism: s/p methimazole and prednisone for type II amiodarone induced hyperthyroidism, likely type II per endocrinology and given that patient developed hypothyroidism. Initially it was unclear hence patient treated with methimazole and prednisone. (Type I is iodine-induced increased thyroid production and Type II is amiodarone-induced thyroid destruction causing transient hyperthyroidism followed by hypothyroidism). Hyperthyroidism was likely contributing to rapid heart rate, and if patient were to become hyperthyroid again a tachyarrhythmia-induced cardiomyopathy could ensure. Levothyroxine continued at home dose initially. He recently had thyroid function tests which showed TSH/t4 normal (t4 high normal) so levothyroxine reduced from 88mcg to 75mcg daily As above, surgery consulted for possible thyroidectomy. If necessary, they would prefer to wait until SDH resolved. Patient should be off coumadin anticoagulation prior to this procedure as bleeding is a major risk of thyroid surgery. This issue is to be decided in followup. . # [**Name (NI) **] foot One day prior to discharge patient noted right foot pain and inner thigh pain. This was new for the patient and on exam the right lower extremity was relatively [**Name2 (NI) **] and had diminished pedal pulses by doppler. Given concern for embolic event in this patient with atrial fibrillation off anticoagulation, vascular surgery consult called who felt pulses were symmetrically diminished suggesting an element of chronic vascular disease. They did not find evidence for acute limb ischemia. They recommended arterial noninvasives which were performed in house and showed significant right SFA and tibila disease but normal left lower extremity arterial supply. Pain had resolved by the time the consultants saw patient and did not return. Patient scheduled to see Dr. [**Last Name (STitle) **] of vascular surgery as an outpatient. . #. Osteoporosis: Continued vitamin D/calcium . # Social Patient has significant social barriers to care including immigration status, a language barrier, a young child at home, and a wife who is busy at work while patient cannot work. He has complicated medical issues however he will be unable to overcome these issues without further social support. Case management was able to arrange a few free visits from a VNA in [**Location (un) **] who may be able to set patient up with resources for portuguese speakers in [**Location (un) **]. Social work consulted who gave patient information on [**State 350**] Alliance for Portuguese Speakers who may be able to help with immigration issues. Patient applied and qualified for free care so all medications including Toprol XL and levothyroxine will be covered. (in past patient had difficulty paying for the latter). Social work, nursing, case management, and medical team met with wife and patient to discuss coordination of his care in the future. She seemed to understand complexity of his medical issues and was hopeful that above resources could ease some of the difficulty of caring for him given the need for her to work. She will also need continued support in followup and hopefully will be able to be more engaged in his healthcare in the future. Medications on Admission: 1. Aspirin 325 mg daily 2. Warfarin 2.5 mg two tabs on monday, wednesday, and friday; three tabs on tuesday, thursday, saturday, sunday (held since [**Hospital1 112**] visit) 3. Lisinopril 10 mg daily 4. Metoprolol Succinate 200 mg TID (confirmed with cardiologist) 5. Diltiazem HCl 180 mg daily 6. Digoxin 125 mcg daily 7. Furosemide 120 mg [**Hospital1 **] (changed at [**Hospital1 112**] to 40mg PO bid) 8. Spironolactone 25 mg daily 9. Levothyroxine 88 mcg daily 10. Pantoprazole 40 mg daily 11. Potassium Chloride 10 mEq daily . [**Hospital1 112**] added phenytoin 200mg PO bid Discharge Medications: 1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. Disp:*120 Tablet(s)* Refills:*2* 7. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO three times a day: dosing confirmed with cardiology. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while using morphine for pain. Disp:*60 Capsule(s)* Refills:*2* 10. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) for 4 days. Disp:*24 Capsule(s)* Refills:*0* 12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Furosemide 80 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 **] Home Health Care Discharge Diagnosis: Primary: Atrial Fibrillation Subdural Hematoma Amiodarone-induced Thyroid Toxicity Chronic Systolic Congestive Heart Failure . Secondary Idiopathic cardiomyopathy Discharge Condition: Stable. heart rate 80s-100. Ambulating unassisted. Discharge Instructions: You were admitted for a rapid heart rate and we increased one of your medications, diltiazem, to help control this rapid heart rate. You were also seen for the bleeding in the brain which you sustained before coming to [**Hospital1 756**] [**Hospital5 **] [**Hospital6 44770**] Hospital. The neurosurgery team felt that this was stable and thought you should followup at [**Hospital6 **] with Dr. [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) **] (see below). Dr.[**Name (NI) 4213**] office will talk to your heart doctor Dr. [**Last Name (STitle) **] to help decide when you should restart coumadin (blood thinning medication) . You made need a medication or a surgery for your thyroid gland to prevent toxicity from a medication called amiodarone that you need to be on. Please followup with Dr. [**Last Name (STitle) 13059**] of endocrinology below. . You had right leg pain which we think might be due to poor circulation. you were evaluated by a vascular surgeon who did not feel this was due to a clot in the leg. Please followup with Dr. [**Last Name (STitle) **] of vascular surgery as below. . For your heart you have heart doctors. One is Dr. [**First Name (STitle) 437**] who deals with the function of the heart and the other is Dr. [**Last Name (STitle) **] who deals with the heart rhythm. You have an appointment with Dr. [**First Name (STitle) 437**] (see below). Dr.[**Name (NI) 1565**] nurse [**First Name9 (NamePattern2) 3525**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will contact you regarding a followup appointment. . For your congestive heart failure: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L. Please speak with Dr. [**First Name (STitle) 437**] about your dose of Lasix when you see him next week. Medication changes: Increased diltiazem dose to 240mg extended release Changed furosemide to 80mg twice daily (please ask Dr. [**First Name (STitle) 437**] what dose he would like you to be on) Started phenytoin which you should continue for 4 more days. Reduced dose of levothyroxine to 75mcg Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2121-9-29**] 2:00 [**Location (un) 8661**] building ([**Hospital Ward Name **]) [**Location (un) 436**]. Primary Care Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2121-10-10**] 2:00 Atrium Suite (ground floor of the [**Hospital Ward Name **] building) Endocrinology Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2121-10-20**] 9:00 [**Hospital Ward Name 23**] building ([**Hospital Ward Name **]) [**Location (un) 436**]. [**Hospital1 112**] Neurosurgery: please followup on [**10-6**], at 12pm in the Neurosurgery department. The office is on the [**Location (un) **] of the ambulatory building, [**Last Name (NamePattern1) **]. Please call [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 44771**] at [**Telephone/Fax (1) 44772**] beeper [**Numeric Identifier 44773**]. Please bring the CD copies of your head CT scans with you to the appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Dr.[**Name (NI) 1565**] office will call you to schedule followup with Dr. [**Last Name (STitle) **] and to discuss when you should restart coumadin. For your foot pain, please see Dr. [**Last Name (STitle) **] of vascular surgery. we have scheduled you at 3pm on [**11-13**]. The office is located at [**Last Name (NamePattern1) **], [**Location (un) 442**] [**Hospital Unit Name **]. Phone number is ([**Telephone/Fax (1) 8343**].

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Discharge summary

report

Admission Date: [**2163-12-8**] Discharge Date: [**2163-12-14**] Date of Birth: [**2105-4-26**] Sex: F Service: NEUROLOGY Allergies: Demerol Attending:[**Doctor Last Name 15044**] Chief Complaint: Seizures Major Surgical or Invasive Procedure: EEG History of Present Illness: Mrs. [**Known lastname 916**] is a 58 yo woman with a history of a Left parietal IPH in [**2163-3-19**] after presenting with expressive aphasia and R arm weakness. There was some concern that the sentinel event was a seizure so at that time she was started on Keppra 750 mg [**Hospital1 **]. A CTA showed an AVM with some filling from a Left MCA branch. She underwent embolization on [**2163-4-15**]. The embolization was successful, however a left branch MCA clot was noted during the procedure and was placed on ASA 81mg. She had done well and was tapered off Keppra. On [**2162-12-7**] she had told her husband that her right arm felt weird like the time when she first presented with the IPH. EMS was called and she was transported to an OSH. She was verbal at that time with some R arm weakness and a "word salad". A ct of the head was being completed and a right sided seizure was noted but still verbal. 500mg of keppra was given along with 2 mg ativan and then transferred here for further care. Here she has been non-verbal and not following commands.her eyes were open and reports from the ED physician is that she initially had right eye deviation. Past Medical History: - pneumonia - 2 years ago - Right shoulder pain s/p repair of some kind Social History: - former nurse - married for 35 yrs with two children - lives in [**Location 8641**] Family History: - negative for known vascular diseases, stroke, seizure - bone cancer (father) Physical Exam: GENERAL: Pleasant middle-aged woman, no distress. HEENT: Atraumatic, normocephalic. NECK: Supple without bruits. CHEST: Clear. CVS: S1, S2 normal. No murmurs. ABDOMEN: Soft, nontender. EXTREMITIES: No edema or erythema. Peripheral pulses palpable. NEUROLOGICAL: Awake, alert and oriented to person, unable to name the date, or place.. Speech is fluent, paraphrasis errors at times. Naming is intact apart for occasional paraphasic errors with low-frequency objects. CN:Pupils symmetric and reactive to light. Bilateral INO appreciated on exam. Disk margins are sharp. Field testing reveals full visual fields. Full eye movements. Normal facial sensation bilaterally. Face is symmetrical. Hearing intact bilaterally. Palate symmetrically upgoing. Tongue is midline. Motor Examination: No drift. Normal strength and tone in all four extremities. DTR: Deep tendon reflexes at +3 throughout and symmetric and toes are down. Sensory examination is intact to light touch, pinprick bilaterally. No finger-to-nose dysmetria. Gait is normal. Pertinent Results: [**2163-12-8**] 05:30AM GLUCOSE-143* UREA N-13 CREAT-0.8 SODIUM-135 POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16 [**2163-12-8**] 05:30AM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-2.0 [**2163-12-8**] 05:30AM TSH-1.7 [**2163-12-8**] 05:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2163-12-8**] 05:30AM WBC-13.6* RBC-4.96 HGB-14.2 HCT-43.9 MCV-89 MCH-28.6 MCHC-32.3 RDW-13.7 [**2163-12-8**] 05:30AM PLT COUNT-434 [**2163-12-8**] 12:20AM COMMENTS-GREEN TOP [**2163-12-8**] 12:20AM GLUCOSE-141* LACTATE-2.0 NA+-138 K+-4.6 CL--100 TCO2-26 [**2163-12-8**] 12:18AM UREA N-17 CREAT-0.9 [**2163-12-8**] 12:18AM estGFR-Using this [**2163-12-8**] 12:18AM cTropnT-<0.01 [**2163-12-8**] 12:18AM URINE HOURS-RANDOM [**2163-12-8**] 12:18AM URINE GR HOLD-HOLD [**2163-12-8**] 12:18AM WBC-13.3*# RBC-4.75 HGB-13.8 HCT-41.3 MCV-87 MCH-28.9 MCHC-33.3 RDW-13.9 [**2163-12-8**] 12:18AM NEUTS-87.1* LYMPHS-10.6* MONOS-1.5* EOS-0.2 BASOS-0.6 [**2163-12-8**] 12:18AM PLT COUNT-436 [**2163-12-8**] 12:18AM PT-10.9 PTT-26.9 INR(PT)-0.9 [**2163-12-8**] 12:18AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022 [**2163-12-8**] 12:18AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2163-12-8**] 12:18AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 RENAL EPI-0-2 Brief Hospital Course: Neurology: Patient was transferred from the ICU where she was noted to be in status. Patient needed to be restarted on her Keppra and Dilantin. Upon arrival to the floor Mrs.[**Known lastname 916**] was clinically stable. She continued to be confused at times. Her dose of Keppra was increased to 1500 mg PO BID. Patient was continued on Dilantin. Dilantin level remained in a therapeutic range. Patient continued to have some confusion at baseline with orientation to person , however had trouble with the date and place on daily examination. The patient was noted to improve daily. A bilateral INO was noted on exam. She was also noted to have MRI findings that appeared suggestive of Multiple sclerosis. We spoke to Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] who will follow Mrs.[**Known lastname 916**] as am outpatient. The patient was seen by PT and OT who both recommended 24 hour supervision through the weekend and continued outpatient services. A thyroid ultrasound was performed that showed a 10 mm x 10 mm x 21mm cystic lesion. I discussed the finding with the patient and th eneed to follow up with th e PCP regarding this matter. Dr.[**First Name (STitle) **] was involved in th epatients admission and will follow Ms.[**Known lastname 916**] as an outpatient. On [**2163-12-14**] Mrs. [**Known lastname 916**] was stable and sent home on Keppra and Dilantin. Medications on Admission: ASA 81 mg Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for nausea, pain, . 6. Dilantin Extended 100 mg Capsule Sig: Three (3) Capsule PO at bedtime. Disp:*90 Capsule(s)* Refills:*2* 7. Outpatient Lab Work Dilantin level - please obtain dilantin level in about 7 to 10 days from discharge 8. Outpatient Physical Therapy 9. Outpatient Occupational Therapy Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA and hospice Discharge Diagnosis: Seizure Disorder Multiple Sclerosis AVM Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for further evaluation of right arm contraction. The episode was thought to be a seizure. Originally you were in the ICU and then transferred to the floor. EEG was performed while you were here. You were continued on Keppra and Dilantin. The Keppra dose was increased to 1500 mg [**Hospital1 **]. Dilantin was continued at 100 mg PO TID. Your dilantin level was checked and noted to be in a normal range. You have continued to improve daily. Dr.[**First Name (STitle) **] will follow you as an outpatient. You were noted to have abnormal eye movements on examination which along with MRI findings are suggestive of Multiple Sclerosis. Dr.[**Last Name (STitle) **], the MS specialist, is aware and will follow you as an outpatient. A thyroid US was performed that showed a cystic mass measuring 10 mm x 10 mm x 21 mm. This will need to be followed up by your PCP. [**Name10 (NameIs) **] were seen by PT and OT. PT recommends out patient therapy.OT also recommends 24 hour supervision through sunday and continued outpatient therapy. Followup Instructions: Please follow up with Dr.[**First Name (STitle) **]. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2164-1-23**] 3:00 Please follow up with Dr.[**Last Name (STitle) **] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**] Date/Time:[**2164-2-14**] 10:00 Please follow up with PCP [**Name Initial (PRE) 176**] 1~2 weeks of discharge and follow-up with the repeat Dilantin level. Goal level should be between 10~20 Completed by:[**2163-12-15**]

[ "345.70", "246.9", "438.89", "V45.89", "340" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6517, 6584

4285, 5714

280, 285

6667, 6667

2866, 4262

7942, 8532

1693, 1774

5775, 6494

6605, 6646

5740, 5752

6851, 7919

1789, 2847

232, 242

313, 1478

6682, 6827

1500, 1574

1590, 1677

54,826

184,220

39457

Discharge summary

report

Admission Date: [**2177-8-28**] Discharge Date: [**2177-9-1**] Date of Birth: [**2107-2-15**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7729**] Chief Complaint: Malignant melanoma left temple/cheek Major Surgical or Invasive Procedure: 1. Left modified radical neck dissection. 2. Wide re-excision of malignant melanoma left temple/cheek. 3. Left parotidectomy with facial nerve monitoring. 4. Right antero-medial thigh flap to left face. 5. Autologous fat grafting to pedicle left side. 6. Harvest of the lateral circumflex pedicle. History of Present Illness: 70-year-old man who noted the rapid appearance of a raised, red nodular lesion on his left temple area in [**2177-5-6**]. Excisional biopsy was performed by Dr. [**Last Name (STitle) **] on [**2177-6-11**], with pathology revealing a 4 mm thick ulcerated melanoma invasive to [**Doctor Last Name 10834**] level IV with up to 3 mitoses per mm squared. He has no prior history of melanoma, although he did have prior basal cell cancers. Following surgery, he has noted the appearance of 2 flesh-colored lesions in the area of the resection site, of unclear significance. He denies swollen glands, cough, dyspnea, abdominal complaints, headaches, or anything that might be suggestive of more widespread disease. Past Medical History: HTN hypercholesterolemia Social History: He is remarried and has 2 biologic children from his first marriage. He is retired but works part time as a security guard at [**Company 33655**]. He does not smoke but drinks up to 2 beers per night. Family History: No history of melanoma Physical Exam: Pre-procedure PE per Anesthesia Record [**2177-8-28**]: Pulse: 65/min Resps: 16/min BP: 115/70 O2sat: 100% General: NAD Mental/psych: awake, alert, oriented x 3 Airway: as documented in detail on Anesthesia Record Dental: Other (Torus palatinus of hard palate) Head/Neck Range of Motion: Free range of motion Heart: RRR Lungs: Clear to auscultation Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2177-8-28**] and had a wide re-excision L temple/cheek area, left parotidectomy w/facial nerve monitoring, modified radical neck dissection and thigh free flap to left face. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received Morphine PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to Percocet with good pain control noted. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#2. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cephalexin on POD#4. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#4, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Patient was discharged on Cefadroxil PO for antibiotic. His left temple/cheek flap remained pale in color (baseline), warm to touch, with good cap refill and good doppler pulse. Sutures were clean and dry. Left clavicular JP with serosang fluid draining. Right lower abdominal JP drain with serosang fluid. Right thigh incision clean, dry intact without signs of infection or dehiscence with steri-strips intact. Medications on Admission: percocet 5-325 1-2 Tabs Q4H PRN pain, keflex 500 mg QID, enalapril 20 mg daily, pravastatin 20 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, HA, T>100 degrees: Max 12/day. Do not exceed 4gms/4000mgs of Tylenol per day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily) for 30 days. Disp:*45 Tablet, Chewable(s)* Refills:*0* 4. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cefadroxil 500 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours for 7 days. Disp:*14 Capsule(s)* Refills:*1* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Max 12/day. 325 mg of tylenol per tablet. Do not exceed 4gms/4000mgs of Tylenol per day. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: The Homemakers Discharge Diagnosis: 1. Malignant melanoma left temple/face. 2. Metastatic melanoma left parotid region. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: DISCHARGE INSTRUCTIONS: Personal Care: 1. Please keep your right thigh steri-strips in place. They will fall off on their own. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) [**1-8**] times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may shower daily with assistance as needed, but no baths until after directed by your surgeon . Activity: 1. You may resume your regular diet. Avoid caffeine and chocolate for 1 week. 2. DO NOT engage in strenuous activity for 6 weeks following surgery. 3. Do not lie/sleep on the left side of your face. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. Take Aspirin, 120 mg by mouth once daily, for 30 days after surgery. 3. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take your antibiotic as prescribed. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness,swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**] Date/Time: [**2177-9-5**] 1:40 . Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**] Date/Time: [**2177-9-9**] 12:00 Completed by:[**2177-9-1**]

[ "196.3", "272.0", "707.21", "V10.83", "707.02", "401.9", "172.3" ]

icd9cm

[ [ [] ] ]

[ "86.74", "86.4", "40.41", "26.30" ]

icd9pcs

[ [ [] ] ]

5064, 5109

2101, 4013

357, 661

5237, 5237

8528, 8864

1689, 1713

4168, 5041

5130, 5216

4039, 4145

5413, 8505

1728, 2078

281, 319

689, 1404

5252, 5364

1426, 1452

1468, 1673

5,823

165,240

6868

Discharge summary

report

Admission Date: [**2169-3-15**] Discharge Date: [**2169-3-24**] Date of Birth: [**2120-12-15**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7055**] Chief Complaint: CC:[**CC Contact Info 25938**] Major Surgical or Invasive Procedure: none History of Present Illness: 48 F with PMH MS (wheelchair bound) presented to [**Hospital 4068**] Hospital [**2168-3-13**] with complaints of fever on last Fri. Prior to presentation, pt had fevers and UTI and was treated with 10 d of levo (completed [**3-11**]). Initial CXR from [**Last Name (un) 4068**] demonstrated enlarged L pleural effusion. While at [**Location (un) 620**], had CT chest which demonstrated large pericardial effusion / L pleural effusion. Was started on Ceftriaxone/Azithro to cover for Strep pneumo. Also spiked T101 at OSH on [**3-14**]. Transferred to [**Hospital1 18**] for diagnostic/therapeutic pericardiocentesis. . 220 ml serosanguinous fluid was removed from pericardial sac, pigtail was placed for continuous drainage. Effusion was thought to be loculated. . Pt has hx of basal cell ca on her nose, that was removed several years ago. She been having intermittent fevers for months. 20 lb unintentional weight loss in the last month. Pt has been having mammograms since age 40, last in [**Month (only) **], all wnl. No past or present smoking hx. Has not had colonoscopy since age 48, but no colon ca in family. CT chest showed no mediastinal or hilar LAD. Family hx of cancer on both sides. Past Medical History: Multiple sclerosis (wheelchair bound) History of basal cell ca on her nose, removed Social History: Former pediatrician. She lives at home with her husband and has a home health aide. Family History: Father - skin ca. Aunt - breast ca. Physical Exam: 99.7 / 111 / 128/77 / 16 / 98% 2L nc Pulsus: 6 . Gen: NAD, lying in bed HEENT: No LAD, JVD to 12 cm, OP clear, CN2-12 intact, PERRL Lungs: Dull posteriorly, rales diffusely Heart: RRR, crescendo SEM, clear S1/S2, no r/g, pericardial window clean, no erythema Abdomen: Thin, soft, +BS, ND, NT Extr: No c/c/e Neuro: [**5-12**] motor only in head and LUE; [**1-12**] motor RUE; 0/5 LE bilaterally. Sensation equal and intact bl. . Pertinent Results: Pericardiocentesis [**2169-3-15**]: 1. Baseline resting hemodynamics demonstrated mildly elevated right sided pressures (RA mean 10 mmHg), normal pulmonary, and normal left sided pressures with a normal cardiac index (3.3 l/min/m2). The initial pericardial pressure equaled the RA pressure (10 mmHg). 2. Pericardiocentesis was performed and approximately 220 ml of sero-sanguinous fluid was removed until pericardial pressure was less than 0. It was not possible to remove more fluid despite posterior positioning of the catheter. RA pressure following the intervention was 5 mmHg. A pericardial catheter was left to drain and the patient left the laboratory in stable condition. . TTE [**2169-3-15**] 7 pm: There continues to be a moderate to large pericardial effusion. No significant change compared to prior. No evidence of RV collapse in diastole to suggest tamponade. . EKG: NSR at 119, Q in III, TWI I, low voltage . TTE [**2169-3-15**]: EF 70-75%, 1+MR, 1+TR, large pericardial effusion, question of loculation, echodense, no tamponade, no RV collapse . CT chest [**2169-3-14**]: No mediastinal or hilar LAD, L left pleural effusion, collapsed LLL, small R effusion, no pneumonia. VERY LARGE PERICARDIAL EFFUSION, LARGE LEFT PLEURAL EFFUSION, AND SMALL RIGHT PLEURAL EFFUSION. COMPRESSIVE LEFT LOWER LOBE COLLAPSE SECONDARY TO THE EFFUSION. NO PNEUMONIA SEEN IN THE VISUALIZED AERATED PORTIONS OF THE LUNGS. . ESR 46 CRP 7.2 . [**3-13**] Blood cx NGTD [**3-14**] Blood cx pend [**3-13**] Urine cx negative Brief Hospital Course: 48 F with PMH MS (wheelchair bound) presenting with intermittent fevers, pericardial effusion and pleural effusion. . # Pericardial effusion and Cardiac: Differential Dx: Possibilities for etiology of pericardial and pleural effusion include drug-induced hypersensitivity (increased serum eosinophil count), drug effect (patient was taking copaxone for years and zenapax for 4 months, both of which deviates T cells to a Th2 response, which promotes an eosinophilic response), infection (GPC in broth from pericardial biopsy), and autoimmune disease (unusual presentation of lupus or vasculitis to have isolated effusions). . On admission, a TTE showed a large possibly loculated pericardial effusion (greater posteriorly - 3.5 cm compared with anteriorly - 1.2 cm) that was echodense and consistent with blood, inflammation and cellular elements without evidence of tamponade. The patient was taken to the cath lab for pericardiocentesis with removal of 220 ml of serosanguinous fluid and placement of a pigtail catheter. Another 200 cc drained on the floor before the catheter stopped draining and was pulled on [**3-17**]. Analysis of the fluid was consistent with an exudate (see pertinent results). Cytology showed 79% lymphocytes, some activated forms consistent with a reactive process. Microbiology studies showed no bacterial or fungal growth. Acid fast culture continues to show NGTD, but the AFB smear was negative. Following pericardiocentesis and drainage, she continued to have a large circumferential pericardial effusion by TTE without signs of tamponade. Repeat pulsus checks were consistently 6. CT surgery performed VATS to evacuate the pericardial effusion without complication. TTE showed EF 70%, 1+ MR, 1+ TR. . All autoimmune and vasculitic markers checked returned negative. Pericardial biopsy showed Gram positive cocci only growing in broth, which may be contamination. Biopsy showed lymphocytes, degranulating eosinophils, and a few scattered PMNs. Tissue culture needs to be followed after discharge, although the effusion is unlikely to be caused by a bacterial infection because the patient has clinically been asymptomatic other than fevers. . # Pleural effusion: Pt has had fevers and 20 lb weight loss over the last several weeks. To evaluate for a source of possible malignancy and L pleural effusion seen on CXR, she was sent for a CT with IV and oral contrast following the pericardiocentesis which showed a large left pleural exudative effusion, small right pleural effusion, indeterminant 1.4-cm adrenal nodule, dilated common duct measuring 7-8 mm with no obvious obstructing source. The L pleural effusion was tapped 1L by interventional pulmonology, revealing straw-colored, clear fluid. There was no pus noted in the pericardial or pleural fluid. Patient was asymptomatic before and after procedure, with >95% O2 sat. . # Fevers: Etiology unknown. Fevers up to 103 were intermittent, and patient would spike once a day and then remain afebrile for the remainder of the day. Patient's fever improved after surgical evacuation of pericardial effusion, with maximum temp 99.5 during last day. . # Multiple sclerosis: Patient was advised to follow up with her neurologist and stop taking Copaxone (glatiramer) HS and Zenapax for life. Patient will continue to take Baclofen 60 [**Hospital1 **]. . # Osteoporosis: Fosamax and Ca carb were held during admission, but may be continued after discharge. . # Anxiety: Paxil and Zyprexa prn were continued during admission. . PPX: PPI, no heparin sc, pneumoboots CODE: Full COMM: [**First Name8 (NamePattern2) **] [**Known lastname 25939**] (daughter), [**Telephone/Fax (1) 25940**] HCP: [**Name (NI) **] [**Name (NI) 25939**] (husband), [**Telephone/Fax (3) 25941**] Medications on Admission: Copaxone HS Baclofen 60 [**Hospital1 **] Paxil 10 QD Colace 100 [**Hospital1 **] Ca carbonate 650 [**Hospital1 **] Fosamax 70 Qweek Zyprexa prn Ceftriaxone/Azithromycin (day 2) Dulcolax Discharge Medications: 1. Prescription Home [**Doctor Last Name 2598**] Lift Disp: 1 (one) Refills: 0 (zero) 2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Baclofen 10 mg Tablet Sig: Six (6) Tablet PO BID (2 times a day). 6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Pericardial effusion, pleural effusion, fevers . Secondary Diagnosis: MS Discharge Condition: Good. Pt has no chest pain, no SOB, satting 95% RA. Discharge Instructions: Do not continue your copaxone or Zenapax before discussing your pericardial and pleural effusion with your oncologist to see if these might be side effects from these drugs. Followup Instructions: Please make a follow-up appointment with your primary care doctor, Dr. [**Last Name (STitle) 696**] at [**Telephone/Fax (1) 25942**] for within the next [**1-9**] weeks. . Please make a followup appointment with your neurologist within the next 1-2 weeks. Completed by:[**2169-3-24**]

[ "428.0", "397.0", "340", "424.0", "511.0", "423.8", "428.30", "V10.83" ]

icd9cm

[ [ [] ] ]

[ "37.23", "37.0", "37.12", "34.91", "88.56", "34.24" ]

icd9pcs

[ [ [] ] ]

8439, 8518

3847, 7614

346, 352

8654, 8708

2306, 3824

8930, 9217

1805, 1842

7850, 8416

8539, 8539

7640, 7827

8732, 8907

1857, 2287

277, 308

380, 1580

8628, 8633

8558, 8607

1602, 1687

1703, 1789

16,081

195,388

27620+57556

Discharge summary

report+addendum

Unit No: [**Numeric Identifier 67480**] Admission Date: [**2182-6-7**] Discharge Date: [**2182-6-21**] Sex: M Service: VSU CHIEF COMPLAINT: A right 1st and 2nd toe cellulitis with known cellulitis. HISTORY OF PRESENT ILLNESS: This is an 84-year-old Kuwaiti male with type 2 diabetes, known peripheral vascular disease who has had bilateral fem/[**Doctor Last Name **] bypasses in [**2170**] and a left TMA who presented to [**Last Name (un) 67481**] Hospital in [**Country 22390**] on [**2182-5-28**] with a right foot swelling and erythema for a duration of 7 days. He had known absent peripheral pulses at that time of the right foot with a right 1st and 2nd toe erythema which extended to the anterior leg. He was begun on Zosyn and Flagyl with improvement of his cellulitis. The vascular surgeon in [**Country 22390**] advised a right 2nd toe amputation secondary to wet/dry gangrene and an angiogram diagnostic planned, but the patient requested evaluation and transfer to Dr.[**Name (NI) 1392**] service in the United States at [**Hospital1 346**]. The patient is now here for definitive treatment of his peripheral vascular disease. ALLERGIES: No known allergies. MEDICATIONS ON ADMISSION: Include Zosyn 4.5 grams q.8h., Flagyl 500 mg q.8h. IV, aspirin 100 mg daily, Imdur 30 mg daily, digoxin 0.25 mg daily, Lopressor 25 mg b.i.d., Zocor 10 mg at [**Hospital1 21013**], Cozaar 50 mg daily, Lasix 20 mg daily, Lovenox 40 mg daily; he had been on Coumadin, which was on hold. PAST MEDICAL HISTORY: Include type 2 diabetes with neuropathy; history of hypertension; history of coronary artery disease, status post coronary angioplasty and stenting at the [**Hospital 3340**] Clinic Foundation in [**Location (un) 3340**], [**State 4260**]; history of complete heart block requiring pacemaker implantation in [**2172**]; status post bilateral fem/[**Doctor Last Name **] bypasses in [**2170**]; status post left TMA in [**2174**]; history of renal artery stenosis; history of peripheral vascular disease. SOCIAL HISTORY: The patient lives in [**Country 22390**]. He is a smoker. No alcohol use. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.3, pulse 84, respiratory rate 16, blood pressure 128/70, oxygen saturation 96% on room air. Fasting fingerstick on admission was 214. GENERAL APPEARANCE: Alert male, non-English- speaking, in no acute distress. HEART: Regular rate and rhythm without murmur, gallop or rub. LUNGS: Clear to auscultation bilaterally. ABDOMINAL EXAM: Unremarkable, without bruits. EXTREMITIES: The left foot has a well-healed TMA. The right 2nd toe shows necrotic tissue with ulceration of 1 cm in size. The right 2nd toe also shows dry/wet gangrenous changes with ulcerations. PULSE EXAM: Shows palpable femoral's bilaterally. PT and DP are monophasic dopplerable signals only bilaterally. The radial arteries are palpable. There were no carotid bruits. LABORATORY DATA ON TRANSFER: Include a white count of 17.6, with a hemoglobin of 15.3. HOSPITAL COURSE: The patient was admitted the vascular service. Wound cultures were obtained. He was continued on the Zosyn and Flagyl. The patient's wound culture grew staph coag-negative sparse growth of 3 colonies and staph coag- positive sparse growth, but oxacillin resistant and staph coag-positive second morphology oxacillin resistant. The staph sensitivities of both species sensitive to gentamicin, rifampin, tetracycline, vancomycin. The anaerobe cultures were no growth. The patient's admitting chest x-ray showed pacing device seen, with a single-lead overlying right ventricle. There were cardiomediastinal and hilar contours, appeared unremarkable. Pulmonary vasculature appeared within normal limits. There were no focal consolidations within the lungs. The patient's admitting white count was 11.7, hematocrit 39.3, BUN was 16, with a creatinine of 0.9, and a potassium of 4.5. The patient had vein mapping done of the upper extremities which showed patent right basilic and cephalic veins. The patient also had a Duplex of the carotids secondary to a history of carotid bruit. Right internal carotid artery stenosis was less than 40%. The left internal carotid artery was totally occluded. The patient's electrocardiogram on admission demonstrated atrial fibrillation with a controlled ventricular response and occasional premature ventricular contractions, underlying right bundle branch block with a secondary ST wave abnormality. The patient underwent a diagnostic arteriogram on [**2182-6-10**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] via the left common femoral artery with abdominal and right leg runoff imaging. The infrarenal aorta was patent but diseased. There were single renal's with mild origin stenosis of less than 50% with brisk nephrograms. There was patent bilateral common iliac. The internal and external iliac's were also patent. The right lower extremity runoff showed a patent common femoris and profunda femoris. The SFA was occluded along with the bypass on the right side. There was reconstruction of the mid popliteal at the knee with 50% stenosis in the mid distal popliteal artery. The BK [**Doctor Last Name **] was patent. The anterior tibial artery occluded. The tibial peroneal trunk was patent. The peroneal and the posterior tibial filled retrograde via the DP via large plantar's. The PT was a large vessel in the foot. The patient did develop a small hematoma post arteriogram, which was controlled with manual pressure. His hematocrit's remained stable. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] diabetic physicians were consulted for diabetic management. He was begun on NPH insulin b.i.d., and his Humalog scale was increased with improved glycemic control. Because of the patient's history of cardiac disease, Dr. [**Last Name (STitle) **] was requested to evaluate the patient preoperatively for perioperative risk assessment. The patient had an echocardiogram done which showed an ejection fraction of 25% to 30%. The findings demonstrated left atrium was elongated. The right atrium and interatrial septum moderately dilated. Right atrium, a catheter or pacing wire seen in the right atrium and extending to the right ventricle. The left ventricle was normal wall thickness and cavity size with severely depressed left ventricular ejection fraction. No resting LVOT gradient. No LV mass or thrombus. The right ventricle was normal in chamber size. There was borderline normal RV systolic function. The aortic root was a normal diameter. There was mild dilatation of the ascending aorta. The aortic arch diameter was normal. The aortic valve showed moderately thickened aortic valve leaflets with moderate aortic stenosis, mild-to-moderate aortic regurgitation. The mitral valve showed moderately thickened mitral valve leaflets, moderately mitral anular calcification with mild thickening of the mitral valve chordae. There was no mitral stenosis. There was mild mitral regurgitation. Due to the acoustic shadowing, the severity of the mitral regurgitation may be significantly underestimated. The tricuspid valve was mildly thickened. There was mild-to-moderate tricuspid regurgitation and mild pulmonary systolic hypertension. A Persantine MIBI was obtained. This study demonstrated moderate partially reversible perfusion defect in the basal and mild segments of the anterolateral and inferolateral walls, but also may include lateral aspect of the inferior wall. The left ventricle was enlarged with severe global hypokinesis and an ejection fraction of 23%. Both studies were reviewed with Dr. [**Last Name (STitle) **] at the time of interpretation. The patient proceeded to surgery at a moderate risk. He underwent on [**2182-6-12**] a right femoral-to-popliteal bypass with PTFE grafting of 8 mm in size. The right upper extremity was explored for vein conduit. The right 2nd toe was amputated. The patient tolerated the procedure well. He required a unit of packed red blood cells intraoperatively. He was transferred to the PACU in guarded condition. In the PACU the patient remained hemodynamically stable. His postop hematocrit was 30.1, BUN 10, creatinine 0.8. He had a palpable PT and a strong dopplerable signal. His wounds were clean, dry and intact. The patient had serial cardiac enzymes drawn. He remained in the PACU overnight. The patient was transferred to the VICU after extubated and weaned from his nitroglycerin. IV heparin was continued at 400 units per hour. On postoperative day #2, the patient remained in the VICU. Vancomycin was started. On operative day, his physical exam remained unchanged. He remained hemodynamically stable. The patient's diet was advanced as tolerated. He was placed on oral medicines preop and pain medications. He was diuresed with Lasix and remained in the VICU. The patient continued to be followed by Dr. [**Last Name (STitle) **]. He was started on Zestril 5 mg daily with continued Lasix diuresis. His Swan was discontinued. His glycemic control remained stable. On postoperative day #3, coumadinization was begun at 2 mg. He continued to require diuresis with Lasix 20 IV b.i.d.. Ambulation was begun. His physical exam remained unchanged. The patient required a transfusion for a hematocrit of 24.8; down from 26.6. His INR was 2.0. He continued on low-dose heparin of 500. Continued on vancomycin and Zosyn. His white count was 12.1, BUN 11, creatinine 0.7. He remained in the VICU. On postoperative day #4, the patient continued to be diuresed. Physical therapy was requested to see the patient. The patient was transferred to the regular nursing floor on postoperative day #5. His pacemaker was interrogated as a standard of practice, and it was found to be working appropriately with a single-chamber Prodigy SR VVI mode 70. The patient's battery was okay. The longevity of battery is usually about 22 months. His family was recommended that the patient should have followup on battery life once every month. The patient continued with anticoagulation. Even with minimal dosing of Coumadin, his INR peaked at 5.8; and Coumadin was held. He will be discharged on 1 mg of Coumadin at the time of discharge. He should follow up with his primary care physician for continued monitoring of his INR. The goal is 2.0 to 3.0. He did have borderline troponin rises of 0.10/0.12 with no EKG changes. DISCHARGE STATUS: The patient was discharged to home in stable condition. DISCHARGE MEDICATIONS: Aspirin 81 mg daily, simvastatin 10 mg daily, losartan 50 mg daily, Colace 100 mg b.i.d., bisacodyl tablets 2 daily as needed for constipation, Protonix 40 mg daily, oxycodone/acetaminophen 5/325 tablets 1 to 2 q.4-6h. p.r.n. for pain, isosorbide mononitrate 30 mg sustained release daily, digoxin 250 mcg daily, Reglan 10 mg before meals and at [**Last Name (STitle) 21013**], warfarin 1 mg at [**Last Name (STitle) 21013**], Lasix 20 mg daily, NPH insulin 13 units at breakfast and 6 units at [**Last Name (STitle) 21013**], with a Humalog sliding scale before meals as follows: Glucose's less than 80 use [**Location (un) 2452**] juice 4 ounces; glucose's 81 to 120 use no insulin; 121 to 160 use 3 units; 161 to 200 use 4 units; 201 to 240 use 5 units; 241 to 280 use 7 units; 281 to 320 use 8 units; 321 to 360 use 9 units; 361 to 400 use 10 units; greater than 400 notify physician. [**Name10 (NameIs) **] sliding scale is as follows: No insulin for glucose's of less than 200; 201 to 240 use 2 units; 241 to 280 use 3 units; 281 to 320 use 4 units; 321 to 360 use 5 units; 361 to 400 use 6 units; greater than 400 notify physician. [**Name10 (NameIs) **] patient at present is on metoprolol 50 mg b.i.d.; this will be converted to equivalent carvedilol at the time of discharge. We await the final culture results on the toe pathology, but anticipate sending the patient out on Augmentin 875 b.i.d. for 2 to 4 weeks. DISCHARGE DIAGNOSES: Ischemic cellulitis of the right 2nd and 1st toes; history of hypertension, controlled; history of coronary artery disease, status post angioplasty and stenting; history of complete heart block, status post pacemaker in [**2174**], last interrogated on this admission in [**2182-5-30**]; history of atrial fibrillation; history of peripheral vascular disease, status post bilateral femoral-to- popliteal bypasses in [**2170**], status post left transmetatarsal amputation in [**2174**]; history of renal artery stenosis; postoperative blood loss anemia, transfused, corrected; post angio hematoma of left groin, stable. MAJOR SURGICAL PROCEDURES: Include diagnostic arteriogram with right leg runoff on [**2182-6-10**] and a right femoral-to- popliteal artery bypass with PTFE, right arm vein exploration, right 2nd toe amputation on [**2182-6-12**]. DISCHARGE INSTRUCTIONS: The patient should follow up with his primary care physician on arriving home for continued care regarding his antibiotics, monitoring of his INR and warfarin dosing, and adjustment of his cardiac medications and diabetic insulin regimen. He may ambulate essential distances wearing a healing sandal on the right foot when ambulating. He should elevate the leg when sitting. He should notify his physician if the wounds become red, swollen or drain purulent material, if he develops a fever of greater than 101.5 or his glucose's are not well controlled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2182-6-19**] 16:16:50 T: [**2182-6-19**] 18:23:05 Job#: [**Job Number 67482**] Name: [**Known lastname **] [**Known lastname 11685**],[**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 11686**] Admission Date: [**2182-6-7**] Discharge Date: [**2182-7-13**] Date of Birth: [**2098-1-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2182-6-22**] patient found unresposive by family, CT head left cebellar ischemic stroke. with right [**Hospital 11687**] Transfered to ICU . Neuro consulted. EEG negative for active seizures. dilantin began. [**2182-6-24**] tube feed began [**2182-6-25**] continued to show improvement.dilantin discontinued Transfered to VICU. [**2182-6-26**] bedside swallowing exam.Patient to lethargic to began oral feeds. [**2182-6-27**] Vanco discontinued. PT and Ot continue to work with patient.Repeat swallow study at bedside positive for aspiration of food of all consistancies.Will be evaluated when less lethargic by speech service. [**2182-6-28**] transfered to floor status with sitter.Picc line replaced and TPN began.GI consulted for PEG placement.No changes in swallowing exam. [**2182-7-1**] PEG placement. leg skin staples discontinued. [**2182-7-2**] Peg feedings began. [**2182-7-4**] PEG tube site leak. tube feeds held, reconsult Gi. site inspected by GI and retightened and levofloxcin started with improvement of PEG site drainage and erythema. [**2182-7-5**] Evaluated by Speech and swallow service, still aspirating will continue with current PEG feeds. [**2182-7-9**] Evaluated by speech and swallow at bedside and with video swallow.no aspiration noted. [**Month (only) 412**] began with thin liquids and grouond consistancey solids. Give liquids by straw. alternate liquids and ground consitancies between bite and sip. Use chin tuck position when taking liquids. NO PILLS by mouth. pills should be crushed and given with purees or liquid form. Moniter oral intake and if remains llimited continue with tube feeds. [**2182-7-10**] oral ground solids began. Tubefeeds continued.INR 2.2 coumadin dosing changed to 2mgm Mon.,Wed, Fri. with 1mgm coumadin Tues,Thursday,Sat, Sunday. [**2182-7-13**] d/c to home with Rn escort to Kuwit. stable. tolerating po's and continued tube feeds via peg. Discharge Disposition: Home With Service Facility: private nursing care Discharge Diagnosis: postoperative left cebellar ischemic stroke [**2182-6-22**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2182-7-16**]

[ "427.31", "V45.82", "682.7", "V45.01", "250.72", "250.62", "997.02", "440.24", "428.0", "440.31", "401.9", "707.15", "357.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "38.03", "88.48", "84.11", "99.04", "43.11", "96.6", "39.29" ]

icd9pcs

[ [ [] ] ]

15986, 16037

11921, 12775

10474, 11899

16058, 16277

1209, 1495

3009, 10450

12800, 15963

2138, 2991

146, 205

234, 1182

1518, 2023

2040, 2115

16,832

190,160

5145

Discharge summary

report

Admission Date: [**2111-5-25**] Discharge Date: [**2111-6-2**] Date of Birth: [**2066-9-20**] Sex: M Service: [**Last Name (un) **] ADMITTING DIAGNOSIS: Chronic hepatitis C admitted for potential liver transplant. HISTORY OF PRESENT ILLNESS: The patient is a 44 year-old male with past medical history significant for hepatitis C, genotype 1 who has not responded to multiple courses of interferon based therapy. In [**2110-11-12**] he was found to have biopsy-proven hepatocellular disease. Status post radiofrequency ablation. CT [**2111-2-26**] revealed no reoccurrence of radiofrequency ablation site but did reveal small perfusion abnormality. A CT of abdomen was scheduled on [**2111-5-26**] for follow up. Bone marrow biopsy on [**2110-12-22**] demonstrated osteopenia of the spine and hips. MIBI was normal. Patient called in on [**2111-5-25**] for potential liver transplant. No fevers, no chills, no recent weight loss. No abdominal pain. No dysuria, no lower extremity edema. PAST MEDICAL HISTORY: Hepatitis C, genotype 1, hepatocellular carcinoma. History of motor vehicle accident 27 years ago. Hepatitis AB positive, anxiety, hypertension. No asthma, no shortness of breath, no history of myocardial infarction. No history of anemia. PAST SURGICAL HISTORY: Status post nasal repair surgery x2, liver ablation [**2109**]. ALLERGIES: No known drug allergies. Also hypersensitive to tape. MEDICATIONS ON ADMISSION: Vitamin E 400 units q day, diazepam 200 mg p.r.n., Nexium 40 mg q day, hydrochlorothiazide 25 mg q day, Zyrtec 10 mg q day and nadolol 20 mg b.i.d., Mycelex. SOCIAL HISTORY: Married since [**23**] years. No children. History of alcohol abuse. Stopped eight years ago. No tobacco. No history of IV drugs. FAMILY HISTORY: Mother died of a brain aneurysm at 34 years old. Father died of lung cancer at 47. Brother alive at 48 who has a history of quadruple bypass. Two sisters who are alive and well. REVIEW OF SYSTEMS: No fever, no chills, no nausea or vomiting. No abdominal pain. No lower extremity edema. No problems with urination or bowel movements. No jaundice. No shortness of breath. No chest pain. PHYSICAL EXAMINATION: Patient appears healthy in no acute distress sitting on bed. He is well developed, well nourished. Skin good color, no erythema, no dryness, afebrile. Vital signs are stable. Weight 91.5. Head, eyes, ears, nose and throat: Atraumatic, normocephalic. Eyes: Pupils equal, round and reactive to light, extraocular movements are full. Anicteric. Mouth: Moist mucosa. Tongue midline. No exudate. Neck supple, no palpable nodes, no thyromegaly. No carotid bruits. Full range of motion. Lungs clear to auscultation and percussion bilaterally. Cardiovascular: Tachycardic, regular rate and rhythm, normal S1, S2 without murmurs or rubs. Abdomen: Positive bowel sounds, soft, nontender. Liver border felt 2 to 3 fingers below the subcostal ribs. No flank pain. Extremities: No clubbing, cyanosis or edema. Pulse 2+ AT and DP bilaterally. The patient went to the operating room on [**2111-5-25**] for orthotopic liver transplant performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please seen dictated operating room note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for details. The patient had T tube placed and [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain placed. Patient tolerated this surgery well, was taken to Intensive Care Unit in stable condition. In the Intensive Care Unit the patient did well, awake, alert, afebrile, vital signs stable. Patient was intubated. Patient received tacrolimus. Patient was on Unasyn. He received 20 of Simulect on postoperative day 1. Patient had a duplex ultrasound on [**2111-5-26**] demonstrating that there was flow in the main hepatic and lesser hepatic arteries with patent expected wave forms. Portal and hepatic veins appear patent. At that time there was limiting examination demonstrating patent hepatic transplant vasculature. Further intrahepatic artery not seen but further Doppler scanning demonstrates full patency of the main left and right hepatic arteries. Postoperative day 1 in the afternoon patient was extubated. Patient was given platelets x2 and 1 unit of packed red blood cells for a hematocrit of 21.1 and platelets of 81. Incision looked fantastic. Drains were intact. He complained of mild incisional pain. Awake, alert, oriented x3, positive bowel sounds on postoperative day 2. Making good urine. Patient received morphine q 1 hour. Patient was on insulin drip that was discontinued in the evening of [**5-27**]. Patient had two [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains that were draining sanguineous fluid but were intact. Patient did receive Solu-Medrol starting preoperatively 500 IV x1 and after surgery was tapered from 200 to 150, 100, 75, 35 and 20. Patient had been transferred to the floor on postoperative day 2, continued on Unasyn and the Unasyn was stopped. On [**2111-5-27**] physical therapy was consulted. Oxygen was weaned off. Postoperative day 3 patient was on continued tacrolimus, MMF, Solu-Medrol and received another dose of Simulect on postoperative day 5. On [**2111-6-1**] one drain was removed. The other drain is in place. One stitch was placed where the other [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] was removed because of persistent leakage, so patient will be going home on postoperative day 6 with a lateral drain in place. Patient does not need any [**Hospital6 407**]. He will be going home with his wife. Patient will leave on the following medications: Fluconazole 400 mg q 24. Protonix 40 mg 1 tablet q 24. MMF 1,000 mg b.i.d. Bactrim SS 1 tablet q day. Percocet 1 to 2 p.o. q 4 to 6 hours p.r.n. Prednisone 20 mg p.o. q day. Metoprolol 100 mg b.i.d. Furosemide 40 mg b.i.d. Tacrolimus 2 mg b.i.d. Valganciclovir 900 mg q day. Patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2111-6-4**] at 9:30 A.M. located in the LM [**Last Name (un) 2577**] Building, transplant center. Please call [**Telephone/Fax (1) 673**] if any questions or concerns about the appointment. He will also follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2111-6-11**] at 9:50 A.M. at the [**Last Name (un) 2577**] Building, and on [**2111-6-18**] at 9:40 A.M. in the [**Last Name (un) 2577**] Building. The patient needs to call transplant service immediately at [**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting, inability take medications, redness/bleeding, trouble vision, increased drainage from drain, jaundice or abdominal pain. Patient needs to have laboratories every Monday and Thursday for a CBC, chem-10, AST, ALT, alkaline phosphatase, total bilirubin, albumin and Prograf trough level. Patient should have results faxed immediately to the [**Hospital1 69**] transplant office at [**Telephone/Fax (1) 21087**]. Patient should not drive while taking pain medications, may shower and empty the drain when half full and record amount/color of drainage. FINAL DIAGNOSIS: Orthotopic liver transplant on [**2111-5-25**] for hepatitis C cirrhosis and hepatocellular carcinoma. Patient is [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2111-6-1**] 14:52:34 T: [**2111-6-1**] 16:12:36 Job#: [**Job Number 21088**]

[ "070.70", "155.0", "571.5" ]

icd9cm

[ [ [] ] ]

[ "50.59", "99.04", "00.93" ]

icd9pcs

[ [ [] ] ]

1782, 1961

1458, 1617

7234, 7615

1299, 1431

2193, 7216

1981, 2170

266, 1012

175, 237

1035, 1275

1634, 1765

9,686

163,022

28010

Discharge summary

report

Admission Date: [**2148-5-22**] Discharge Date: [**2148-5-30**] Date of Birth: [**2082-3-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: EGD/colonoscopy Angiography Left (completion) colectomy History of Present Illness: 66 y/o M with a PMHx of CVA in [**2144**] c/b residual R facial droop, HTN, diverticulosis s/p R hemi-colectomy who was doing well at his NH until yesterday when he developed the progressive onset of BRBPR and passing clots in his stool. No N/V/abd pain. No CP/SOB, LH, dizziness, presyncope/syncope. He has a hx of diverticulitis s/p Right hemi-colectomy but he describes that episode as different from his current BRBPR. He does not remember ever having a colonoscopy in the past. He denies any unusual food intake, sick contacts. . In the ED, his initial VS were 98.9, HR 59, BP 150/94, RR 15, 97%RA. 2 18G PIVs were placed, and an NG lavage was performed which was negative. He was transferred to the ICU for further management. . Past Medical History: HTN Vitamin D deficiency CVA [**2144**] urinary incontinence diverticulosis s/p R colectomy, s/p appendectomy Social History: Lives at [**Hospital3 537**]. Former cook at B&WH now retired. Previously married x 2. 10 children. Resident of [**Hospital 4382**] facility. Bathes and clothes himself. Does not cook or pay bills. Walks with a walker. 20 pack years, quit 20 years ago. 2 beers/week. Family History: Mother - HTN Physical Exam: VS: Temp:98.3 BP:163/72 HR:59 RR:15 O2sat:99%RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: No supraclavicular or cervical lymphadenopathy, no jvd RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: NTND, +b/s, soft, no masses or hepatosplenomegaly. Midline scar incision from prior surgery present. EXT: no c/c/e SKIN: no rashes/no jaundice NEURO: AAOx3. +R facial droop present; otherwise CN II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. RECTAL: clots, BRB in vault. . Pertinent Results: [**2148-5-22**] 09:56PM HCT-27.2* [**2148-5-22**] 02:15PM GLUCOSE-117* UREA N-29* CREAT-1.6* SODIUM-140 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14 [**2148-5-22**] 02:15PM estGFR-Using this [**2148-5-22**] 02:15PM WBC-5.0 RBC-3.66* HGB-11.5* HCT-33.5* MCV-92 MCH-31.4 MCHC-34.3 RDW-14.7 [**2148-5-22**] 02:15PM NEUTS-57.8 LYMPHS-34.6 MONOS-5.6 EOS-1.8 BASOS-0.3 [**2148-5-22**] 02:15PM PLT COUNT-203 [**2148-5-22**] 02:01PM GLUCOSE-118* NA+-140 K+-4.5 CL--107 TCO2-24 [**2148-5-22**] 02:01PM HGB-11.7* calcHCT-35 [**2148-5-22**] 01:15PM PT-12.7 PTT-27.3 INR(PT)-1.1 Brief Hospital Course: Patient was evaluated in the [**Hospital1 18**] ED. NG lavage negative in the ED; BRBPR and clots suggest lower GI source. Likely diverticular bleed given hx of diverticulosis vs AVMs. Unclear when had last colonoscopy (no records in OMR) and patient denies any prior hx. Seen by GI in ED who recommended admitting for c-scope in AM. Had EGD/c-scope which despite a poor prep did not note any active bleeding. Despite this, his hematocrit continued to drop and he was taken for a tagged RBC study which showed localization to the sigmoid colon. Angiography was not able to localize the bleeding and he was returned to the MICU. Surgery was consulted who felt given his ongoing bleeding, a colectomy was indicated. He was taken to the OR on HD#2 and underwent completion colectomy without complication. He was then transferred to the SICU for observation. The patient did well post-operatively and was advanced to a regular diet on POD3. He was transferred to the surgical [**Hospital1 **] in stable condition, having normal bowel movements and tolerating a regular diet and PO analgesia. Medications on Admission: ASA 81mg PO qd Prilosec 40mg POqd VIT D3 Aggrenox 1 [**Hospital1 **] Captopril 50mg tid Metoprolol 25mg tid Sertraline 75 qHS Colace 200mg po qhs Zocor 20PO qhs Senna 86.mg PO bid Tylenol PRN Fleets PRN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. 4. Captopril 12.5 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection AS DIR. 8. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 9. Sertraline 25 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Tablet(s) 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Lower GI Bleed Discharge Condition: Stable Discharge Instructions: Please [**Name8 (MD) 138**] MD or return to ED if any of the following occur: 1. Fever >101.5 2. Intractable nausea/vomiting 3. Redness/Swelling/Discharge from wound 4. Any other concerning symptoms Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in two weeks. Call [**Telephone/Fax (1) 6429**] for appointment. Psyllium for diarrhea. Completed by:[**2148-5-30**]

[ "280.0", "562.12", "585.9", "403.90", "438.9", "553.20", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.75", "53.59", "45.93", "45.23", "88.47", "45.13" ]

icd9pcs

[ [ [] ] ]

5124, 5195

2847, 3948

320, 377

5254, 5263

2230, 2824

5510, 5682

1584, 1598

4201, 5101

5216, 5233

3974, 4178

5287, 5487

1614, 2211

275, 282

405, 1142

1164, 1276

1292, 1568

1,494

191,711

29897

Discharge summary

report

Admission Date: [**2116-12-16**] Discharge Date: [**2116-12-29**] Date of Birth: [**2069-12-25**] Sex: M Service: MEDICINE Allergies: Prevacid Attending:[**First Name3 (LF) 943**] Chief Complaint: transferred for liver transplant eval, encephalopathy Major Surgical or Invasive Procedure: thoracentesis and chest tube placement on R side History of Present Illness: 45yo man with history of chronic Hepatitis C, distant ETOH abuse, and cirrhosis was transferred from [**Hospital **] hospital with encephalopathy. His liver disease has been complicated historically by encephalopathy, SBP, hyodrothorax, variceal bleeding, and has undergone TIPS placement two weeks prior to admission. . Over the past 6weeks, he had a decompensation with worsening hydrothorax resistant to diuretics and thoracentesis, ascites requiring TIPS placement ([**2116-12-2**] at [**Hospital1 112**]), and encephalopathy partially responsive to incraesing doses of lactulose. . He was brought in to [**Hospital **] hospital after he was found down at home by his daughter. Initial vitals there were ( T 95.7, BP 173/103, HR 113). He was intubated for airway protection. Concerning his encephalopathy, he was treated with lactulose. He was empirically treated for SBP (no paracentesis done as Abdominal US showed no ascites) with cefepime, flagyl, and albumin. He was also initially treated with levofloxacin and vancomycin for RLL pneumonia, but these were discontinued prior to transfer when repeat CXR showed persistant effusion but no consolidation. . During his MICU stay, he was treated with lactulose and rifaxamin for his encephalopathy which cleared dramatically. He underwent abd US which demonstrated no focal masses, patent portal vessels, and stenosis of the TIPS. He had a chest CT demonstrating his known pleural effuion but no infiltrates. He did not undergo paracentesis, as there was not enough ascites for a safe tap; he was empirically treated for SBP with Cipro 500mg [**Hospital1 **]. No other new events. No fever spikes. No evidence of GI bleeding. . On interview, he reports feeling well. No fevers, chills, cp, sob, vomiting/hematemesis, blood in stool or confusion. Does report mild diffuse abdominal fullness. Has been eating normal diet. Past Medical History: 1. HCV/EtOH cirrhosis - h/o varices [**2109**], GIB in [**2111**] and [**2114**]; EGD with portal gastropathy and distal erosive esophagitis, s/p variceal banding 2. h/o SBP 3. s/p umbilical hernia repair [**9-3**] 4. Transitional cell bladder Ca s/p resection [**2105**], [**2107**] 5. Type II diabetes mellitus - on insulin 6. h/o multiple knee surgeries s/p trauma Social History: Lives alone. Daughter and two brothers are involved in his care. h/o EtOH abuse, none x 15yrs; h/o Tob use, none x 5yrs Family History: Mother d. EtOH cirrhosis c/b varices at 34yrs Father d. sepsis at 75yrs Physical Exam: VS: 97.0, 102, 135/75, 18, 97% RA+ GEN: NAD HEENT: anicteric, OP clear, dry MM Neck: supple, no LAD, JVP nondistended CV: RRR, no mrg, PMI nondisplaced Resp: decreased at right lung base Abd: +BS, soft, ND, NT, no fluid wave, liver edge palp below costodiaphragmatic edge Ext: 2+ LE edema, abrasions on BLE Pertinent Results: Labs on admission: WBC 2.5 (64% neutrophils, 25% lymphs, 8% monos), Hgb 10.6, Hct 29.3, Plt 58,000 INR 1.9, PTT 43 glucose 128 creatinine 1, potassium 3 ALT 42, AST 65, LDH 291, alk phos 144, amylase 34, total bili 3.5, lipase 33 albumin 2.6 haptoglobin < 20 ammonia 74 TSH 0.97, free T4 1.1 Hepatitis serologies: Hep B negative, Hep A antibody positive, IgM Hep B negative, HCV antibody positive CEA 13, PSA 0.1, AFP 2.2 Herpes I IgG antibody positive Herpes II IgG antibody negative Ca [**28**]-9 50 (elevated) . Urine studies: UA without sign of infection (X 2) Urine urea 748, urine creatinine 119, urine sodium 61, urine potassium 39 . Pleural fluid ([**12-22**]): 27 WBCs, 262 RBCs, total protein 1, glucose 246, creatinine 0.5, LDH 72, amylase 20, albumin < 1 . Imaging: Abdominal US ([**12-17**]): 1. Patent TIPS with elevated velocities in the proximal aspect of the TIPS (244 cm/sec) which diminishes distally (128 cm/sec). These findings are suggestive of a TIPS stenosis; however, there is appropriate reversal of flow within the left and anterior right portal vein. 2. Cirrhotic liver with large amount of ascites and splenomegaly. 3. Cholelithiasis without definite evidence for cholecystitis . CT chest ([**12-17**]): 1. Large right pleural effusion with complete right lower lobe collapse and right upper lobe atelectasis. 2. Cirrhotic liver. . Abdominal US ([**12-18**]): 1. Patent portal vein. 2. Right pleural effusion and ascites. No safe spot for marking was identified. . EKG ([**12-18**]): Sinus rhythm at 100 bpm. Q waves in the anterior leads consistent with possible prior infarction. No previous tracing available for comparison. . MRI abdomen ([**12-19**]): Image quality is severely degraded by non-breath hold strategies, patient body habitus, and large amount of ascites/diffuse retroperitoneal edema. The liver was much better imaged by the CT. The appearance of the liver is unchanged allowing for differences in modality. As shown on CT, several small arterial enhancing foci are present in segments 4A and II. Not all lesions visualized on CT are depicted by MRI, and the individual lesions are better depicted on the prior CT scan. No further characterization is possible. Vessels are grossly patent but are suboptimally evaluated. There is a large amount of ascites and a large right pleural effusion. There is no gross biliary dilatation. T2 weighted images were completely non-diagnostic. Please refer to liver CTA for liver volume. IMPRESSION: Severely limited study. Re-demonstration of arterial foci seen on CT, poorly visualized on other images. No additional tissue characterization is possible. The liver is better visualized by CT. Short-term ([**3-5**] month) follow up of the arterial enhancing lesions is recommended with multiphasic CT. . Revision of TIPS ([**12-21**]): 1. Venography demonstrated wall-to-wall flow within two in situ TIPS stents. Initial portosystemic pressure gradient constituted 4 mmHg. 2. Successful deployment of 10 mm x 68 mm Wallstent extending the boundary of the TIPS proximally into the main portal vein, for better alignment of stents at this locale. . ECHO ([**12-21**]): The left atrium is normal in size. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 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) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Bilateral pleural effusions and ascites. . Abdominal ultrasound ([**12-22**]): 1. Patent TIPS with wall-to-wall flow. Focal increased velocities within the middle of the TIPS are seen with aliasing although the TIPS appears patent throughout. 2. Cirrhotic liver with ascites and right-sided pleural effusion. 3. Splenic vein not well visualized. . CXR ([**12-22**]): There is complete whiteout of the right lung. Air bronchograms are present in the right hila. Complete whiteout is a combination of complete lung collapse and effusions. A TIPS stent is in place. The left lung is clear. The left PICC line terminates in the mid SVC. . CXR ([**12-23**]): 1. Interval development of moderate-to-large right hydropneumothorax, with rapid reaccumulation of right pleural fluid. No evidence of tension pneumothorax. . CXR ([**12-23**]): The small-bore catheter for drainage has been inserted. There is slight decrease in the size of pneumothorax which is still at least moderate in size. There is small right subcutaneous emphysema in the axilla. There is no significant change of the right lower lobe atelectasis and right pleural effusion. There are no other new findings comparing to the previous film. . Microbiology: Blood culture ([**12-18**]): no growth Urine culture ([**12-17**]): no growth Pleural fluid culture ([**12-22**]): no growth CMV antibody IgG positive, IgM weakly positive EBV IgM negative, IgG positive Toxo IgG positive Hep C viral load ([**12-18**]): 1,320,000 IU/mL., genotype 1 RPR not reactive Rubella IgG positive VZV IgG positive . Brief Hospital Course: Mr. [**Known lastname 10137**] is a 46 year old male with ESLD secondary to HCV and EtOH cirrhosis with history of a variceal bleed and SBP in the past who was transferred from an outside hospital for further management of encephalopathy and for liver transplant evaluation. . # Encephalopathy: The patient was transferred for encephalopathy with a MELD ~ 30 requiring intubation as he could not protect his airway. Once placed on lactulose, rifaximin, the patient's mental status improved. He was extubated shortly after his admission and deemed stable for a regular floor bed. He was continued on lactulose/rifaximin. His mental status remained normal for the rest of the hospital course. . # Cirrhosis/ESLD: His liver disease is secondary to ETOH abuse and chronic hepatitis C. He has a history of variceal bleeding, encephalopathy, hydrothorax, and ascites with recent TIPS placement. At our institution, he underwent a revision of the TIPS on [**12-21**] which showed patent stents; at that time, an additional stent was placed for vessel tortuosity. He was given cipro daily 250 PO for SBP prophylaxis as he has a history of SBP. He was given lasix & spironolactone for diuresis. Also a transplant re-evaluation was performed. . # Pneumothorax: Once on the floor, the patient became more short of breath; on CXR, he had complete white-out of his right lung. He then had a thoracentesis performed by Interventional Pulmonology with 4 L fluid removed and sent for studies. Cultures of this fluid were negative. His post-thoracentesis film showed improvement of the hydrothorax; however, on [**12-23**], he complained of pleuritic chest pain and had notably decreased breath sounds on right. A repeat CXR showed large pneumo/hydrothorax with total collapse of the right lung. IP was reconsulted and placed a pigtail catheter into the right pleural space. As the patient has a chronic hydrothorax, he drained 2-3 liters of fluid per day from the chest tube. On [**12-26**], the chest tube was removed as multiple chest x-rays had demonstrated resolution of the pneumothorax. Once the chest tube was removed, he was restarted on diuretics with lasix/spironolactone. . # Anemia, thrombocytopenia: This is a chronic problem for Mr. [**Known lastname 10137**]. Values were at baseline during his stay. . # Rib pain: The patient has chronic right-sided rib pain secondary to a prior accident. He did not receive tylenol. He was treated with oxycodone, 5-10 mg, as needed. . 4. Type II DM: The patient is insulin dependent at baseline. He was discharged on lantus 50 u at bedtime and sliding scale regular insulin. . 5. FEN: He tolerated a regular, low sodium diet with a 2L fluid restriction. Nutrition followed him due to poor albumin on admission. We repleted his electrolytes as necessary. . # Access: He had a left-sided PICC (placed by IR [**12-18**]) which was removed at discharge. . # PPx: He was ambulatory throughout his stay. He received a PPI. . # Communication: daughter [**Name (NI) 8771**] [**Name (NI) 10137**] [**0-0-**] (c); [**Telephone/Fax (1) 71457**](w) . # Full Code Medications on Admission: Lactulose 30mL QID Albumin 25g iv Q3hr Lasix 40mg iv BID Cefepime 500mg iv Q24hr Protonix 40mg iv BID Flagyl 500mg iv Q8hr Neomycin 1g daily per NG ISS Vitamin K 5mg x 2doses Discharge Medications: 1. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Aldactone 100 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). Disp:*3600 ML(s)* Refills:*2* 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) Subcutaneous ASDIR: Take 50 units at bedtime. 9. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous ASDIR. 10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): for SBP prophylaxis. Disp:*30 Tablet(s)* Refills:*2* 11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: hepatitis C alcoholic cirrhosis type 2 diabetes Discharge Condition: stable Discharge Instructions: Take all medication as prescribed. Do not stop or change your medications without first speaking to your physician. . Please continue to eat a low sodium diet and restrict yourself to less than 1.5 liters of fluid per day. This includes all drinks, including soda, water, tea, and coffee. . If you have any fevers, chills, nausea, vomiting, chest pain or pressure, palpitations, light-headedness, or any other concerning symptoms, call your physician [**Name Initial (PRE) 2227**]. Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2117-1-15**] 9:00 You had tests including: urine cytology, VZV, and CMV. Please be sure to ask Dr. [**Last Name (STitle) 497**] about the results of these tests. Completed by:[**2117-1-6**]

[ "287.5", "284.1", "285.9", "997.3", "572.2", "250.00", "511.8", "571.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "00.40", "34.91", "00.45", "39.50", "39.90", "34.04", "38.93" ]

icd9pcs

[ [ [] ] ]

13346, 13384

8838, 11932

325, 376

13476, 13485

3242, 3247

14017, 14347

2825, 2898

12157, 13323

13405, 13455

11958, 12134

13509, 13994

2913, 3223

232, 287

404, 2281

3261, 8815

2303, 2672

2688, 2809

5,662

162,632

45398

Discharge summary

report

Admission Date: [**2171-10-11**] Discharge Date: [**2171-10-14**] Date of Birth: [**2091-5-8**] Sex: F Service: MEDICINE Allergies: Compazine / Lisinopril / Ativan Attending:[**First Name3 (LF) 689**] Chief Complaint: Fever ALOC Abd Pain Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo woman with a h/o pancreatic cancer s/p Whipple in [**2160**], dementia and recurrent UTIs who presented two days ago with delirium and fever to 101.6. 4-5 days PTA the pt complained of some nausea and small amount of emesis. She did not complain of abdominal pain. Per the daughter, she had not complained of CP, SOB, cough, constipation. She has diarrhea at baseline that has not changed. . She was seen by IP about 2 weeks PTA for drainage of a recurrent pleural effusion. She was seen in the ED 2 days PTA for replacement of her J tube. She was most recently admitted to [**Hospital1 18**] from [**Date range (1) 75072**]/06 with delirium and UTI. UCx at that time grew only yeast. . In triage, SBP was around 85, but in the ED it had increased to 110s spontaneously. HR ranged 35-60. She received vancomycin and ceftazidime, as well as about 3L NS. She also received calcium, insulin/dextrose, bicarb, and kayexelate for a potassium of 6.0. EKG was noted to be sinus bradycardia. A R femoral line was placed for access. . Her CXR was unchanged, her UA and culture were normal, and an abdominal CT showed focal thickening of the right colonic wall. She was started on ciprofloxacin and metronidazole, and her fevers defervesced and her delirium improved. Past Medical History: - h/o pancreatic adenocarcinoma s/p Whipple in [**2160**] and L hepatic lobectomy with feeding jejunostomy [**10-6**] c/b postoperative nonconvulsive seizures, chronic biliary leak, and pleural effusion - endoscopic myotomy for upper esophageal achalasia and a Zenker's diverticulum - VRE - h/o pleural effusion [**2-4**] with +WBC, culture negative, cytology negative Social History: Lives in [**Location 745**] with her husband. [**Name (NI) **] a personal care attending who helps her walk and dress. No tobacco, EtOH, or IVDU. Family History: noncontributory Physical Exam: VS: 99.2, 120/32, 69, 20, 97% on RA Gen: NAD, lying flat in bed, appears comfortable HEENT: PERRL, MMM, OP clear Neck: no JVD, supple Lungs: Decreased breath sounds [**12-3**] way up R lung Heart: RRR, II/VI systolic murmur at the base Abd: +BS, soft, J tube in place with erythma and small amount of purulent drainage around site. Mild LLQ tenderness with no rebound or guarding. Extrem: No edema. Warm and well perfused. 2+ DP pulses. Neuro: A+Ox1. Answers most questions appropriately. Follows commands. Moving all extremities. Further exam limited by patient cooperation. Pertinent Results: Admit Labs [**2171-10-11**] 01:55PM BLOOD WBC-16.8*# RBC-3.41* Hgb-11.3* Hct-31.6* MCV-93 MCH-33.2* MCHC-35.9* RDW-16.5* Plt Ct-217 [**2171-10-11**] 01:55PM BLOOD Neuts-84.5* Lymphs-9.8* Monos-3.3 Eos-2.3 Baso-0.1 [**2171-10-11**] 01:55PM BLOOD Glucose-114* UreaN-28* Creat-1.5* Na-128* K-6.0* Cl-99 HCO3-22 AnGap-13 [**2171-10-11**] 07:48PM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.2 Mg-2.1 [**2171-10-11**] 07:48PM BLOOD ALT-22 AST-38 LD(LDH)-177 CK(CPK)-351* AlkPhos-547* Amylase-40 TotBili-0.7 [**2171-10-11**] 01:55PM BLOOD PT-17.4* PTT-30.3 INR(PT)-1.6* [**2171-10-11**] 01:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024 [**2171-10-11**] 01:20PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2171-10-11**] 01:20PM URINE RBC-0-2 WBC-[**2-3**] Bacteri-OCC Yeast-NONE Epi-[**2-3**] . Imaging . CXR: Large right-sided pleural effusion increasing size since the prior examination. A small left-sided pleural effusion appearing since the prior examination. . Head CT: No evidence of intracranial hemorrhage or mass. No change from [**2171-8-2**]. Brief Hospital Course: MICU course: Pt was admitted from the ED to the MICU for management of presumed early sepsis, but by the early AM following her admission, her symptoms had dramatically improved. Upon evaluation on the morning of [**10-12**], pt was normotensive with excellent mentation, and a benign physical exam. Pt's WBC continued to trend downward, BCX failed to identify a pathogen, and c-diff assay was negative x1. CK also continued to trend down. Hyperkalemia resolved with reversal of EKG changes following treatment in ED. ARF responded to fluid resuscitation and trended down toward baseline. Due to her clinical improvement, pt was stepped-down to the floor for futher observation and treatment. Floor course: 80 year old woman with a history of pancreatic CA, L hepatic lobectomy, pleural effusion, who presents with fever, elevated WBC, LLQ tenderness, and persistent pleural effusion on CXR . ## Fever: Elevated WBC on admission with left shift but no bands. UA clean. CXR with increased R pleural effusion and small L pleural effusion. LLQ tenderness was concerning for possible diverticulitis. J tube drainage was also suspicious for source of infection. Colonic wall thickening on Ab CT thought to be the root of her fevers. Blood cultures showed no growth at the time of discharge. She was continued on ciprofloxacin and metronidazole for a total of a 14-day course. . ## Delirium: Likely related to fevers/infxn. Has improved as her fever curve has defervesced. At discharge, she was close to baseline, per her family, although she continued to be very anxious. . ## Tachypnea: Pt tachypneic but satting fine on room air. Likely related to anxiety, as she is not tachypneic when she sleeps. There was no evidence of L- or R-sided volume overload on exam. Also could be due to chronic pleural effusion. Will need to f/u with Dr. [**Name (NI) **] regarding tx for pleural effusion. . ## Pleural effusion: Present since hepatic lobectomy. Unclear etiology per medical records. Apparently pleurodesis vs. pleurex catheter have been considered, although pt was comfortable at home before presenting with delirium. ? whether dyspnea is due to anxiety vs. pleural effusion. . ## ARF: Baseline Cr 0.7-0.8, elevated to 1.5 on admission. Resolved with fluid administration. . ## Anemia:</I> Recent baseline 29-33. Hct 31.6 on admission. Down to 27.2. Previous iron studies c/w anemia of chronic inflammation. Likely also due to volume resuscitation. . ## Pancreatic CA: s/p Whipple. No active issues . ## h/o seizures: Recently tapered off keppra. No evidence of seizure activity . ## Paroxysmal afib: Not anticoagulated. Episodes seem to mostly occur when ill with urosepsis, etc. In sinus rhythm at time of discharge. . ## HTN: Currently normotensive. Initially held BP meds as were worried about BP. Discharged on home regimen. Medications on Admission: Pepcid 20 mg PO at bedtime Aspirin 325 mg daily Metoprolol Tartrate 12.5 mg PO BID Amylase-Lipase-Protease 468 mg PO TID Zoloft 50 mg daily Loperamide 2 mg PO QID prn diarrhea. Captopril (uncertain of dose) Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Name (NI) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Aspirin 325 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily). 3. Amylase-Lipase-Protease 468 mg Tablet [**Name (NI) **]: One (1) Tablet PO TIDAC (3 times a day (before meals)). 4. Sertraline 50 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily). 5. Loperamide 2 mg Capsule [**Name (NI) **]: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 6. Metronidazole 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a day). Disp:*33 Tablet(s)* Refills:*0* 7. Ciprofloxacin 250 mg Tablet [**Name (NI) **]: Two (2) Tablet PO Q24H (every 24 hours). Disp:*22 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet [**Name (NI) **]: 0.5 Tablet PO BID (2 times a day). 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily). 10. Captopril 12.5 mg Tablet [**Name (NI) **]: 0.5 Tablet PO TID (3 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: colitis . Secondary: Pancreatic CA s/p resection R pleural effusion s/p hepatic lobectomy Hypertension Paroxysmal atrial fibrillation Discharge Condition: Stable, afebrile Discharge Instructions: Please return to the hospital or call your PCP if you experience chest pain, shortness of breath or fevers. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2171-10-30**] 11:00

[ "558.9", "285.29", "276.1", "V10.09", "511.9", "427.31", "345.90", "276.7", "584.9" ]

icd9cm

[ [ [] ] ]

[ "97.02" ]

icd9pcs

[ [ [] ] ]

8094, 8152

3965, 6800

312, 319

8339, 8358

2815, 3852

8615, 8761

2186, 2203

7058, 8071

8173, 8318

6826, 7035

8382, 8592

2218, 2796

253, 274

347, 1613

3861, 3942

1635, 2006

2022, 2170

76,390

149,222

42238

Discharge summary

report

Admission Date: [**2110-11-18**] Discharge Date: [**2110-12-3**] Date of Birth: [**2030-10-19**] Sex: F Service: NEUROLOGY Allergies: lisinopril Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: lethargy Major Surgical or Invasive Procedure: None History of Present Illness: 80F with hx of HTN, DM, hypothyroidism who was recently admitted for left thalamic and right frontoparietal intraparenchymal hemorrhages secondary to cerebral venous thrombosis of unknown etiology. She was discharged on [**11-6**] and subsequently readmitted on [**11-8**] for altered mental status, thought to be related to UTI. She was discharged on [**11-9**] on cefpodoxime. She represented to [**Hospital **] hospital with worsening lethargy at which point urine culture showed extended spectrum resistant klebsiella. She was started on Meropenem on [**11-13**] to be continued for a 14-day course. She continued to have intermittent episodes of somnolence at the OSH. Neurology was consulted and an EEG was performed which showed slowing (on prelim read). CT scans were reportedly stable. She was transferred to [**Hospital1 18**] on [**2110-11-18**] for further management. Past Medical History: Hypothyroidism HTN Gout DM HLD Social History: Had lived alone until recent admission in [**10/2110**]; has been in and out of hospitals and rehab since then. Family History: No hx of early strokes. Physical Exam: Physical exam on admission: Vitals: T96.6 P 57 R 22 O2 97% CPAP, BP 132/77 General: Sleeping, arouses to loud voice and stimulation, denies pain HEENT: NC/AT Neck: Supple, No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: soft. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: - Had her eyes closed. opens to voice. not following any commands. No verbal output now. Looks to right and left (tracks). Moving all four ext but not giving much effort and not antigravity when testing. I did not apply pain to further test. Pupils reactive, equal. face looks symmetric. did not give me a smile. Reflex are brisk. no big asymmetry noted. Toes equivocal. Tone normal. Physical Exam on Discharge: Vitals: T 98.9 BP 160/80 HR 70 RR 18 O2 99% on CPAP General: Awake and alert, lying in bed in NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Opens eyes spontaneously, smiles at examiner. Able to state name and answer a few yes/no questions. Follows both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm and brisk. III, IV, VI: EOMI full, no nystagmus V: intact to light touch VII: No facial droop, facial musculature symmetric. VIII: Hearing intact bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: Poor effort but appears intact XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. Raises both arms antigravity and provides some resistance on strength testing. Raises proximal legs slightly off bed. Mild 4/5 weakness in LUE and LLE. -Sensory: Responds to light touch throughout -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 3 1 R 2 2 2 2 1 Strong withdrawal to plantar stimulation bilaterally. -Coordination: unable to assess -Gait: deferred Pertinent Results: [**2110-11-19**] 03:48AM BLOOD WBC-4.9 RBC-3.42* Hgb-10.5* Hct-33.6* MCV-98 MCH-30.7 MCHC-31.2 RDW-15.1 Plt Ct-253 [**2110-11-19**] 03:48AM BLOOD Neuts-55.9 Lymphs-31.5 Monos-6.1 Eos-5.9* Baso-0.5 [**2110-11-19**] 03:48AM BLOOD Plt Ct-253 [**2110-11-19**] 03:48AM BLOOD PT-32.1* PTT-56.6* INR(PT)-3.2* [**2110-11-19**] 03:48AM BLOOD Glucose-128* UreaN-11 Creat-0.8 Na-145 K-3.5 Cl-104 HCO3-30 AnGap-15 [**2110-11-19**] 08:50AM BLOOD ALT-14 AST-16 AlkPhos-60 TotBili-0.4 [**2110-11-19**] 06:09AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2110-11-19**] 06:09AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.0 Leuks-LG [**2110-11-19**] 06:09AM URINE RBC-85* WBC->182* Bacteri-NONE Yeast-MANY Epi-0 [**2110-11-19**] 06:09AM URINE CastHy-12* [**2110-11-19**] 06:09AM URINE Mucous-MOD CXR [**2110-11-19**]: In comparison with the study of [**11-8**], there are continued low lung volumes without vascular congestion or pleural effusion. Left central catheter extends to the level of the mid portion of the SVC. MRI/MRV [**2110-11-19**]: 1. New FLAIR/T2 signal abnormalities within the medial parieto-occipital lobes, bilaterally with associated petechial hemorrhage and mild enhancement. Areas of slow diffusion within the splenium and right thalamus appear to have progressed to venous infarction (with surrounding cytotoxic edema). These findings are most consistent with changes from subacute-to-chronic venous occlusive disease/venous hypertension 2. Residual hemorrhage present within the left thalamus and right frontoparietal lobe. Trace hemorrhage remains in the occipital horns of the lateral ventricles. 3. Straight sinus better seen on today's study. Internal cerebral veins remain less visible, however. EEG [**2110-11-20**]: IMPRESSION: This is an abnormal extended routine EEG due to a moderately slow and disorganized background. There were intermittent generalized blunted sharp wave discharges that at times appeared pseudoperiodic. The latter finding in combination with generalized background slowing is indicative of an underlying moderate encephalopathy. Potential causes include but are not limited to: medication effect, metabolic/ toxic, or infectious disturbances. Additionally, the brief intermittent bursts of generalized delta slowing of background are indicative of deep midline cerebral dysfunction. CXR [**2110-11-20**]: Borderline cardiomegaly unchanged. Lungs grossly clear. Pleural effusions small, if any. Left PIC catheter ends at the junction of brachiocephalic veins. No pneumothorax. Cerebral angiogram [**2110-11-24**]: FINDINGS: Right common carotid artery arteriogram shows that the right common carotid artery is widely patent with no evidence of stenosis at the bifurcation. The intracranial runs demonstrate that the right internal carotid artery fills well along the cervical, petrous, cavernous and supraclinoid portion. Both anterior and middle cerebral arteries are seen normally with no evidence of aneurysms or dural AV fistula. The external carotid artery branches did not show any evidence of AV dural fistula. The venous sinuses are seen in their entirety. The superior sagittal sinus and both transverse sinuses including the torcula is patent. Both jugular bulbs are open. The straight sinus is visualized along with the basal vein of [**Doctor Last Name **]. The internal cerebral vein is not seen. Right common femoral artery arteriogram shows widely patent right common femoral artery. KUB [**2110-11-30**]: There is no free air. There is air seen in the small and large bowel and the rectum in a non-specific pattern. A G-tube is in place. There are some degenerative changes in the lower lumbar spine. Brief Hospital Course: Ms. [**Known lastname 91562**] was admitted to the neurology service on [**2110-11-18**] after being transferred from [**Hospital **] hospital for further workup of intermittent episodes of somnolence. Repeat MRI/MRV showed some new areas of signal abnormality in the b/l medial occipital lobes, as well as areas of restricted diffusion in the splenium and R thalamus suggestive of subacute to chronic [**Last Name (un) **]-occlusion. MRV showed better visualization of the straight sinus as compared with her prior study, but the deep cerebral veins were still unable to be visualized. EEG showed evidence of diffuse encephalopathy but no epileptiform activity. She was also found to have several metabolic disturbances which were likely contributing to her somnolence. She was continued on Meropenem for her UTI. Repeat urine culture showed yeast; per ID this was felt to most likely represent colonization. A second UA and culture were performed at the end of her antibiotic course and was clear. She was also treated for hypernatremia to 150. Her TSH was 14 on admission; it appeared that her levothyroxine had been stopped for unclear reasons. This was restarted. She was also maintained on CPAP for severe OSA. An angiogram was performed on [**2110-11-26**] to better evaluate her thrombosis and showed clear cerebral venous sinuses with no evidence of thrombosis or occlusion. No interventions were performed. She was restarted on her heparin and coumadin. She was seen by speech and swallow but failed swallow evaluation several times throughout her stay. She was maintainted NPO on IVF; we were unable to place an NG tube due to the necessity of her CPAP mask. After discussion with her family a PEG tube was placed on [**2110-11-28**]. Tube feeds were started and gradually advanced. On [**11-30**] she was witnessed to have brownish-colored emesis which was heme positive. Heparin gtt was stopped. She was started on Protonix IV. Hb/hct remained stable. She was continued on coumadin. Tube feeds were restarted at a low rate on [**12-1**] and slowly titrated up. She was restarted on all of her home medications. Blood pressure began to run high in the 160-180's; she was started on amlodipine 5mg daily in addition to her home atenolol 25mg [**Hospital1 **]. Her mental status fluctuated somewhat throughout her hospitalization but she gradually began to improve. Ritalin was increased to 5mg [**Hospital1 **] on [**12-2**]. By her discharge she was much more awake and alert, opening her eyes spontaneously, saying a few words, and following some commands. She was seen by PT and OT who recommended acute rehab placement upon discharge. She was discharged to [**Hospital3 7665**] on [**2110-12-3**] in stable condition. She will follow up with Dr. [**First Name (STitle) **] in clinic. TRANSITIONAL CARE ISSUES: Ms. [**Known lastname 91562**] will require intensive PT and OT to regain her prior level of functioning. She will also need to be followed by speech therapy to assess her swallow function as well as respiratory therapy to continue her CPAP treatment. She will require daily INR checks until therapeutic between [**3-20**]. ***Coumadin should be HELD on evening of [**12-3**] and restarted at 2mg daily on [**12-4**] pending repeat INR.*** She will also need monitoring of her potassium and magnesium with repletion as needed. Her electrolyte imbalances should improve now that she is on a stable tube feeding regimen. Medications on Admission: Meropenenm 500 IV Q 8 start [**2110-11-13**] Coalce 100 [**Hospital1 **] Atenolol 25 daily synthroid 0.1 daily ritalin 2.5mg [**Hospital1 **] pepcid 20 daily zocor 40 daily RISS tylenol PRN Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Patient may refuse. Hold if patient has loose stools. 3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. miconazole nitrate 2 % Cream Sig: One (1) Topical [**Hospital1 **] (2 times a day). 15. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. 16. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-16**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 17. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO once a day. 18. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). 20. Pepcid 40 mg/5 mL Suspension Sig: One (1) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Intraparenchymal hemorrhage Somnolence Hypothyroidism Discharge Condition: Mental status: arouses to voice, answers some yes/no questions, follows some simple commands Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 91562**], You were admitted to [**Hospital1 69**] on [**2110-11-18**] with episodes of somnolence. An MRI of your brain showed stable appearance of the bleeding in your brain but also showed slight worsening of the abnormalities in your thalamus on both sides (an area important for staying awake). You were also found to have a high sodium level and very low levels of thyroid hormone. You were continued on antibiotics for your urinary tract infection. You were maintained on CPAP for your sleep apnea. Your sleepiness is likely due to a combination of all of these factors. You had an angiogram performed on [**2110-11-26**] to take a better look at the blood clot in your cerebral vein. This showed that the blood clot has dissolved and your vessels are now clear. You were evaluated by speech therapy but continued to have difficulty swallowing during your admission. A PEG tube was placed on [**2110-11-28**] to help give you nutrition. We made the following changes to your medications: DECREASED Coumadin to 2mg daily INCREASED Ritalin to 5mg twice a day to help you stay awake STARTED Amlodipine 5mg daily for your blood pressure STARTED Potassium 40meQ daily for supplementation RESTARTED Levothyroxine 100mcg daily for your hypothyroidism If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay. Followup Instructions: The following appointment has been made for you in our stroke clinic: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2111-1-5**] 1:00

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2199-5-23**] Discharge Date: [**2199-5-29**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1711**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 174**] is an 88 year old woman who was admitted to the hospital for chest pain (sudden, epigastric pain radiating to back) on [**2199-5-23**] and had MRA that showed an almost completely thrombosed focal dissection at the superior aspect of the aortic arch with no involvement of the ascending aorta. The pt was initially admitted to CT surgery but Dr. [**Last Name (STitle) 914**] evaluated the pt and determined that since the dissection is type B (does not go into aorta) management would be medical, and the pt was called out to the floor on [**2199-5-24**]. On the morning of [**2199-5-25**] the pt was due to be discharged, but was noted to have a new hct drop, acute renal failure and a rise in CK and troponin. . Of note, the pt recently sustained a mechanical vs. syncopal fall 1 week ago and does not remember the event. She reportedly was brought to the [**Hospital 756**] Hospital (may have been [**Name (NI) 34109**], unclear) and was diagnosed with a [**Name (NI) 12952**] fracture. She was set up with follow up and was told to wear a C-collar for at least 6 weeks. . . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for transient chest pain this afternoon ([**2199-5-25**]) and ankle edema, but no dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: unstable C-2 fracture hypertension coronary artery disease s/p PTCA [**10**] years ago prior myocardial infarction breast cancer with XRT atrial fibrillation anemia hypercholesterolemia GI bleed Social History: Lives with daughter in a suite attached to daughter's house. Since recent cspine fx has been at [**Hospital 582**] Rehab. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: father with CVA Physical Exam: VS: Tm= 99.1, Tc= 97.2 BP= 101/56 HR= 40 RR= 18 O2 sat= 95%RA GENERAL: Thin, elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Pinpoint pupils, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: C collar in place. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Bradycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: +kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Symmetric bilateral 1+ pitting edema to knees. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2199-5-26**] 07:15AM BLOOD WBC-10.0 RBC-3.66* Hgb-10.4* Hct-31.2* MCV-85 MCH-28.4 MCHC-33.4 RDW-17.8* Plt Ct-257 [**2199-5-26**] 07:15AM BLOOD Glucose-90 UreaN-67* Creat-3.5* Na-133 K-5.3* Cl-104 HCO3-14* AnGap-20 [**2199-5-24**] 03:07AM BLOOD ALT-49* AST-123* AlkPhos-103 Amylase-186* TotBili-0.3 [**2199-5-26**] 07:15AM BLOOD CK(CPK)-689* [**2199-5-26**] 07:15AM BLOOD CK-MB-1 EKG: afib in the 40's, no ST changes from prior . TELEMETRY: afib in the 40's . MRA OF THE CHEST, [**2199-5-23**] AT 20:43: FINDINGS: The ascending aorta is normal in caliber measuring 3.5 cm in maximum diameter with no evidence of intramural hematoma or intimal flap. The transverse dimension of the aortic arch is 3.1 cm. At the distal, superior aspectof the arch beyond the origin of the left subclavian artery, there is a cap of relatively low signal material in a lenticular shape on the bright blood sequences. This cap measures 4.9 cm in length and 1.4 cm in thickness, terminating at the beginning of the descending aorta. On coronal images, there is an irregular interface with the flow lumen. The findings are consistent with an isolated dissection that is almost completely thrombosed. Some axial cine images suggest some trace flow within. The descending aorta, beyond this finding, shows no evidence of intimal flap, intramural hematoma or penetrating atherosclerotic ulcer, and at the level of the pulmonary artery, the descending aorta measures 2.5 cm in maximum diameter. There are bilateral pleural effusions and no evidence of a pericardial effusion. The proximal aspect of the abdominal aorta to the level of the origin of the celiac axis is normal in caliber without dissection. There are bilateral renal cysts incidentally seen. . IMPRESSION: Findings most consistent with isolated almost completely thrombosed focal dissection to the superior aspect of the aortic arch. No involvement of the ascending aorta. Maximum diameter of the arch, including the thrombosed component, is 4.4 cm (craniocaudad dimension). There are bilateral pleural effusions; no pericardial effusion. . CT C spine w/ contrast: IMPRESSION: Type 2 dens fracture with a subacute appearance. No other fractures are identified. Extensive degenerative changes with prominent posterior osteophytes. Spinal cord contusion cannot be excluded on this study. Final Attending Comment: There is also prominent epidural soft tissue at th fracture site. Recommend MRI to exclude hematoma although this may represent a prominent epidural venous plexus. . CT HEAD: IMPRESSION: No subdural hematoma. No acute intracranial process. . CXR: IMPRESSION: Partial left lower lobe collapse and a small left pleural effusion. 5* MB Indx-2.2 cTropnT-10.00* Brief Hospital Course: 88 year old woman who was admitted to the hospital with chest pain, found to have an aortic dissection, now in ARF, with new anemia and a troponin elevation. . CVICU COURSE: Patient was admitted and MRA done of chest which showed localized Type B aortic dissection with localized thrombosis in aortic arch. Pt. seen and evaluated by Dr. [**Last Name (STitle) 914**]. She was determined not to be a surgical candidate for any thoracic aortic surgery, and was admitted to the CVICU for BP control and neck pain management. . ACUTE RENAL FAILURE: Patient developed progressive renal failure, with a creatinine on admission of 1.7 that rose to 4.2 and near anurea. Renal u/s with non-obstructive calculus and no hydronephrosis. Low FeNa but isoomotic urine. Her symptoms were likely ATN from contrast load on [**2199-5-23**] at [**Hospital1 18**] [**Location (un) 620**]. Renal was consulted. Her urine output and creatinine are improving. - [**Last Name (un) **] and hctz, would plan to restart [**Last Name (un) **] once ARF improved - She was treated with NaHCO3 given acidosis - continue daily labs and repleat/adjust electrolytes PRN . ALTERED MENTAL STATUS: Patient had some waxing/[**Doctor Last Name 688**] confusion c/w delerium in the setting of NSTEMI, ARF, and prolonged hospitalization. Her mental status is improving with recovery of kidney and cardiac function. - held opiates, standing Tylenol, continued to reorient . CORONARIES: Troponin elevation consistent with NSTEMI/demand ischemia, although may be elevated [**2-18**] ARF. Patient has h/o MI and PCTA many years ago but no recent eval. EKG from Neeham showed STE in III and aVF and reciprocal depressions in I and aVL, but now normalized and patient is chest pain free. Will continue medical managment as renal failure increases morbidity of cath. Echo shows some regional wall motion abnormality but overall relatively well preserved systolic function with an ef 40-45%. She was not treated with beta-blocker given bradycardia, but was continued on statin and plavix. . PUMP: Cardiac echo as above - Continue losartan once ARF improves . RHYTHM: Afib with slow ventricular response on telemetry currently. This is c/w EKG from [**Hospital1 112**] from a week ago. She has elected not to be treated with coumadin. This possibiltiy was readdressed. She was continued on aspirin and plavix. . ANEMIA: Admission Hct 35 and then fell to 27.4. She recieved 2 units of blood and is now at reported baseline of ~30. There was concern about neck fracture with CT showing "prominent epidural soft tissue at the fracture site, recommend MRI to exclude hematoma". Given normal neuro exam and stable Hct, will defer on MRI for now. . C2 FRACTURE: Collar in place. She was evaluated by neurosurgery who recommended non-operative management and outpatient follow up. She should have a collar for 6 weeks. . HYPOTHYROIDISM: Home synthroid. . PROPHYLAXIS: -DVT ppx with pneumoboots -Pain management with dilaudid -Bowel regimen with as above . CODE: Presumed full Medications on Admission: norvasc 10 mg daily cozaar 100 mg daily zoloft 50 mg daily zocor 80 mg daily toprol XL 100 mg daily plavix 75 mg daily HCTZ 25 mg daily temazepam 15 mg QHS protonix 40 mg daily Tums Vitamin D Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 doses. 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 BID (2 times a day). 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 10. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 15. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 1 days. 16. Outpatient Lab Work Please monitor Hct and electrolytes daily 17. Omnipred 1 % Drops, Suspension Sig: One (1) gtt OS Ophthalmic twice a day. 18. Zymar 0.3 % Drops Sig: One (1) gtt OS Ophthalmic twice a day. 19. Acular 0.5 % Drops Sig: One (1) gtt OS Ophthalmic twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: NSTEMI Acute renal failure/contrast nephropathy Type B aortic dissection with thrombus unstable C-2 fracture hypertension coronary artery disease s/p PTCA [**10**] years ago prior myocardial infarction breast cancer with XRT atrial fibrillation anemia hypercholesterolemia GI bleed Discharge Condition: stable Discharge Instructions: It was a pleasure taking care of you at the [**Hospital1 18**]. You were admitted to the hospital with a neck fracture and found to have a heart attack and renal failure. You were evaluated by neurosurgery and admitted to the cardiology service. You were treated with medications for the heart attack and you were given electrolytes to correct your renal function. You were monitored for potential dialysis but did not need it. You should followup with Dr. [**Last Name (STitle) 914**] in 3 months. You will need CTA of chest/abd. You MUST WEAR cervical collar for 6 weeks. You should follow up with your neurosurgeon from the [**Hospital1 756**]. Please seek medical attenion for fevers, chest pain, shortness of breath, or any other concerning symptom. Followup Instructions: - Please see [**Hospital1 756**] neurosurgeon for followup of C-2 fracture within the next 3 weeks - Please see your PCP, [**Last Name (NamePattern4) **]. [**Hospital Ward Name 93841**] in [**1-18**] weeks. Please call [**Telephone/Fax (1) 56757**] to set up this appointment - Please see CT surgeon Dr. [**Doctor Last Name 93842**] [**Telephone/Fax (1) 170**] to arrange clinic appt - Please schedule an appointment with a kidney doctor within the next 2 weeks. You can call [**Telephone/Fax (1) 3637**] to set this up Completed by:[**2199-6-1**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2112-4-28**] Discharge Date: [**2112-5-8**] Date of Birth: [**2058-11-17**] Sex: M Service: SURGERY Allergies: Kiwi (Actinidia Chinensis) Attending:[**First Name3 (LF) 1384**] Chief Complaint: HCC/HCV cirrhosis, liver failure Major Surgical or Invasive Procedure: Liver [**First Name3 (LF) 1326**] [**2112-4-28**] History of Present Illness: 53 M diagnosed with HCC and HCV cirrhosis in [**6-/2111**], presents for OLT. He was last seen by Hepatology (Dr [**Name (NI) **]) in [**Month (only) 404**] at which time his MELD was 28. Past Medical History: He was diagnosed with cirrhosis and HCC in [**6-/2111**] for which he underwent cyberknife therapy in 6/[**2111**]. He has been listed for liver [**Year (4 digits) **] since 6/[**2111**]. He has had an EGD at an OSH in [**2110-8-13**] with grade 2 esophageal varices and portal hypertensive gastropathy. He also had a colonoscopy in [**Month (only) 956**] [**2110**] which showed rectal varices. He was last seen by Hepatology on [**2111-11-18**] at which time his MELD was 25 and his diurectics were increased for ongoing lower extremity edema. He has also had ongoing issues with poor sleep. Social History: Positive for EtOH abuse but sober seven years. Positive for tobacco. Question of past cocaine use. Lives alone. Not currently working. Family History: Mother - colon cancer Father - ESRD Physical Exam: Afebrile, vitals wnl Gen - A&O x 3 NAD Pulm - CTAB CV - rrr no m/g/r Abd - +BS, ND, mild TTP near subcostal and midline incisions Extrem - no c/c/e Pertinent Results: [**2112-4-28**] WBC-5.3 Hct-37.6* Plt Ct-92* [**2112-4-28**] WBC-12.9* Hct-29.4* Plt Ct-105* [**2112-4-28**] WBC-21.7* Hct-24.5* Plt Ct-77* [**2112-4-29**] WBC-14.7* Hct-30.6* Plt Ct-89* [**2112-4-30**] WBC-14.4* Hct-28.7* Plt Ct-78* [**2112-4-30**] WBC-19.2* Hct-31.0* Plt Ct-72* [**2112-5-2**] WBC-14.3* Hct-30.3* Plt Ct-81* [**2112-4-28**] PTT-32.7 INR(PT)-1.3* [**2112-4-28**] PTT-150* INR(PT)-3.1* [**2112-4-28**] PTT-150* INR(PT)-2.9* [**2112-4-28**] PTT-72.1* INR(PT)-2.2* [**2112-4-29**] PTT-26.2 INR(PT)-1.3* [**2112-4-29**] PTT-25.9 INR(PT)-1.2* [**2112-4-30**] PTT-23.6 INR(PT)-1.1 [**2112-5-2**] PTT-23.0 INR(PT)-1.0 [**2112-4-28**] Creat-0.8 Na-139 K-3.7 [**2112-4-29**] Creat-1.5* Na-137 K-4.0 [**2112-4-29**] Creat-1.6* Na-138 K-4.1 Cl-104 [**2112-4-30**] Creat-1.4* Na-138 K-3.6 Cl-102 [**2112-5-2**] Creat-0.8 Na-135 K-4.2 Cl-102 [**2112-4-28**] ALT-226* AST-303* AlkPhos-95 TBili-1.3 [**2112-4-28**] ALT-1444* AST-[**2126**]* AlkPhos-51 Amylase-33 TBili-2.4* LD(LDH)-3050* [**2112-4-29**] ALT-1155* AST-1646* AlkPhos-52 TBili-2.6* DBili-1.9* IBili-0.7 [**2112-4-29**] ALT-749* AST-727* AlkPhos-52 TBili-4.0* [**2112-4-30**] ALT-621* AST-501* AlkPhos-50 TBili-2.3* [**2112-5-1**] ALT-485* AST-253* AlkPhos-70 TBili-1.6* [**2112-5-2**] ALT-399* AST-122* AlkPhos-75 TBili-1.3 LD(LDH)-398* [**2112-5-3**] ALT-318* AST-105* AlkPhos-74 TBili-1.4 [**2112-5-4**] ALT-316* AST-110* AlkPhos-91 TBili-1.3 [**2112-5-5**] ALT-270* AST-118* AlkPhos-119 TBili-2.5* [**2112-5-6**] ALT-272* AST-92* AlkPhos-197* TBili-4.5* [**2112-4-29**] POD 1 Liver U/S - IMPRESSION: 1. Status post liver [**Month/Day/Year **] with patent vasculature. 2. 9-cm hematoma inferior to the porta hepatis and small amount of free fluid throughout the abdomen and pelvis. [**2112-5-5**] Liver U/S: IMPRESSION: 1. Status post liver [**Month/Day/Year **] with patent vasculature. 2. Two focal fluid collections adjacent to the left lateral segment (measuring 3 cm) and inferior to the right lobe of the liver (measuring approximately 1.4 cm) are noted. 3. Two echogenic structures within the transplanted liver may represent surgical clips versus calcifications and less likely pneumobilia and are in unchanged position compared to [**2112-4-29**]. [**5-6**] ERCP - Impression: The [**Month/Year (2) **] bile duct above the stricture was approximately 5mm and the native CBD was approximately 8mm. Given the small contrast leak at the anastomosis, balloon dilation of the stricture was not performed. A sphincterotomy was performed in 12 o'clock position with a sphincterotome successfully. A 10Fr x 9cm Advanix plastic biliary stent was placed across the stricture with excellent drainage of bile and contrast. Brief Hospital Course: The patient was admitted to the [**Month/Year (2) 1326**] surgery service on [**2112-4-28**] and had an Orthotopic liver [**Date Range **]. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative note for further details. The patient tolerated the procedure well and was transferred intubated to the SICU for management. On POD 1 he was found to have a large hematoma near the porta and was taken back to the OR for washout and evacuation of the hematoma. This procedure was also well tolerated. Neuro: Post-operatively, the patient received Fentanyl & Dilaudid IV with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was hypertensive on beginning POD 1 and initially required hydralazine IV. Once tolerating Po he was switched to PO Norvasc and Lopressor. The patient was otherwise stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Following extubation, the patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: IV fluids were given until tolerating oral intake. His diet was advanced to clears on POD 3 and to a regular diet on POD 4, which was tolerated well. Patient had lower extremity edema and rhonchi on auscultation. The lateral JP, located in the hepatic/diaphragmatic gutter was discontinued on POD [**5-3**] and the medial JP, located near the porta hepatis was discontinued on [**5-8**]. He was thought to be fluid oveloaded and on POD 3, 4, & 6 and was administered Lasix IV. Foley was removed on POD 4, once his fluid status had stabalized. Intake and output were closely monitored. The patients LFT's increased on POD 7&8 and he underwent an unremarkable liver U/S. on POD 8 he had an ERCP that showed a stricture and a small bile leak at the CBD anastamosis. A plastic stent was placed by GI. The patient tolerated the procedure well and his LFT's trended down after the procedure. Endo: He experienced hyperglycemia from the steroids and required and insulin drip for several days. This was transitioned to Glargine and a Humalog sliding scale per the consulting [**Name8 (MD) **] MD. He was taught how to check his blood glucose and how to draw up and administer insulin. VNA services were arranged to assist at home as insulin was new for him. ID: Post-operatively, the patient was started on Bactrim, Valcyte, and Fluconazole for PCP, [**Name Initial (NameIs) 1074**]/EBV, and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **]. The patient's temperature was closely watched for signs of infection. Immunosuppression: He received induction immunosuppression (solumedrol and cellcept). Postop, solumedrol was taperedb by post op day 6 to prednisone 20mg daily. Cellcept 1 gram [**Hospital1 **] was well tolerated. Prograf was initiated on postop day 1 and dose adjusted per daily trough levels. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD [**11-20**], the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. PT cleared him for home. VNA for medication (newly on insulin) was arranged. Medications on Admission: Pantoprazole 40mg Daily, Nadolol 20mg Daily, Lasix 80mg Daily, Spironolactone 200mg daily, MVI, Fish oil Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. tacrolimus Oral 10. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 12. insulin glargine 100 unit/mL Solution Sig: Twenty Nine (29) units Subcutaneous once a day. Disp:*1 bottle* Refills:*2* 13. insulin lispro 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous four times a day. Disp:*1 bottle* Refills:*2* 14. tacrolimus Oral 15. insulin lispro 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous four times a day. Disp:*1 bottle* Refills:*2* 16. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous four times a day. Disp:*1 kit* Refills:*1* 17. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous four times a day. Disp:*1 bottle* Refills:*2* 18. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:*1 box* Refills:*2* 19. insulin syringe-needle U-100 1 mL 26 x [**2-14**] Syringe Sig: One (1) Miscellaneous four times a day: Low dose syringes. Disp:*1 box* Refills:*2* 20. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 doses. Disp:*7 Tablet(s)* Refills:*0* 21. Outpatient Lab Work Labs for AM Monday [**5-9**]: CBC, Chem 10, LFT's, Tacrolimus level 22. FreeStyle Lite Lancets and Strips Dispense 2 boxes of sterile lancets and test strips for glucose monitoring. FreeStyle Lite Refills: 2 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: HCC HCV cirrhosis HA anastomosis bleeding Hyperglycemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the [**Hospital 1326**] Office [**Telephone/Fax (1) 673**] if you have any of the following: fever, chills, nausea,vomiting, inability to take any of your medications, jaundice, increased abdominal/incision pain, incision redness/bleeding/drainage, constipation or diarrhea You will need to have blood drawn every Monday and Thursday at [**Last Name (NamePattern1) 439**] Lab on [**Location (un) 453**] You may not drive while taking pain medication. No heavy lifting/straining You may shower with soap and water, but do not put powder/ointment or lotion on your incision Followup Instructions: Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-5-18**] 11:20 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-5-12**] 9:30 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-5-19**] 2:00 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-5-26**] 1:40

[ "572.3", "998.12", "E932.0", "070.54", "155.0", "455.6", "537.89", "571.2", "456.1", "249.00", "276.69", "305.1", "997.4", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "54.12", "51.85", "50.11", "51.87", "00.93", "50.59" ]

icd9pcs

[ [ [] ] ]

10059, 10117

4347, 7734

319, 371

10217, 10217

1603, 4324

10976, 11564

1380, 1420

7890, 10036

10138, 10196

7760, 7867

10368, 10953

1435, 1584

247, 281

399, 589

10232, 10344

611, 1211

1227, 1364

32,478

162,614

44815

Discharge summary

report

Admission Date: [**2158-1-2**] Discharge Date: [**2158-1-7**] Date of Birth: [**2075-1-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: weakness, dark stool Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: 82yo M w/ Alzheimer's dementia, colon CA s/p R hemicolectomy, multiple myeloma, and CRI who presented with complaint of melena and weakness. He presented to [**Hospital 2657**] clinic today with c/o weakness and dark stools. Per his family, he fell twice in the bathroom and was very shaky and weak. They reported that he had been having very dark stools x 3 days. History is limited as the patient is an unreliable historian and his family is not available upon presentation to the ICU for clarification. He noted tremors for 2-3 minutes with left facial droop one day before admission. He had a repeat 30 second episode of tremors today. Symptoms have resolved. In the ED, T 97.5 BP 105/62 P 90 RR 16 SpO2 100%. His blood pressure dropped to 86/50 at times. Rectal exam with melena; unable to place NGT x 3. His Hct was 14.4 from his baseline of 36. GI was consulted and recommended ICU admission. He was crossmatched x 6 units, transfusing one unit prior to transfer. He also received a liter of NS. EKG showed STD in V4-V6 (new); cardiac enzymes negative. Neuro was consulted re TIA sx and will see him in the a.m. He went for Head CT prior to transfer. On arrival to the ICU, he denies SOB, chest pain, n/v, headache, back pain, fever/chills, abdominal pain, hematuria, dysuria, decreased urine output, frequency, or numbness/tingling/weakness of extremities. He states that he fell twice in the bathroom about 3-4 days ago but had no head injury. He claims he was dizzy but not lightheaded and got up immediately on his own. His family was not available at the time of admission to corroborate his story. Past Medical History: # Multiple Myeloma - recently diagnosed [**9-12**] - smoldering, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. # H/o colon cancer s/p post R hemicolectomy in [**2142**] and lysis for post-surgical adhesions in [**2143**]. Colonoscopy negative in [**2153**]. # H/o Pulmonary embolism. Started coumadin in [**10/2156**], stopped taking it in [**2157-6-5**] due to frequent falls. # Mixed Alzheimer's/vascular dementia # Hypothyroidism # Chronic kidney disease with baseline creat 1.5-1.6 # Glaucoma # h/o Achilles tendon status post repair. # Significant for retinitis pigmentosa # osteoarthritis # B12 deficiency NKDA Social History: Lives in [**Street Address(2) 58042**] Senior Independent Housing and has two private pay aides who help with laundry, cooking, cleaning. Family History: not available Physical Exam: VS: Temp: 97.5 BP: 104/58 HR:79 RR:18 O2sat 99% on RA GEN: Marked pallor. Pleasant, comfortable, NAD but inappropriately jovial affect; oriented to [**Location (un) 86**] and hospital but thinks it's "[**Location (un) 8599**]Hospital," and [**2077**], though he knows it's [**Month (only) 404**]. HEENT: +Conjunctival pallor. PERRL, EOMI, anicteric, MMM, no palpable LAD CV: Distant heart sounds. S1, S2, RRR, no m/r/g PULM: CTAB ABD: +BS, soft, NT, ND, no palpable mass. EXT: + clubbing; no LE edema NEURO: Orientation as above. Cannot answer why he is in the hospital. Attentive and follows commands appropriately. Strength 5/5 UE and LE both distal and proximal. No orbiting, no pronator drift. DTRs [**Name (NI) 20772**] throughout, toes equivocal. Sensation intact to light touch in LE and UE b/l, no extinction with b/l stimuli. + Fine, high frequency tremor in hands b/l. No difficulty with rapid alternating movements. Mild dysmetria with finger to nose b/l but appropriate to age. Pertinent Results: [**2158-1-2**] 04:10PM BLOOD WBC-12.4* RBC-1.66*# Hgb-4.8*# Hct-14.4*# MCV-87 MCH-28.7 MCHC-33.1 RDW-18.4* Plt Ct-227 [**2158-1-3**] 05:44AM BLOOD WBC-11.2* RBC-2.78*# Hgb-8.4*# Hct-24.4*# MCV-88 MCH-30.2 MCHC-34.4 RDW-16.7* Plt Ct-154 [**2158-1-3**] 05:44AM BLOOD PT-12.2 PTT-26.3 INR(PT)-1.0 [**2158-1-2**] 04:10PM BLOOD Glucose-118* UreaN-31* Creat-1.5* Na-137 K-4.1 Cl-106 HCO3-19* AnGap-16 [**2158-1-3**] 05:44AM BLOOD Glucose-96 UreaN-25* Creat-1.3* Na-140 K-4.0 Cl-111* HCO3-20* AnGap-13 [**2158-1-2**] 04:10PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2158-1-3**] 05:44AM BLOOD CK-MB-6 cTropnT-0.03* [**2158-1-3**] 05:44AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1 EKG: NSR @ 88, nl axis, 1 degree AV block, STD in V4-V6. Colonoscopy [**2153**]: Normal colonoscopy to anastamosis right transverse colon. CT Head [**2158-1-2**]: There is no evidence of acute intracranial hemorrhage, shift of normally midline structures, mass effect or acute major vascular territorial infarction. Symmetric large size of the ventricular system and prominence of the extra-axial CSF spaces is chronic and unchanged compared to [**2157-4-20**], compatible with involutional change. Approximately 9 x 3-mm focal hyperdensity along the falx cerebri is unchanged and likely a small meningioma. The small focus of hyperdensity in the right frontal lobe corresponding to susceptibility artifact on the recent MR study is less conspicuous on today's examination. As previously described, this more likely represents a cavernous malformation. There are small mucus-retention cysts in both maxillary sinuses. Mastoid air cells and middle ear cavities are clear. No concerning osseous or surrounding soft tissue abnormality. . [**1-3**] EGD Ulcer in the lower third of the esophagus (biopsy). Normal mucosa in the whole stomach. Erythema and congestion in the first part of the duodenum compatible with mild duodenitis. Small hiatal hernia. Otherwise normal EGD to second part of the duodenum Recommendations: 1. PPI po BID for 6 weeks 2. Repeat EGD in 6 weeks to follow ulcer healing. 3. Follow biopsy results 4. Colonoscopy in am to evaluate colon. [**1-5**] COLONOSCOPY: Findings: Lumen: Evidence of a previous side to side ileo-colonic anastomosis was seen at the hepatic flexure. Mucosa: Normal colonic mucosa was noted in the whole colon. Normal small bowel mucosa was noted in the terminal ileum. Impression: Previous side to side ileo-colonic anastomosis of the hepatic flexure. Otherwise normal colon and terminal ileum. Recommendations: Follow-up with refering physician as already scheduled Return to hospital floor Brief Hospital Course: 82yo gentleman with melena and Hct of 14, initially admitted to MICU for further care . # Melena/UGIB: No coagulopathy identified. Received 1 unit of PRBCs in the ED and three more during ICU course. HCT improved to 25. Was also given IV protonix 80mg x 1 then 8mg/hr gtt. 2 large bore pIVs (18g) were maintained. Bleeding resolved. Was kept NPO and GI performed EGD in the ICU, which showed large ulceration at GE junction with no active bleeding, and duodenitis. Pt was switched over to po PPI [**Hospital1 **] and serial HCTs were being followed at time of ICU transfer. Patient's ASA was discontinued. The patient was transfused one additional unit of PRBCs on the general medical floor on [**1-4**] and underwent prep for Colonoscopy. The colonoscopy showed evidence of a previous side to side ileo-colonic anastomosis at the hepatic flexure, with normal colonic mucosa in the whole colon. Normal small bowel mucosa was noted in the terminal ileum. H. pylori Ab was sent and was pending at the time of discharge. He will need to undergo a repeat EGD in 6 weeks to ensure resolution of this ulceration. On the medical floor he remained hemodynamically stable without evidence of recurrent bleeding, hematocrit 29, tolerating a regular diet. . # Episodes of tremor/facial droop: ? TIA or watershed infarcts in setting of decreased Hct. Difficult to evaluate given dementia. No neurologic findings on exam to indicate stroke; no mass effect or bleed on CT Head. No recurrence while on medical floor. While he may indeed have cerebrovascular disease, further evaluation (eg carotid dopplers) were deferred for now, as he is not a candidate for aspirin or Plavix in the setting of his acute GI bleed. This was discussed with his HCP/[**Month/Year (2) 802**] [**Name (NI) 1494**], and this can be readdressed by his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], especially after his follow-up endoscopy in 6 weeks. . # CKD stage III: Was admitted at his baseline Cr of 1.5-1.6 and maintained good urine output. CKD may be from multiple myeloma. Had Foley placed in ED and maintained through ICU course. It was d/c'd on the floor on [**1-4**], no further issues. . # H/o PE: L lower lobe segmental and subsegmental PE. Previously on coumadin, but not currently anticoagulated at home due to fall risk and now due to active bleeding issues. . # History of colon cancer: colonoscopy negative [**2153**]; no active treatment, and with source for GIB identified, a bleeding tumor is unlikely to be the etiology for his presentation. . # Dementia: Mild mixed Alzheimer and vascular. Continued Aricept, Zocor. Discontinued ASA as above, explained to HCP/[**Year (4 digits) 802**] [**Name (NI) 1494**]. . # Hypothyroidism: Continue levoxyl 125mcg qday. TSH elevated at 13, no changes made to regimen given acute problems. Would recommend rechecking TSH in 6 weeks time and modify dose as needed. . # FEN: repleted lytes prn, was intitially NPO pending endoscopy, later changed to regular diet . # Access: 2 large bore peripheral IVs (18g) . # PPX: Pneumoboots, oral PPI . # CODE: FULL (corroborated on admission with HCP) . # Communication: Healthcare proxy: [**Name (NI) 1494**] [**Name (NI) 12412**] [**Telephone/Fax (1) 95881**](h), updated on [**1-5**] and [**1-6**] by me. [**Telephone/Fax (1) 95882**](c)Nephew: [**Name (NI) **] [**Name (NI) 95883**] [**Telephone/Fax (1) 95884**](h) [**Telephone/Fax (1) **] [**Telephone/Fax (1) 32729**]: [**Telephone/Fax (1) 95885**] h; [**Telephone/Fax (1) 95886**] cell Medications on Admission: 1. Aspirin 81 mg once daily. 2. Azopt 1% eyedrop twice daily. 3. Vitamin B12 500 mcg Q Monday, Wednesday, and Friday. 4. Aricept 10 mg once daily. 5. Xalantan 0.005% drop one time QHS. 6. Levoxyl 125 mcg one tablet once daily. 7. Zocor 10 mg once daily. Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 6 weeks. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia: or agitation. 9. Haloperidol 0.5 mg Tablet Sig: half Tablet PO BID (2 times a day) as needed for agitation . PLEASE NOTE ASPIRIN WAS DISCONTINUED. Discharge Disposition: Extended Care Facility: [**Hospital **] health center Discharge Diagnosis: Primary: 1) Acute Upper GI Bleed due to peptic ulcer disease 2) Acute Blood Loss Anemia 3) hypovolemia 4) Possible TIA Secondary: 1) Delirium, resolved 2) Dementia - attributed to mixed Alzheimer's and Vascular Dementia 3) Hypothyroidism with abnormal TSH (13) 4) Chronic Kidney Disease, Stage III 5) History of "smoldering" multiple myeloma - with plans for conservative management 6) History of Pulmonary embolism - no longer on systemic anticoagulation since Summer [**2156**] due to frequent falls, now also s/p UGIB 7) History of multifactorial gait disorder NOS 8) Glaucoma 9) history of B12 deficiency Advance Directive: HCP = [**Name (NI) **] [**Name (NI) 1494**] [**Name (NI) 12412**] ([**Telephone/Fax (1) 95881**], cell [**Telephone/Fax (1) 95882**]). Nephew = [**Name (NI) **] [**Name (NI) 95883**] [**Telephone/Fax (1) 95884**]. Friend = [**Name (NI) **] [**Name (NI) 32729**] [**Telephone/Fax (3) 95887**]. Discharge Condition: At baseline mental status, hemodynamically stable with stable hematocrit, tolerating regular diet. Physical activity below baseline, acute rehab has been recommended. Discharge Instructions: You were admitted with a very significant anemia related to bleeding from your stomach/bowels. You were transfused five units of blood and may have some lingering fatigue. Please take your new proton pump inhibitor (pantoprozole) twice daily as directed to help heal the ulcer in your stomach. You will need a repeat endoscopy to look at this ulcer in 6 weeks to make sure it's healed. Your aspirin was discontinued as it increases your risk of bleeding. Followup Instructions: You have an EGD scheduled for 6 weeks from now. The instructions will be mailed to your home. Please report to the [**Hospital Ward Name **] on [**2-17**]. Please call [**Telephone/Fax (1) 87101**] to confirm. GI WEST,ROOM ONE GI ROOMS Date/Time:[**2158-2-17**] 12:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2158-2-2**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2158-2-2**] 11:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2158-2-28**] 10:00 You should have your TSH checked by your PCP [**Last Name (NamePattern4) **] 6 weeks. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2158-1-6**]

[ "290.41", "276.52", "365.9", "276.8", "435.9", "244.9", "331.0", "V12.51", "V10.05", "585.3", "530.21", "437.0", "535.60", "203.00", "285.1", "294.10" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.23", "45.16" ]

icd9pcs

[ [ [] ] ]

11223, 11279

6544, 10076

333, 350

12246, 12415

3910, 6521

12921, 13919

2860, 2875

10387, 11200

11300, 12225

10102, 10364

12439, 12898

2890, 3891

273, 295

378, 2013

2035, 2689

2705, 2844

32,771

173,639

33257

Discharge summary

report

Admission Date: [**2193-8-24**] Discharge Date: [**2193-8-27**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Lisinopril Attending:[**First Name3 (LF) 4588**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 77230**] is an 87F with a PMH s/f CHF with an EF of 30%, A fib s/p pacemaker not anticoagulated, on home O2 who presented on [**2193-8-24**] after developing acute onset of shortness of breath with a new O2 requirement (her baseline is 92% on 2L, and she was requiring 6L NC to maintain sats). Otherwise her ROS was negative. She ruled out for an MI by enzymes. The team attempted to diurese her for a presumed CHF exacerbation based on her CXR findings of cephalization and pleural effusions, they anticoagulated her for suspicion for a PE and a chads score of 4, and put her in for an echo and CTA of the chest. Initially her hemodynamics improved with diuresis, with a decrease in her creatinine, so the team attempted further diuresis today. She has recieved a total of 160mg of IV lasix, and has put out approximately 1100cc of urine. Today the patient was noted to drop her sats to 70s on room air whenever she would take her face mask off. She was in no acute respiratory distress, and was mentating well with this. An ABG was obtained which showed 7.44/41/48. She was taken down for a STAT CTA, and transferred to the ICU for closer monitoring. Past Medical History: - Atrial fibrillation not anticoagulated - S/p pacemaker - HTN - Chronic systolic and diastolic CHF, last EF 30% in [**12-22**] - Hypothyroidism - DM type II - Depression - Dementia - Gout - H/o falls - Urinary incontinence - Uterine cancer s/p hysterectomy 10 years ago - Pulmonary nodules, followed by thoracic oncology, serial CT scans revealing no change - Home oxygen (was discharged on oxygen from last hospitalization in [**12-22**] with oxygen) Social History: Lives at [**Hospital 100**] Rehab. Walks with a walker. Son [**Name (NI) **] is involved in her care (HCP). Family History: NC Physical Exam: VS: T 98.3 BP 153/64 P 66 RR 18 Initially 86% on 4L, then up to 91% on 6L GEN: Comfortable appearing, NAD HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema or exudate, NC in place NECK: Supple, elevated JVP CV: RRR, 3/6 SEM loudest at LUSB, no murmurs, rubs or gallops PULM: Rales at bases, occasional expiratory wheeze, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema NEURO: Minimal english, but responds appropriately to questions, CN 2-12 grossly intact Pertinent Results: [**2193-8-23**] 11:55PM BLOOD WBC-8.6# RBC-4.41 Hgb-13.7 Hct-39.0 MCV-89 MCH-31.1 MCHC-35.1* RDW-16.1* Plt Ct-217 [**2193-8-27**] 04:40AM BLOOD WBC-5.7 RBC-3.85* Hgb-11.6* Hct-34.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-15.9* Plt Ct-185 [**2193-8-25**] 03:49AM BLOOD PT-13.2 PTT-27.8 INR(PT)-1.1 [**2193-8-23**] 11:55PM BLOOD Glucose-134* UreaN-41* Creat-2.0* Na-144 K-4.2 Cl-108 HCO3-26 AnGap-14 [**2193-8-27**] 04:40AM BLOOD Glucose-130* UreaN-38* Creat-1.7* Na-142 K-4.3 Cl-105 HCO3-32 AnGap-9 [**2193-8-24**] 05:15PM BLOOD ALT-23 AST-23 LD(LDH)-243 CK(CPK)-31 AlkPhos-85 Amylase-55 TotBili-1.0 [**2193-8-24**] 05:15PM BLOOD calTIBC-306 VitB12-250 Folate-18.8 Hapto-45 Ferritn-225* TRF-235 Brief Hospital Course: Ms. [**Known lastname 77230**] is an 87F with a PMH s/f chronic systolic HF (EF 30%), afib off coumadin, with baseline home O2 requirement who presents with acute worsening of dyspnea and new oxygen requirement. 1)Respiratory distress: Likely CHF exacerbation given Chest X-ray findings. She is normally on 2L of O2 at home, which increased to 6L during her hospital stay. She received 160mg IV Lasix on the floor with 2L of urine output. In the MICU, she received an additional 80mg IV. Cardiac enzymes were negative. Her oxygen requirements continued to improve with diuresis. On the day of discharge, she was at baseline of 2 liters and satting at 90-91%. She had been adequately diuresed and it was felt that low baseline saturations were likely secondary to bibasilar atelectasis as identified on Chest CT. Her home Lasix dose was increased and she was discharged on 60mg PO BID, (vs 40mg PO BID on admission). Clinically she appeared euvolemic at the time of discharge. Discharged with instruction to encourage ambulation, incentive spirometry to improve air movement. 2)Acute on chronic renal failure: Baseline Cr 1.3-1.5; elevated to 2.0 on admission. Her Cr was monitored closely and her medications were renally dosed. Her creatinine stabilized at 1.7 and it was felt that this liekly represents new baseline creatinine for her. 3)Chronic systolic/diastolic heart failure: Patient was diuresed as above. Losartan was held in light of elevated creatinine, but restarted prior to discharge. She was continued on beta-blocker. ECHO showed improvement of global systolic function with EF of 50-55%, improved from [**2193-1-10**] Echo with 30% EF. 4)HTN: She was continued on home regimen of Amlodipine and Metoprolol. 5)Atrial fibrillation: s/p pacemaker. She is not on anticoagulation as an outpatient. She was continued on beta-blocker for rate control. Her outpatient PCP at [**Name9 (PRE) 15303**] rehab was contact[**Name (NI) **] and it was recommended that anticoagulation be initiated for atrial fibrillation.He will investigate why this was not previosuly done and consider starting. No anticoagulation was started while inpatient. 6)Dementia: Continued on Aricept and Namenda. 7)Hypothyroidism: Continued on Levothyroxine. 8)DM type II: Patient is on Glipizide as outpatient; this was held in light of her acute renal failure. She was placed on an insulin sliding scale with good blood sugar control. Prior to discharge, glipizide was restarted at home dose. 9)Gout: Continued on Allopurinol which was renally dosed. 10)Depression: Continued on Paxil. Medications on Admission: Allopurinol 100 mg daily Amlodipine [Norvasc] 10 mg daily Donepezil [Aricept] 10 mg daily Furosemide [Lasix] 40 mg [**Hospital1 **] Levothyroxine 50 mcg daily Losartan [Cozaar] 50 mg daily Memantine [Namenda] 10 mg [**Hospital1 **] Metoprolol Succinate 100 mg daily Paroxetine HCl [Paxil] 40 mg daily Simvastatin [Zocor] 20 mg daily Tolterodine [Detrol LA] 4 mg Capsule, Sust. Release 24 hr daily Zolpidem [Ambien] 5 mg QHS Acetaminophen [Tylenol] 650 mg Q4H prn Aspirin 325 mg daily Bisacodyl [Dulcolax] 5 mg daily Calcium Carbonate 650 mg (1,625 mg) [**Hospital1 **] Ergocalciferol (Vitamin D2) [Vitamin D] 1,000 unit daily Glipizide XL 5mg daily Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 12. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for pain. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Calcium Carbonate 650 mg (1,625 mg) Tablet Sig: One (1) Tablet PO twice a day. 16. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 17. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis 1. CHF exacerbation 2. Bibasilar Atelectasis Secondary Diagnosis Atrial fibrillation not anticoagulated S/p pacemaker HTN Chronic systolic and diastolic CHF, last EF 30% in [**12-22**] Hypothyroidism DM type II Depression Dementia Gout H/o falls Urinary incontinence Uterine cancer s/p hysterectomy 10 years ago Pulmonary nodules, followed by thoracic oncology, serial CT scans revealing no change Home oxygen (was discharged on oxygen from last hospitalization in [**12-22**] with oxygen) Discharge Condition: Good. hemodynamically stable and afebrile. At baseline oxygen saturation of 90-92% on 2 liters Discharge Instructions: You were admitted to the hospital with shortness of breath. Your symptoms were secondary to an exacerbation of congestive heart failure. We made the following changes to your medications. 1. Lasix from 40mg twice daily to 60mg twice daily Please return to the ER or call your primary care doctor if you have worsening shortness of breath, chest pain, worsening leg edema, fever, chills, or any other concerning symptoms. You should weigh yourself every day and call your primary care doctor if you have weight gain of more than 2lbs daily. You should adhere to a low sodium diet. Followup Instructions: Please follow up with your primary care physician as needed. Completed by:[**2193-8-27**]

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icd9cm

[ [ [] ] ]

[]

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