ChanBeDu/relevant_section_length · Datasets at Hugging Face

43,261

162,221

1764

Discharge summary

report

Admission Date: [**2145-2-26**] Discharge Date: [**2145-3-5**] Date of Birth: [**2064-4-30**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / bee stings Attending:[**First Name3 (LF) 165**] Chief Complaint: New onset lower throat pain Major Surgical or Invasive Procedure: [**2145-2-26**] Coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal and posterior descending arteries History of Present Illness: This 80 year old woman with no prior cardiac history first started to experience chest discomfort sensed as a "gagging feeling" and a dull pain at the base of her throat in [**2144-5-24**]. This occurred during rehabilitation after her knee surgery. In [**Month (only) **], she began walking approximately one-half mile on a track and noted the same symptoms occurring then. She denies any chest pain or dyspnea. She denies any symptoms occurring at rest. She has noted some mild lightheadedness on occasion and increased fatigue over the past year. She denies any lower extremity edema but does note some longstanding numbness in her feet/toes bilaterally, work-up has been negative. A stress test was positive for ischemic changes and she was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who recommended cardiac catheterization. Underwent cardiac cath which revealed signifcant 3 vessel disease. Referred for surgery. Past Medical History: Hypothyroidism on thyroid replacement Hyperlipidemia Hypertension- recently diagnosed Numbness lower extremities work-up negative s/p Appendectomy s/p T&A s/p RTK [**2144-5-24**] Social History: Race:Caucasian Last Dental Exam: few months ago SOCIAL HISTORY: Widowed. lives alone in [**Location (un) **]. Daughter lives nearby Tobacco: no ETOH: no Contact upon discharge: daughter [**Name (NI) 402**] [**Name (NI) **] will accompany. [**Telephone/Fax (1) 9968**] Home Care Services: no Family History: A brother had coronary bypass surgery at age 60 and again at age 70. A grandmother had an MI at age 67 and had apparent cardiac death atage 68. Two grandfathers had diagnosis of heart failure. Her daughter had what she describes as "a tear in a heart vessel" suggesting coronary dissection. Physical Exam: Pulse: 56 SR Resp: 16 O2 sat:2L 100% B/P Right: cath site Left:117/40 Height: 5ft 6" Weight: 176lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft protruberent [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] significant bilateral toe numbness Pulses: Femoral Right: +1 Left:+1 DP Right:trace Left:trace PT [**Name (NI) 167**]:Trace Left:Trace Radial Right:cath site Left:+2 Carotid Bruit Right:none Left:None Pertinent Results: [**2145-2-26**] Echo: Pre-CPB: 1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. 7. Trivial mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine initially, then nitroglycerine for blood pressure control. A pacing for slow sinus rhythm. Preserved biventricular systolic function. LVEF = 60%. MR remains trace. Aortic contour is normal post decannulation. [**2145-3-3**] CXR: There is a new moderate left and small right pleural effusion. Right lower lobe atelectasis has slightly worsened. There is an indistinct haziness over the right lower lung field which may represent layering effusion. There is stable bilateral apical pneumothoraces. IJ catheter is seen in unchanged position terminating within the upper right atrium. The cardiomediastinal silhouette is stable and demonstrates a mildly enlarged heart. Pre-op labs: [**2145-2-26**] 07:00AM FIBRINOGE-321 [**2145-2-26**] 07:00AM PT-11.0 PTT-22.9* INR(PT)-1.0 [**2145-2-26**] 07:00AM PLT COUNT-133* [**2145-2-26**] 07:00AM WBC-4.9 RBC-5.06 HGB-15.3 HCT-43.7 MCV-86# MCH-30.3 MCHC-35.0# RDW-12.4 [**2145-2-26**] 07:47AM HGB-12.6 calcHCT-38 [**2145-2-26**] 07:47AM GLUCOSE-86 LACTATE-1.7 NA+-139 K+-3.9 CL--106 Discharge labs: [**2145-3-4**] 06:00AM BLOOD WBC-10.2 RBC-3.64* Hgb-10.8* Hct-32.1* MCV-88 MCH-29.8 MCHC-33.8 RDW-13.3 Plt Ct-242 [**2145-3-5**] 05:00AM BLOOD PT-26.0* INR(PT)-2.5* [**2145-3-4**] 06:00AM BLOOD UreaN-17 Creat-0.8 Na-140 K-4.4 Cl-103 [**2145-3-5**] 05:00AM BLOOD Na-137 K-4.6 Cl-101 [**2145-3-5**] 05:00AM BLOOD Mg-2.0 Brief Hospital Course: Mrs. [**Known lastname 9969**] was a same day admission to the operating room on [**2145-2-26**], she underwent a coronary artery bypass grafting. Please see operative report for surgical details. Her bypass time was 67 minutes with a cross clamp time of 59 minutes. She tolerated the operation well and following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day 1 she was started on ASA, Bblockers, statin and diuretics. She remained hemodynamically stable and was transferred from the ICU to the stepdown floor for further post-operative management. All tubes lines and drains were removed per cardiac surgery protocol. She worked with nursing physical therapy to improve her strength and conditioning. On post-op day 4 she went into rapid atrial fibrillation with a rate in the 140-150s. IV Lopressor was administered and she converted to normal sinus rhythm. She was also given Amiodarone bolus and placed on oral dosing. Due to several episodes of postoperative AF she was placed on anticoagulation with Coumadin. The remainder of her hospital course was essentially uneventful. She continued to progress and was discharged to [**Location (un) 246**] Nursing Center on post-op day 7 with the appropriate medications and follow-up appointments. Medications on Admission: ATORVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day EPIPEN - 0.3MG Pen Injector - USE FOR ALLERGIC EMERGENCIES LEVOTHYROXINE - 75 mcg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually prn chest pain; call 911 Medications - OTC ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth daily ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] - (Prescribed by Other Provider) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily CROMOLYN - 5.2 mg/actuation (4 %) Spray, Non-Aerosol - 2 sprays nasal twice a day IBUPROFEN - Prescribed by Other Provider) - 200 mg Tablet - 2 Tablet(s) by mouth daily in pm Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day: Patient still aproximately 8 lbs above pre-op weight with edema and pleural effusion. Continue diuretic and KCl until back to pre-op weight and edema resovles. 9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day. 10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take two 200mg tablets twice daily for 4 days. Then one 200mg tablet twice daily for 7 days. Finally, one 200mg [**Last Name (un) 9970**] daily until stopped by cardiologist. 11. warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day: Please adjust acccording to INR goal of [**2-25**].5. Discharge Disposition: Extended Care Facility: [**Location (un) 246**] Nursing Center - [**Location (un) 246**] Discharge Diagnosis: Corornary artery disease s/p Coronary artery bypass graft x 4 Past medical history: Hypothyroidism on thyroid replacement Hyperlipidemia Hypertension- recently diagnosed Numbness lower extremities work-up negative s/p Appendectomy s/p T&A s/p RTK [**2144-5-24**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tramadol and nonsteroidals Incisions: Sternal - healing well, no erythema or drainage Leg Right/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 one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] 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. [**First Name (STitle) **] [**2145-3-30**] at 2:15 [**Telephone/Fax (1) 1504**] Cardiologist: Dr. [**Last Name (STitle) **] [**2145-3-16**] at 3:40p [**Location (un) **] office Please call to schedule appointment with your Primary Care Dr. [**Last Name (STitle) 9971**] in [**4-29**] weeks [**Telephone/Fax (1) 2789**] **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 Atrial filbrillation Goal INR 2.0-2.5 First draw [**2145-3-5**] Coumadin follow up to be arranged upon discharge from rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2145-3-5**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "38.93", "36.15" ]

icd9pcs

[ [ [] ] ]

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313, 516

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3089, 4950

10558, 11393

2034, 2329

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7118+7119

Discharge summary

report+report

Admission Date: [**2135-7-24**] Discharge Date: [**2135-7-28**] Service: MICU CHIEF COMPLAINT: Fever, dyspnea, and hypotension. HISTORY OF THE PRESENT ILLNESS: This is an 88-year-old Russian-speaking female who recently had undergone a complicated postoperative course from an elective cholecystectomy at [**Hospital3 **] in [**2135-4-9**] who was admitted for a day of low-grade fevers, hypoxia, and hypotension. The patient had gone to [**Hospital3 **] in [**Month (only) 958**] to undergo a laparoscopic cholecystectomy for cholelithiasis which was performed there. The surgery was complicated by a transection of the common bile duct and had to be converted to a Roux-en-Y hepaticojejunostomy. She had a complicated postoperative course including two non ST elevation MIs, PE, and pneumonia. She was transferred to rehabilitation from there in [**Month (only) 116**] and then transferred to [**Hospital3 **] Nursing Home where she has been a resident since the middle of [**Month (only) 116**]. At [**Hospital3 1761**], she was noted to be fatigued and dyspneic, saturating 84% on room air and up to 96% on 2 liters nasal cannula. She denied any chest pain or shortness of breath at that time. She had recently been diagnosed with C. difficile colitis and was on Flagyl since [**2135-7-11**]. EMTs were called for the hypoxia and in the field the patient's blood pressure was 70/palpable with a pulse of 86 and respirations of 16. On arrival to the Emergency Room, she had a temperature of 100.2 with a pulse of 88 and a blood pressure of 80/palpable. In the Emergency Room, she was given 500 cc of normal saline and then started on a dopamine drip to which the blood pressure did respond. She was given 1.5 liters of fluids down in the Emergency Room and was admitted to the ICU. She was also given a dose of levofloxacin. PAST MEDICAL HISTORY: 1. Roux-en-Y hepaticojejunostomy and hernia repair in [**2135-4-9**]. 2. [**Hospital 15046**] hospital course complicated by MI times two, VRE UTI, C. difficile colitis, pneumonia, PE by positive V/Q scan. 3. History of hypertension. 4. Cardiac disease with Persantine MIBI showing reversible ischemic in the anterior wall and an EF of 70%. ADMISSION MEDICATIONS: 1. Multivitamins one capsule q.d. 2. Aspirin 325 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Imdur 15 mg p.o. q.d. 5. Lopressor 50 mg p.o. b.i.d. 6. Flagyl 500 mg p.o. t.i.d. 7. Zocor 40 mg p.o. q.d. 8. Coumadin 2 mg p.o. q.d. 9. Prevacid 15 mg p.o. q.d. 10. Augmentin which was given in the middle of [**Month (only) 116**] for ten days for pneumonia. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is originally from [**Country 532**]. There is no history of alcohol or tobacco consumption. She had been living independently before her admission to [**Hospital3 **] earlier this year. She remains close to her daughter and granddaughter who were reachable by phone. The patient's code status is DNR/DNI. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 100.2, pulse 88, blood pressure 80/palpable, 02 saturation 88% on room air. General: She was a pleasant elderly woman speaking Russian and is oriented and appears not to be in any acute distress. She appears to be responding to her granddaughter's questioning appropriately. HEENT: Moist oropharynx. Chest: Crackles at the left base with diminished breath sounds at the right base. Abdomen: Soft but diffusely tender and exquisitely tender in the right upper quadrant. She does have positive bowel sounds. Rectal: Stage I decubitus ulcer with Guaiac negative stool and the presence of external hemorrhoids. Extremities: There was 2+ pitting edema to the knees bilaterally. LABORATORY/RADIOLOGIC DATA: White count 29.5, hematocrit 30.7, platelets 687,000, 93% neutrophils, 25% bands, 2% lymphocytes. Her INR was 1.8 on admission. Her U/A revealed small blood and trace leukocyte esterase, otherwise a normal U/A with 6-10 white blood cells and [**4-13**] squamous epithelial cells. Her Chem-7 was unremarkable, notable are the BUN of 16 and creatinine 1.0. The CK on admission was 50 and troponin 5.7. The EKG showed a sinus rhythm at 88 beats per minute with a normal axis and T wave inversions present in V1 through V4. The chest x-ray showed small bilateral pleural effusions, right greater than left with a right lobe collapse and a retrocardiac infiltrate versus atelectasis. HOSPITAL COURSE: 1. HYPOXIA/FEVER/HYPOTENSION: The patient's source of sepsis was thought to possibly be from two different sources including pneumonia and a biliary source given the right upper quadrant pain and fever and complicated postoperative course. The patient, on the night of admission, underwent a CTA of the chest as well as a CT of the abdomen with contrast to evaluate. On the CT of the chest, she had some evidence of small segmental pulmonary emboli in the periphery bilaterally with some right lower lobe collapse/consolidation. On the CT of the abdomen with contrast, she was revealed to have pneumobilia with intrahepatic ductal dilatation with no bowel wall thickening. There was also noted evidence of a left adnexal cyst measuring 2 by 2. Both the GI and the Surgery Services were consulted for a question of cholangitis and a question of intervention. Since the patient was DNR/DNI, she was definitely not a surgical candidate and this was discussed with the granddaughter. The patient did have LFTs that were elevated upon admission with an alkaline phosphatase of 1,100 and a total bilirubin of 1.2. She was empirically started on vancomycin and ceftazidime in addition to the Flagyl for coverage of biliary source as well as a pulmonary source. She was also covered with Flagyl for the question of a recurrent C. difficile. 2. GASTROINTESTINAL: It was recommended a HIDA scan which was done to evaluate for biliary obstruction and this scan was normal. Surgery had recommended MRCP if the family desired more aggressive intervention such as ERCP to alleviate any stricture that might be present; however, this study was held off since the patient was improving on antibiotics and that ERCP would likely not be done by GI given the complicated anatomy given her complicated postoperative course. She continued on her vancomycin, ceftazidime, and Flagyl. Gradually, the vancomycin was peeled back as it was revealed that her blood cultures were growing gram-negative rods. Finally, the blood cultures taken on arrival eventually grew out Klebsiella pneumonia that was pan sensitive as well as Enterococcus, the speciation of which is still being identified. By this time, the patient's white count has decreased to 8,000. She has been completely afebrile on the regimen of ceftazidime and levofloxacin. The ampicillin was substituted for ceftazidime on [**2135-7-27**] given the identification of Enterococcus. It was doubtful that this was vancomycin-resistant Enterococcus since the patient continued to improve on the regimen that did not account for VRE. Thus, her final regimen is ampicillin, levofloxacin, and Flagyl for two weeks duration. She also had a TTE to demonstrate that there was no endovascular source, i.e., endocarditis that was the source of her bacteremia and this was negative for vegetation. The EF was 60% and there was mild aortic stenosis on this transthoracic echocardiogram. 3. TROPONIN LEAK: Cardiology was consulted for troponin leak in a patient who has a reversible ischemic defect found after her surgery at the outside hospital as well as multiple complications. She did have yet another troponin leak but this was not deemed an indication for cardiac catheterization. She was kept on adequate blood pressure control and was started on an aspirin as well as an H2 blocker for prophylaxis. She did well on this regimen and she was gradually put back on her original dose of metoprolol. She did have one episode of chest pain which was evaluated by EKG showing no significant ischemic changes from prior EKG but did show what seemed to be some wandering atrial foci with intermittent tachycardia. She was stable during these periods and spent most of her time in normal sinus rhythm while in the ICU. 4. PULMONARY EMBOLUS: She was put on heparin for subtherapeutic INR and held off her Coumadin until it was clear that no interventions would be done. On [**2135-7-27**], she was restarted on Coumadin at 3 mg p.o. q.d. given some evidence of liver dysfunction and potentiation by Flagyl. She will remain in the hospital until she can be taken off her heparin drip when her INR becomes therapeutic for PE which should be continued for at least a total of six months from the time of diagnosis which would put her at [**2135-10-10**]. 5. LEG PAIN: She did complain of leg pain on [**2135-7-28**] which appeared to be more in the knee. There does not appear to be any effusion or warmth or erythema over the area. She does have her knee medially internally rotated and flexed. Therefore, hip films are being done to rule out a hip fracture. Also, an ultrasound of the lower extremity is being done to rule out [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst. Even if a DVT is found, there will be no change in medical management and the patient is being administered pain medicines to keep her comfortable. Discharge medications and diagnoses will be addended at a later date. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AEW Dictated By:[**Name8 (MD) 4064**] MEDQUIST36 D: [**2135-7-28**] 12:28 T: [**2135-7-28**] 12:41 JOB#: [**Job Number 26515**] Admission Date: [**2135-7-24**] Discharge Date: [**2135-7-29**] Service: ADDENDUM: DISCHARGE DIAGNOSES: (The discharge diagnoses were as follows) 1. Cholangitis with biliary sepsis. 2. Status post open cholecystectomy; complicated by common bile duct transection and Roux-en-Y gastrojejunostomy and hernia repair in [**2135-4-9**]. 3. History of non-ST-elevation myocardial infarction times three; the most current one with a troponin of up to 5.7 during this hospitalization. 4. History of vancomycin-resistant enterococcus urinary tract infection. 5. History of Clostridium difficile (which has been negative here at [**Hospital1 69**]). 6. History of stenotrophomonas pneumonia in [**2135-5-10**]. 7. Pulmonary embolism in [**2135-5-10**]. 8. Mild aortic stenosis on transthoracic echocardiogram in [**2135-7-10**]. 9. Hypertension. MEDICATIONS ON DISCHARGE: 1. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed (for fever or pain). 2. Flagyl 500 mg p.o. three times per day (times 10 days; ending [**8-7**]). 3. Albuterol/ipratropium meter-dosed inhaler 1 to 2 puffs inhaled q.6h. as needed (for wheezes or shortness of breath). 4. Atorvastatin 20 mg p.o. once per day. 5. Levofloxacin 500 mg p.o. q.24h. (times 10 days; ending [**8-7**]). 6. Enteric-coated aspirin 81 mg p.o. once per day. 7. Nitroglycerin 0.4-mg tablets sublingually every three to five minutes as needed (for chest pain). 8. Metoprolol 50 mg p.o. twice per day. 9. Docusate 100 mg p.o. twice per day. 10. Warfarin 3 mg p.o. once per day. 11. AmBisome 2 g intravenously q.6h. (for 10 days; ending [**8-7**]). 12. Enoxaparin 60 mg subcutaneously twice per day (until INR greater than 2). 13. Imdur 15 mg p.o. once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with her primary care physician (Dr. [**Last Name (STitle) 26516**] [**Name (STitle) **]). CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to [**Hospital3 1761**] nursing home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 8038**] Dictated By:[**Name8 (MD) 4064**] MEDQUIST36 D: [**2135-7-28**] 12:40 T: [**2135-7-28**] 12:43 JOB#: [**Job Number 26517**]

[ "707.0", "401.9", "576.1", "038.49", "410.71", "424.1", "415.19" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9799, 10541

10568, 11421

4484, 9777

2247, 2665

11456, 11587

11602, 11977

108, 1856

3040, 4466

1878, 2224

2682, 3025

13,330

185,944

1791

Discharge summary

report

Admission Date: [**2106-11-12**] Discharge Date: [**2106-11-18**] Date of Birth: [**2048-10-2**] Sex: M Service: CARDIOTHORACIC Allergies: Bacitracin Attending:[**First Name3 (LF) 4679**] Chief Complaint: Gastroesophageal reflux disease. Gastroparesis. Tracheobronchomalacia. Major Surgical or Invasive Procedure: [**2106-11-12**]: Laparoscopic Nissen fundoplication. Laparoscopic pyloroplasty, Upper endoscopy. History of Present Illness: The patient is a 58-year-old gentleman with a complex past medical history, including long- standing type 1 diabetes with resultant gastroparesis as well as a tracheobronchomalacia and documented gastroesophageal reflux disease. He was brought to the operating room today for a Nissen fundoplication and pyloroplasty. Past Medical History: 1. IDDM - complicated by gastroparesis and peripheral neuropathy. On insulin pump. 2. Hypothyroidism 3. Hyperlipidemia 4. CAD - s/p LAD stent in [**2097**] 5. Bipolar disorder 6. ADD 7. OSA - on BIPAP at home but has not been using it. 8. Tracheobronchomalacia s/p tracheal bronchoplasty [**2104-6-5**] 9. Right pleural effusion s/p pleurodesis(FEVI 1.95, FVC 2.13)[**2104-7-4**] 10. Osteoarthritis 11. GERD 12. Lactose intolerance 13. Constipation 14. H/O fundic gland polyp with focal low grade dysplasia [**11-4**] Social History: Married with 4 children (2 daughters and 2 adopted sons). [**Name2 (NI) 1403**] as a teacher for 6th-8th grade special education children. Denies any tobacco, EtOH, or drug use. Family History: Mother with CAD and DM. Father with HTN. Brother healthy. [**Name2 (NI) **] history of UC/Crohn's. Physical Exam: VS: General: walking in halls in no apparent distress Card: RRR Resp: decreased breath sounds otherwise clear GI: benign Extr: warm Incision: abdominal clean, dry intact Neuro: Pertinent Results: [**2106-11-17**] WBC-5.7 RBC-4.13* Hgb-10.2* Hct-32.1* Plt Ct-228 [**2106-11-16**] WBC-9.0 RBC-4.00* Hgb-9.9* Hct-30.9* Plt Ct-232 [**2106-11-12**] WBC-5.8 RBC-3.83* Hgb-9.7* Hct-28.7* Plt Ct-244 [**2106-11-17**] Glucose-225* UreaN-25* Creat-1.2 Na-139 K-4.0 Cl-98 HCO3-27 [**2106-11-16**] Glucose-142* UreaN-28* Creat-1.5* Na-146* K-3.5 Cl-104 HCO3-33* [**2106-11-12**] Glucose-186* UreaN-56* Creat-2.5* Na-140 K-2.8* Cl-95* HCO3-35* [**2106-11-16**] CK(CPK)-996* CK(CPK)-1167* BLOOD CK(CPK)-568* [**2106-11-17**] Calcium-9.3 Phos-3.3 Mg-2.2 UGI SGL W/O KUB [**2106-11-14**] No evidence for obstruction or leak. UGI SGL CONTRAST W/ KUB [**2106-11-13**] IMPRESSION: Passage of tiny amount of contrast through fundoplication site, with holdup of majority of ingested barium in the distal esophagus. This is likely related to postoperative edema. Followup radiograph can be obtained to assess for passage of the residual esophageal contrast. Chest CT w/o contrast & Abdomen [**2106-11-14**]: IMPRESSION: No intra-abdominal or mediastinal collection. Small amount of debris in the distended gallbladder, possibly sludge or small calculi without definite evidence of cholecystitis. Head CT [**2106-11-14**] IMPRESSION: No acute abnormality. Pathology [**2106-11-12**] "Gastroesophageal junction": 1. Fibroadipose tissue and three hyperplastic lymph nodes. 2. No tumor. Clinical: Gastroesophageal reflux disease. Gross: The specimen is received fresh labeled with the patient's name, "[**Known lastname 10087**], [**Known firstname **]," the medical record number and "GE Junction." It consists of a fragment of yellow tan adipose tissue measuring 4.1 x 3.1 x 0.5 cm. The specimen is serially sectioned to reveal unremarkable tan fibrofatty cut surfaces. The specimen is entirely submitted in A-D. Brief Hospital Course: Mr. [**Known lastname 10087**] was admitted on [**2106-11-12**] taken to the operating room for an uneventful Laparoscopic Nissen fundoplication. Laparoscopic pyloroplasty. Upper endoscopy. He tolerated the procedure well. He was extubated in the PACU placed on CPAP over night in stable condition and diuresed with IV lasix prior to transfer to the floor. His pain was controlled with a Dilaudid PCA. On POD 1 he did well. He was restarted on his home medications. On POD 2 he had fevers with severe mental status changes requiring transfer to the SICU. He was started on Zosyn. He was pancultured with no growth to date. Psychiatry was consulted for question of delirium requiring 4 point restraints and management of his psychiatric meds. They recommended not restarting his psych meds, haldolol prn and allow his mental status to clear. They continued to follow him and adjust his meds as tolerated. On [**2106-11-14**]: CT head: normal CT torso: small amount of debris in the distended gallbladder UGI SGL: No evidence for obstruction or leak. [**Last Name (un) **] was consulted for his Type I diabetes requiring an insulin drip. He remained in the SICU until his mental status improved and his glucose level was stable. On POD 3 he was started on a clear liquid diet which he tolerated. His home cardiac medications and neuropathy meds were restarted. On POD 4 he transferred to the floor in stable condition. His mental status slowly improved. POD [**4-6**] his lamictal and abilify were slowly titrated per psychriatry recommendation. His diet was advanced to soft. Physical therapy saw him and cleared him for home. He was seen by occupational therapy who made recommendations for his cognitive dysfunction. On POD7 he continued to do well and was discharged to home with VNA to assist with his medications. He will follow-up with psychriatry and outpatient MRI for his history of hullcinations and cognitive decline. Medications on Admission: Albuterol 90 mcg, Adderall 20 mg, Abilify 30 mg, Atorvastatin 80 mg, Tessalon 200 mg, Codeine-Guiafenisin, Flexeril 5 mg, Doxazosin 8 mg, Finasteride 5 mg, Lasix 160 mg [**Hospital1 **], Neurontin 800 mg, Hydrocodone-Acetominophen, Lamotrigine 200 mcg, Levothyroxine 200 mcg, Levoxyl 25 mcg, Amitiza 24 mcg, Metoclopramide 10 mg [**Hospital1 **], Metolazone 2.5 mg every other day, Metoprolol 25 mg daily, Modafinil 200 mg [**Hospital1 **], Nabumetone 750 mg, Nortriptyline 25 mg tid, Oxycodone, Protonix 40 mg [**Hospital1 **], Spiriva 18 mcg, Trazodone 50 mg, Aspirin 81 mg Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]: One (1) Cap Inhalation DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Metolazone 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: Daily as needed for weight gain. 5. Lubiprostone 24 mcg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 6. Doxazosin 8 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime. 7. Lipitor 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 8. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. Metoclopramide 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO four times a day: AC & HS. 10. Benzonatate 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY (Daily). 11. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 12. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 14. Furosemide 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 15. Finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Lactaid Ultra 9,000 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a day as needed. 18. Vitamins & Minerals Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 19. Abilify 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO at bedtime: then 30 mg hs. Disp:*60 Tablet(s)* Refills:*2* 20. Lamictal 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO once a day: increase by 25mg daily to goal of 200mg daily. Disp:*90 Tablet(s)* Refills:*2* 21. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4 hours) as needed. 22. Insulin Pump [**Doctor Last Name **] 1:10 Sensitivity 1:45, goal 130 12am-2am 1.65 3am-7am 1.8 7am-12pm 1.3 12pm-12am 1.1 23. Gabapentin 800 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Tracheobronchiomalacia, IDDM Type I, GERD, Gastroparesis, Neuropathy, Nephropathy, Hypothyroidism, CAD s/p stent '[**97**], Mood Disorder, OSA on CPAP, HTN, borderline pulmonary HTN by ECHO, hypertrophic cardiomyopathy and chronic dyspnea, mild ASD Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased nausea, vomiting, abdominal pain, diarrhea. -Eat all meals sitting up in chair, remain sitting up for 45 minutes after eating. Eat small frequent meals. -Head of the bed elevated 30 degrees at all times -Insulin Pump [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations DO NOT RESTART: adderall, modafanil, nortriptyline. fluoxetine. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] [**11-30**] at 10AM on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. Report to the [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Follow-up with Dr. [**Last Name (STitle) **] PCP [**Telephone/Fax (1) 250**] Follow-up with Dr. [**Last Name (STitle) 1681**] Psychiatry [**Telephone/Fax (1) 1682**] Follow-up with Dr. [**Last Name (STitle) 10088**] [**Name (STitle) **] [**Hospital 982**] Clinic [**Telephone/Fax (1) 2378**] Completed by:[**2106-11-18**]

[ "E878.2", "518.4", "276.0", "276.8", "250.61", "530.81", "519.19", "536.3", "V45.85", "244.9", "296.80", "293.0", "425.1", "496", "331.83", "V45.82", "327.23", "333.94" ]

icd9cm

[ [ [] ] ]

[ "44.29", "93.90", "44.67", "45.13" ]

icd9pcs

[ [ [] ] ]

8651, 8713

3696, 4627

351, 451

9005, 9014

1867, 3673

9532, 10134

1554, 1655

6265, 8628

8734, 8984

5664, 6242

9038, 9509

1670, 1848

240, 313

479, 800

4636, 5637

822, 1342

1358, 1538

41,768

105,730

9194

Discharge summary

report

Admission Date: [**2116-6-18**] Discharge Date: [**2116-6-24**] Date of Birth: [**2061-11-9**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: CODE STROKE/DIZZINESS, BLURRED VISION Major Surgical or Invasive Procedure: None History of Present Illness: [**Known firstname 1743**] [**Known lastname 31603**] is a 54 yo right handed woman with a history of hypertension, PVD s/p radiation to the pelvis for vaginal cancer. She presents today after waking at 6am with an unsteady gait and feeling as though her vision was blurred. When walking, she felt as if she was lurching back and forth and this prompted her to seek medical attention. The patient states that she had a mild UTI last week as well as a mild occiptal, thobbing headache yesterday. Otherwise, she has been feeling in her usual state of health. She normally takes coumadin for her peripheral stents but had stopped this 3 days prior in preparation for a possible dental proceedure. She denies ever having symptoms like this before. She reports remote migraine headaches but her current symptoms do not compare. On neurologic review of systems, the patient reports the return of a dull [**2-12**] denied headache, she reports blurred vision, but debies diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty. She denied difficulties producing or comprehending speech. She has no focal weakness, numbness, parasthesiae. She straight caths several times daily as she has an umbilical ostomy. She denied difficulty with gait. On general review of systems, the patient reports a mild fever with her URI symptoms last week (did not take her temperature but felt warm and then woke up in a sweat at night). She denies cough or shortness of breath. Denied chest pain or tightness, palpitations. She denies nausea, vomiting, diarrhea, constipation or abdominal pain. All other ROS was negative. Past Medical History: -Vaginal cancer 10 years ago; s/p pelvic exeneration with neovagina and neobladder -Hypertension -Vasovagal episodes -s/p small bowel obstruction -S/p R ilio-AKpop BPG w/vein ([**8-5**]), stents placed -S/p left kidney surgery as a child, has left hydronephrosis -Osteopenia -Migraines- not in many years, no aura Social History: Married. Works as a neuroscience nurse [**First Name (Titles) **] [**Last Name (Titles) 112**]. Has a history of tobacco use, 1ppd x 20 years. Still smokes on occasion. Social alcohol use. No drugs, no over the counter supplements. Family History: Hx of maternal hypertension. No history of cancer, stroke, clotting disorders. Physical Exam: 97.7 BP 145/72 HR 62 RR 16 O2% General: Awake, cooperative, NAD. Head and Neck: no cranial abnormailites, no scleral icterus noted, mmm, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear to auscultation bilaterally Cardiac: regular rate and rhythm, normal s1/s2. No murmurs, rubs, or gallops appreciated. Abdomen: soft, non-tender, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Had difficulty [**Location (un) 1131**] (very slow, but reads correctly) stated that her vision is blurrie, like parts of the words are missing. Speech was not dysarthric. There was no evidence of apraxia or neglect. Registered [**3-4**] and recalled [**1-5**] at 5 minutes. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. Visual fields full to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. Visual acuity 20/25 +/- both eyes with corrective lenses. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No rigidity. No adventitious movements, such as tremors, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to double simultaneous stimuli. -Deep tendon reflexes: [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor on right, mute on left. -Coordination: No intention tremor, no dysdiadochokinesia noted. mild dysmetria on FNF on the left, normal HKS bilaterally. -Gait: deferred Pertinent Results: [**2116-6-23**] 03:25AM BLOOD WBC-6.9 RBC-4.64 Hgb-14.3 Hct-43.1 MCV-93 MCH-30.8 MCHC-33.2 RDW-13.9 Plt Ct-238 [**2116-6-22**] 03:45AM BLOOD WBC-6.7 RBC-4.56 Hgb-14.3 Hct-42.3 MCV-93 MCH-31.3 MCHC-33.8 RDW-13.7 Plt Ct-228 [**2116-6-21**] 05:01AM BLOOD WBC-6.8 RBC-4.70 Hgb-14.4 Hct-43.8 MCV-93 MCH-30.6 MCHC-32.8 RDW-14.0 Plt Ct-237 [**2116-6-23**] 03:25AM BLOOD Glucose-109* UreaN-24* Creat-1.1 Na-141 K-3.9 Cl-106 HCO3-25 AnGap-14 [**2116-6-23**] 03:25AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.1 Imaging: Brief Hospital Course: Ms. [**Known lastname 31603**] was admitted to neurology ICU after she presented to ED for visual blurring and was evaluated initially as code stroke. Neuro She underwent code stroke evaluation with CT scan of head as well as CTA of head and neck which showed hypodense areas within the right cerebellum and complete occlusion of right vertebral artery. This suggested possible embolic source either from heart or from the veins in legs travelling as paradoxical emboli through a PFO or emboli from large vessels. This was addressed by MRI with contrast to look for any underlying mass , given h/o vaginal cancer. The MRI showed "multiple infarcts in bilateral posterior circulation territory in the setting of a very irregular distal right vertebral artery with a short segment of high-grade stenosis versus a short dissection. There appears to have been interval partial recanalization of the right vertebral artery compared to the CTA." She was closely monitered with neuro checks Q1H. She was started on heparin IV with goal; PTT between 50-70. Coumadin was added on day 2 with therapeutic goal INR [**2-5**]. The possibility of neuro intervention such as clot retrieval was discussed but it was felt that this may carry high risk and she did not have significant deficits on exam, hence it was held off. Heparin was stopped and she was discharged on coumadin with an INR Cards She was frequently monitored on telemetry for any arrthymia such as fibrillation. The tele review was negative. She underwent ECHO which showed mild left ventricular hypertrophy with normal biventricular systolic function; mild mitral regurgitation. No PFO/ASD were identified. Blood pressure goal initially was MAP 95-110 and pressors were used to increase cerebral perfusion, however after 24-48 hrs, pressors were tapered off and Blood pressure was allowed to autoregulate. Her BP mediations will be slowly re-added as an outpatient. Endo RISS with gluocose checks. Fingerstick were normal and this was discontinued Renal close watch over BUN CR and well as fluid status. OT/PT/SS She was seen by speech therapy who felt that she needed outpatient therapy for her alexia. Medications on Admission: Coumadin 5mg/6mg QOD Cardizem 240mg daily Lisinopril 40mg daily [**Month/Day (3) 25712**] XL 100mg daily Discharge Medications: 1. Warfarin 6 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*6 Tablet(s)* Refills:*0* 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. INR check Sig: One (1) on [**2116-6-26**]. Disp:*1 1* Refills:*0* 5. Speech therapy Sig: 10 every seventy-two (72) hours: Speech therapy . Disp:*1 1* Refills:*0* These will be restarted by your PCP: [**Name10 (NameIs) **] Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Cardizem LA 240 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Right cerebellar stroke and complete occlusion of right vertebral artery. Discharge Condition: She has mild dyslexia. MS: intact CN: 20/40 in R eye, 20/20 in L, Motor: no deficits [**Last Name (un) **]: no deficits Gait: normal, narrow based. Discharge Instructions: You have had a stroke. You were placed on anticoagulation and will need follow up with your PCP to check your INR levels. You also had a UTI for which you were treated Followup Instructions: You will follow up with Dr. [**First Name (STitle) **] in the stroke clinic on [**7-17**] at noon ([**Hospital Ward Name 23**] building, [**Location (un) 442**]). You will follow up with your PCP [**Last Name (NamePattern4) **] 48 h to check your INR. You will receive speech therapy as prescribed [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "433.21", "790.92", "V10.44", "443.9", "401.9", "V12.51", "733.90", "781.3", "368.40" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8911, 8917

5824, 7993

355, 362

9036, 9186

5297, 5801

9404, 9818

2620, 2702

8149, 8888

8938, 9015

8019, 8126

9210, 9381

3832, 5278

2718, 3274

277, 317

390, 2011

3289, 3815

2033, 2349

2365, 2604

27,086

109,812

18586

Discharge summary

report

Admission Date: [**2104-6-3**] Discharge Date: [**2104-6-9**] Date of Birth: [**2047-6-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Fever, rash Major Surgical or Invasive Procedure: Skin biopsy History of Present Illness: Ms. [**Known lastname 28412**] is a 56 year old woman with history of diabetes, hypothyroidism, and remote history of Hodgkin's disease who presented for the evaluation of fever and rash. Last Wednesday (six days prior to admission, she noticed a rash on her face. She went with her husband to his doctor's appointment, and he took a urine sample and diagnosed her with the flu. The rash started on her face and then spread over her entire body, including extremities, although she denies involvement of the hands and soles. It is not painful and not itchy. She then developed chills and fevers to 101F, along with "excruciating" intermittent headaches, located over her right eye, for which she was prescribed Vicodin with good effect on both her headaches and ability to sleep. She also reports muscle and joint aches, as well as diffuse body weakness. She was not improving, and the day prior to admission, her daughter took her to an OSH (but she vomited in the car on the way to the hospital and traveled the rest of the way via ambulance), where she had an elevated white count, was diagnosed with a UTI, given IVF, ciprofloxacin and compazine, and sent home. She denies sick contacts, genital ulcers or lesions, travel outside of the country, prolonged exposure in the [**Doctor Last Name 6641**] (although she does have to walk in high grass to and from the mailbox), tick or mosquito bites, pets, unusual foods, and raw seafood. She denies new medications preceding the rash, and she denies use of new deodorants or lotions. Per her family (daughter), she seemed to have trouble concentrating, but was not particularly altered in cognition. Mental status worsened with fevers/rigors but improved after Tylenol. She reports being up to date on all her vaccines. Of note, her husband recently had quadruple bypass surgery two weeks ago at [**Hospital1 18**] and is currently recovering; she reports increased stress and minimal sleep since the operation. . In the ED, her vitals were T99.6F, HR 109, BP 148/81, RR 24, Sat 100%2LNC. She was given IVF, diphenhydramine without improvement in the rash. She was transferred to the floor. Past Medical History: 1)Type 2 Diabetes 2)Hypercholesterolemia 3)s/p Hodgkin's lymphoma, rx splenectomy/radiation 20 years ago 4)Hypothyroidism Social History: Lives in [**Location 51056**] with husband. Denies tobacco, alcohol, and drugs. Has not been sexually active with husband in several weeks, but denies sexual activity outside of marriage. Family History: Significant for diabetes and coronary artery disease. Physical Exam: VS: T:102.1F, BP:148/76, HR:117, RR:22, O2:96%RA GEN: Uncomfortable appearing HEENT: EOMI, PERRL, dry mucus membranes NECK: Supple, no cervical lymphadenopathy, no meningismus CHEST: Bibasilar dry crackles at bases, no wheezes or rhonchi CV: Tachycardic, no m/r/g ABD: Soft, voluntary guarding, decreased (but present) bowel sounds, mild tenderness to palpation in RUQ EXT: No clubbing, cyanosis, edema NEURO: A&O x3, but easily distractable; speaking coherently in full sentences SKIN: Diffuse macular blanchable rash on trunk, extremities, back, and with partial involvement of palms and soles Pertinent Results: U/A: Tr prot, 150 ket, otherwise unremarkable . Lactate 1.8 . Na 135 K 4.9 Cl 99 HCO3 20 BUN 17 Creat 1.0 Gluc 74 . WBC 12.9 N:83 Band:0 L:11 M:2 E:0 Bas:0 Atyps: 4 Hgb 11.5 Hct 34.0 Plt 545 MCV 85 . ALT: 69 AST: 48 AP: 191 Tbili: 0.4 LDH: 323 . Blood Cx x 2: Pending Urine Cx: Pending Lyme serologies: Pending RPR: Pending Monospot: Pending . ECG: None performed . CXR: Mild edema with small bilateral pleural effusions. There is presumed partially calcified mass lesion likely within the anterior mediastinum of indeterminate etiology. Diagnostic considerations include prior granulomatous disease or possibly treated lymphoma. A calcified mass possibly from thyroid origin is also in the differential diagnosis. This lesion does not likely represent an acute finding. If indicated, consider non-urgent outpatient chest CT for further characterization. Brief Hospital Course: A/P: Ms. [**Known lastname 28412**] is a 56 year old woman with remote history of Hodgkin's disease, and history of diabetes, presenting with fever, intermittent headache, malaise, fatigue, arthralgias/myalgias, mild transaminitis, and diffuse macular blanching rash. . #. Fever and rash. Dermatology and ID were consulted. Doxycycline initially added to cover rickettsial/atypical infections, then stopped. Initially there was concern for Sweet's; however, pathology from skin biopsy was not consistent with this. Pathology prelim with edema and perivascular neutrophilic infiltrate (similar to urticaria, but not consistent with clinical picture). No evidence of leukemic infiltrate. Rheumatology was consulted following biopsy results (as could be consistent with Still's); felt to be non-rheum in nature. Differential included post viral hypersensitivity reaction, drug reaction, less likely viral exanthem. The following serologies and additional studies were obtained during her admission: Parvovirus IgG/IgM negative, Mycoplasma IgG pos/IgM neg, RPR neg, Lyme neg, monospot neg, resp viral antigen neg, Rubella and Rubeola IgG pos, ESR 115, RF 20, [**Doctor First Name **] neg. Blood and urine cultures negative. Her rash improved significantly (in intensity and distribution) over the course of her admission without any intervention. At discharge she had also been afebrile x >48hours. . # Atrial fibrillation with rapid ventricular response. On [**6-5**] was noted to be tachycardic to 160s+ on routine vitals, ECG with ?MAT. Back into sinus with IV lopressor and fever control. On [**6-6**] again persistently tachycardic to 140s with rhythm more consistent with atrial fibrillation, very difficult to rate control. Briefly transferred to MICU where received diltiazem gtt. Normotensive during episodes but did drop briefly into upper 80s with receiving dilt. Eventually titrated up to diltiazem 360 daily plus metoprolol 150 daily; with this regimen she has been in and out of Afib with rates generally in 90s, very briefly increasing into 120's. Heparin gtt as bridge to coumadin started. Cardiology was consulted and she will have followup with them as an outpaient. INRs will be checked by her PCP. [**Name10 (NameIs) **] control can further be adjusted by her PCP. [**Name10 (NameIs) **] reason for Afib was unclear. She had repeat echo without significant change (normal LV function, no evidence of RV strain, normal atrial size). No underlying pulmonary disease, though did have new pulmonary edema on CXR (despite normal LV function on echo) which may have triggered the arrhythmia. TSH normal. . #. Hypoxia/pulmonary edema. Pulmonary edema and effusions on chest xray (?cardiogenic vs. noncardiogenic/inflammatory source). This initially worsened during admission with new O2 requirement; with diuresis this improved and she was not requiring O2 at discharge. Unclear why she developed pulmonary edema as above. BNP was elevated at 3855. . #. Transaminitis. Likely related to above viral/hypersensitivity process. Transaminases peaked at admission and subsequently declined. However, alk phos continued to rise through her discharge (353 at discharge) with elevated GGT as well. RUQ ultrasound without significant gallbladder/liver findings. LFTs will be followed by her PCP following discharge. . # Anemia. Hct slowly trended down since admission. Fe studies c/w inflammation. No evidence of active bleeding. She should have repeat CBC as an outpatient. . # Thrombocytosis. Most likely is reactive given significant inflammtion/acute illness. ASA was continued. . # Leukocytosis. Unclear as to etiology. Stable in 13-15K range. Neutrophilia without bandemia. . #. Diabetes. Held PO meds and administered sliding scale insulin. . #. Hypothyroidism. Continued levothyroxine. TSH normal. Medications on Admission: Ciprofloxacin 500mg [**Hospital1 **] Vicodin 1 tab Q6H Compazine (but not taking) Aspirin 325mg daily Metformin 500mg [**Hospital1 **] Glyburide 1.25mg [**Hospital1 **] Sertraline 100mg daily Synthroid 125mcg daily Pravastatin 40mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Diltiazem HCl 360 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:*1* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*1* 9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Fever Rash, NOS Atrial fibrillation with rapid ventricular response . Pulmonary edema Diabetes type II Hypothyroidism Leukocytosis Anemia Thrombocytosis Transaminitis Discharge Condition: Stable, afebrile, with intermittent rate controlled Afib Discharge Instructions: You were admitted with fever and rash. You were seen by multiple specialists regarding your illness. Although the exact cause is still unknown, you have improved significantly. You will continue to follow with your doctors closely over the next few weeks. . Please return to the hospital or call your doctor immediately if you again develop fever, shortness of breath, chest pain, palpitations, lightheadedness or fainting, bleeding, or any new symptoms that you are concerned about. . Since you were admitted, we have made the following changes to your medications: - You have started a blood thinning medication, COUMADIN. - You have started 2 new medications for fast heart rate, DILTIAZEM and METOPROLOL. Followup Instructions: You have the following followup appointments: - Dr. [**Last Name (STitle) **]: you need to see him in the office this week. We were unable to schedule an appointment for you prior to discharge. We will call his office in the morning and then call you with an appointment time. - Dermatology with Dr. [**First Name (STitle) **]. [**7-24**] at 9:15 am. [**Telephone/Fax (1) 1971**]. - Cardiology with Dr. [**Last Name (STitle) **]. [**7-9**] at 3pm. Located on [**Location (un) 436**] of [**Hospital Ward Name 23**]. [**Telephone/Fax (1) 285**] . You will need to have the following labwork done this week: INR (because of coumadin), CBC, LFTs. Dr. [**Last Name (STitle) **] can order these labs for you at your appointment this week.

[ "238.71", "427.32", "201.90", "427.31", "079.99", "250.00", "057.9", "428.0", "244.9" ]

icd9cm

[ [ [] ] ]

[ "86.11" ]

icd9pcs

[ [ [] ] ]

9428, 9434

4445, 8284

324, 338

9645, 9704

3564, 4422

10464, 11206

2877, 2932

8573, 9405

9455, 9624

8310, 8550

9728, 10441

2947, 3545

273, 286

366, 2509

2531, 2656

2672, 2861

72,189

102,559

42042

Discharge summary

report

Admission Date: [**2185-11-17**] Discharge Date: [**2185-11-21**] Date of Birth: [**2146-3-18**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: h/a, Nausea Major Surgical or Invasive Procedure: [**2185-11-17**]: Suboccipital Craniotomy and resection of 4th ventricular tumor. History of Present Illness: This is a 39 years old right handed man with no significant medical history who presents to the [**Hospital1 18**] for further evaluation of a recent 4th ventricle mass that was picked up on his brain Mri. Patient was seen in the BTC on [**2185-10-27**]. During initial visit, MRI of spine was ordered. Spine MRI showed focal enhancement seen along the anterior surface of the spinal cord at T12 level and joint degenerative disease. Patient was also sent home on dexamethasone 2 mg [**Hospital1 **]. Today he reports improvement with headaches, rash. He denies any seizures or weakness, numbness or tingling. Past Medical History: Vasectomy Social History: Patient is married, lives with his wife and they have two children. He occasionally drinks alcohol. He denies any drugs use or tobacco use. He is currently unemployed. He has a family history of skin cancer Family History: NC Pertinent Results: [**11-17**] MRI Brain- IMPRESSION: MRI performed for surgical planning with surface markers demonstrates a small inferior fourth ventricle tumor with subtle enhancement. [**11-17**] CT Brain- IMPRESSION: Expected post-operative changes status post suboccipital craniotomy including pneumocephalus and blood layering within the occipital horns of the lateral ventricles. A metallic density object within the cisterna magna is noted- correlate with surgical details if this is expected. [**11-18**] MRI Brain- IMPRESSION: 1. Punctate signal abnormality and slow diffusion in the right posteromedial aspect of the medulla, suggestive of a tiny acute infarct. 2. No evidence of residual tumor within the 4th ventricle. 3. Expected post-operative appearance, little changed since the head CT performed the previous day. Brief Hospital Course: Pt electively presented and underwent a suboccipital craniotomy and resection of a 4th ventricular tumor. Surgery was without complication and the patient tolerated it well. He was extubated and transferred to the ICU. Post op head CT revealed post operative changes. On [**11-18**] he was neurologically intact and pain was well controlled. He was cleared for transfer to the floor. MRI was completed and revealed gross total resection of the 4th ventricular mass. Decadron was weaned and foley was discontinued. Medications on Admission: DEXAMETHASONE - 2 mg Tablet - 2 Tablet(s) by mouth 2 TABS TWICE/DAY Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, T>38.5. Disp:*30 Tablet(s)* Refills:*6* 2. 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* 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 5. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 7 days. 6. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q8hrs () for 1 days. Disp:*qs Tablet(s)* Refills:*0* 7. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12hrs () for 1 days. Disp:*qs Tablet(s)* Refills:*0* 8. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Qday () for 1 days. Disp:*qs Tablet(s)* Refills:*0* 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day: While taking dexamethasone. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Biopsy result pending. Results will be discussed at future follow-up appointment. Discharge Condition: Normal mental status and neurological function at time of discharge. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Dressing may be removed on Day 2 after surgery. ?????? If you have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? If your wound was closed with staples or non-dissolvable sutures then you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: Follow-Up Appointment Instructions ** No wound check needed if being seen in BTC within 14 days. ?????? Please return to the office in [**8-21**] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? You have an appointment in the Brain [**Hospital 341**] Clinic. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions.

[ "237.5", "331.4", "728.85", "088.81" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

3930, 3979

2186, 2701

322, 406

4105, 4175

1343, 2163

6125, 6978

1320, 1324

2820, 3907

4000, 4084

2727, 2797

4199, 6102

271, 284

434, 1046

1068, 1080

1096, 1304

61,415

124,749

1903

Discharge summary

report

Admission Date: [**2104-2-12**] Discharge Date: [**2104-2-24**] Date of Birth: [**2033-10-22**] Sex: M Service: SURGERY Allergies: clindamycin / Cephalexin Attending:[**First Name3 (LF) 6088**] Chief Complaint: AAA Major Surgical or Invasive Procedure: Resection of juxtarenal abdominal aortic aneurysm and reconstruction with an 18 x 9-mm Dacron bifurcated graft through a retroperitoneal incision. History of Present Illness: 70 year old male with recurrent episodes of R flank pain for the last 4-5 days. Has been intermittent, however , last night pain was progressively worse such that he came to the hospital this morning. No nausea no vomiting; No fever. No urinary symptoms; No hematuria. No change in appetite or loss of weight. Known AAA being followed by a vascular surgeon at VA. Unsure of size but thinks it has been in the "3's" for 15 years. Past Medical History: AAA, smoking History, HTN, High cholesterol, Renal stones PAST SURGICAL HISTORY: Left nephrectomy, CABG, Repair of SMA Social History: former smoker - quit in [**2097**] no etoh no illegal drugs lives alone; independent Family History: denies h/o aortic aneurysms Physical Exam: Neuro/Psych: Oriented x3, Affect Normal. Neck: No masses, Trachea midline. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear. Gastrointestinal: Non distended, No masses, Guarding or rebound, No hernia, abnormal: Midline scar with incisional hernia reducible. Nontender abdomen and groins. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Brachial: P. LUE Radial: P. Brachial: P. RLE Femoral: P. Popiteal: P. DP: D. PT: D. LLE Femoral: P. Popiteal: P. DP: D. PT: D. Pertinent Results: [**2104-2-12**] 05:05PM BLOOD WBC-8.5 RBC-5.00 Hgb-14.7 Hct-42.4 MCV-85 MCH-29.3 MCHC-34.6 RDW-13.7 Plt Ct-200 [**2104-2-13**] 10:15AM BLOOD WBC-7.3 RBC-4.85 Hgb-14.2 Hct-41.3 MCV-85 MCH-29.3 MCHC-34.5 RDW-13.7 Plt Ct-178 [**2104-2-12**] 05:05PM BLOOD PT-12.1 PTT-23.2 INR(PT)-1.0 [**2104-2-13**] 10:15AM BLOOD PT-13.5* PTT-24.0 INR(PT)-1.2* [**2104-2-12**] 05:05PM BLOOD Glucose-96 UreaN-11 Creat-1.1 Na-140 K-5.0 Cl-105 HCO3-26 AnGap-14 [**2104-2-13**] 10:15AM BLOOD Glucose-186* UreaN-11 Creat-1.2 Na-140 K-4.6 Cl-105 HCO3-29 AnGap-11 [**2104-2-13**] 10:15AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0 CT ABDOMEN WITH INTRAVENOUS CONTRAST: The heart size is at the upper limits of normal. Dense coronary calcifications are identified. In the lung bases, there is bibasilar atelectasis, new compared to prior examination. There are also chronic pleural inflammatory changes including fat deposition and fibrotic changes, left greater than right. Bilateral small pleural effusions are also identified, right greater than left. No focal pulmonary nodules or opacities are identified in the lung bases. The liver exhibits homogeneous parenchymal enhancement without focal hepatic lesion. The gallbladder is unremarkable without evidence of stones. There is a heterogeneous appearance of the spleen, likely secondary to the late arterial phase of the scan. No focal area of splenic infarct is identified. The portal venous system and hepatic veins are patent. No intra- or extra-hepatic biliary ductal dilatation is identified. Dense calcifications are seen within the dorsal pancreatic head and distal tail, findings consistent with chronic pancreatitis. The right adrenal gland is within normal limits. There is symmetric enhancement of the right kidney without evidence of ischemia. There is no hydronephrosis or focal renal mass. The patient is status post left nephrectomy. Surgical clips are seen within the resection bed. The visualized stomach and small bowel are normal in caliber and configuration, without evidence of obstruction or ischemia. CTA OF THE ABDOMEN AND PELVIS: The patient is status post open repair of an inflammatory abdominal aortic aneurysm via a retroperitoneal approach. The grafted abdominal aorta and its branch vessels are patent without evidence of leak. The left hepatic artery arises from the celiac axis and the right hepatic artery arises from the SMA. There is complete opacification of the celiac axis, SMA, right renal artery, common iliac arteries, external iliac arteries, and distally into the superficial femoral arteries bilaterally. No focal thrombus or dissection is identified. The left renal artery has been previously oversewn at the time of prior left nephrectomy. The [**Female First Name (un) 899**] was oversewn during the surgery. Collateral flow to the distal colon is identified. The bypass graft extends from the supraceliac aorta to the right common iliac artery and left external iliac artery. There is retrograde filling of the left internal iliac artery via collaterals. The aneurysm sac appears to have been entered from a left anterior approach, and there is a small postoperative fluid collection lateral to the grafted aorta at the level of the kidneys (2:69). The hyperattenuating rind of inflammatory tissue appears unchanged compared to prior and extends from the 11 o'clock to 6 o'clock position seen at the level of the lower pole of the right kidney. Small foci of air are identified adjacent to the graft consistent with recent surgery (2:78). There is a clear fat plane between the abdominal aorta and duodenum without evidence of fistulous tract formation. There is a hyperattenuating fluid collection within the left nephrectomy bed extending into the left retroperitoneum(2:80). No thick enhancing wall is identified around the collections to suggest abscess formation. The left flank postoperative fluid/hematoma extends inferiorly into the left inguinal canal where foci of gas and blood are identified within the left scrotum. In the midline abdomen/pelvis, there is another fluid collection exhibiting a hematocrit level, consistent with a post-operative hematoma (2:123). The right ureter is in close proximity to this midline hematoma, though there is no evidence of obstruction of the right kidney at this time. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum and sigmoid colon are normal in caliber and configuration without evidence of acute inflammation or ischemia. Postoperative fluid collections are identified within the pelvis as described above. There is a small foci of air within the bladder most likely secondary to recent Foley catheterization, recommend correlation with clinical history (2:146). Otherwise, the bladder, prostate, and seminal vesicles are within normal limits. No pathologically enlarged mesenteric, retroperitoneal, pelvic or inguinal lymph nodes are appreciated. There are bilateral fat-containing direct inguinal hernias, unchanged compared to prior. OSSEOUS STRUCTURES: No bone destructive lesion identified. There are degenerative changes of the lower lumbar spine, most severe at L5-S1 with disc space narrowing and sclerosis. IMPRESSION: 1. Patent abdominal aortic graft without evidence of leak. Adequate distal runoff into the proximal thighs without evidence of focal thrombus, dissection or acute aortic syndrome. 2. Residual soft plaque or thrombus within the abdominal aorta and persistent rind of hyperattenuating inflammatory tissue. 3. Post-surgical fluid collection on the left side of the graft at the level of the lower pole of the right kidney, near the site of surgical approach. Additionally, a retroperitoneal hematoma is identified extending from the left flank into the pelvis and into the left inguinal canal. A midline pelvic hematoma is identified, in close proximity to the right ureter. No thick enhancing wall is identified around these fluid collections, though infection cannot be excluded. 4. Normal parenchymal enhancement of the abdominal organs without evidence of ischemia. 5. Stable changes of chronic pancreatitis. 6. Bibasilar atelectasis and small bilateral pleural effusions, right greater than left. Brief Hospital Course: Mr. [**Known lastname 10607**] was transfered to [**Hospital1 18**] on [**2-12**] and admitted to the Vascular Surgery service. He had a CTA of his abdomen/pelvis which showed: 1. Multilobulated infrarenal abdominal aortic aneurysm measuring up to 4.8 cm in maximal dimension. Additionally, there is aneurysmal dilatation of the bilateral common iliac arteries. There is no rupture. 2. Left lung basilar atelectasis. 3. Fatty infiltration of the liver. 4. Mild stranding around the middle third of the left ureter is nonspecific. Correlate with patient's symptoms and urine cytology. When Dr. [**Last Name (STitle) **] reviewed the CT scan, he measured the maximal aortic dimension at 4cm. The scan was also concerning for a non specific finding which was thought to be consistent with ureteral inflammation, although urology reviewed the scan and felt this was not the case. There were no previous CT scans sent with the patient. We called the [**Hospital **] hospital where he has been followed and asked them to overnight a CD of his most recent abdominal CT scan. During his hospital course Mr. [**Known lastname 10607**] experienced virtually no pain. He reports an occasional dull twinge in his right low back/ upper gluteal region which he reports has been happening on occasion for many years. He denied any other back pain, abdominal pain, chest pain, dysuria, abnormal bowel movements, or difficulty eating throughout his course. A UA done on [**2-12**] showed trace blood with no other abnormalities. A repeat UA on [**2-13**] showed no blood, and again no other abnormalities. It was decided to repair the AAA. He agreed to have an elective surgery. Pre-operatively, she/he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a: Resection of juxtarenal abdominal aortic aneurysm and reconstruction with an 18 x 9-mm Dacron bifurcated graft through a retroperitoneal incision. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. He was then transferred to the VICU for further recovery. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabalized from the acute setting of post operative care, he was transfered to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home in stable condition. To note Pt did have what looked like livido reticularis. A CT scan was obtained. this revealed: CT ABDOMEN WITH INTRAVENOUS CONTRAST: The heart size is at the upper limits of normal. Dense coronary calcifications are identified. In the lung bases, there is bibasilar atelectasis, new compared to prior examination. There are also chronic pleural inflammatory changes including fat deposition and fibrotic changes, left greater than right. Bilateral small pleural effusions are also identified, right greater than left. No focal pulmonary nodules or opacities are identified in the lung bases. The liver exhibits homogeneous parenchymal enhancement without focal hepatic lesion. The gallbladder is unremarkable without evidence of stones. There is a heterogeneous appearance of the spleen, likely secondary to the late arterial phase of the scan. No focal area of splenic infarct is identified. The portal venous system and hepatic veins are patent. No intra- or extra-hepatic biliary ductal dilatation is identified. Dense calcifications are seen within the dorsal pancreatic head and distal tail, findings consistent with chronic pancreatitis. The right adrenal gland is within normal limits. There is symmetric enhancement of the right kidney without evidence of ischemia. There is no hydronephrosis or focal renal mass. The patient is status post left nephrectomy. Surgical clips are seen within the resection bed. The visualized stomach and small bowel are normal in caliber and configuration, without evidence of obstruction or ischemia. CTA OF THE ABDOMEN AND PELVIS: The patient is status post open repair of an inflammatory abdominal aortic aneurysm via a retroperitoneal approach. The grafted abdominal aorta and its branch vessels are patent without evidence of leak. The left hepatic artery arises from the celiac axis and the right hepatic artery arises from the SMA. There is complete opacification of the celiac axis, SMA, right renal artery, common iliac arteries, external iliac arteries, and distally into the superficial femoral arteries bilaterally. No focal thrombus or dissection is identified. The left renal artery has been previously oversewn at the time of prior left nephrectomy. The [**Female First Name (un) 899**] was oversewn during the surgery. Collateral flow to the distal colon is identified. The bypass graft extends from the supraceliac aorta to the right common iliac artery and left external iliac artery. There is retrograde filling of the left internal iliac artery via collaterals. The aneurysm sac appears to have been entered from a left anterior approach, and there is a small postoperative fluid collection lateral to the grafted aorta at the level of the kidneys (2:69). The hyperattenuating rind of inflammatory tissue appears unchanged compared to prior and extends from the 11 o'clock to 6 o'clock position seen at the level of the lower pole of the right kidney. Small foci of air are identified adjacent to the graft consistent with recent surgery (2:78). There is a clear fat plane between the abdominal aorta and duodenum without evidence of fistulous tract formation. There is a hyperattenuating fluid collection within the left nephrectomy bed extending into the left retroperitoneum(2:80). No thick enhancing wall is identified around the collections to suggest abscess formation. The left flank postoperative fluid/hematoma extends inferiorly into the left inguinal canal where foci of gas and blood are identified within the left scrotum. In the midline abdomen/pelvis, there is another fluid collection exhibiting a hematocrit level, consistent with a post-operative hematoma (2:123). The right ureter is in close proximity to this midline hematoma, though there is no evidence of obstruction of the right kidney at this time. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum and sigmoid colon are normal in caliber and configuration without evidence of acute inflammation or ischemia. Postoperative fluid collections are identified within the pelvis as described above. There is a small foci of air within the bladder most likely secondary to recent Foley catheterization, recommend correlation with clinical history (2:146). Otherwise, the bladder, prostate, and seminal vesicles are within normal limits. No pathologically enlarged mesenteric, retroperitoneal, pelvic or inguinal lymph nodes are appreciated. There are bilateral fat-containing direct inguinal hernias, unchanged compared to prior. OSSEOUS STRUCTURES: No bone destructive lesion identified. There are degenerative changes of the lower lumbar spine, most severe at L5-S1 with disc space narrowing and sclerosis. IMPRESSION: 1. Patent abdominal aortic graft without evidence of leak. Adequate distal runoff into the proximal thighs without evidence of focal thrombus, dissection or acute aortic syndrome. 2. Residual soft plaque or thrombus within the abdominal aorta and persistent rind of hyperattenuating inflammatory tissue. 3. Post-surgical fluid collection on the left side of the graft at the level of the lower pole of the right kidney, near the site of surgical approach. Additionally, a retroperitoneal hematoma is identified extending from the left flank into the pelvis and into the left inguinal canal. A midline pelvic hematoma is identified, in close proximity to the right ureter. No thick enhancing wall is identified around these fluid collections, though infection cannot be excluded. 4. Normal parenchymal enhancement of the abdominal organs without evidence of ischemia. 5. Stable changes of chronic pancreatitis. 6. Bibasilar atelectasis and small bilateral pleural effusions, right greater than left. There was no acute findings noted, a Rheumatology consult was obtained. They thought this was from aortic sholesteral enboli. Nothing to do. Pt also had normal post op constipation he was treated with different modalities, Had a KUB. Normal postoperative illeus. This resolved with bowel medications. Medications on Admission: Asa 81mg daily Rosuvastain 40mg daily Methimazole 15mg daily Atenolol 50mg daily Discharge Medications: 1. methimazole 5 mg Tablet Sig: Three (3) Tablet PO QD (). 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO ONCE (Once) for 7 days: take prn for constipation. Disp:*2 bottles* Refills:*0* 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for . for 10 days: prn for pain. Disp:*30 Tablet(s)* Refills:*0* 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 10 days: prn. Disp:*30 Tablet(s)* Refills:*0* 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: abdominal pain abdominal aortic aneurysm bilateral common iliac aneurysms post op illeus livido reticularis post op confusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have an abdominal aortic aneurysm Please check your blood pressure twice daily and record. Your goal BP is 120/80 or less. If it is consistently higher than this, you need to call your primary care physician and have your medications adjusted If you have acute pain in your back, abdomen or chest you need to go to the emergency room immediately. Followup Instructions: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2104-3-5**] 11:00

[ "441.4", "442.2", "577.1", "293.9", "560.1", "401.9", "997.4", "998.12", "272.0", "V10.52", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "38.44" ]

icd9pcs

[ [ [] ] ]

18336, 18407

8082, 16912

289, 438

18577, 18577

1876, 8059

19106, 19251

1164, 1193

17044, 18313

18428, 18556

16938, 17021

18728, 19083

1004, 1045

1208, 1857

246, 251

466, 899

18592, 18704

922, 981

1061, 1148

51,094

119,202

50202

Discharge summary

report

Admission Date: [**2112-9-24**] Discharge Date: [**2112-10-5**] Date of Birth: [**2041-5-9**] Sex: F Service: MEDICINE Allergies: Benadryl / Lipitor / Codeine / Enablex / Latex / Iodine Attending:[**First Name3 (LF) 3016**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: pericardiocentesis with drain placement pericarical drain removal pericardial window placement History of Present Illness: Ms. [**Known lastname 13469**] is a 71 year old female with a PMH significant for recently diagnosed non-small cell lung cancer with metastases to the brain and C2 vertebrae, HTN, and Grave's disease s/p ablation on replacement therapy that presents with a 2 day history of dyspnea on exertion. She has noticed new onset shortness of breath over the past two days walking around her apartment. In the past she had become short of breath with walking up the stairs, but now the onset is with much less effort. She denies any accompanying lightheadedness, dizziness, or chest pain. She does describe associated tightness in her lower chest/epigastric area. Denies any fever or chills, though notes she was recently treated with an antibiotic for diarrhea. . Of note, this [**Month (only) 205**] she presented to her PCP with complaints of neck pain, double vision, and was found to have an elevated ESR. She was started on prednisone for suspected PMR and sent for a temporal artery biopsy to rule out temporal arteritis. Her biopsy was negative. Her symptoms improved on prednisone, but she had a recurrence of blurry vision. She presented to the ED and had a head CT that showed 2 lesions in the brain. She was admitted and found to have metastatic non-small cell lung cancer. The inferior images on the CTA neck also revealed a large lung mass with concern for invasion into the aortic arch. Her brain mets were treated with total brain irradiation and she is scheduled to start chemotherapy for the lung masses [**9-29**]. . Positive review of systems as above. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, ankle edema, palpitations, syncope or presyncope. . In the ED, initial vitals were T 97.4, BP 154/78, HR 112, RR 20, SaO2 96%. She was given aspirin 325mg x 1 and levofloxacin 750mg IV x1 for CXR showing new retrocardiac opacity and lactate of 3.5. She had a CTA to rule out PE that showed left pulmonary arterial invasion by the left upper lobe/hilar mass with associated occlusion with tumor thrombus of left lower lobe pulmonary artery branches as well as a moderate to large pericardial effusion. Wet Read There was question of tumor invasion into the aorta of pericardium. She was transferred to the CCU for close monitoring and possible pericardial effusion tap. . On the floor, a bedside echo was performed which showed a large pericardial effusion with RV and RA collapse during diastole. She was hemodynamically stable and asymptomatic. She had pulsus paradoxis on exam. Past Medical History: # [**Doctor Last Name 933**] or (hyperactive thyroid) patient s/p RAI, on replacement. # Urinary incontinence # Allergic Rhinitis # Exzema # Hyperlipidemia # Recent dx of PMR, but neg temporal artery biopsy. Has been on prednisone and GI PPX with steroids. Social History: Lives in [**Location **], does spend some time outdoors working in a garden, no recent travel. Partially retired teacher of math and electronics at [**University/College 104713**]. No EtOH. [**Name (NI) 104714**] pt reports that she smoked for approx 8-10 years in the [**2062**]. No illicits Family History: Mother died at 96 of Parkinson's disease. Father died at 68 of an aortic aneurysm Physical Exam: Physical Exam upon ADMISSION: . VS: BP 160/82 (pulses paradoxis at 142), HR 105, RR 25, O2 sat 93% GENERAL: Older woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT, thinning hair. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 9 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. tachycardic, normal S1, S2. No murmurs. Muffled heart sounds. 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. EXTREMITIES: mild upper extremity clubbing. SKIN: Warm dry, no lesions. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . Discharge Physical Examination: . VS: Tm:98.6, Tc:97.1, HR:79-87, BP:(138-146)/(54-64), RR:18-20, SO2:95%RA General: Comfortable HEENT: minimal cervical TTP CV: RRR, normal S1, S2, no m/r/g Resp: CTAB Abdominal: S/NT/ND Extremities: warm, 2+ pulses Pertinent Results: Labs Upon Admission to CCU: . [**2112-9-24**] 12:10PM BLOOD WBC-12.9* RBC-3.31* Hgb-9.9* Hct-29.5* MCV-89 MCH-29.9 MCHC-33.5 RDW-18.1* Plt Ct-386 [**2112-9-24**] 12:10PM BLOOD Neuts-89* Bands-2 Lymphs-7* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2112-9-24**] 12:10PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ [**2112-9-24**] 12:10PM BLOOD PT-13.6* PTT-22.5 INR(PT)-1.2* [**2112-9-24**] 12:10PM BLOOD UreaN-26* Creat-0.9 Na-132* K-4.2 Cl-97 HCO3-18* AnGap-21* [**2112-9-24**] 12:10PM BLOOD cTropnT-<0.01 [**2112-9-24**] 12:10PM BLOOD Calcium-9.5 Phos-4.1 Mg-2.3 [**2112-9-24**] 12:10PM BLOOD TSH-1.1 [**2112-9-25**] 05:20PM BLOOD Type-ART Temp-36.1 pO2-62* pCO2-24* pH-7.50* calTCO2-19* Base XS--2 Intubat-NOT INTUBA [**2112-9-24**] 12:26PM BLOOD Lactate-3.5* [**2112-9-25**] 05:20PM BLOOD O2 Sat-92 . Labs Upon Discharge from CCU: . Microbiology: . Blood culture [**2112-9-24**] and [**2112-9-25**]: No growth Urine culture [**2112-9-25**]: No growth . ECHO [**2112-9-24**]: Overall left ventricular systolic function is normal (LVEF>55%). There is a large pericardial effusion. The effusion appears circumferential. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . ECHO: [**2112-9-28**]: The estimated right atrial pressure is 0-5 mmHg. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). There is borderline pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . Cardiac cath [**2112-9-25**]: . Resting hemodynamics revealed evidence of pericardial tamponade as evident from the equalization of diastolic pressures in the RA, RV and PA. Left and right sided filling pressures were elevated with RVEDP of 16mmHg and PCWP of 18. There was moderate pulmonary systolic hypertension with an PASP of 41 mm Hg. 2. Using standard technique and ECHO guidance, the blunt tipped pericardial needle was used to the access the pericardial space via a subxiphoid approach. Position was confirmed fluoroscopically and by pressure tracing. 60 cc of serous fluid was rapidly removed. An 8 French drainage catheter was then placed over the wire and an additional 350 cc of serous and mildly bloody fluid was removed and sent for analysis. Final hemodynamics after removal showed pericardial pressure to be subatmospheric, RA pressure decreased to 5 mm Hg with return of the y Descent. SBP increased from 130 mm Hg to 170 mm Hg. Post procedure ECHO confirmed placement of the catheter in the pericardial space as well as well as complete resolution of the pericardial effusion. 3. Patient went into paroxysmal atrial fibrillation post procedure and was given 300mg Amiodarone IV as well as 5 mg of IV lopressor with good resultant rate control. . Pericardial Fluid [**2112-9-25**]: . GRAM STAIN (Final [**2112-9-26**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2112-9-28**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2112-9-26**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . Pathology: [**2112-9-25**]: Pericardial fluid: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic adenocarcinoma, . CXR [**2112-9-28**]: As compared to the previous radiograph, there is unchanged evidence of both right and left pleural effusion. Unchanged large left-sided paramediastinal mass. Unchanged size of the cardiac silhouette. Well-defined lucency at the left lung base, potentially reflecting a small left basal intrapleural air collection. No evidence of tension. . CT-A chest [**2112-9-24**]: 1. Left lower lobe pulmonary artery tumor thrombus extending to the left lower lobe artery branches with possible invasion by the left upper lobe/hilar mass, as described above. 3. New moderate to large pericardial effusion, possibly malignant, with findings above suggesting pericardial tamponade including mild right heart strain. 4. The upper lobe/perihilar mass with abutment and partial encasement of branches of the left upper lobe artery is not significantly changed. 5. No significant change in metastatic lymphadenopathy. 6. New bilateral pleural effusions with associated compressive atelectasis, worse on the right side. . Discharge Labs: Na 136, K 4.2, Cl 101, HCO3 17, BUN 25, Cr 0.6, Gluc 94 Ca: 8.6 Mg: 2.2 P: 3.7 WBC 11.3, Hgb 9.2, Hct 27.8, PLT 391 Brief Hospital Course: 71 y/o female with non-small cell lung cancer with metastases to the brain and C2 vetebral body, hypertension and hypothyroidism admitted with cardiac tamponade. . # Cardiac Tamponade/Pericardial effusion: Ms. [**Known lastname 13469**] presented to ED with a 2 day history of dyspnea, worse with exertion. On arrival, she had CXR showing new retrocardiac opacity and lactate of 3.5. CTA to rule out PE showed left pulmonary arterial invasion with tumor thrombus of as well as a moderate to large pericardial effusion. She was transferred to the CCU, and a bedside echo was performed which showed a large pericardial effusion with RV and RA collapse during diastole. She was hemodynamically stable and asymptomatic, but with pulsus paradoxis on exam. Patient went for right heart catheterization, with placement of right-sided pericardial drainage catheter, which showed large bloody pericardial effusion. Cytology demonstrated adenocarcinoma in the pericardial fluid. Due to persistent output through the pericardial drain, a surgical pericardial window was placed along with a temporary pericardial chest tube (removed after 24 hours). CT Surgery was comfortable following the patient outside of ICU care, and patient will be transferred to heme-onc service for management and preparation chemotherapy next week. . #Paroxysmal Afib: S/p pericardial drain placement, patient developed paroxysmal atrial fibrillation. She received metoprolol 5mg x3, diltiazem 10mg x2, Amiodarone 150mg x3, and started on amio gtt 1mg/min over 2.5h before she converted to NSR. She was maintained on amio 400mg [**Hospital1 **] and this was stopped before leaving the CCU. Likely new onset related to irritation of drain placement. However, this could represent infiltrative disease. ** Anticoagulation was deferred during this admission due to concern over vascular invasion of the tumor. Patient remained in sinus rhythm throughout her admission. ** . # Shortness of Breath: Likely secondary to pleural effusions (secondary to leakage from pericardial window) and atelectasis and possibly anemia. She takes shallow breaths due to chest discomfort and coughing which has resulted in a mild respiratory alkalosis. She responded well to furosemide, which was given to help decrease her pleural effusions. She can continue on furosemide as needed while on the OMED service (and possibly on discharge) if short of breath or if effusions grow in size. Incentive spirometry, coughing and activity (out of bed daily) was encouraged. . # Hypertension: Recently diagnosed with hypertension and started on amlodipine 5mg daily. Pressures SBP 150-60s in CCU. Her amlodipine was increased to 10mg daily which controlled her pressures well. The patient's pressures normalized throughout admission. Prior to discharge, the patient felt that her blood pressure was too low. The Amlodipine dose was decreased back to 5 mg PO daily. . # Non-Small Cell Lung Cancer with Metastases to brain and spine, s/p total brain irradiation, scheduled to start chemo week of [**2112-10-2**]. Patient was discharged to a rehabilitation facility with Hematology-Oncology appointments at [**Hospital1 18**] on [**2112-10-6**]. These appointments will likely deal with when to initiate chemotherapy. ** If problems arise with getting the patient to her appointments, please call the Hematology-Oncology appointment line at ([**Telephone/Fax (1) 14703**]. ** . # Anemia: Normocytic, HCT trending down now to 26.8, slow drop may be due to blood loss through pericardial drain. [**Month (only) 116**] also have anemia of chronic disease (admission Hct 30). No signs of GI bleed. She did not receive any transfusions as hematocrit remained stable throughout her admission with hematocrit ranging from 26 to 28. # Leukocytosis: The patient has a leukocytosis without evidence of infection, no fevers, cultures were negative and there was no evidence for an infiltrate on CXR. Her leukocytosis was resolving upon discharge from the CCU. The WBC continued to trend down throughout her stay and was 11.3 at discharge. . # Hypothyroidism: She has a history of Grave's disease s/p ablative therapy. Her TSH was normal during admission. She was continued on her home dose of levothyroxine without complications. . The patient was full code for this admission. Medications on Admission: AMLODIPINE 5 mg Tablet PO daily DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a day TAKE THE DAY BEFORE CHEMOTHERAPY AND THE DAY AFTER CHEMOTHERAPY FLUTICASONE 50 mcg Spray 2 sprays intranasally daily FOLIC ACID 1 mg Tablet PO daily LEVOTHYROXINE 112 mcg PO daily 30 minutes before breakfast ONDANSETRON HCL 8 mg PO Q8H PRN nausea/vomiting PROCHLORPERAZINE MALEATE 10 mg PO Q6H PRN nausea/vomiting ACETAMINOPHEN 500 mg PO Q6H SENNA 8.6 mg PO BID Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 7. Ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. 8. Acetaminophen 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for pain: Do not exceed 8 capsules a day. . Discharge Disposition: Extended Care Facility: [**Hospital3 537**] Skilled Nursing Center Discharge Diagnosis: Pericardial effusion with tamponade Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 13469**], . You were admitted to [**Hospital1 18**] for shortness of breath. A fluid collection was found around your heart which ultimately required the outer lining of your heart to be opened to relieve the collection. You subsequently developed an irregular heart beat (atrial fibrillation) that resolved with a medication. You were transferred to the oncology service for further evaluation. It was decided that you should begin your chemotherapy as an outpatient and you have several appointments for this reason as described below. Of note, cardiology recommends that you follow up with your primary care doctor (or cardiologist, if you currently have one) to discuss whether or not to pursue further testing for the episode of the irregular heart beat that you had while in the hospital. ** No other changes were made to your medications and you should continue taking all other medications as previously prescribed. ** Followup Instructions: Please follow up with your cardiologist in [**2-10**] weeks. Department: [**State **]When: WEDNESDAY [**2112-10-5**] at 12:45 PM With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2112-10-6**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2112-10-6**] at 9:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**] Completed by:[**2112-10-11**]

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Discharge summary

report

Admission Date: [**2180-7-23**] Discharge Date: [**2180-8-14**] Date of Birth: [**2113-2-2**] Sex: F Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**7-21**] emergent tracheal intubation [**7-27**] rigid bronch/stenosis dilation/ETT advancement [**8-1**] balloon dilation of trachea [**8-3**] extubated [**8-7**] tracheal resection bronchoscopy History of Present Illness: 67-year-old woman who presented to an outside hospital on [**2180-7-14**] with shortness of breath, stridor and wheezing, and after extensive workup, was found to have subglottic stenosis. Her history dates back to [**5-/2180**] when she was found down in [**Male First Name (un) 1056**] and diagnosed with a large myocardial infarction. She was intubated for four days, subsequently extubated and reintubated several hours later due to respiratory distress. She was eventually extubated, discharged to home where she then flew on to [**Last Name (LF) 6185**], [**First Name3 (LF) 108**], where she underwent a coronary artery bypass grafting. Her surgery was uneventful and she was extubated without difficulty but subsequently developed progressive dyspnea and wheezing and was admitted on [**2180-7-14**] and found to have moderate-to-severe post-intubation tracheal stenosis commencing approximately 3 cm below the vocal cords. While waiting transfer to a tertiary care medical center, she developed an episode of bradycardia and required intubation, however, the endotracheal tube was unable be advanced beyond the stenosis. Her endotracheal tube was changed to 6.5, but again it could not be advanced beyond the area of stenosis. She was subsequently transferred to the [**Hospital1 346**] for further management by the airway service. Past Medical History: Significant for coronary artery disease status post myocardial infarction in [**5-/2180**], status post coronary artery bypass grafting x3 in [**Location (un) 6185**], hypertension, hypercholesterolemia, and type 2 diabetes. Social History: She is married, has children, no history of tobacco use or alcohol use. Physical Exam: On Admission: Vitals: 100.7F, HR 79, BP 142/72, RR 16 100% Gen - intubated, sedated HEENT - PERRL, EOMI B/L Neck - supple, no adenopathy CV - RRR, nl s1, s2 Pul - rhonchi b/l Abd - soft, NT, ND, +BS Ext - no c/c/e Pertinent Results: On admission: [**2180-7-23**] 08:30PM WBC-6.2 RBC-2.98* HGB-8.2* HCT-24.4* MCV-82 MCH-27.4 MCHC-33.5 RDW-16.3* [**2180-7-23**] 08:30PM PLT COUNT-76* [**2180-7-23**] 08:30PM PT-11.8 PTT-25.7 INR(PT)-1.0 [**2180-7-23**] 08:30PM GLUCOSE-128* UREA N-24* CREAT-0.4 SODIUM-145 POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-32 ANION GAP-7* [**2180-7-23**] 08:30PM ALT(SGPT)-23 AST(SGOT)-21 LD(LDH)-253* CK(CPK)-29 ALK PHOS-44 TOT BILI-0.4 [**2180-7-23**] 08:30PM CK-MB-NotDone cTropnT-0.01 [**2180-7-23**] 08:30PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-1.6* MAGNESIUM-2.1 [**2180-7-23**] 10:16PM TYPE-ART TEMP-38.2 RATES-/16 TIDAL VOL-466 O2-40 PO2-209* PCO2-49* PH-7.46* TOTAL CO2-36* BASE XS-10 INTUBATED-INTUBATED VENT-SPONTANEOU At Discharge: [**2180-8-13**] 05:37AM BLOOD WBC-5.5 RBC-3.06* Hgb-9.1* Hct-26.0* MCV-85 MCH-29.8 MCHC-35.0 RDW-15.8* Plt Ct-357 [**2180-8-14**] 05:40AM BLOOD PT-31.8* PTT-45.1* INR(PT)-3.4* CXR [**8-8**]: IMPRESSION: The post-surgical drain is again demonstrated with its tip overlying the upper mediastinum. The heart size and mediastinal contours are unremarkable. The left lower lobe discoid atelectasis is unchanged. The right lung and upper portion of the left lung are unremarkable. CT HEAD W/O CONTRAST [**2180-8-10**] 8:25 AM Reason: ? acute bleed IMPRESSION: 1) No acute intracranial hemorrhage or major vascular territorial infarct identified. 2) Absence of the septum pellucidum, likely congenital in origin. CT TRACHEA [**2180-7-28**] IMPRESSION: 1. Focal segment of tracheal stenosis involving the subglottic and upper intrathoracic trachea. 2. Nonspecific mild ground-glass opacity in the medial aspect of the superior segment of the right lower lobe, which could be secondary to aspiration. 3. Small bilateral pleural effusions, unchanged Brief Hospital Course: Pt was transferred to [**Hospital1 18**] on [**7-23**] from an OSH for management of her tracheal stenosis likely secondary to intubation. She was admitted to the MICU service, intubated and sedated. On admission she was started on levofloxacin and flagyl for empiric coverage against a possible pneumonia, for which she was being treated with zosyn and ceftriaxone at her OSH. For her tracheal stenosis she was started on solumedrol and given nebs. Bronchoscopy on [**7-24**] showed severe tracheal stenosis 5mm in diamter and 2.5cm in length. On [**7-25**] Ms [**Known lastname **] was found to be HIT positive and was therefore started on an argatroban drip. At that time she was seen by cardiology for pre-operative clearance. Although she had had recent CABG, the cardiologists felt that she had no current high risk prognostic features and therefore cleared her for surgery. She was also seen by Dr. [**Last Name (STitle) 952**] at that time who planned to do a tracheal resection 8 days later. Tube feeds through her OG tube were started at that time to optimize pre-op nutrition. Pt. also began having runs of SVT at this time requiring IV lopressor 15-20mg. On [**7-27**] she was underwent rigid bronch and tracheal dilation without incident. Pt had TTE done as well which showed: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. She was planned for surgery on [**7-31**] for a tracheal resection, although her runs of SVT continued. Bronchial washings at this time were negative for malignancy. Pt contiued to have SVT with non-specific ST changes on [**7-31**], and therefore the surgery was postponed. Cardiac enzymes were negative. On [**8-1**] she went to the OR for rigid bronch and balloon dilation of trachea to 14mm without complications. No stent was placed at that time. For details please see OP note. On [**8-2**] pt was extubated without difficulty and was seen by speech and swallow who felt she was aspirating with thin liquids and recommended nectar thick liquids and ground solids. On [**8-3**] her abx were stopped after a total of 11 days (14 days of all abx's including OSH). She continued to have episodes of narrow complex SVT. On [**8-4**] she was transfered out of the MICU onto the regular floor in stable condition onto the thoracic surgery service. She was cleared by swallow for a regular diet and thin liquids and her tube feeds were stopped. Tracheal resection was planned for [**8-7**]. CT of trachea on [**8-4**] confirmed subglottic stenosis. on [**8-7**] she was made NPO after midnight and her argatroban drip was held 4 hours prior to the procedure. The procedure went without incident and she was transfered to the CSRU extubated in stable condition. Post-operatively her argatroban drip was restarted at her stable pre-op dose of 5.75. She was transfered out of the unit on POD 1 and was given 5mg coumadin in order to stop the argatroban. She was cleared by speech and swallow for a regular diet. On POD 2 pt became supratherapeutic on her coumadin. Her coags on [**8-9**] were as follows: PT - 49, PTT - 90, INR - 5.3. The argatroban was decreased to 5.0 at that time and she was given only 2.5 of coumadin. In addition, her metoprolol was decreased to 12.5 [**Hospital1 **] from 25 [**Hospital1 **] for hypotension into the low 90's/50s. On the morning of POD3 pt was noted to be hypoglycemic and was given 1amp of D50. However she continued to be lethargic and began having a short run of narrow complex SVT. This resolved with 15mg IV lopressor and her PO dose was placed back to 25 [**Hospital1 **]. When pt got up to ambulate, physical therapy noted right-sided weakness. Pt was sent for a head CT which was negative for an intracranial bleed and was seen by neurology. The right-sided weakness resolved later that day. Her coags were noted to be PT 98, PTT 100, and INR of 18.3 However these were drawn from the same PICC line as the argatroban was being given. Regardless, the argatroban was stopped and she recieved on coumadin that night. On POD4 pt had another run of SVT and her metoprolol was changed to toprol xl 50mg qday per cardiology. Her strength improved after daily and on POD7 she was cleared by physical therapy to go home without services. Her coags on [**8-14**] (the day of discharge) were PT 32, PTT 45, and INR 3.4. She was sent home on 1 day of coumadin at 1mg followed by 2 days of 0.5mg. Her INR will be followed by Dr. [**Last Name (STitle) **] until she returns to [**State 108**] and she will follow up with Dr. [**Last Name (STitle) **] on [**8-17**] at which point her coumadin dose will be readdressed. Medications on Admission: [**Last Name (un) 24116**], enalapril 5', imdur 30', lipitor 10', coreg 6.25", plavix 75', toprol 50', zofran prn Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). Disp:*500 ml* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Disp:*30 Tablet(s)* Refills:*0* 11. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 12. Outpatient Lab Work INR [**2180-8-15**] [**Hospital Ward Name 23**] Clinical Center Lab 13. Outpatient Lab Work INR [**8-17**] [**Hospital Ward Name 23**] Clinical Center Lab 14. One Touch Ultra Test Strip Sig: One (1) strip Miscell. four times a day: check glucose 3-4 times daily. Disp:*1 box* Refills:*2* 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-12 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*1 1* Refills:*1* 16. Albuterol 90 mcg/Actuation Aerosol Sig: 8-12 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*1 1* Refills:*1* 17. Coumadin 2 mg Tablet Sig: One (1) Tablet PO AS directed: as directed. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: tracheal stenosis, Coronary artery disease s/p MI and Coronary artery bypass graftx 3 in [**5-/2180**], hypertension, hypercholesterolemia, Diabetes Mellitus type 2, HEparin induced thrombocytopenia +. Discharge Condition: good Discharge Instructions: CAll Dr.[**Name (NI) 14680**] office Interventional Pulmonary/Dr. [**Last Name (STitle) 17224**] Thoracic Surgery office for: fever, shortness of breath, chest pain. TAke medications as stated on discharte instructions. 2 sets of prescriptions provided- one month for now, 2 nd set for [**State 108**] use. NO lifting more than 5-7lbs. YOu may shower. Wipe incision dry after showering. Let white strips on incision fall off. REgular walking as in hospital. Go to [**Hospital Ward Name 23**] Clinical Center Lab for Blood draw Tuesday-[**2180-8-15**], and Thursday-[**2180-8-17**]. Appointment [**8-17**] 9:30am w/ Thoracic surgery Clinic- [**Hospital Ward Name 23**] clinical center, [**Location (un) **]. Take Coumadin 1mg tonight- [**2180-8-14**] ONLY. Dr.[**Name (NI) 14680**] office will call to let you know what dose of coumadin to take after blood draw.- on Tuesday and Wednesday, then again on Thursday. through the weekend until seen by following MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6185**]. Be sure to eat well, add supplements as needed as taken in hospital. Followup Instructions: Appointment [**2180-8-17**]-Thursday @9:30am with Dr [**Last Name (STitle) **], [**First Name3 (LF) 1092**] Surgery Clinic, [**Hospital Ward Name 23**] Clinical Center-[**Location (un) **], [**Hospital Ward Name 516**], [**Hospital1 18**]- [**Location (un) **], [**Location (un) 86**], MA. CAll [**Telephone/Fax (1) 170**] for any questions regarding this appointment Completed by:[**2180-8-16**]

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icd9cm

[ [ [] ] ]

[ "33.24", "33.23", "31.79", "31.99", "96.6" ]

icd9pcs

[ [ [] ] ]

11254, 11260

4296, 9227

308, 508

11506, 11512

2475, 2475

12655, 13053

9391, 11231

11281, 11485

9253, 9368

11536, 12632

2241, 2241

3222, 4273

249, 270

536, 1887

2489, 3208

1909, 2136

2152, 2226

79,404

175,875

38493

Discharge summary

report

Admission Date: [**2123-12-13**] Discharge Date: [**2123-12-23**] Date of Birth: [**2053-3-31**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Flomax / Hydrochlorothiazide / Biaxin / Atenolol / Lisinopril / Levaquin / Ativan Attending:[**First Name3 (LF) 3021**] Chief Complaint: Nausea, vomiting, abdominal pain. Major Surgical or Invasive Procedure: Paracentesis [**2123-12-14**] and [**2123-12-15**]. Stripping of clot from port [**2123-12-16**]. Paracentesis [**2123-12-23**]. History of Present Illness: Patient is a 70 Y M with Stage IV colon cancer and extensive portal vein thrombosis who presents from the ER with severe nausea and vomiting. He began modified FOLFIRI on [**12-8**], and after he experienced severe nausea and vomiting. He was unable to take anything PO and went to the ER on [**12-10**] where he received fluids, antiemetics, and felt well enough to go home. Since that time, he has had continued nausea and non-bilious vomiting where he is barely able to keep down water. He has also had full body shakes without fever or chills. He notes inceased abdominal girth and a 6lb weight gain over the past week. He notes difficulty urinating but no urinary incontinance or hematuria. He has [**10-28**] pain in his abdomen that is worse with inspiration but decreases to [**1-28**] with PO morphine. Vitals in the ER: Afebrile 98 148/87 16 95% RA; he received 2L NS, IV morphine, Zofran and was transfered to the floor for further management. . Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies diarrhea, constipation, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: ONCOLOGIC HISTORY: He presented in [**4-/2122**] with abdominal pain. He had a cecal cancer with no evidence of metastatic disease by CT. At the time of open colectomy, there was evidence of miliary studding and he underwent resection of at least one metastatic macroscopically visible omental nodule. FOLFOX chemotherapy was begun in [**7-/2122**] because of symptomatic left lower quadrant pain related to disease progression. We switched to an every three-week basis in [**1-/2123**] because of myelosuppression, especially thrombocytopenia. A repeat CT after four courses showed slight progression. He had restless legs that was felt to represent oxaliplatin toxicity and he was subsequently switched to short-term infusional 5-FU and leucovorin according to the De Gramont schedule in 07/[**2122**]. CTs since then have shown gradually progressive disease. His last CT scan two weeks ago showed increasing ascites and the decision was made to discontinue 5-FU and leucovorin and proceed with FOLFIRI. He received C1 D1 of modified folfiri on [**2123-12-8**]. . Other Past Medical History: 1) Hypertension 2) Hyperlipidemia 3) Osteoarthritis 4) Extensive portal vein thrombosis extending up the right hepatic vein on Lovenox since [**2123-9-9**] 5) BPH 6) s/p tonsillectomy 7) s/p traumatic finger amputation of left hand at age 4 8) Nephrolithiasis Social History: Lives with his wife. [**Name (NI) **] 2 sons who live nearby and nine grandchildren. Works 6 days a week as a furniture maker along with his son. Denies tobacco or ETOH use. Family History: Mother had lung cancer. No other family history of malignancy. Physical Exam: ADMISSION EXAM: VS: T 98.2 bp 139/71 HR 96 RR 16 SaO2 97 RA GEN: Elderly man in NAD, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and without lesion NECK: Supple, no JVD appreciated CV: Reg rate and rhythm, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: very firm and distended but no rebound or guarging, minimal tenderness, bowel sounds present MSK: normal muscle tone and bulk EXT: No c/c/e, 2+ DP/PT bilaterally SKIN: No rash, warm skin NEURO: oriented x 3, normal attention, no focal deficits PSYCH: appropriate Pertinent Results: ADMISSION LABS: [**2123-12-13**] 01:36PM LACTATE-1.2 [**2123-12-13**] 01:30PM GLUCOSE-118* UREA N-22* CREAT-0.9 SODIUM-137 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [**2123-12-13**] 01:30PM ALT(SGPT)-39 AST(SGOT)-24 ALK PHOS-84 TOT BILI-1.1 [**2123-12-13**] 01:30PM LIPASE-23 [**2123-12-13**] 01:30PM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-2.5 [**2123-12-13**] 01:30PM WBC-5.4 RBC-4.12* HGB-11.9* HCT-36.6* MCV-89 MCH-29.0 MCHC-32.6 RDW-16.9* [**2123-12-13**] 01:30PM NEUTS-88.2* LYMPHS-9.5* MONOS-0.7* EOS-1.2 BASOS-0.3 [**2123-12-13**] 01:30PM PLT COUNT-168 . [**2123-12-13**] CXR: FINDINGS: As compared to the previous examination, there is no relevant change in extent of the known bilateral pleural effusions. The effusions are better appreciated on the lateral than on the frontal radiograph. Minimal subsequent areas of atelectasis but no evidence of pneumonia. Unchanged size of the cardiac silhouette. Unchanged left Port-A-Cath. . [**2123-12-13**] CT abdomen: 1. Interval increase in the abdominal ascites since [**2123-11-29**]. Stable peritoneal metastatic disease. 2. Stable main and left portal vein thrombosis. 3. Bilateral small pleural effusions, now larger. 4. Mild right hydronephrosis, but no obstructing stone seen. . [**2123-12-16**] CXR: IMPRESSION: Essentially unchanged left greater than right small pleural effusions. . [**2123-12-17**] LE DOPPLER U/S: IMPRESSION: No evidence of DVT. . [**2123-12-17**] KUB: IMPRESSION: 1. Non-obstructive bowel gas pattern. 2. No free air. . [**2123-12-17**] U/S ABD: IMPRESSION: 1. Small volume ascites. 2. Right pleural effusion. . [**2123-12-17**] CXR: IMPRESSION: Extensive new consolidation in the right lower lung on the current study subsequently improves. This could represent the changes of acute aspiration rather than pneumonia resolving from it. Small-to-moderate bilateral pleural effusions are unchanged since the prior study. Left lower lobe atelectasis has improved. Heart size is normal. Infusion port catheter ends in the mid SVC. No pneumothorax. . [**2123-12-18**] ECHO: LVEF>55%. Unremarkable. . [**2123-12-18**] UE DOPPLER U/S: IMPRESSION: No evidence of DVT. Right cephalic vein not visualized. . [**2123-12-18**] CTA CHEST: IMPRESSION: 1. Probable subsegmental right middle lobe pulmonary embolus without evidence of heart strain. No additional pulmonary emboli are identified, although this study is limited by respiratory motion artifact. 2. Small ground-glass opacities within the right upper lobe are likely infectious or inflammatory in etiology. 3. Small-to-moderate bilateral pleural effusions slightly increased from [**2123-12-13**] CT. 4. Large volume ascites as before. 5. Cholelithiasis without evidence of acute cholecystitis. . [**2123-12-19**] CXR: IMPRESSION: Mild to moderately severe consolidation in the right lower lobe has worsened compared to [**12-18**], not as severe as on [**12-17**]. The variability suggests atelectasis is largely responsible, and there is accompanying small right pleural effusion. Question of pneumoperitoneum was raised on the interpretation of [**12-18**] study. There is no evidence of free air either in the abdomen or pleural space. Upper lungs are clear. Heart size is normal. Pulmonary vasculature is not engorged. . DISCHARGE LABS: [**2123-12-23**]: WBC 13.7, HB 10.3, HCT 31.3, MCV 91, PLT 257. [**2123-12-23**]: PT 18.3, PTT 41.4, INR 1.7. [**2123-12-20**]: Anti-factor Xa (LMWH) level 0.81. [**2123-12-23**]: GLU 105, BUN 13, CREAT 0.7, NA 141, K 3.9, CL 112, CO2 24. [**2123-12-19**]: ALT 15, AST 9, LDH 147, ALP 57, T BILI 0.9. [**2123-12-23**]: ALBUMIN 2.2, Ca 7.0, PHOS 1.9, MG 2.0. [**2123-12-19**]: GALACTOMANNAN NEGATIVE, BETA GLUCAN 93. [**2123-12-19**], [**2123-12-20**], [**2123-12-21**]: C. diff toxin x3 NEGATIVE. Brief Hospital Course: 70yo man with Stage IV colon cancer and portal vein thrombosis on enoxaparin admitted for severe nausea, vomiting, and increased ascites. He was transferred to the ICU [**2123-12-17**] for hypoxia and aspiration pneumonia. . # Nausea/vomiting: Due to chemotherapy. KUB showed no obstruction. Given fosaprepitant, however will avoid this in the future given his hiccup-reaction to aprepitant in the past. Anti-emetics PRN. - AVOID FOSAPREPITANT AND APREPITANT DUE TO HICCUPS. . # Febrile neutropenia: Due to 1st cycle FOLFIRI. Started G-CSF (Neupogen). Low-grade fever to 100.7F, pan-cultured. Started on vancomycin/cefepime and metronidazole in setting of low BPs and hypoxia worrisome for sepsis. C. diff negative. He had another temp to 101.3 while in the ICU. CXR and CT scan revealed RLL pneumonia suggesting aspiration. . # Aspiration RLL pneumonia and hypoxemic respiratory distress: Vancomycin stopped. Swallow eval normal; aspiration occurred during unremitting vomiting. Galactomannan negative. Positive beta glucan 93, unlikely significant given his clear clinical course with aspiration pneumonia and resolution with antibiotics. ID fellow also pointed out that some medications/antibiotics can falsely elevate beta glucan. Changed cefepime and metronidazole to amoxicillin/clavulanate at discharge to complete a ten day course (only three days of amoxicillin/clavulanate needed). - F/U cultures. . # Metastatic colon cancer with peritoneal carcinomatosis: s/p modified FOLFIRI x1 cycle [**2123-12-8**]. Paracentesis x2 [**2123-12-14**] and [**2123-12-15**] drained 3+4L. Acites SAAG consistent with malignant ascites. Cytology: Atypical cells highly suspicious for malignancy. He will need to continue chemotherapy, but with changes to his regimen (dose-reduction vs. FOLFOX) considering current complications. Family meeting yesterday discussed treatment options. Mr. [**Known lastname **] seems likely to opt for additional chemotherapy after rehab. Therapeutic paracentesis repeated [**2123-12-23**]: 3L drained. . # Hiccups: Likely due to diaphragmatic irritation from peritoneal mets. Avoided metoclopramide due to recent diarrhea. Mild improvement with chlorpromazine. Starting baclofen. Could also consider haloperidol or scheduling prochlorperazine. . # Mental status changes: Likely due to meds lorazepam and/or olanzapine plus infection. Per family, Mr. [**Known lastname **] has not tolerated lorazepam in the past. Tolerating chlorpromazine for hiccups. - AVOID BENZODIAZEPINES. . # Sinus tachycardia: Due to infection, volume depletion, and small PE. ECG unremarkable. Cardiac enzymes negative. LE doppler U/S negative. Already on enoxaparin. . # PE: Continue enoxaparin; no changes given the very small size of the PE, its indeterminant age (no previous CTA), and the negative UE/LE doppler U/S. Anti-factor Xa level therapeutic at 0.81. . # Neutropenia: Due to chemo. Resolved; D/C'd G-CSF (now leukocytosis from G-CSF). Afebrile. Hypotension and tachycardia with aspiration pneumonia. Antibiotics as above. . # Diarrhea: Likely due to antibiotics. Severe, resolving. C. diff toxin x3 negative. Guaic stool negative x3. Loperamide PRN. . # Port clot: Angio study and stripping of fibrin sheath done [**2123-12-16**]. . # Urethral obstruction: Secondary to BPH and probably tumor/ascites. Continued outpatient alfuzosin (Uroxatral); allergy to tamsulosin. . # Portal vein thrombosis: SAAG not c/w portal HTN and CT did not show progression of clot burden. Continued enoxaparin. . # Pleural effusions and acute pulmonary edema: Given furosemide 20mg IV x1 in ICU. Weaned off O2. . # HTN: [**Last Name (un) **] (formulary substitution) stopped because of hypotension. . # Hypercholesterolemia: Stopped etezimibe and pravastatin based on family meeting agreement [**2123-12-22**]. . # Pain (abdomen): Continued PRN morphine. Stopped MSContin due to well controlled pain. Therapeutic paracentesis x3 ([**2123-12-14**], [**2123-12-15**], and [**2123-12-23**]). . # Hypernatremia: Volume depleted due to diarrhea, recent N/V, and poor PO intake. Resolved. Stopped IV fluids with new dyspnea and pulmonary congestion. . # FEN: Regular diet, normal swallow eval. IV fluids stopped. Repleted hypokalemia and hypophosphatemia (worsened from diarrhea). Metabolic acidosis also due to diarrhea, now resolved. . # GI PPx: PPI. Bowel regimen on hold with diarrhea. . # DVT PPx: Enoxaparin for portal vein thrombosis and PE. . # Precautions: None. . # Full Code. Medications on Admission: ALFUZOSIN [UROXATRAL] 10 mg PO once a day ENOXAPARIN 100 mg/mL Syringe - inject 100 mg SQ [**Hospital1 **] EZETIMIBE [ZETIA] 10 mg PO once a day FLUTICASONE 50 mcg Suspension 1 spray nasally PRN congestion IRBESARTAN [AVAPRO] 300 mg PO once a day LIDOCAINE-DIPHENHYD-[**Doctor Last Name **]-MAG-[**Doctor Last Name **] [FIRST-MOUTHWASH BLM] 400 mg-400 mg-40 mg-25 mg-200 mg/30mL Mouthwash - Swish and swallow q2-3HR PRN MORPHINE 15 mg Extended Release PO BID MORPHINE 15 mg PO q3-4HR PRN pain OMEPRAZOLE 20 mg PO Daily PRAVASTATIN [PRAVACHOL] 80 mg PO once a day PROCHLORPERAZINE MALEATE 10 mg PO q8HR PRN nausea ZOLPIDEM [AMBIEN CR] 6.25-12.5 mg Ext Release Multiphase PO qHS. Zofran PRN ASPIRIN 81 mg Delayed Release (E.C.) PO once a day Discharge Medications: 1. alfuzosin 10 mg Extended Release 24 hr PO daily. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 2. fluticasone 50 mcg/Actuation, SIG: One (1) Spray Nasal DAILY PRN congestion. 3. morphine 15 mg Extended Release PO Q12H. 4. morphine 15-30 mg PO Q4H PRN pain. 5. omeprazole 20 mg PO DAILY. 6. prochlorperazine maleate 10 mg PO Q6H PRN nausea. 7. aspirin 81 mg PO DAILY. 8. enoxaparin 100 mg/mL SC Q12H. 9. ZOFRAN ODT 4-8 mg Rapid Dissolve PO q8HR PRN nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 10. Imodium A-D 2 mg PO q6HR PRN diarrhea x5 days. 11. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40mg/30mL Mouthwash Sig: 30mL Mucous membrane QID PRN pain. 12. zolpidem 6.25-12.5mg PO qHS PRN insomnia. 13. acetaminophen 325-650mg PO Q6H PRN Pain. 14. loperamide 2 mg PO QID PRN Diarrhea. 15. baclofen 10 mg PO Q8H PRN Hiccups. 16. pantoprazole 40 mg PO Q24H. 17. potassium & sodium phosphates 280-160-250 mg Powder in Packet PO TID: Neutra-phos. 18. Augmentin 875-125 mg PO BID x3 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Nausea with vomiting. Ascites (fluid in the abdomen). Metastatic colon cancer. Portal vein thrombosis (blood clot in the abdomen). Neutropenia (low white blood cell count). Blocked port (fibrin sheath). Aspiration pneumonia. Hiccups. Altered mental status (acute delirium, confusion). Pulmonary embolus (blood clot in lung). Diarrhea. Hypertension (high blood pressure). Hypotension (low blood pressure). Hypokalemia (low potassium level). Hypophosphatemia (low phosphorous level). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for severe nausea, vomiting, and abdominal pain. The nausea/vomiting was a likely complication of your recent chemotherapy for metastatic lung cancer. CT scan of the abdomen showed increased fluid in your abdomen (ascites) and you underwent a paracentesis (drainage of fluid from the abdomen). Since you still had pain and fluid in the abdomen, you underwent a second paracentesis. Both procedures removed a total of 7 liters of fluid. Nausea and vomiting worsened despite nausea medication and you then aspirated some vomit (going down the wind-pipe into the lungs) causing a severe pneumonia. You had an episode of low blood pressure and were satrted on IV antibiotics. Because your oxygen was dangerously low, you were transferred to the Intensive Care Unit and needed oxygen support for several days. A CT scan of the chest showed a pulmonary embolus (blood clot in the lung) in addition to the pneumonia. The blood clot was very small and its age was unclear. Therefore, you remained on the current dose of enoxaparin (Lovenox). Your white blood cell count was low due to chemotherapy and a medication called G-CSF (Neupogen) was given to help this. You also became temporarily delirious (confused) because of a dose of lorazepam (Ativan) given for nausea. You should never take this medication again. A swallow evaluation was normal. Lastly, you developed severe diarrhea, possibly from the antibiotics. Tests for infection were negative. After IV fluids, electrolyte replacement for low potassium and low phosphorous, and loperamide (Immodium), the diarrhea improved. You will need to complete a course of antibiotics for the pneumonia. More fluid from the abdomen (ascites) was drained the day you left the hospital. . MEDICATION CHANGES: 1. Viscous lidocaine/Maalox/diphenhydramine for mouth/throat pain as needed. 2. Baclofen 10 mg 3x a day as needed for hiccups. 3. Neutra-phos 3x a day for low phosphorous levels. Your phosphorous levels should be monitored and this can be stopped when it is normal. 4. Amoxicillin/clavulanate (Augmentin) 2x a day for three days to complete the antibiotic course for aspiration pneumonia. 5. DO NOT TAKE LORAZEPAM (ATIVAN). Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2124-1-5**] at 1 PM With: [**Doctor First Name **] [**Last Name (NamePattern5) 21185**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2124-1-5**] at 2:00 PM With: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "96.57", "54.91" ]

icd9pcs

[ [ [] ] ]

14601, 14648

8219, 12742

394, 524

15173, 15173

4401, 4401

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321, 356

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23,999

172,820

26275

Discharge summary

report

Admission Date: [**2106-8-20**] Discharge Date: [**2106-8-24**] Date of Birth: [**2034-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Salicylates / Morphine / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 348**] Chief Complaint: bloody secretions Major Surgical or Invasive Procedure: none History of Present Illness: 71 y/o F, h/o airway obstruction w/ trach, presents via ambulance from [**Hospital 745**] Health Center with white secretions, bleeding x 15 minutes bright red blood, locally around trach site- low volume, + tachypnea. . In ER, had some blood around trach site. O2 sats in 97-98% on TM. T to 101. Hct 41. INR 2.4. Few additional episodes of small volume bright red blood per trach, ~60cc. Rec'd Vit K. CXR w/ ?LLL infiltrate. Given Vancomycin one dose. Spoke with pulmonary fellow, likely will need bronch. Admit to MICU. Past Medical History: h/o trach, airway obstruction, pancreatitis, MR, CHF, Afib, hypothyroidsm, depression, CRF, DMII, CVA Social History: From [**Hospital 745**] Health Care Center Family History: unknown Physical Exam: T 98.7, BP 158/72, HR 64, RR 22, 50% FiO2 on TM Gen- awake, responsive, NAD HEENT- EOMI. op clear. TM in place- no active blood Pulm- Coarse ronchi diffusely w/ occ exp wheeze CV- RRR. distant heart sounds. no m/r/g ABD- soft, NT/ND EXT- b/l venous stasis change, 1+ edema b/l Neuro- alert, oriented, following commands Pertinent Results: Admission Labs: =============== . [**2106-8-20**] 08:00PM PT-24.3* PTT-29.2 INR(PT)-2.4* [**2106-8-20**] 08:00PM WBC-11.2* RBC-5.00 HGB-13.4 HCT-41.2 MCV-82 [**2106-8-20**] 08:00PM NEUTS-85.7* LYMPHS-8.9* MONOS-2.2 EOS-1.0 BASOS-2.2* [**2106-8-20**] 08:00PM CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-2.5 [**2106-8-20**] 08:00PM GLUCOSE-170* UREA N-37* CREAT-1.5* SODIUM-138 POTASSIUM-7.2* CHLORIDE-102 TOTAL CO2-29 ANION GAP-14 [**2106-8-20**] 08:20PM LACTATE-2.2* K+-5.7* [**2106-8-20**] 10:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2106-8-20**] 10:10PM URINE RBC-[**5-22**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 TRANS EPI-0-2 . CXR [**8-22**]: ======== FINDINGS: There has been no significant change in the tracheostomy tube or the left subclavian line with tip projecting over the SVC. The heart size appears mildly enlarged. There continues to be opacity at the left lateral lung base which may represent atelectasis, consolidation or effusion. There is patchy area of increased opacity in the right lower medial lung as well. This is slightly increased compared to the prior day. Otherwise, there is no significant change. . [**2106-8-21**] 3:55 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2106-8-21**]** GRAM STAIN (Final [**2106-8-21**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2106-8-21**]): TEST CANCELLED, PATIENT CREDITED. MICRO: ======== [**8-20**] Blood Culture- No growth to date [**8-21**] Blood Culture- [**2106-8-21**] 4:00 am BLOOD CULTURE **FINAL REPORT [**2106-8-23**]** AEROBIC BOTTLE (Final [**2106-8-23**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 830PM ON [**2106-8-21**]. PROTEUS MIRABILIS. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC BOTTLE (Final [**2106-8-23**]): PROTEUS MIRABILIS. IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. Brief Hospital Course: 71 y/o F w/ trach, found to have bloody secretions, fever and proteus bacteremia. . # Proteus Bacteremia- Blood cultures from [**8-21**] grew 2 out of 2 bottles positive for proteus, with intermediate sensitivity to quinolones. Levofloxacin had been initially started prior to return of sensitivities. This was changed to IV meropenem to complete 14 day course (Allergies to pcn, cephalosporins, sulfa). Suspected source is her urine, given her floridly positive urinalysis on admission. However initial urine culture was contaminated, so there is no positive urine cultures to support this. Sputum cultures were also taken, but also returned contaminated. She has had no evidence of shock, remaining hemodynamically stable, with good urine output, mentation, and baseline renal function. Midline placed for completion of IV antibiotics at rehab. . # Pneumonia- Left lung opacity on initial CXR. Clinically with increased secretions from trach, diffuse ronchi on lung exam. Initially covered with Vancomycin and Levofloxacin, subsequently changed to Meropenem on [**8-23**]. Sputum cultures contaminated. Repeat sputum cultures taken [**8-23**]. She remained stable from an oxygenation standpoint throughout her hospital course, maintained on trach mask at 30% FiO2 with intermittent suctioning for secretions. . # Bloody secretions- Small volume blood from trach site, likely secondary to bronchitis vs tracheal irritation/inflamed granulation tissue. Less likely endobronchial lesion. Bleeding in setting of anti-coagulation w/ INR 2.4 on admission. Coumadin held and given Vitamin K in ER. No further bleeding from trach over next 48 hours and hematocrit remained stable. Initial plan was for bronchoscopy to evaluate bleeding source, however patient refused procedure. This was also discussed with her son. Since she remained stable, with no further bleeding, and refused procedure, bronchoscopy was deferred and she was discharged back to her care facility on coumadin. . # CHF- She was continued on her b-blocker and lasix. . # Afib- Rate controlled with b-blocker; Anti-coagulated w/ coumadin. Initially on hold given her tracheal bleeding. Re-started prior to discharge given h/o recent CVA. . # DMII- Controlled on sliding scale insulin. Diabetic diet. . # Psych- Continued on klonpin, seroquel . # Chronic pain- Continued on methadone, gabapentin . # psoriasis- on chronic prednisone 10mg/day . # precautions- mrsa precautions, VRE . # FEN: ground textures for all meals; low fat-diabetic; cuff must be up when she takes fooby mouth. . Full Code- per rehab records . # Communication- regular care at [**Location (un) 745**] [**Location (un) 3678**]; currently at [**Hospital 745**] Health Center. [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 65059**]; [**Name (NI) **] [**Name (NI) **] (sister- emergency contact): home [**Telephone/Fax (1) 65060**] . The pt was discharged to [**Hospital 745**] Health Center in stable condition to complete 14 day course of IV Meropenum for Proteus bacteremia, PNA, and UTI. Medications on Admission: Meds: coumadin 4mg qhs macrobid 10mgPO [**Hospital1 **] nifedipine 60mg/day effexor 225mg/day folic acid 1mg/day prednisone 10mg/day prilosec 10mg/day dilantin 400mg/day ursodiol 300mg daily colace FeSO4 325mg daily Seroquel 50mg [**Hospital1 **] Klonopin 0.5 qhs lopressor 50mg [**Hospital1 **] lasix 40mg [**Hospital1 **] gabapentin 300mg qam albuterol inhaler prn lorazepam 1mg q6prn methadone 45mg TID nystatin powder Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Methadone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 16. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 17. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 14 days. 19. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital 745**] Healthcare Center Discharge Diagnosis: 1. Proteus Mirabilis Bacteremia 2. Urinary Tract Infection 3. Pneumonia 4. Tracheal Bleeding Discharge Condition: stable Discharge Instructions: Please report fever, chills, productive cough, blood from sputum to your primary physician. You will need to take all of your medications as prescribed. We started you on an IV antibiotic called Meropenum to treat an infection in your blood. You will receive a total of a 14 day course of Meropenum. Followup Instructions: Complete 14 day course of IV meropenem as prescribed. You will need to follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week of discharge. Completed by:[**2106-8-24**]

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icd9cm

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Discharge summary

report

Admission Date: [**2129-11-15**] Discharge Date: [**2129-11-17**] Date of Birth: [**2044-3-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: 1. tachycardia 2. hyperglycemia Major Surgical or Invasive Procedure: 1. PICC line placement History of Present Illness: Mr. [**Known lastname 17738**] is an 85M with PMH of vascular dementia, HTN, DM2, with multiple admissions for UTI and hyperosmolar nonketoic hyperglycemic state who is presenting from NH with hyperglycemia in the context of having MRSA UTI [**2129-11-11**] (currently on Bactrim). The patient was found to have FSG>500 and received a total 26 units of insulin (Novolog) with no changes in blood sugar, as well as temperature of 100.1. . On arrival his VS were T 101 HR 86 BP 128/83 RR 16 SpO297% RA . Confused and non verbal on exam. U/A suggestive of UTI. Labs significant for cr 1.7, na 147, lactate 3.1, no leukocytosis. cxr normal. He was given 3L NS and vanc/ceftriaxone. On call out to the medicine floor he was persistently tachycardic to 130 and agitated, and the floor was uncomfortable taking him in this condition. He was given haldol 0.5mg IV and ativan 2mg IV, as he had missed him home dose. On transfer his VS were 122/54, 90, 25, 100%/RA. He was admitted to the ICU for concern for urosepsis. Of note, patient would not want a central line or other invasive procedures. . Could not obtain ROS, as patient noncommunicative. Past Medical History: DM2 hypertension hypercholesterolemia vascular dementia with prominent frontal lobe findings and behavioral problems and wandering hepatitis B deafness asbestosis glaucoma cataract essential tremor psoriasis Social History: Lives at nursing home. Prior to his recent hospitalizations, he was living with his wife and participating in daycare. More recently, he has been at [**Hospital 37**] Nursing Home. As noted in prior admits, he has had a notable decline in his level of functioning over the past few months. Tob: quit one year ago EtOH: none recently IVDA: family denies Family History: non-contributory Physical Exam: VS: T96 155/77 21 99 on RA Skin: Decreased skin turgor General: Not speaking, eyes closed, somewhat responsive to commands, would squeeze hand, moving head HEENT: Dry mucous membranes. Neck: supple, no JVP appreciated Resp: anterior lung fields clear to auscultation, limited exam given patient cooperation CV: RRR. Normal s1, s2. No M/G/R. Abd: +BS, could not elicit tenderness on exam, soft, nondistended Ext: Warm, well perfused, no LE edema, 2+ DP pulses Pertinent Results: [**2129-11-17**] 03:55AM BLOOD WBC-6.8 RBC-2.81* Hgb-8.6* Hct-27.2* MCV-97 MCH-30.5 MCHC-31.5 RDW-14.3 Plt Ct-208 [**2129-11-16**] 04:43AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.1* Hct-29.5* MCV-96 MCH-29.7 MCHC-30.9* RDW-14.5 Plt Ct-260 [**2129-11-15**] 09:13PM BLOOD WBC-8.4# RBC-3.25* Hgb-9.9* Hct-32.5*# MCV-100*# MCH-30.6 MCHC-30.6*# RDW-14.4 Plt Ct-256# [**2129-11-16**] 04:43AM BLOOD PT-15.3* PTT-32.3 INR(PT)-1.4* [**2129-11-15**] 08:00PM BLOOD PT-14.6* PTT-31.7 INR(PT)-1.4* [**2129-11-17**] 03:55AM BLOOD Glucose-261* UreaN-26* Creat-1.1 Na-143 K-3.8 Cl-108 HCO3-30 AnGap-9 [**2129-11-16**] 10:15PM BLOOD Glucose-162* UreaN-30* Creat-1.1 Na-145 K-3.9 Cl-112* HCO3-29 AnGap-8 [**2129-11-16**] 03:46PM BLOOD Glucose-249* UreaN-31* Creat-1.2 Na-149* K-3.8 Cl-112* HCO3-31 AnGap-10 [**2129-11-16**] 04:43AM BLOOD Glucose-347* UreaN-40* Creat-1.3* Na-151* K-4.9 Cl-116* HCO3-30 AnGap-10 [**2129-11-15**] 08:00PM BLOOD Glucose-525* UreaN-53* Creat-1.7* Na-147* K-4.7 Cl-110* HCO3-26 AnGap-16 [**2129-11-15**] 08:00PM BLOOD ALT-38 AST-33 LD(LDH)-210 AlkPhos-157* TotBili-0.1 [**2129-11-17**] 03:55AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.9 [**2129-11-16**] 10:15PM BLOOD Calcium-9.1 Phos-2.8 Mg-2.0 [**2129-11-16**] 03:46PM BLOOD Calcium-9.4 Phos-2.7 Mg-2.1 [**2129-11-16**] 04:43AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.3 [**2129-11-15**] 08:00PM BLOOD Calcium-9.5 Phos-2.1* Mg-2.7* [**2129-11-17**] 03:55AM BLOOD Vanco-4.6* Brief Hospital Course: 85 yo male h/o vascular dementia p/w UTI, hyperglycemia and tachycardia, now improved. Found to have MRSA UTI on urine culture. # UTI - The patient has history of recurrent UTIs, with past cultures including coag negative staph, coag positive staph, and enteroccocus, with most recent urine culture from [**2129-11-11**] growing out MRSA sensitive to Bactrim. Although already on Bactrim, the patient still has a dirty UA. CXR was clear and patient does not have signs/sx of pulmonary source of infection. His urine culture grew MRSA, and he was started on ceftriaxone initially then broadened to vancomycin once the results of the culture were available. He will complete a 14 day course of vancomycin. PICC was placed. Vanc level was subtherapeutic during the morning of [**11-17**]. We increased his dose to vancomycin 1g Q24hrs. He will need to have vanc trough checked in the next several days at his extended care facility. His blood cultures did not show any growth throughout his course. . # acute renal failure: Pt with baseline creat of 1.0, creat 1.7 on admission. Most likely prerenal/hypovolemic given his hyperglycemic state. He was rehydrated until euvolemic and his creatinine was trending downward on discharge. We avoided nephrotoxic agents and renally dosed his medications during his hospital course. . # tachycardia: Pt was in sinus tachycardia in the ED during episode of agitation, which is why he came to the MICU instead of the floor. Got Ativan and Haldol in the ED; they were not suspicious of sepsis for etiology of tachycardia. His tachycardia has since resolved. . # Hyperglycemia - likely due to UTI, sugars were elevated on admission, he was given insulin to treat his hyperglycemia and started on lantus with a sliding scale. No gap, no acidosis. Will send him to extended care facility on lantus with insulin sliding scale. . # Hypernatremia. Free water deficit was calculated and D5W infusion was started until his free water deficit was corrected. . # Vascular dementia - continued home antipsychotics . # Transitional considerations on discharge: - will need to continue vancomycin until [**11-30**], vanc trough will need to be checked within the next several days - lantus 15units started, will continue this medication along with his insulin sliding scale but fingersticks blood sugars should be checked at least 4 times daily Medications on Admission: Ativan 1mg/Benadryl 25 mg/haldo 1 mg gel 2p, 4p, 6p, 10p Novolin ISS artifical tears Bisacodyl PR PRN qhs constipation Docusate Lactulose [**Hospital1 **] PRN constipation Guafenesin PRN cough Milk of magnesia Senna Seroquel 12.5 mg qday as needed for when family leaves trazodone 25 mg qhs acetominophen 325 mg q6h PRN pain Fleet enema qday PRN constipation Vitamin D [**Numeric Identifier 1871**] qWednesday Miralax qday Metformin 500 mg [**Hospital1 **] acidolphilus daily Finasteride 5 mg tablet qhs Latanoprost 0.005% eye drops 1 drop/eye at bedtime mirtazapine 15 mg tablet qhs Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 4. vancomycin in D5W 1 gram/200 mL Piggyback Sig: [**12-5**] gram Intravenous Q48H (every 48 hours) for 12 days. Disp:*12 gram* Refills:*0* 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 6. Artificial Tears Drops Sig: Two (2) drops Ophthalmic three times a day as needed for dry eyes. 7. Seroquel 25 mg Tablet Sig: [**12-5**] Tablet PO once a day as needed for agitation: give as needed for agitation. 8. Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous once a day. 9. Insulin sliding scale Please see attached documentation for insulin sliding scale 10. trazodone 50 mg Tablet Sig: [**12-5**] Tablet PO QHS. 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 12. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 13. finasteride 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a day. 15. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at bedtime: both eyes. 17. Other Remove PICC line once vancomycin antibiotic course is completed Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. Urinary tract infection 2. Hyperglycemia 3. Sinus tachycardia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname 17738**], We appreciated the opportunity to particpate in your care while you were at [**Hospital1 18**]. You initially admitted to the hospital for an elevated blood sugar to >500 mg/dl and a fast heart rate. We found that you had a urinary tract infection that was likely causing your symptoms. Your urine culture showed that MRSA bacteria was causing your infection. We started you on vancomycin, an antibiotic, to treat your infection. You will need to continue this antibiotic for a total of 14 days. Because vancomycin can only be given intravenously, we have also placed a PICC line, a special type of IV, that will remain in place until you complete your course of antibiotics. Start taking: - vancomycin 1g every 48 hours IV until [**11-30**] You were also found to be hyperglycemic in the emergency department. We treated you with insulin and fluid hydration. On discharge from the hospital we will have you continue your home regimen of diabetes medication. You were initially admitted to the ICU due to persistent sinus tachycardia in the ED. On arrival in the ICU your tachycardia had resolved. We continued to monitor you, and you had intermittent episodes of tachycardia, but nothing concerning was found on evaluation. Please call your primary care physician or return to the ED if you experience: - increasing confusion, high fever, chest pain, trouble breathing, abdominal pain, decreased or absent urine output, persistent nausea/vomiting, or any other concerns. Followup Instructions: Please continue to follow up with your primary care physician. [**Name10 (NameIs) **] suggest you call within the next several days to schedule a followup appointment. Completed by:[**2129-12-8**]

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icd9cm

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Discharge summary

report

Admission Date: [**2171-4-2**] Discharge Date: [**2171-4-9**] Date of Birth: [**2125-1-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12174**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: EGD [**2171-4-2**] History of Present Illness: 46 year old male with EtOH cirrhosis, c/b severe esophagitis, ESRD due to Hepatorenal syndrome, presenting with upper GI bleed. Patient has longstanding history of ETOH cirrhosis, taken off transplant list last year in setting of alcohol relapse and loss to followup. Reportedly had recent EGD showing gastritis, but no varices. Per ED, reported having melenous stools for the past few days. Vomited two buckets BRB at [**Hospital 39437**] with SBP 140s, HR 140s. Trended down to SBP 80s. Hb initially 3, 9 units PRBCs and 9 units FFP at OSH. HCt 9 with platelets of 28. Got 9U pRBC, 9 units FFP at [**Hospital3 26615**] with SBPs up to 140s. Repeat hgb was 9, Hct 20. . On arrival to ED, initial VS: HR 130. Repeat labs notable for HCT of 23.7, Plts 28, INR 1.5, CR 2.9, T bili 7.3, AST 1600, ALT 360. Repeat HCT 29 RUQ u/s was performed with preliminary read showingpatent portal vein and recanalized umbilical vein. Cholelithiasis. No large ascites. Patient intubated for aspiration risk and EGD performed at bedside in ED with no evidence of varices, but severe esophagitis. Started on PPI and octreotide drip. At [**Hospital1 18**], got 4 units PRBCs, 2 FFP, 1 plts and Ca gluconate. BP stable while at [**Hospital1 18**] at 110s-120s. Patient was subsequently admitted to the ICU for further treatment. Had one melanotic stool. . On arrival to the MICU, patient is intubated and sedated. Unable to obtain further history. Patient has two 18g peripheral IVs and one femoral CVL. Past Medical History: (#) MRSA bacteremia [**10-23**] treated with vancomycin (#) EtOH abuse with h/o seziures ? during intoxication (#) EtOH Liver disease-- acute EtOH hepatitis in [**8-27**] (was not started on corticosteroids due to GI bleed, UTI and [**Last Name (un) **]); was started on pentoxyphyline to prevent HRS with a planned 4 week course from [**2168-9-26**] (last day [**2168-10-24**]); negative hepatitis A, B and C serologies. (#) Hemodialysis dependent-- since last admission, dx multifactorial with ATN +/- NSAIDs +/- HRS; HD through tunneled line TuThSat (#) Gastroesophageal Reflux Disease (#) Seizures in setting of heavy alcohol consumption, seen by a neurologist who did not feel that it was a primary seizure disorder (first [**12-26**]) (#) MVA [**3-/2153**] - Right femur fracture with [**Male First Name (un) **] placement, pelvic fracture (#) Asthma Social History: Has never smoked. Drank [**11-22**] Vodka daily until recently, but denies drinking in the past 4 months (last drink first week of [**Month (only) 359**]). Never has used IV drugs. Lives with girlfriend, [**Name (NI) 5627**] [**Name (NI) 83758**] [**Telephone/Fax (1) 83759**]. Has 2 children, daughter 17, son, 16 who live with their mother who the patient is still very close to. Pt formerly worked at Mass Electric. Family History: Mother - Deceased [**12-20**] alcoholic liver disease Father - Deceased [**12-20**] [**Name2 (NI) 499**] cancer, diagnosed in his 40s. No other family history of [**Name2 (NI) 499**] cancer. Physical Exam: Vitals: T: 99.6 BP: 134/53 P: 125 R: 18 O2: 98% on CMV General: Sedated, intubated, opens eyes on command, shakes head yes and now, intermittently following commands HEENT: Sclera icteric, dry blood around mouth, ETT in place Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Distended, soft, nontender, large umbilical hernia GU: foley in place Ext: warm, well perfused, 2+ pulses, 2+ pitting edema bilaterally on lower extremities up to knees with superficial erythema bilaterally, RUE fistula with palpable thrill and audible bruit Neuro: moves all extremities, opens eyes on command and shakes head yes/no, follows commands intermittently DISCHARGE EXAM: 98.4, 134/65, 80. 20, 95% RA Gen: AOx3, NAD HEENT: scleral icterus CV: RRR, referred murmur from AV fistula site across precordium Lungs: Slight decreased breath sounds of R base consistent with pleural effusion with partial reaccumulation Ext: [**12-21**]+ LE edema, tense, slightly erythematous, but no signs of infection. Neuro: nonfocal Pertinent Results: Admission labs: [**2171-4-2**] 12:40AM GLUCOSE-142* UREA N-86* CREAT-2.9*# SODIUM-143 POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-12* ANION GAP-39* [**2171-4-2**] 12:40AM ALT(SGPT)-365* AST(SGOT)-1615* ALK PHOS-97 TOT BILI-7.3* [**2171-4-2**] 12:40AM LIPASE-88* [**2171-4-2**] 12:40AM ALBUMIN-3.0* [**2171-4-2**] 12:40AM WBC-7.5# RBC-2.54*# HGB-7.9*# HCT-23.9*# MCV-94 MCH-31.3 MCHC-33.2 RDW-16.2* [**2171-4-2**] 12:40AM NEUTS-89.4* LYMPHS-5.0* MONOS-5.3 EOS-0.2 BASOS-0.2 [**2171-4-2**] 12:40AM PLT COUNT-28*# [**2171-4-2**] 12:40AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2171-4-2**] 12:40AM URINE RBC-5* WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 [**2171-4-2**] 12:40AM URINE MUCOUS-RARE Imaging: EGD [**4-2**]: 1. Keep patient intubated and NPO 2. Continue ocreotide gtt @ 50 mcg / hr 3. Continue Protonix gtt @ 8 mg hr 4. Ceftriaxone 1 gram IV Q24 for a total of 7 days 5. Check HCT q12 hrs 6. Transfuse to keep an HCT of 25-27 7. Try to keep plt > 50 and INR < 1.5 8. Once BP and HR stable will need a non selective beta-blocker 9. Follow hepatology recs RUQ Ultrasound: IMPRESSION: 1. Coarsened and echogenic hepatic parenchyma with the sequelae of portal hypertension including splenomegaly and recanalized paraumbilical vein with patent portal vein and no evidence of ascites. 2. Cholelithiasis without cholecystitis 3. Large right pleural effusion AP CXR [**4-2**]: IMPRESSION: 1. Nasogastric tube in the distal esophagus, could be advanced 15 cm. 2. Large right pleural effusion and mild pulmonary edema with cardiomegaly, new since [**2168**]. CXR [**4-4**]: FINDINGS: As compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed. The extensive right pleural effusion has minimally decreased in extent, the evidence of moderate pulmonary edema is still present. Unchanged size and appearance of the cardiac silhouette. DISCHARGE LABS: [**2171-4-8**] 05:25AM BLOOD WBC-1.8* RBC-3.15* Hgb-9.8* Hct-31.2* MCV-99* MCH-31.0 MCHC-31.3 RDW-19.1* Plt Ct-37* [**2171-4-8**] 05:25AM BLOOD Glucose-83 UreaN-58* Creat-3.1* Na-141 K-3.9 Cl-106 HCO3-23 AnGap-16 [**2171-4-8**] 05:25AM BLOOD PT-16.1* PTT-33.3 INR(PT)-1.5* [**2171-4-8**] 05:25AM BLOOD ALT-80* AST-71* AlkPhos-119 TotBili-16.6* [**2171-4-8**] 05:25AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7 Brief Hospital Course: 46 year old M with ETOH cirrhosis MELD of 32, CKD, presenting with massive upper GI bleed. . 1. GI Bleed: patient with large volume hematememsis and coffee ground emesis, with HCT of 9 at OSH. Transfused 9U PRBC, 8U FFP and 10U plts. HCT up to 23 on arrival and up to 29 on repeat. No evidence of varices on previous EGDs, but hepatology performed EGD bedside in ED which showed severe esophagitis and severe portal gastropathy, and still no evidence of varices. Started on octreotide and PPI drips, which were continued for 72 hours. Started on IV ceftriaxone 1 gram IV Q24hrs, which was switched to Cipro 500mg [**Hospital1 **] which he completed a 7 day course. The patient's Hct remained stable around 30 on the floor. He was transitioned to [**Hospital1 **] protonix. He was given sucrafate for esophagitis. He will have a repeat EGD in 12 weeks after starting PPI (already scheduled). . 2. Narrow Complex Tachycardia: The patient's HR was sustained in the 140s during one night of admission. EKG showed a narrow complex tachycardia most consistent with an SVT. Vagal maneuvers were attempted without success. The patient was given low dose beta blockers. He spontaneously converted to NSR the next morning. He remained in NSR during the remainder of his hospitalization. . 3. Pleural Effusion: The patient had a moderate to large R sided pleural effusion seen on CXR. This was new from [**2168**], but likely subacute and c/w hepatic hydrothorax. A thoracentesis was performed that showed a transudate. Cytology is pending on discharge. 4. Alcohoic Cirrhosis: Patient with alcholic cirrhosis and MELD score of 31. No longer a candidate for transplant given alcohol relapse and loss to followup. LFTs elevated significantly above baseline likely secondary to GI bleed and hepatic decompensation. These continued to trend down. The patient will be discharged with plan for relapse prevention. The patient understood that he risks death if he continues to consume alcohol. . 5. CKD: patient previously on HD in the past for hepatorenal syndrome. CR 2.9 on admission, which is below previous baseline, but trended up slightly. He has a right sided fistula. He had adequate urine output and his electrolytes were stable. FOLLOW-UP: - The patient had a leukopenia on discharge, likely from nutrition and medications. This should be followed as an outpatient to ensure it is trending up. - F/U cytology from pleural fluid Medications on Admission: (from d/c summary [**2168-12-24**]): - Xifaxan 550 mg Tab 1 Tablet(s) by mouth twice a day - omeprazole 20 mg Cap, Delayed Release2 Capsule(s) by mouth twice a day - Sucralfate 1 gram Tab 1 Tablet(s) by mouth four times a day - Lasix 40 mg Tab Oral 1 Tablet(s) Twice Daily - Celexa 20 mg Tab Oral 1 Tablet(s) Once Daily - folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily - Mag-Oxide 400 mg Tab Oral 1 Tablet(s) Twice Daily - thiamine 100 mg Tab Oral 1 Tablet(s) Once Daily - metoprolol tartrate 25 mg Tab Oral 1 Tablet(s) Twice Daily - allopurinol 100 mg Tab Oral 1 Tablet(s) Once Daily Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Upper GI Bleed EtOH Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a severe GI bleed that required many blood transfusions. You underwent an EGD that showed severe inflammation of the lower part of the esophagus and large vessels in the stomach. You were on a ventilator initially in order to protect your lungs. Your bleeding resolved and your blood counts remained stable. You had lower extremity muscle weakness. You will be discharged to rehab in order to help regain your strength. Please take your medications as prescribed. Please attend all of your follow-up appointments. Please refrain from drinking any alcohol. MEDICATION CHANGES: These will be relayed to your facility. They will give you a list when you leave from there. Followup Instructions: Department: LIVER CENTER When: TUESDAY [**2171-4-23**] at 1:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2171-4-25**] at 1:30 PM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], 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) 3202**] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: THURSDAY [**2171-4-25**] at 1:30 PM

[ "585.6", "427.89", "V45.11", "572.3", "276.0", "511.9", "530.81", "578.9", "571.2", "530.10", "493.90", "303.90" ]

icd9cm

[ [ [] ] ]

[ "34.91", "45.13" ]

icd9pcs

[ [ [] ] ]

10858, 10941

6962, 9389

318, 338

11015, 11015

4557, 4557

11901, 12680

3191, 3384

10025, 10835

10962, 10994

9415, 10002

11166, 11763

6537, 6939

3399, 4180

4196, 4538

11783, 11878

264, 280

366, 1859

4573, 6521

11030, 11142

1881, 2739

2755, 3175

43,923

190,118

36787

Discharge summary

report

Admission Date: [**2174-8-25**] Discharge Date: [**2174-8-27**] Date of Birth: [**2114-3-24**] Sex: F Service: MEDICINE Allergies: Phenergan Attending:[**First Name3 (LF) 5893**] Chief Complaint: Transient unresponsiveness s/p ERCP Major Surgical or Invasive Procedure: ERCP History of Present Illness: This is a 60 year old female with a history of cervical cancer s/p TAH and radiation c/b radiation enteritis here with cholangitis s/p ERCP. She was in her usual state of health until this Saturday when she experienced sudden onset of abdominal pain. This pain lasted for about 4 hours and self-resolved. On Monday she again began to have the same pain, diffuse in her abdomen. No nausea, vomitting or fever. She went to [**Hospital3 **] where she had a CT that revealed a dilated CBD and CBD stones (this is per ERCP fellow note, awaiting records from OSH). She was transferred to [**Hospital1 18**] for an ERCP today where 2 CBD stones were visualized and extracted along with pus. Biliary sphincterotomy was performed and a biliary stent was placed for possible residual stones/sludge. She was given gentamicin, ampicillin and zosyn. During the procedure, after receiving midazolam 2 mg and fentanyl 25 mcg, she became unresponsive but with a pulse and breathing spontanenously. She was given benadryl 50 mg IV for possible dystonic reaction without effect. ECG at the time revealed sinus tachycardia and ABG did not reveal hypercarbia (7.44/32/207). Notable vital signs during her post ERCP course were HR 97 BP 121/71 100% on 4L and T 104.4. Her mental status improved without further intervention and she was transferred to the [**Hospital Unit Name 153**]. . On the floor, she reports feeling sleepy and has diffuse abdominal pain, [**4-12**]. Prior to her procedure her abdominal pain was [**11-12**] in severity. Denies nausea, vomitting. Reports chronic diarrhea in the setting of her radiation enteritis. Past Medical History: Cervical cancer s/p TAH and radiation c/b radiation enteritis [**2161**] GERD Social History: Lives with her husband and daughter and her family. Denies ETOH and tobacco. Family History: Non-contributory Physical Exam: General: Drowsy, oriented, able to follow commands HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bibasilar crackles, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to palpation diffusely, most prominent in RUQ, hypoactive bowel sounds Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2174-8-26**] 04:11AM BLOOD WBC-17.4* RBC-3.10* Hgb-8.7* Hct-26.2* MCV-85 MCH-28.0 MCHC-33.1 RDW-15.7* Plt Ct-143* [**2174-8-25**] 09:56PM BLOOD Neuts-92.5* Lymphs-4.1* Monos-3.1 Eos-0.2 Baso-0.2 [**2174-8-25**] 09:56PM BLOOD PT-13.8* PTT-26.8 INR(PT)-1.2* [**2174-8-26**] 04:11AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-142 K-3.4 Cl-107 HCO3-23 AnGap-15 [**2174-8-25**] 09:56PM BLOOD Glucose-89 UreaN-17 Creat-0.8 Na-142 K-3.6 Cl-107 HCO3-19* AnGap-20 [**2174-8-26**] 04:11AM BLOOD ALT-115* AST-60* LD(LDH)-196 AlkPhos-464* Amylase-33 TotBili-5.0* [**2174-8-25**] 09:56PM BLOOD ALT-141* AST-78* LD(LDH)-255* AlkPhos-477* Amylase-38 TotBili-5.1* [**2174-8-26**] 04:11AM BLOOD Lipase-15 [**2174-8-25**] 09:56PM BLOOD Lipase-18 [**2174-8-26**] 04:11AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.8 [**2174-8-25**] 09:56PM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.8 Mg-1.7 Iron-12* [**2174-8-25**] 09:56PM BLOOD calTIBC-278 Ferritn-142 TRF-214 [**2174-8-25**] 04:00PM BLOOD Type-ART pO2-207* pCO2-32* pH-7.44 calTCO2-22 Base XS-0 Intubat-NOT INTUBA [**2174-8-26**] 04:48AM BLOOD Lactate-1.0 [**2174-8-25**] 04:00PM BLOOD Glucose-125* Lactate-3.5* Na-136 K-3.8 Cl-101 [**2174-8-25**] 04:00PM BLOOD Hgb-9.9* calcHCT-30 [**2174-8-26**] 08:37AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2174-8-26**] 08:37AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-MOD Urobiln-NEG pH-6.0 Leuks-TR [**2174-8-26**] 08:37AM URINE RBC-12* WBC-13* Bacteri-FEW Yeast-NONE Epi-1 TransE-1 [**2174-8-26**] 08:37AM URINE CastGr-1* CastHy-3* ERCP Report: 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: There was pus discharge in the major papilla. A single periampullary diverticulum with large opening was found at the major papilla. Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree: Two irregular stones ranging in size from 5mm to 6mm with one of them consistent with pigmented stones that were causing partial obstruction were seen at the lower third of the common bile duct. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. 2 stones and sludge were extracted successfully using a 12 mm balloon. A 5cm by 10FR double pig tail biliary stent was placed successfully using a Oasis 10FR stent introducer kit for possible residual sludge/stone. Impression: Periampullary diverticulum Stones at the lower third of the common bile duct. A biliary sphincterotomy was performed. Stones along with copious amout of sludge and pus was extracted from the bile duct. A double pig tail stent was placed. (sphincterotomy, stone extraction, stent placement) Recommendations: Admit to ICU Broad spectrum antibiotics. Transfer to referring facility tomorrow if stable for cholecystectomy. CXR: FINDINGS: The hemidiaphragms are in normal position. PICC line inserted over the right upper extremity, the tip projects over the distal SVC. Normal size of the cardiac silhouette, no evidence of aspiration, no pleural effusions, no overhydration. No evidence of pneumonia. Marked scoliosis of the thoracic spine. CT-Head w/o constrast: (Prelim) no acute process Brief Hospital Course: While in the GI suite the patient received Gentamycin, Ampicillin, and Zosyn. At start of procedure pt was given 25 mcg fentanyl and 2 mg versed and apparently became unresponsive for a couple minutes while spiking a temp to 104 with HR 140??????s, and spontaneous breaths were never lost. 50 mg IV benadryl was given for possible dystonic reaction without effect and ECG at the time revealed sinus tachycardia and ABG 7.44/32/207. The procedure was completed without any further complications and transferred to MICU. Other etiologies of concern include seizure episode especially in setting of fever unmasking possible seizure potential, sedative effects of versed and fentanyl also possible. Also on differential on this patient with fever and known cholangitis is infectious etiologies for AMS, though per description of events, pt appears to have actually been unresponsive, not just altered. A preliminary head CT on [**8-26**] ruled out intracranial bleed or other acute process. Patient was afebrile and hemodynamically stable overnight in the [**Hospital Unit Name 153**]. Only complaints were persistent abdominal pain on palpation, but unchanged from post-procedure The patient had a headache which resolved w/ morphine. After receiving morphine, she developed nausea which resolved with Zofran. LFTs, WBC trending down. Pt continues to be NPO on TPN. Medications on Admission: Oxycontin 140 [**Hospital1 **] Zofran prn Acifex Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). injection 2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 3. Piperacillin-Tazobactam 4.5 g IV Q8H 4. Morphine Sulfate 0.5-1 mg IV Q4H:PRN pain pls hold for sedation 5. Ondansetron 2 mg IV Q8H:PRN nausea 6. Pantoprazole 40 mg IV Q24H Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: 1. Cholangitis Discharge Condition: Stable. On TPN. A&O x3. Discharge Instructions: You were transferred to the hospital because you had a problem with gallstones being stuck in your bile duct. An ERCP procedure was performed and 2 stones were removed. A section of your duct was also removed. You will be transferred back to [**Hospital3 **]. After receiving some medications while getting the ERCP, you became unresponsive. A head CT ruled out an intracranial bleed. The medications could have made you unresponsive. You should consult with a health care professional if you have a fever, more abdominal pain, diarrhea, or become confused. Followup Instructions: Transfer to OSH

[ "574.51", "276.2", "576.1", "787.91", "V15.3", "285.9", "780.09", "346.90", "V10.41", "530.81", "V88.01" ]

icd9cm

[ [ [] ] ]

[ "99.15", "51.87", "51.85" ]

icd9pcs

[ [ [] ] ]

7942, 7957

6066, 7434

306, 312

8035, 8061

2647, 6043

8669, 8688

2170, 2189

7533, 7919

7978, 7978

7460, 7510

8085, 8646

2204, 2628

231, 268

340, 1958

7997, 8014

1980, 2060

2076, 2154

18,420

174,032

22977

Discharge summary

report

Admission Date: [**2168-5-25**] Discharge Date: [**2168-6-22**] Date of Birth: [**2097-6-30**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Keflex / Sulfa (Sulfonamides) / Nickel / Erythromycin Ethylsuccinate Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: increased shortness of breath, trachealmalacia. Allergic to metal stents, admitted for silicone stent placement Major Surgical or Invasive Procedure: s/p tracheobronchoplasty + R thoracotomy due to tracheomalacia and tracheostomy on [**5-30**]. History of Present Illness: 70-year-old woman who has had a lifelong history of ineffective cough with inability to properly clear secretions and history of recurring bronchitis. She has required yearly treatments for her bronchitis but has never been hospitalized with pneumonia. She does have orthopnea and as a result sleeps in the incline position using a medical bed. She does not have a significant cough. She has always reported that she has something essentially stuck in her chest and if she could only clear she could breathe better. In the past several years, she has developed progressive dyspnea and on [**2167-8-6**] she was diagnosed by you with tracheobronchomalacia. Of note, she has required prednisone since [**2165**] and was also started on inhalers in [**2167**]. Past Medical History: GERD, osteoporosis, tracheabronchialmalacia, polymyalgia rheumatica, s/p TAH, chronic obstructive pulmonary disease, pneumonias Social History: Lives in [**State 622**] w/ husband. Daughter and son and their families live nearby. Very supportive family network. Brief Hospital Course: Patient admitted [**2168-5-25**] for rigid bronch for tracheal stent placement for trachealmalacia. Pt developed respiratory distress POD#1, despite inhalers, suctioning and aggressive CPT. Pt transferred to MICU for Heliox inhalation therapy, steroids, and recemic edpinephrine. [**2168-5-27**] bronch pt found to have subglottis swelling and [**5-27**] stent was removed. Pt extubated during procedure and remained so post-op and transferred to MICU stable and intubated. Episodes of extreme cough and valsalva manuvers> R blot retinal [**Last Name (un) 22392**], seen by Ophthamology,advised no treatment. F/U clinic upon discharge as needed. [**5-28**]- Pt did not tolerate spon breathing trial w/ ^ HR, BP, RR and anxiety and decision to re-sedate and keep comfortable and intubated until trachealplasty [**5-30**]. [**2168-5-30**] trachealplasty via right thoracotomy and tracheostomy done. Post op in CSRU, ventilated, sedated and pain control w/ epidural w/ Dilaudid and bupivicaine. VAnco (for total 14 days s/p trachealplasty) and aztreonam (for total 7 days for UTI) started. POD#[**2-1**]- Weaned off vent then placed back on CPAP for decompensation, epidural for pain control cont, bronch for airway clearance and confirmation of trach in good position, tube feeding restarted POD#[**5-3**]-- Weaning from vent on CPAP,awake, OOB- CPT, receiving Lasix for diuresis w/ goal of 1L neg/day to assist w/ vent wean, tube feeding advanced w/ 1 episode of vommitting, regaln started, dulcolox w/ min result, pain control w/ Dil+ bup epidural transitioned to PCA- dilaudid. POD#6- Episode of Afib-tx w/ amiodarone, lasix changed to diamox w/ excellent result, tube feeding to be advanced if doboff post pyloric. thoracotomy incision and CT dsg C/D/I. Antibx vanco(for total 14 days) and aztreonam cont. POD#7- Weaned from vent x24hrs, bronch done, preference to avoid NGT sx and bronch for secretions in setting of endobronchial bleeding. Transfer to ICU - Surgery/thoracic border.Diamox d/c, lasix resumed qd for diuresis. ID consulted. POD#8- [**Hospital 59313**] transfer to floor, TF to goarl, cont diuresis. Speech and swallow eval- unable to tolerate passey-muir valve die to excessive secretions. POD#9-Episode of Afib overnight, tx w/ lopressorIV x2and Amiod IV 15omg bolus. Po amiod resumes, Sx and pul toilet cont via tracheostomy. POD#10 ([**2168-6-9**])- Bradycardic, unresponsive, no pulse- ACLS started, ? from resp arrest w/ mucous plugging; transferred to SICU for care. Bronch in am -no plugging, clear airways. POD#10--14- SICU course Neuro-sedation weaned, anxiety medicated w/ versed and ativan, now ativan po RTC; REsp- Vent CPAP slow wean, bronch qd -qod for secretions- no plugs, bovona trach placed [**6-11**] due to sig air leak; Cardiac- NSR rate controlled w/ amiod iv>po, esmolol IV> lopressor po [**6-13**]. With rate > 70 pt has PVC's and runs VT, diuresis qd w/ lasix 10 mg qd until [**6-13**] when auto diuresing began. GI- Tube feeds at goal via post pyloric doboff. NGtube d/c [**6-12**]. BM- [**6-13**]. Activity- OOB> chair [**6-13**], PT resumed. Aztreonam cont for UTI w/ sig antibx resistance, vanco d/c today. WBC 16K POD#14-23- Vent weant was persistently delayed by two problems. [**Name (NI) **], there was a tendency for patient to go into an idiopathic arryhtmia after 4-6 hours on trach mask. Although she remained hemodynamically stable throughout these events, they were uncomfortable for the patient and neccesitated abortion of vent wean. Cardioloy was consulted and they recommended Amiodorone 400mg [**Hospital1 **] for 1 week (starting [**6-20**]), then Amio 400mg QD x1 wk, and finally amio 200mg QD. Vent wean was also delayed by a large amount of agitation/anxiety during wean. Patient was on benzodiazepines pre-op for anxiety, supplementing these during wean appeared to help wean attempts. Medications on Admission: advair", theophylline 200", albuterol/atrovent nebs, aciphex 20", asa 81', fosamax qwk, prednisone 10mg qd Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: tracheabronchialmalacia, gastroesophogeal reflux disease, osteoporosis Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**] office for; fever, shortness of breath, chest pain, drainage or reddness at incision site. Continue all medications as previous to hospitalization. Take all new medications as directed. Specifically, prednisone will be tapered over 1 month Followup Instructions: Follow-up appointment w/ Dr. [**Last Name (STitle) 952**] once leaving rehab facility- Call [**Telephone/Fax (1) 170**] prior to returning to [**State 622**] Completed by:[**2168-6-22**]

[ "511.9", "E928.9", "285.9", "518.81", "427.31", "519.1", "599.0", "512.1", "362.81", "E849.7", "733.00", "491.20", "725", "530.81", "300.00", "427.1", "427.5", "995.1", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "34.04", "33.23", "99.04", "98.14", "31.1", "33.48", "96.72", "38.93", "38.91", "33.22", "96.05", "96.6", "33.21", "97.23", "31.79", "33.24", "31.42", "34.91", "96.04" ]

icd9pcs

[ [ [] ] ]

5691, 5770

1668, 5534

469, 565

5885, 5891

6209, 6400

5791, 5864

5560, 5668

5915, 6186

318, 431

593, 1359

1381, 1510

1526, 1645

79,851

197,624

44433

Discharge summary

report

Admission Date: [**2102-11-20**] Discharge Date: [**2102-12-7**] Date of Birth: [**2050-1-17**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2009**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 17926**] is a 52 F transfered to [**Hospital1 18**] from [**Hospital3 **] where she presented on [**11-8**] with diarrhea, brown emesis, and back pain. The patient presented from rehab where she had recetly been discharged to after a hospitalization for PNA and had been on azithromycin. KUB of the abdomen was negative for any acute pathology. Stools were initially "trace" guiac positive, but were guaic negative prior to transfer. Stool culture was negative. Pt refused colonoscopy or other invasive GI workup. Diarrhea resolved a few days into the admission. Coumadin was initall held but re-started. Sputum cultures werte also negative. The patient had been having poor "respiratory status" since her previous admission, so she underwent bronchoscopy [**2102-11-13**], which showed "near complete occlusion bilaterally of the right main bronchus and left main bronchus with occulsions." Cultures from the bronch grew only [**Female First Name (un) 564**], for which she recieved a 3 days course of fluconazole. At that point, she was transferred to the ICU so a percussion bed could be used for intensive chest PT. She was treated with nebs and Mucinex. Case management was working on getting the patient a SmartVest to help improve airway clearance. However, the patient continued to desaturate and have worsening hypercarbia. A rapid response was called on [**11-15**] for staff concern and was found to be saturating 87% on 2L NC, and CXR done at the time showed worsening PNA. There was concern for aspiration and that pt unable to clear secretions. Labs at [**Hospital1 **] were notable for albumin 2.3 and total protein 4.2. Bicarb ranged from 27-41 during the hospital course, and was mainly in the high 30s. WBC count peaked at 25.6 in [**11-8**] and was 12.1 on the day prior to transfer. Hct ranged from 42.2 on admission to 29.1 It was mainly around 33, and was 31.1 on the day prior to transfer. INR was therapeutic at 2.34 at the time of transfer. CXR showed cardiomegaly, mild pleural effusions attributed to CHF, and bibasilar patchy infiltrates R>L. Blood Cx were without growth. Vitals at the time of trasfer to [**Hospital1 18**] were T 98.3, BP 130/70, HR 99, RR 22. She was reported as being in AFib with occassional PVCs. Upon arrival to the [**Name (NI) 153**], pt endorsed feeling SOB, which improved with being placed on 100% face mask. ROS was also positve for headache, sore throat, pleuritic chest pain, intermittent fevers and chills, and B/L LE edema. Past Medical History: [**Doctor First Name **] Syndrome- "elfin" facial appearance, developmental delay, Depression DM [**1-3**] steroids Afib CHF COPD Diverticulitis CAD MVR malnutrition, on Megace Social History: Lives in [**Location 686**] with 2 brothers, but per patient is independent with ADLs. Not working. Former smoker, quit 2 years ago. Denies EtOH or ilicit drugs. Family History: CAD. No other congenital abnormalities in the family Physical Exam: Physical Exam: VS: Temp: 97.1 BP:126/79, HR: 89, RR: 21, O2sat 79% on 5L, improved to 97% on 100% FM, currently 97% on 2L NC GEN: pleasant, comfortable, NAD, cachectic appearing HEENT: pupils equal. sclera and conjunctiva clear B/L RESP: Crackles through right and left upper lung fields, poor air movement throughout CV: RR, S1 and S2 wnl ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm, B/L LE edema NEURO: Alert, appropriate. No focal deficit. Most recent physical exam: T 95.6 BP 104/72 Hr 90 RR 20 97% 4L GEN: pleasant, comfortable, NAD, cachectic appearing. elfin face. HEENT: pupils equal. sclera and conjunctiva clear B/L RESP: Scant wheezes bilateral, some coarse crackles base CV: irregular, S1 and S2 wnl ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm, trace B/L LE edema NEURO: Alert, appropriate. No focal deficit. Pertinent Results: Admission labs: [**2102-11-20**] 04:01PM GLUCOSE-131* UREA N-16 CREAT-0.5 SODIUM-142 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-39* ANION GAP-11 [**2102-11-20**] 04:01PM estGFR-Using this [**2102-11-20**] 04:01PM ALT(SGPT)-28 AST(SGOT)-24 LD(LDH)-411* ALK PHOS-44 TOT BILI-0.3 [**2102-11-20**] 04:01PM ALBUMIN-3.4* CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.2 [**2102-11-20**] 04:01PM DIGOXIN-1.1 [**2102-11-20**] 04:01PM WBC-9.8 RBC-3.62* HGB-10.9*# HCT-35.3* MCV-98 MCH-30.0 MCHC-30.8* RDW-14.0 [**2102-11-20**] 04:01PM NEUTS-94.5* LYMPHS-3.8* MONOS-1.6* EOS-0.1 BASOS-0 [**2102-11-20**] 04:01PM PT-31.1* PTT-26.1 INR(PT)-3.1* [**2102-11-20**] 04:01PM PT-31.1* PTT-26.1 INR(PT)-3.1* [**2102-11-20**] 02:41PM TYPE-ART PO2-174* PCO2-79* PH-7.35 TOTAL CO2-45* BASE XS-14 [**2102-11-20**] 02:41PM LACTATE-1.3 . CHEST (PORTABLE AP) Study Date of [**2102-11-20**] 2:05 PM 1. Emphysema worse than [**2093**]. 2. Small bilateral pleural effusions with associated atelectasis. 3. Right basilar opacity may be effusion, pneumonia or aspiration. . VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2102-11-22**] 9:17 AM IMPRESSION: Mildly prominent upper esophageal sphincter. Otherwise normal video swallow. . ECG Study Date of [**2102-11-28**] 2:05:28 PM Atrial fibrillation with rapid ventricular response. Ventricular ectopy versus aberrant conduction. Non-specific ST-T wave changes. Compared to the previous tracing of [**2102-11-25**] aberrant conduction versus ventricular ectopy is new. Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 105 0 80 292/370 0 39 -167 CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2102-11-29**] 4:02 PM IMPRESSION: 1. No CT evidence of pulmonary embolus. 2. Severe diffuse emphysema. 3. Interstitial edema and moderate right and small left pleural effusions. . CXR [**12-4**]: Final Report HISTORY: Acute desaturation with worsening pneumonia. FINDINGS: In comparison with study of [**11-27**], there is persistent enlargement of the cardiac silhouette with bibasilar opacification most likely consistent with pneumonia and pulmonary vascular congestion. . INR Trend: [**2102-12-7**] 06:25AM BLOOD PT-29.6* INR(PT)-2.9* 2 mg ordered [**2102-12-6**] 06:47AM BLOOD PT-26.4* INR(PT)-2.6* 3mg [**2102-12-4**] 06:50AM BLOOD PT-19.7* INR(PT)-1.8* 3mg [**2102-12-3**] 05:54AM BLOOD PT-14.9* INR(PT)-1.3* . ECHO [**12-5**]: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload with reverse Bernheim effect. The aortic valve leaflets are mildly thickened (?#). The mitral valve leaflets are moderately thickened. There is borderline/mild anterior leaflet mitral valve prolapse. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with normal gradient. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Discharge labs: [**2102-12-7**] 06:25AM BLOOD WBC-11.2* RBC-2.90* Hgb-8.3* Hct-27.3* MCV-94 MCH-28.5 MCHC-30.2* RDW-14.4 Plt Ct-428 [**2102-12-7**] 06:25AM BLOOD Glucose-101* UreaN-10 Creat-0.5 Na-139 K-4.4 Cl-97 HCO3-39* AnGap-7* [**2102-12-4**] 09:24AM BLOOD Type-ART Temp-37.8 Rates-/26 FiO2-95 pO2-48* pCO2-72* pH-7.42 calTCO2-48* Base XS-17 AADO2-560 REQ O2-92 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-AX TEMP = Brief Hospital Course: 52 y/o female with Willams' Syndrome, COPD, CAD, recently discharged after a hopsitalization for PNA who re-presented to [**Hospital3 **] from rehab 11 days ago with diarrhea/vomitting, now resolved, who was transfered to [**Hospital1 18**] for worsening hypoxia and hypercapnea depite aggressive chest PT and mycolytics. #. Hypoxia/[**Hospital 95243**] Hospital Acquired Pneumonia: Given persistantly elevated HCO3, pt is likely hypercarbic at baseline. After arrival to the ICU, the patient was able to be weaned back to NC, which she has needed at home previously, maintaining O2 sats in the low to mid-90s. Given RLL infiltrate and recent hospitalizations (including rehab stay), the patient was empirically treated for HAP with Vancomycin and Cefepime. By report, she recieved a 3 day course of Fluconazole for [**Female First Name (un) 564**] on BAL without any obvious risk factors for Candid pneumonia. LDH was elevated on this admission so a sputum culture and sputum for PCP immunofluorescence were sent. Sputum culture revealed gram-positive rods but fewer than < 10 PMNs which seemed more consistent with colonization versus infection as most GPRs are not commonly infective. Following transfer to the floor, given severe persistent hypoxia at rest (80% RA) a pulmonary consult was obtained. CTA obtained which demonstrated severe emphysema. Her steroids were tapered to 40 mg daily with taper to 30 mg on [**12-6**], with goal of taper by 10 mg q week, for 3 week taper. She completed her antibiotics were stopped on [**2102-11-30**], however her respiratory status remained very tenuous. Repeat CXR on [**12-4**] after desaturation showed persistent infiltrate and she was started back on broad spectrum antibiotics, with goal of a 2 week course of vancomycin/zosyn and azithromycin. Vanco trough on [**12-6**] before fourth dose was 16.1 Continued mucomyst nebs, guafenisen, chest PT and incentive spirometry. Continue home Advair, Spiriva, and Singulair for COPD. Albuterol nebs PRN were changed to Xopenex due to recurrent tachycardia. Given concern for aspiration, speech and swallow evaluation was obtained which was unremarkable. She will require follow up with pulmonary on [**1-4**] as scheduled. . # Atrial fibrillation with Rapid Ventricular Response # Acute on chronic systolic CHF # Severe pulmonary hyeprtension She was continued on metoprolol and diltiazem, but given short-acting forms in house as she has occasional episodes of hypotension. Digoxin was continued. TTE was obtained, which showed severe pulmonary artery hypertension and evidence of volume overload, PCWP of over 18. Coumadin was initially held due to coagulopathy with antibiotic, which was restarted on [**2102-11-30**]. She was continued on home Lasix at 40 mg daily for slow diuresis due to borderline low blod pressure. INR should still be monitored daily with level today of 2.9, after receiving 3 mg of coumadin for the past 4 nights. She still has occasional bursts of a wide complex tachycardia that appears consistent with afib with aberrancy. . # Type 2 Diabetes Uncontrolled with Complications, hyperglycemia Reported to be [**1-3**] chronic steroid use. Pt does not want to eat off diabetic diet. Given poor nutritional status, will allow a regular diet. Metformin initially held, but restarted due to inability to get glucose below 400 consistently, then increased to 1000 [**Hospital1 **]. She was continued on home megesterol to encourage appetite. . Emergency Contact: brother [**Name (NI) **] (HCP and guardian) [**Telephone/Fax (1) 95244**] Code: full . Key follow up: Pulmonary on [**1-4**] PCP after discharge Repeat CXR 4-6 weeks to verify resolution . Outstanding labs: Blood cultures from [**12-2**] Medications on Admission: Ambien 5mg qHS Advair 500/50 [**Hospital1 **] Colace 100mg [**Hospital1 **] Coumadin 4mg daily 1600 Diflucan 150mg daily Digoxin 0.125 daily Dlucolax 10mg PR PRN Lasix 40mg daily Metoprolol 25mg daily Megesterol 80mg daily Milk of Mag 10mL daily Mucinex 1200mg [**Hospital1 **] Mucomyst nebs TID Nitroglycerin SL 0.4mg PRN Insulin sliding scale Pepcid 20mg po BID Prednisone 60mg po daily Singulair 10mg po daily Spiriva 1 puff daily Theragenerix (multivitamin) 1 tab po daily Tylenol 650mg po q6hrs PRN Cardizem 240mg po daily Xopenex nebs TID, QID PRN Discharge Disposition: Extended Care Facility: [**Hospital1 **] Lower [**Doctor Last Name 4048**] Discharge Diagnosis: Healthcare associated PNA Severe COPD Acute on chronic CHF Atrial fibrillation with RVR Poorly controlled diabetes mellitus type II with complications Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. on 4L o2 at 97% (Feels short of breath at lower levels) Discharge Instructions: You were admitted with pneumonia after being admitted to [**Hospital1 **] with gastroenteritis symptoms. You had recently been admitted for the same. You were initially admitted to the ICU, and then transferred to the floor. Your respiratory status has been up and down, but you are now doing well back on antibiotics for pneumonia. We have scheduled a follow up for you with the lung doctors to further [**Name5 (PTitle) 4656**] your lung function. . You will need IV antibiotics through [**12-18**]. Followup Instructions: Department: PULMONARY FUNCTION LAB When: THURSDAY [**2103-1-4**] at 9:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES/PULMONARY When: THURSDAY [**2103-1-4**] at 10:00 AM With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12475, 12552

8133, 11722

314, 320

12747, 12747

4218, 4218

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266, 276

348, 2859

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174,547

30736

Discharge summary

report

Admission Date: [**2190-5-4**] Discharge Date: [**2190-5-6**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: Tracheobronchomalacia Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: [**Age over 90 **]F apparently in good health until mid-[**Month (only) 547**] when she had a pneumonia with respiratory distress and presented to [**Hospital **] [**Hospital **] hospital where an emergency trach was performed due to difficult intubation, the cause of which is unclear - pt unable to wean from vent and ENT tracheoscopy found severe TBM yesterday. They would like us to consider airway stenting, but stent not placed due to supraglottic edema and subglottic stenosis/granulation tissue. Will return to CT thurs. 10am, thoracics aware. When edema decreased, may return to get stent. Aneurysm old per cards. Atenolol decreased to 50qd per cards rec. TF restarted and KVO'd. Past Medical History: HTN atrial fibrillation mild dementia s/p trach and PEG [**3-20**] Social History: Social History: no tob/etoh/drugs, lives alone Physical Exam: Afebrile HR 81 BP 99/37 on CPAP 40% 5PEEP/14PS taking 380x21 NAD coarse BS bilaterally RRR Pertinent Results: [**2190-5-4**] 09:21PM proBNP-3291* [**2190-5-4**] 09:21PM PT-12.8 PTT-23.6 INR(PT)-1.1 Brief Hospital Course: Had newly diagnosed TBM and was sent here to see if there was any intervention we could offer. Broncospy demonstrated severe, disease, and swelling; the hope was that treating the inflammation with steroids would allow stent placement. On the day prior to d/c she under went a second bronchoscopy that showed no significnat change in he condition. The IP team decided there was no possibility of placing a stent in her. She was having a difficult time weaning her vent dependency. At the time of this discharge summary, she was about to be transferred back to her vented rehab. Medications on Admission: Atenolol 100', norvasc 5', seroquel, prevacid Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: 5000 (5000) units Injection [**Hospital1 **] (2 times a day) as needed for dvt. 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation Q6H (every 6 hours) as needed for bronchospasm. 3. Amlodipine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily) as needed for htn. 4. Donepezil 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime) as needed for dementia. 5. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 6. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Hospital1 **]: One (1) Spray Nasal DAILY (Daily) as needed for Post-nasal drip. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day) as needed for pud. 8. Atenolol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) as needed for htn. 9. Dexamethasone Sodium Phosphate 4 mg/mL Solution [**Last Name (STitle) **]: Four (4) mg Injection Q8H (every 8 hours) as needed for supraglotic edema for 2 days. Discharge Disposition: Extended Care Facility: Hospital for Special Care Discharge Diagnosis: tracheobronchomalacia Discharge Condition: fair Discharge Instructions: call your local PCP in [**Name9 (PRE) 7349**] if you develop chest pain, fever, chills. Call if you have difficulty swallowing, nausea, vomiting or diarrhea. Followup Instructions: follow up with your local pulmonologist in [**Location (un) 7349**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

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icd9cm

[ [ [] ] ]

[ "96.71", "99.04", "96.6", "33.22" ]

icd9pcs

[ [ [] ] ]

3268, 3320

1420, 2003

287, 302

3386, 3393

1304, 1397

3600, 3762

2099, 3245

3341, 3365

2029, 2076

3417, 3577

1192, 1285

226, 249

330, 1021

1043, 1112

1144, 1177

40,310

186,361

36853

Discharge summary

report

Admission Date: [**2144-7-11**] Discharge Date: [**2144-11-12**] Date of Birth: [**2103-12-5**] Sex: M Service: MEDICINE Allergies: Vincristine Attending:[**First Name3 (LF) 3918**] Chief Complaint: Tumor lysis, respiratory failure, pituitary macroadenoma. Major Surgical or Invasive Procedure: Endotracheal Intubation Central Venous Line Occuloplasty: Right Eye Lid approximation History of Present Illness: 40 yo homeless [**Male First Name (un) 4746**] admitted for workup of acromegaly, found to have laboratory abnormalities consistent with tumor lysis syndrome, also with respiratory distress. He was admitted on [**2144-7-11**] as OSH transfer for multiple concerns including bell's palsy, urinary retention, pituitary macroadenoma, acromegaly, persistent sinus tachycardia, scrotal pain and swelling, bilateral LE weakness, thecal/ epidural enhancement in thoracic region, and tumor lysis syndrome concerning for underlying malignancy. . Patient received 150cc NS/hr for rising tumor lysis labs and became progressively more dyspnic with increasing oxygen requirement. Cardiology was consulted for persistent sinus tachycardia non-responsive to IV fluids and he was started on po metoprolol 50mg TID. He was being treated w/ acyclovir and prednisone for question of viral-induced Bell's Palsy. Endocrine and neurosurgery were following and work-up ongoing for pituitary macroadenoma and acromegaly. MR of T spine was performed to evaluate LE weakness, without evidence of cord compression. Heme/onc on the day prior to transfer attempted bone marrow biopsy but could not obtain due to respiratory distress induced with prone positioning. . Patient transferred from floor to the ICU because, he had received 150cc NS/hr, received 20mg IV lasix x3 in 8 hours. UOP had been good but oxygen requirement had increased to 5L. . On arrival to the MICU, non-invasive ventilation was attempted but unsuccessful [**2-17**] facial structure. He received nitro gtt, morphine 2mg Iv, metoprolol 10 mg Iv, and 40mg IV lasix without improvement in his respiratory status and was intubated. Past Medical History: - not documented, questionable f/u - r.tibial plateau fx Social History: Pt unemployed, living in automobile. Denies ETOH, +smoking (2.5 packs X 25 years), denies IVDA/other illicit drug use. Brother incarcerated. 19yr old son in [**Name (NI) **]. Family History: Unknown. Physical Exam: General: Alert, oriented, in respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear, frontal bossing, maxillary protrusion Neck: supple, JVP elevated, no LAD Lungs: gurgle apparent from door, diffuse b/l rales, using accessory muscles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: exam limited [**2-17**] acute respiratory distress, + right facial droop . Pertinent positives on discharge physical exam: Vitals: T: 98 HR 98 BP 110/80 RR 18 SpO2 97% RA -acromegaly, frontal bossing, enlarged hands/feet -sacral ulcer -portacath in place -asymmetric eyelids -CV: RRR, no m/r/g -PULM: CTAB -ABD: soft, NT, ND, +BS -Neuro: alert, oriented, conversational. Pertinent Results: Labs on discharge: [**2144-11-12**]: WBC-1.0* RBC-2.74* Hgb-8.6* Hct-24.8* MCV-90 MCH-31.5 MCHC-34.8 RDW-16.9* Plt Ct-99* Neuts-57 Bands-0 Lymphs-29 Monos-7 Eos-7* Baso-0 Atyps-0 Metas-0 Myelos-0 Glucose-152* UreaN-8 Creat-0.4* Na-143 K-3.7 Cl-105 HCO3-29 AnGap-13 ALT-16 AST-11 LD(LDH)-147 AlkPhos-58 TotBili-0.2 Albumin-3.0* Calcium-9.1 Phos-4.4 Mg-1.9 UricAcd-2.6* . [**2144-10-27**] CT torso w/contrast: IMPRESSION: 1. Interval decrease of left lower lobe atelectasis. 2. Stable biliary ductal dilatation without etiology identified. 3. Unchanged picture of severe constipation. 4. Sacral decubitus ulcer defect decreased in size with apparent vacuum dressing in place. No definite evidence for sacral destructive process. 5. Filling defects in the left and possibly right common femoral veins. While this could represent flow artifact, cannot exclude deep vein thrombosis. Recommend followup with ultrasound study. 6. Mild splenomegaly unchanged. . [**9-12**] U/S LE: IMPRESSION: Nonocclusive thrombus in the left common femoral, superficial femoral and popliteal veins. No thrombus in the right lower extremity. . [**9-10**] MRI L-spine: IMPRESSION: Limited examination demonstrates markedly decreased bone marrow signal, likely relating to the patient's lymphoma. There is no cauda equina compression, though evaluation for intradural disease is limited in the absence of intravenous contrast. Degenerative changes are present as detailed. Striking signal abnormality and probable atrophy within paraspinal musculature and psoas muscles which should be correlated with the patient's history. . [**8-15**] ECG: Sinus tachycardia in an atrial bigeminal pattern. RSR' pattern in lead V1 with early transition suggests an incomplete right bundle-branch block. Low QRS voltage in the precordial leads. Non-specific ST-T wave changes. Compared to the previous tracing of [**2144-8-12**] atrial bigeminy is present. The QRS voltage in the precordial leads has decreased. . Echo 7.30: Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets are mildly thickened (?#). The mitral valve leaflets are mildly thickened. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [**8-4**] MRI head: IMPRESSION: 1. Enlarged pituitary gland, mostly the left lobe, without evidence of hyperenhancement to suggest lymphomatous infiltration. This may represent a macroadenoma. Clinical correlation is recommended. 2. No other evidence of intracranial lymphoma. 3. Fluid in the mastoid air cells bilaterally. . [**9-1**] CT torso: IMPRESSION: 1. Large ulceration mainly containing air and no discrete fluid just superficial to the sacrum, without evidence of osteomyelitis. 2. No evidence of inflammatory change in the abdomen to explain constipation; large amount of stool in the rectum. 3. Small amount of air around the right chest port device. . Brief Hospital Course: In summary, 40M with tumor lysis syndrome, started chemotherapy on [**7-21**] for Burkitt-like lymphoma. New diagnosis of acromegaly, in ICU with respiratory failure in setting of pneumonia, possible ARDS, and diffuse malignant infiltration. Original presenting complaint was Bell??????s Palsy, urinary retention, and lower extremity weakness. RESPIRATORY FAILURE: Intubated on [**7-12**] in the setting of LLL PNA, lactic acidosis, and significant evidence of infiltrative malignant process on CT with peribronchial thickening. Two failed extubations on [**7-15**] and [**7-25**] secondary to copious secretions and work of breathing, respectively. Patient was initially maintained on AC, but was intermittently dysynchronous with vent which improved with PSV. Throughout stay he maintained large tidal volumes (700-800cc) and large minute ventilations (10-15L/min). On [**7-18**] patient had increasing evidence of infection and met criteria for ARDS, although compliance remained normal and large tidal volumes were tolerated. Respiratory status improved on broad spectrum abx and significant diuresis. Patient was gradually weaned on PSV and successfully extubated on [**7-30**]. On discharge, patient breathing comfortably on room air. PNEUMONIA/INFECTION: Initial CXR on [**7-12**] showed a LLL PNA. Later CXRs showed a persistent infiltrate at the R base. Patient received vanco, meropenem, cipro, cefepime, and doxycycline during his stay. BAL grew mycoplasma hominis on [**7-19**] and sputum grew coag+ staph on [**7-23**]. Starting [**7-22**], patient was neutropenic and put on prophylactic fluconazole, acyclovir, and atovaquone. EBV serum PCR was positive (level of 40). CSF fungal, AFB, and viral cx and EBV PCR were negative. HIV, HBV, HCV, galactomannan, and B-glucan were negative as was evidence for acute CMV or HHV-6 infection. Cultures from an A-line and from an IJ both grew coag-negative staph on [**7-25**] and [**7-27**] respectively, which was covered by vancomycin. Repeated surveillance cultures were negative. Treatment with doxycycline and ciprofloxacin was also continued for mycoplasma hominis pneumonia. Atovaquone was switched to IV bactrim after extubation. On discharge, patient breathing comfortably on room air, afebrile, without sign of infeciton. TUMOR LYSIS SYNDROME: Labs at admission were significant for elevated LDH, hyperkalemia, hyperphosphatemia, hyperuricemia which all resolved to baseline after 1 week admission after 2 doses rasburicase. Tumor lysis labs started to rise again on [**7-21**] with chemo and patient received 1 dose rasbiricase on [**7-24**]. Tumor lysis labs stabilized thereafter and UOP>100cc/hr and allopurinol was maintained. Laboratory values without evidence of tumor lysis on discharge. BURKITT-LIKE HIGH GRADE LYMPHOMA: CT showed diffuse evidence of malignancy - c/w lymphangitic spread of diffuse malignant process, thickening in stomach, ureters, peribronchial. MRI showed epidural enhancement in T-spine. Bone marrow bx c/w Burkitt/high grade lymphoma on [**7-19**]. Hyper-CVAD started on [**7-21**] and intrathecal chemo given 2x/wk alternating methotrexate and cytarabine for + malignant cells on LP. Future imaging should include gadolinium-enhanced MRI of the head to pursue possible radiation (pt's original complaints of CN V and VII palsies possibly related to lymphoma vs acromegaly). Patient then started on R-[**Hospital1 **] alternating with HD MTX chemotherapy. Patient developed lower extremity weakness and severe polyneuropathy (followed by neurology), either from oncovorin therapy or presumed leptomeningeal disease. As such, oncovorin was held in the R-EP(O)CH therapy. Patient received his last treatment with HD methotrexate on [**11-6**] and is day 7 at discharge with evidence of his counts approaching nadir. His methotrexate level on day of discharge was 0.03. He will be continued on leucovorin for 2 more days given that he had significant mucositis in the past from MTX. He should start on neupogen on [**11-13**] and should be stopped as advised by his outpatient oncologist once he is through his nadir. Patient to be seen in outpatient heme/onc follow-up on [**11-16**]. Patient's last dose of Inhaled Pentamidine, for prophylaxis, was on [**11-12**]/9 (previous dose was 9/30/9). PANCYTOPENIA: Platelets falling throughout admission. Precipitous drop in WBC and platelets on day 1 of chemo, Hct in low 20s throughout most of admission. ANC<<500 starting [**7-23**]. Supported with PRBCs to maintain Hct>21 and Plts>15. Neupogen started [**7-24**]. This was felt to be initially secondary to his lymphoma and then later his chemotherapy. Currently his counts are plts 99, HCT 24.8, WBC 1 with ANC 570. He will be reaching his nadir from HD methotrexate soon. Goal would be to keep HCT >25 and platelets >10 (transfuse as needed to meet these goals). He should be started on neupogen on [**11-13**]. This should be continued through his nadir, and discussed with his outpatient oncologist at Monday's ([**11-16**]) appointment. TACHYCARDIA: Consistently tachycardic to 110s/120s. TSH WNL, TTE showed normal EF and no evidence of heart failure. Repeat EKGs showed frequent PVCs, no signs of myocardial ischemia. PVCs consistently present throughout ICU stay. Thought to be physiologic tachycardia secondary to infection, lymphoma, anemia, high [**Hospital1 **]. Tachycardia improved with increased comfort on ventilator, reduced sedation. Patient was maintained on low dose metoprolol. Patient's heart rate in high 90s, low 100s typically, even on low-dose metoprolol. ACUTE RENAL FAILURE: Bump in creatinine from baseline 0.6 to 1.6 early in admission, thought to be ATN secondary to tumor lysis with contributions from one episode of hypotension just after intubation and IV contrast. Resolved and then remained at baseline. ABDOMINAL DISTENTION: Developed on [**7-19**] with hypoactive bowel sounds. Abdomen remained soft but no stool for 6 days despite colace, senna, dulcolax, lactulose, SC methylnaltrexone, and PO narcan. Throughout the hospitalization constipation remained an issue and colace, senna, dulcolax, lactulose, bisacodyl were continued. Bowel movements began to occur at more regular frequency, and were soft. Patient continued to feel constipated but was having BM's - aggressive control of bowel regimen is required for patient comfort - through medications, ambulation, hydration. HYPERGLYCEMIA: blood glucose in the 200-300s starting [**7-23**]. Thought to be due to the dexamethasone, antibiotics in D5W and acromegaly. Maintained with ISS and insulin drip to glucoses < 200. While hospitalized this hyperglycemia resolved. LLE DVT: Diagnosed on [**2144-9-12**]. On heparin gtt. Transitioned to Lovenox for oupatient management on 10.28. This should be continued for a minimum 6 months and should be addressed by his outpatient oncologist. If the patient's platelets drop below 75, then the lovenox should be held, and only restarted when the platelets rise above 75 again. SACRAL ULCER: Followed by surgery with several debridements, and wound vac in place. Completed course of IV flagyl. Wound vac removed. Pain improved as hospital course. At discharge his wound care included: Site: sacral ulcer: -Pack with [**Doctor Last Name 12536**] AMD Kerlix # [**Numeric Identifier 28080**] -Barely dampen with normal saline and pack loosely into the wound bed and undermined areas. -Cover with dry gauze, Soft sorb sponge -Secure with softcloth tape -Change daily. ACROMEGALY: New presumptive diagnosis based on clinical features: large hands, feet, digits, frontal bossing, coarse facial features, large jaw, large chest. Suspected that this contributed to the cause of many of his presenting symptoms, possibly including CN V and VII palsies on the right, urinary retention (?enlarged prostate), joint pain, and lower extremity paresthesias. [**Hospital1 **] was high, IGF-1 was normal although this can be depressed in acute illness. LH was elevated, testosterone was slightly depressed. TSH, cortisol, FSH, LH were all normal. Other labs ordered per endocrine, but definitive work-up postponed until patient stabilized. Optho consult for visual field testing was suggested when patient stabilized/alert. Ophtho and endocrine and neurology and neurosurgery follow-up important for patient as outpatient. These have been scheduled for him at discharge. KERATITIS: Right corneal ulcer, biopsied by opthalmology. Cultures grew coag negative staph and mycelia sterilia. Patient with important antibiotic eye-drop regimen per opthalmology and infectious disease. Patient also had: Occuloplasty: Right Eye Lid approximation. Patient will follow-up with ophthalmology as outpatient. TENDER SCROTAL SWELLING: Noted on admission, scrotal US suggested epididymitis/orchitis. No clear masses. G&C swab negative. Exam starting [**7-17**] shows marked increase in testicular swelling, particularly on the left. Thought to be secondary to malignant infiltration and generalized edema. This issue had resolved. NEUROLOGIC ABNORMALITIES: Initial patient complaints included R Bell??????s palsy, loss of R facial sensation, urinary retention, and weakness/decreased sensation of lower extremities. MRI T-spine at OSH showed epidural enhancement of thoracic spine; MRI head showed pituitary macroadenoma. Initial concern was for cord compression but neurosurgery had low suspicion and MRI was not initially repeated. Repeat MRI of pituitary needed eventually for acromegaly work-up. Subsequently, Neurology followed Mr. [**Known lastname **] for some time. It was decided that his neurological deficits and neuropathic pain likely arose from two etiologies: Infiltration of roots by disease, producing some impairments prior to admission. These are poorly documented, but would have been somewhat asymmetric if this hypothesis is correct, as was his facial nerve involvment, for example. Superimposed on this is another more symmetrical and diffuse, stocking and glove-like process that is likely a toxic neuropathy. Vincristine is the most likely causative [**Doctor Last Name 360**]. Neuropathy pain improved through medications (nortriptyline and pregabalin). Patient to f/u with neurosurgery and neurology as an outpatient. JOINT PAIN: Patient has severe and diffuse arthralgias, most likely secondary to hypertrophic arthropathy from acromegaly. At discharge patient stabilized on Methadone, Dilaudid PRN Pain (ie when working with PT, Sacral Decubitus dressing change). Patient ambulated with assistance up to 10 feet, with pain controlled. Follow-up with endocrine as outpatient. Medications on Admission: Acetaminophen 325-650 mg PO Q6H:PRN Allopurinol 300 mg PO DAILY Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Artificial Tears 1-2 DROP BOTH EYES PRN Azithromycin 500 mg IV Q24H CeftriaXONE 1 gm IV Q24H Ciprofloxacin HCl 500 mg PO Q12H Day number 1 - [**2144-7-11**] Docusate Sodium 100 mg PO BID Famotidine 20 mg PO BID Fluticasone Propionate NASAL 2 SPRY NU DAILY Heparin 5000 UNIT SC TID Insulin SC Metoprolol Tartrate 50 mg PO TID Ondansetron 4 mg IV Q8H:PRN nausea PredniSONE 60 mg PO DAILY Senna 1 TAB PO BID:PRN constipation Xopenex Neb *NF* 1 amp Other Q4H prn Discharge Medications: 1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please hold for SBP <100 or HR<60. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 6. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 7. Moxifloxacin 0.5 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours): Please put into eyes BEFORE erythromycin eyedrops. 8. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dryness/irritation. 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2) Drop Ophthalmic Q2H (every 2 hours). 13. Erythromycin 5 mg/g Ointment Sig: 0.5 in OD Ophthalmic QID (4 times a day): Instructions: Erythromycin 0.5% Ophtho Oint 0.5 in OD QID. Please put into eyes 10-15 minutes AFTER Vigamox. 14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Pregabalin 25 mg Capsule Sig: Five (5) Capsule PO TID (3 times a day). 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 17. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 18. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO every six (6) hours as needed for titrate to one to two bowel movements per day. 19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 20. Leucovorin Calcium 10 mg Tablet Sig: Four (4) Tablet PO every six (6) hours for 2 days: To be taken on [**11-13**] and [**11-14**] and then discontinued. 21. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: 7 day course for prophylaxis during neutropenic phase, ends on [**2144-11-19**]. 22. Saliva Substitution Combo No.2 Solution Sig: Thirty (30) ML Mucous membrane QID (4 times a day). 23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 24. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea/anxiety/insomnia: Hold for sedation. 26. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Hold for sedation or RR<12. 27. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea/vomiting. 28. Heparin, Porcine (PF) 10 unit/mL Solution Sig: Five (5) ML Intravenous PRN (as needed) as needed for line flush: Indwelling Port (e.g. Portacath), heparin dependent. Flush with 10mL Normal Saline followed by Heparin as above daily and prn per lumen. 29. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five (5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING port: Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 30. Lidocaine Viscous 2 % Solution Sig: 10-20 cc Mucous membrane three times a day as needed for mucositis: Swish and spit for oral mucosal lesions, if present and painful. 31. Enoxaparin 100 mg/mL Syringe Sig: [**9-24**] mL Subcutaneous Q12H (every 12 hours): Please give 90mg SQ lovenox q12h. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Aggressive B Cell Lymphoma Secondary: Left Lower Extremity Deep Vein Thrombosis Exposure Keratitis R Eye Acromegaly Discharge Condition: Stable. Afebrile. Improving lower extremity weakness. Patient able to ambulate a few yards with Physical Therapy's assistance. Discharge Instructions: You were admitted on [**2144-7-11**] from an outside hospital for multiple concerns including bell's palsy, urinary retention, pituitary macroadenoma, acromegaly, persistent sinus tachycardia, scrotal pain and swelling, bilateral LE weakness, and tumor lysis syndrome concerning for underlying malignancy. . On admission you were transferred to the intensive care unit when you developed respiratory distress and changes in your labs concerning for tumor lysis of an underlying malignancy. You were intubated in the intensive care unit and a breathing machine continued to help you breath. Oncologists were consulted and you were found to have an aggressive lymphoma. . You were treated with chemotherapy for this lymphoma and had excellent response to therapy. Repeat BM biopsy and repeat CT scan of the torso were negative for disease. You will be followed by your oncologist, Dr. [**Last Name (STitle) **]. You are being discharged with a very low WBC count, so you will be discharge on levofloxacin (an antibiotic) which Dr. [**Last Name (STitle) **] can decide to continue or to stop when you see him on Friday [**11-13**]. Please see the discharge medications list for up to date medication list. Please return to the hospital or contact your physician if you develop shortness of breath, chest pain, fever, nausea, vomiting, diarrhea, bleeding from the rectum, changes in your bowel or bladder habits, or other concerning symptoms. . [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**] Completed by:[**2144-11-12**]

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Discharge summary

report

Admission Date: [**2151-3-6**] Discharge Date: [**2151-3-16**] Date of Birth: [**2084-7-23**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Found down. Major Surgical or Invasive Procedure: -Enotracheal intubation [**2151-3-5**], extubated [**2151-3-8**]. -Femoral line placement History of Present Illness: Ms. [**Known lastname 49957**] is a 66 year-old woman with a history of lung cancer who presents after being found down by her family She was found down by her son tonight and it is beleived she has been down since early afternoon of [**3-5**]. At the OSH, labs showed K of 8.3 with peaked T-waves, bicarb of 6, glucose of >1200, ABG of 6.8/29/572. Additional labs included a WBC of 47.5, HCT of 43.7, PLT of 252, CK of 967, lipase of 616, Troponin 0.07. She was intubated at the OSH with etomidate and succ. Hyperkalemia was treated with calcium, [**Date Range 31217**], bicarb and kayexalate. Also given zosyn and decadron (10mg IV). Past Medical History: 1. Lung cancer: CT chest ([**2149-9-5**]) shows right infrahilar mass 2. Diabetes 3. GERD 4. Uterine CA (hysterectomy when 30) Social History: Former smoker (pack and half a day for 50yrs, quit 3yrs ago). Retired laundry worker. Family History: Significant for 2 sisters with cancer of unclear site. Physical Exam: On admission: VITALS: T 97.1, BP 111/59, HR 97, FiO2 1.0 and 100% GEN: Intubated, sedated. HEENT: Pupils 3mm->2mm bilaterally. Unable to assess EOM. Anicteric CV: Regular. No murmurs. PULM: Anteriorly clear. ABD: Soft. No apparent tenderness. EXT: Warm. No edema. NEURO: Pupils as above. Weak gag. No response to nailbed pressure. Does not move extremitites. On Discharge: VS: Tm 98.6 Tc 97.6 BP 127/77 (112-144/70-80) HR 90 (90-106) RR 18 O2sat: 95% ra. I/O [**2151-3-15**] - NR; [**2151-3-16**] SMN: 1.0/250 FSBS: 184 (52-240) GEN: Alert, oriented, NAD HEENT: NCAT, sclera white, Pupils 3mm->2mm bilaterally. EOMI intact. OP with moist mucosa, no erythema. NECK: no LAD, JVP 7 cm CV: RRR, S1 & S2 nl No m/r/g PULM: CTA in all lung fields. ABD: Soft. +BS, mild distended. tympanitic. No apparent tenderness. EXT: Warm. No edema. NEURO: CN II-12 intact except left sided facial droop, but pt has some movement of left side of face. Strentgh [**2-11**] in UE bilat with good grip strenght [**4-13**] bilat. DTRs 2+ at patella bilat. Pt able wiggle toes in left leg, unable to move RLE. babinski positive on right. Pt reports intact sensation to light touch bilat in LE. Pt is full assist for any movement. Pertinent Results: Labs on admission: [**2151-3-6**] 03:49AM BLOOD WBC-37.2* RBC-3.79* Hgb-11.5* Hct-36.8 MCV-97 MCH-30.4 MCHC-31.4 RDW-13.6 Plt Ct-221 [**2151-3-6**] 03:49AM BLOOD Neuts-64 Bands-3 Lymphs-19 Monos-11 Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2151-3-6**] 03:49AM BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1 [**2151-3-6**] 03:49AM BLOOD Glucose-941* UreaN-53* Creat-2.7* Na-143 K-3.8 Cl-110* HCO3-10* AnGap-27* [**2151-3-6**] 03:49AM BLOOD ALT-32 AST-71* CK(CPK)-3787* AlkPhos-120* TotBili-0.3 [**2151-3-6**] 03:49AM BLOOD Lipase-818* [**2151-3-6**] 03:49AM BLOOD CK-MB-35* MB Indx-0.9 [**2151-3-6**] 03:49AM BLOOD Albumin-3.2* Calcium-7.7* Phos-5.2* Mg-2.7* [**2151-3-6**] 03:49AM BLOOD Osmolal-292 [**2151-3-6**] 08:29AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2151-3-6**] 04:28AM BLOOD Type-ART Temp-36.7 Rates-/20 Tidal V-500 PEEP-5 O2 Flow-50 pO2-225* pCO2-29* pH-7.12* calTCO2-10* Base XS--19 -ASSIST/CON Intubat-INTUBATED [**2151-3-6**] 03:53AM BLOOD Lactate-3.1* [**2151-3-6**] 09:48AM BLOOD freeCa-1.20 Chest x-ray [**2151-3-6**]: IMPRESSION: 1. ET tube just above the thoracic inlet and could be advanced slightly for standard positioning. 2. Nodular opacity in the left lung concerning for mass lesion adjacent to wedge resection site. This is further evaluated on subsequent CT. CT head without contrast, read on outside study: Numerous hypodense lesions with areas of hyperdensity concerning for diffuse metastatic disease. Approximately 2-mm leftward shift of normally midline structures. Extensive vasogenic edema surrounding many of these lesions is noted. CT Torso [**2151-3-6**]: 1. Left upper lobe mass, ill-defined lesions within the liver and left adrenal nodule are identified. These are incompletely evaluated without contrast and are concerning for neoplastic disease given patient's history of metastatic brain disease. 2. Trace pericardial effusion. 3. Simple left renal cyst. 4. Nonspecific mesenteric fat stranding which may be related to the pancreas. Clinical correlation is recommended for possible pancreatitis. No evidence of free air or free fluid. Chest x-ray [**2151-3-9**]: The NG tube tip is in stomach. Bilateral atelectasis accompanied by bilateral pleural effusions are grossly unchanged. There is interval decrease in the degree of pulmonary edema otherwise no significant change since the prior study is demonstrated. The patient was extubated in the meantime interval. The left upper lobe lesion demonstrated on CT torso from [**2151-3-6**] is seen but the CT technique characterized better dimensions of the mass. MRI BRAIN [**2151-3-10**] IMPRESSION: Numerous lesions in both cerebral and cerebellar hemispheres, the largest with central cystic-appearing necrosis and many, hemorrhagic with blood products of varying ages, consistent with extensive metastatic disease. These demonstrate significant associated vasogenic edema (despite the history of corticosteroid therapy x 3 days), with the right inferior frontal lesion demonstrating associated slight leftward deviation of the septum pellucidum and possible early trapping of the contralateral lateral ventricle. There is no uncal or downward transtentorial herniation at this time. The findings on DWI are somewhat unusual in metastatic disease and raise the possibility of a markedly hypercellular aggressive neoplasm with cystic necrosis. LABS ON DISCHARGE: [**2151-3-16**] COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2151-3-16**] 07:30AM 12.2* 3.61* 10.7* 32.0* 89 29.5 33.3 14.7 250 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2151-3-16**] 07:30AM 171* 19 0.8 141 4.4 106 28 11 CHEMISTRY Calcium Phos Mg [**2151-3-16**] 07:30AM 8.9 3.3 2.1 GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **] [**2151-3-15**] 01:49PM Yellow Clear 1.017 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks MOD NEG TR 1000 15 NEG NEG 6.0 MOD RBC WBC Bacteri Yeast Epi >50 >50 MANY NONE 0-2 MICROBIOLOGY: [**2149-3-14**] URINE CULTURE PENDING. Brief Hospital Course: This is a 66 year old female with history of lung cancer, now presenting with DKA/HHS and ARF after being found down. She was admitted to the MICU. # Altered mental status / Brain mets: The most likely cause for this patient's altered mental status was felt to be cerebral edema secondary cerebral edema from a large amout of brain metastasis. This caused altered mental status and the patient did not take her [**Month/Day/Year 31217**] and she then developed HONK. Her cerebral edema was treated with steroids, and her mental status improved greattly. She was initially intubated to protect her airway and she was successfully extubated on [**2151-3-8**]. Neurosurgery was consulted initiated, and they did not feel surgical intervention was appropriate. Once the patient was transferred out of the ICU, both radiation oncology and hematology/oncology were consult to discuss the patient's treatement option with her. The patient and her family declined both radation therapy and chemotherapy. Palliative care was consulted and patient patient's goals of care were directed towards comfort. They did not wish to persue aggressive treatment strategies. When the patient's mental status clear she was found to have new focal neurologic deficits. Please see physical exam for details. In short, the patient is A&Ox3, she has difficulty with attention and is slow to respond to questions. She has a left sided facial droop, she is unable to move her RLE. She was place of seizure prophylaxis to be continued indefinately given vagogenic cerebral edema. Her steroids were tapered down to Decadron 4mg PO BID and the plan is to continue this dose indefinately. In addition, she was placed on bactrim for PCP prophylaxis in the setting chronic steroids. # Hypernatremia: The patient presented with hypernatremia. Hypotonic fluids were avoided given cerebral edema concerns. She was encouraged to take in free water with PO intake. This eventually resolved. # Diabetes Type II/HONK: The patient presented with likely Hyperosmolar non-ketoic acidosis and she was started on an insuln drip which was switched to sliding scale after her AG closed. Her blood sugars remained difficult to control in the setting of steroids. Her lantus was eventually increased to 50mg PO qam and may need to be uptitrated further. Her humalog sliding scale requirements decreased recently in the setting of her steroid taper. Her steroid regimen should not change further. Her lantus and sliding scale regimens will likely need to be titrated further. # Acute kidney injury: This is likely from volume depletion and has responded to IVF. CK peaked at 7800 and trended downward; she likely did not have rhabdomyolysis. She received aggressive IVF resuscitation initially to protect her kidneys and is maintaining a good urine output with improvement in her creatinine. Her electrolytes are normal at this point. # Elevated lipase / acute pancreatitis at presentation: Lipase >800 with CT showing some mesenteric stranding consistent with pancreatitis at presentation. Unclear etiology for this but may have contributed to hyperglycemia. Lipase trended down. Once the patient's mental status improved she did not complain of any clinical symptoms of pancreatitis. The patient's diet was advanced and she is tolerated regular diet. # Back pain: The patient complains of back pain likely secondary to immobility. However, possibly related to spinal mets although none were noted on CT abdomen/pelvis. A dedicated spinal CT was not done as the patient did not have spinal tenderness, rectal tone was normal, and the patient and family did not want to persue palliative radiation tx to that area. Plan is for aggressive pain control. We transitioned to fentanyl 12.5 mcg/q72 hrs today. She also benefits from morphine and tylenol prn. # Urinary incontinence - The patient's foley was removed and she subsequently had urinary incontinence that did not improve over several days. The patient stated that she could sense the need to urinate but could not hold it to get a bed pan. On [**2151-3-15**], she complained of a dysuria. Her perineal area was somewhat irritated and a foley cath was placed. Her U/A was positive for UTI, but the urine culture is still pending. She was started on Ciprol 250mg PO BID on [**2151-3-15**] in the afternoon to complete a 3 day course. . # Insommnia - The patient has had difficulty with insomnia possible secondary to pain and steroids. The patient's was started on trazadone 100 po qhs. # Constipation - The patient was having constipation despite standing senna and colace. Miralax and bisacodyl were added to the patients bowel regimen. Her BM will need to be closely monitored and her bowel regimen should be adjusted PRN. # FEN - Diabetic diet. # PPX - PPI, heparin sq # Access - PIV # Code - DNR/DNI Medications on Admission: 1. Aspirin 81 mg daily 2. Inuslin Humalog 75/25 28U QAM and 5-8U before dinner 3. [**Date Range **] Levemir 18U 4. Avapro 150 mg daily 5. Neurontin 6. Gabapentin 7. Clacium with Vit D 8. Fioricet 9. Protonix 40 mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units/ml Injection TID (3 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): hold for loose stools. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q3H (every 3 hours) as needed. 8. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. [**Date Range **] Glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous once a day. 10. Humalog 100 unit/mL Solution Sig: 6-12 units Subcutaneous qachs: as directed per [**Date Range 31217**] sliding scale. 11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO once a day as needed for constipation. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for constipation. 14. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 15. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 doses: first dose [**2151-3-15**] in the afternoon. 16. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Discharge Disposition: Extended Care Facility: Oaks Long Term Care Facility - [**Location (un) 5503**] Discharge Diagnosis: Lung cancer metastatic to brain causing cerebral edema and altered mental status Diabetic Ketoacidosis Secondary Diagnoses: Hypernatremia Urinary Incontinence Urinary tract infection (treatment started [**2151-3-15**]) Back pain Insommnia Constipation Diabetes Mellitus type II Discharge Condition: fair Discharge Instructions: Dear Ms. [**Known lastname 49957**], You were admitted to the ICU after being found down and unresponsive. Your altered mental status was most likely due metastatic spread of your lung cancer to your brain and subsequent brain swelling. This caused you to miss [**First Name (Titles) **] [**Last Name (Titles) 31217**] dose and develop DKA. You and your family members spoke with several consulting teams regarding further treatment of your metastatic lung cancer and you declined further aggressive treatment in favor of comfort care. You were made DNR/DNI. Please take medications as prescribed. Please adjust [**Last Name (Titles) 31217**] regimen and pain regimen as needed. Followup Instructions: Patient will be followed by physicians at rehab. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2151-3-17**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "88.91" ]

icd9pcs

[ [ [] ] ]

13537, 13619

6806, 11664

280, 371

13942, 13948

2610, 2615

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18,436

128,268

29624

Discharge summary

report

Admission Date: [**2117-1-10**] Discharge Date: [**2117-2-10**] Date of Birth: [**2054-1-9**] Sex: M Service: CARDIOTHORACIC Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 922**] Chief Complaint: Generalized fatigue Major Surgical or Invasive Procedure: [**2117-1-11**] Ultrasound-guided right-sided Thoracentesis [**2117-1-13**] Bronchoscopy [**2117-1-20**] Redo, Redo Sternotomy. AVR with 25mm Pericardial Valve. TV Repair with 28mm Annuloplasty Ring. Re-implantation and repair of proximal saphenous vein graft. Pericardial Patch Repair of Ascending Aorta. Insertion of IABP. [**2117-1-22**] Sternal Washout and Closure [**2117-1-29**] Right Sided Chest Tube Placement [**2117-2-8**] Pleurx catheter placement History of Present Illness: This is a 62 year old man with a complicated cardiac history including AVR/CABG in [**2111**] and redo sternotomy, AVR(homograft)/MVR(tissue)/CABG in [**2113**] secondary to Staph. epi endocarditis. Postoperative course in [**2113**] was complicated by HIT resulting in left TMA and right 3rd and 4th metatarsal amputation, and placement of permanent pacemaker. . He was his USOH until a recent admission at the [**Hospital1 789**] VA for shortness of breath. He underwent thoracentesis and paracentesis for pleural effusions and ascites thought to be attributed from progressive aortic insufficiency. . He was then admitted from [**2116-12-22**] to [**2116-12-30**] to [**Hospital1 18**] for evaluation of operative management of severe aortic regurgitation. Hospitalization was complicated by contrast nephropathy from cardiac catheterization. His diuretics were held after that admission due to his acute renal insufficiency. . He subsequently required readmission from [**2117-1-5**] to [**2117-1-8**] to [**Hospital1 18**] for recurrent congestive heart failure. Underwent a right-sided thoracentesis and restarted on diuretics. Eventually discharged on home oxygen. . Despite medical therapy, he presented to the [**Hospital1 18**] on [**2117-1-10**] with worsening fatigue, malaise, and generalized weakness. He denied increased dyspnea but noted that home oxygen helped. He also denied worsening orthopnea and PND. He was readmitted for further evaluation and treatment. Past Medical History: Chronic Systolic Heart Failure (EF 35-45%) Aortic Insufficiency, Tricuspid Regurgitation Coronary Artery Disease History of Heparin Induced Thrombocytopenia Hodgkin lymphoma, s/p XRT and Splenectomy in [**2080**] Thyroid cancer - s/p Thyroidectomy in [**2102**] Hypothyroidism Hypercholesterolemia History of Prosthetic Aortic Valve Endocarditis Prior PCI RCA [**2110**] Recurrent Ascites Recurrent Pleural Effusions Mediastinal mass/pulmonary nodule s/p Carotid Endarterectomy [**2110**] s/p Left TMA, Right 3rd/4th Metatarsal Amp [**2113**] Social History: Lives with wife. Married with 2 children. Occupation: Works as clerk for Hasbro company. Tobacco: Quit [**2084**], [**1-3**] ppd for 30 years ETOH: Occasional Other: Denies IVDA Family History: Father died from prostate CA in 80s. No family h/o cardiac disease (including valvular disease), thyroid disease, or malignancy. Physical Exam: Admission: VS - Temp 97.1 F, BP 110/58, HR 95, RR 20, O2-sat 96% on 3L GENERAL - propped up on pillows, occasionally coughing, mildly uncomfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, JVP 12 cm, bounding carotid pulses without bruits, no thyromegaly, no LAD LUNGS - speaking in full sentences, no use of accessory muscles, decreased bs to midway up R lung field with crackles posteriorly and dull to percussion, crackles at L base scattered expiratory wheezes HEART - RRR, nl S1-S2, Systolic and Diastolic murmurs heard best at RUSB ABDOMEN - protuberant abdomen, +bs, soft, mildly tender in suprapubic region, no masses or HSM, no rebound/guarding, no visible ascites or fluid wave EXTREMITIES - WWP, 1+ pitting edema to midway up shin, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-6**] in RUE (pt reports this is stable) and [**5-6**] otherwise, sensation diffusely intact to LT. Pertinent Results: Admits Labs: [**2117-1-10**] WBC-11.6* RBC-4.01* Hgb-12.4* Hct-38.7* Plt Ct-217 [**2117-1-10**] Neuts-84.2* Lymphs-7.5* Monos-7.2 Eos-0.2 Baso-0.9 [**2117-1-10**] PT-17.0* PTT-30.8 INR(PT)-1.5* [**2117-1-10**] Glucose-106* UreaN-38* Creat-1.6* Na-133 K-4.6 Cl-98 HCO3-27 [**2117-1-12**] CK(CPK)-90 [**2117-1-10**] cTropnT-0.02* [**2117-1-10**] Calcium-8.5 Phos-2.9 Mg-2.3 [**2117-1-10**] Lactate-1.5 K-4.6 . [**2117-1-11**] Pleural Fluid: Negative for malignant cells . [**2117-1-20**] Intraop TEE: Prebypass Aortic Valve - aortic homograft in place Severe (4+) aortic regurgitation is seen. The regurgitation is transvalvular.. Tricuspid Valve - severe tricuspid regurgitation, the etiology of the Regurgitation is a dilated annulus. Mitral Valve - bioprosthetic valve in place, with a mean gradient of 4 mmhg and valve area of 2.7 cm2. Right ventricle - severe RV free wall hypokinesis, with RV Dilatation. Left Ventricle - dilated,with hypokinesis of the inferior and inferoseptal walls, the LVEF 40-50%. . [**2117-1-22**] Intraop TEE: This is a limited study with poor windows to monitor patient as his chest is being closed s/p re-do sternotomy. He is on very high doses of pressors (Neo and Levo) and Epi @ 0.02 mcg/kg/min. There is a prosthetic mitral valve with no MR, and a residual mean gradient of 6 mmHg. There is a prosthetic aortic valve with no leak, no AI and a residual mean gradient of 30 mmHg. The RV is not seen well enough to comment on it. Overall LV systolic fxn. Is mildly depressed with an EF of 40 - 45%. The anterior wall moves well, while the inferior wall if akinetic. The tricuspid annuloplasty is not well seen but there appears to be little or no TR. . [**2117-1-27**] Upper Extremity Ultrasound: Nonocclusive thrombus within the right cephalic vein. No thrombus is seen involving the deep veins of the right upper extremity. . [**2117-1-27**] Abd Ultrasound: Normal appearance of the liver, without evidence of biliary obstruction. Gallbladder wall edema, right pleural effusion, and small ascites, all suggesting third spacing. Limited evaluation of midline structures secondary to overlying bowel gas. . [**2117-1-28**] Transthoracic Echo: Overall left ventricular systolic function is severely depressed (LVEF= 20 %). The right ventricle is also severely hypokinetic. A bioprosthetic aortic valve prosthesis is present. A bioprosthetic mitral valve prosthesis is present. Trivial mitral regurgitation is seen. There is no pericardial effusion. . [**2117-1-29**] Barium Swallow: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There is mild penetration of nectar and trace aspiration of thin liquids. There is residue with all consistencies. There is swallowing initiation delay. . [**2117-2-9**] 05:21AM BLOOD WBC-9.8 RBC-2.76* Hgb-8.5* Hct-25.6* MCV-93 MCH-30.9 MCHC-33.3 RDW-17.6* Plt Ct-279 [**2117-2-10**] 06:17AM BLOOD UreaN-16 Creat-1.1 Na-133 K-4.1 Cl-99 [**2117-2-1**] 03:04AM BLOOD ALT-19 AST-42* LD(LDH)-261* AlkPhos-166* Amylase-175* TotBili-1.5 [**2117-1-30**] 01:49AM BLOOD ALT-16 AST-52* AlkPhos-189* Amylase-412* TotBili-2.8* [**2117-1-30**] 01:49AM BLOOD Lipase-660* [**2117-1-13**] 10:30AM BLOOD Triglyc-73 HDL-17 CHOL/HD-4.5 LDLcalc-44 [**2117-1-28**] 12:34PM BLOOD TSH-16* [**2117-1-28**] 12:34PM BLOOD T4-3.4* T3-42* [**2117-1-22**] 09:32AM BLOOD HEPARIN DEPENDENT ANTIBODIES- GRAM STAIN (Final [**2117-1-28**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2117-1-30**]): Commensal Respiratory Flora Absent. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. 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----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S POTASSIUM HYDROXIDE PREPARATION (Final [**2117-1-28**]): TEST CANCELLED, PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). FUNGAL CULTURE (Preliminary): YEAST. Brief Hospital Course: PREOPERATIVE COURSE: Patient was admitted with acute on chronic systolic heart failure with an EF of 35-45%, severe tricuspid regurgitation and severe aortic regurgitation. On admission, he was noted to have recurrent right sided pleural effusion, lower extremity edema, and large volume ascites. He was taken for right-sided thoracentesis by interventional pulmonology during which 1.2L were drained. A catheter was left in place and the following day, 1.4L was drained with improvement in symptoms. He was initially treated with intravenous Lasix, but this was discontinued due to persistently low blood pressures. His ACE-I and Carvedilol were also held intermittently for low blood pressure. Patient also underwent bronchoscopy for evaluation of an enlarging superior mediatinal mass and enlarging left upper lobe pulmonary nodule. Biopsy results were non-diagnostic, and he will eventually need to follow-up with Dr. [**Last Name (STitle) **] from Interventional Pulmonology. Renal function prior to surgery remained stable. Given prior history of HIT, hematology was consulted and cleared patient to receive Heparin and proceed with redo-surgery. OPERATIVE COURSE: On [**1-20**], Dr. [**Last Name (STitle) 914**] performed redo, redo sternotomy (3rd time sternotomy), aortic valve replacment and tricuspid valve repair. Given cardiogenic shock and coagulopathy, an IABP was placed and chest was left open. On [**1-22**], patient returned to the operating room for sternal washout and chest closure. For further surgical details, please see operative notes. POSTOPERATIVE COURSE: CARDIAC: Initially required multiple inotropes and pressors. IABP was gradually weaned and removed without complication on postoperative day three. Inotropes and pressors were weaned by postoperative day five. Maintained on heart failure regimen. Postop pacemaker interrogation showed that pacemaker was functioning appropriately. Patient is pacemaker dependent and the lower rate was decreased from 80 to 70 beats per minute. Underlying rhythm atrial tachycardia and also noted for some episodes of atrial fibrillation during admission, so was started on coumadin for anticoagulation, discharged with 100% Vpaced with plan to return for cardioversion in [**Month (only) 958**] with cardiology. PULMONARY: Prolonged intubation due to cardiogenic shock. Eventually extubated on postoperative six. Required re-intubation on postoperative day eight for aspiration. Diagnostic and therapeutic bronchoscopy was performed, and was re extubated in less than 24 hours. He also required placement of right sided chest tube for recurrent pleural effusion. Approximately 2L of fluid was drained and continued to drain, on [**2-8**] pleurx catheter was placed on right side by interventional pulmonary. He remains stable on room air. RENAL: Initially required aggressive diuresis with intravenous Lasix. Temporarily placed on Diamox for metabolic alkalosis. Creatinine remained stable running between 1.2 to 1.3, continues on oral lasix daily NEURO: Remained neurologically intact. No evidence of stroke. GI: Patient became jaundiced with elevated LFTs, amylase and lipase. RUQ ultrasound showed normal appearance of the liver, without evidence of biliary obstruction. There was evidence of gallbladder wall edema. LFT's, amylase and lipase improved and his abdominal exam remained benign and his jaundice resolved. HEME: Transfused with PRBC to maintain hematocrit near 30%. Platelets dropped as low as 70K on postoperative day two. HIT assay was negative, and platelet count gradually normalized. ID: Persistent leukocytosis, white count peaked to 18K on postoperative day two. Following aspiration episode, he was started on broad spectrum antibiotics. Sputum cultures grew out Klebsiella, and antibiotics were adjusted accordingly. He should remain on Ciprofloxacin until [**2-11**]. NUTRITION: Initial speech and swallow evaluation showed moderate-severe oropharyngeal dysphagia with silent aspiration. He was kept NPO and started on tube feedings. Repeat swallow evaluation on [**2-2**] revealed silent aspiration of liquids but aspiration was prevented with nectar thick liquids and use of chin tuck. He was maintained on aspiration precautions but diet was advanced to nectar thick liquids and moist, ground solids. Swallow therapy was continued for the remainder of his hospital stay. He will continue to require 1 to 1 supervision with meals. On [**2-10**] underwent repeat video swallow and was cleared for thin liquids and regular consistency with chin tuck, plan for follow evaluation in [**Month (only) **]. DISP: Cleared for discharge to home on postoperative day 21. Medications on Admission: Simvastatin 40 mg daily Levothyroxine 100 mcg and 112 mcg daily Amoxicillin 500 mg twice daily Docusate sodium 100 mg twice daily Aspirin 325 mg Daily Lisinopril 2.5 mg Daily Furosemide 20 mg twice daily Trazodone as needed for insomnia Senna as needed for constipation Discharge Medications: 1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 doses. Disp:*3 Tablet(s)* Refills:*0* 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). Disp:*300 ml* Refills:*0* 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily): take 100 and 112 for total of 212 daily . Disp:*30 Capsule(s)* Refills:*0* 7. levothyroxine 112 mcg Capsule Sig: One (1) Capsule PO once a day: take 100 and 112 for total of 212 daily . Disp:*30 Capsule(s)* Refills:*0* 8. warfarin 2 mg Tablet Sig: goal inr 2-2.5 Tablets PO once a day: please take 4 mg [**2-11**] and then lab draw [**2-12**] for further dosing . Disp:*100 Tablet(s)* Refills:*2* 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. simvastatin 40 mg Tablet Sig: 1.5 Tablets PO once a day: 60 mg daily . Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Care [**Location (un) 511**] Discharge Diagnosis: Acute on Chronic Systolic Heart Failure Aortic Insufficiency s/p AVR Tricuspid Regurgitation s/p TV repair Coronary Artery Disease Atrial fibrillation Atrial tachycardia Postop Acute Respiratory Failure secondary to Aspiration Aspiration Pneumonia (Klebsiella Pneumoniae) Mediastinal Lymphadenopathy Pre and Postop Pleural Effusions Postop Elevated LFT's with Elevated Amylase and Lipase Postop Non-occlusive Thrombus of Right Cephalic Vein Acute on Chronic Renal Insufficiency Dyslipidemia Ascites Cerebrovascular Disease, Prior CEA History of Heparin Induced Thrombocytopenia [**2113**] Prior Pacemaker Implantation [**2113**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisions: Sternal - healing well, no erythema or drainage Edema trace bilateral lower extremities 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** Pleurx catheter per interventional pulmonary - please call with any questions or concerns [**0-0-**] Followup Instructions: You are scheduled for the following appointments Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] Phone:[**Telephone/Fax (1) 170**] [**2117-2-16**] 3:30 Cardiologist: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] [**2117-2-17**] 3:00 Pulmonary: Dr. [**Last Name (STitle) **] [**0-0-**] [**2117-3-4**] 11:00 - please go to radiology for chest xray prior to appointment Please call to schedule appointments with your Primary Care [**Last Name (LF) **],[**First Name3 (LF) 41866**] B [**Telephone/Fax (1) 71014**] 3336 in [**4-6**] weeks Speech therapy for for re evaluation - [**Telephone/Fax (1) 3731**] for [**3-5**] 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 atrial fibrillation Goal INR 2.0-2.5 First draw Friday [**2117-2-12**] Completed by:[**2117-2-10**]

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icd9cm

[ [ [] ] ]

[ "39.61", "37.61", "35.22", "34.79", "40.11", "34.91", "34.04", "96.72", "35.33", "96.6", "36.11", "96.71" ]

icd9pcs

[ [ [] ] ]

15275, 15338

8910, 13582

310, 771

16010, 16170

4249, 8842

17113, 18139

3058, 3188

13903, 15252

15359, 15989

13608, 13880

16194, 17090

3203, 4230

8878, 8887

251, 272

799, 2279

2301, 2846

2862, 3042

28,754

174,255

31377

Discharge summary

report

Admission Date: [**2181-1-11**] Discharge Date: [**2181-1-19**] Date of Birth: [**2110-4-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: 1. Ampullary carcinoma. 2. Reducible umbilical hernia. Major Surgical or Invasive Procedure: 1. Pylorus preserving Whipple's pancreaticoduodenectomy. 2. Open cholecystectomy. 3. Umbilical hernia repair (separate procedure). History of Present Illness: This is a 70 year old male with a pyogenic liver abscesses in the setting of cholangitis and an obstructed bile duct during this summer. This is extremely debilitating to Mr. [**Known lastname 73946**], and he still has not fully recovered to normal. Prior to this event, however, he was very stout and hardy healthy man. In the analysis of this problem, he was found to have obstructing common bile duct stones, and he was referred for an ERCP. Dr. [**Last Name (STitle) **] performed that and evacuated stones from his bile duct, and at the same time however, recognized a fungating mass indicative of a large adenoma at the base of his bile duct. Biopsies have been performed on multiple occasions and have identified this as an ampullary adenoma. However, the most recent biopsy suggests that there might be a tiny focus of invasive malignancy at the mucosal level. He has a threatening mass at the base of his bile duct, which is clearly an adenoma of the ampulla. Past Medical History: 1. PAF (only one episode several years ago). s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter and on coumadin. 2. BPH 3. chronic left hydronephrosis (has urologist) 4. h/o DVT/PE s/p MVC in [**2177**] 5. partial hip replacement in [**2172**] as well as treatment for his trauma including a pneumothorax, broken ribs and a concussion. Social History: lives with wife, retired, former smoker Physical Exam: AVSS Gen: NAD HEENT: anicteric, PERRLA. CV: RRR, no M/R/G Pulm: CTA bilat. Abd: significant umbilical hernia, which is easily reducible but quite large. Soft and nontender. There is a drain in the gallbladder, right upper quadrant, with normal appearing bile. Ext: peripheral edema in the lower extremities but this waxes and wanes according to him based on whether he is upright or not. Pertinent Results: [**2181-1-15**] 05:16AM BLOOD WBC-12.6* RBC-2.78* Hgb-8.0* Hct-24.8* MCV-89 MCH-28.7 MCHC-32.1 RDW-16.2* Plt Ct-238 [**2181-1-16**] 05:15AM BLOOD Hct-30.2* [**2181-1-14**] 01:59AM BLOOD Glucose-109* UreaN-20 Creat-0.8 Na-135 K-4.5 Cl-103 HCO3-25 AnGap-12 [**2181-1-15**] 05:16AM BLOOD Glucose-128* UreaN-19 Creat-0.7 Na-139 K-4.0 Cl-104 HCO3-28 AnGap-11 [**2181-1-14**] 01:19PM BLOOD Albumin-2.7* . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2181-1-13**] 11:35 AM IMPRESSION: 1. No pulmonary embolism. No dissection. 2. Right lower lobe and posterior right upper lobe pneumonia which could be secondary to aspiration. 3. Small bilateral pleural effusions without abnormal enhancement. 4. Ascites seen in the left upper quadrant in this patient with recent abdominal surgery. This is incompletely evaluated on this study. . CHEST (PORTABLE AP) [**2181-1-13**] 6:47 AM IMPRESSION: Postoperative findings include intraperitoneal free air, and bibasilar atelectasis, right greater than left. Small right effusion. No discrete pneumothorax. . Cardiology Report ECG Study Date of [**2181-1-13**] 7:53:02 AM Intervals Axes Rate PR QRS QT/QTc P QRS T 109 132 88 304/389 43 12 22 . Brief Hospital Course: Mr. [**Known lastname 73946**] was went to the PACU extubated following his operation; for details please see operative note. The patient recovered in the PACU, and was then sent to the floor for recovery. Neuro: The patient had a PCA for pain control. When appropriate, he was transitioned to PO medications CV: The patient was put on perioperative metoprolol. Pulm: IS was encourage, and the patient was mobilized (OOB to chair, ambulating) when appropriate. On the morning of [**1-13**], the patient had an acute drop in his oxygen saturation, which did not immediately improve with a change of oxygenation from nasal cannula to face tent. An ABG at that time showed poor oxygenation. The patient received nebulized treatments, labs were drawn, and an x-ray was performed as well as a CT to rule out pulmonary embolus. Though there was no pulmonary embolus, the patient had developed a RUL/RLL pneumonia for which he was put on levofloxacin. The patient had chest PT, was put on aspiration precautions, with the head of his bed elevated > 30 degrees. His sputum was also cultured, and the patient was closely monitored. His respiratory status improved, and the patient was able to be transitioned back to nasal cannula oxygen. GI: The patient was made NPO with a NGT. Per the Whipple pathway, the NGT was removed on POD 3. His diet was advanced per the pathway. He was tolerating a regular diet on POD [**8-6**]. He reported +BM prior to discharge. His JP amylase was 38 and the drain was removed the next day. His staples were removed and steri strips applied. GU: The patient's urinary output was closely monitored; he was bolused when appropriate. He was diagnosed with a UTI for which he received levoquin. Heme: The patient's hematocrit was routinely monitored, and he received a blood transfusion when appropriate. He received 2 units of PRBC on POD 4 and his HCT rose from 24.8 to 30.2. Endo: The patient was put on a sliding scale of insulin ID: Sputum cultures were obtained, however were inadequate. The patient was put on levoquin for his RUL/RLL pneumonia as well as his UTI. Proph: The patient received DVT and GI prophylaxis throughout his stay. On discharge, the patient was doing well. He was afebrile with vital signs stable, ambulating, tolerating diet, and voiding appropriately. Medications on Admission: Flomax, Proscar, MVI 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. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*56 Tablet(s)* Refills:*1* 5. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*24 Tablet(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*35 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Diversified VNA and hospice Discharge Diagnosis: Ampullary adenoma Discharge Condition: Good tolerating a 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 vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * No heavy lifting >10lbs for 4-6 weeks. * It is OK to shower and wash, no tub baths or swimming * Please drink plenty of fluids and maintain your hydration. Eat several small, frequent meals throughout the day. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**] Date/Time:[**2181-2-9**] 9:00 You have been put on a medication to control your blood pressure called Metoprolol. Please continue to take this medication. You should follow up with your PCP [**Last Name (NamePattern4) **] [**2-1**] weeks for a blood pressure check and any medication changes. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2181-2-20**] 11:20 Completed by:[**2181-1-19**]

[ "V58.61", "600.00", "230.8", "599.0", "591", "577.1", "401.9", "507.0", "574.10", "553.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "52.7", "51.22", "53.49" ]

icd9pcs

[ [ [] ] ]

6963, 7021

3575, 5892

369, 502

7083, 7129

2373, 3552

8386, 8978

5963, 6940

7042, 7062

5918, 5940

7153, 8363

1964, 2354

274, 331

530, 1506

1528, 1890

1906, 1949

53,549

109,928

38090

Discharge summary

report

Admission Date: [**2152-5-25**] Discharge Date: [**2152-5-30**] Date of Birth: [**2069-11-7**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Evaluate for IPH Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo ambidextrous man with HTN, CAD, CRF who presented to ED from OSH (medflighted for IPH), for evaluation. He lives in TN with his wife. [**Name (NI) **] came to [**Location (un) 86**] yesterday for family reunion. Last night when he slept, he was asymptomatic. When he woke up this am at 7 am or so, he noted that his left UE felt funny. He didnt think it was weak then but felt it was "heavy". He had breakfast at 7.45-8 am. He ate doughnut and had coffee with left hand without any trouble and his wife was with him. Then he went up the stairs and took a shower. After coming from shower, he noted that he was not able to dress especially with the left hand which was "very weak". He kept on fumbling with the buttons of his jeans with the hand. When his wife went to see him, she noted that his left UE was weak, but she did not notice any other weakness, facial asymmetry or any different speech. He did not have any trauma , headache, fevers, or any other symptom. He was taken to OSH, where he was noted to be afebrile, BP 230/120, and noted to have "left UE weakness". He was given labetalol 20 IV followed by drip and underwent CT head which showed 3 cm right parietal bleed. He underwent EKG which did not show any new ST/T changes, CBC was normal, chem 10 showed BUN 42 Cr 2.4 and ca of 10.6. After recieving labetelol, his blood pressure dropped to high 90s. It was stopped and his BP came up again to 130's. In the meantime he recieved ativan 0.5 Iv for unclear reasons. There is no history of seizures or agitation. He was medflighted to [**Hospital1 18**]. Neurology consult was called after arrival. After coming to [**Hospital1 18**] ED, his blood pressure became high at 170/90 and he was started on nicardipine drip. Of note, he has h/o unexplained weight loss of 25 pounds in last 6 months. He was admitted for pna in TN few weeks ago and recieved IV abx. Metoprolol dose was decreased from 50 [**Hospital1 **] to 25 [**Hospital1 **] few weeks ago. other review of systems is negative. Past Medical History: HTN Dyslipidemia CAD s/p stents cognitive decline over last few years Glaucoma CRF ? etiology (likely HTN) BL inguinal hernia s/p prostate operation 20-30 years ago for BPH Social History: Retd. Lives with wife in TN, quit smoking 25 years ago, about 30 pack years before that. Non alcoholic, No drugs. Family History: No strokes but h/o DM and HTN in many members. Physical Exam: Exam: Vitals- 98.6 66 134/66 19 99 Gen: Lying in bed, supine, not in any acute distress HEENT: NCAT, moist mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or 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 Please note that patient was given ativan this am at OSH and hence the examination was difficult as he was becoming drowsy during the examination. Mental status: Awake,cooperative with exam, somewhat drowsy and flat affect. Oriented to person, place, and date. inattentive, unable to say [**Doctor Last Name 1841**] backwards but able to say it forwards. able to say DOW in backward fashion. Speech is fluent with normal comprehension and repetition; naming intact. No Dysarthria noted. He doesnt attend to objects on the left side of page while [**Location (un) 1131**] or while looking at the picture on the stroke card. He missed the kids stealing cookies on the left side of picture. Registers [**2-9**], recalls 0/3 in 5 minutes. No evidence of apraxia. He was somewhat inattentive towards left side. He kept on calling the right arm as his "left arm' even after reminding him. However, he was able to touch right thumb to left ear and was able to identify the fingers. Cranial Nerves: Pupils equally round and slugggishly reactive to light, 4 to 3 mm bilaterally. he has BL cataracts. has left visual field cut. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Face symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Motor: Normal bulk bilaterally. Tone decreased on the left upper extremity. No observed myoclonus or tremor Has pronator drift in left upper arm [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 4- 4 5 4 4 4 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, temparature, vibration and proprioception on the right. He has extinction to DSS in the left arm more so than the left leg. Intact JPS and vibration. He has loss of cortical sensations on the left hand. RAMs are clumsy on left side. Reflexes: Reflexes are +1 on the right and left, except ankle jerks which are absent. Right toe is downgoing, left toe is mute Coordination: finger-nose-finger normal on right, difficult to test on left, KHS test normal. Gait: deferred Pertinent Results: [**2152-5-29**] 06:21PM BLOOD WBC-7.9 RBC-4.17* Hgb-11.8* Hct-35.1* MCV-84 MCH-28.3 MCHC-33.7 RDW-15.5 Plt Ct-269# [**2152-5-29**] 06:55AM BLOOD WBC-7.0 RBC-3.90* Hgb-10.9* Hct-32.3* MCV-83 MCH-27.9 MCHC-33.6 RDW-15.5 Plt Ct-163 [**2152-5-29**] 06:21PM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1 [**2152-5-29**] 06:21PM BLOOD Plt Ct-269# [**2152-5-29**] 06:21PM BLOOD Glucose-114* UreaN-54* Creat-2.7* Na-137 K-5.1 Cl-103 HCO3-24 AnGap-15 [**2152-5-29**] 06:55AM BLOOD Glucose-105* UreaN-45* Creat-2.6* Na-138 K-4.0 Cl-107 HCO3-19* AnGap-16 [**2152-5-28**] 04:02AM BLOOD Glucose-105* UreaN-41* Creat-2.5* Na-144 K-3.8 Cl-111* HCO3-24 AnGap-13 [**2152-5-27**] 02:50AM BLOOD Glucose-110* UreaN-39* Creat-2.3* Na-143 K-4.4 Cl-108 HCO3-22 AnGap-17 [**2152-5-25**] 11:40AM BLOOD cTropnT-0.03* [**2152-5-26**] 01:04AM BLOOD CK-MB-3 cTropnT-<0.01 [**2152-5-26**] 01:04AM BLOOD PEP-NO SPECIFI Imaging: CT [**5-25**]: Overall, this examination is unchanged. A 2.7 x 2.0 right parietal intracerebral hemorrhage is stable. There is surrounding edema as well as some extension of hemorrhage through the cortex into the subarachnoid space (2:21). No new hemorrhage is identified. No midline shift or evidence of herniation is seen. There is prominence of the ventricles and sulci, reflecting generalized atrophy, age related. Lacunes are seen in the bilateral caudates. No concerning osseous lesion is seen. The visualized paranasal sinuses are clear. No evidence of mass effect is seen. IMPRESSION: Overall unchanged examination with right parietal ICH, surrounding edema and subarachnoid extension. No midline shift. MRI/A: As seen on the recent CT there is an approximately 2.9 x 2.1 cm acute to subacute right parietal hematoma with surrounding vasogenic edema. There is no shift of normally midline structures. There is minimal mass effect on the occipital [**Doctor Last Name 534**] of the right lateral ventricle. There are no other areas of susceptibility artifact apart from a small focus within the left middle cerebellar peduncle. There is no definite evidence of acute infarct. There is a focus of high signal on diffusion-weighted images in the periventricular white matter of the right frontal lobe which appears to correspond to a focus of FLAIR signal hyperintensity and may be related to T2 shine-through as it is not resolvable on the ADC map. Otherwise there is no evidence of acute infarct. The ventricles and sulci are prominent likely related to age-related involutional change. The major intracranial flow voids appear maintained. MRA OF THE BRAIN: There is no abnormal vascular structure in the area of the hemorrhage. There is hypoplasia of the A1 segment of the right anterior cerebral artery, normal variant. The posterior cerebral arteries bilaterally are somewhat attenuated which may be related to atherosclerosis but there is no evidence of flow-limiting stenosis, occlusion, or aneurysm in the vessels of the anterior or posterior circulation. IMPRESSION: 1. No findings on the MRI or MRA to suggest underlying vascular malformation in the area of the right parietal hematoma. 2. Punctate focus of susceptibility artifact in the left middle cerebellar peduncle is non-specific and could be a calcification, microhemorrhage or cavernoma. CT [**5-26**]: There is a 2.7 x 1.8-cm right parietal intracerebral hemorrhage, stable from prior exam with similar perilesional edema. There is no significant midline shift. Minor subarachnoid extension exists. There is no new intraparenchymal hemorrhage. Prominence of ventricles and sulci relate to age-related atrophy. Lacunes are redemonstrated on the right. Mastoid air cells are clear. Visualized paranasal sinuses are unremarkable. IMPRESSION: Stable appearance to right parietal intracerebral hemorrhage. No midline shift. EEG: This telemetry captured no pushbutton activations; however, it captured frequent sharp activity in the right parasagittal area which sometimes became more rhythmic and evolving suggestive of electrographic seizures without clear clinical correlate. The background activity was also slower in the right parasagittal area suggestive of subcortical dysfunction in the region. Brief Hospital Course: Mr. [**Known lastname **] was admitted to neurology ICU service for evaluation of IPH. He was closely monitered in unit and was transfered to neurology floor after initial stabilisation. Neuro He was closely monitered with neuro checks initially Q1h. Signs of new deficits as well as that of raised ICP such as headache, vomiting, visual blurring were monitered and he did not have any of those. Antiplatelets and heparin SC was avoided given IPH. He was put on comtinuous LTM EEG for 2 days given history of IPH, however he did not have any clinical seizures but had few discharges on EEG in the area on right parasaggital region c/w IPH location. He underwent repeat CT scan after 24 hrs which did not show any evidence of edema or increasing bleed or new bleed. he underwent MRI to evaluate for any underlying mass or other areas of bleed which was negative for the above. The mechanism of bleed was thought to be HTN or amyloid. Cards He was closely monitered on telemetry. He was ruled out for cardiac ischemia by EKG and cardiac enzymes. Heart healthy diet was given. Renal Creatinine was closely watched. I/O was monitered. nephrotoxic agents and dyes were avoided. SPEP and UPEP were done to evaluate for myeloma which was negative Endo close watch over blood sugars was kept and he was on RISS. FEN- Nutrition He was closely monitered and underwent swallow test.. Rehab he was seen by OT/PT who felt that the patient needed rehab. Medications on Admission: Clonidine 0.1 [**Hospital1 **] Metoprolol 25 [**Hospital1 **] Travast eye drops aspirin 81 /day Fish oil MVI Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Right parietal bleed Discharge Condition: awake, alert, follows commands (1 and 2 steps), able to say days of week backward, oriented to person, place, year, but not month, day, spatial memory intact, mild naming difficulty to low frequency objects, comprehension and repition intact, calculation intact, attends to both side CN: EOMI, visual fields appear full, occ inattentive on left, but no extinction to DSS, tongue midline, face symmetric Motor: slight left sided drift, weakness ([**3-13**])at the left delt/tricep/ finger extensors, strong at biceps, full at RUE, full at legs [**Last Name (un) **]: reports slight decreased to light touch and pinprick, astereognosis and agraphasthesia on the left hand Discharge Instructions: You were admitted with the onset of left upper extremity weakness. You were brought to an outside hospital where an image of your head was performed and you were noted to have a bleed in your brain a small area in the right side called the parietal lobe. You were medflighted to [**Hospital1 18**] for further evaluation. Here you were admitted to the neuro ICU for blood pressure controll and frequent monitoring. You did well and were transferred out to the floor for further monitoring. You were seen by physical therapy who recommended rehab. Your medications were changed as follows: You clonidine was increase to 0.2 TID You were started on amlodipine 10mg daily Your aspirin was stopped Please take all medications as prescribed. Please make all follow up appointments. If you have any new weakness or any of the symptoms listed below please call your doctor or return to the nearest emergency room. Followup Instructions: Patient lives in [**Location **], he will need to follow up with his primary care provider when he gets released from rehab and be set up with a neurologist in his home area. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "272.4", "293.0", "403.90", "783.21", "431", "277.39", "585.9", "V45.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12005, 12052

9558, 11006

334, 340

12117, 12789

5361, 9535

13753, 14042

2732, 2781

11166, 11982

12073, 12096

11032, 11143

12813, 13730

2796, 3307

277, 296

368, 2386

4154, 5342

3322, 4138

2408, 2584

2600, 2716

26,838

168,774

31099

Discharge summary

report

Admission Date: [**2195-7-7**] Discharge Date: [**2195-7-9**] Date of Birth: [**2114-10-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: UGIB, Acute leukemia Major Surgical or Invasive Procedure: leukophareisis CVVH History of Present Illness: 80 yo M with cutis leukemia presents with UGIB. Pt had 1 episode of hematemasis and melana on day of presentation. He was c/o feeling more fatigued, unable to do ADLs due to fatigue, feeling "really sick", "wiped out", feeling very dizzy and light headed. He was having difficulty walking, problems with his balance and gait instability. He denied any fevers/chills but has had sweats. No sick contacts or recent travelling. On morning of admission pt had an acute episode of brown emesis without any nausea. 2 days PTA pt noticed black stools, no frank blood in stools or urine and no episodes of hematemesis. His weight has been steady. He denies any back pain, + HA but no visual changes, no floaters or blurry vision. He presented to an OSH due to increasing lethargy, fatigue and episode of coffee ground emesis and melena. . OSH Course: ?. no records sent from ED to [**Hospital Unit Name 153**]. . ED Course: Initial VS: 97.0 BP 109/65 HR 74 18; NGL grossly positive with ~250cc bright red blood, protonix 40 IV x1, GI aware. Heme Onc C/S. Pt remained HD stable in ED. Admitted to ICU for further monitoring. Past Medical History: . PastOncHx #MDS/Myeloproliferative Disease - He noticed a LLE rash in early [**Month (only) 116**]. He went to his PCP and had an US which was negative for DVT. He was given a tetanus shot and started on Keflex. The rash did not improve. He underwent a skin biopsy on [**5-15**] with the final dx of "atypical dermal mononuclear infiltrate with monocytic features - findings c/w leukemia cutis". He was seen by Dr. [**First Name (STitle) **] in Oncology at [**Location (un) 73424**] Cancer Center. Per report -CBC on [**5-14**] -WBC 9800 51N 28Bands 18Mono. H/H 11.8/35. PLT [**Numeric Identifier 73425**]. He had a bone marrow bx on [**6-16**] which was notable for Markedly hypercellular marrow with orderly maturation, mild dysmegakaryopoiesis and slightly decreased iron stores. No blasts noted. Aspirate had <1% ringed sideroblasts. Flow - nl study - no increased blasts. No clonal abnormalities. Negative JAK2 mutation. WBC on [**6-16**] was 11. #Prostate cancer s/p Turp and Lupron x 1 yr (last [**10-26**]) . -Sarcoid [**2144**] -Endocarditis [**2182**] -S/P CABG - 2 vessel/AVR -S/P L THR -S/P herniorrhaphy -S/P cataract surgery Social History: -He is married and lives with his wife. [**Name (NI) 73426**] [**Name2 (NI) **] II Veteran, ?toxin exposure during war, unclear about occupational exposures -He chews [**1-24**] cigars/day x60 years, +ETOH 4-5oz whiskey per day, however no ETOH in few weeks. Family History: -no known CA in family, no bleeding d/o Physical Exam: on admission: VS: 98.9 BP 126/74 HR 70 RR 19 96% 4LNC GEN: Comfortably lying in bed in NAD HEENT:MMM, OP clear-no mucositis, no oral lesions, no cervical LAD, R eye w/echymosis over lid-no orbital edema or conjunctival bleed RESP: CTABL, no crackles, no wheezing CV: Reg Nml S1, S2, no M/R/G, Sternotomy scar well healed ABD: Soft ND/NT +BS EXT/skin: LLE swollen, non-pitting edema, large 3x3cm raised violacious mass on lower LLE shin, large raised papules/indurated on posterior knee, thigh and inguinal area on L side, diffuse indurated papules ~.5mm x1cm lesions on chest, abdomen, legs and back NEURO: A&O x3, no focal deficits Brief Hospital Course: 1. AML with monocytic differentiation: - Heme onc followed patient. Patient received Leukophoresis, and Hydroxyurea with WBC decreasing from 170 initially to 51 thousand. . 2. UGIB: gastric ulcer vs. cutis leukemia infiltration, PLT wnl although appear to be non functional. serial Hct q2-4hr were drawn. GI following was following patient. Patient was given protone pump inhibitor. . 3. ARF: It remained unclear what patients baseline was, however creatinine worsening 4.2 to 5 probably due to tumor lysis syndrome. Renal consult followed patient, and CVVH was initiated to balance electrolyte dearrangement secondary to tumor lysis syndrome. CVVH was discontinued after a discussion with patients wife regarding patients own wishes and thoughts about comfort meassures vs. aggressive managment. Ms. [**Known lastname **] clearly stated that comfort has priority and aggressive managment in the setting of poor prognosis would have not been patients wishes. . 4. Hematuria: Foley catheter was changed urology team, with continues bladder irrigations. Patient had signs of urethral obstruction . Given multi-organ system dysfunction, severe alteration of patients mental status and progression of dysfunction extensive discussions were conducted wtih patient's wife. She expressed that patient would not want continued aggressive measures in the absence of meaningful chance of return to pre-morbid baseline function. This was shared with the patient's primary oncology team and decision was made to maintain patient comfort as the primary goal of care in the setting of progressive respiratory decline and likely ongoing aspiration in the setting of imparied mental status. Patient died in respiratory failure in the morning of [**2195-7-9**] Medications on Admission: -ASA 81 mg daily -Atenolol 25 mg daily -Tricor 145 mg daily -Calcium/Vitamin D -MVI -Omega3 Discharge Disposition: Expired Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: .

[ "205.00", "V43.64", "286.6", "788.20", "585.9", "599.7", "V10.46", "135", "578.9", "V45.81", "584.9" ]

icd9cm

[ [ [] ] ]

[ "57.32", "99.05", "38.93", "39.95", "99.04", "99.07", "99.72" ]

icd9pcs

[ [ [] ] ]

5564, 5573

3672, 5422

336, 357

5619, 5622

5672, 5676

2959, 3000

5594, 5598

5448, 5541

5646, 5649

3015, 3015

275, 298

385, 1504

3029, 3649

1526, 2667

2683, 2943

74,727

158,815

42530

Discharge summary

report

Admission Date: [**2188-12-17**] Discharge Date: [**2189-1-3**] Date of Birth: [**2112-6-27**] Sex: F Service: SURGERY Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4691**] Chief Complaint: Polytrauma Major Surgical or Invasive Procedure: Left chest tube placement [**2188-12-17**] Tracheostomy and [**Month/Day/Year 282**] [**2188-12-21**] EGD [**2188-12-26**] History of Present Illness: 76F s/p MVC vs tree transferred from OSH. A&O upon arrival to OSH, reported she lost consciousness for unknown period of time and hit a tree. Intubated prior to transfer for declining mental status. Panscanned, L CT placed for L pnx. L pigtail also placed for non-re-expansion. Patient became hypotensive, started on 10 of Dopamine, given 2L of crystalloids. Digoxin level 3.1 at OSH. Transferred to [**Hospital1 18**], received 2 additional L of crystalloids with good response, Dopamine down to 5 in the ED. Transferred to TSICU. Past Medical History: COPD, afib, hypothyroidism, PVD, obstructive bronchitis, cardiomyopathy, CHF, ETOH abuse, MRSA cellulitis of L foot, tracheostomy, hysterectomy Social History: Main family contact is son. Unclear tobacco use, with possible alcohol consumption. Denies illicit drugs. Family History: NC Physical Exam: Day made CMO: Gen: Appears cachectic, bruised all over thorax and LE CV: Irregular Resp: CTAB, diminished at bases Abd: Soft, nontender, [**Last Name (LF) 19973**], [**First Name3 (LF) 282**] site clean and dry Ext: Groin laceration weeping serous fluid but without signs of infection. Multiple sites of skin denudation and chronic venous stasis ulcers with no signs of infection Pertinent Results: [**2188-12-17**] 04:39PM BLOOD Digoxin-4.3* [**2188-12-18**] 09:04AM BLOOD Cortsol-16.4 [**2188-12-17**] 04:39PM BLOOD WBC-19.3* RBC-3.70* Hgb-10.7* Hct-32.7* MCV-88 MCH-29.0 MCHC-32.8 RDW-16.3* Plt Ct-104* [**2188-12-17**] 09:17PM BLOOD Glucose-179* UreaN-15 Creat-1.1 Na-136 K-3.1* Cl-106 HCO3-21* AnGap-12 CT chest/abdomen/pelvis: 1. Moderate-sized pneumothorax, mild rightward displacement of the mediastinum. Left thoracostomy tube within the upper pleural space with contusion in the left upper lobe and moderate left pleural effusion. 2. Multiple left rib fractures and sternal fracture. 4. Moderate-to-severe emphysema. An 8-mm left upper lobe nodule warrants evaluation in six months with a chest CT following resolution of acute symptoms or evaluation with PET-CT should be considered with attention in follow-up to mildly prominent central mediastinal nodes. 5. Extensive right basilar opacity with volume loss including mucus plugging, suggesting extensive atelectasis versus aspiration or pneumonia. 6. Severe atherosclerotic calcifications of the coronary vessels and aorta. 2.4-cm infrarenal abdominal aortic ectasia. 3-cm left iliac arterial aneurysm. No evidence of rupture. Follow-up CT imaging is recommended within six months for surveillance. 7. Endotracheal tube terminating at the distal trachea. Orogastric tube terminating within the stomach. 8. 19 x 14-mm non-obstructing right renal pelvis stone. Likely tiny left hemorrhagic renal cyst. CT Cspine: 1. Nondisplaced fractures of the left T2 and T3 transverse processes. There is a small hematoma within the left supraclavicular fossa and along the base of the posterolateral left neck. 2. Acute left clavicle fracture. 3. Trace left pneumothorax. 4. Emphysema. XR R knee: No definite fracture. If there is continued concern, given the history of trauma, recommend CT. L Foot: There is generalized osteopenia of the visualized bony elements. However, no evidence of gas in soft tissues or bone destruction. There is a moderate inferior calcaneal spur. L Hand: 1. Intra-articular fracture of the long finger proximal phalanx. 2. Degenerative changes. MR [**Name13 (STitle) 430**]: 1. Study limited due to motion-related artifacts. Within this limitation, there is no obvious focus of slow diffusion to suggest an acute infarct. No mass effect. 2. Moderate dilation of the lateral and the third ventricles, as described above, which may relate to volume loss or communicating hydrocephalus such as NPH. Correlate clinically. 3. Diffuse mucosal thickening and fluid in the mastoid air cells, moderate amount of fluid in the sphenoid sinus and mild-to-moderate mucosal thickening in the ethmoid air cells. 4. Diffuse hypointense signal of the marrow is noted related to anaemia, myeloproliferative or infiltrative disorders. Correlate with hematology labs. Echo: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size is normal. with normal free wall contractility. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Renal US: 1. No hydronephrosis bilaterally. Subcentimeter non-obstructive right renal calculus. Limited Doppler images show normal arterial and venous flow at the renal hilae bilaterally. 2. Heterogenous area within the right lobe of liver concerning for a mass but incidentally noted and only partially imaged. Dedicated ultrasound imaging of the liver is recommended. 3. Increase in amount of intraabdominal ascites. 4. Apparent fluid distended bladder may represent a pocket of ascitic fluid given reported presence of Foley catheter. Brief Hospital Course: Ms. [**Known lastname 92039**] work up in the ED revealed the following injuries: - L clavicle fracture - L ribs [**1-10**] fracture with associated pneumothorax s/p chest tube and pigtail placement - Sternal fracture - T2-T4 L transverse process fractures She was transferred to the TSICU for further management. Her course is below by system: Neuro: Patient's CT evaluations revealed no head or spinous trauma. Her c-collar was kept on until cleared by neurosurgery. She was taken off log roll. She was neurologically intact while intubated, though sedated on propofol and fentanyl. Given her prior possible history of ethanol abuse, she was monitored with a CIWA scale. Her sedation was weaned as her pain improved, however she was lethargic and minimally responsive. Neurology was consulted and an MRI was performed which ruled out stroke. Neurology felt her mental status was a result of her global trauma state. She gradually improved and was intermittently aware and interative, though resigned mostly. CV: On admission, patient was found to have a supratherapeutic digoxin level. She received digibind on HD1 and was seen by the cardiology team. Echo was performed with preserved EF and hypokinesis of the left ventricular wall inferomedially. She required pressor support despite fluid resuscitation and blood transfusion, prompting adrenal cortical evaluation. Cortisol was relatively low for her stressed state and she was started on hydrocortisone, allowing a small wean in her pressor requirement. With antibiotic therapy for sepsis from MSSA pneumonia, patient's pressors were weaned off. Her bradycardia improved and she was taken off dopamine. Cardiology was consulted for possible pacer, however, given her fragile state and high risk for infection and skin breakdown, it was not recommended. Repeat echo on [**2188-12-24**] showed normal cardiac function with no valvular disease. Patient had almost daily episodes of bradycardia with hypotension and lethargy requiring atropine to recover. After a long discussion with the family, the decision was made not to escalate care and to only provide a maximum of 2 mg of atropine for symptomatic bradycardia and the patient was made DNR. Resp: Patient was intubated prior to arrival in our ED. A large air leak was noted in her chest tube, presumably from parenchymal injury to the lung. Chest tube was kept on suction until air leak diminished and then changed to waterseal. Pigtail was removed on [**2188-12-24**]. Significant consolidation of the RLL was noted on CXR and CT. Bronchoscopy showed thin bloody secretions consistent with pulmonary contusion. BAL was initially negative for pneumonia, however repeat bronchoscopy showed purulent secretions in the RLL which grew MSSA. Patient was treated with a complete course of cipro and vanc. Her left chest tube was removed on [**2188-12-30**] after a clamp trial with xray showing no pneumothorax. Patient was difficult to wean from the ventilator. Tracheostomy was performed on [**2188-12-11**]. Pressure support weans were attempted daily with some improvement. Diuresis was attempted with minimal improvement. Patient would develop severe respiratory acidosis as pressure sipport was weaned. Patient was gradually weaned down to CPAP but required being turned back to CMV with each bradycardic episode. GI: Patient was kept NPO initially due to abdominal distension. Bladder pressures were normal. Once distension resolved, she was started on tube feeds which she tolerated well. Patient was noted to have melena on [**2187-12-24**], though her Hct was stable. EGD showed mild gastritis and she was kept on [**Hospital1 **] protonix. Her melena resolved thereafter. GU: Urine output was low to normal during initial post-trauma period. Cr began to rise and peaked at 1.7. UA was positive and patient was started on cipro on HD1, however cultures were ultimately negative. Patient has persistent anion gap metabolic acidosis with acute kidney injury. Renal was consulted with recommendations for presumed renal tubular acidosis, treated with bicarb. Her creatitine gradually improved. Heme: Patient received 2U PRBC for persistent hypotension and Hct of 23 post-injury. She was tranfused intermittently when Hct was below 22. Once Hct was stable, she was started on Heparin SC for DVT prophylaxis. ID: Patient was noted to have a UTI upon admission and was started on cipro. With persistent hypotension, no evidence of cardiac dysfunction, and possible RLL pneumonia, coverage was expanded to include vanco and cefepime. She was treated for a complete course as above. Endo: Patient was treated with stress steroids for persistent hypotension and relative adrenal insufficiency, which were gradually weaned off. She was kept on an insulin sliding scale. MSK: Patient's clavicle, sternal, and rib fractures were treated nonoperatively. After multiple family meetings about the patient's prognosis, the family chose to make the patient "Comfort measures only" given her fragile condition, lack of options for long term treatment of her bradycardia, and persistent respiratory failure. She was extubated on [**2189-1-3**] and expired shortly thereafter. Medications on Admission: Digoxin 0.125mg daily, furosemide 40mg [**Hospital1 **], and levothyroxine 50mcg daily. Discharge Medications: NA Discharge Disposition: Extended Care Discharge Diagnosis: Polytrauma - L clavicle fracture - L ribs [**1-10**] fracture with associated pneumothorax s/p chest tube and pigtail placement - Sternal fracture - T2-T4 L transverse process fractures - Symptomatic bradycardia - Respiratory failure Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: NA Completed by:[**2189-1-3**]

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icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "33.22", "38.97", "45.13", "31.1", "96.6", "86.28", "43.11" ]

icd9pcs

[ [ [] ] ]

11136, 11151

5786, 10971

301, 426

11429, 11439

1712, 5763

11490, 11522

1293, 1297

11109, 11113

11172, 11408

10997, 11086

11463, 11467

1312, 1693

251, 263

454, 987

1009, 1154

1170, 1277

51,914

128,777

783

Discharge summary

report

Admission Date: [**2132-3-11**] Discharge Date: [**2132-4-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5608**] Chief Complaint: abnormal CXR, anemia Major Surgical or Invasive Procedure: intubation central line placement bronchoscopy arterial line placement History of Present Illness: The patient is an 84M with prostate CA, CAD, HTN who presents with 2 weeks dry cough. He saw his hematologist who ordered a CXR for the cough, and it showed extensive heterogenous opacification in the right lung. Because of these abnormal findings, his PCP told him to come to the ED for evaluation. He has had the intermittent dry cough for about two weeks but has not had fevers, chills, weight loss, change in appetite, shortness of breath, nausea, vomiting, diarrhea. He has noticed some fatigue, as he used to walk two miles a day until the cough started, but notes he is limited by fatigue, not DOE. No other symptoms. In the ED he was noted to have a dropping Hct (25.4, down from 29.6 the previous day). He has not noted blood in his stool or had any lightheadedness. He was guaiac negative. He was being worked up for anemia and was not found to have evidence of iron, folate or B12 deficiency in [**2-4**]. SPEP was also normal. After discussion with his PCP by the [**Name9 (PRE) **], he is being admitted for expedited workup of CXR findings and anemia. Pulmonology was consulted in the ED. ROS: -Constitutional: []WNL []Weight loss [x]Fatigue/Malaise []Fever []Chills/Rigors []Nightsweats []Anorexia -Eyes: [x]WNL []Blurry Vision []Diplopia []Loss of Vision []Photophobia -ENT: []WNL [x]Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: [x]WNL []Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: []WNL []SOB []Pleuritic pain []Hemoptysis [x]Cough -Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain []Abdominal Swelling []Diarrhea []Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy -GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria []Discharge []Menorrhagia -Skin: [x]WNL []Rash []Pruritus -Endocrine: [x]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain -Neurological: []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache -Psychiatric: [x]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [x] WNL []Seasonal Allergies Past Medical History: prostate cancer diagnosed [**2130**], getting treated with hormonal therapy, followed by Dr. [**Last Name (STitle) 365**] CAD, s/p CABG [**2112**] dyslipidemia HTN NSVT, SSS s/p ICD/PM severe left ventricular dysfunction (EF 20% in [**2-3**]) Social History: He lives in [**Hospital3 **] with his wife. [**Name (NI) **] has a son who has had multiple bypass surgeries and significant cardiac disease. He had a daughter who passed away from cancer. He has no smoking history. Reports drinking alcohol, drinking one glass of alcohol every night prior to dinner. He is retired. Family History: Son w/ multiple CABGs daughter w/ cancer Physical Exam: Physical Exam: Appearance: NAD Vitals: T: 96.4 BP: 124/59 HR: 71 RR: 20 O2: 100% 2L Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no exudate ENT: Moist Neck: No JVD, no LAD, no thyromegaly, no carotid bruits Cardiovascular: RRR, nl S1/S2, no m/r/g Respiratory: exam limited by coughing, poor air movement, diffusely wheezy Gastrointestinal: soft, non-tender, non-distended, no hepatosplenomegaly, normal bowel sounds Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint swelling, no edema in the bilateral extremities Neurological: Alert and oriented x3, fluent speech, no pronator drift, no asterixis, sensation WNL, CNII-XII intact, strength [**4-1**] in upper and lower extremities bilaterally Integument: warm, no rash, no ulcer Psychiatric: appropriate, pleasant Hematological/Lymphatic: No cervical lymphadenopathy Pertinent Results: [**2132-3-11**] 11:15AM GLUCOSE-116* UREA N-23* CREAT-1.1 SODIUM-133 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-26 ANION GAP-13 [**2132-3-11**] 11:15AM CK(CPK)-117 [**2132-3-11**] 11:15AM CK-MB-4 [**2132-3-11**] 11:30AM cTropnT-0.01 [**2132-3-11**] 11:15AM WBC-7.9 RBC-2.85* HGB-8.5* HCT-25.4* MCV-89 MCH-29.9 MCHC-33.6 RDW-13.9 [**2132-3-11**] 11:15AM PLT COUNT-274 [**2132-3-10**] 10:10AM LD(LDH)-259* TOT BILI-0.5 DIR BILI-0.2 INDIR BIL-0.3 [**2132-3-10**] 10:10AM HAPTOGLOB-492* [**2132-3-10**] 10:10AM IgG-1510 IgA-278 IgM-58 [**2132-3-10**] 10:10AM RET AUT-1.3 [**2132-3-10**] 09:45AM WBC-7.9 RBC-3.34* HGB-10.0* HCT-29.6* MCV-89 MCH-29.9 MCHC-33.7 RDW-14.2 [**2132-3-10**] 09:45AM NEUTS-74.5* LYMPHS-11.7* MONOS-4.7 EOS-9.0* BASOS-0.2 [**2132-3-10**] 09:45AM PLT COUNT-266# [**2132-3-11**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2132-3-11**] 03:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2132-3-11**] 03:30PM URINE RBC-0-2 WBC-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**3-10**] PA AND LATERAL CHEST RADIOGRAPH: Multiple midline sternotomy wires are unchanged in position. Small surgical clips are seen along the left cardiac border, compatible with prior CABG. The two-chamber pacemaker with ICD is seen with leads in the right ventricle and right atrium, unchanged. There is mild cardiomegaly. The mediastinal and hilar contours are unchanged. Pulmonary vasculature is unremarkable. There is no pneumothorax or large pleural effusion. New, extensive, heterogeneous opacification is seen predominately in the right lung, with peripheral consolidation and lesser degree of central opacification. Right- sided volume loss suggests a chronic process. Left basilar opacities are compatible with atelectasis, and the left lung is otherwise clear. IMPRESSION: Compared to [**2124**] study, new extensive heterogeneous opacification in the right lung with peripheral consolidation and lesser degree of central opacification. Loss of right lung volume suggests a subacute process. Differential is broad, including pneumonia, postinfectious and cryptogenic organizing pneumonia, multifocal bronchioloalveolar cell carcinoma, chronic eosinophilic pneumonia, Churg- [**Doctor Last Name 3532**] vasculitis, amiodarone toxicity. [**3-11**] CXR: No interval change over one day in appearance of diffuse airspace opacity involving the right hemithorax. Additional opacity seen in the left base, also unchanged. Original differential diagnosis stands and multifocal pneumonia cannot be excluded. CT CHEST: FINDINGS The patient is intubated. Pooling of secretions are above the cuff of the endotracheal tube. Small layering bilateral non-hemorrhagic pleural effusions are increased on the right and new on the left. Diffuse extensive areas of ground-glass opacity, peribronchial consolidation, and bronchiectasis have worsened in the left lung, minimally improved in the right upper lobe. Right central catheter tip is in the mid SVC. Transvenous pacemaker lead terminates in a standard position. NG tube tip is out of view below the diaphragm. Dense calcifications are in the native coronary arteries. There is mild-to-moderate cardiomegaly. The cardiac [**Doctor Last Name 1754**] are hypodense. This suggests anemia. Calcification in the aortic valve is of unknown hemodynamic significance. AP window and prevascular lymph nodes have increased in size; for instance, to 8 mm from 5 mm and to 5 mm from 3 mm respectively. This examination is not tailored for subdiaphragmatic evaluation, and the upper abdomen is unremarkable. There are no bone findings of malignancy. In the abdomen, previously described renal lesion is not included in this examination. IMPRESSION: Worsening of pre-existing opacity in the left lung and slight improvement of the abnormalities in the right upper lobe The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe regional left ventricular systolic dysfunction with akinesis of the anterior septum, anterior wall and apex. There is mild hypokinesis of the inferior septum and inferior wall. There is an anteroapical left ventricular aneurysm. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: severe regional LV systolic dysfunction consistent with multi-vessel CAD. No significant valvular abnormality seen. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2131-2-1**], LV systolic dysfunction appears regional on the current study (as it did on study of [**2130-2-21**]). Estimated pulmonary artery systolic pressures are higher on the current study Brief Hospital Course: Mr. [**Known lastname 5609**] is an 85 yo M with CAD s/p CABG/ICD,CHF ef20% prostate ca who presents with dry cough found to have diffuse right sided patchy peripheral opacities on cxr, transferred to the ICU for hypoxia. He had a [**Hospital 5610**] hospital course and was intubated with persistant hypoxic resp failure. Etiology was unclear with concern for eosinophilic pneumonia, HAP, pulm edema. Due to progressive decline and poor prognosis, family decided to make him comfort measures only and patient passed away on [**2132-4-2**] 17:10. Hospital Course by problem: . #Hypoxic Resp Failure: Over his [**Hospital 5610**] hospital course, he had continued decline of respiratory status of unclear etiology. Initial bronchoscopy revealed high eosinophilia and he was felt to have eosinophilic pneumonia and treated with a course of steroids although he did not have a dramatic improvement in his resp status. Shortly after this, he was transferred to the ICU for worsening hypoxia and intubated. Repeat CT chests showed worsening progression of disease adn well as new infiltrates concerning for infectious etiology. Initially, it was also felt there was a component of pulm edema and he was aggressively diuresed. At this point, after meeting w/ family and CT Surgery, it was felt that VATS was not an option given his tenuous status. Repeat bronch on [**3-28**] was w/o infectious results. Sputum culture ultimately with sparse orpharyngeal flora. Galactomannan, Tularemia, Strongyloides, and IgE were unremarkable. He was treated with broad coverage antibiotics with no improvement in resp status and further worsening of disease. Finally, it was decided by family, given his additional decline of other organ systems, to withdraw care. # ? VAP pneumonia - s/p bronch, infectious studies with no obvious source. No microorganisms on gram stain from BAL. Sputum culture ultimately with sparse orpharyngeal flora. On CT, infiltrate had the appearance of progressive underlying process rather than new consolidation. Fever and infiltrate on CXR may not really have been VAP but rather part of underlying lung disease. # Diffuse right peripheral infiltrates - BAL 30% eosinophils, also with peripheral eosinophilia most likely [**12-31**] acute eosinophilic pneumonia. PCP negative, respiratory viral antigens neg, BAl neg for bacterial pathogens. Legionella neg. Per pulmonary consult, he may have "eosinophilic process secondary to malignancy or something like a non-steroid responsive BOOP". Beta-glucan and galactomannan negative; mycolytic blood culture negative. Histo negative. Chest CT worse. # Fever: During his hospital course, he intermittently had high fevers with no clear infectious etiology isolated. Blood, urine, sputum, BAL, stool all negative. CT sinuese negative. CVL were changed. # ARF: He had waxing and [**Doctor Last Name 688**] course, but towards end of hospital stay, his creatinine was rapidly rising. Urine sediment revealed muddy brown casts c/w ATN. # LUE DVT - increased welling L>R, confirmed on U/S [**3-27**] to involve axillary and probably brachial veins. Heparin gtt was started. # Anemia: he was noted to have anemia since [**2-4**], slowly trending down but without any acute drops and no evidence of bleeding. He has been followed by [**Known firstname 449**] [**Last Name (NamePattern1) 410**]/[**First Name8 (NamePattern2) **] [**Doctor Last Name **] of hematology. Work up thus far is negative for iron/folate/B12 deficient. Thought possibly from hormone therapy for prostate CA. No evidence of hemolysis on admission. Bone marrow biopsy showed anemia of chronic dz, maybe MDS. Transfused 1unit [**2-24**] with good response. Found to have warm autoimmune ab. # Warm autoimmune Ab: previously no evidence of hemolysis with elevated haptoglobin. Hapto/LDH not suggestive of hemolysis. # VT/ NSVT, SSS, s/p PM/ICD: has had runs of VT; likely in setting of intubation. Had 2 further episodes of SVT [**3-26**], ECG w/ new T-wave changes but CEs negative x3. EP was aware and felt this was most likely related to intubation. # CAD s/p MI/CABG: no evidence of acute ischmia on arrival to ICU, chest pain free. EKG with LBBB at baseline, no change. [**3-27**] ECG w/ new T-wave changes but CEs negative x3. #Chronic Systoic heart failure - likely [**12-31**] ischemic cardiomyopathy - Echo [**2-3**] with EF of 20%, PCWP >18, 1+ MR, 1+TR. Repeat TTE unchanged. # h/o prostate cancer: receiving hormonal therapy q3 months but patient reports his treatment was skipped this month due to his symptoms. He is followed by Dr. [**Last Name (STitle) 5611**]. Medications on Admission: Lipitor 80mg daily lisinopril 10mg daily ASA 325mg daily Toprol XL 50mg daily Flomax 0.4mg qhs Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

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icd9cm

[ [ [] ] ]

[ "96.72", "33.24", "33.27", "96.04", "38.91", "41.31", "38.93", "96.6", "93.90" ]

icd9pcs

[ [ [] ] ]

14173, 14182

9367, 9916

282, 354

14241, 14258

4175, 9344

14322, 14340

3249, 3291

14133, 14150

14203, 14220

14014, 14110

14282, 14299

3321, 4156

222, 244

9944, 13988

382, 2627

2649, 2894

2910, 3233

21,651

189,508

46714

Discharge summary

report

Admission Date: [**2160-11-22**] Discharge Date: [**2160-11-26**] Date of Birth: [**2111-4-11**] Sex: M Service: MEDICINE Allergies: Codeine / Serax Attending:[**First Name3 (LF) 1936**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: endoscopy [**2160-11-26**] History of Present Illness: 49 yom with HCV, Seizure disorder [**2-4**] head trauma from MVA at age 12, EtOH abuse s/p seizures and DT's, hx of Pancreatitis, hx of Gastritis who presents s/p hematemesis this morning. Patient reports +N/V x 1 week. Last night he reports 3cups of +hematemesis, one episode this morning. He denies any prior history of hematemesis. Denies coffee grounds. +melena over the past few weeks but none today, denies hematochezia. +RUQ abdominal pain over the past week. +fevers and chills over the past week. +chronic cough which is unchanged. He denies any recent CP, SOB, or dysuria. He reports 3 seizures per week for the past few weeks. He reports +seizure this morning at about 12pm. He reports walking near the Commons and then found himself waking up on the floor. He does not recall falling and reports it is similar to his prior seizure episodes. Reports taking his dilantin and phenobarbital but has not taken it in the past few days [**2-4**] Nausea and Vomiting. +Fall 2 days ago which he received stitches in his left forhead. +HA but denies any weakness or numbness of his extremities. In the ED, initial VS: Temp 99.8, HR 104, BP 147/81, RR 16 97%. Patient was given Ativan 2mg IM x 1, Ativan 2mg IV x1, Pantoprazole 40mg IV x 1, 1L NS IVF. Stool guiac negative. Patient refused NG lavage. PIV access attempted and was unsuccessfule so Subclavian CVL was placed. GI was consulted and recommended to follow HCT overnight. Patient was admitted to ICU out of concern for withdrawal and UGIB. Past Medical History: 1. HCV 2. Seizure disorder- [**2-4**] head trauma at age 12 (MVA) treated with dilantin and phenobarbital- describes grand mal seizures 3. ETOH dependence- h/o ETOH W/D seizures and DTs 4. Hx of acute pancreatitis 5. Hx of gastritis 6. s/p toe amputation [**2-4**] frostbite 7. reports h/o CVA with slurred speach, no residual deficits currently 8. h/o lung CA s/p RLL lobectomy [**2156**] Social History: Lives in "rooming house". Hx of EtOH abuse, currently drinking a case of beer per day. Hx of IV heroin, cocaine, marijuana, but none recently. +tobacco, [**3-5**] cigarettes per day. Sister: [**Name (NI) **] [**Name (NI) 15852**] ([**Telephone/Fax (1) 99153**]. Divorced with one daughter. Family History: -Mother (d. 77) ?????? MI; h/o IDDM, HTN -Father (d. 81) ?????? MI, Alzheimer's Disease, alcoholic -Brother ?????? recovering alcoholic, h/o heroin abuse -Brother ?????? recovering alcoholic -Sister ?????? grew out of absence seizure disorder Physical Exam: Vitals - T: 98.8 BP: 117/69 HR: 79 RR: 16 02 sat: 97% GENERAL: NAD, lying in bed comfortably, mildly diaphoretic HEENT: PERRLA, EOMI, +stiches in left forehead, no scleral icterus CARDIAC: +S1/S2, no M/R/G, RRR LUNG: CTAB, no wheezes, crackles or ronchi ABDOMEN: +BS, NT/ND, negative [**Doctor Last Name 515**] sign EXT: no C/C/E, +2 DP pulses NEURO: CN II-XII intact, 5/5 strength, sensation intact, +minor hand tremor, finger to nose intact, no prontator drift DERM: no rashes Pertinent Results: LABS: admission: 6.9>37.2/11.8<247 Hct remained stable and was 36.3 at discharge. N61.3 L34.6 M2.9 E0.7 B0.5 135/4.0/98/21/12/0.7<74 bicarb increased to 30 at discharge ALT 37, AST 58 (decreased to 33 at discharge), LD 244, Alk Phos 134 (to 121 at discharge), TB 0.3 Ca 8.6, Phos 3.2, Mg 1.8 Folate 13.3 Hepatitis studies pending Phenytoin 1.9 at admission, 11.8 on [**11-23**] Tox 225 etoh, Acet 13.4, pos barbit urine tox pos barbit, neg otherwise HCV viral load [**11-25**]: HCV-RNA NOT DETECTED STUDIES: EKG: Normal sinus rhythm. Baseline artifact. Tracing is within normal limits. Compared to the previous tracing of [**2160-9-30**] there are no diagnostic changes. CXR [**2160-11-22**]: A new right subclavian central venous catheter tip terminates in the mid SVC. No pneumothorax is present. The cardiac, mediastinal, and hilar contours are normal. The lungs are clear. The patient is status post right lower lobe lobectomy with evidence of volume loss. Chronic changes with blunting of the right costophrenic sulcus are unchanged. Old right fifth posterior rib fracture is again noted. CT head [**11-22**] 1. Slight hyperdensity along the right and left cerebral convexity, likely due to artifact. No definite evidence of acute hemorrhage. No shift of normally midline structures. 2. Left frontal soft tissue swelling. Abd u/s [**11-25**] Prominent pancreatic duct, unchanged from multiple prior studies, otherwise normal abdominal son[**Name (NI) **]. endoscopy [**11-26**] No source of bleeding was found. Otherwise normal EGD to third part of the duodenum CXR [**2160-11-22**]: IMPRESSION: No acute intrathoracic abnormality. Brief Hospital Course: 49 yom with HCV, Seizure disorder [**2-4**] head trauma from MVA at age 12, EtOH dependance s/p seizures and DT's, hx of Pancreatitis, hx of Gastritis who presents s/p hematemesis this morning. # Seizure: Initially thought to be EtOH related, however EtOH level 225 on admission so EtOH seizure seems unlikely. Patient had a recent fall 2 days PTA and had stitches in his left forehead. Given seizure, a CT Head was done to r/o intrancranial bleed and was negative for any acute intracranial process. Patient has a history of seizure disorder [**2-4**] head trauma and takes dilantin and phenobarbital for this condition. Dilantin level was subtherapeutic on admission which seems to be the more likely cause of his seizure. He was loaded with Dilantin 1000mg IV x 1 and then restarted on his normal home dose of 400mg daily. Phenobarb was held initially as he was on a Valium CIWA scale while in the hospital for treatment of EtOH withdrawal. Phenobarb was restarted prior to discharge. # Hematemesis: Patient presented with complaint of several episodes of hematemesis the morning of and night prior to admission. HCT 37 on arrival, and then 32 after IVF. HCT remained stable throughout his hospital stay. GI was consulted and recommended ebdiscopy which did not identify a source of bleeding. They recommended a PPI. # HCV: not on any medications currently # Dispo: Patient has historically had poor compliance with follow-up as an outpatient. He was provided with contact information of alcohol cessation organizations. Medications on Admission: Phenytoin Sodium Extended 400 mg DAILY Phenobarbital 90 mg TID Discharge Disposition: Home Discharge Diagnosis: [**Doctor First Name 329**] [**Doctor Last Name **] tear Discharge Condition: stable, no bleeding Discharge Instructions: You were admitted to [**Hospital1 69**] because you were vomiting blood and you were going through withdrawl from alcohol. Your dilantin level was low and we think that this contributed to you having a seizure. You had an endoscopy which did not identify any bleeding. The bleeding was probably caused by repetitive vomiting due to alcohol use. While you were here you were restarted on phenobarbital and you were started on a medication called Protonix to help your bleeding. You should continue to take both of these medications in addition to the other medications as prescribed by your doctors. If you have bloody bowel movements, vomit blood, feel light headed or dizzy, develop abdominal pain which does not go away, develop chest pain or shortness or breath, or with any other concerns, you should call your doctor or go to the emergency room. Followup Instructions: You should follow-up with the programs and people whose names were provided to you by Dr. [**Last Name (STitle) **]. We strongly recommend that you stop drinking alcohol. Completed by:[**2160-11-27**]

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icd9cm

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icd9pcs

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42622

Discharge summary

report

Admission Date: [**2118-3-7**] Discharge Date: [**2118-3-15**] Date of Birth: [**2064-5-29**] Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 1271**] Chief Complaint: This is a 53 year old man who was transfered from OSH with upper extremity weakness and MRI showing C spine cord signal change after a fall down stairs. Major Surgical or Invasive Procedure: [**2118-3-11**] C3-7 posterior laminectomy and fusion History of Present Illness: This is a 53 year old man who had been drinking early the day of admit when he fell down the stairs. He was taken to OSH where exam showed minimal strength in UE's and LE's. CT C spine showed no fx, MRI T/L spine showed degenerative changes but did capture C5-C6 stenosis and cord signal change. He has no dedicated C spine MRI. He was in a collar and transfered to [**Hospital1 **] for further care. Past Medical History: - ASD repair at 18 yrs old at [**Hospital3 1810**], then followed every few years by Dr. [**Last Name (STitle) **] - Bradycardia -- followed by Dr. [**Last Name (STitle) 14677**] at [**Location (un) 270**] Cardiology (after Dr. [**Last Name (STitle) **] retired) in [**Location (un) **], MA [**Telephone/Fax (1) 92177**] or [**Telephone/Fax (1) 92178**] - Seizures since [**24**] yrs old previously on Tegretol currently on Depakote, followed by Dr. [**Last Name (STitle) **] - S/p L nephrectomy - IVC filter - EtOH abuse - Rotator cuff tear - Hernia repair Social History: Prior 2ppd smoker but now cut down to 1/2 ppd, smoked for 30 yrs. Active drinker, reports 12 pack/day on Friday, Saturday, Sunday; reports having had [**3-27**] drinks when he fell down stairs during [**2-/2118**] admission. Lives with sister. Currently works the night shift at [**Company 92179**] in the pharmacy warehouse, has been there 31 yrs. Family History: NC Physical Exam: On Admission: BP: 101/71 HR: 54 R 10 O2Sats 98 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: Reactive EOMs Full Neck: C Collar in place Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q AT [**Last Name (un) 938**] G R 3 5 2 3 3 3 0 4 4 5 L 3 5 3 3 3 3 0 4 4 5 Sensation: Decreased sensation from T4 down. Reflexes: B T Pa Ac Right 0 0 2 0 Left 0 0 2 0 Toes mute No rectal tone At discharge:[**3-15**] His is a cervical collar. His wound is clean and dry with staples in place. Motor strength: R Tr 3, Gr 3 D 4+ B 5-, L tr 2, Gr 3 D 4+ B 5+ 4+ IP's, full distal. OD [**5-27**] OS [**4-26**] He was anisocoric with Left pupil [**5-27**] and right pupil [**4-26**]. He was awake, alert and oriented x 3. Pertinent Results: Trauma scan [**2118-3-7**] Mildly enlarged heart. No evidence of intrathoracic trauma CT Torso [**2118-3-7**] 1. No evidence of intra-abdominal or intrathoracic injury. 2. No evidence of acute fracture. 3. Delayed excretion of the right kidney; left kidney is surgically absent; IV hydration is recommended MR CERVICAL SPINE W/O CONTRAST [**2118-3-7**] 1. Abnormal signal intensity involving C3 to C6 vertebral bodies concerning for bone marrow edema/contusions with prevertebral soft tissue edema. 2. Increased spinal cord signal from C4 to C6 levels as described above may represent spinal cord edema/contusion or prior myelopathic changes. 3. Anterior longitudinal ligament is not well seen at C6-C7 levels. Possibility of ALL injury cannot be entirely excluded at this level. 4. Increased signal also seen in the posterior paraspinal soft tissues and in the interspinous spaces extending from C2 to C7 levels concerning for interspinous ligament injury. EEG [**2118-3-8**] A single EKG channel shows a generally regular rhythm with an average rate of 35 bpm. IMPRESSION: This is an abnormal awake and drowsy portable EEG because of occasional right frontotemporal epileptiform discharges indicative of a potential epileptogenic focus in this region. There is one marked event with arousal-related myoclonic jerk most likely representing a hypnic jerk. Background otherwise shows a normal 9 Hz posterior dominant rhythm. Note is made of continuous bradycardia throughout the recording. CXR [**2118-3-9**] Heart size is enlarged but stable. Median sternotomy wires are unremarkable. Lungs are clear with no appreciable pleural effusion or pneumothorax demonstrated. Minimal right basal opacity most likely reflects area of atelectasis, better appreciated on the CT torso from [**3-7**], [**2118**]. Carotid dopplers [**3-11**] Right ICA no stenosis. Left ICA <40% stenosis. LENS [**2118-3-14**] DVT with small focal nonocclusive clot seen in the right popliteal vein. This is the only site of disease Brief Hospital Course: This is a 53 y/o man with history of heavy ETOH consumption presents s/p fall down stairs after losing his balance. He was taken to an OSH where c-spine imaging revealed stenosis and he was then transferred to [**Hospital1 18**] for further neurosurgical evaluation. He was admitted to neurosurgery in the ICU for monitoring for DTs. MRI c-spine revealed stenosis at C4-6 with T2 signal changes. He remains in a c-collar. On [**3-8**], his exam revealed weakness in his bilateral triceps and IPs. He is antigravity distally in his lowers and proximally in his uppers. He was transferred out of the ICU and upon bed transfer he was noted to be dusky and non responsive. FSBS was stable / his VS were stable except for his persistent bradycardia. There was a second brief episode that was questionable for sz activity as well. His heart rate was as low as 24. He was transferred back to the TSICU. Cardiology consult was called the following am: They felt that there was a negligible risk of endocarditis and that antibiotic prophylaxis was not recommended. EP consult was done for bradycardia. They felt that Given that he had a good chronotropic response to the 150's on stress echo in [**10/2117**], he will likely be able to mount a response to the physiologic stressors during the operation planned for Friday. A pacer was not necessary. EEG was done to eval for seizure activity in light of seizure history from age 18, the last one in [**2117-7-23**]. He can not fully describe the events, He has LOC and her might have a generalized convulsion. EEG was done and this showed some occasional right frontotemporal epileptiform discharges indicative of a potential epileptogenic focus in this region. Depakote was continued. Level was 90 on [**3-9**]. Nephrology was contact[**Name (NI) **] due to his history of left nephrectomy, decreased clearing at right kidney during torso scan and elevated BUN/creatinine. He was being hydrated. Morphine was changed to oxycodone per the pharmacy due to clearance rate. Pm labs on [**3-9**] showed a drop in Creat from 1.5 to 1.2 and drop in Bun from 39 to 35 and K was 4.4. Urine studies were sent due to high UO. Nephrology recommended to stop IVF and to get a renal ultrasound as an outpatient. He was cleared medically for the OR and he went for C3-7 posterior laminectomies and fusion on [**3-11**]. He tolerated the procedure very well with no complications. Post operatively he was taken to the PACU for further care. His post op exam remained stable. On [**3-12**] his lower extremity strength did improve as did his deltoid and biceps strength. His Foley was removed but he was unable to void on his own and had over 1L on bladder scan and the catheter was replaced. On [**3-14**] he had LENIS and this showed R popliteal non occlusive DVT. No treatment was started as it was non occlusive and the plan is to repeat these studies in one week. He was medically stable on [**3-15**] and telemetry was discontinued. He was found to be anisocoric but has no other neurologic change. Medications on Admission: Theophylline, Depakote, Neurontin Discharge Medications: 1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. insulin regular human 100 unit/mL Solution Sig: Two (2) units Injection ASDIR (AS DIRECTED): see sliding scale. 3. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): hold for lethargy. 4. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 5. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever: max 4g/24 hrs. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. theophylline 200 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO BID (2 times a day) as needed for bradycardia. 12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain: hold rr < 12 . 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: cervical stenosis cervical myelopathy Spinal cord injury Hyponatremia Azotemia Profound hypotension Urinary retention 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: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? If you are required to wear one, wear your cervical collar or back brace as instructed. ?????? You may shower briefly without the collar or back brace; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office in [**8-2**] days (from date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**] to be seen in 4 weeks. ??????You will need cervical x-rays prior to your appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2118-3-15**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2168-8-29**] Discharge Date: [**2168-9-11**] Date of Birth: [**2117-2-16**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: brain mass Major Surgical or Invasive Procedure: Right craniotomy for brain tumor PICC line placed History of Present Illness: 51 yo M h/o R-sided brain mass, first documented by CT [**2168-5-16**], presented to the ED of [**Hospital6 **] c/o n/v x 2 days. Also c/o 3 days of decreased left sided strength. Denies h/o trauma, headache, vision changes, double vision, and photophobia. In [**Month (only) 116**], he elected for non-aggressive care of his brain lesion. He is being followed by neurologist Dr. [**First Name (STitle) 5936**]. Past Medical History: PMHx:h/o seizures, chronic renal insufficiency, questionable h/o cystercercosis, HTN Social History: Social Hx: denies tobacco, drugs, and etoh use Family History: Family Hx: non-contributory Physical Exam: PHYSICAL EXAM: on admission O: T:98.2 BP: 186/112 HR:67 R 15 O2Sats 98 on 2L nc Gen: thin, NAD. HEENT: Pupils:PEERL EOMs full but R eye slow to look left Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, flat affect. Orientation: Oriented to self, place, and year, not month or date. Language: Speech non-spontaneous. Comprehension intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact. V, VII: Facial strength and sensation intact and symmetric. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk. Increased tone left side. Some left sided tremor. Strength power [**2-21**] LUE, LLE, 4+ RUE, RLE. Drift could not be assessed due to left sided weakness. Sensation: Intact to light touch. Reflexes: B Br Pa Ac Right 3+ 3+ 2 1 Left 3+ 3+ 2 1 Toes downgoing bilaterally Pertinent Results: [**2168-8-29**] 01:30AM PT-13.1 PTT-25.0 INR(PT)-1.1 [**2168-8-29**] 01:30AM PLT COUNT-163 [**2168-8-29**] 01:30AM NEUTS-78.7* LYMPHS-15.9* MONOS-3.8 EOS-0.5 BASOS-1.1 [**2168-8-29**] 01:30AM WBC-7.9 RBC-4.57* HGB-14.1 HCT-40.8 MCV-89 MCH-30.8 MCHC-34.5 RDW-14.5 [**2168-8-29**] 01:30AM PHENYTOIN-11.8 [**2168-8-29**] 01:30AM OSMOLAL-304 [**2168-8-29**] 01:30AM ALBUMIN-4.5 CALCIUM-9.3 PHOSPHATE-4.1 MAGNESIUM-2.3 [**2168-8-29**] 01:30AM CK-MB-6 cTropnT-0.01 [**2168-8-29**] 01:30AM LIPASE-42 [**2168-8-29**] 01:30AM ALT(SGPT)-47* AST(SGOT)-30 LD(LDH)-190 CK(CPK)-259* ALK PHOS-88 AMYLASE-101* TOT BILI-0.4 [**2168-8-29**] 01:30AM GLUCOSE-119* UREA N-40* CREAT-3.8* SODIUM-137 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15 [**2168-8-29**] 05:00AM PT-12.8 PTT-23.3 INR(PT)-1.1 [**2168-8-29**] 05:00AM PLT COUNT-177 [**2168-8-29**] 05:00AM WBC-6.6 RBC-4.46* HGB-13.4* HCT-39.9* MCV-89 MCH-30.0 MCHC-33.6 RDW-14.6 [**2168-8-29**] 05:00AM CALCIUM-9.2 PHOSPHATE-3.9 MAGNESIUM-2.6 [**2168-8-29**] 05:00AM GLUCOSE-130* UREA N-40* CREAT-3.8* SODIUM-137 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-20* ANION GAP-15 [**2168-8-29**] 07:47AM CK-MB-5 cTropnT-<0.01 BRAIN MRI: Multiplanar T1- and T2-weighted images of the brain was obtained without and with intravenous gadolinium administration. Correlation is made to the recent head CT examination, performed 7 hours earlier. As noted on the head CT examination, there is a large space-occupying mass lesion involving the right frontoparietal lobe measuring 6.3 x 5.5 cm and resulting in significant surrounding vasogenic edema and sulcal effacement. There is a second lesion involving the right posterior parietal lobe seen slightly inferior to the larger mass lesion which demonstrates mostly cystic characteristics and could be necrotic in nature. There is vasogenic edema extending into the right temporal lobe from this lesion. Significant mass effect is seen over the right lateral ventricle with left-sided subfalcine herniation. There is 60-mm shift of the midline structures. The mass enhances heterogeneously following intravenous gadolinium administration. The findings are suggestive of either metastatic disease or a primary neoplastic process such as glioblastoma multiforme. There is mild dilatation of the left lateral ventricle indicating possible obstruction at the level of the foramen of [**Last Name (un) 2044**] due to the midline shift present. There is also significant compression of the third ventricle. The fourth ventricle, however, is in the midline. Signal flow voids are present along the intracranial portions of the carotid arteries. IMPRESSION: Large intraparenchymal mass lesion involving the right frontoparietal lobe with a second heterogeneously enhancing lesion involving the right posterior parietal lobe. Both lesions demonstrate significant surrounding vasogenic edema, mass effect and subfalcine herniation of the brain. In addition, there is early uncal herniation and effacement of the posterior quadrigeminal cistern. Left-sided ventricular dilatation is seen due to compression of the third ventricle. The findings were conveyed to the emergency room physician [**Last Name (NamePattern4) **] 2 a.m. and discussed with Dr. [**Last Name (STitle) **] by the resident when the CAT scan was obtained. MRA OF THE CIRCLE OF [**Location (un) **]: 3D time-of-flight MRA of the circle of [**Location (un) 431**] was performed. The distal vertebrobasilar circulation is patent and not compromised. There is normal signal along the cavernous ICA. The anterior cerebral arteries are deviated to the left side due to the presence of subfalcine herniation of the brain. The right middle cerebral artery circulation is displaced anteriorly. There is a prominent portion of the right posterior division of the MCA which is seen draped along the anterior aspect of the mass. No intracranial vascular stenosis or occlusions are present. IMPRESSION: Displacement of the right anterior and middle cerebral arteries by the presence of the mass and subfalcine herniation as noted on the brain MRI report and the previously dictated CT report of the brain. Prominent posterior division of the right MCA is noted abutting the anterior aspect of the parietal mass. TECHNIQUE: CT of the head without IV contrast. FINDINGS: The patient is status post right frontoparietal craniectomy. There is a moderate amount of air and fluid within the scalp. There is interval decrease in amount of pneumocephalus when compared to prior study. There is again noted surgical defect in the right parietal region. There is continued severe edema involving the white matter in the right frontal and parietal lobes. The edema appears to be slightly more prominent than the prior studies. However, the mass effect with a 1.5 cm shift of midline structures appear not significantly changed. IMPRESSION: Interval slight increase in the amount of edema. However, the overall mass effect appears not to be significantly changed. REASON FOR THIS EXAMINATION: r/o DVT, please do bilateral exam HISTORY: 51-year-old man with fever of unknown origin and long hospital stay. FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of both common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. Intraluminal thrombus is not identified. IMPRESSION: No evidence of DVT [**Hospital 93**] MEDICAL CONDITION: 51 year old man with fever 103 - s/p crani REASON FOR THIS EXAMINATION: r/o aspiration - pt coming down for stat head CT sp fall - please coordinate AP CHEST, 1:43 P.M., [**9-5**]. HISTORY: Fever. Status post fall. IMPRESSION: AP chest compared to [**8-29**]: Lung volumes have improved and right lower lobe consolidation has cleared. Heart size top normal. No pleural abnormality. Brief Hospital Course: this patient was admitted to the hospital through the emergency department after being transfered from an outside hospital. He presented to the ED of [**Hospital6 **] c/o n/v x 2 days. Also c/o 3 days of decreased left sided strength. Denies h/o trauma, headache, vision changes, double vision, and photophobia. In [**Month (only) 116**], he elected for non-aggressive care of his brain lesion. He is being followed by neurologist Dr. [**First Name (STitle) 5936**]. he was admitted to the ICU for close observation and frequent neuro checks as his Ct of the brain demonstrated MLS wtih vasogenic edema. he was started on mannitol and decardon, and his exam improved over the course of a doay or so. He was evaluated by the renal team for his CRI, as we needed a CTA of the brain to further evaluate the tumor bed for pre-op study. Being that the CTA requires a dye load there was concern for causing ARF. the pt had appropriate pre-and post CTA management and has not required HD. he underwent the Craniotomy on the right without incidence. He was transfered to the step down unit after he stabilized. His post op scans were stable. The pt did have an incidence of confusion x2. Pt with fevers- cultures grew out pseudomonas in his blood and urine. IV abx (ceftriaxone/vanco) were switched to zosyn which should continue until [**2168-9-21**]. Be aware of high salt load in zosyn; watch for fluid overload in [**Last Name (un) 8114**] pt with renal failure. Pt has been continuing to progress, working with physical therapy daily. Medications on Admission: unknown Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 2500 units Injection [**Hospital1 **] (2 times a day). 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Dexamethasone 4 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours). 10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): hold for HR<55 SBP<100. 12. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): please dc [**9-21**]. 13. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: brain tumor Discharge Condition: good Discharge Instructions: Please call the office or come to the hospital for any changes in mental status, weakness or seizure activity. Please call the office or come to the emergency room for excessive redness from wound, drainage or fever >101.5. Followup Instructions: Please call the [**Doctor Last Name **] tumor clinic Monday [**9-11**] to make an appoinment w/ Drs. [**Last Name (STitle) 724**] and [**Name5 (PTitle) **]. The phone number is ([**Telephone/Fax (1) 27543**]. Please call Dr.[**Name (NI) 14277**] (renal) office to make a follow up appointment. Completed by:[**2168-9-11**]

[ "403.90", "198.4", "576.8", "585.4", "438.20", "348.4", "780.39", "521.9", "038.43", "191.8", "041.7", "599.0" ]

icd9cm

[ [ [] ] ]

[ "01.59", "03.31", "38.93" ]

icd9pcs

[ [ [] ] ]

10990, 11069

8118, 9663

330, 382

11125, 11132

2230, 7242

11405, 11731

1016, 1046

9721, 10967

7708, 7751

11090, 11104

9689, 9698

11156, 11382

1076, 1345

280, 292

7780, 8095

410, 826

1553, 2211

1360, 1537

848, 935

951, 1000

11,862

106,778

3679

Discharge summary

report

Admission Date: [**2124-3-16**] Discharge Date: [**2124-3-22**] Date of Birth: Sex: Service: HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male with past medical history significant for CHF, atrial fibrillation, and cardiomyopathy who presents with left lower extremity cellulitis and hematoma. The patient bumped his left shin with a suitcase approximately 6 days prior to admission. He then developed a focal hematoma, which progressively increased in size over the next few days. He saw his PCP 4 days prior to admission, he was concerned for concurrent cellulitis. He was started on Keflex to cover for cellulitis and also Vicodin for pain. The patient subsequently noted a decrease in his hematoma size. Today, he went to see his cardiologist, who was concerned given the significant hematoma size and concurrent cellulitis and referred him to the Emergency Department to be admitted for IV antibiotics. The patient does complain of shin pain localizing to the hematoma site. He denies any distal weakness or any sensory deficits. No fevers or chills. He does note his INR was noted to be supratherapeutic this week, at which point his Coumadin dose was decreased. At the time of presentation in the Emergency Department, the patient was afebrile with vital signs stable. He was started on IV Ancef following attainment of blood cultures. REVIEW OF SYSTEMS: Negative except as per HPI. PAST MEDICAL HISTORY: Coronary artery disease, status post CABG in [**2102**] and [**2106**] with LIMA to LAD, SVG to diagonal 1, SVG to PDA. Ischemic valvular cardiomyopathy. Pulmonary hypertension. Paroxysmal atrial fibrillation, on Coumadin. Basal cell carcinoma. Obstructive sleep apnea, on BiPAP. Status post aortic valve replacement in [**2116**]. Hypercholesterolemia. CHF with EF 35 percent. Moderate mitral regurgitation. Bradycardia, status post pacemaker and ICD placement in [**2120**]. Gynecomastia. HOME MEDICATIONS: 1. Coumadin. 2. Digoxin. 3. Toprol XL. 4. Diovan. 5. Bumex. 6. Aspirin. 7. Zoloft. 8. [**Doctor First Name **]. 9. Flonase. 10. Astelin. 11. Keflex. 12. P.r.n. Vicodin. ALLERGIES: PENICILLIN CAUSES RASH. MORPHINE CAUSES PARANOIA. SOCIAL HISTORY: Married. Lives at home with wife. [**Name (NI) **] alcohol, tobacco or IV drug use at present. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: Afebrile, temperature 97.3 degrees, blood pressure 116/50, pulse 62, and respirations 20. GENERAL: An elder male sitting in bed in no acute distress. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx clear. Two punctate lesions on roof of mouth. No vesicles or focal bleeding. NECK: Soft and supple, no JVD. CARDIOVASCULAR: Irregular rate and rhythm. No murmurs. LUNGS: Clear to auscultation, equal bilaterally. ABDOMEN: Soft and nontender. EXTREMITIES: Left shin with an approximately 4 cm circumferential hematoma with surrounding erythema and 2 plus pitting edema. NEUROLOGIC: Strength 5/5 in bilateral lower extremities, although left lower extremity exam limited secondary to pain. Sensation intact. Nonfocal neurologic exam. LABORATORY DATA: White count 9.6, hematocrit 35.2, platelets 337, with a differential of 70 neutrophils, 20 lymphs, 5 monocytes, and 4 eosinophils. PT 25.8, PTT 36.7 with an INR of 4.4. HOSPITAL COURSE: Cellulitis: The patient with left lower extremity hematoma occurring in the setting of supratherapeutic INR. He then developed a secondary cellulitis. At the time of admission, he had been on 4 days of oral antibiotics as an outpatient with failure to clear his infection. He was started on IV Ancef at the time of admission. Blood cultures were obtained, which remained negative. He was continued on IV antibiotics throughout the admission as his hematoma issues were treated and addressed. The surrounding erythema did resolve, and his edema markedly improved. On the day of discharge, he was then converted over to oral antibiotics to complete a 7-day course of Keflex. Hematoma: The patient with left shin hematoma, which did occur in the setting of a supratherapeutic INR. Anticoagulation was held at the time of admission. Given the lack of resolution of hematoma and concern for a concurrent cellulitis, in addition to functional deficits due to immobility due to pain, a Vascular Surgery consult was obtained to evaluate the hematoma. He was taken to the OR for evacuation. He tolerated this procedure well without any complications. However, several hours after the procedure, he did have extensive bleeding from the hematoma site. The wound was compressed and pressure dressings were applied with subsequent control of bleeding. He remained in-house several days after this to ensure hemodynamic stability. He was then discharged to home with plan to follow up in [**Hospital **] Clinic in the next week. He also will have VNA for continued dressing changes and wound care. Atrial fibrillation/AVR: The patient was admitted with diagnosis of atrial fibrillation and a recent AVR, for which he takes Coumadin. His INR was noted to be supratherapeutic at the time of admission. This was thought to be due to a recent dose adjustment in his Coumadin with over aggressive titration of his Coumadin dose. Coumadin was initially held as per above. He was then restarted on this the day of admission. He was on VNA at home to monitor his INR. CHF: The patient with ischemic cardiomyopathy, CHF with an EF of 35 percent. He had no clinical evidence of failure during this hospitalization. He was maintained on beta- blocker, ACE, Bumex and digoxin as per his home regimen. His inputs, outputs, and weights were followed, and he was maintained on a cardiac diet with fluid restriction. CHF Service did see him while he was in-house and felt he was doing well on his current regimen. SVT: The patient with AICD defibrillator in place. He did have a short run of an SVT, an approximately 6-beat run, for which he was asymptomatic while in-house. The EP team did come by and interrogate his pacemaker and felt that it was functioning well. He will follow up as an outpatient in [**Hospital **] Clinic. DISCHARGE DIAGNOSES: Left lower extremity hematoma. Left leg cellulitis. Congestive heart failure. Atrial fibrillation, on Coumadin. Status post aortic valve replacement. Coronary artery disease. DISCHARGE MEDICATIONS: 1. Digoxin 0.125 mg daily. 2. Sertraline 50 mg daily. 3. Colace 100 mg b.i.d. 4. Valsartan 80 mg b.i.d. 5. Toprol XL 100 mg q.d. 6. Coumadin 6 mg at q.h.s. 7. Bumex 2 mg b.i.d. 8. Keflex 500 mg b.i.d. x 7 days. 9. Percocet p.r.n. x 7 days. DISCHARGE FOLLOW-UP: Follow up with primary care doctor Dr. [**First Name (STitle) **] on Wednesday, [**2124-3-29**]. Follow up with Surgery Dr. [**Last Name (STitle) **] on Friday, [**2124-3-31**]. Follow up with Dr. [**First Name (STitle) **] in [**12-24**] weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16638**], [**MD Number(1) 16639**] Dictated By:[**Last Name (NamePattern1) 14186**] MEDQUIST36 D: [**2124-5-29**] 09:32:39 T: [**2124-5-29**] 22:51:59 Job#: [**Job Number 16640**]

[ "V58.61", "V43.3", "924.21", "V45.81", "E878.8", "428.0", "427.31", "998.11", "682.6" ]

icd9cm

[ [ [] ] ]

[ "99.04", "86.04" ]

icd9pcs

[ [ [] ] ]

2374, 2406

6293, 6474

6497, 7284

3435, 6271

1992, 2242

1419, 1448

152, 1399

2421, 3417

1471, 1974

2259, 2357

70,396

166,952

42860

Discharge summary

report

Admission Date: [**2122-1-23**] Discharge Date: [**2122-2-3**] Date of Birth: [**2047-12-5**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: HA then LOC Major Surgical or Invasive Procedure: [**2122-1-22**]: R frontal [**Year/Month/Day 5041**] placement [**2122-1-23**]: Cerebral angiogram with coiling of basilar tip aneurysm History of Present Illness: HPI: Patient is a 74-year-old right-handed woman with hypertension here after presenting to [**Hospital3 **] (OSH) with headache and neck pain. Per husband, patient and the husband were at [**Name (NI) **] [**Name (NI) 45193**] getting dinner around 4 pm when she complained of headache, neck pain and not feeling well. Hence she went outside to the car while the husband was waiting for the food. She was found on the floor of the parking lot next to the car and she vomited multiple times. EMS was call and she was taken to the OSH around 5pm. She underwent emergent imaging which showed diffuse SAH with intraventricular extension. While at the hospital, she was interactive and oriented to self. While en route, she became more lethargic and the patient was intubated upon arrival to [**Hospital1 18**] ED at 7:50pm. Her initial BP at the OSH was 161/62. Review of systems completely negative including fever, cough, chest pain, palpitations, diarrhea, dysuria, and/or falls. Past Medical History: PMH: 1. Hypertension 2. Hypothyroidism 3. Hx of goiter Social History: Social Hx: Lives with husband. Retired salesperson. Smokes 1~2 cigarettes daily. Rare EtOH. Full code. Husband is HCP/NOK and the contact number is [**0-0-**]. Family History: Family Hx: NC Physical Exam: PHYSICAL EXAM: O: T: 98 BP: 105/82 HR:80 RR: 18 O2Sats: 100% intubated Gen: Intubated and sedated HEENT: Pupils: 3->2mm Lungs: CTA bilaterally. Cardiac: RRR. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Sedated and intubated. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. No blinking to visual threats. V, VII: Face symmetric. IX, X: +Gag Motor: Moves all extremities antigravity and spontaneously. Does not follow commands. Sensation: Intact to noxious stimuli. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 Toes upgoing bilaterally On discharge: Patient is Alert, at times disoriented to place and time. Non focal motor exam. Pertinent Results: [**2122-1-23**] CXR FINDINGS: The heart is normal in size. The mediastinal and hilar contours appear within normal limits. The lungs are clear. There are no pleural effusions or pneumothorax. An endotracheal tube terminates 3 cm above the carina. An orogastric tube terminates in the stomach, where it made a single coil. IMPRESSION: No evidence of acute disease. Suitable positioning of endotracheal tube. [**2122-1-23**] CTA of the head and neck. FINDINGS: CT head demonstrates diffuse subarachnoid hemorrhage with extension into ventricles. There is moderate dilatation of the temporal horns indicating obstructive hydrocephalus. CT angiography of the neck demonstrates no evidence of vascular occlusion or stenosis in the carotid or vertebral arteries. CT angiography of the head demonstrates an approximately 5-mm basilar tip aneurysm. No other aneurysms are seen. No vascular occlusion or stenosis is identified. There is enlargement of the thyroid involving both lobes with heterogenous density. Calcifications are seen in the thyroid. Clinical correlation on ultrasound can help if clinically indicated.Endotracheal and nasogastric intubations are visualized. IMPRESSION: 1. Diffuse subarachnoid hemorrhage with moderate ventriculomegaly indicating obstructive hydrocephalus. 2. CT angiography of the head demonstrates 5-mm aneurysm at the basilar tip. No vascular occlusion or other aneurysms are seen. 3. CT angiography of the neck demonstrates no evidence of stenosis or occlusion. 4. Mild degenerative changes in the cervical region. [**2122-1-24**] CT BRAIN IMPRESSION: Status post aneurysm coiling and right frontal approach ventriculostomy catheter with overall stable extent of diffuse subarachnoid hemorrhage and redistribution of intraventricular blood products.Centricular size decreased after [**Month/Day/Year 5041**] placement. Brief Hospital Course: The pt was admitted through the emergency department as an intubated transfer from OSH for SAH. She was started on Dilantin and Nimodipine. CT angiography revealed a basilar tip aneurysm. An external ventricular drain was placed in the right frontal region. The morning following admission she was taken to the Angio suite and the basilar aneurysm was successfully coiled with balloon assist. She was returned to the ICU for continued close monitoring, she was later extubated. On the early morning of the 8th - the pt pulled her own [**Month/Day/Year 5041**] and TLC out. There were no sequelae from this. A decision was made to monitor her closely for HCP and avoid replacing the [**Name (NI) 5041**] emergently. She continued to improve. Her exam was stable on the morning of the 9th and PT/OT were ordered, TCDs showed no vasospasm. She remained stable on [**1-27**] and was out of bed walking with PT. TCDs were done and showed normal velocities and no evidence of vasospasm. Patient spiked fevers on the twelveth of [**Month (only) 404**] and was pan cultured. Her UA came back positive after a few day, but all other cultures were negative. She was started on Cipro on the 16th and should maintain a ten day course. Attempts were made to remover her foley catheter,but she had a post void residual of 1000cc. On [**2-3**] she is noted to be afebrile and neurologically stable. She is beig discharged to rehab with appropriate follow up. Medications on Admission: ASA, Amlodipine 5mg, Levothyroxine - dose unknown Discharge Medications: 1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours): Last day [**2122-2-13**] then dc. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-19**] Tablets PO Q4H (every 4 hours) as needed for headache. 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days: last day [**2-12**]. 11. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 12. HydrALAzine 10 mg IV Q6H:PRN SPB>200 13. 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. 14. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 15. Ondansetron 4 mg IV Q8H:PRN N/V Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: BASILAR TIP ARTERY ANEURYSM HYDROCEPHALUS SUBARACHNOID HEMORRHAGE INTRAVENTRICULAR HEMORRHAGE ACUTE DELERIUM URINARY TRACT INFECTION Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please call the office of Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 4296**] to make an appointment to be seen in 4 weeks with an MRI/MRA ([**Doctor Last Name **] protocol) of the brain to evaluate the coils in your basilar tip aneurysm. Completed by:[**2122-2-3**]

[ "430", "244.9", "331.4", "041.49", "305.1", "293.0", "599.0", "788.20", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.75", "96.71", "02.21", "88.41" ]

icd9pcs

[ [ [] ] ]

7307, 7354

4431, 5890

317, 455

7531, 7531

2548, 4408

9646, 9926

1740, 1756

5991, 7284

7375, 7510

5916, 5968

7684, 8704

8730, 9623

1786, 2008

2448, 2529

266, 279

483, 1467

2063, 2434

7546, 7660

1489, 1546

1562, 1724

22,516

143,470

46556

Discharge summary

report

Admission Date: [**2149-9-25**] Discharge Date: [**2149-9-27**] Date of Birth: [**2073-6-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Right carotid artery stent placement Major Surgical or Invasive Procedure: Carotid artery stent placement - [**2149-9-25**] History of Present Illness: 76yoF with HTN, HL, PVD, s/p PTCa with stents to LEs and carotid artery stenosis now s/p R carotid artery stenting, no complications, transferred to CCU for monitoring. She was seen in vascular consultation with Dr. [**First Name (STitle) **] on [**2149-8-29**] for evaluation of carotid stenosis. She was found on routine exam to have a carotid bruit several years ago and has been followed with surveillance carotid ultrasounds. Her lastest study was performed on [**2149-6-30**] and demonstrated 70-79% stenosis of the right internal carotid artery and a 40-59% stenosis of the left internal carotid artery. . On arrival, she had labile BPs, on and off Neo. She was intermittently woozy, nauseous with low BP. She denies any chest pain, palpitations, SOB. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She has chronic low back pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope. Past Medical History: Hypertension Hyperlipidemia COPD PVD, s/p overlapping 6.0 x 100 mm and 7 x 28 mm Dynalink stents to the right SFA in [**7-/2146**] and s/p left SFA stent in [**3-/2145**] with ISR s/p PTA on [**2148-9-26**] Continued claudication of the right leg Carotid stenosis GERD with h/o duodenal ulcer S/P pelvic hematoma and hypovolemic shock post catheterization [**2144-7-22**] Shingles [**12-4**] with recurrence on OS in [**9-4**] Anemia S/P D&C in [**5-/2148**] Low back pain Osteoarthritis Tonsillectomy Social History: She is a widow with 6 children and lives with two of her sons. She does not drink alcohol and quit smoking 10 years ago, previously smoked [**3-2**] ppd x 50 years. Family History: Her older brother had a CABG in his early 70s and her father died of a stroke at age 58. Physical Exam: VS: BP 137/47on Neo 0.8, HR 86, RR 21, 98% on 4L NC. Gen: elderly female, NAD, a/o x3, mood, affect appropriate. HEENT: sclera anicteric, PERRL, EOMI. No pallor or cyanosis of the oral mucosa. Neck: Supple without JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. No murmur. 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 but no identified hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ with bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ with bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: ADMISSION LABS: [**2149-9-26**] 04:56AM BLOOD Hct-24.9*# Plt Ct-300 [**2149-9-26**] 07:45AM BLOOD WBC-9.3 RBC-2.80*# Hgb-9.4*# Hct-25.9* MCV-92 MCH-33.5* MCHC-36.3* RDW-13.2 Plt Ct-273 [**2149-9-26**] 04:56AM BLOOD Plt Ct-300 [**2149-9-26**] 04:56AM BLOOD UreaN-11 Creat-0.7 K-3.5 [**2149-9-26**] 07:45AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-140 K-3.7 Cl-108 HCO3-24 AnGap-12 [**2149-9-26**] 07:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9 . . PERTINENT LABS/STUDIES: Hct: 25.9 ([**9-26**]) -> 28.2 -> 25.8 ([**9-27**]) Cardiac cath, [**2147-12-19**]: 1. Selective coronary angiography in this right dominant system revealed minimal CAD. The LMCA had minimal distal disease. The LAD was patent with mild luminal irregularities. The LCX and ramus were patent. The RCA had very mild ostial disease. 2. Left ventriculography was deferred. 3. Resting hemodynamics demonstrated normal left and right sided filling pressures with an LVEDP of 11 mmHg and an RVEDP of 6 mmHg. There was systemic arterial hypertension, with a central aortic pressure of 151/61 mmHg. Cardiac index was perserved at 2.6 l/min/m2. There was no gradient on pull back across the aortic valve. There was no mitral stenosis. FINAL DIAGNOSIS: 1. Coronary arteries are normal. . . LABS: Preop 142 104 13 AGap=15 --------------- 4.8 28 0.8 estGFR: 70 / >75 (click for details) 12.5 6.9 > --- < 267 36.2 PT: 12.4 INR: 1.1 . . DISCHARGE LABS: [**2149-9-27**] 06:09AM BLOOD WBC-6.3 RBC-2.82* Hgb-9.4* Hct-25.8* MCV-92 MCH-33.2* MCHC-36.3* RDW-14.9 Plt Ct-209 [**2149-9-27**] 06:09AM BLOOD Plt Ct-209 [**2149-9-27**] 06:09AM BLOOD Glucose-97 UreaN-8 Creat-0.6 Na-140 K-4.1 Cl-107 HCO3-25 AnGap-12 [**2149-9-27**] 06:09AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0 Brief Hospital Course: Patient is a 76 year-old female with a history of hypertension, hyperlipidemia, PVD, s/p PTCA with stents to lower extremities and carotid artery stenosis who presents for right carotid artery stenting. . # CAD/PVD/ischemia - Patient was admitted for stenting of her right internal carotid artery. Patient did not have any complications from the procedure. Patient required neosynepherine overnight. She had one episode of numbess and tingling in both hands on the morning of the 29th, which was concurrent with a drop in SBP to the 60's. Patient was upright during this episode and her symptoms quickly resolved with lying supine. Patient was continued on her Plavix 75 mg daily, Lipitor, and aspirin 81 mg daily. Patient was ambulating on the floor prior to discharge and was asymptomatic. . # Anemia: Patient's hematocrit dropped during this hospital stay to 24.6 on [**9-26**]. She was transfused one unit of blood, and her hematocrit increased appropriately to 28. Patient's hematocrit again dropped to 25.9 prior to discharge. The patient was asymptomatic and was ambulating in the CCU. Patient will be seen again in clinic on [**2149-9-30**], where her hematocrit will again be checked. . # Code - FULL CODE periprocedure, DNR/DNI otherwise Medications on Admission: Albuterol 90 mcg 1 puff IH qd Fosamax 70 mg 1 tab weekly Lipitor 10 mg 1 tab daily Pletal 100 mg 1 tab [**Hospital1 **] Plavix 75 mg 1 tab daily Advair 250-50 mcg 1 puff IH [**Hospital1 **] Ativan 1 mg 1 tab q hs Toprol XL 100 mg 1 tab daily Xopenex 15 gm 1 puff prn Singulair 10 mg 1 tab daily Protonix 40 mg 1 tab daily Spiriva 18 mcg 2 caps daily Tramadol 50 mg 1 tab prn ASA 81 mg 1 tab daily Vitamin C 500 mg 1 tab daily Vitamin B-6 100 mg 1 tab daily Vitamin B-12 250 mg 1 tab daily Calcium + D 500 mg -200 Units 1 tab daily Iron 325 mg 1 tab daily Centrum Silver 1 tab daily Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation once a day. 2. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pletal 100 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 7. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 8. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 9. Montelukast 10 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. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: Two (2) capsules Inhalation once a day. 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day. 16. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a day. 17. Calcium 500 with Vitamin D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. 18. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 19. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Carotid artery stenosis Peripheral vascular disease Secondary: COPD Hypertension GERD Discharge Condition: Good. Patient's vital signs are stable and she is able to ambulate without difficulty. Discharge Instructions: You were admitted to the hospital for an elective carotid artery stent. After the procedure, you experienced hypotension and your hematocrit decreased. You were given one unit of RBCs and you were monitored in the CCU for two days. You are now able to walk around the CCU without difficulty. While you were here, we made the following changes to your medications: 1. We are holding you Toprol XL because your blood pressure was low during this admission 2. We increased your aspirin to 325 mg daily Please take all medications as prescribed. Please keep all previously scheduled appointments. Please return to the ED or your healthcare provider if you experience shortness of breath, chest pain, excessive fatigue, difficulty walking, unsteadiness, pain or warmth around the wound in your groin, fevers, chills, or any other concerning symptoms. Followup Instructions: Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2149-9-30**] 11:00 Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2149-10-14**] 1:30 Completed by:[**2149-9-27**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8686, 8692

5132, 6393

352, 403

8832, 8922

3353, 3353

9823, 10149

2416, 2507

7026, 8663

8713, 8811

6419, 7003

4576, 4780

8946, 9800

4797, 5109

2522, 3334

276, 314

431, 1693

3370, 4559

1715, 2218

2234, 2400

82,147

199,452

41333

Discharge summary

report

Admission Date: [**2155-3-22**] Discharge Date: [**2155-4-3**] Date of Birth: [**2135-4-3**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5790**] Chief Complaint: [**4-12**] rib fractures, left hemopneumothorax, grade II-III splenic laceration Major Surgical or Invasive Procedure: left tube thoracostomy History of Present Illness: 19M brought to the ED by ambulance after colliding into a road rail on his motorcycle. He had decreased breath sounds on his left side on auscultation and decreasing O2 Saturation to the low 90's in the ER. Hemopneumothorax was seen on CXR. He underwent CT torso which demonstrated a grade II-III splenic laceration and a T11 vertebral body chip fracture. Past Medical History: None Social History: Lives with parents. Non smoker, no EtOH, no recreational drug use. Family History: Non-contributory. Pertinent Results: [**2155-4-3**] WBC-17.6* RBC-3.52* Hgb-10.5* Hct-30.3 Plt Ct-835* [**2155-4-2**] WBC-19.0* RBC-3.74* Hgb-11.0* Hct-32.7 Plt Ct-627* [**2155-4-1**] WBC-21.0*# RBC-3.83* Hgb-11.8* Hct-32.6 Plt Ct-648* [**2155-3-22**] WBC-22.2* RBC-4.67 Hgb-13.8* Hct-39.7 Plt Ct-244 [**2155-3-30**] Neuts-76* Bands-0 Lymphs-8* Monos-12* Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2155-4-1**] Glucose-128* UreaN-6 Creat-0.9 Na-134 K-4.8 Cl-97 HCO3-28 [**2155-3-23**] Glucose-120* UreaN-12 Creat-0.9 Na-135 K-5.3* Cl-104 HCO3-25 [**2155-3-28**] ALT-45* AST-31 LD(LDH)-227 AlkPhos-76 TotBili-0.8 [**2155-4-1**] Calcium-8.4 Phos-5.3*# Mg-2.2 Micros [**2155-3-28**] L chest tissue 2+ PMN, 1+ GPC pair/clusters; sparse GPs, suggestive of staph; neg AFB [**2155-3-28**] L effusion 4+ PMN, no organisms; rare GPCs MSSA [**2155-3-28**] L fibrous 4+ PMN, no organisms; sparse GPs, suggestive of staph; neg AFB [**2155-3-28**] UCx NEG CXR [**2155-4-3**]: Right PICC tip is in the mid SVC. Left chest tube remains in place. There is no evident pneumothorax. Elevation of the left hemidiaphragm is unchanged. Cardiomediastinal contours are normal. Left lower lobe atelectasis has increased. A combination of left pleural thickening and small left pleural effusion has minimally increased. Rib plates are in place. CCT [**2155-3-27**] 1. Four different compartments of fluid in the left thoracic cavity. The posterior one likely a freely layering pleural effusion. The anterior one likely a loculated effusion. The medial and lateral collections are concerning for a combination of lung contusion/laceration and hematoma with superimposed infection such as empyemas. 2. Small left pneumothorax. Left chest tube terminates in the apex, unchanged. 3. Grossly unchanged multilevel displaced left lateral rib fractures, constituting a flail chest. No acute spinal injury. 4. Interval decrease of left lateral chest/abdominal wall subcutaneous gas. [**2155-3-22**]: IMPRESSION: 1. Left hemopneumothorax, as above. Left chest tube, kink/coiled, and extending distally posteriorly along the left mediastinum, as above. Recommend repositioning. Left pulmonary contusions. Dependent left pulmonary consolidation may be due to contusion, aspiration, and/or atelectasis. 2. Multiple left-sided rib fractures involving ribs 4 through 9 with at least 6 through 8 displaced. Extensive left chest wall subcutaneous edema extending superiorly into the left neck and inferiorly along the left flank and back to just above the left iliac crest. Evidence of intramuscular emphysema with air extending to the left flank abdominal wall, difficult to exclude focus of intra-abdominal air. 3. Mild dependent right pulmonary consolidation may be due to atelectasis, aspiration, cannot exclude contusion. 4. Grade III splenic laceration, measuring approximately 3.9 cm in length, with small amount of perisplenic hemoperitoneum, without definite active extravasation. Trace hemoperitoneum at the inferior edge of the right lobe of the liver and in the pelvis. 5. Markedly distended stomach containing gastric contents, consider nasogastric tube placement. 6. Foley catheter within a partially decompressed bladder; diffusely thickened bladder wall, most likely related to underdistension, clinical correlation suggested. 7. 0.5 cm calcific/ossific structure just posterior to the inferior aspect of T11 vertebral body, at T11/T12, may represent focal calcification of the posterior longitundinal ligament, a tiny chip fracture can not be entirely excluded, although would be atypical in appearance. Brief Hospital Course: He was admitted to the ACS service. A left chest tube was placed urgently in the ED with a return of breath sounds on his left side and improving O2 saturation. Chest tube position and re-expansion of the lung was confirmed with CXR. He was transferred to the ICU for close hemodynamic monitoring. His splenic laceration was managed non-operatively; serial Hct's were followed and remained stable ranging between 34-36. Final radiological read of his CT torso revealed a possible T11 chip fracture of his vertebral body. Neuro Spine were consulted but no further interventions were warranted per their recommendation. His activity was liberalized and he was independent with ambulation. On HD 2 while in the ICU he was transition ed to a regular diet for which he has tolerated. Incentive spirometry was encouraged. Subcutaneous heparin for prophylaxis was started. He was subsequently transferred out of the ICU to the regular nursing unit. His chest tube remained in place; on HD 4 the CT was placed to water seal and the chest xray that was obtained several hours later showing a small left apical pneumothorax. The CT was placed back to suction and repositioned on the following day. He did have pain control issues requiring IV narcotics initially, he was later changed to an oral narcotic regimen. Toradol was added for 3 days which seemed to improve comfort. His chest tube output decreased and the chest tube removed on HD 6 with purulent drainage noted at time removal. He was spiking fevers. A Chest CT showed hematoma and possible empyema. Thoracic surgery was consulted. He was taken to the operating room on [**2155-3-28**] for Left video-assisted thoracic surgery (VATS) decortication and freeing of trapped lung from rib fragments. He was extubated in the operating room monitored in the PACU prior transfer to the floor in stable condition with 2 chest tubes, Foley and Dilaudid PCA for pain. He was monitored closely. He was taken back to the operating room on [**2155-3-31**] for Open reduction and internal fixation (rib plating) of 4 rib fractures, left. He was extubated in the operating room, monitored in the PACU prior transfer to the floor with a Foley right chest tube and Dilaudid PCA for pain. Respiratory: incentive spirometer, good pain control he titrated off oxygen with saturations of 97% room air. Chest-tube: right once drainage decreased and intraoperative pleural cultures were final the chest tube was removed on [**2155-4-2**]. ID: intra-operative cultures grew MSSA. He was continued on Nafcillin 2 gm and will be continued for a 4 week course. PICC line was placed [**2155-4-2**] right basilic, 50 cm placement confirmed terminates mid SVC Pain: Dilaudid PCA was converted to PO Dilaudid, Motrin and acetaminophen were given with good pain control. Disposition: he was discharged to home [**2155-4-3**] with his mother, home solutions care team for IV antibiotics. He will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: None Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation . 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 5. Advil 200 mg Tablet Sig: Three (3) Tablet PO every 6-8 hours as needed for pain. 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gm Intravenous Q6H (every 6 hours) for 4 weeks. Disp:*224 gm* Refills:*0* 8. 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* Discharge Disposition: Home With Service Facility: Home Solutions Infusion therapy Discharge Diagnosis: s/p Motorcycle crash Injuries: 1. Left [**4-12**] rib fractures 2. Left hemopneumothorax 3. Grade II-III splenic laceration 4. T11 vertebral body chip fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Incisions develops drainage -Should chest tube site drain cover with a clean dressing and change as needed -Cover chest tube site with a bandaid until healed -Shower daily. Wash incision with soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed Antibiotics: Nafcillin 2 gm every 6 hrs: complete course Pain -Take motrin 600 mg 3 x day with food and water for pain -Take prontonix's while taking motrin -Take Dilaudid as needed for severe pain. Taper off narcotics -Warm packs on left side for muscle spams Activity: -AVOID all contact sports for the next 6 weeks to allow for proper healing of your spleen injury. -No lifting anything greater than 10 pounds -Walk frequently Followup Instructions: Follow up in [**Hospital 2536**] clinic in [**2-6**] weeks, call [**Telephone/Fax (1) 600**] for an appoinment. Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2155-4-15**] 2:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray [**Location (un) 861**] Radiology 30 mintues before your appointment Chest Suture removal on Monday [**4-7**]. Weekly CBC w/diff & BMP weekly. Fax to [**Telephone/Fax (1) 89999**] [**First Name9 (NamePattern2) **] [**Location (un) 1439**] Completed by:[**2155-4-3**]

[ "865.02", "E812.2", "807.06", "E849.5", "805.2", "958.7", "860.4" ]

icd9cm

[ [ [] ] ]

[ "34.04", "79.39", "34.52", "38.93" ]

icd9pcs

[ [ [] ] ]

8527, 8589

4537, 7540

389, 413

8793, 8793

967, 4514

9847, 10433

929, 948

7595, 8504

8610, 8772

7566, 7572

8944, 9824

269, 351

441, 801

8808, 8920

823, 829

845, 913

12,425

110,056

49491

Discharge summary

report

Admission Date: [**2199-8-12**] Discharge Date: [**2199-8-20**] Date of Birth: [**2143-10-8**] Sex: F Service: GREEN SURGERY HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old female with a history of multiple ventral hernia repairs, the latest being on [**2199-6-15**], who presents to the Emergency Room today with diaphoresis, nausea, vomiting, and fever. Her abdominal wound was opened secondary to intermittent serous drainage and mild scattered erythema. She was put on Keflex followed by levaquin and the erythema resolved. At present, she has no complaints of chest or abdominal pain. Patient has also had some loose stoo since last night. PAST MEDICAL HISTORY: 1. Hypertension. 2. Goiter. 3. Obesity. 4. Asthma. 5. Fibromyalgia. PAST SURGICAL HISTORY: 1. Multiple mesh ventral hernia repairs, last one being [**2199-6-15**], with prior panniculectomy. 2. Cesarean section x2. 3. Right salpingo-oophorectomy. 4. Liver hemangioma resection. 5. Left breast biopsy. MEDICATIONS: 1. Synthroid. 2. Diovan. 3. Calcium. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs: Temperature is 99.8, blood pressure is 85/52, pulse is 96, respiratory rate is 14. Her heart examination is regular, rate, and rhythm with no murmurs, rubs, or gallops. Her lungs are clear to auscultation bilaterally. Abdomen is soft with mild to moderate right upper quadrant tenderness distinct from her incisional wound on the right mid abdomen. She is obese. Positive bowel sounds in all four quadrants. Rectal examination is guaiac negative. Extremities are without clubbing, cyanosis, or edema. LABORATORIES: White blood cell count was 23.5, hematocrit 33.9, platelets 268. Sodium 137, potassium 3.6, chloride 100, bicarbonate 23, BUN 21, creatinine 1.0, glucose of 138. After Dr [**Last Name (STitle) 519**] noted her to be icteric, LFTs were obtained (below) and found elevated. Chest x-ray was negative. CT scan of the abdomen and pelvis showed a stable appearance of a fatty infiltrated liver with no abscesses in either the peritoneal cavity or the abdominal wall. It also showed some stranding and soft tissue thickening adjacent to the skin defect in the right anterior abdominal wall without any associated abscess. There is some evidence of diverticulosis and inguinal hernia on the right that was nonobstructive. HOSPITAL COURSE: Patient was admitted to the floor for apparent sepsis without any localizing source. She was given empiric levofloxacin and Flagyl antibiotics. She was kept NPO and was aggressively rehydrated. On hospital day one, [**2199-8-13**], patient was admitted to the SICU with hypotension of 70s-80s systolic blood pressure. On hospital day one, the patient was transferred from the floor to SICU with hypotension. Patient has had chronic right upper quadrant abdominal wound for multiple hernia repairs. She denied any chest pain, shortness of breath, cough, congestion, or any blood in her bowel movements. She also denies any stiff neck, photophobia, rash, numbness, weakness, or tingling. She also denies any dysuria, hematuria, or frequency. On admission to the SICU, the patient was hypotension with minimal response with fluids. She is on levofloxacin and Flagyl. Vancomycin was added on the day of admission to the SICU. Her laboratories prior to admission to the SICU was white blood cell count of 23.5, hematocrit of 33.9, platelets 268. Chem-7 was normal. Urinalysis was preliminarily negative. AST 86, ALT 89, LDH 229, alkaline phosphatase 76, total bilirubin 3.8, amylase 47, ESR of 75 with a C-reactive protein of 29. While in the SICU, patient received an arterial line. Also received a left subclavian central venous line. Infectious Disease was consulted and requested hepatitis serology as well as blood and stool cultures which were sent. While in the SICU, a PA catheter was inserted. The patient was treated with Levophed with good response. Patient's levo was weaned off with approximately 12 hours. Patient continued to be treated with Levaquin, Flagyl, and Vancomycin. An echocardiogram was negative for any vegetations. Patient was ruled out for myocardial infarction by electrocardiogram and cardiac enzymes. She had a liver and a gallbladder ultrasound done on [**8-14**] that was negative. She had intermittent episodes of atrial fibrillation and flutter that was self limiting. She was treated with Lopressor and transfused 1 unit of packed red blood cells. Electrolytes were repleted. Patient was transferred to the floor on hospital day three. Upon transfer to the floor, patient's LFTs were AST 108, ALT 139, alkaline phosphatase 124, total bilirubin of 4.1 with a direct bilirubin of 2.7. GI was consulted. They suggested that the LFT pattern was suggestive of sepsis of unknown etiology. The surgical service felt that an episode of self-limiting cholangitis, given the RUQ pain, unclear source of sepsis, and previous major liver resection, was equally plausible. Hepatitis panels were drawn and were all negative. In addition, an MRI cholangiogram was normal. Stool cultures were all negative. While on the floor, the patient was advanced from NPO to a regular diet as tolerated. The patient was able to tolerate regular food without difficulty. The patient was out of bed and ambulating. She had no complaints of pain and was afebrile. She had no other episodes of hypotension. Her LFTs and white blood cell count continued to trend downward. White blood cell count on the day of discharge was down to 10.7. Her last Chem-7 on the day prior to discharge was a sodium of 143 potassium 4.1, chloride 108, bicarb of 29, BUN of 8, creatinine of 0.5, and a glucose of 110. LFTs showed an ALT of 36, and AST of 23, alkaline phosphatase of 78, amylase 42, and total bilirubin of 0.8. Patient's abdominal wound continued to be changed twice a day on the floor with Dakin solution. On the day of discharge, the wound is clean, dry, and intact without any evidence of erythema. The patient was discharged home on a seven day course of Flagyl and levofloxacin. CONDITION ON DISCHARGE: Good/stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSES: 1. Bacteremia/sepsis (fever, nausea, vomiting, diarrhea, and hypotension) of unknown origin, possibly biliary. 2. Hypertension. 3. Goiter. 4. Asthma. DISCHARGE MEDICATIONS: 1. Dakin solution sodium hypochloride 0.5% liquid to be applied on wet-to-dry dressings [**Hospital1 **]. 2. Flagyl 500 mg tablets one tablet po tid for seven days. 3. Levaquin 500 mg tablets one tablet po q day for seven days. 4. The patient is also instructed to go back on her home medications. FOLLOW-UP PLANS: The patient is to followup with Dr. [**Last Name (STitle) 519**] next [**Last Name (LF) 2974**], [**2199-8-30**]. She is instructed to call his secretary to schedule an appointment, and telephone number is provided. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 28130**] MEDQUIST36 D: [**2199-8-20**] 11:35 T: [**2199-8-28**] 08:23 JOB#: [**Job Number 103555**]

[ "276.5", "493.90", "785.59", "682.2", "401.9", "E878.8", "998.59", "427.31" ]

icd9cm

[ [ [] ] ]

[ "89.64", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

6193, 6344

6367, 6666

2382, 6107

786, 1086

1109, 2364

6684, 7184

171, 672

694, 763

6132, 6172

6,588

171,653

2551

Discharge summary

report

Admission Date: [**2136-1-16**] Discharge Date: [**2136-1-24**] Date of Birth: [**2070-7-12**] Sex: F Service: MICU [**Location (un) **] HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 12933**] is a 65-year-old female, with multiple medical problems including COPD, diabetes mellitus, history of a DVT, and hypothyroidism, who was transferred from [**Hospital 1562**] Hospital on [**1-16**], after failing to wean from the ventilator. The patient, according to the hospital transfer, had a sore throat for four or five days, and symptoms of a lower respiratory tract infection. She presented to [**Hospital 1562**] Hospital on [**1-10**] and proceeded to rapidly decompensate with hypoxemic and hypercapnic respiratory failure. She was found to have a left lower lobe consolidation and required mechanical intubation. The hospital course there was notable for thick pulmonary secretions, an MSSA growing out of sputum, and a chest CT showing extensive alveolar interstitial process involving both the left and right lung, with left greater than right. The patient underwent bronchoscopy. It was notable just for the thick secretions. She received aggressive antibiotics including vancomycin, piperacillin, tazobactam, Levofloxacin and clindamycin, but was unable to be weaned from the ventilator for persistent hypoxemia. She was transferred to [**Hospital6 256**] for further evaluation and treatment of her hypoxemic and hypercapnic respiratory failure. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. COPD. 3. Diabetes mellitus. 4. History of DVT several years ago. 5. Peptic ulcer disease. 6. GERD. 7. Chronic lower back pain, on narcotics for spinal stenosis. ALLERGIES: No known drug allergies. MEDS ON TRANSFER: 1. Cleocin 600 mg q 8. 2. Levofloxacin 500 mg q 24. 3. Protonix 40 mg q 24. 4. Digoxin 0.25 q 24. 5. Metoprolol 25 mg IV q 6. 6. Fluconazole 100 mg IV q 24. 7. Synthroid 0.125 mg q 24. 8. Flexeril 10 mg q 8. 9. Chlorzoxazone 500 mg po tid. SOCIAL HISTORY: The patient does not work. She lives with her husband on [**Hospital3 **]. She has a remote tobacco history and minimal alcohol use. No intravenous drug use. PHYSICAL EXAM: On presentation, the patient's vital signs were as follows: Temperature 99.9, blood pressure 156/93, heart rate 77, respirations 14, satting 97% on room air. She was on AC 550x18 with pressure support of 10, PEEP 5, FIO2 0.5. GENERAL: She was an obese female, intubated, following simple commands, in no acute distress. HEENT: Normocephalic, atraumatic. Pupils 2 mm and reactive, anicteric. Oropharynx clear with moist mucous membranes. NECK: Supple. No lymphadenopathy appreciated. I was unable to assess her JVP. There were no bruits. CARDIOVASCULAR: Regular rate and rhythm with occasional premature beats, a II/VI systolic murmur at the left sternal border. No rubs or gallops. LUNGS: She was moving a good amount of air bilaterally with the exception of the right base, but she had crackles at the midlung fields bilaterally. There were no wheezes. ABDOMEN: Obese, soft, diffusely tender to palpation at that point. No rebound or guarding. Normal bowel sounds. No masses or hepatosplenomegaly appreciated. EXTREMITIES: Trace pitting edema, bilateral lower extremities. NEUROLOGIC: Squeezes both hands. There was 4/5 strength. Wiggles toes bilaterally. Toes were downgoing. OUTSIDE LABORATORY VALUES: Notable for white blood cell count 22.6, hematocrit 32. Her chem-7 was within normal limits with the exception of a glucose of 214. She had also a dig level of less than 1 at the outside hospital. A troponin-I peaked at 0.20. [**Hospital3 **] LABS AT PRESENTATION: White count 23.4, hematocrit 32.9. Her coags were normal, as was her chem-10. Her CK was 23, troponin less than 0.01. ABG - 7.44, 43, 103. Chest x-ray showed diffuse air space opacities involving the left middle and lower lobes, and the right lower lobe. HOSPITAL COURSE - 1) PNEUMONIA: The patient was continued on clindamycin for her MSSA pneumonia before being switched to oxacillin. The oxacillin was continued for a total of a 10-day course. The patient was extubated 2 days after admission, and thereafter remained stable on 2 liters nasal cannula with oxygen saturations greater than 95%, and her lungs remained fairly clear. It was presumed that the respiratory failure was due to an MSSA pneumonia superimposed on her chronic obstructive pulmonary disease. 2) LEUKOCYTOSIS: The patient had a leukocytosis which we attributed to her steroid use. Her steroids were tapered, and her white blood cell count was down to 13 the day prior to discharge. She had no further signs of infection, such as fever. 3) WEAKNESS: The patient, 3 days prior to discharge, was noticed to have diffuse peripheral weakness and bifacial weakness with some garbled speech. The patient underwent a lumbar puncture which was unremarkable. She was due to have an MRI prior to discharge, and seen by the neurology service who felt that it was possible that the patient had suffered a CVA during her Intensive Care Unit stay, or that she was suffering from ICU neuropathy or myopathy. The day prior to discharge, however, her strength was slightly better. At baseline, the patient is dependent on a scooter to move about secondary to her lower back pain, but she has full strength in her upper extremities and is able to lift her scooter. 4) CHF: The patient had an outside hospital echo showing an EF of roughly 40%. She was continued on ACE inhibitor and beta blocker which she tolerated well during her hospital stay. She required occasional doses of hydralazine for systolic blood pressures above 160. 5) CORONARY ARTERY DISEASE: The patient had a non-Q wave MI versus CHF troponin leak at outside hospital. She was continued on beta blocker, aspirin, ACE inhibitor while in house. DISCHARGE MEDICATIONS: They are to be dictated the day of discharge. DISCHARGE DIAGNOSES: 1. Methicillin sensitive Staphylococcus aureus pneumonia, left greater than right. 2. Weakness likely secondary to ICU neuropathy/myopathy versus cerebrovascular accident. 3. Leukocytosis secondary to steroid use. 4. Congestive heart failure. 5. Coronary artery disease. DISCHARGE CONDITION: The patient was discharged in stable condition. DISPO: The patient is being discharged to possibly [**Location (un) **]-[**Location (un) 9188**]. FOLLOW-UP: The patient is to follow-up with her primary care physician on [**Location (un) **]. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 5838**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2136-1-23**] 13:04 T: [**2136-1-23**] 13:07 JOB#: [**Job Number 12934**]

[ "244.9", "428.0", "359.81", "V58.65", "518.82", "250.00", "482.41", "410.71", "491.21" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "03.31", "96.71" ]

icd9pcs

[ [ [] ] ]

6261, 6770

5967, 6239

5899, 5946

2185, 5875

187, 1487

1509, 1731

2007, 2169

1749, 1990

3,695

103,997

28719

Discharge summary

report

Admission Date: [**2115-11-5**] Discharge Date: [**2115-11-27**] Date of Birth: [**2049-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Cardio-pulmonary Failure Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: 66 yo man with PMH HTN and recent admission for pna in [**Month (only) **] who presents to ED after syncopal episode. Pt intubated and sedated w/o family memeber in ICU so HPI by report and records which is missing ED resident note. Pt presented after syncopal episode with 5-6 minute of LOC with head trauma after he got up from dinner to get to the bathroom. No other Sx compliant but noted to be diaphoretic; no CP or SOB. ON arrival pale and diaphoretic. HDS during EMS travel but tachycaric with tarnsient RBBB. ECG w/ ? STE. Given ASA/BB/NTG and started on hep gtt. Pt became more pale, diaphoretic and less responsive. Pt intubated for airway protection as MS changed and Pt became hypotensive. Post intubateion SBP 50's -> levophed. CVL placed. Bedside echo obtained which showed evidence of right sided ventricular dilation and hypokinesis. CTA demonstrated massive b/l PE While in ED, became hypotensive with respiratory distress. Intubated. Bedside echo showed evidence of right sided dilation and hypok. CTA demonstrated massive b/l PE -> heparin restarted and then administered TPA (15 mg IVP, 42mg/hr). Unable to place foley prior to TPA. Pt transfered to MICU. Past Medical History: HTN Social History: Lives in [**Location 86**] with his wife. Retired quality engineer. Does not smoke or drink. Family History: noncontributory Physical Exam: General - intubated and sedated HEENT - blood around ETT neck - supple, oozing from left SC sight and soft tissue swelling CVS - tachycardic but RR, s1/s2 possible s4. no M Lungs - CTAB b/l - ant Abd - soft ND, + BS Ext - cool/moist, no edema Neuro- moves all extremities Pertinent Results: Admit Labs [**2115-11-5**] 07:22PM BLOOD WBC-11.6* RBC-5.49 Hgb-17.4 Hct-49.3 MCV-90 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-227 [**2115-11-5**] 07:22PM BLOOD Neuts-56.5 Lymphs-35.8 Monos-4.0 Eos-1.7 Baso-2.0 [**2115-11-5**] 07:22PM BLOOD Glucose-157* UreaN-16 Creat-1.1 Na-140 K-4.4 Cl-106 HCO3-23 AnGap-15 [**2115-11-6**] 03:30AM BLOOD Calcium-7.6* Phos-3.7 Mg-2.2 [**2115-11-6**] 05:21AM BLOOD Type-ART Temp-36.8 Rates-18/ Tidal V-650 FiO2-40 pO2-84* pCO2-44 pH-7.31* calTCO2-23 Base XS--4 -ASSIST/CON Intubat-INTUBATED [**2115-11-5**] 07:22PM BLOOD PT-12.7 PTT-23.7 INR(PT)-1.1 . . Significant Diagnostic Imaging Studies . [**2115-11-5**] ECHO: Conclusions: There is moderate 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>75%). The right ventricular cavity is moderately dilated. Right ventricular systolic function appears depressed. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . [**2115-11-5**] CXR: PORTABLE CHEST: Cardiac and mediastinal contours appear stable. Pulmonary vasculature appears within normal limits. Small nodular densities are seen over the right mid lung. No evidence of focal consolidation or pleural effusions. Likely bibasilar atelectasis is seen. . [**2115-11-5**] CTA Chest: IMPRESSION: 1. Massive burden of pulmonary embolism bilaterally extending from the mid to distal right and left main pulmonary arteries outward into nearly all branches of the pulmonary arterial vasculature. 2. Multiple pleural-based calcified plaques consistent with prior asbestos exposure. . [**2115-11-5**] Head CT: IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. No fractures. 2. Soft tissue lesion on vertex of scalp. Please correlate with physical examination to confirm sebaceous cyst versus neoplasm. . [**11-6**] U/S Bil LE: Nonocclusive thrombus identified within the right popliteal vein. . [**11-8**] CXR: Mild edema has developed in the lower lungs. Upper lungs are clear, with persistent vascular congestion on the left and diminished vascularity peripherally. . [**11-8**] f/u CXR: Worsening patchy areas of opacity in both lower lobes. This could be due to aspiration, hemorrhage, or pneumonia. . [**11-9**] CXR: Slight interval improvement in bilateral pulmonary infiltrates. . [**11-10**] CXR: Persistent bibasilar pulmonary infiltrates. No significant internal change. . [**11-11**] CXR: Lung volumes are low, and mild cardiomegaly with mediastinal vascular engorgement are stable. Atelectasis at the left lung base is more pronounced. There is no pulmonary edema or pneumonia. Lateral aspect of the left lower chest is excluded from the examination. Pleural effusion, if any, is on the left and small; the other pleural surfaces are unremarkable. No pneumothorax. . [**11-12**] CXR: Left lower lobe collapse has worsened, accompanied by increasing small left pleural effusion. Major interval change has been significant increase in caliber of mediastinal vessels suggesting marked elevation in central venous pressure, which could be a reflection of either volume overload, cardiac decompensation or right heart failure due to increase in pulmonary vascular resistance from worsening pulmonary embolism. Left subclavian line tip projects over the left brachiocephalic vein. No pneumothorax. . [**11-13**] CXR: Lung volumes are lower, mild-to-moderate pulmonary edema has developed. Severe mediastinal widening suggests persistence of marked increase in central venous pressure, exaggerated by lower lung volumes. Tip of the left subclavian line projects over the left brachiocephalic vein. Small left pleural effusion has increased. No pneumothorax. . [**11-13**] f/u CXR: Portable AP chest radiograph compared to [**2115-11-13**]. The enlarged heart size is unchanged as well. There is increased width of the mediastinum, most likely was known to be due to fat deposition. The bilateral pleural effusions and left lung consolidation are again noted. Noted, right more than left. The ET tube tip is 7.8 cm above the carina. The left subclavian line tip is in the mid portion of the left brachiocephalic vein. . [**11-13**] Echo: Preserved global and regional biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2115-11-5**], the right venticular cavity is smaller and free wall motion is normal. Pulmonary artery systolic hypertension is now identified. . [**11-14**] CT-PA: 1. Reduction in bulk of bilateral pulmonary embolus. The largest amount centrally is seen about the right upper lobe pulmonary artery origin with minimal opacification of right upper lobe pulmonary arteries. No infarcts. 2. Bilateral pleural effusions and atelectasis/consolidations. . [**11-14**] CT Head w/o Contrast: No acute intracranial hemorrhage. Increasing sinus opacification, likely related to intubation. . [**11-14**] CXR: The ET tube tip is too high, 6.7 cm above the carina. The mediastinal width has been decreased with the decrease of pulmonary edema. The left lower lobe atelectasis is unchanged. . [**11-15**] U/S RUQ: 1. Extremely limited study. No gallstones or biliary dilatation. 2. Right-sided pleural effusion. . [**11-18**] U/S Bil LE: Persistent nonocclusive thrombus identified within the right popliteal vein. No evidence of DVT within the left lower extremity. . [**11-20**] CT Head w/ Sinus Views Study significantly degraded by patient motion artifact, demonstrating resolution of the hyperdense air/fluid level in the right maxillary sinus, partial clearing of the left sphenoid sinus air cell, and relatively stable, virtually complete opacification of the right sphenoid sinus. ENT consultation suggested, and particularly if drainage is contemplated, a repeat study is advised. . [**11-22**] CXR: Stable left lower lobe atelectasis versus airspace consolidation. Small left-sided pleural effusion. . . Micro . BCX - negative from [**11-6**], [**11-8**], [**11-14**], [**11-17**]. . UCX - negative from [**11-17**] . C-Diff - negative from [**11-15**] and [**11-18**]. . Sputum - [**11-7**] & [**11-9**] STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S . Sputum - [**11-14**] RARE GROWTH OROPHARYNGEAL FLORA. . Sputum - [**11-17**] SPARSE GROWTH OROPHARYNGEAL FLORA. . Central Venous Cath Tip [**11-15**] - No significant growth. Brief Hospital Course: Given massive bilateral PEs with associated respiratory failure and shock, pt was stabilized in the ED, treated with TPA, and admitted to the MICU for further management. During pt's course in the MICU, the following issues were addressed: . 1. Respiratory failure: Pt was intubated in the ED for airway protection and cardiopulmonary failure [**2-14**] massive PE. Pt was maintained on the ventilator from [**11-5**] to [**11-9**], extubated on [**11-9**], reintubated on [**11-13**] due to further respiratory distress, and extubated on [**11-22**]. Throughout course, pt received oral care, HOB > 30%, serial CXRs, and daily attempts to wean O2 and ventilator control of respiration. During intubation, pt was sedated with propofol, midazolam, and fentanyl. Pt's respiratory failure was complicated by resolving PEs, VAP (which was treated with abx specific to sputum culture growth), and some level of pulmonary edema (secondary to resuscitation efforts which was treated with diuresis). Pt's initial trial of extubation (beginning [**11-9**]) was successful until an acute spontaneous decompensation of respiration on [**11-13**] during bathing; because several nurses were with pt (bathing), he was immediately bag-mask ventilated following desaturation; pt progressed to hypotension with ALOC, and anesthesia was called to bedside w/in 5 minutes of decompensation; anesthesia was able to reintubate pt via fiberoptic ETT placement. F/u CT-PA failed to reveal new or worsening clot burden, and CXR failed to reveal signs of acute CHF or PTX; pt's decompensation was likely secondary to transient mucus plugging. Pt was maintained on the ventilator with daily efforts to wean O2 and to decrease PS; discussion with pt's wife and family regarding trach and trial of reextubation occurred daily, and the decision was made to pursue trial of extubation and to defer trach unless absolutely necessary. Following significant improvement in RSBI and overall clinical appearance, pt was extubated on [**11-22**] w/o issue. Pt's f/u CXR was encouraging, and pt was verbal and AAOx3 following weaning of sedation. . 2. Bilateral PE with hypotension - Diagnosed with [**Name (NI) **], pt's hemodynamic shock showed significant improvement s/p TPA. Pt was placed on heparin gtt per [**Hospital1 18**] weight-based nomogram. Pt was supported on levophed for < 24 hours with subsequent return of normotension. Serial HCTs and f/u CT head failed to reveal signs of hemorrage secondary to TPA and anticoagulation. U/S Bil LE revealed residual RLE popliteal DVT. Initial TTE revealed that the right ventricular cavity was moderately dilated with right ventricular systolic function appearing depressed. F/u TTE revealed pulmonary hypertension but improved right heart dilatation. F/u CT-PA following [**11-13**] resp distress showed improvement w/o further clot burden. Given that this was pt's initial episode of DVT/PE, he will need further hypercoagulability workup following step-down from ICU setting. . 3. Ventilator Associated PNA - Pt's difficulty weaning from the ventilator, worsening CXRs, fever spikes, and continued copious sputum production prompted empiric broad-spectrum abx which were subsequently narrowed to nafcillin due to sputum samples which grew MSSA. Pt continued to produce copious secretions and experienced reintubation on [**11-13**] and subsequent fever spikes, prompting switch back to broad spectrum abx. Pt's CXRs and respiratory status continued to improve subsequenty, sputum from [**11-18**] was negative, and the cause of his fevers became better explained by sinusitis; pt was then switched to Unasyn to cover sinusitis w/o further issue from VAP. . 4. Sinusitis - pt began to spike fevers following reintubation on [**11-13**], and he was treated with broad spectrum abx until CT of the head identified significant maxillary and sphenoid sinusitis. Unasyn was started to cover typical pathogens, and ENT was consulted for advice regarding the need for drainage. Dedicated sinus CT revealed interval improvment on Unasyn, and surgical drainage was deferred given improving fever and leukocytosis. Plan is to continue unasyn (or transition to augmentin) for total of 14 day course. . 5. Cardiovascular (a) Rhythm - no history of rhythm abnormalities; pt developed atrial flutter and fibrillation following his PE, which were muted via vagal maneuvers (such as passage of stool) but returned subsequently. Pt was managed with beta blockade and started on amio per cardiology recommendations. Subsequently, pt regained sinus rhythm w/o further issue. (b) [**Name (NI) **] - pt's EF and ventricular function remained intact as evidenced by two encouraging TTEs. Fluid overload was managed by diuresis. (c) Vessels = epigastric pain was worked-up for possible ACS, and was negative on several occassions via markers and EKGs. Pt was maintained on daily ASA. . 5. Epigastric Pain - r/o MI with negative markers and EKGs; occurred on several occassions when pt was intubated and NPO, so unable to provide GI cocktail for relief; seemed to worsen with pt was sitting up; treated with IV PPI (GERD) and IV morphine for pain. . 6. HTN - initially held home meds due to hypotension, metoprolol was started as patient had tachycardia. . 7. Right Popliteal DVT - on heparin gtt for PE, stable per f/u U/S. Patient will need labs to eval for hypercoaguability status. Medications on Admission: HCTZ 25mg PO QD Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Bilateral Pulmonary Emboli Discharge Condition: Stable Discharge Instructions: Please return to the hospital if you have sudden shortness of breath, chest pain, dizziness or fevers. . Please take all medications as directed. You have been started on a new medication, Coumadin, which is a blood thinner. It is very important that you take this medication as directed and have your blood checked weekly. Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks of discharge to rehab.

[ "473.0", "789.06", "427.31", "293.0", "507.0", "415.19", "518.81", "458.9", "275.3", "584.9", "784.7", "428.0", "453.8", "598.8", "285.9", "276.0", "999.9", "401.9", "473.3", "933.1", "785.59", "786.3", "427.32" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.72", "38.93", "33.23" ]

icd9pcs

[ [ [] ] ]

14328, 14407

8854, 14262

341, 366

14478, 14487

2050, 3871

14859, 14972

1725, 1742

14428, 14457

14288, 14305

14511, 14836

1757, 2031

277, 303

394, 1571

3880, 8831

1593, 1598

1614, 1709

16,787

193,030

20647

Discharge summary

report

Admission Date: [**2103-3-26**] Discharge Date: [**2103-3-30**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old female with a history of hypertension, diabetes type 2, inflammatory breast cancer who presented to an outside hospital ED on [**2103-3-19**] with chest pressure and shortness of breath at 11 a.m. The patient reported also having palpitations associated with tightness and shortness of breath. She has had palpitations on and off x2 months now. Denies any history of chest pain, paroxysmal nocturnal dyspnea, or orthopnea. She denied any associated nausea, vomiting, or diaphoresis. In the ED, she was noted to be in CHF. She ruled out for myocardial infarction, was noted to have T-wave flattening inferiorly and laterally, with an echocardiogram which showed global hypokinesis, mild MR [**First Name (Titles) **] [**Last Name (Titles) **], mild AS, and ejection fraction of 30 to 35 percent with a dilated hypokinetic right ventricle, severe pulmonary hypertension. She had a Persantine MIBI, which showed diffuse fixed defects with partially reversible septal defect. She was sent for a CT angiogram, which showed no pulmonary embolism, moderate bilateral pleural effusions. She was subsequently sent for catheterization, which revealed severe pulmonary hypertension, pulmonary capillary wedge pressure 15 with calcified 80 percent proximal LAD lesion and a 75 percent mid LAD lesion. Left main with 30 to 40 percent distal stenosis without dampening of pressures, 70 percent ostial RCA lesion. She was subsequently transferred here initially for possible CABG, but felt to be contraindicated with chronic right breast wound status post XRT and poor healing would be expected. She therefore underwent rotablation of her proximal LAD and mid LAD lesions today. PHYSICAL EXAMINATION: Temperature 94.2 degrees, heart rate 86, blood pressure 150/92, respirations 17, saturating 99 percent on 2 liters. Generally, she is in no acute distress. Alert and oriented x3. HEENT: Mucous membranes moist. JVP at 9 cm . No bruits. CARDIOVASCULAR: Regular rate and rhythm, 2/6 systolic murmur at the right upper sternal border, [**1-19**] holosystolic murmur at the apex. PULMONARY: Bibasilar crackles. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. EXTREMITIES: Two plus pedal edema, trace dorsalis pedis pulses, 1 plus posterior tibial pulses bilaterally. BREAST: Small right breast ulcer with small amount of clear drainage, no fluctuance or erythema. LABORATORY DATA: White count 8.6, hematocrit 36, platelets 228,000, INR 1.1, sodium 142, potassium 4, chloride 107, bicarbonate 27, BUN 43, creatinine 1.6, glucose 100, magnesium 1.8, ALT 10, AST 14, LDH 204, alkaline phosphatase 74. EKG: Normal sinus rhythm at 84 beats per minute. Normal interval and axis. Inferior T-wave flattening. T- wave flattening in AVL, V5, and V6. No ST changes. Chest x- ray: Unchanged collapse and consolidation of the right middle lobe, right lower lobe, and partial right upper lobe. Catheterization here revealed left main distal 30 to 40 percent stenosis into the origin of the LAD, no dampening, LAD calcified, 85 percent proximal and 75 percent mid lesions both rotablated, circumflex 40 percent mid vessel OM margins, and small vessel 60 percent, RCA ostial 70 percent, and 50 percent distal lesions. HOSPITAL COURSE: Ischemia: The patient remained chest pain- free after interventions. She was continued on Lopressor and Integrilin after catheterization for 18 hours, Plavix, aspirin, and statin. She will need to have likely future RCA intervention, pumped ejection fraction 30 to 35 percent, global hypokinesis with severe pulmonary hypertension. Euvolemic after catheterization, Lasix was held initially. Rhythm, normal sinus rhythm. Breast ulcer: Was seen by Dr. [**Last Name (STitle) **] of Breast Surgery, looked uninfected during her stay. She can follow up with Dr. [**Last Name (STitle) **] if she wants possible revision of her fistulous tracts. Chronic renal insufficiency: Creatinine baseline at 1.3. She was given 2 doses of Mucomyst after catheterization. Her ACE inhibitor and Lasix were held initially. Diabetes: Her oral agents were held. After catheterization, was continued on Regular Insulin sliding scale and was restarted on her oral agents on discharge. DISCHARGE DISPOSITION: Stable. DISCHARGE STATUS: The patient was discharged to home. FOLLOW UP PLANS: The patient is to follow up with her primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6051**], in the next week. She is also to have her labs drawn on Monday, to have her renal function and electrolytes checked with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6051**]. She is to follow up with her cardiologist, Dr. [**Last Name (STitle) 55162**], in 2 weeks regarding further intervention on her right coronary artery. She is to make appointment with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] of Breast Surgery if she is interested in having surgical revision of her chronic right breast wound. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Nitroglycerin 0.3 mg p.o. every 5 minutes p.r.n. 3. Plavix 75 mg p.o. q.d. 4. Lipitor 80 mg p.o. q.d. 5. B12, 50 mcg p.o. q.d. 6. Glipizide 15 mg p.o. q.a.m., 10 mg p.o. q.p.m. 7. Pioglitazone 45 mg p.o. q.d. 8. Enalapril 10 mg p.o. q.d. 9. Toprol XL 100 mg p.o. q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], [**MD Number(1) 10119**] Dictated By:[**Last Name (NamePattern1) 15388**] MEDQUIST36 D: [**2103-5-15**] 17:37:48 T: [**2103-5-16**] 12:06:19 Job#: [**Job Number 55163**]

[ "416.0", "593.9", "411.1", "428.0", "998.83", "250.00", "285.9", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.07", "88.56", "99.20", "36.01", "37.61" ]

icd9pcs

[ [ [] ] ]

4400, 5162

5185, 5759

3403, 4376

1846, 3385

118, 1823

20,202

106,501

22861

Discharge summary

report

Admission Date: [**2109-1-10**] Discharge Date: [**2109-1-18**] Date of Birth: [**2109-1-10**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 24049**] is a former 3.20 kilogram product of a 38 [**1-7**] week gestation pregnancy born to a 38 year old gravida V, now P III woman. Prenatal screens: Blood type A positive, anti-[**Doctor Last Name **] antibody positive, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status unknown. The pregnancy was complicated by hypertension for two weeks prior to delivery. The mother had an elective induction which resulted in a vaginal delivery under epidural anesthesia. Apgars were 9 at one minute and 9 at five minutes. The infant was admitted to the newborn nursery. Course was notable for significant jaundice. Blood type was A positive, Coombs negative. Phototherapy was initiated for a peak serum bilirubin of 12.9/0.4 mg per dl. On day of life number 4 he developed a fever to 101.3 degrees Fahrenheit and he was admitted to the neonatal Intensive Care Unit for evaluation for sepsis. Of note his 18 year old brother had been to visit and held him. He later reported sore throat and fever. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit weight 3.095 kilograms, head circumference 35 cm. In general nondysmorphic term male. Head, eyes, ears, nose and throat: Anterior fontanelle soft and flat, nondysmorphic facies. Palate intact. Chest: Clear breath sounds. Cardiovascular: No murmur. Femoral pulses plus 2. Abdomen soft with normal bowel sounds, no hepatosplenomegaly. Genitourinary: Normal male genitalia. Testes descended bilaterally. Musculoskeletal: No hip click, no sacral dimple. Neurologic: Active with normal tone, cries but easily consoled. Normal activity. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. RESPIRATORY: [**Known lastname **] was on room air for his entire Neonatal Intensive Care Unit admission. There was no evidence of respiratory distress. 2. CARDIOVASCULAR: [**Known lastname **] maintained normal heart rates and blood pressure. No murmurs were noted. 3. FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] continued to ad lib P.O. feed breastfeeding or Similac formula. He had normal urine and stool output. 4. INFECTIOUS DISEASE: Due to the fevers [**Known lastname **] was evaluated for sepsis. A complete blood count was within normal limits. Blood and cerebrospinal cultures were obtained. He was started on intravenous ampicillin, gentamicin and Acyclovir. The bacterial cultures were no growth at 48 hours and the ampicillin and gentamicin were discontinued. The herpes simplex virus PCR was obtained at the time of the lumbar puncture and was negative with the results reported on [**2109-1-18**]. Upon performance of the lumbar puncture there were 311,000 red blood cells and 3,000 white blood cells. There were no bacterial organisms seen on the gram stain and as both cultures were negative the possibility of meningitis was ruled out. At the time of discharge [**Known lastname **] continued to have a higher than normal body temperature with baseline temperatures 98.6 to 99.6 degrees Fahrenheit. The parents are instructed to call the pediatrician if the fever is over 101 degrees Fahrenheit. 5. GASTROINTESTINAL: As previously noted [**Known lastname **] was treated for unconjugated hyperbilirubinemia with phototherapy. His rebound bilirubin was 10.5/0.8 on day of life number three. Liver function tests were sent as part of his sepsis evaluation and were within normal limits. 6. HEMATOLOGY: [**Known lastname **] is blood type A positive and is Coombs negative. 7. NEUROLOGY: [**Known lastname **] has maintained a normal neurological examination during admission. There were no concerns at the time of discharge. Due to the bloody (reportedly non- traumatic) LP, HUS was done to rule out intracranial hemorrhage. HUS was normal. Subarachnoid hemorrhage is possible, and would not have been picked up on HUS alone, but would not have necessitated further clinical management, therefore further imaging was not done. 8. AUDIOLOGY: Hearing screen was performed with automated auditory brain stem responses. [**Known lastname **] passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. The primary pediatrician is either Dr. [**Last Name (STitle) 38832**] or Dr. [**First Name (STitle) 4223**] [**Hospital 59106**], [**Hospital1 59107**], [**Location (un) 686**], [**Numeric Identifier 59108**]. Phone number [**Telephone/Fax (1) 7976**]. Fax number [**Telephone/Fax (1) 12895**]. 1. Feeding ad lib breast feeding. 2. No medications. 3. Car seat position screening not indicated. 4. State newborn screen was sent on [**2109-1-12**] with no notification of abnormal results to date. 5. Hepatitis B vaccine administered on [**2109-1-12**]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria of: 1) born at less than 32 weeks; 2) born between 32 and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings; or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW UP APPOINTMENTS SCHEDULED OR RECOMMENDED: 1) [**Hospital6 407**] will be making home visits to check temperature and support mother with breast feeding. 2) Appointment [**Location **] within three days of discharge. DISCHARGE DIAGNOSES: 1. Fever likely secondary to viral illness. 2. Suspicion for sepsis, ruled out. 3. Suspicion for HSV infection, ruled out. 4. Unconjugated hyperbilirubinemia, treated. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**] Dictated By:[**Last Name (NamePattern1) 59109**] MEDQUIST36 D: [**2109-1-18**] 13:26:59 T: [**2109-1-18**] 14:46:16 Job#: [**Job Number 59110**]

[ "774.6", "V30.00", "V29.0", "079.99", "V05.3" ]

icd9cm

[ [ [] ] ]

[ "99.55", "03.31", "99.83" ]

icd9pcs

[ [ [] ] ]

4524, 5109

6116, 6555

1272, 4468

5137, 6095

164, 1249

4493, 4500

13,494

188,037

8248

Discharge summary

report

Admission Date: [**2147-4-27**] Discharge Date: [**2147-5-4**] Date of Birth: [**2085-6-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3624**] Chief Complaint: hyperglycemia, fever, lethargy Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This is a 58 year old white male with diabetes mellitus, hypertension, end stage renal disease, status post renal transplant on rapamune, prednisone and Imuran, severe PVD status post bilateral AKA presenting with hyperglycemia, diarrhea, fever. Onset 2 weeks PTA with diarrhea, watery large volume as per patient, twice daily, brown colored, with no associated abdominal pain. Last on Abx in [**Month (only) **]. Diarrhea relieved with imodium. Pt also reports "feeling out of it" starting two weeks PTA feeling week, fatigued and forgetful. One week prior to admission onset of dry cough, not worse with position or movement with associated fever, rhinorrhea. Decreased urination, brownish colored, increased thirst. Reports finger sticks increasing to 400 range this week as per wife. Checked this AM, 480, one hr later to 500. Given general malaise and high FS to the ED. . glucose to 483, BUN 66, Cr 5.6 up from 1.4, Sodium 134, Bicarb 16. Gap 19. Potassium to 5.3. Lethargic with low grade fevers. Bld cx x 2, urine culture. insulin gtt, ket in urine. pyuria. CTX 1 gram and Vanc 1 gram given. lactate 4.2 central placed - L femoral (no right), could not get R IJ, or R Subclavian. CXR neg. Vitals 100.5, BP 130/60 no pressors, HR 74, 96% 2L. 2L NS given. Renal Fellow notified. To floor, where patient febrile to 102.6, complaining of general illness and cough. . He was hospitalized [**2143-4-1**],through [**2143-4-5**], and [**2143-5-8**], through [**2143-5-20**], with an infected right below the knee amputation stump. The patient underwent a revision of his right below the knee amputation stump on [**2143-5-9**], by Dr. [**Last Name (STitle) 1391**]. Wound cultures grew pseudomonas, Staphylococcus coagulase negative (Oxacillin resistant), and Stenotrophomonas multifilia. During that hospitalization, the patient was treated with intravenous Vancomycin and Zosyn. Elective Left AKA [**2145-3-22**]. Stable since that time. Creatinine 1.7 stable x several years. Reports usually takes medications, including immunosuppressants but sometimes forgets Past Medical History: 6 yrs 10 months post cadaveric kidney transplant. Type 1 diabetes triopathy secondary to [**Doctor Last Name 360**] [**Location (un) 2452**] HTN end-stage renal disease status post cadaveric renal transplant in [**2142**] history of recurrent UTIs status post right BKA and [**2140**] left BKA in [**2140**], right BKA revision in [**2143**] with AKA. Left AKA [**2145-3-22**]. possible stricture or stenosis of the proximal central veins - very difficult IJ or subclavian access in the past PAST SURGICAL HISTORY: 1. Open reduction and internal fixation left hip [**2139**]. 2. AV fistula with revision both arms. 3. Laparoscopic lysis of adhesions. 4. Cataract extraction and intraocular lens O.U. 5. Penile implant. 6. Cadaveric renal transplant [**2140-6-23**], by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16495**] at [**Hospital1 69**]. 7. Renal biopsy [**2140-10-23**]. 8. Bilateral below the knee amputations [**2139**], at outside hospital. 9. Revision of right below the knee amputation on [**2143-5-9**], by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**]. L AKA [**2145**] Social History: The patient is married, second marriage, prosthesis and wheelchair. Denies alcohol. Smoked [**2-25**] cigarrettes daily. Prior one pack per year smoker. Family History: Brother with Diabetes Physical Exam: Vitals: T: 102.2 P: 106 BP: 147/60 R: 20 93% RA General: somnolent disheveled male laying in bed. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus. Dentures. Mucous membranes dry. Neck: supple, no JVD or carotid bruits appreciated. Echymoses and erythema at sight of attempted IJ. Pulmonary: diminished breath sounds bilaterally, no crackles, or wheezing heard. Cardiac: RRR, nl. S1S2, no M/R/G noted, soft heart sounds Abdomen: soft, NT/ND, normoactive bowel sounds, Mass- presumed kidney felt RLQ. Insicional scar. Extremities: bilateral AKA, no lesions, echymoses, fluctuance as distal aspects. Warm. 2+ Fem pulse on the right. Skin: no rashes or lesions noted. Neurologic: oriented to person, date,did not know the name of the hospital. Pertinent Results: [**2147-4-27**] 05:40PM PT-10.7 PTT-30.5 INR(PT)-0.9 [**2147-4-27**] 05:40PM PLT COUNT-167 [**2147-4-27**] 05:40PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-1+ BURR-OCCASIONAL ACANTHOCY-OCCASIONAL [**2147-4-27**] 05:40PM NEUTS-84* BANDS-12* LYMPHS-1* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2147-4-27**] 05:40PM WBC-13.6*# RBC-3.85* HGB-11.4* HCT-33.9* MCV-88 MCH-29.7 MCHC-33.8 RDW-16.2* [**2147-4-27**] 05:40PM rapamycin-10.3 [**2147-4-27**] 05:40PM CALCIUM-9.0 PHOSPHATE-5.5*# MAGNESIUM-2.1 [**2147-4-27**] 05:40PM estGFR-Using this [**2147-4-27**] 05:40PM GLUCOSE-483* UREA N-66* CREAT-5.6*# SODIUM-134 POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-16* ANION GAP-24* [**2147-4-27**] 05:53PM LACTATE-4.2* [**2147-4-27**] 07:00PM URINE RBC-[**3-27**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2147-4-27**] 07:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2147-4-27**] 07:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018 [**2147-4-27**] 08:20PM CRP-GREATER TH [**2147-4-27**] 08:20PM CORTISOL-53.5* [**2147-4-27**] 08:20PM LIPASE-8 [**2147-4-27**] 08:20PM ALT(SGPT)-32 AST(SGOT)-32 ALK PHOS-90 AMYLASE-10 TOT BILI-0.3 [**2147-4-27**] 09:46PM LACTATE-2.3* [**2147-4-27**] 09:46PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF [**2147-4-27**] 11:54PM CALCIUM-7.9* PHOSPHATE-3.0# MAGNESIUM-1.9 [**2147-4-27**] 11:54PM GLUCOSE-238* UREA N-65* CREAT-5.6* SODIUM-139 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-18* ANION GAP-20 [**2147-4-27**] 11:57PM URINE RBC-184* WBC->1000* BACTERIA-MANY YEAST-NONE EPI-0 [**2147-4-27**] 11:57PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2147-4-27**] 11:57PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2147-4-27**] 11:57PM URINE HOURS-RANDOM UREA N-442 CREAT-146 SODIUM-27 Brief Hospital Course: 1. Gram negative rod bacteremia from urosepsis: The patient was treated with a 14 day course of ciprofloxacin with good result. Surveillance cultures were all negative. . 2. Renal failure: Likely due to prerenal azotemia. He had a renal ultrasound which demonstrated increased resistive indices, however, it was not thought his renal insufficiency was from rejection. The patient was hydrated and given blood transfusions and he had an improvement in his creatinine. He was maintained on his home immunosuppression of Imuran, prednisone and Rapamune. The patient had elevated rapamune levels related to his concurrent antibiotic use. He required decreased rapamune dosing during his period of antibiotic treatment. His labs will be closely followed as an outpatient and his dose adjusted as necessary. . 3. Type I diabetes: the patient presented in DKA and was well controlled on an insulin drip. He was converted back to his home regimen of 45 units every morning and sliding scale. . 4. Anion gap metabolic acidosis: due to dka and uremia. In addition to treating the underlying precipitants, he was given bicarbonate replacement for a short time. . 5. Anemia: the patient was transferred to the floor after having a 12 point hematocrit drop over a period of 3 days. His initial hematocrit was likely dry. Repeat of his 22.9 value was 25. The patient received 2 units blood transfusion without complication. . 6. Access: Had a femoral line during ICU stay which intermittently had difficulty drawing back. Ultimately a bedside PICC was placed which required IR revision. Access is very difficult in this patient. . 7. Disposition: he was discharged home with close follow up. PICC removed. Medications on Admission: Ranitidine 150 mg qd Amlodipine 10 mg qd, Pancrelipase (Creon) 4 cap tid Azathioprine (Imuran) 50 mg qd with dinner Furosemide 40 mg prn Metoprolol 200 mg [**Hospital1 **] Bactrim SS 1 MWF prednisone 5 mg qd, Rapamune 3 mg qd 2 PM daily Calcium Carbonate 648 mg, 2 TID Lisinopril 5 mg daily Lipitor 40 mg daily NPH 45 units [**Hospital1 **], humulog sliding scale. Discharge Medications: 1. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 2 weeks. Disp:*qs * Refills:*0* 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QMWF (). Disp:*12 Tablet(s)* Refills:*2* 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*360 Cap(s)* Refills:*2* 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 9. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 15. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Forty Five (45) units Subcutaneous qAM. 16. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: PER SLIDING SCALE Subcutaneous four times a day: PER SLIDING SCALE. Disp:*qs * Refills:*2* 17. Outpatient Lab Work Please check a chem-10, rapamycin level, and CBC. To the laboratory: Please forward lab results to: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 15170**], [**Street Address(2) **]., [**Location (un) **], [**Numeric Identifier 19662**] Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic ketoacidosis Acute renal failure Bacteremia scrotal lesion Secondary: diabetes type I hypertension peripheral vascular disease Discharge Condition: Stable. The patient is asymptomatic, at his baseline functional status and his renal function is improving. Discharge Instructions: Please take all medications as prescribed. Please follow-up with your appointments as below. Please contact your doctor or go to the emergency room if you experience: --lightheadedness or weakness --chest pain or shortness of breath --abdominal pain --fever or chills --blood in your stool or black, tarry stool Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-5-23**] 10:40 The office of your primary care physician, [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] contact you for an appointment within the next week. IF you have not hear from his office by [**2147-5-9**], please call them at [**Telephone/Fax (1) 19657**] to set up an appointment. On [**2147-5-8**] you should have your labwork drawn as attached at the C-lab near your home. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

[ "V49.76", "996.81", "584.5", "401.9", "362.01", "250.43", "276.50", "250.13", "038.42", "599.0", "250.53", "250.63", "357.2", "583.81", "276.7", "E878.0", "995.92" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

10939, 10945

6619, 8318

344, 350

11135, 11245

4610, 6596

11608, 12329

3795, 3818

8734, 10916

10966, 11114

8344, 8711

11269, 11585

2987, 3609

3833, 4591

274, 306

378, 2450

2472, 2964

3625, 3779

50,391

182,520

54429

Discharge summary

report

Admission Date: [**2188-10-1**] Discharge Date: [**2188-10-9**] Date of Birth: [**2104-12-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: hematuria Major Surgical or Invasive Procedure: None History of Present Illness: 83 y/o F with PMH severe dementia (nonverbal at baseline), chronic UTIs, stage III-IV sacral decubitus ulcers, afib and recurrent DVTs on coumadin p/w hematuria and vaginal bleed in the setting of an elevated INR. Per nursing home, patient was found to have an elevated INR to 7.34 on routine labs and her coumadin was being held. She was noted to have vaginal oozing and hematuria so was brought to [**Hospital1 18**] for further evaluation. In the ED, initial VS 96.4 96 105/72 18 100%. Initial exam was notable for large stage 3-4 sacral decub and ulcer on right buttocks with packing in place. Pelvic exam revealed dried blood in vaginal vault with no signs of active bleeding. Chronic foley in place draining tea colored urine. Initial labs notable for Na of 174, Cr of 1.7 (baseline of 0.8) and INR of 6.5. CXR was negative and AP pelvis to evaluate for OA pnding. She was reversed with vit K 10mg SC x 1, 1L NS bolus x 2, and received vanc and ceftriaxone for UTI. She was subsequently transferred to the ICU. Past Medical History: PMH last Updated [**2187-5-31**] - cholilithiais and choledocholithiasis with recurrent admissions for ascending cholangitis s/p [**Month/Day/Year **]/stents, perc chole. last [**Month/Day/Year **] [**4-20**] stent placement, removed on [**5-30**] with more stone extraction and another stent placed. - recurrent C.diff [**3-21**] and [**4-20**] - paroxysmal Afib -on coumadin - DVT on coumadin, dx [**3-21**], L common femoral, still present [**4-20**] - DM2 on insulin - HTN - Recurrent admission for dehydration/hypernatremia - Recurrent UTIs with MDR organisms (ecoli, pseudomonas-?colonizer)-on chronic foley - Dysphagia-dx [**4-20**], on pureed diet with nectar thicks, 1:1 supervision, aspiration precautions - Osteochondroma of L knee as a child - MVP - Alzheimer's disease - severe, baseline speaks to self, doesnt recognize people - Sacral decub (stage IV) and bilateral heel (stage III) pressure and deep tissue wounds - severe knee arthitis-bed bound - Anemia-?ACD, baseline H/H [**9-11**] - s/p right ORIF of hip fracture at age 75 Social History: Lives at nursing home. No alcohol or drugs. Family History: Daughter with arthritis, father died of hepatitis C from a blood transfusion. Mother died at age 86 of a myocardial infarction. Son with hypertension. Physical Exam: VS: T98.2, P 83, BP 82/40, RR 18, O2 Sat 100% on RA GEN: Extremely frail appearing elderly woman lying in bed HEENT: PERRL, anicteric, MM extremely dry appearing, pt will not open mouth for full exam, no jvd RESP: CTA Bilaterally with good air movement CV: RRR, normal S1 and S1 ABD: Soft, NT, ND, BS+, no organomegaly EXT: No clubbing, cyanosis, edema, faint pulses SKIN: no rashes/no jaundice/no splinters NEURO: Babbling a small amount nonsensically, moving all four extremities, no facial droop or other obvious focal deficits. Pertinent Results: Admission/pertinent labs: [**2188-10-1**] 05:08AM BLOOD WBC-10.3 RBC-5.01# Hgb-11.0*# Hct-38.1# MCV-76* MCH-22.0*# MCHC-29.0* RDW-18.7* Plt Ct-278 [**2188-10-1**] 05:08AM BLOOD Neuts-75.1* Lymphs-19.2 Monos-2.5 Eos-2.7 Baso-0.5 [**2188-10-1**] 05:08AM BLOOD PT-57.7* PTT-35.5* INR(PT)-6.5* [**2188-10-1**] 05:08AM BLOOD Glucose-256* UreaN-56* Creat-1.7* Na-174* K-4.1 Cl-144* HCO3-19* AnGap-15 [**2188-10-1**] 05:08AM BLOOD ALT-12 AST-13 LD(LDH)-215 AlkPhos-128* TotBili-0.5 [**2188-10-1**] 05:08AM BLOOD Lipase-36 [**2188-10-1**] 05:08AM BLOOD cTropnT-0.04* [**2188-10-1**] 05:08AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.7 Mg-2.3 [**2188-10-3**] 08:32AM BLOOD Lactate-1.9 [**2188-10-1**] 05:20AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.015 [**2188-10-1**] 05:20AM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [**2188-10-1**] 05:20AM URINE RBC->50 WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0 . Other Pertinent Labs: [**2188-10-4**] 12:43PM BLOOD calTIBC-170* Ferritn-46 TRF-131* [**2188-10-3**] 08:32AM BLOOD Lactate-1.9 . Discharge Labs: [**2188-10-9**] 05:38AM BLOOD WBC-5.5 RBC-4.10* Hgb-9.8* Hct-30.8* MCV-75* MCH-23.8* MCHC-31.7 RDW-20.4* Plt Ct-182 [**2188-10-9**] 05:38AM BLOOD PT-19.1* PTT-34.4 INR(PT)-1.7* [**2188-10-9**] 05:38AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-141 K-3.8 Cl-110* HCO3-25 AnGap-10 [**2188-10-9**] 05:38AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.7 . MICRO: [**10-1**] MRSA Screen: positive [**10-1**] UCx: negative [**10-3**] UCx: YEAST. 10,000-100,000 ORGANISMS/ML [**10-3**] BCx: pending, no growth to date at time of discharge [**10-3**] C. diff: negative [**10-5**] UCx: YEAST. 10,000-100,000 ORGANISMS/ML. PROBABLE ENTEROCOCCUS. ~3000/ML. [**10-5**] BCx: pending, no growth to date at time of discharge . STUDIES: [**10-1**] ECG: Baseline artifact. Probable sinus rhythm with atrial premature beats with some aberration. Borderline low limb lead voltage. ST-T wave abnormalities. Since the previous tracing of [**2188-4-19**] the rate is slower. ST-T wave abnormalities are less prominent. [**10-1**] CXR: Stable left basilar atelectasis and/or scarring. No acute cardiopulmonary process including no evidence of pneumonia. [**10-1**] Pelvic Film: Suboptimal exam. No osteomyelitis suggested. [**10-5**] CHEST X-RAY (PORTABLE AP) FINDINGS: As compared to the previous radiograph, there is a diffuse increase in density of the lung parenchyma, presumably caused by projection. However, in addition, there is a newly appeared retrocardiac opacity that could be caused by a combination of atelectasis and pneumonia. Increasing diameter of the azygos vein, increasing diameters of the pulmonary vessels. Both could indicate mild overhydration. The presence of a minimal left pneumothorax cannot be excluded. The left PICC line has been pulled back, the tip now projects over the mid SVC. Brief Hospital Course: 83 y.o. female w/ history of DVT, AF, decubitus ulcers, and hypernatremia who presents with vaginal bleeding and hypernatremia. #. Hypernatremia: Patient appeared volume depleted and had perfusion-related kidney injury on admission. Likely associated with free water deficit from inadequate access to fluids/free water. The patient was hydrated with IV fluid, and had general downward trend in Na levels to within normal range prior to discharge. IVF were discontinued, and the patient's Na remained WNL with adequate PO intake. The patient should have adequate access to food/fluids on discharge, as this is essential to prevent recurrence of hypernatremia.. She is unable to ask for food and water, but is able to eat if she is fed. #. Hypotension: After transfer from ICU to floor, the patient was noted to be hypotensive to the 80s on occasion. During one episode of hypotension, she was noted to have an axillary temperature of 99.5. Blood cultures obtained ([**2188-10-5**]) were negative to date at time of discharge. Urine culture was positive for yeast, thought to be colonization and not acute infection. A CXR was also obtained, and showed a possible retrocardiac opacity, ?atelectasis vs pneumonia. She was not started on antibiotics given absence of fever, leukocytosis, pulmonary symptoms or findings on lung exam. SBP had improved to 130s prior to discharge after transfusion of 2 units PRBCs on [**2188-10-7**] for anemia, other vitals remained stable, and the patient remained afebrile. . #. Blood Loss/Anemia: Bleeding (hematuria/vaginal bleeding prior to admission) was presumably secondary to elevated INR, which occurred in setting of antibiotic use/interaction with regular warfarin dose. No signs of bleeding on ED pelvic exam and the patient was hemodynamically stable on arrival to MICU. She received vitamin K in ED and was given FFP on arrival to MICU, to decrease INR for PICC line placement. Upon transfer to the floor the patient was noted to have anemia, but it was unclear how much of her HCT drop was secondary to hemodilution in setting of fluid resuscitation. Iron studies c/w iron deficiency anemia, and the patient was started on iron supplementation as she did not have any active signs of bleeding. HCT continued to trend down, but there was no clear source of active bleeding. Stool was guiac negative. The patient was transfused 2 units pRBCs on [**2188-10-7**], with appropriate rise in HCT. HCT stable prior to discharge. Of note, her coumadin was restarted prior to discharge, INR still subtherapeutic at 1.7 on day of discharge. . #. Stage III/IV decubitus ulcer: Wound care and social work consults placed on admission. The patient was given vitamin C and zinc therapy. She should continue to receive wound care at nursing facility, and a foley catheter should remain in place to help prevent infection of sacral/perineal wounds. She had a flexiseal in place during this admission, which was removed prior to discharge as she leaked stool around it. . #. Acute Kidney Injury: Cr elevated at 1.7 on admission, from baseline of 0.8, in setting of severe dehydration. Cr improved with IV fluids, and was back to baseline of 0.7 at time of discharge. #. Diabetes Mellitus type II: The patient was written for an insulin sliding scale, which was uptitrated early in MICU admission. She was started on long-acting insulin once taking PO. #. Urine yeast: Urine culture from [**2188-10-3**] showed 10,000-100,000 yeast. Foley was changed, and repeat urine culture from [**2188-10-5**] also positive for yeast. The patient was not started on antibiotics or antifungals, as this was felt to represent colonization and not acute infection. Her foley was replaced after [**2188-10-5**], and should remain in place chronically. . #. h/o DVT/a fib: The patient was in sinus rhythm during the admission. Her coumadin was initially held in setting of supratherapeutic INR and bleeding, and INR was reversed. As above, coumadin restarted prior to discharge. Dose should be adjusted accordingly based on INR trend, and dose was changed back to pre-admission dosing of 3mg daily prior to discharge. INR 1.7 on day of discharge. . Code Status: The patient is DNR, but may be intubated for short-term airway protection per family wishes. Medications on Admission: Medications at Rehab: -Regular insulin sliding scale -Insulin NPH 20 units QAM -Coumadin 3 mg daily -Omeprazole 40 mg daily -Trazodone 12.5 mg PO QHS -Vitamin C -Zinc sulfate 220 daily -Ciprofloxacin 250 mg dialy (started [**9-27**]) Discharge Medications: 1. zinc sulfate 220 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO DAILY (Daily). 2. ascorbic acid 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Year (2) **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg Iron) Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 650 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 6. heparin (porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) injection Injection TID (3 times a day). 7. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 8. polyethylene glycol 3350 17 gram/dose Powder [**Month/Year (2) **]: One (1) 17 gram/dose PO DAILY (Daily) as needed for constipation. 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable PO TID (3 times a day). 10. warfarin 3 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 11. insulin glargine 100 unit/mL Solution [**Month/Year (2) **]: Twenty (20) units Subcutaneous at bedtime. 12. insulin regular human 100 unit/mL (3 mL) Insulin Pen [**Month/Year (2) **]: as per sliding scale Subcutaneous with meals and at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare of [**Location (un) 1439**] Discharge Diagnosis: Primary Diagnosis: - Hypernatremia, hypovolemic Secondary Diagnosis: -Anemia of chronic disease plus iron deficiency -Dementia -Multiple decubitus ulcers -Diabetes Mellitus type II, controlled Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Ms. [**Known lastname 4027**], you were admitted to the hospital after having an episode of bleeding. We also found that your sodium level was high, and you were brought to the ICU to be given fluids. Your bleeding resolved while you were in the hospital after we stopped your blood-thinning medication. Your sodium levels also improved after we gave you fluids. You became more anemic after the bleeding, and we started you on an iron supplement. We also gave you a blood transfusion. We made the following changes to your medications: 1. STOPPED ciprofloxacin 2. STOPPED trazaodone 3. STARTED ferrous sulfate 4. STARTED vitamin D 5. STARTED calcium carbonate 6. STARTED miralax as needed for constipation 7. CHANGED omeprazole from 40mg daily to 20mg daily . We did not make any other changes to your medications, so please continue to take them as prescribed by your physician. Followup Instructions: Please have your facility make an appointment for you with Dr. [**First Name (STitle) 19961**] by calling [**Telephone/Fax (1) 33016**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

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32341

Discharge summary

report

Admission Date: [**2134-9-15**] Discharge Date: [**2134-10-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: fever, jaundice, abdominal pain Major Surgical or Invasive Procedure: ERCP ([**9-15**]) Intubation Central Venous Line Insertion Blood Transfusion ([**10-3**]) History of Present Illness: History obtained from chart, patient was intubated and sedated and has not been to [**Hospital1 18**] previously. Patient is an 86 yo male with pmhx of HTN, colon CA, prostate CA, s/p cholecystectomy transferred from [**Hospital **] Hospital with acute cholangitis. Patient presented to [**Hospital1 **] with fever to 102, jaundice, and complaints of pain for 24 hours. His total bilirubin was 11 and direct bilirubin was 9. He had a RUQ US that showed CBD/intrahepatic ductal dilatation at the OSH and was transferred here for ERCP. Patient was tacchypneic and had mental status changes per the ED and was intubated for airway protection. . In the [**Hospital1 18**] ED, initial VS were: T 96.2 HR 98 BP 106/82 R 12 O2 sat 96% on RA. He was given 1 g vancomycin and 3 g unasyn and 5 liters of NS. Both surgery and ERCP were consulted. ERCP planned for this morning. . On presentation to the [**Hospital Unit Name 153**], patient was intubated and sedated. His vs were: T 102.8 rectal, BP 88/48, P 94, 100% vented. Past Medical History: HTN prostate cancer colon cancer s/p cholecystectomy Social History: unable to obtain Family History: unable to obtain Physical Exam: VS: T 102.8 (rectal) P 94 BP 88/48, 93/45 RR 25 O2sat 100% Vent settings: TV 550, rate 14 (breathing over at 25) FiO2 50% PEEP 5 Gen- intubated and sedated HEENT- ncat, mmd, perrl, icteric sclera Cor- tachycardic, distant heart sounds, 1/6 SEM loudest at LUSB and RUSB, no r/g Pulm- ctab anteriorly with no w/r/r Abd- soft, hypoactive bowel sounds, nondistended, no hsm Extrem- distal LE pulses not appreciated, no c/c/e Skin- jaundiced, no rashes Pertinent Results: [**2134-10-7**] 06:40AM BLOOD WBC-3.1* RBC-3.19* Hgb-9.0* Hct-26.2* MCV-82 MCH-28.1 MCHC-34.2 RDW-18.4* Plt Ct-182 [**2134-10-6**] 06:05AM BLOOD WBC-3.0* RBC-3.23* Hgb-9.0* Hct-26.5* MCV-82 MCH-28.0 MCHC-34.1 RDW-17.9* Plt Ct-175 [**2134-10-5**] 06:05AM BLOOD WBC-3.5* RBC-3.47* Hgb-9.7* Hct-28.2* MCV-81* MCH-27.9 MCHC-34.3 RDW-18.1* Plt Ct-212 [**2134-10-4**] 01:00PM BLOOD WBC-3.3* RBC-3.48*# Hgb-9.9*# Hct-28.4*# MCV-82 MCH-28.5 MCHC-34.9 RDW-17.9* Plt Ct-168 [**2134-10-3**] 06:00AM BLOOD WBC-2.3* RBC-2.60* Hgb-7.1* Hct-21.8* MCV-84 MCH-27.3 MCHC-32.6 RDW-18.7* Plt Ct-175 [**2134-9-14**] 11:20PM BLOOD WBC-3.0* RBC-3.47* Hgb-10.1* Hct-31.4* MCV-91 MCH-29.0 MCHC-32.0 RDW-22.6* Plt Ct-127* [**2134-9-15**] 05:09AM BLOOD WBC-13.2*# RBC-2.65* Hgb-7.7* Hct-23.8* MCV-90 MCH-29.2 MCHC-32.4 RDW-21.2* Plt Ct-77* [**2134-9-15**] 04:59PM BLOOD Hct-34.6*# Plt Ct-153# [**2134-9-16**] 04:46AM BLOOD WBC-19.0* RBC-3.76*# Hgb-10.8*# Hct-32.8* MCV-87 MCH-28.8 MCHC-33.1 RDW-21.1* Plt Ct-127* [**2134-10-5**] 06:05AM BLOOD Neuts-62.4 Bands-0 Lymphs-30.7 Monos-4.6 Eos-2.0 Baso-0.2 [**2134-10-5**] 06:05AM BLOOD PT-13.4* PTT-32.1 INR(PT)-1.2* [**2134-9-15**] 12:11PM BLOOD Fibrino-432* D-Dimer-5149* [**2134-10-3**] 06:00AM BLOOD Ret Man-.4* [**2134-10-7**] 06:40AM BLOOD Glucose-77 UreaN-31* Creat-1.6* Na-146* K-3.8 Cl-109* HCO3-25 AnGap-16 [**2134-9-14**] 11:20PM BLOOD Glucose-98 UreaN-26* Creat-1.9* Na-140 K-3.9 Cl-105 HCO3-18* AnGap-21* [**2134-10-7**] 06:40AM BLOOD ALT-22 AST-20 AlkPhos-253* TotBili-2.7* [**2134-9-29**] 04:50AM BLOOD Lipase-15 [**2134-9-26**] 04:31PM BLOOD CK-MB-4 cTropnT-0.03* [**2134-10-7**] 06:40AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 [**2134-10-3**] 06:00AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.4* Mg-1.8 [**2134-10-2**] 08:15AM BLOOD VitB12-955* Folate-15.9 [**2134-9-29**] 04:50AM BLOOD calTIBC-150* Ferritn-702* TRF-115* [**2134-9-15**] 12:11PM BLOOD Hapto-99 [**2134-10-2**] 08:15AM BLOOD Ammonia-26 [**2134-10-2**] 08:15AM BLOOD TSH-2.1 [**2134-9-21**] 04:06AM BLOOD Vanco-17.2 [**2134-9-19**] 06:00AM BLOOD Vanco-23.3* [**2134-10-2**] 03:00PM BLOOD Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2134-9-26**] 10:20AM BLOOD Lactate-1.4 [**2134-9-16**] 04:53AM BLOOD freeCa-1.13 [**2134-9-15**] 09:40AM BLOOD freeCa-1.08* [**2134-9-15**] 07:25AM BLOOD freeCa-0.94* CXR [**2134-10-4**]: FINDINGS: In comparison with the study of [**9-27**], there is again enlargement of the cardiac silhouette with bilateral pleural effusions and atelectasis and pulmonary edema. EEG: FINDINGS: ABNORMALITY #1: The posterior waking background was generally of moderate voltage and in the [**3-28**] Hz range. Anterior rhythms were lower with mixtures of theta and delta. Some eye movement artifact was seen. BACKGROUND: The anterior-posterior voltage gradient was preserved. No frank epileptiform discharging was seen. HYPERVENTILATION: Not performed. INTERMITTENT PHOTIC STIMULATION: Not performed. SLEEP: Not obtained. CARDIAC MONITOR: No arrhythmias noted. IMPRESSION: Abnormal EEG due to a slowed and disorganized posterior background with predominant theta rhythms. This record was diffusely abnormal and suggestive of a mild to moderate diffuse encephalopathy. CT HEAD: IMPRESSION: No evidence of intracranial hemorrhage or acute major vascular territorial infarction. ECHO: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal to mid septum and inferior segment and severe hypokinesis of the basal inferolateral wall. The other segments are mildly hypokinetic.. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Regional akinesis and mild global hypokinesis. Dilated, depressed right ventricle. Moderate to severe tricuspid regurgitation with moderate pulmonary artery systolic hypertension. LIVER U/S: FINDINGS: Liver architecture appears diffusely echogenic. No focal lesion identified within the liver. There is no evidence of intra- or extra-hepatic biliary ductal dilatation. Patient is status post cholecystectomy. Common duct is seen measuring approximately 7 mm. No free fluid is seen. The right kidney measures 10.1 cm. The left kidney measures 12.2 cm. There is no evidence of hydronephrosis or stones. 5.2-cm rounded hypoechoic structure with through transmission seen in the left kidney, consistent with a cyst. The spleen appears enlarged measuring upwards of 16.1 cm. Limited views of the pancreas head appear grossly unremarkable, though assessment of the body and tail are limited by abdominal gas. Moderate right pleural effusion is noted. IMPRESSION: 1. Echogenic liver consistent with fatty infiltration, other forms of liver disease, including more significant forms of liver disease such as hepatic fibrosis/cirrhosis cannot be excluded. No focal lesions are identified within the liver. 2. No evidence of intra- or extra-hepatic biliary ductal dilatation. Status post cholecystectomy. 3. Small moderate of right pleural effusion. 4. Left renal cyst. 5. Splenomegaly. EGD: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Other procedures: A 20FR percutaneous gastrostomy tube (PEG) was placed successfully using standard techniques at the stomach body. Impression: PEG placement. Recommendations: PEG can be used for medications today and for feeding starting tomorrow. Dry sterile dressing can be placed OVER bumper- to be changed once daily x 1 week. I will loosen external bumper slightly tomorrow prior to discharge. 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: There was pus discharge in the major papilla. Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. The procedure was not difficult. Biliary Tree: A mild diffuse dilation was seen at the biliary tree with the CBD measuring 8mm. The limited intrahepatic cholangiogram was normal. There were few filling defects in the distal CBD consistent with CBD stones. Procedures: A 7 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed successfully using a OASIS stent introducer kit. Impression: Pus in the major papilla Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. A mild diffuse dilation was seen at the biliary tree with the CBD measuring 8mm. The limited intrahepatic cholangiogram was normal. There were few filling defects in the distal CBD consistent with CBD stones. A 7 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed successfully using a OASIS stent introducer kit. Fluoroscopic images are available in PACS system for review. Recommendations: Continue IV antibiotics CT scan of the abdomen and pelvis to rule out metastatic disease Follow-up with Dr. [**Last Name (STitle) **] Continue ICU care for now. Follow LFT's and cultures. Repeat ERCP with stent pull, sphincterotomy and stone extraction in 2 months. Brief Hospital Course: A/P: Pt is an 86 yo male with pmhx htn, prostate cancer who presents with jaundice, fever, elevated bilirubin and dilated ducts on RUQ US suggesting acute cholangitis. . 1. Acute cholangitis with resulting sepsis- Diagnosed with fever, abd pain, jaundice, dilated CBD on RUQ ultrasound and elevated bilirubin. S/P ERCP with stent placement, passage of pus and sludge. Resolved with decreasing WBC and only minimally elevated Alk Phos and bilirubin. Afebrile and hemodynamically stable. Initially on Vancomycin/Zosyn. Later changed to just Zosyn to complete a 14-day course (completed [**9-28**]). Pressors weaned off and blood pressure subseqeuntly remained stable. Improved UOP. Also had metabolic acidosis with bicarb of 13 on admission. DIC labs negative. Blood cultures negative. Will need billiary stent removed in 2 months. . 2. Severe Malnutrition PEG placed. No clear for usage. Bumper at 4.5cm. Should have dry sterile dressing over bumper daily. Do not remove peg for 1 month. . 3. Respiratory Failure requiring Intubation- intubated for airway protection. Subsequently extubated. Transferred to floor, but then back to ICU due to hypoxic and hypercarbic respiratory failure. Required non-invasive ventilation. Respiratory status improved and subsequently returned to floor. No further events . 4. Delerium - Acute: - Given that patient was intubated for airway protection and not respiratory distress, he had a prolonged weaning course. CT of the head showed no acute abnormalities. Mental status waxed/waned. At times very lethargic. At other times more alert. Many labs to rule out specific causes (infection, thyroid, ammonia) sent and were negative as above. Neurology evaluated patient and felt that mental status was slow to recover due to severe nature of initial infection and respiratory distress. EEG was consistent with toxic/metabolic etiology. . 5. Peripheral edema/Acute on chronic systolic heart failure: EF 30-35% on echo. Also with TR. Required intermittent doses of Lasix. B-blocker held due to low blood pressure. . 6. Acute Renal Failure on CKD Stage IV - Resolved. Likely from decreased perfusion and possible ATN. Cr back at baseline 1.8. . 7. Hyperphosphatemia- Resolved. Likely from combination of sepsis and renal failure. . 8. Anemia Chronic Disease Hct trended down as did WBC count. Likely from bone marrow suppression due to infection. Required blood transfusion since patient's nutritional status was so poor. . 9. Hypernatremia Likely from no PO intake. Required D5W and D51/2NS at various times. . 10. Benign Hypertension- Beta blocker held due to tenous blood pressures. Normontensive off medications . 11. Prostate/colon cancers- No active issues. Will require follow up for these. Medications on Admission: doses unknown oxybutinin lopressor amiodarone Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution [**Month/Day (4) **]: One (1) puff Inhalation Q6H (every 6 hours). 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (4) **]: One (1) puff Inhalation Q2H (every 2 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) syringe Injection TID (3 times a day). 4. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Day (4) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day). 6. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six Hundred (600) mg PO Q6H (every 6 hours) as needed for pain. 9. PEG Flush PEG with 100ml for all medications Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: Cholangitis Hypoxic Respiratory Failure Altered Mental Status Secondary: Prostate Cancer Colon Cancer Hypertension Discharge Condition: Afebrile, vital signs stable. Remains mildly disoriented with waxing/[**Doctor Last Name 688**] mental status. Discharge Instructions: You were admitted for cholangitis. You will need the stent placed in your bile duct to be removed in 2 months. You also had respiratory failure requiring intubation, which has now resolved. You were treated with antibiotics. . Your aspirin and B-blocker have been held. These can be restarted upon discussion with your doctor. . Please call your doctor or return to the emergency room if you have worsening abdominal pain or shortness of breath. . You have a PEG tube (feeding tube) in your stomach to facilitate feeding. All of your medicines can be given via this tube. . You will need to follow up with ERCP to have your stent removed within 2 months. Followup Instructions: 1) PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12416**]. [**0-0-**]. Please call for a follow up appointment within 2 weeks of leaving [**Hospital1 1501**]. 2) ERCP - Dr. [**Last Name (STitle) **]/Dr. [**First Name (STitle) **]. Please call ([**Telephone/Fax (1) 10532**] to schedule a follow up to have stent removed (should be done within 2 months)

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icd9cm

[ [ [] ] ]

[ "38.93", "51.87", "96.72", "99.04", "96.04", "96.6", "43.11" ]

icd9pcs

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8212

Discharge summary

report

Admission Date: [**2161-1-28**] Discharge Date: [**2161-2-14**] Date of Birth: [**2115-12-1**] Sex: M Service: VSU ADMISSION DIAGNOSIS: Gangrenous third right toe. DISCHARGE DIAGNOSIS: 1. Gangrenous third right toe. 2. Ray amputation, third right toe, debridement. 3. Torsades [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 29185**]. 4. Necrotic fingertips. HISTORY OF PRESENT ILLNESS: The patient is a 45 year old gentleman who is well known to Dr. [**Last Name (STitle) **] and the vascular surgery service. He has been followed for a long time for his worsening vascular disease. He has had a right third toe dry gangrene, now with a worsening foot pain and some increasing erythema and infection. He presented through the emergency department and is now admitted for workup for potential amputation of his toe. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus, diagnosed age thirteen. 2. Hypertension. 3. Gastroesophageal reflux disorder. 4. Hiatal hernia. 5. Renal transplant, [**2154**], with chronic rejection. 6. Depression. 7. Peripheral vascular disease. 8. Chronic pain. 9. Lactose intolerance. PAST SURGICAL HISTORY: 1. Bilateral third finger amputations. 2. Left second and third toe amputations. 3. Left hand sympathectomy. 4. Left below knee popliteal to posterior tibial bypass with non reverse saphenous vein graft. 5. Right inguinal hernia. 6. Renal transplant, [**2154**]. 7. Bilateral lower extremity angiogram with angioplasty of left distal graft and angioplasty of right posterior tibial ([**2161-1-2**]). ALLERGIES: Lobster. Lactose intolerance. MEDICATIONS ON ADMISSION: Vitamin B. Folate. Norvasc 10 mg daily. Nexium 40 mg daily. Nifedipine XL 60 mg q Tuesday, Thursday and Sunday. Methadone 10 mg tabs 100 mg at 7 a.m., 100 mg 5 p.m., 200 mg at midnight, 50 mg q 2-3 hours for breakthrough pain. Lantus insulin 36 units at bedtime. Humalog insulin two units for blood sugar greater than 175. Phos-Lo 667 mg tablets, four tablets each meal and two tablets with snack. Nephrocaps 1 tablet at bedtime. Vitamin E 400 units daily. Lisinopril 5 mg daily. Doxazosin 1 mg tab, four tablets at bedtime. Nortriptyline 50 mg at bedtime. Plavix 75 mg daily. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Denies drinking, denies alcohol. PHYSICAL EXAMINATION ON ADMISSION: Generally, the patient appears exhausted but is not in acute distress. Chest is clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm without murmur, rub or gallop. Abdomen is soft, nontender, nondistended. Extremities are significant for a right lower extremity with dry gangrene of the third toe, adjacent erythematous change of the second and fourth toes. Tender to palpation, especially over the plantar surface. There is significant malodor, but no obvious purulent discharge. Palpable right posterior tibial. The left foot looks relatively healthy, with a palpable left posterior tibial and graft pulses. LABS ON ADMISSION: CBC 10.9/38.0/404. Chemistry 133/5.9/86/34/49/6.6/211. Lactate is 2.0. RADIOLOGY ON ADMISSION: Right foot x-ray demonstrates no obvious osteomyelitis or subcutaneous air in the right foot. HOSPITAL COURSE: The patient was admitted for antibiotics to treat his right foot cellulitis. He was evaluated for potential amputation, and also given hemodialysis. On [**2161-1-29**], the patient was brought to the operating room and had a right third toe ray amputation and debridement performed. For details of this, please see the previously dictated operative note. Subsequent to this, the patient had a fairly [**Male First Name (un) 3928**] postoperative course complicated by what was thought to be torsades [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 29185**]. Cardiology was consulted, and they felt that the offending factor was likely the large dose of methadone that he was one, which can lengthen the QT interval. The patient was transferred to the intensive care unit for close monitoring. Cardiology consultation service was obtained. The torsades which was encountered perioperatively required direct cardioversion. Subsequent to this, the [**Hospital 228**] hospital stay was prolonged primarily due to volume overload requiring hemodialysis, as well as infectious disease workup. The patient had had high fevers and was treated with vancomycin, ceftriaxone and Flagyl under the guidance of the infectious disease consult service. Ultimately the patient had no significant blood cultures. He did, however, have wound swab which upon initial presentation grew out coag negative staph as well as E. coli. Repeat foot swab on [**2161-2-11**] demonstrated C. albicans as well as coag negative staph. The patient had no significant blood cultures. Though he had some fever issues and was followed by the infectious disease consult service, ultimately the workup demonstrated no obvious source within the foot. Ultimately, the patient was discharged home, having been afebrile for 48 hours and with a normal white count. The patient also had a history of dry gangrene and necrosis of his fingertips, for which the plastic surgery service was consulted. They felt there was no need to do emergent surgery. DISPOSITION: To home with [**Date Range 269**] and physical therapy. Diet is 1800 calorie diabetic diet. MEDICATIONS: Vitamin C, B complex and folic acid capsule 1 daily. Clonidine 0.1 mg patch q week. Protonix 40 mg daily. Norvasc 10 mg daily. Captopril 50 mg t.i.d. Ambien 5-10 mg at bedtime p.r.n. Neurontin 300 mg p.o. t.i.d. Aspirin 325 mg daily. Phos-Lo 667 mg p.o. t.i.d. with meals. Nitroglycerin 0.4 mg tablets sublingually q 5 minutes p.r.n. x 3 for chest pain. Lipitor 40 mg p.o. daily. Lopressor 50 mg p.o. b.i.d. Dilaudid 2-4 mg p.o. q 6 hours p.r.n. Insulin glargine 42 units subcutaneously at bedtime. Humalog insulin sliding scale. DISCHARGE INSTRUCTIONS: The patient is to be discharged home with [**Date Range 269**] and home physical therapy. He will continue hemodialysis and continue vancomycin with dialysis x two weeks. He is full weightbearing and should wear a healing sandal to the right foot. He should work with physical therapy upon ambulation and gait training. The patient should follow up with Dr. [**Last Name (STitle) **] in two weeks' time. The patient should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with the plastic surgery service in two weeks' time for evaluation of his necrotic fingertips. Should the patient spike high fevers, having shaking chills or otherwise have wound breakdown, erythema or gross purulence, he should call Dr.[**Name (NI) 19759**] office or the emergency department for re- evaluation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**] Dictated By:[**Last Name (NamePattern1) 23688**] MEDQUIST36 D: [**2161-2-14**] 11:44:32 T: [**2161-2-14**] 12:21:04 Job#: [**Job Number 29186**]

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icd9cm

[ [ [] ] ]

[ "99.62", "86.22", "84.12", "39.95" ]

icd9pcs

[ [ [] ] ]

2260, 2278

208, 390

1665, 2243

3240, 5922

5947, 7044

1183, 1638

158, 187

419, 852

3127, 3222

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146,906

6689

Discharge summary

report

Admission Date: [**2127-7-23**] Discharge Date: [**2127-7-30**] Service: MEDICINE Allergies: Augmentin / Keflex / Cephalosporins Attending:[**First Name3 (LF) 4095**] Chief Complaint: Hypotension, Acute on chronic kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: 88M with history of CAD s/p CABG with CHF (EF 25%) s/p BiV ICD, COPD (vital capacity was 1.22 liters, 48% predicted; FEV1 is 0.97 liters, 54% predicted, FEV1/FVC ratio is 79%), HTN and multiple recent pneumonias admitted with hypotension. Per patient, has had vague fatigue for past 2 weeks. Today, had routine labs at PCP for diuresis monitoring, creatinine elevated. Family called EMS - On arrival, BP 70/p and pale, 90/50 supine. He was brought to [**Hospital1 18**] ED for further eval. Per patient, he is asymptommatic, family states he was dizzy with decreased Po intake for past 4 days. Reports cough x 1 day, non-productive. Breathing at baseline. + increase in peripheral edema, denies orthopnea. No fevers, chills, chest pain, palpitations, N/V/D, dysuria. . In the ED, initial vs were: 98.9 69 85/29 20 92% 4L Nasal Cannula. Chest x-ray was notable for raised left diaphragm with LLL atelectasis. Recieved 500 cc NS IV, Vancomycin, Levofloxacin and Aztreonam for possible pneumonia. SBP 98-106 while in ED. Admitted to MICU for concern for sepsis. . On the floor, patient with no complaints. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: status post CABG in [**2116**]. -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: BiV ICD in [**2123**] 3. OTHER PAST MEDICAL HISTORY: Past Medical History: - CAD with multiple MIs - Severe ischemic cardiomyopathy with LVEF of 25% with biventricular failure. - Mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. - History of LV thrombus. - CVA(right medial occipital pareital region). - Pneumonia. - Glaucoma. - War injury with a left lower leg deformity. - Hx of Splenectomy c/b ureteral injury & reimplantation Social History: -Russian-speaking, originally from [**Location (un) 25508**]. -[**Location (un) 269**] services -Daughter and son very involved in daily care, [**Name (NI) 269**] also helps at home. Pt needs help with most ADLs. -Remote hx of tobacco use -No use of ETOH Family History: Father died of MI at 64 years Physical Exam: Admission Exam: Vitals: T: 97.6 BP: 96/63 P: 71 R: 30 O2: 97% 4L General: Alert, answers questions appropriately HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP equivocal. Lungs: Bibasilar crackles L>R, minimal dullness to percussion over left posterior lung base. No wheezes, rales, ronchi. gynecomastia. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. PMI displaced. Abdomen: soft, non-tender, minimally distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: pitting edema in bilateral lower extremities, slightly greater on left distal to previous traumatic leg injury (healed). Warm, well perfused, 1+ pulses, no clubbing, cyanosis. + fungal growth on toe nails Skin: + chronic venous stasis changes in bilateral LE . Discharge Exam: On room air bibasilar rales abdomen benign Pertinent Results: [**2127-7-23**] 09:00PM BLOOD WBC-19.8* RBC-3.81* Hgb-12.3* Hct-35.2* MCV-92 MCH-32.1* MCHC-34.8 RDW-14.7 Plt Ct-472* [**2127-7-23**] 09:00PM BLOOD Neuts-67 Bands-1 Lymphs-17* Monos-5 Eos-10* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2127-7-23**] 09:00PM BLOOD PT-25.1* PTT-32.1 INR(PT)-2.4* [**2127-7-23**] 09:00PM BLOOD Plt Smr-HIGH Plt Ct-472* [**2127-7-23**] 09:00PM BLOOD Glucose-156* UreaN-65* Creat-2.0* Na-128* K-4.3 Cl-92* HCO3-21* AnGap-19 [**2127-7-24**] 02:57AM BLOOD CK(CPK)-38* [**2127-7-23**] 09:00PM BLOOD cTropnT-0.04* proBNP-2600* [**2127-7-23**] 09:00PM BLOOD Calcium-9.0 Phos-4.6* Mg-2.6 [**2127-7-23**] 09:00PM BLOOD Osmolal-294 [**2127-7-23**] 09:14PM BLOOD Lactate-2.2* [**2127-7-23**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2127-7-23**] 10:48PM URINE Hours-RANDOM UreaN-249 Creat-44 Na-34 K-47 Cl-42 [**2127-7-23**] 10:48PM URINE Osmolal-249 Micro: [**2127-7-24**] MRSA SCREEN-no MRSA isolated [**2127-7-23**] URINE CULTURE-No growth [**2127-7-23**] Blood Culture, Routine-PENDING [**2127-7-23**] Blood Culture, Routine-PENDING Imaging: [**7-23**] CXR: Cardiomegaly, mild central congestion. Left lower lobe atelectasis. [**7-28**] CXR: Compared to [**2127-6-10**], both diaphragm contours and the infrahilar regions of both lungs were clear, there is opacification in both locations today, not appreciably changed since [**7-23**]. Whether this is pneumonia or atelectasis or even early dependent edema is radiographically indeterminate. There is greater pulmonary vascular engorgement on the current study than there was on [**6-10**], so there may be a component of cardiac decompensation. Small bilateral pleural effusions are also likely. Severe cardiomegaly and marked hilar dilatation due to pulmonary arterial hypertension are longstanding. Transvenous right atrial pacer and right ventricular pacer defibrillator leads follow their expected courses, unchanged. No pneumothorax. Discharge Labs: [**2127-7-30**] 04:27AM BLOOD WBC-23.9* RBC-3.41* Hgb-11.2* Hct-31.5* MCV-92 MCH-32.8* MCHC-35.5* RDW-14.0 Plt Ct-480* [**2127-7-30**] 04:27AM BLOOD Plt Ct-480* [**2127-7-29**] 04:35AM BLOOD PT-28.5* INR(PT)-2.8* [**2127-7-30**] 04:27AM BLOOD Glucose-109* UreaN-28* Creat-1.3* Na-138 K-4.2 Cl-98 HCO3-28 AnGap-16 [**2127-7-24**] 03:18PM BLOOD CK(CPK)-35* [**2127-7-24**] 03:18PM BLOOD CK-MB-3 cTropnT-0.04* [**2127-7-29**] 04:35AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.3 Brief Hospital Course: 88M with chronic sCHF (EF 25-30%), BiV, COPD and metastatic squamous cell carcinoma admitted with hypotension and acute on chronic kidney injury. . ACTIVE ISSUES: # Hypotension due to Intravascular Depletion - Differential included heart failure, intravascular volume depletion [**2-19**] poor PO intake, and sepsis [**2-19**] possible pneumonia. Pt had no fever, and a chronically elevated WBC and a CXR without obvious pna. Intravascular volume depletion from overdiuresis was favored, and the patient received gentle rehydration and his blood pressure improved while in the ICU. His SBP on the floor was ~100 while lying. (Please see below for CHF Management) . # Acute on Chronic Kidney Injury Stage [**Name (NI) 25509**] - Pt presented with Cr 2.0 in setting of diuresis and poor PO intake, baseline 1.2-1.4. FeNa 1.2%. Pre-renal vs ATN vs AIN. Urine eosinophils were checked and were negative. Nephrology was consulted and continued to follow. His creatine improved during the hospitalization. Cr was 1.3 at the time of discharge. . # Hyponatremia - Thought to be most likely hypovolemic hyponatremia. Resolved with hydration. # Chronic Systolic CHF - EF 25%, on lasix/spironolactone with metolazone weekly. Currently with some peripheral edema, BNP elevated at 2600 - recent baseline ~[**2116**]. His beta blocker was continued, and his ACI-i was held given his acute renal failure. The patients BiV was reprogrammed during the hospitalization. Repeat TTE was performed just prior to discharge, final read was pending at the time of discharge. Of note, this was a sub optimal study. The patient was continued on Lasix 100mg [**Hospital1 **], Digoxin and his ACEi. Spirinolactone and Metolazone were held. **Any questions related to patients hemodynamic status or diuretics should be directed towards Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (Cardiology) and/or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]** **The patient is to follow-up in Cardiology Clinic this coming Monday** Weight at the time of discharge is 75.6kg. His SBP is ~100. Cr. 1.3. On room air with sats ~93 with bilateral basilar rales. # Chronic Leukocytosis - Pt with hx of chronic with eosinophilia, IgE elevated, ANCA negative, strongy negative. This was thought to be less likely related to acute infection given chronic nature. Cortisol was checked to rule out adrenal insufficiency as etiology, but cortisol level was appropriate. AEC was 1400. WBC was 23K at the time of discharge. Pt to follow-up with Heme (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] following his PET-CT) . INACTIVE ISSUES: # CAD - stable. Statin, ASA, beta-blocker were continued, ACE-i was held until blood pressures became stable. ACEi restarted on final day of admission. # COPD - no e/o acute exacerbation, continued advair, nebs. The patient is due to undergo PFTs and see Dr. [**Last Name (STitle) **] as an outpatient. . # Squamous cell carcinoma - Recent diagnosis. Stable throughout admission. His outpatient oncologist Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] and recommended continuing with plan for PET-CT as an outpatient. This was scheduled for follow-up as an outpatient. . # Anticoagulation: INR goal of [**2-20**]. Pt on Warfarin 2mg and 4mg alternating days. Anticoagulation should be followed up through patients PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]. INR prior to d/c was 2.8. Pt should receive 2mg the night of [**2127-7-30**]. Medications on Admission: Lipitor 40 mg daily Buspirone 10 mg [**Hospital1 **] Digoxin 125 mcg daily Aricept 5 mg daily Advair 250-50 [**Hospital1 **] Lasix 100 mg [**Hospital1 **] Combivent nebulizer QID Imdur 30 daily Lactulose prn constipation Latanoprost 0.005% 1 drop both eyes qhs Metolazone 2.5 mg daily on mondays Metoprolol Succinate 25 mg daily Nitroglycerin 0.4 mg SL prn chest pain Ranitidine 150 mg [**Hospital1 **] Spirinolactone 12.5 mg daily Timolol Maleate 0.5% solution 1 drop both eyes qam Trandolapril 2 mg daily Warfarin 2mg/4mg alternating daily Aspirin 81 mg daily Colace 100 mg [**Hospital1 **] Discharge Medications: 1. warfarin 2 mg Tablet Sig: One (1) 2mg alternating with 4mg PO Once Daily at 4 PM: Goal INR [**2-20**]. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. trandolapril 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 8. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 11. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual As needed as needed for chest pain. 15. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. timolol maleate 0.5 % Drops Sig: One (1) drop Ophthalmic QAM: 1 drop both eyes daily. 17. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 18. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: # Hypotension/Hypovolemia # ARF on CKD stage II-III (baseline 1.2-1.3) # hypovolemic hyponatremia # chronic sCHF # leukocytosis, chronic with eosinophilia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with low blood pressure which appears to be due to dehydration from your diuretics and not drinking enough fluids. These medications were slowly added back. Please stop taking the following medications: 1) Spirinolactone 2) Metolazone Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. If your weight is >170lbs please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2127-8-4**] at 9:00 AM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Nuclear Medicine/[**Telephone/Fax (1) 2103**] When: Monday, [**2127-8-4**]:45AM Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *This appointment is for a PET CT scan. Department: PULMONARY FUNCTION LAB When: MONDAY [**2127-8-11**] at 9:30 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES/PULMONARY When: MONDAY [**2127-8-11**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11608, 11678

5808, 5956

287, 294

11896, 11896

3315, 5303

12520, 13621

2371, 2402

9998, 11585

11699, 11875

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11911, 12023

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11,722

147,260

12968+56409

Discharge summary

report+addendum

Admission Date: [**2139-10-26**] Discharge Date: [**2139-11-4**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: Cardiac catheterization. History of Present Illness: This is an 87 year old man with past medical history significant for coronary artery disease with multiple stents to LCx and LAD, diabetes, hypertension, who was admitted two months ago for GI bleed and NSTEMI and now presents from OSH with chest pain. This morning, he was using stationary bicycle at home for less than five minutes when he developed burning substernal chest pain [**9-13**], similar in quality to previous ischemic episodes. Took 3 nitros with minimal relief and decided to go to hospital. At [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] Hospital ED, he was found to have TropI 5.02, BNP 2699; he was transferred by helicopter to [**Hospital1 18**] for possible intervention. . In the ED at [**Hospital1 18**], T 99.9, HR 104, BP 150/68, RR 24, 96% on 3L NC. ECG notable for sinus tach with ST depression across anterior precordium. Initially pain free and plan was cath next AM. Patient then had return of chest pain with SBP in 80's. No change in EKG. Taken to Cath lab emergently. . In cath lab [**10-26**]: LMCA was patent; LAD had 80% restenosis at ostium; LCx had 100% in-stent restenosis. DES was placed to L main distal into the opening of LAD. DES was also placed to ostium/proximal LCx. Right heart catheterization showed a wedge pressure of 35. PASP was 67. CI was 1.69. He was transiently on levophed and dopamine during the procedure and was transferred from the cath to the CCU for further monitoring . Now in the CCU, patient denies lightheadedness; no palpitations. Now endorses CP [**4-13**], never fully disappeared during or after cath. . Of note, he presented with CP in setting of GI bleed and NSTEMI in [**2139-8-4**]. He had 100% occlusion of LCx stent; this was balloon angioplastied. There was also 70% occlusion of ostial LAD; BMS was placed to this occlusion. Past Medical History: PAST MEDICAL HISTORY: Cardiac Risk Factors: +ve Diabetes +ve Dyslipidemia +ve Hypertension .. CARDIAC HISTORY: CABG: None Percutaneous coronary intervention: Multiple stents to LAD and LCx most recent on [**8-23**] Pacemaker/ICD: None .. OTHER PAST HISTORY: # Chronic obstructive pulmonary disease # Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**]. Cypher stent to the ostial CX in 06, chronically occluded RCA. Circumflex received a DES in [**2138**]. 2 DES to LAD in [**11-10**] # Type II Diabetes ?? diet-controlled # CRI baseline cr: 1.3-1.7 # Hypertension # Hyperlipidemia # Diverticulosis # Peripherial vascular disease # Peptic ulcer disease - EGD on [**2139-8-11**] Social History: Retired gunsmith. Lives with wife on MV. Prior alcoholic, last drink 20 years ago. Smoked 2 ppd x 50 years; quit 15 years prior. No IVDU. Family History: Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN; brother had "[**Last Name **] problem", sister had ovarian cancer. Physical Exam: PHYSICAL EXAM AT ADMISSION: VITALS: T HR 110, BP 110/64, RR 16, 94% on 2L O2 GENERAL: AAOx3, NAD, lying and speaking comfortably in bed HEENT: EOMI; PERRLA NECK: supple; no JVD appreciated LUNGS: scattered rhonchi and faint expiratory wheezes; no crackles HEART: RRR; distant heart sounds; no murmurs ABDOMEN: obese; non-tender with normal bowel sounds; no HSM; negative [**Doctor Last Name 515**] sign left and right sides EXTREMITIES: no pitting edema; skin hyperpigmentation over the medial malleolus indicative of venous stasis disease .. PHYSICAL EXAM AT DISCHARGE: Pertinent Results: LAB RESULTS AT ADMISSION: .. [**2139-10-26**] 09:06PM GLUCOSE-187* UREA N-64* CREAT-2.5* SODIUM-133 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-17 [**2139-10-26**] 09:06PM PLT COUNT-225 [**2139-10-26**] 06:59PM TYPE-ART PO2-73* PCO2-32* PH-7.44 TOTAL CO2-22 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-2L NP [**2139-10-26**] 06:59PM O2 SAT-93 [**2139-10-26**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2139-10-26**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2139-10-26**] 03:00PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 [**2139-10-26**] 03:00PM URINE HYALINE-25* [**2139-10-26**] 03:00PM URINE MUCOUS-RARE [**2139-10-26**] 02:35PM LACTATE-2.4* [**2139-10-26**] 02:20PM GLUCOSE-158* UREA N-64* CREAT-2.6* SODIUM-134 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-23 ANION GAP-19 [**2139-10-26**] 02:20PM estGFR-Using this [**2139-10-26**] 02:20PM CK(CPK)-134 [**2139-10-26**] 02:20PM CK-MB-17* MB INDX-12.7* [**2139-10-26**] 02:20PM cTropnT-1.20* [**2139-10-26**] 02:20PM CALCIUM-9.2 PHOSPHATE-4.7*# MAGNESIUM-2.5 [**2139-10-26**] 02:20PM WBC-19.6* RBC-4.19* HGB-11.9* HCT-36.2* MCV-86 MCH-28.5 MCHC-33.0 RDW-15.6* [**2139-10-26**] 02:20PM NEUTS-92.4* LYMPHS-3.5* MONOS-3.9 EOS-0.2 BASOS-0 [**2139-10-26**] 02:20PM PT-17.3* PTT-117.4* INR(PT)-1.6* .. STUDIES: . EKG: NSR 100 with PACs. RBBB with LAFB. Diffuse ST-segment depression in leads V1-V5. TWI in I and aVL. . CORONARY CATHETERIZATION ([**2139-10-26**]): 1. Successful stenting of the ostial LAD restenosis with a 3.0x16mm Taxus stent that was postdilated to 3.5mm. Final angiography revealed no residual stenosis, no angiogrpahically apparent dissection and TIMI 3 flow (see PTCA comments). 2. Successful stenting of the ostial LCX restenosis with a 2.5x12mm Taxus and a 3.0x8mm Taxus stents in overlapping fashion. Final angiography revealed little residual stenosis, no angiographically apparent dissection and TIMI 3 flow (see PTCA comments). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal ventricular function. 3. Successful stenting of the LAD and LCX. . TRANSTHORACIC ECHOCARDIOGRAM ([**2139-10-28**]): The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) with inferior and infero-lateral akinesis. The remaining segments are hypokinetic. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. 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. . RIGHT GROIN DOPPLER ULTRASOUND ([**2139-10-28**]): FINDINGS: Views of the right groin demonstrate a patent common femoral artery and common femoral vein with adequate wall-to-wall flow. There is no evidence of a pseudoaneurysm, hematoma, or arteriovenous fistula. . RENAL ULTRASOUND ([**2139-10-29**]): FINDINGS: The right kidney measures 11.5 cm and the left kidney measures 11.3 cm. There is no hydronephrosis and no stones or solid masses are identified in either kidney. A simple cyst is seen in the lower pole of the right kidney measuring 3.6 x 4.4 x 3.2 cm. DOPPLER EXAMINATION: Note is made that this is a limited study due to the patient's body habitus and the patient's ability to hold his breath. Color Doppler and pulse-wave Doppler images were obtained. Arterial waveforms of the main renal arteries bilaterally demonstrate sharp upstrokes. RIs of the intraparenchymal arteries in the right kidney range from 0.69-0.80. RIs of the intraparenchymal arteries of the left kidney range from 0.73-0.76. Appropriate flow is seen in the main renal vein bilaterally. IMPRESSION: 1. No hydronephrosis and no renal stones identified. Simple 4.4-cm right renal cyst. 2. Within the technical limits of the examination there is no evidence of renal artery stenosis. Brief Hospital Course: In summary, this is an 87 year old man with PMHx of CAD with multiple stents most recently to proximal LAD and angioplasty of ostial LCx in [**2139-8-4**] presents with exertional substernal chest pain not responsive to nitrate, positive troponins, and ST-segment depressions indicative of antero-lateral ischemia. Now s/p PTCA and DES to LAD and LCx, admitted to the CCU for closer monitoring. .. # CAD/ISCHEMIA: He went straight to the cath lab and had DES placed to his left circumflex and left anterior descending arteries. Post-procedure, his chest pain gradually improved and he was continued on aspirin, Plavix, and Integrillin. The Integrillin was stopped after 18 hours. During the rest of his stay Mr. [**Known lastname **] was continued on Aspirin, Plavix, Simvastatin and a Beta Blocker. .. # PUMP: His most recent TTE at time of admission showed an LVEF of 40% with regional left ventricular systolic dysfunction consistent with coronary artery disease. After the heart attack and catheterization repeat echo showed EF of 30%. Post-procedure, physical exam and oxygen requirements indicated that he was slightly volume overloaded. He was diuresed with IV Lasix, then Lasix drip for about two days at which point his UOP decreased and his creatinine began to rise. The Lasix was stopped he was kept even. His SBP remained in the mid 90s to 100s throughout his hospitalization. . As noted, he was continued on metoprolol and ACEI was held due to acute renal failure. .. # RHYTHM: During this hospitalization he developed new atrial fibrillation. His ventricular rate was well controlled w/ metoprolol. He was started on amiodorone with the goal to convert him back to normal sinus rhythm. Anticoagulation was started with heparin and bridged to coumadin. At time of discharge the patient was on 2.5 mg Coumadin daily and INR was 1.6, Heparin had been continued until discharge. The patient was instructed to follow-up the day after discharge with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to follow his continued Warfarin monitoring and INR checks with the therapeutic goal of [**3-8**] INR. The patient had better controlled atrial fibrillation but was still having less frequent, asymptomatic atrial fibrillation on telemetry with evidence of fascicular block and bradycardia. He denied any chest pain, palpitations, dizziness or shortness of breath at the time of discharge. He will plan to continue rhythm control with 200mg daily of Amiodarone. Given the patient's bradycardia he will hold his beta blocker, Metoprolol, for now and he will follow-up with his PCP and Dr. [**Last Name (STitle) **] regarding restarting this medication. He will continue telemonitoring on [**Hospital3 4298**] with the services of local VNA. .. # ACUTE ON CHRONIC RENAL FAILURE: He has chronic kidney disease with a baseline creatinine of 1.4 to 1.7, elevated at time of admission to 2.6 likely due to hypoperfusion in the setting of NSTEMI and low-cardiac output. He was treated pre and post-cath with sodium bicarbonate and n-acetylcytsteine. However, after the procedure his creatinine continued to rise. A renal ultrasound was negative for obstruction or hydronephrosis. Urine electrolytes were indicative of prerenal azotemia. Urine eosinophils were negative. There were granular casts on urinalysis which indicated ATN. A renal consult corroborated this diagnosis. His ACEI was held, as above, and his Is/Os were kept even given the concern of hypovolemia and renal hypoperfusion. Mr. [**Known lastname 26785**] Cr eventually plateaud and began to trend down and fortunately he did not need any dialysis intervention. At time of discharge the patient's BUN was 92 and Cr 3.2. The patient's baseline Cr is 1.7 range. The patient was instructed to follow-up with a local nephrologist in [**Location (un) 7453**] regarding a renal follow up over the coming 1-2 weeks time. Dr. [**Last Name (STitle) **], Mr. [**Known lastname 26785**] PCP, [**Name10 (NameIs) **] also continue to monitor the patient's electrolytes and renal funtion as well. The patient's Allopurinol dose was renally adjusted to 100mg daily. .. # RIGHT AV FISTULA: This was seen on cardiac catheterization and subsequently not seen on duplex ultrasound. Vascular is involved and he will need follow-up with Dr. [**Last Name (STitle) **] in 6 to 8 weeks. .. # DM: He was given a diabetic diet and insulin sliding scale. .. # COPD: We continued his home albuterol and ipratropium. .. # GERD: We continued his home PPI at twice daily dosing. .. # GOUT: We continued his home allopurinol at decreased dose due to development of acute renal failure. .. During the hospitalization, he was kept on a diabetic and heart-healthy diet. DVT prophylaxis was achieved first with heparin subQ, and when he developed atrial fibrillation he was started on heparin drip and bridged to warfarin. GI prophylaxis, as above, with PPI twice daily. His code status was full code throughout his hospital stay. Medications on Admission: # Simvastatin 80 mg QHS # Ipratropium Bromide 17 mcg/Actuation Aerosol; 2 puffs QID # Omeprazole 20 mg Tablet [**Hospital1 **] # Clopidogrel 75 mg Tablet QDAY # Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs q6H # Aspirin 325 mg QDAY # Captopril 12.5 mg [**Hospital1 **] # Metoprolol Tartrate 12.5 mg [**Hospital1 **] # Furosemide 80 mg [**Hospital1 **] # Isosorbide 30 mg [**Hospital1 **] # Allopurinol 300 mg QDAY Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNS Discharge Diagnosis: Acute Renal Failure / Acute Tubular Necrosis Non ST elevation myocardial infarction Systolic congestive heart failure Atrial fibrillation Discharge Condition: stable Hct:30.4 Bun:92 creat:3.2 Discharge Instructions: You had a heart attack with drug eluting stents to two coronary arteries to repair a narrowing. Your kidneys were not working very well so we adjusted your medicines. Your heart is weak so you are on medicines to help it pump better (metoprolol and captopril) You have a tendency to retain fluid so please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 2000cc You have a heart rhythm irregularity called atrial fibrillation. We are controlling your heart rate with metoprolol and amiodarone and preventing strokes with coumadin. For now, please do not take your Metoprolol until you follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. . New medicines: warfarin ( a blood thinner) amiodarone( to slow your heart rate) Metoprolol Succinate (a long acting medicine to slow your heart rate) Your usual Allopurinol dose was decreased to 100mg daily due to your renal impairment. Please continue to take this dose until your PCP informs you that your renal function is back to normal. Please call Dr. [**Last Name (STitle) **] if you have any chest pain, trouble breathing, fluid accumulating in your arms or legs, a new cough or nausea. For now, please do not take your Metoprolol until you follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. You may need to take some Lasix to help you to promote additional urine production but this will be discussed at your follow-up appointment with Dr. [**Last Name (STitle) **]. Followup Instructions: Primary care: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 29822**] Date/Time: Friday [**11-6**] at 11:45am. . Cardiology: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 5455**] Date/Time: Please call to make a follow-up appointment with Dr. [**Last Name (STitle) **] in [**4-7**] weeks time Nephrology: Please follow-up with Nephrologist in [**Location (un) **], Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 15170**] at [**Telephone/Fax (1) 19657**] within the next week Vascular Department -please follow-up with Dr. [**Last Name (STitle) **] in [**7-12**] weeks time . Office phone # [**Telephone/Fax (1) 3121**] Completed by:[**2139-11-4**] Name: [**Known lastname **],[**Known firstname 7138**] V Unit No: [**Numeric Identifier 7139**] Admission Date: [**2139-10-26**] Discharge Date: [**2139-11-4**] Date of Birth: [**2052-6-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 276**] Addendum: Addendum to discharge summary [**2139-11-4**] to note that Mr. [**Known lastname **] was set up for a follow-up appointment with Dr. [**Last Name (STitle) 274**] on [**2139-12-2**] at 1pm for a repeat echo and general follow-up for atrial fibrillation and recent MI. Patient and family made aware of this prior to discharge and given phone number for Dr.[**Name (NI) 7140**] office in case patient needs to contact Dr. [**Last Name (STitle) 274**] sooner ([**Telephone/Fax (1) 7141**]). [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7142**], M.D. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNS [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 284**] MD [**MD Number(1) 285**] Completed by:[**2139-11-4**]

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icd9cm

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icd9pcs

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17456, 17662

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2218, 2893

2909, 3048

15,546

141,648

45963

Discharge summary

report

Admission Date: [**2127-8-1**] Discharge Date: [**2127-8-21**] Date of Birth: [**2063-11-28**] Sex: M Service: MEDICINE Allergies: Nitroglycerin Attending:[**First Name3 (LF) 6195**] Chief Complaint: admitted from [**Hospital 191**] clinic w/ 5 days worsening SOB, DOE Major Surgical or Invasive Procedure: thoracentesis cardiac catheterization History of Present Illness: Pt is a 63M w/ h/o metastatic carcinoid tumor, HTN, hyperlipidemia who reports increasing SOB and DOE starting about a month ago but worsening significantly within the last 5 days. It has recently gotten so bad he can barely get up out of a chair without getting short of breath. He reports orthopnea but no PND. In clinic today, he was using accessory muscles of respiration and was mildly diaphoretic, and his O2 sat on room air was 97%, dropping to 94% with ambulation. He reports no fever or chills, no URI symptoms, no recent travel, no changes in his medications. Pt also reports ~5 episodes of chest pain in the last few weeks which he describes as pressure on his mid-sternum and usually occurs during exertion. There is no associated nausea or vomiting. He says he takes a [**12-29**] tablet of Xanax when he gets this pain sometimes which seems to help. He cannot take nitroglycerin because of his Viagra. Past Medical History: 1. metastatic carcinoid tumor, Dx'ed [**2123**] -was on a study drug for a year and a half (ended about a year ago) and was on octreotide for a few months earlier this year but stopped because of diarrhea 2. hypertension 3. hyperlipidemia 4. carotid endarterectomy [**2120**] 5. depression/anxiety 6. cellulitis 2 weeks ago, given Keflex IV at [**Hospital3 **], now resolved 7. DM2/prediabetic state: random blood sugar was high, was on glyburide for a brief time but made his sugars low so stopped 8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI 9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and [**7-1**]) Social History: Lives alone, has two daughters Distant tobacco use (25 pack-years, quit 30 years ago), distant EtOH use (quit 28 yrs ago), no drugs Family History: early CAD Physical Exam: VS: T 97.7, HR 97, BP 140/52, RR 20, O2sat 97% on RA Gen: awake, alert, conversant, elderly man, mildly short of breath HEENT: PERRL, EOMI, MMM Neck: supple, JVP elevated (~8cm) Chest: fine cracles at left base, otherwise CTA CV: RRR, nl S1S2, no m/r/g, distant heart sounds Abd: S/ND, mildy tender to palpation in LLQ Ext: WWP, 1+ LE edema bilaterally, no c/c Neuro: nonfocal Pertinent Results: [**2127-8-1**] 03:30PM PLT COUNT-201 [**2127-8-1**] 03:30PM NEUTS-69.9 LYMPHS-23.5 MONOS-4.8 EOS-1.1 BASOS-0.7 [**2127-8-1**] 03:30PM WBC-9.2 RBC-4.68 HGB-14.6 HCT-42.0 MCV-90 MCH-31.3 MCHC-34.8 RDW-13.7 [**2127-8-1**] 03:30PM TSH-4.0 [**2127-8-1**] 03:30PM CK-MB-NotDone cTropnT-<0.01 [**2127-8-1**] 03:30PM CK(CPK)-50 [**2127-8-1**] 03:30PM GLUCOSE-125* UREA N-14 CREAT-1.0 SODIUM-138 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-19 Brief Hospital Course: 1. SOB: likely from CHF The patient was initially diuresed for mild pulmonary edema: he received 20 IV Lasix on night of admission and 40mg [**8-2**], with good UOP. On [**8-2**], pt was reporting improvement of symptoms and able to walk around his room with 4L O2 NC. The following day he reported feeling worse, with increasing SOB, and was found to now be in oliguric renal failure. CXR [**8-3**] 8am showed showed atelectasis with possible superimposed pneumonia. Emergent TTE showed decreased EF (30%), anteroapical infarct with moderate-to-severe overall left ventricular contractile dysfunction; bicusapid aortic valve with at least mild aortic stenosis. He was sent to the MICU [**8-3**] to [**8-10**] (see below for course). . On transfer back from the MICU, SOB was much improved, and he was on 2L NC intermittently for comfort. After his ARF resolved, he was cathed [**8-15**], showing persisting right heart failure [**1-29**] tricuspid regurg. He was monitored in the CCU post-cath and diuresed 1.3L until transfer back to the floor on [**8-17**]. There, diuresis was continued with stable Cr, and the pt was weaned off O2, able to maintain O2 saturation throughout PT exercise and reporting much improvement from initial symptoms. . 2. chest pain -MI (no ischemic changes on EKG) vs. GERD vs. anxiety vs. PE (CTA negative) Cardiac enzymes were negative. Viagra was discontinued while in-house so nitrates could be used if necessary. He was monitored on tele, with no abnormalities. Xanax was continued 0.25mg prn. . 3. HTN/hyperlipidemia/CAD Norvasc and Lipitor were continued initially, but the anti-hypertensive regimen was changed in MICU (see below), and lipitor was stopped due to transaminitis. He had clean coronaries on cath [**8-15**]. A repeat TTE on [**8-18**] showed no change from [**8-3**]. On [**8-19**], given restoration of renal and hepatic function, he was restarted on lipitor, and hydralazine and nitrate were replaced with toprol XL 25qd per cardiology recs. He may benefit from lisinopril in the future. Aspirin was continued throughout his hospital course. . 4. diabetes/pre-diabetic state -diabetic diet, RISS . 5. depression/anxiety -continued Paxil, Xanax . 6. PPx: subq heparin, H2B/PPI . 7. PT: pt was started on physical therapy during his hospital stay. By the time of discharge, he was tolerating [**12-29**] physical therapy sessions a day and maintaining O2 sats in high 90s. PT felt he would be able to tolerate a total of [**2-28**] hours of PT per day spread across multiple sessions in an acute rehab setting. . . MICU Course 1. Hypoxic respiratory failure: On hospital day 3, the patient began to have desaturations requiring 100% NRB to maintain oxygen saturation. His hypoxia was attributed to a right lower lobe pneumonia and congestive heart failure given his new wall motion abnormality with an EF of 35-40%. He completed a 7-day course of Levofloxacin and Vancomycin for empiric treatment of hospital acquired pneumonia. He was also given lasix for diuresis given his positive fluid status. Several times during his ICU stay, he desaturated to the low 70% for brief episodes. Some of these episodes were attributed to anxiety since his saturations improved with ativan. However, anxiety alone could not explain his persistent oxygen requirement. A chest CT was performed to look for parenchymal disease that was not evident on plain films. The CT showed bilateral pleural effusions with the right greated than the left. The effusions were attributed to CHF. He was started on hydralazine and insosorbide mononitrate for afterload reduction. Given his persistent oxygen requirement a diagnostic and therapeutic thoracentesis was performed to rule out a malignant or infected effusion. Approximately 1 litre of clear yellow fluid that was consistent with a transudate was removed from the right. Pleural cultures showed no growth at the time of transfer from the ICU. His oxygenation improved post-thoracentesis and he was able to tolerate being on room air. 2. Hypotension: His hypotension was concerning for SIRS/early sepsis given his intial concurrent leukocytosis and elevated lactate. His pressure stabilized after fluid boluses during his first 24 hours in the ICU. After resolution of the hypotension, his blood pressure was elevated and he required metoprolol to maintain adequate blood pressure control. . 3. Metabolic acidosis: His initial metabolic acidosis was likely due to lactic acidosis secondary to hypoperfusion. He received bicarbonate infusion with correction of the acidosis during the first 24 hours of his ICU stay. . 4. ARF: The acute renal failure was likely secondary to contrast nephropathy and overdiuresis with lasix given his intial presentation with CHF. His FeUrea was consistent with pre-renal. Renal felt that he had a resolving ATN in the setting of hypotension and recommended repleting half his urine output with 1/2NS for a resolving ATN. He initially appeared to be volume overloaded on exam and aggressive diuresis was attempted once his creatinie returned to [**Location 213**]. However, he experience a bump in his creatinine. Subsequently, lasix was used sparingly and his creatinine and electrolytes were followed closely. His ARF was resolving upon transfer from the MICU. . 5. Hepatitis: He had normal LFTs prior to his episode of hypotension. His LFTs drastically increased. An ultrasound showed old metastasis and fluid overload. Initially, the possibility of cyanide toxicity was thought to contribute to his presentation give his herbal supplements. He received one dose of mucomyst and sodium thiosulfate. Per Toxicology consult, his hepatitis was unlikely from his medications/supplements. His hepatitis serologies were negative. His AST/ALT peaked on ICU day 2 and his tbili peaked on ICU day 6. This pattern is consistent with shock liver. . 6. Coagulopathy: His elevated PT/PTT was likely secondary to acute liver failure. There was no evidence of aute bleeding initially, but his hematocrit decreased 48 to 39 after two liters iv fluids. His platelets and fibrinogen also trended down. His coagulopathy could be attributed to live dysfunction, however, a mild DIC could not be ruled out. He was given a total of 20 mg vitamin K, 5 units of 6 units FFP, and 1 unit cryoprecipitate to decrease INR prior to placing central line on the day of transfer to the ICU. He was also given 3 Units of FFP prior to performing a thoracentesis for an elevated INR. Upon transfer from the ICU, his platelets, fibrinogen, and INR were returning to normal levels. . 7. CAD: He had a history of a previous MI and now has new anterior wall hypokinesis on echo and reduced EF 35%. He ruled out for an acute MI by serial enzymes. His ASA and statin were held in the setting of liver dysfuntion. On ICU day 4, low dose metoprolol was started once his blood pressure was stable. He will need a stress MIBI once stable. . 8. DM: He initially required an insulin drip for glycemic control and was transitioned to an insulin SS on ICU day 3. His blood glucose remained in good control generally between 110-160. . 9. FEN: He was intially NPO. His diet was advanced as tolerated. He initially required fluid resucitation to maintain his blood pressure. On admission to the ICU, he had an elevated potassium to 7.0. He received calcium gluconate, insulin with D50, kayexelate, and bicarb. His potassium overcorrected and he required repletion. His magnesium and calcium were also repleted. . 10. Access: He had a left IJ central line. . 11. Prophylaxis: He was maintained on a PPI and pneumoboots. Medications on Admission: ASA 81mg po qd Lipitor 20mg po qpm Norvasc 5mg po qd Paxil 30mg po qd ranitidine 150mg po bid Viagra 25mg po qd [**Doctor First Name **] 180mg po qd Xanax 0.25 mg po qd prn Discharge Medications: 1. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-29**] Sprays Nasal TID (3 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 12. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary: congestive heart failure Secondary: metastatic carcinoid tumor, hypertension, hyperlipidemia, diabetes mellitus type 2, basal cell carcinoma Discharge Condition: good, stable Discharge Instructions: If you experience worsening shortness of breath, fevers/chills, chest pain, seek medical attention immediately. If you gain more than 3 lbs, contact Dr. [**First Name (STitle) **]. Your anti-hypertensive medications have been changed while you were in the hospital. You are currently prescribed for Toprol XL 25mg daily. You may benefit from an ACE inhibitor in the future. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2127-9-10**] 4:15 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2127-9-10**] 6:40 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] VASCULAR [**Name12 (NameIs) 3628**] (NHB) Where: VASCULAR [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2127-12-2**] 2:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]

[ "428.0", "197.7", "424.1", "276.2", "584.5", "458.9", "518.81", "401.9", "486", "250.00", "V10.05", "286.7", "570", "397.0", "416.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.06", "34.91", "99.07", "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

12081, 12178

3076, 10730

344, 384

12372, 12387

2597, 3053

12811, 13568

2172, 2184

10954, 12058

12199, 12351

10756, 10931

12411, 12788

2199, 2578

235, 306

412, 1330

1352, 2007

2023, 2156

64,160

163,936

47148

Discharge summary

report

Admission Date: [**2173-3-25**] Discharge Date: [**2173-3-31**] Date of Birth: [**2096-3-12**] Sex: F Service: MEDICINE Allergies: Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult / Shellfish Attending:[**Male First Name (un) 4578**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: cath History of Present Illness: 77 y/o F PMH significant CAD s/p several stents, DM, hyperlipidemia, HTN who presents with shortness of breath of 2 days duration. Patient reports difficulty breathing at rest and with exertion. She denies any associated chest pain. She reports baseline ankle edema. She denies orthopenia and PND. She denies any chest pain or SOB since her cath in [**Month (only) **]. She denies sick contacts, fevers, [**Name2 (NI) **], increased sputum production, sore throat and muscle aches. She reports nausea and episode of soft stool yesterday. She denies bloody or black stool. . Patient presented to [**Location (un) 620**] ED - reported to be hypoxic with improvement on NC. Initial vitals T 100.3, Tm 100.8, P 107, RR 20, Bp 137/62, O2Sat 87% RA. Concern for PNA based on CXR and given Ceftriaxone/Azithromycin. Per report no EKG changes and given 4 baby aspirin. Troponin elevated 0.28 consequently transferred to [**Hospital1 18**] for further management. On arrival to [**Location (un) 86**] [**Hospital1 18**] T 96.9, BP 124/63, HR 82, RR 18, 97% 4L. Patient normotensive. O2 sat 97-98% 2-3L. Nitro drip started. Ordered for 1 pRBC but not hung prior to transfer. Guaiac negative. . Patient had recent admission [**Date range (1) **] for NSTEMI s/p DES to LM, LAD and RCA during the course of two catheterizations. Metoprolol and Norvasc increased, Hydralazine started. Patient transfused 2 units for angioseal bleed. CT scan ruled out RP bleed. Acute on chronic renal failure - felt to be related to contrast load in cath and required ultrafiltration in CCU. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension 2. CARDIAC HISTORY: -Extensive CAD s/p multiple stents -CABG: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: # H/o CVA [**2157**] # Visceral stenosis (70% stenosis of the celiac, SMA, and [**Female First Name (un) 899**] followed by [**Doctor Last Name **]) # PVD # DM II - not on insulin, most recent A1c 7.1 in [**6-25**] # Hypertension # Migraine headaches # Gastritis - no peptic ulcer disease history. # Depression x30 years, initially reactive Social History: Widowed, daughter lives with her. Previously independent. -Tobacco history: Denies -ETOH: Will have one drink when she goes out to dinner. Family History: Mother had CAD and MI. Father died at a young age of MI. Physical Exam: GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, jvd to clavicle RESP: Decreased breath sounds left base. Mild wheezes throughout. No crackles. CV: RR, S1 and S2 wnl, 3/6 systolic ejection murmur radiates throughout. ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. 5/5 strength throughout. RECTAL: Guaiac negative. Pertinent Results: Labs on admission: [**2173-3-25**] 12:55AM BLOOD WBC-9.9 RBC-2.64* Hgb-7.9*# Hct-23.0*# MCV-87 MCH-29.9 MCHC-34.3 RDW-14.2 Plt Ct-390 [**2173-3-25**] 12:55AM BLOOD Neuts-82.3* Lymphs-13.2* Monos-4.0 Eos-0.2 Baso-0.3 [**2173-3-25**] 12:55AM BLOOD PT-14.0* PTT-31.3 INR(PT)-1.2* [**2173-3-25**] 12:55AM BLOOD Glucose-201* UreaN-40* Creat-1.4* Na-142 K-4.2 Cl-109* HCO3-20* AnGap-17 [**2173-3-25**] 06:29AM BLOOD Calcium-8.5 Phos-5.6*# Mg-2.2 Iron-15* . CE trend: [**2173-3-25**] 12:55AM BLOOD proBNP-[**Numeric Identifier 99917**]* [**2173-3-25**] 12:55AM BLOOD cTropnT-0.30* [**2173-3-25**] 06:29AM BLOOD CK-MB-4 cTropnT-0.33* [**2173-3-25**] 04:00PM BLOOD CK-MB-5 cTropnT-0.46* [**2173-3-26**] 05:26AM BLOOD CK-MB-4 cTropnT-0.56* . Labs on discharge from MICU: [**2173-3-26**] 05:26AM BLOOD WBC-8.2 RBC-3.84*# Hgb-11.5*# Hct-32.9* MCV-86 MCH-29.8 MCHC-34.8 RDW-14.6 Plt Ct-408 [**2173-3-26**] 05:26AM BLOOD Glucose-133* UreaN-38* Creat-1.4* Na-141 K-4.4 Cl-107 HCO3-24 AnGap-14 [**2173-3-26**] 05:26AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.1 [**2173-3-25**] 06:29AM BLOOD Calcium-8.5 Phos-5.6*# Mg-2.2 . DISCHARGE LABS [**2173-3-31**] 09:05AM BLOOD WBC-8.1 RBC-3.82* Hgb-11.3* Hct-34.0* MCV-89 MCH-29.7 MCHC-33.3 RDW-14.1 Plt Ct-574* [**2173-3-31**] 09:05AM BLOOD Glucose-178* UreaN-41* Creat-2.3* Na-141 K-4.2 Cl-105 HCO3-23 AnGap-17 [**2173-3-31**] 09:05AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.4 . Iron studies: Iron-15* [**2173-3-25**] 06:29AM BLOOD calTIBC-157* Ferritn-654* TRF-121* . CXR on admission: 1) Persistent loculated left effusion with increasing fluid within the left pleural cavity and new partial left lower lobe atelectasis. 2) New mild pulmonary edema. 3) New small right pleural effusion. . ECHO [**2173-3-25**]: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Elevated left ventricular filling pressures. Mild aortic stenosis with mild aortic regurgitation. Mild to moderate mitral and tricuspid regurgitation. Mild pulmonary artery systolic hypertension. Very small to small anterior pericardial effusion. . CARDIAC CATH [**2173-3-26**] (PRELIMINARY REPORT): Coronary Angiography- Right domimant LMCA- Stent widely patent. Because of the proximal mild lucency, it was interrogated with pressure wire that showed FFR of 0.92 indicative of no significant disease. LAD- Patent mid LAD stent with 30% ISR, no other significant disease LCX- Small vessel with no significant disease RCA- All stents are widely patent. Mild mid PDA disease. FINAL DIAGNOSIS: 1. Widely patent stents in LMCA, LAD and RCA 2. Mildly elevated LVEDP 3. Minimal aortic valve gradient . CT CHEST WITHOUT CONTRAST [**2173-3-27**]: The trachea and central airways are patent to the subsegmental level. There is mild senile calcification of the tracheobronchial tree. The aorta and great vessels are normal in caliber and contour, though dense calcification of the aorta, as well as dense calcification of the right and left coronary arteries, is noted. The heart is normal in size. There is a small pericardial effusion. There is no mediastinal or hilar adenopathy identified. The esophagus appears normal. Calcification of the aortic valve is also noted. There are small bilateral pleural effusions, though the effusion on the right has slightly increased compared to [**2172-11-18**]. This is simple fluid in attenuation. On the left, the amount of pleural fluid is likely unchanged, also simple fluid in attenuation. There is a focal higher-density region at the periphery of the lingula and left lower lobe, which might represent rounded atelectasis, which appears slightly larger than on the prior study. Within the lungs, there is a small calcified granuloma seen at the left base (2:25). There are no additional pulmonary nodules or masses identified. Apical pleural scarring is seen bilaterally. In the visualized upper abdomen, visualized liver, spleen, and adrenal glands are normal. Hyperdense material in the upper pole of the left renal collecting system likely represents retained contrast from cardiac catheterization performed one day prior. BONE WINDOWS: Degenerative changes are noted in the thoracic spine. No suspicious lytic or sclerotic osseous lesions identified. IMPRESSION: 1. Bilateral small simple pleural effusions, likely unchanged on the left and slightly increased on the right. 2. Probable subpleural rounded atelectasis/collapse in the lingula and left lower lobe, slightly worse in appearance since the most recent comparison of [**2172-11-18**]. The oval hyperdense mass previously seen in the pleural space anteriorly adjacent to the lingula on [**2172-11-18**] might also represent a focus of atelectasis/collapse. Recommend followup imaging after resolution of pleural effusions to assess stability of findings. 3. Dense aortic and coronary atherosclerotic calcification, with additional calcification of the aortic valve. 4. Retained contrast within the renal collecting system secondary to recent cardiac catheterization. Brief Hospital Course: 77 y/o F PMH significant CAD s/p stents, DM, hyperlipidemia, HTN who presented with shortness of breath of 2 days duration, found to have large pleural effusions and was diuresed. Hospital course complicated by episode concerning for ACS but taken to cardiac cath and stents found to be patent. On discharge breathing well, but continued to have drenching night sweats which will require very close outpatient follow-up. . # Pleural effusions/Acute Diastolic Heart Failure: Most likely secondary to CHF and pleural effusion. Patient reports recent increase in salt intake (Chinese, Pizza over the weekend). Improved with diuresis on lasix drip (greater than 2 L) during stay. Pleural effusion (chronic) most likely secondary to CHF but other possibility is malignancy based on CT scan last admission with ? lung lesion. CXR demonstrates loculated left pleural effusion and left lower lobe collapse. Transthoracic echocardiogra showed preserved EF, 1+ MR, and elevated left ventricular end-diatolic pressures. Following diuresis, pt went to cath which found LVEDP 12, demonstrating euvolemia consequently lasix drip stopped prior to transfer to cardiology. On cardiology service, patient was successfully weaned off oxygen and breathing comfortably. Repeat imaging showed improvement in pleural effusions after diuresis and no thoracentesis was pursued. The possibility of malignant effusions cannot be ruled out. Repeat CT of the chest reported that they hyperdense mass commented on CT from [**2172-11-18**] is most likely rounded atelectasis, and not a mass; however repeat imaging after resolution of pleural effusions is recommended. The patient has had thoracentesis on previous admissions sent for cytology and found to be negative for malignancy. She may benefit from repeat diagnostic thoracentesis in future if pleural effusions reaccumulate. She was discharged on po lasix 20 mg daily. . # Type B symptoms: Pt reports several months of night sweats and indeed had drenching night sweats while an inpatient. She also notes a [**10-7**] pound weight loss over past 2-3 months. These symptoms are highly concerning for occult malignancy or chronic infection. There was a concerning area on Chest CT from [**2172-11-18**] which seemd more likely to represent rounded atelectasis on repeat CT from this admission. Follow-up imaging is recommended after resolution of pleural effusions. Of note, thoracentesis from [**2172-11-18**] was consistent with transudative process and cytology was negative for malignancy. . # CAD: EKG on admission t-wave flattening and inversions anterior leads. Patient had episode of acute nausea/diaphoresis [**2173-3-25**] with EKG changes borderline ST elevation V1/V2, depression V4-V6. Patient with mild diaphoresis morning [**2173-3-26**] and continued to have ST depressions V4-V6. Troponins increased in setting of worsening renal function, but CK-MB remained flat. Patient started on a heparin drip and underwent cath which demonstrated no in-stent thrombosis. Heparin drip was stopped. ASA and [**Month/Day/Year 4532**] continued throughout stay. . # Anemia: Guaiac negative. Likely secondary to chronic kidney disease with a question of contribution from other systemic source of inflammation (? occult malignancy). Responded to 1 pRBC. Iron studies consistent with anemia of chronic inflammation. . # Acute on Chronic Renal failure: Improved from baseline. Losartan was held as patient was at high risk of contrast nephropathy following cath, last cath on CVVH due to renal failure. Given mucomyst and IVF following cath. Pt did develop contrast induced nephropathy after cath with Cr peaking at 3.3. Renal Consult was called. Pt was monitored and Cr improved prior to discharge (down to 2.3) with expected continued improvement. Of note, losartan was held on discharge but should be restarted as an outpatient. . # Diabetes: Held metformin and placed on insulin sliding scale in house. Discharged on home metformin. . # Hyperlipidemia: Continued lipitor. . # Hypertension: Continued Hydralazine, Norvasc, Metoprolol . # Depression/Psych: Continued trazadone, remeron, ritalin. . # Hypothyroidism: Continued home dose Levothyroxine 100 mcg cap. . # Transition of Care: -Pt requires close follow-up for highly concerning symptoms of persistent night sweats and weight loss. -Pt needs follow-up chest imaging with resolution of pleural effusions. -Pt should have creatinine checked in next 2-4 weeks to ensure return to previous renal function. -Pt's losartan should be re-started as an outpatient. -Pt needs further teaching regarding adherence to low salt diet. Medications on Admission: Per Needhem Med Rec - patient does not know - Losartan 50 mgs qd - Levothyroxine 100 mcg cap - Hydralazine 50 mg TID - Imdur 120 mg 24 hour daily - Lipitor 80 mg tab - Metformin ER 500 mg qd - Prilosec 20 mg [**Hospital1 **] - [**Hospital1 **] 75 mg qd - Trazadone 75 mgs qhs - Remeron 30 mg qhs - Norvasc 10 mg qd - Metoprolol tartate 150 mgs [**Hospital1 **] - ASA 81 mg - Ambien 5 mg - Lasix 20 mg - Ritalin 5 mg 1 qam and 1 qpm - Nitro prn Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Imdur 120 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. trazodone 50 mg Tablet Sig: 1.5 Tablets PO at bedtime. 9. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Ritalin 5 mg Tablet Sig: One (1) Tablet PO twice a day. 16. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual three times a day as needed for chest pain: can take 1 tablet every 5 minutes for up to three tablets for chest pain. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Bilateral pleural effusions, Acute Renal Failure, Contrast Induced Nephropathy . Secondary Diagnoses: Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for shortness of breath. You were found to have fluid around your lungs. You were given diuretics to help remove extra fluid from your lungs. You had an episode that was concerning for a cardiac event. You were taken to the cath lab where we found the blood vessels supplying your heart, including those with stents, to all be patent. You developed an injury to your kidneys from the contrast dye used during the catherization. Your kidneys recovered on their own and you were discharged home. You have a follow-up with Dr. [**Last Name (STitle) 2903**] (see below) during which you should be evaluated for your night sweats. . The following change was made to your medications: -- STOP losartan. Dr. [**Last Name (STitle) 2903**] should restart this medication after your kidneys have completely recovered. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please be sure to limit the amount of salt in your diet to less than 2 grams daily. . It was a pleasure taking care of you. Followup Instructions: Department: [**State **]When: TUESDAY [**2173-4-6**] at 12:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking

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icd9cm

[ [ [] ] ]

[ "89.69", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

14705, 14711

8215, 12844

351, 357

14900, 14900

3173, 3178

16141, 16446

2667, 2725

13339, 14682

14732, 14732

12870, 13316

5713, 8192

15051, 16118

2740, 3154

14853, 14879

2055, 2120

292, 313

385, 1948

14751, 14832

4672, 5696

14915, 15027

2151, 2494

1970, 2035

2510, 2651

27,077

162,888

48398

Discharge summary

report

Admission Date: [**2128-5-17**] Discharge Date: [**2128-6-25**] Date of Birth: [**2080-2-22**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Codeine / Latex Attending:[**First Name3 (LF) 898**] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: Anterior/posterior spinal L2-4 fusion Intubation Thoracentesis Chest tube placement and removal IR guided percutaneous abdominal fluid collect drainage Central venous line placement IR guided hemodialysis line placement IR guided AV fistula dilation History of Present Illness: Mr. [**Known lastname **] is a 48 y/o man with ESRD on HD who presented initially on [**2128-5-17**] with increasing low back pain since MVC in [**Month (only) 404**] [**2128**]. He has had a complicated complicated hospital course since then, which I will summarize briefly here. He initially had an outpatient MRI which showed question of paraspinal abscess. He had been told to come to the ED right away, but did not do so until several days later. The back pain at that time was centered in his low back with radiation down the anterior bilateral thighs (R>L). He denied fevers. Spine CT showed findings concerning for a destructive infectious process. OSH MRI showed L3 burst fx and retropulsion onto cauda, as well as paraspinal abscess. He was admitted to medicine for further evaluation, with ortho spine service consulting. He was initially started on vanc/gent, and then changed to nafcillin/gent. Blood cultures grew MSSA. . Of note, he was seen in the ED in [**3-12**] with anemia, at which time he spiked a temp to 101 and blood cultures were obtained. The patient left AMA from that ED visit, and cultures ultimately grew MSSA. He was treated for MSSA with cefazolin at HD from [**3-24**] to [**5-4**], but it is unclear if this course was optimal given patient's history of missing HD sessions. . The patient was treated with antibiotics on the medical service until [**5-25**], when the patient was taken to the OR for L2-L4 anterior fusion, following which he remained intubated and on pressors in the SICU. On [**5-28**] he had a posterior fusion. He initially did well and was weaned off pressors. He was extubated on [**6-2**], but on [**6-4**] his respiratory status worsened and he became more hypoxic. He had a thoracentesis followed by a L chest tube placement for pneumothorax. He was reintubated that day. A CT scan of his torso on [**6-4**] also showed a large left sided abdominal fluid collection. On [**6-5**] a drain was placed by IR, producing 800 cc bloody fluid not noted to be purulent (no growth to date on culture). Around that time the patient developed a new pressor requirement. . On [**6-8**] he was extubated. On [**6-12**] he was taken back to the OR for a posterior wound dehiscence. I&D was performed, and a VAC device was applied. He has now been off pressors since the morning of [**6-13**]. He was extubated again on [**6-13**] and passed a speech and swallow evaluation on [**6-14**]. His chest tube was taken out today, as was the intra-abdominal drain. . Currently, he states that his pain is well controlled with medications, but he does feel anxious. He denies other complaints. Past Medical History: 1. Esrd of unknown etiology: s/p HD fistula LUE 2. HTN 3. CAD with positive stress test [**5-8**] 4. restless leg syndrome 5. Psoriasis 6. Anemia [**3-6**] esrd Social History: Smokes [**2-4**] ppd, cut down from 1 ppd. Denies alcohol use. Denies illicit drug use. Resides with mother and brother in [**Name (NI) 745**]. Family History: Father died of MI in 60's; mother alive and well 77; 8 siblings, one of whom has HTN, one who has a cerebral aneurysm; he has no children. Physical Exam: T: 97.7 BP: 110/74 HR: 100 RR: 14 O2 99% on 2L nc Gen: Cachectic male in NAD HEENT: PERRL, anicteric. MMM. OP clear. NECK: No lymphadenopathy, no JVD. CV: RRR, no m/r/g. LUNGS: CTAB. ABD: +BS, soft, NT/ND. EXT: Thin extremities, [**2-4**]+ pitting edema b/l. NEURO: A&Ox3. Appropriate. Pertinent Results: [**2128-5-17**] 04:30PM BLOOD WBC-13.6* RBC-4.03*# Hgb-12.7*# Hct-43.6# MCV-108*# MCH-31.6 MCHC-29.2* RDW-16.9* Plt Ct-212 [**2128-5-25**] 11:47PM BLOOD WBC-34.4*# RBC-2.47*# Hgb-7.8*# Hct-23.8* MCV-96# MCH-31.6 MCHC-32.8 RDW-18.7* Plt Ct-353 [**2128-6-2**] 01:43AM BLOOD WBC-10.6 RBC-2.50* Hgb-7.6* Hct-21.0* MCV-84 MCH-30.4 MCHC-36.1* RDW-18.7* Plt Ct-106* [**2128-6-5**] 01:18AM BLOOD WBC-10.8 RBC-3.09* Hgb-9.4* Hct-26.9* MCV-87 MCH-30.3 MCHC-34.7 RDW-19.0* Plt Ct-212 [**2128-6-13**] 01:43AM BLOOD WBC-10.0 RBC-2.73* Hgb-7.9* Hct-24.8* MCV-91 MCH-28.7 MCHC-31.7 RDW-17.8* Plt Ct-506* [**2128-6-20**] 06:15AM BLOOD WBC-8.5 RBC-2.89* Hgb-8.7* Hct-26.6* MCV-92 MCH-30.2 MCHC-32.9 RDW-20.1* Plt Ct-574* [**2128-5-17**] 04:30PM BLOOD Plt Ct-212 [**2128-5-17**] 04:45PM BLOOD PT-22.1* PTT-43.3* INR(PT)-2.1* [**2128-5-21**] 06:08AM BLOOD PT-16.1* PTT-38.6* INR(PT)-1.4* [**2128-5-26**] 08:11PM BLOOD PT-15.6* PTT-36.8* INR(PT)-1.4* [**2128-5-29**] 07:22AM BLOOD PT-16.7* PTT-44.6* INR(PT)-1.5* [**2128-6-7**] 09:16PM BLOOD Plt Ct-205 [**2128-6-13**] 01:43AM BLOOD PT-14.2* PTT-35.1* INR(PT)-1.2* [**2128-6-19**] 05:55AM BLOOD PT-15.7* PTT-37.9* INR(PT)-1.4* [**2128-5-28**] 11:22PM BLOOD Fibrino-297 [**2128-6-1**] 10:36AM BLOOD Ret Aut-2.1 [**2128-5-17**] 04:30PM BLOOD ESR-2 [**2128-6-17**] 06:30AM BLOOD Glucose-91 UreaN-23* Creat-2.1* Na-139 K-4.0 Cl-99 HCO3-33* AnGap-11 [**2128-5-18**] 11:30AM BLOOD Glucose-91 UreaN-24* Creat-5.6* Na-143 K-3.9 Cl-96 HCO3-18* AnGap-33* [**2128-6-18**] 04:35AM BLOOD ALT-13 AST-19 LD(LDH)-375* AlkPhos-142* Amylase-43 TotBili-0.8 [**2128-5-20**] 06:17AM BLOOD ALT-25 AST-38 CK(CPK)-44 AlkPhos-373* TotBili-0.7 [**2128-5-17**] 04:45PM BLOOD ALT-52* AST-112* LD(LDH)-302* AlkPhos-344* Amylase-31 TotBili-0.3 [**2128-6-18**] 04:35AM BLOOD Lipase-25 [**2128-5-20**] 06:17AM BLOOD GGT-198* [**2128-5-17**] 04:45PM BLOOD Lipase-15 [**2128-5-20**] 06:17AM BLOOD CK-MB-6 cTropnT-0.21* [**2128-5-25**] 11:47PM BLOOD cTropnT-0.09* [**2128-5-26**] 10:02AM BLOOD CK-MB-3 cTropnT-0.10* [**2128-6-20**] 06:15AM BLOOD Calcium-7.8* Phos-3.9 Mg-1.9 [**2128-6-11**] 03:22AM BLOOD Calcium-8.0* Phos-4.4 Mg-2.5 [**2128-6-7**] 03:10AM BLOOD Albumin-1.8* Calcium-8.8 Phos-2.8 Mg-2.1 [**2128-6-18**] 04:35AM BLOOD Albumin-1.6* Calcium-7.5* Phos-3.8 Mg-2.1 [**2128-5-19**] 08:15AM BLOOD calTIBC-81* Ferritn-888* TRF-62* [**2128-6-15**] 04:19AM BLOOD TSH-6.4* [**2128-6-18**] 04:35AM BLOOD Cortsol-12.7 [**2128-5-28**] 01:53AM BLOOD Cortsol-47.0* [**2128-5-17**] 04:45PM BLOOD CRP-87.0* [**2128-6-9**] 05:56AM BLOOD Vanco-16.4 [**2128-5-29**] 02:48PM BLOOD Genta-0.3* [**2128-5-20**] 06:17AM BLOOD Vanco-22.3* [**2128-6-15**] 12:32AM BLOOD Type-ART pO2-111* pCO2-34* pH-7.46* calTCO2-25 Base XS-0 [**2128-5-25**] 03:54PM BLOOD pO2-58* pCO2-58* pH-7.30* calTCO2-30 Base XS-0 [**2128-6-12**] 11:47AM BLOOD Glucose-41* Lactate-0.6 Na-134* K-3.9 Cl-102 [**2128-5-25**] 04:38PM BLOOD Glucose-96 Lactate-1.4 Na-131* K-3.2* Cl-102 [**2128-6-12**] 11:47AM BLOOD freeCa-1.07* [**2128-6-7**] 03:17PM BLOOD freeCa-1.12 [**2128-6-2**] 08:59AM BLOOD freeCa-0.94* [**2128-5-25**] 03:54PM BLOOD freeCa-0.97* [**2128-5-25**] 04:38PM BLOOD freeCa-0.88* [**2128-5-25**] 04:38PM BLOOD freeCa-0.88* VITAMIN B1, BLOOD 115 87-280 NMOL/L CT Spine [**5-17**]: CT lumbar spine without contrast. FINDINGS: There is extensive destructive process, centered at L2-3 disc space, which is obliterated, with extensive irregularity of end-plates and significant loss of height of vertebral body of L3 and marked irregularity of L2 inferior endplate and retropulsion of the bony fragments. The canal measures only 9 mm (AP) at this level. Additionally, there is high- attenuation material in the epidural space, adjacent to the largest retropulsed fragment, which may represent hemorrhage but is also concerning for infection. There is associated kyphotic angulation at L2-3 level. Calcification of the abdominal aorta is noted. Paraspinal soft tissues are not well evaluated in this non-contrast non-dedicated study. IMPRESSION: Extensive destructive process at L2-3 level, with significant retropulsion of bony fragments, narrowing the spinal canal and compressing the thecal sac at this level. This constellation of findings, including significant osseous destruction, disc and endplate involvement and adjacent density in the epidural space, are concerning for infection, perhaps complicated by recent trauma. However, occasionally, the chronic spondyloarthropathy associated with ESRD can mimic the diskitis/vertebral osteomyelitis complex. For this reason, review of the prompting OSH MR, and comparison to any prior studies would be most helpful. TTE [**6-17**]: 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 = 15-20%), without regional wall motion abnormalities (c/w a diffuse process, such as toxic, metabolic, sepsis, etc). Right ventricular cavity size and systolic function are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. CT Chest [**5-20**]: CT CHEST WITHOUT CONTRAST: There is overall evidence of volume overload with a moderate right pleural effusion and small-to-moderate left pleural effusion with associated passive atelectasis. There is body wall edema consistent with anasarca and the partially visualized upper abdomen demonstrates ascites. Septal thickening in this case in a predominantly bibasilar distribution, is consistent with hydrostatic edema. It is indeterminent whether thickening of the peribroncovascular bundles is secondary to hydrostatic edema or attributable to infection. A nodular opacity with irregular margins is present at the periphery of the right upper lobe (3:7) in segment 1 measuring 1.7 x 1.3 cm. A second nodular opacity in a peribronchovascular distribution is present in the right upper lobe measuring 9 x 8 mm. Focal regions of peribronchiolar nodules are present within the lungs for example in the left upper lobe (3:10) suggesting bronchiolar infection. Focal bulla is stable in the left lower lobe. A left PICC line and left double-lumen dialysis catheter present with tips residing within the distal SVC. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. Diffuse volume overload with moderate effusions, anasarca and ascites. 2. Mild widespread bronchiolar infectious process. Given that several opacities have a nodular configuration, followup CT chest without contrast is recommended in three months to ensure resolution. In a patient with paraspinal abscess, septic emboli should also be considered as a cause for nodules although the appearance and distribution of these opacities are not typical of this condition. MIBI: Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Following resting images and two minutes following intravenous dipyridamole, approximately three times the resting dose of Tc-[**Age over 90 **]m sestamibi was administered intravenously. Stress images were obtained approximately 45 minutes following tracer injection. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: The image quality is adequate. Left ventricular cavity size is marked dilated at stress and rest. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. No reversible defects. Gated images reveal global hypokinesia. The calculated left ventricular ejection fraction is 16%. IMPRESSION: 1) Severe dilated cardiomyopathy; LVEF 16%. New from study of [**2127-2-11**]. 2) No reversible perfusion defects. L4 Disc biopsy: Intervertebral disc L3-4: Acute osteomyelitis with osteonecrosis. See note. Note: Sections of bone show fibrosis of the marrow space with chronic inflammatory cells. This finding may represent changes due to trauma or chronic osteomyelitis. In addition, there are small aggregates of neutrophils, some admixed with fibrinous exudate, adjacent to bone and within bony lacunae. This finding is consistent with an on-going acute osteomyelitis. Slides B and C reviewed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **]. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1352**] notified of diagnosis [**2128-5-28**] at 3:30 PM. RUQ U/S: 1. Large right pleural effusion and moderate ascites, new since [**2128-1-3**]. 2. Normal-appearing gallbladder without evidence of acute cholecystitis. 3. Bright linear echogenic regions in the expected region of the ductal confluence of uncertain etiology. Diagnostic possibilities include air and stones within the central biliary tree, more likely than interposed loops of bowel within the porta hepatis. These findings may be expected if patient has had endoscopic sphincterotomy or similar procedure; however, reports in CareWeb do not reflect this. Further evaluation may be obtained with CT or MRI as indicated. CT-GUIDED DRAINAGE PROCEDURE The patient's sister and medical proxy, [**Name (NI) 4311**], was contact[**Name (NI) **]. Discussion of risks and benefits including specific risks of bleeding, infection, injury to abdominal organs and bowel, and need for additional surgery, was discussed. Informed consent was obtained over the telephone and witnessed. The patient was placed on the CT examination table in the supine position. The left lower abdomen was marked. The skin was prepped and draped in the usual sterile fashion. Local anesthesia was administered with 1% lidocaine. A 10 French all-purpose drainage catheter was then introduced into a large heterogeneous fluid collection containing both high-density foci and air consistent with clot and abscess. Approximately 800 cc of hemorrhagic fluid was aspirated. The fluid was sent for microbiology. The drain was secured in place. A sterile dressing was applied. The patient tolerated the procedure well and was returned to the intensive care unit for additional monitoring. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was present and available throughout the entire procedure. Sedation was administered by the ICU nurse. IMPRESSION: Technically successful placement of a 10 French all-purpose drainage catheter into a large intra-abdominal abscess. 800 cc of hemorrhagic fluid aspirated. CXR [**6-15**]: There has been interval removal of left-sided central venous catheter. Left-sided chest tube and right-sided central venous catheter are in unchanged position. Previously seen left apical pneumothorax not identified on current study. Cardiac and mediastinal contours appear unchanged. Bilateral pleural effusions are again seen, not significantly changed allowing for positional differences. Spinal fusion hardware again noted. IMPRESSION: Interval removal of left-sided central venous line. No definite pneumothorax identified. PICC Placement: Using sterile technique and local anesthesia, the left brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of the ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over the guidewire and a single lumen PIC line measuring 37 cm in length was placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was then secured to the skin, flushed, and sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the left brachial vein approach. Final internal length is 37 cm with the tip positioned in the SVC. The line is ready to use. AVF evaluation and dilation: PROCEDURE AND FINDINGS: After explaining the risks and benefits of the procedure, written informed consent was obtained from the patient. The patient was placed supine on the angiographic table and the right upper arm was prepped and draped in standard sterile fashion. A preprocedure timeout was performed. After injection of local anesthesia, access was gained into the proximal cephalic vein of the right upper extremity AV fistulogram with a 21-gauge micropuncture needle. A 0.018 guidewire was advanced through the needle into the upper cephalic vein and a needle was exchanged for a 4.5 French micropuncture sheath. Venogram was performed with injection of contrast through the micropuncture sheath to evaluate from the cephalic vein to the central vein, whch demonstrated no area of stenosis. Inflation of blood pressure cuff at the right upper arm, another venogram was performed with injection of the contrast through the sheath to evaluate the arterior anastomosis site of AV fistula. Venogram demonstrated about 2 cm tight stenosis at proximal cephalic vein with multiple collateral veins and venous dilatation of cephalic vein proximal to the stenotic portion. Based on the diagnostic findings, it was decided that the patient would benefit from and was a good candidate for angioplasty. The micropuncture sheath had to be removed because stenotic portion is too near the puncture site. Thus we decided to get another access into the upper cephalic vein. Using ultrasound guidance and palpatory technique, after several attempts, retrograde access was gained into the upper cephalic vein with a 21- gauge micropuncture needle. A 0.018 guidewire was advanced through the needle into the proximal cephalic portion under fluoroscopic guidance and the needle was exchanged for a 4.5 French micropuncture sheath. The micropuncture sheath was exchanged for a 6 French [**Last Name (un) **] tip sheath. Another venogram was performed with a 5 French straight multisided-holed catheter, which demonstrated about 2 cm stenotic portion at the proximal cephalic vein. Stenotic portion of the proximal cephalic vein was dilated with 6 mm x 4 cm and 8 mm x 4 cm balloons. A followup venogram demonstrated widely patent stenotic portion at proximal cephalic vein and multiple collateral veins disappeared. After balloon dilatation, venous bulging proximal to the stenotic portion also decreased. Vascular sheath was removed and manual compression was held for 15 minutes until hemostasis was achieved. A v-pad was applied at the puncture site of upper cephalic vein to prevent the bleeding at the puncture site. The patient tolerated the procedure well and there were no immediate complications. Sedation was provided by administering divided doses of fentanyl and Versed throughout the total intraservice time of 105 minutes during which the patient's hemodynamic parameters were continuously monitored. IMPRESSION: Fistulogram demonstrated about 2 cm tight stenosis at the proximal cephalic vein of right UE AV fistula with multiple collateral veins. Balloon dilatation was performed with 6 and 8 mm x 4 cm balloons and with good angiographic results. HD line placement: PROCEDURE AND FINDINGS: Details of the procedure and possible complications were explained and informed consent was obtained. A preprocedure timeout was performed. The patient was placed supine on the angiographic table and the indwelling catheter and left upper chest were prepped and draped in standard sterile fashion. An initial fluoroscopic image demonstrated a temporary catheter with tip in the SVC/right atrium junction. 10 cc of 1% lidocaine with epinephrine were used to anesthetize the skin and subcutaneous tissues. Following a small skin incision, the subcutaneous tunnel was created by blunt dissection and the line was tunneled through the subcutaneous tissue. After aspirating each lumen, a 0.035 guidewire was advanced through the catheter to the inferior vena cava under fluoroscopic guidance. Catheter was then exchanged for a peel-away sheath. The wire and the inner dilator of the peel-away were then removed and the line was advanced through the peel-away sheath and positioned with its tip at the level of the SVC/right atrium junction. The peel-away sheath was removed. The line was flushed, heplocked and secured to the skin with 0 silk sutures. The venous access site incision was closed with Dermabond and 2-0 Vicryl sutures. A sterile dressing was applied. Final fluoroscopic image demonstrated tip of the catheter to be located in the SVC/right atrium junction. Moderate sedation was provided by administering Fentanyl and Versed in divided doses The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Successful conversion of temporary line to a tunneled 27-cm tip to cuff double lumen line for dialysis via the left subclavian vein with tip in the SVC/right atrium. The line is ready for use. Brief Hospital Course: Please see HPI for a summary of events prior to his transfer from the SICU to the floor. After transfer to the floor the events are as follows: . . # Low back pain, paraspinal abscess, s/p s/p L2-L4 anterior [**5-25**] followed by posterior fusion [**5-28**]: Now s/p anterior and posterior fusion by ortho spine surgery. Most recently had wound dehiscence and I+D done on [**6-12**]. The patient was started on and should continue on IV nafcillin and rifampin for at least 8 weeks after the dates of his surgery for treatment of his MSSA bacteremia and paraspinal abscess. A PICC line is in place for continued IV antibiotics. Furthermore, enterobacter was cultured from tissue taken from the wound dehiscence on [**6-12**] which was treated with ciprofloxacin and should be continued until his follow up appointment with the ID fellow, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Originally he had a vacuum dressing in place on his anterior fixation wound but that was removed on [**6-20**]. An occlusive dressing should be maintained with daily changes. He should be in his TLSO brace when he is out of bed. His pain was controlled with methadone and percocet with good effect. He will follow up with the orthopedic surgeons as well. . # Hypoglycemia: The patient developed episodes of hypoglycemia towards the endo of his SICU course, treated with a D10 drip. These episodes continued on transfer to the floor, worst first thing in the morning. Endocrine was consulted and felt that these episodes were likely due to poor oral intake of protein and complex carbohydrates C-peptide, betahydroxybutyrate and insulin levels sent at the time of a hypoglycemic event were normal, making a hyperinsulinemic cause much less likely. He was encouraged to increase his intake which improved his blood sugars. It should be ensured that the patient receives a high protein snack such as peanut butter and crackers just before bed to lessen am hypoglycemia. The patient should be encouraged to eat calorie dense, high protein food. . # Diarrhea: The patient began having diarrhea towards the end of his SICU course, requiring a rectal tube. C.difficile was checked x3 as well as a cytotoxin B, which were all negative. Diarrhea was felt to be a combination of antibiotic effect, low albumin (1.6) and a mild intolerance to lactose. He was started on loperamide, lomotil and a lactose free diet with improvement of his diarrhea. . # Right arm swelling: The patient developed swelling of his right arm superior to his fistula. A fistulogram confirmed a stenosis which was dilated by intervential radiology. However, the nephrology team did not feel his fistula was ready for use immediately after and it may take a week or two to recover. A tunnelled left IJ HD line was place to be used in the interim. . # Anemia: Post-op, likely related to blood loss, plus component of anemia from ESRD. Epogen at HD. Monitor hct. . # Pleural effusions: He had bilateral effusions- could be due to CHF, given EF 15%. L effusion was tapped, but unfortunately TP and LDH were not sent so not certain if transudate vs. exudate. Fluid culture and cytology were negative. Respiratory status remained stable and he was on room air at the time of discharge. Unless his respiratory status worsens, these should be followed by his PCP. . # Cardiomyopathy/Depressed EF: The patient developed an apparently new cardiomyopathy with an EF of 15-20% on this admission, down from 45-50% in [**2125**]. Pre-op stress MIBI showed no reversible perfusion defects making ischemia less likely. He was started on metoprolol and low dose lisinopril. His fluid status was managed via hemodialysis. . # ESRD on HD: On [**Last Name (LF) 12075**], [**First Name3 (LF) **] need continued renal follow up. Continued nephrocaps, phoslo and epogen with HD. . # FEN: Very poor nutritional status (INR has been elevated, albumin 1.6 on admission to the floor). Regular lactose free diet, with pudding and shake supplements. He should be encourage to eat as much as possible. If further improvements in nutritional intake are not met, TPN, NG, or PEG tube feedings may be considered. . # PPx: HSC. Bowel meds prn. H2-blocker . # Access: L PICC line . # CODE: full . Medications on Admission: MEDS at home: allopurinol 100 mg daily (pt unsure of dosing) toprol XL 50 mg daily (pt unsure of dosing) phosrenol (per patient), dose unknown renal vitamin dilaudid 4 mg PO TID . MEDS on Transfer: Insulin Sliding Scale D10W Continuous at 20 ml/hr Ipratropium Bromide MDI 6 PUFF IH QID Artificial Tear Ointment 1 Appl BOTH EYES PRN Lorazepam 0.5 mg IV Q8H:PRN agitation Bisacodyl 10 mg PO DAILY:PRN Lorazepam 1 mg PO HS:PRN Calcium Gluconate IV Sliding Scale Magnesium Sulfate IV Sliding Scale Calcium Acetate 667 mg PO TID W/MEALS Methadone 5 mg PO TID Cepacol (Menthol) 1 LOZ PO PRN Metoprolol Tartrate 25 mg PO TID Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **] Nafcillin 2 gm IV Q4H Ciprofloxacin 200 mg IV Q12H Nephrocaps 1 CAP PO DAILY Dextrose 50% 12.5 gm IV PRN Ondansetron 4 mg IV Q8H:PRN Docusate Sodium (Liquid) 100 mg PO BID OxycoDONE-Acetaminophen Elixir [**6-12**] mL PO Q4H:PRN Famotidine 20 mg PO BID Potassium Chloride IV Sliding Scale HYDROmorphone (Dilaudid) 0.5-2 mg IV Q2-4H:PRN pain with movement Promethazine 6.25 mg IV Q6H:PRN Heparin 5000 UNIT SC BID Psyllium 1 PKT PO TID:PRN Rifampin 600 mg PO Q24H Order date: [**6-12**] @ 1133 Discharge Medications: 1. Outpatient Lab Work please have the following labs drawn weekly: cbc, diff, chem7, LFTs, ESR, CRP. please fax to [**Telephone/Fax (1) **], care of dr. [**First Name (STitle) **] [**Doctor Last Name **] 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection [**Hospital1 **] (2 times a day). 4. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 6 weeks. 5. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 7. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 weeks. 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 16. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed. 17. Ondansetron 4 mg IV Q8H:PRN 18. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 6 weeks. 19. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 21. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: MSSA paraspinal abscess and bacteremia Enterobacter wound infection AV fistula stenosis Malabsorptive diarrhea Bilateral pleural effusions End Stage Renal Disease on hemodialysis Discharge Condition: All vital signs stable, afebrile Discharge Instructions: You were admitted with an infection in your spinal cord. This was treated with IV antibiotics and surgery to clean out the infection. You will continue the IV antibiotics while you are at the rehab facility and you will follow up with the infectious disease doctor for further management of your antibiotics. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2128-7-19**] 10:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2128-7-8**] 10:20 Please call Dr.[**Doctor Last Name 6493**] (orthopedics) office at ([**Telephone/Fax (1) 2007**] to schedule a follow up appointment in the next 3-4 weeks. Please call Dr. [**Last Name (STitle) 4921**] office at [**Telephone/Fax (1) 2205**] to schedule a follow up appointment in the next 4-5 weeks.

[ "428.21", "251.2", "512.1", "403.91", "730.08", "790.7", "805.4", "E819.9", "737.41", "731.3", "998.32", "996.1", "567.22", "722.93", "041.11", "E879.8", "425.4", "305.1", "261", "518.81", "285.21", "324.1", "585.6" ]

icd9cm

[ [ [] ] ]

[ "86.05", "96.6", "81.05", "84.51", "93.59", "03.53", "39.95", "38.93", "38.95", "81.63", "34.91", "39.50", "84.52", "81.06", "54.91", "86.04", "81.62", "00.40", "99.15" ]

icd9pcs

[ [ [] ] ]

29042, 29121

21508, 25742

299, 550

29344, 29379

4035, 21485

29736, 30327

3573, 3713

26970, 29019

29142, 29323

25768, 25948

29403, 29713

3728, 4016

250, 261

578, 3211

3233, 3395

3411, 3557

25966, 26947

48,274

152,274

36170

Discharge summary

report

Admission Date: [**2183-12-3**] Discharge Date: [**2183-12-11**] Date of Birth: [**2107-2-1**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: CC: neck pain Major Surgical or Invasive Procedure: 1. Lateral mass and part screw insertion, C1-C2, at left Altius, EBI). 2. Harvest of iliac crest bone graft structural right posterior-superior iliac crest. 3. Posterior arthrodesis C1-C2. 4. Open reduction of a C1-C2 deformity. History of Present Illness: HPI: 76yo RH M who was driving tonight and remembers going the wrong way and feeling as if his blood sugar was low. The next thing he remembers is having the fire dept extract him from his car; he was unrestrained and fractured the windshield. He reports neck pain but denies weakness, numbness or bowel/bladder dysfunction. Pt. ran into a tree as a result of his low blood sugar and confusion. Past Medical History: PMH: DM HTN dyslipidemia Social History: SH: retired. No tob/etoh Lives at home independently 3 sons single Family History: FH: non-contribtory for MVA Physical Exam: PE VS 95.5 147-206/83-109 108 19 96% Gen Awake, cooperative, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck hard collar Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Fully oriented. Months of the year backwards were intact. Speech fluent, with normal naming, [**Location (un) 1131**], comprehension and repetition. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. No apraxia. Interprets cookie theft picture appropriately. No dysarthria. CN CN I: not tested CN II: Visual fields were full to confrontation, no extinction. Pupils 3->2 b/l. CN III, IV, VI: EOMI no nystagmus or diplopia CN V: intact to LT throughout CN VII: full facial symmetry and strength CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**4-28**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. No pronator drift D B T WE FE FF IP Q H DF PF TE Sensory intact to light touch, pinprick, joint position sense, vibration throughout. No extinction to double simultaneous stimulation. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 0 0 0 0 0 down R 0 0 0 0 0 down Coordination Fine finger movements, rapid alternating movements, finger-to-nose, and heel-to-shin were all normal Gait deferred Pertinent Results: Imaging CT head: neg for acute process CT C-spine (prelim): Type 2 dens fracture with fracture of the lateral mass of left C1. Teardrop fracture of c4 with widening of the C4-5 interspace and probable rupture of the ALL. Recommend MRI and MRA of the cervical spine as discussed with trauma. Compared to CT C-spine of [**2183-10-3**]. There is posterior fusion above and below the type 2 dens fracture, with the superior and inferior components in good alignment. The previously described fractures at C1 and C4 are not well assessed. The lateral radiograph images only to the level of superior endplate of C6. There is a longstanding fusion of C5 and C6. There is minimal (1 mm) anterolisthesis of C3 on C4. Flexion and extension views were not performed. Severe uncovertebral degenerative change and hypertrophy are noted on the AP view. Surgical staples remain in place. [**2183-12-3**] 12:20AM WBC-14.8* RBC-5.20 HGB-15.9 HCT-47.5 MCV-91 MCH-30.5 MCHC-33.5 RDW-13.7 [**2183-12-3**] 12:20AM PLT COUNT-290 [**2183-12-3**] 12:20AM PT-13.0 PTT-21.0* INR(PT)-1.1 [**2183-2-2**] 04:22AM GLUCOSE-142* UREA N-24* CREAT-1.3* SODIUM-138 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 [**2183-12-9**] 05:15AM BLOOD WBC-18.0* RBC-3.10* Hgb-9.5* Hct-28.3* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.6 Plt Ct-217 [**2183-12-10**] 06:10AM BLOOD WBC-15.1* RBC-3.01* Hgb-9.5* Hct-27.7* MCV-92 MCH-31.5 MCHC-34.1 RDW-15.2 Plt Ct-313 [**2183-12-8**] 01:57AM BLOOD WBC-25.3* RBC-2.93* Hgb-9.4* Hct-26.3* MCV-90 MCH-32.0 MCHC-35.6* RDW-14.7 Plt Ct-173 [**2183-12-7**] 01:20AM BLOOD PT-13.5* PTT-24.3 INR(PT)-1.2* [**2183-12-10**] 07:35PM BLOOD Glucose-213* UreaN-22* Creat-1.6* Na-135 K-3.6 Cl-97 HCO3-33* AnGap-9 [**2183-12-10**] 07:35PM BLOOD ALT-65* AST-72* [**2183-12-10**] 07:35PM BLOOD Albumin-3.4 Calcium-8.7 Phos-3.3 Mg-2.0 [**2183-12-10**] 07:35PM BLOOD TSH-1.8 Brief Hospital Course: Pt was admitted and remained in hard cervical collar. He underwent MRI that showed odontoid fracture with 4-mm posterior displacement,at C4/C5, there is a small linear T2 hyperintense signal in the intervertebral disc space, with evidence of a small "tear-drop" deformity in the anterior-inferior endplate of C4, There is no posterior longitudinal ligamental injury, no definitive evidence of anterior longitudinal ligamental tear,no encroachment of the spinal canal,no spinal stenosis,no intraspinal hematoma or cord contusion. He was readied for the OR. He was seen in consultation by [**Last Name (un) **] service for diabetes management. On [**12-6**] he went to the OR for a Lateral mass and part screw insertion, C1-C2 and posterior arthrodesis C1-C2. Postoperatively he went to the TSICU for blood pressure instability, he was extubated on post operative day 1. He had full motor strenght. His JP drain was removed on POD#3 and he was transferred to the floor. He was monitored closely by [**Hospital1 **] for control of his diabetes which consisted of a humalog sliding scale and daily changes to his Lantus coverage. In the ICU he was treated for possible aspiration pneumonia a follow up CXR on [**12-9**] showed: : Left lower lobe atelectasis - infiltrate has cleared up and improved. No new abnormalities. Today [**2183-12-10**] the pt. is ready for discharge to rehab, he ie required to wear his cervical collar for 6 weeks and return to the office in 10 day for staple removal, and in 6 weeks with a follow up CT of the Cervical Spine. [**2183-12-10**] Pt. was seen by psychiatry for clearence given a few documented incidences of cofusion and delerium in the evenings. Psychiatry spent a great amount of time with the family and also contact[**Name (NI) **] the patients PCP for suggestions of a workup for early onset dementia, they also recommended a driving test prior to being aloud to drive upon discharge from rehab. Medications on Admission: MEDS: Lipitor 10 Norvasc 5 Avapro 150mg [**Hospital1 **] Naproxen 500 ASA 81 Humalog sliding scale Lantus qhs Creon 10mg tablets 15 per day Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 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. 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. 10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: C1,C2 fractures C4 fracture DM Delerium Discharge Condition: STABLE Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ begin daily showers [**12-9**] ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? you are required to wear cervical collar for 6 weeks. ?????? You may shower briefly without the collar. ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean, shower daily and pat wound dry. ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? you are required to wear cervical collar for 6 weeks. You may take your collar off only when you are showering for a brief period of time and replace the collar when you step out of the shower. Showers should be taken sitting down on a chair in the shower. ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR STAPLE PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED A CT OF YOUR NECK PRIOR TO YOUR APPOINMENT Upon discharge from rehab you will need to: Occupational Therapy Home Safety Assessment -- this should be arranged by rehab as part of their discharge planning. Outpatient dementia w/u including referral to behavioral neuro and neuropsych testing -- I spoke to PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ ([**Telephone/Fax (1) 82044**] to inform of my concerns and recommendations. He will arrange these referrals if remain indicated, we also recommend follow up AST and ALT as they were slightly elevated here on this admition. Please contact [**Name (NI) 501**] [**Last Name (NamePattern1) 16368**] at the Drive wise program at [**Hospital1 **] when pt. is discharged from rehab to determine wether pt. is safe to drive independently safely. Call [**Telephone/Fax (1) 1690**]. Completed by:[**2183-12-11**]

[ "997.39", "E813.0", "507.0", "805.08", "401.9", "293.9", "733.90", "251.3", "518.0", "882.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "81.03", "03.53", "81.62", "86.59", "96.04", "77.79" ]

icd9pcs

[ [ [] ] ]

7688, 7758

4629, 6569

333, 571

7842, 7851

2744, 2752

10948, 12070

1144, 1174

6759, 7665

7779, 7821

6595, 6736

7875, 10925

1189, 2725

280, 295

599, 995

2761, 4606

1017, 1043

1059, 1128

47,965

179,376

50766

Discharge summary

report

Admission Date: [**2112-6-4**] Discharge Date: [**2112-6-6**] Date of Birth: [**2047-8-13**] Sex: M Service: MEDICINE Allergies: Aspirin / Ceftriaxone / Ibuprofen Attending:[**First Name3 (LF) 8404**] Chief Complaint: asthma exacerbation/anaphylaxis Major Surgical or Invasive Procedure: epinephrine pen administration History of Present Illness: 64M with history of CAD s/p CABG and severe asthma who presented from home with respiratory arrest. He had a recent admission at an OSH two weeks ago where he underwent ASA desensitization therapy. He developed wheezing at home today and took 30 prednisone but was then found lying in his back yard cyanotic. EMS was called. On the scene they reported no air movement. They were unablet to bag ventilate. He was given epinephrine and had rapid improvement in symptoms. On arrival to the ED, he was afebrile, BP 141/78 RR18 and 100% NRB. He was placed on continuous nebs, given mthylprednisolone 125 IV x1 and magnesium 2g IV. CXR was negative as was troponin. On transfer to the floor he is [**Age over 90 **]% on room air. . Currently feeling much better but anxious. He states that his symptoms came on relatively suddenly and did not include any itching/rash/angioedema/runny eyes/rhinorrhea as well as no chest pain or nausea. He had gone outside because he thought he might have to call 911 and did not want them to have to manage opening a locked door. He has had two attacks like this since his ASA densensitization but was able to take prednisone soon enough for the prior attack to self-resolve. Prior to the asa desensitization, his last severe attack requiring ED visit was 30 years ago. . His asthma developed at age 20 and is associated with nasal polyposis and ASA sensitivity. In his 20s, he had frequent ED visits (sometimes up to three times weekly), but only one hospital admission and no intubations. He failed and actually had a paradoxical reaction to inhaled steroids and has been prednisone dependent for 10 years. Past Medical History: ASTHMA, ASA sensitive with nasal polypsis/eosinophilia, samter's triad, pred dependent MITRAL VALVE PROLAPSE HYPERCHOLESTEROLEMIA DIVERTICULOSIS COLONIC POLYPS GASTROPARESIS OSTEOPENIA CORONARY ARTERY DISEASE, s/p CABG [**2104**] SLEEP APNEA CATARACT - NUCLEAR SCLEROTIC SENILE ESOPHAGEAL REFLUX CANCER - PROSTATE s/p XRT RADIATION PROCTITIS Social History: Smoking: Quit ([**2077-2-11**]) 1.5 ppd, 13.5 pack-years Alcohol: minimal no drugs Family History: NC Physical Exam: On Admission: General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: cta b/l throughout Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed On discharge: Gen: alert and oriented, NAD HEENT: PERRL, anicteric CV: RRR, no m/r/g Pulm: CTA bilat without wheezing Abd: soft, NTND Extrem: no edema, cyanosis or clubbing Pertinent Results: On Admission: [**2112-6-4**] 05:15PM BLOOD WBC-10.9 RBC-4.60 Hgb-12.8* Hct-39.8* MCV-87 MCH-27.8 MCHC-32.2 RDW-14.4 Plt Ct-285 [**2112-6-4**] 05:15PM BLOOD PT-12.6 PTT-19.2* INR(PT)-1.1 [**2112-6-4**] 05:15PM BLOOD UreaN-24* Creat-1.2 Na-140 K-5.4* Cl-101 HCO3-20* AnGap-24* [**2112-6-4**] 05:15PM BLOOD Calcium-8.9 Phos-6.5* Mg-2.3 [**2112-6-4**] 05:26PM BLOOD Glucose-255* Lactate-5.2* Na-140 K-4.9 Cl-102 [**2112-6-4**] 05:26PM BLOOD Hgb-12.7* calcHCT-38 O2 Sat-94 COHgb-3 MetHgb-0 [**2112-6-4**] 05:26PM BLOOD freeCa-0.98* . ABG: [**2112-6-4**] 05:26PM BLOOD pO2-135* pCO2-41 pH-7.30* calTCO2-21 Base XS--5 Comment-GREEN TOP . Tox: [**2112-6-4**] 05:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG . Imaging: CXR [**2112-6-4**]: 1. Cardiomegaly but no overt edema. 2. Probable small hiatal hernia. On discharge: [**2112-6-6**] 04:33AM BLOOD WBC-13.6*# RBC-4.46* Hgb-12.0* Hct-36.8* MCV-83 MCH-26.9* MCHC-32.6 RDW-14.9 Plt Ct-319 [**2112-6-5**] 05:01AM BLOOD Neuts-93.4* Lymphs-2.9* Monos-2.3 Eos-0.3 Baso-1.2 [**2112-6-6**] 04:33AM BLOOD Plt Ct-319 [**2112-6-4**] 05:15PM BLOOD Fibrino-284 [**2112-6-6**] 04:33AM BLOOD Glucose-152* UreaN-28* Creat-0.9 Na-142 K-3.5 Cl-105 HCO3-25 AnGap-16 [**2112-6-6**] 04:33AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1 Brief Hospital Course: 64 y/o with h/o severe prednisone dependent asthma (adult onset with ASA sensitivity, eosinophilia) s/p ASA densitization at [**Hospital1 112**] two weeks ago with acute asthma attack. . # Asthma exacerbation/anaphylactic reaction: Per report, patient cyanotic at home, which improved with epi pen in field, nebs and prednisone. Patient admitted to the MICU for close monitoring. Trigger felt likely to be aspirin, as asthma previously well controlled prior to starting ASA following recent ASA desensitization. There was no evidence of infection (lack of fever or symptoms). Therefore, aspirin was held. Patient treated with NEBs q4hr + prn, started on outpatient Montelukast and Zyflo. Per discussion with allergy and pulmonary, Zyflo was initiated due to the aspirin desensitization, and can be stopped, as he will not continue these desensitizations. Patient started on 60 mg prednisone and then experienced increased SOB/decreased peak flow consequently started on Solmedrol 125mg q8hr. He was then transitioned to prednisone 60mg PO daily and was stable on this regimen for the following 18 hours. We also held his B-blocker. Peak flow on the day of discharge from the MICU was 417 and he was without wheeze. . The patient's allergist was contact[**Name (NI) **] who agreed with stopping the aspirin. With regard to follow-up, patient and provider will be in close communication, but formal appointment is not required as there is no plan to continue aspirin desensitization. Pulmonary was consulted, and outpatient pulmonologist [**Hospital1 112**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9303**] was the consult attending. With multidisciplinary discussion, patient will be discharged on prednisone 60 mg daily (with 2 week taper and to be managed by Dr. [**Last Name (STitle) 9303**], discharged with epi pen for emergency use (patient educated how to use), and he was continued on outpatient montelukast. Zyflo was discontinued as his aspirin desensitatization is discontinued. He is not on inhaled corticosteroids due to paradoxical allergic reaction. Patient instructed that as he missed dose is now re-sensitized to Aspirin and can not re-start taking without risk of worsening asthma/anaphylaxis. We restarted albuterol and ipratropium INH PRN. He will discuss with his pulmonologist re long acting inhaled steroid and long acting anticholinergic and will follow up with him soon. He will continue to hold B-blocker until breathing/PEF at baseline. . # GERD: Continued omeprazole . # Lactic acidosis: resolved. [**3-16**] cyanosis on presentation . # CAD s/p CABG: Held beta-blocker (bisoprolol) in setting of bronchospasm - patient to re-start once at baseline. Continued pravastatin. As aspirin stopped re-started plavix. . # HTN: Continued HCTZ . # Prostate ca s/p xrt: Held avodart (non-form) Medications on Admission: 1. PREDNISONE 20 MG PO QAM 2. ACETYLSALICYLIC ACID 650 MG PO BID 3. CALCIUM CITRATE 950 MG PO DAILY 4. CHOLECALCIFEROL 5,000 UNITS PO DAILY 5. CLOPIDOGREL 75 MG PO DAILY 6. DIAZEPAM 5 MG PO TID 7. DUTASTERIDE 0.5 MG PO BID 8. HYDROCHLOROTHIAZIDE 25 MG PO DAILY 9. OMEPRAZOLE 40 MG PO DAILY 10. FORMOTEROL 1 INHALATION INH Q24H 11. XOPENEX 1.25 MG Q2H PRN Shortness of Breath,Wheezing 12. Bisoprolol (zebeta) 1.25/day 13. pravastatin 80 Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety/insomnia. 3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Calcium Citrate + Oral 8. Vitamin D Oral 9. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Xopenex 1.25 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation q2hr as needed for shortness of breath or wheezing. 11. prednisone 10 mg Tablet Sig: 1-6 Tablets PO once a day: Please take 6 tabs (60mg) daily for 3 days from [**Date range (1) 11757**], then 5 tabs (50mg) daily for 3 days from [**Date range (1) 40693**], then 4 tabs (40mg) daily for 3 days from [**Date range (1) 58651**], then 3 tabs (30mg) daily from [**Date range (1) 58652**], then 2 tabs (20mg) daily from [**Date range (1) 16935**], then 1 tab (10mg) daily until advised to change. Disp:*90 Tablet(s)* Refills:*1* 12. formoterol fumarate 12 mcg Capsule, w/Inhalation Device Sig: One (1) INH Inhalation every twenty-four(24) hours. 13. bisoprolol fumarate 5 mg Tablet Sig: 0.25 Tablet PO twice a day: Take only if breathing is stable as directed by your cardiologist and pulmonologist. Hold for shortness or breath or wheeze. . 14. ipratropium bromide 0.02 % Solution Sig: One (1) INH Inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) PUFF Inhalation every four (4) hours as needed for shortness of breath or wheezing. 16. epinephrine 1 mg/mL (1:1,000) Solution Sig: One (1) INJ Injection once a day as needed for Severe allergic reaction. Disp:*2 Pens* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Hypoxia/Respiratory distress Acute Asthma Aspirin hypersensitivity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for severe respiratory distress. You improved with epinephrine, aggressive nebulizer therapy and prednisone. You were closely monitored in the ICU prior to discharge and improved significantly. The cause of your respiratory distress was likely secondary to your asthma and the trigger is unclear but may have been related to aspirin therapy. YOUR ASPIRIN WAS DISCONTINUED. IT IS VERY IMPORTANT THAT YOU DO NOT RESTART TAKING ASPIRIN ON YOUR OWN - BECAUSE YOU MISSED A DOSE YOU ARE NO LONGER DESENSITIZED AND RESTARTING PUTS YOU AT RISK FOR WORSENING ASTHMA/ANAPHYLAXIS. We have made the following medication changes: STOP: Aspirin - DO NOT RE-START UNLESS DIRECTED BY YOUR ALLERGIST CHANGE prednisone dosage: Please take 6 tabs (60mg) daily for 3 days from [**Date range (1) 11757**], then 5 tabs (50mg) daily for 3 days from [**Date range (1) 40693**], then 4 tabs (40mg) daily for 3 days from [**Date range (1) 58651**], then 3 tabs (30mg) daily from [**Date range (1) 58652**], then 2 tabs (20mg) daily from [**Date range (1) 16935**], then 1 tab (10mg) daily until advised to change by your pulmonologist. HOLD: Bisoprolol (Zebeta) - you can re-start taking once your breathing is at your baseline and your peak flows are stable CONTINUE Singulair: It is important to take Singulair as directed by your lung doctor START Epinephrine as needed. You have been given a script for Epinephrine shot and instructed how to use it if needed. START Plavix Otherwise we made no changes to your medications. . IT IS IMPORTANT YOU FOLLOW UP WITH YOUR LUNG DOCTOR: Please call your lung doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9303**] to arrange close follow-up. We have also sent him an email and spoke with him on the phone. He will also try to contact you to ensure a close follow up appointment. Followup Instructions: IT IS IMPORTANT YOU FOLLOW UP WITH YOUR LUNG DOCTOR: Please call your lung doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9303**] to arrange close follow-up. We have also sent him an email and spoke with him on the phone. He will also try to contact you to ensure a close follow up appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**] Completed by:[**2112-6-6**]

[ "493.91", "401.9", "799.1", "530.81", "424.0", "185", "272.0", "V45.81", "V58.65", "V14.8", "733.90", "414.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10050, 10056

4719, 7554

324, 356

10167, 10167

3413, 3413

12193, 12636

2504, 2508

8041, 10027

10077, 10146

7580, 8018

10318, 10935

2523, 2523

4261, 4696

10955, 12170

253, 286

384, 2023

3427, 4247

10182, 10294

2045, 2388

2404, 2488

11,569

144,634

26169

Discharge summary

report

Admission Date: [**2160-12-20**] Discharge Date: [**2160-12-31**] Date of Birth: [**2116-3-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: hyponatremia Major Surgical or Invasive Procedure: Endotrachial intubation on [**2160-12-20**] History of Present Illness: 44 yo man with PMH significant for depression, paranoid psychosis, diabetes, and possibly previous hyponatremia, initially admitted to ED for trauma s/p fall found to be hyponatremic with Na 103. Per the patient's wife, he had been feeling "unwell" for the past few days with "flu-like" symptoms. On further questioning, she reports some of this is his anxiety attacks, and possibly his paranoid delusions. In addition, however, he was having full body diaphoresis, like being hosed down with water. On the day of admission, he went to work and was witnessed to fall/collapse from a standing position. He was intubated in the field. No evidence of seizure activity. The patient was given hypertonic saline in the ED for correction of hyponatremia. He also received a tetanus shot. His facial lacerations were sutured. Per his wife, the patient had not started any new medications recently. He does drink a lot of seltzer, approximately a 2L bottle a day, but this has been true for years. She denied him having any cough, shortness of breath, weakness, facial weakness, headache, photophobia, or fever. He had an episode of similar diaphoresis approximately two years ago, which was different in that he did not lose consciousness, and was apparently extensively worked up at [**Hospital3 13313**]. Per his wife, he was never given a particular etiology except possibly medications and possibly polydipsia. Past Medical History: Depression ? h/o of hyponatremia no workup Diabetes Hypercholesteremia Social History: Teacher and medical interpreter in the past per OMR notes, currently works as a security guard. Married, at least one child. Family History: Father - HTN Mother - Diabetes Aunt - Diabetes and MI 2 Healthy brother Physical Exam: T98.2 HR 95 BP 134/83 RR 22 O2Sat 100% CPAP 5/5 FiO2 0.5 VT .913 MV 19 Gen: Patient moving all extremities in bed, sedated Heent: Left pupil RRL, right eyelid swollen with echymosis unable to open, patient with bruise on right side of face and temple. Patient intubated Lungs: Course BS diffuse Cardiac: RRR S1/S2 no murmurs Abd: soft NABS, right groin line in place Ext: no edema, no rashes Neuro: sedated Pertinent Results: REPORTS: . CHEST (PORTABLE AP) [**2160-12-21**] 6:42 AM CHEST: A portable supine AP view at 6:15 a.m. is compared to previous exam a day ago. Since the previous exam, there is new right upper lobe collapse. The remainder of the lungs is clear. The positions of the endotracheal and nasogastric tubes are unchanged and they are in satisfactory position. . CT head: Equivocal blurring versus artifact in the [**Doctor Last Name 352**]-white matter junction in the temporal lobes. A follow-up study is suggested. . CT C-spine: No evidence of fracture or dislocation. Scarring at the lung apices, particularly the left. . CT sinus/mandible/maxillofacial: : No evidence of fracture or postseptal injury. . MR HEAD W/O CONTRAST [**2160-12-24**] 3:41 PM CONCLUSION: The brain appears normal. There are paranasal sinus and mastoid inflammatory changes, and scalp swelling or a scalp hematoma. . CT ABD W&W/O C [**2160-12-23**] 2:41 PM CONCLUSION: 1. Slightly technically limited examination, but there is no intra-abdominal malignancy seen. 2. Extensive bilateral chest consolidation in this intubated patient with some nonspecific ground glass opacities identified. Appearances are unchanged from previous day's chest CT. . CHEST (PORTABLE AP) [**2160-12-25**] 6:38 AM IMPRESSION: AP chest compared to [**12-21**], 10th, and 11th. Mild pulmonary edema and mediastinal vascular engorgement have improved substantially. Although both could be reflection of increased positive pressure ventilatory support, the findings may also represent clearing of cardiac decompensation. The areas is previously ascribed to pneumonia are also improving, particularly in the right upper lobe indicating pneumonia was not as extensive as previously feared. Heart size is normal and there is no pleural effusion or indication of pneumothorax. ET tube is in standard placement. Nasogastric tube is looped several times in the stomach. No central venous catheter is seen. . LABS: . [**2160-12-31**] 12:26PM BLOOD WBC-11.5* RBC-4.52* Hgb-13.0* Hct-37.9* MCV-84 MCH-28.7 MCHC-34.3 RDW-14.2 Plt Ct-637* [**2160-12-28**] 04:20AM BLOOD WBC-12.7* RBC-3.90* Hgb-11.1* Hct-31.5* MCV-81* MCH-28.5 MCHC-35.3* RDW-13.4 Plt Ct-374 [**2160-12-25**] 04:21AM BLOOD WBC-11.3* RBC-3.46* Hgb-10.1* Hct-28.0* MCV-81* MCH-29.2 MCHC-36.1* RDW-14.2 Plt Ct-329 [**2160-12-22**] 06:15AM BLOOD WBC-13.9* RBC-4.05* Hgb-12.1* Hct-31.9* MCV-79* MCH-29.9 MCHC-38.0* RDW-13.5 Plt Ct-269 [**2160-12-20**] 09:30PM BLOOD WBC-18.3* RBC-4.50* Hgb-13.4* Hct-33.7* MCV-75* MCH-29.8 MCHC-37.7* RDW-12.2 Plt Ct-298 [**2160-12-30**] 06:15AM BLOOD Neuts-69.4 Lymphs-22.2 Monos-4.4 Eos-3.5 Baso-0.4 [**2160-12-31**] 12:26PM BLOOD Plt Ct-637* [**2160-12-30**] 06:15AM BLOOD PT-13.2 PTT-25.7 INR(PT)-1.2 [**2160-12-25**] 04:21AM BLOOD Plt Ct-329 [**2160-12-20**] 09:30PM BLOOD Plt Ct-298 [**2160-12-20**] 09:30PM BLOOD PT-13.2 PTT-30.0 INR(PT)-1.2 [**2160-12-20**] 09:30PM BLOOD Fibrino-218 [**2160-12-31**] 12:26PM BLOOD Glucose-111* UreaN-13 Creat-0.6 Na-136 K-4.0 Cl-101 HCO3-26 AnGap-13 [**2160-12-30**] 10:20PM BLOOD Na-136 [**2160-12-30**] 04:45PM BLOOD Na-133 [**2160-12-30**] 12:47AM BLOOD Na-135 [**2160-12-29**] 08:15PM BLOOD Na-136 [**2160-12-29**] 05:50PM BLOOD Na-138 [**2160-12-29**] 12:22PM BLOOD Na-136 [**2160-12-29**] 04:41AM BLOOD Glucose-125* UreaN-19 Creat-0.6 Na-138 K-3.5 Cl-104 HCO3-22 AnGap-16 [**2160-12-28**] 11:38PM BLOOD Na-135 [**2160-12-28**] 05:57PM BLOOD Na-136 [**2160-12-28**] 11:33AM BLOOD Na-143 [**2160-12-28**] 04:20AM BLOOD Glucose-120* UreaN-24* Creat-0.7 Na-141 K-3.9 Cl-108 HCO3-20* AnGap-17 [**2160-12-28**] 12:05AM BLOOD Glucose-121* Na-142 [**2160-12-27**] 06:00PM BLOOD Na-136 [**2160-12-27**] 12:09PM BLOOD Na-141 [**2160-12-27**] 04:57AM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-142 K-4.2 Cl-110* HCO3-20* AnGap-16 [**2160-12-27**] 12:25AM BLOOD Na-137 [**2160-12-26**] 06:02PM BLOOD Na-138 [**2160-12-26**] 11:54AM BLOOD Na-135 [**2160-12-26**] 06:10AM BLOOD Glucose-125* UreaN-11 Creat-0.6 Na-131* K-4.0 Cl-97 HCO3-21* AnGap-17 [**2160-12-25**] 11:30PM BLOOD Na-130* [**2160-12-25**] 05:30PM BLOOD Na-134 [**2160-12-25**] 12:27PM BLOOD Na-131* [**2160-12-25**] 04:21AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-135 K-3.9 Cl-99 HCO3-23 AnGap-17 [**2160-12-24**] 08:01PM BLOOD Na-130* [**2160-12-24**] 10:20AM BLOOD Na-129* [**2160-12-24**] 03:15AM BLOOD Glucose-128* UreaN-5* Creat-0.5 Na-128* K-3.9 Cl-94* HCO3-25 AnGap-13 [**2160-12-23**] 10:39PM BLOOD Na-126* [**2160-12-23**] 04:48PM BLOOD Na-126* K-4.5 [**2160-12-23**] 11:42AM BLOOD Na-125* [**2160-12-23**] 04:57AM BLOOD Glucose-110* UreaN-6 Creat-0.5 Na-122* K-4.1 Cl-93* HCO3-21* AnGap-12 [**2160-12-23**] 12:04AM BLOOD Na-120* [**2160-12-22**] 06:09PM BLOOD Na-119* [**2160-12-22**] 11:40AM BLOOD Na-116* [**2160-12-22**] 06:15AM BLOOD Glucose-72 UreaN-5* Creat-0.6 Na-116* K-4.4 Cl-85* HCO3-19* AnGap-16 [**2160-12-22**] 02:50AM BLOOD Na-112* [**2160-12-21**] 10:10PM BLOOD Na-112* [**2160-12-21**] 06:00PM BLOOD Glucose-133* UreaN-6 Creat-0.6 Na-109* K-4.2 Cl-80* HCO3-19* AnGap-14 [**2160-12-21**] 01:44PM BLOOD Glucose-89 UreaN-6 Creat-0.5 Na-111* K-3.4 Cl-82* HCO3-20* AnGap-12 [**2160-12-21**] 09:40AM BLOOD Na-110* [**2160-12-21**] 06:44AM BLOOD Glucose-105 UreaN-8 Creat-0.5 Na-107* K-3.5 Cl-80* HCO3-19* AnGap-12 [**2160-12-21**] 01:55AM BLOOD Glucose-105 UreaN-9 Creat-0.4* Na-103* K-4.1 Cl-76* HCO3-19* AnGap-12 [**2160-12-20**] 10:14PM BLOOD Glucose-118* UreaN-8 Creat-0.5 Na-102* K-4.3 Cl-75* HCO3-19* AnGap-12 [**2160-12-20**] 09:30PM BLOOD UreaN-9 Creat-0.5 [**2160-12-21**] 06:44AM BLOOD ALT-26 AST-50* LD(LDH)-207 AlkPhos-43 TotBili-1.3 [**2160-12-20**] 09:30PM BLOOD Amylase-44 [**2160-12-31**] 12:26PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2 [**2160-12-25**] 04:21AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.0 [**2160-12-21**] 01:55AM BLOOD Calcium-7.4* Phos-1.3* Mg-1.5* [**2160-12-30**] 04:45PM BLOOD Osmolal-273* [**2160-12-20**] 10:14PM BLOOD Osmolal-218* [**2160-12-21**] 01:55AM BLOOD TSH-1.1 [**2160-12-21**] 12:06PM BLOOD Cortsol-22.6* [**2160-12-21**] 11:34AM BLOOD Cortsol-19.5 [**2160-12-21**] 09:40AM BLOOD Cortsol-13.3 [**2160-12-21**] 03:48AM BLOOD Cortsol-11.4 [**2160-12-21**] 01:55AM BLOOD Cortsol-9.3 [**2160-12-23**] 04:57AM BLOOD PSA-0.5 [**2160-12-27**] 04:57AM BLOOD Vanco-9.1* [**2160-12-26**] 11:54AM BLOOD Vanco-<2.0* [**2160-12-24**] 11:26PM BLOOD Vanco-3.8* [**2160-12-20**] 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2160-12-23**] 01:12AM BLOOD Type-ART pO2-56* pCO2-38 pH-7.36 calHCO3-22 Base XS--3 [**2160-12-21**] 08:46AM BLOOD Type-ART Temp-36.7 pO2-123* pCO2-32* pH-7.40 calHCO3-21 Base XS--3 [**2160-12-20**] 11:21PM BLOOD Type-ART PEEP-5 FiO2-100 pO2-505* pCO2-31* pH-7.41 calHCO3-20* Base XS--3 AADO2-184 REQ O2-39 Intubat-INTUBATED Vent-CONTROLLED [**2160-12-20**] 09:37PM BLOOD Type-[**Last Name (un) **] pH-7.32* [**2160-12-20**] 09:37PM BLOOD Glucose-126* Lactate-2.1* Na-103* K-4.8 Cl-74* calHCO3-22 [**2160-12-20**] 09:37PM BLOOD Hgb-13.4* calcHCT-40 O2 Sat-77 COHgb-2.6 [**2160-12-21**] 08:46AM BLOOD freeCa-0.98* [**2160-12-20**] 09:37PM BLOOD freeCa-<1.0 . CSF: ANALYSIS WBC RBC Polys Lymphs Monos [**2160-12-25**] 12:44PM 3 8*1 72 22 71 TUBE 4 1 CLEAR AND COLORLESS 2 14 CELL DIFFERENTIAL Chemistry CHEMISTRY TotProt Glucose [**2160-12-25**] 12:44PM 29 84 TUBE 2 . MICRO: . [**2160-12-23**] 11:42 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2160-12-25**]** GRAM STAIN (Final [**2160-12-23**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2160-12-25**]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 64896**] [**2160-12-21**]. . [**2160-12-25**] 12:44 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE TUBE 3. **FINAL REPORT [**2160-12-28**]** GRAM STAIN (Final [**2160-12-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2160-12-28**]): NO GROWTH. Brief Hospital Course: This is a 44yo man with PMH significant for psychosis/depression and admitted for unresponsiveness with Na 102. He was intubated for airway protection. Work-up for SIADH did not reveal a central or periphearl source. He was treated with hypertonic saline. he was treated for an aspiration pneumonia. He was extubated on [**12-25**] and his mental status, which had been altered, began improving. he was then sent to the floor. Endocrine, renal, and psychairty services were consulted. . # Hyponatremia - Appeared from labs and U osms that this was SIADH, possibly with some polydipsia. This could be related his effexor, so this medication ws held during the admission. An extensive work-up was done for malingancy or endocrine abnormalities including TSH, [**Last Name (un) 104**] stim, SPEP, PSA, chest/abd/pelvis CTs, LP which all were normal. On [**12-25**], the hypertonic saline was stopped when his Na was 135, however this was restarted when his sodium again dropped while on fluid restriction. Renal and endocrine were consulted, and recommended continued fluid restriction. His sodium then stabilized in the low-mid 130's prior to discharge. Renal recommended a free-water challenge prior to discharge, however this was deferred to the outpatient setting as pt was not excessively thirsty and had stable sodium on discharge. Pt was advised to limit fluid intake on discharge and f/u with nephrology and psychiatry. . # Altered mental status - The paitent's altered mental status was attributed to his hyponatremia. However, improvement lagged significantly behind his sodium recovery. Neurology was consulted on admission. Pt has had several negative head CTs, a negative MRI, and LP without evidence of SAH or infection. Pt then had complete recovery of his mental status prior to discharge. Pt was scheduled to f/u with psychiatry regarding how to treat his depression in the future (given hyponatremia might have been caused by effexor). . # Respiratory support - initially intubated for airway protection, given mental status changes. Likely had aspiration PNA given thick secretions, desaturation. - sputum cx grew [**Month/Year (2) 8974**], levofloxacin sensitive - was on levofloxacin, vancomycin, and flagyl. Levofloxacin would cover [**Last Name (LF) 8974**], [**First Name3 (LF) **] vanco wa sd/c'd. No other growth from cultures. Pt completed 7 day course of levo/flagyl. . # PPx - Heparin sc, lansoprazole . # Code - full Medications on Admission: Effexor XR 150mg [**Hospital1 **] Geodon 80mg [**Hospital1 **] ASA 81mg Clonazapam 0.5mg qid Benztropine 1mg [**Hospital1 **] Lipitor 20mg qhs Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Outpatient Lab Work Please check a chem 7. Thanks. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Hyponatremia Secondary diagnosis: S/P fall [**Hospital1 8974**] pneumonia Depression Type 2 diabetes mellitus Discharge Condition: Stable Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow up appointments. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, confusion, suicidal thoughts, or any other concerning symptoms. 4. Although you should be able to drink to thirst, it is important that you do not resume drinking as much water as you were prior to admission (approximately two gallons). If you begin drinking an excessive amount of water, please contact your physician [**Name9 (PRE) 13434**] as you will need to have your sodium checked and undergo further evaluation. 5. Your new PCP will arrange for outpatient psychiatric follow-up. Followup Instructions: 1. Provider: [**Name10 (NameIs) 3688**] [**Name8 (MD) 3689**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-1-8**] 2:30 Dr.[**Name (NI) 64897**] office is located in the Healthcare Associate practice on the sixth floor of the [**Hospital Ward Name 23**] Building. 2. It is very important that you have labs checked prior to your appointment with Dr. [**Last Name (STitle) **]. Please go to the sixth floor of the [**Hospital Ward Name 23**] Building to have labs drawn on Friday [**2161-1-2**]. Dr. [**Last Name (STitle) 7341**] and [**Doctor Last Name **] will contact you with the results. 3. Your new PCP will arrange for outpatient psychiatric follow-up. 4. Nephrology: Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2161-1-8**] 4:00 Completed by:[**2161-1-7**]

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Discharge summary

report

Admission Date: [**2178-3-6**] Discharge Date: [**2178-3-17**] Date of Birth: [**2095-5-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Right middle/lower lobe pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: 82 M with COPD, s/p bioprosthetic AVR for AS, afib s/p CV, right nephrectomy for RCC, colon ca s/p colectomy who presents with 9 day hostory of productive cough and fevers.light of stairs baseline. dyspnea and productive cough of several weeks. Otherwise patient is without any complaints In the ED, initial vs were: 80, sbp 100, mid 90s on 6L/NC. Last vital signs prior to ER transfer were 98.1, 83, 116/40, 20, 95% on 3L/NC. Patient looked comnfortable. 90% room air, INR 8, ABG, ARF, 2 liters ivf. guiac + brown, got levo, ceftriaxone. Past Medical History: 1. Congestive heart failure - Echo ([**9-26**]) with Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). Mild MR; Moderate TR - Cath ([**1-28**]) with dilated left ventricle with significant generalized hypokinesis and a global ejection fraction of 28% (while the patient is in atrial flutter). 2. COPD- moderate to severe per Dr. [**First Name (STitle) **] (PCP) 3. Hypertension 4. s/p AVR for aortic stenosis 5. Atrial fibrillation, cardioversion ([**5-25**]) 6. s/p splenic artery aneurysm resection/splenectomy ([**7-26**]) 7. GERD 8. History of RCC s/p left nephrectomy ([**8-26**]) 9. History of colon cancer status post colostomy ([**9-/2160**]) 10. History of B12 deficiency 11. History of ITP Social History: Lives with his wife in [**Location (un) 538**]. He quite smoking in [**2172**]. He has 5 to 7 beers three to four times per week. Retired electrician. Family History: Noncontributory. Physical Exam: On discharge: Pertinent Results: CK: 37, Trop-T: 0.04 . 138 102 85 137 AGap=18 5.2 23 2.3 . 94 22.8 > 10.3 < 222 ∆ 31.9 N:89.8 L:5.3 M:4.7 E:0.1 Bas:0.2 . PT: 69.0 PTT: 71.6 INR: 8.0 . Lactate 1.6 . CT torso: 1. Parenchymal opacification at the right lower lobe and, to a lesser extent, the right middle lobe. Possible narrowing or part opacification of the right lower lobe bronchus. An underlying mass is not excluded. 2. Right pre-bronchial and pretracheal mild adenopathy. 3. Small right pleural effusion, with adjacent atelectasis at the right lung base. Minimal left pleural effusion. 4. Lobulated soft tissue in the splenic resection bed could represent regenerative residual spleen. Less likely, given history of renal neoplasm, a local recurrent neoplasm is not excluded. The appearance is not typical of an acute retroperitoneal hemorhage. 5. Aneurysmal dilatation of the abdominal aorta in the subrenal portion, increased from prior. 6. Bilateral emphysema. . Lateral decubitus: 1. Layering mild-to-moderate right pleural effusion. 2. The predominant component of the right basal opacification is the consolidation which may represent aspiration pneumonia giving the patient history, pneumonia in combination with atelectasis giving the slight right mediastinal shift. 3. Minimal upper zone vascular redistribution that may represent mild degree of volume overload. Brief Hospital Course: 82 M with COPD, s/p bioprosthetic AVR for AS, afib s/p CV who presents with a community acquired pneumonia . # Community acquired pneumonia- With clear consolidation on CXR in right middle and lower lobe. Patient was started on Ceftriaxone (for [**8-1**] day course) and Azithromycin (completed 5 day course). Sputum samples were unrevealing, urine legionella was negative. Given his history of renal cell and colon cancer, CT torso was performed which showed no malignancy but pleural effusion on the right side. Patient was continued on albuterol and ipratropium nebulizers, steroids were not initiated for COPD exacerbation. Interventional Pulmonary was consulted for possibility/need of draining his pleural effusion. This was drained 800ccs and the fluid was transudative, c/w a simple parapneumonic effusion. Patient did have an oxygen requirement of 3-4L nasal cannula in the MICU, etiology unclear. Over time this improved on the floor and the patient was discharge with home Oxygen (1-2L) and with home physical therapy. . # Melena: GI was consulted in setting of patient not bumping appropriately to blood transfusions. Given his pulmonary risk factors and likely need for intubation to be scoped, GI recommended conservative medical management with normalizing INR, checking Hpylori antibody, goal Hct >25% and continuing PPI [**Hospital1 **] intravenously. Patient's HPylori antibody came back positive. In setting of digoxin, patient was started on Flagyl and Amoxicillin for two week duration in discussions with Pharmacy. . # Atrial fibrillation - Was supratherapeutic to 8 upon admission, likely in setting of home coumadin interacting with his antibiotics. This bumped to 10+ and so patient was treated with Vitamin K PO. Ultimately, in the setting of slow GI bleed (melena), patient's INR was normalized so coumadin and heparin were held. Given his CHADS2 score of 3 and his bioprosthetic valve, cardiology did not feel there were significant thromboembolic risks for patient to be normalized briefly in setting of GI bleed. Patient was not well rate controlled on Digoxin in setting of held Metoprolol. He would drop his blood pressures without significant rate control with Diltiazem so patient was resumed on Lopressor 12.5mg q4hrs with good effect. His metoprolol was uptitrated on the floor to his discharge dosage. . # Acute on chronic kidney injury - In setting of volume depletion that resolved with intravenous fluids. . # COPD- not on any nebs as outpatient. Was started on ipratropium and albuterol nebulizers in house with good effect. . CODE: Full, confirmed with patient Medications on Admission: 1. Digoxin 0.125mcg daily 2. Coumadin 2.5mg and 5mg alternating 3. Cozaar 50mg daily 4. Metoprolol 50mg daily 5. Lasix 40mg daily (does not take frequently) 6. Calcitriol 0.25mg daily Discharge Medications: 1. Outpatient Oxygen o2 @ 1-2L continuous. pulse dose for portability. Diagnosis: post pleural effusion sequelae 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation once a day. Disp:*1 inhaler* Refills:*2* 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every four (4) hours as needed for SOB. Disp:*1 Inhaler* Refills:*2* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: start after twice per day prescription runs out. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Community acquire Pneumonia GI-bleeding Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were initially admitted to the ICU with pneumonia for which you were treated as an inpatient. This was complicated by fluid outside your lungs which had to be drained. Your course was complicated by GI bleeding which resolved with us stopping your coumadin. You were seen by our GI experts who want to see you as below. . Your oxygen has been improving, but we will send you out with home oxygen, the need for which should resolve as you regain your strength. . You were noted to have high amounts of Thyroid hormone and you need to be evaluated for this as scheduled below.\ . The follwoing changes were made to your medications: You were started on amoxicillin for h.pylori 500mg twice per day for 7 more days. You were started on metronidazole 500mg twice per day for 7 more days. You were started on pantoprazole 40mg twice per day for 7 more days, after this you should take it once per day. You were started on albuterol 2 puffs every 6 hours as needed for shortness of breathe or wheezing. You were started on atrovent 2 puffs everyday to prevent shortness of breath and wheezing. Your cozaar and your lasix have both been stopped and should be readressed with Dr. [**First Name (STitle) **] in the near future. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2178-3-24**] 3:00 - Gastroenterology MD: Dr [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **] Specialty: Primary Care Date/ Time: [**3-30**] at 10am Location: [**Street Address(2) 3375**], [**Location (un) **] Phone number: [**Telephone/Fax (1) 18145**] MD: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Specialty: Interventional Pulmonology Date/ Time: [**3-31**]--8 am for chest xray in [**Hospital Ward Name 23**] 3 and then appt at 8:30am with dr [**Last Name (STitle) **] Location: [**Hospital Ward Name 23**] 3 Phone number: [**Telephone/Fax (1) 3020**] Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2178-4-1**] 4:00 - endocrinology for hyperthyroidism Completed by:[**2178-3-19**]

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icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

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3327, 5933

347, 353

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65,570

121,706

35768

Discharge summary

report

Admission Date: [**2147-3-23**] Discharge Date: [**2147-4-12**] Date of Birth: [**2125-2-7**] Sex: F Service: MEDICINE Allergies: Oxacillin / Codeine Attending:[**First Name3 (LF) 4365**] Chief Complaint: abdominal pain x 3 days Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 22 yo female with a h/o CVID, ESRD on HD who presents with abdominal pain x 3 days. She initially presented to [**Hospital **] Hospital on [**3-21**] with abdominal pain. She states pain was so severe at that time that she was unable to walk. WBC was reported 22,000. At that time, she reported that she had not had a bowel movement for four days prior to presentation. She received a dose of flagyl and subsequently signed out AMA because she did not want to drink contrast for a CT scan. At the advice of her group home director, she returned to the [**Location (un) **] ER on [**3-22**]. At that time, she underwent a CT scan with oral contrast only, as they were unable to obtain IV access. Blood pressure was documented as 60/p, and a Surgical consult was obtained for central venous access. Due to inability to obtain IV access, she was transferred to [**Hospital1 18**] ED. Patient was mentating through ED course, and denies any lightheadedness. On arrival to [**Hospital1 18**] ED, BP 76/42, HR 103, T 98. A 20G PIV was placed in her R wrist without difficulty. Radiology reviewed CT abdomen from OSH, and a Surgical consult was obtained. BP range in ED 68-105/30-47, but patient remained asymptomatic. She was found to have SpO2 80% on RA and placed on 3L NC. She received 1L NS, ciprofloxacin 400 mg IV and metronidazole 500 mg IV and morphine 2 mg IV. On arrival to MICU, patient complains of persistent abdominal pain which radiates from her epigastrum to her RLQ. She describes it as constant and sharp. She states that pain improved with the morphine she received in the ER, but denies any other relieving factors. She denies any inciting factors. She denies any recent nausea, vomiting, fevers, chills, or sick contacts. She denies any blood in her stool or tarry stools. She was constipated prior to original presentation to [**Location (un) **] ED on [**3-21**], but has subsequently had multiple loose stools since drinking oral contrast earlier today. She denies any previous episodes of abdominal pain. Past Medical History: ESRD on HD T/Th/Saturday at Greater [**First Name4 (NamePattern1) 189**] [**Last Name (NamePattern1) **] Center; last HD Tuesday. On HD from ages [**3-10**], then 13-present. s/p cadaveric renal transplant at age 6, failed at age 13 CVID Hypotension with baseline SBP's as low as 70's COPD Chronic bronchitis Asthma Trichotillomania s/p left forearm AV fistula with multiple revisions, now VF graft Tobacco abuse "Mental illness" Social History: Resides in a group home. She smokes [**2-3**] - 1 PPD since age 13. She has a history of marijuana use in high school. She denies any alcohol consumption or drug use. Family History: Mother with MI in her 50's. She denies any family history of renal disease or autoimmune disorders. Physical Exam: Tmax: 35.6 ??????C (96.1 ??????F) Tcurrent: 35.6 ??????C (96.1 ??????F) HR: 88 (83 - 88) bpm BP: 87/43(53) {81/25(40) - 87/44(53)} mmHg RR: 19 (15 - 27) insp/min SpO2: 94% 4L General Appearance: No acute distress, Overweight / Obese, cushingoid Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes : scattered) Abdominal: Soft, Tender: in all quadrants, palpation on left results in pain on right abdomen, no rebound, no guarding, scar in LLQ Skin: Warm, fistula over left forearm Neurologic: Attentive, Follows simple commands Pertinent Results: [**2147-3-22**] 09:15PM PT-12.2 PTT-26.1 INR(PT)-1.0 [**2147-3-22**] 09:15PM PLT COUNT-366 [**2147-3-22**] 09:15PM NEUTS-69.5 LYMPHS-18.0 MONOS-6.0 EOS-6.0* BASOS-0.5 [**2147-3-22**] 09:15PM WBC-11.8* RBC-3.55* HGB-11.3* HCT-33.6* MCV-95 MCH-31.7 MCHC-33.5 RDW-14.8 [**2147-3-22**] 09:15PM GLUCOSE-110* UREA N-33* CREAT-8.5* SODIUM-142 POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-31 ANION GAP-21* [**2147-3-23**] 10:36AM GLUCOSE-136* UREA N-21* CREAT-5.5*# SODIUM-143 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-32 ANION GAP-16 [**3-22**] CXR: Vascular cephalization without overt edema. [**3-23**] CT Abdomen/pelvis: 1. Thickening and inflammatory stranding surrounding the cecum and proximal ascending colon is most consistent with an infectious colitis, especially given the patient's history of immune deficiency. Typhlitis should be considered in the appropriate clinical setting. Inflammatory bowel disease would be considered less likely. 2. Multiple venous collaterals in the subcutaneous tissues, likely related to central venous stenosis or occlusion, presumably related to the patient's reported history of multiple central lines and tunneled venous catheters. Upper chest is not imaged on this evaluation, so definitive characterization is limited. 3. Non-visualization of the patient's native kidneys, could relate to marked atrophy, or possibly surgical resection. 4. Bicornuate uterus. [**3-26**] CXR: PA and lateral chest compared to [**3-22**]: Small region of heterogeneous parenchymal abnormality in the right lower lobe medial basal segment looks more like scarring than pneumonia but could be pneumonia. Lungs are otherwise clear. There is no pleural effusion or evidence of central adenopathy. The massive distention of the azygous vein as well as dilatation of the upper mediastinum securing the aortic knob are both explained by dilated venous collaterals. No pleural effusion. Heart size normal. [**3-27**] CT chest: 1. Diffuse bilateral parenchymal opacities and centrilobular nodules with tree-in-[**First Name5 (NamePattern1) 239**] [**Last Name (NamePattern1) 81343**] suggest acute infection . Part of the ground glass opacities might be explained by expiratory character of the images. The findings are atypical for bacterial or fungal infection and viral or mycoplasma etiologies are considered more likely. 2. Extensive calcified thrombus within the left brachiocephalic vein and superior vena cava presumably from prior indwelling hemodialysis catheter. 3. Right PICC is deviated by the calcified thrombus to a termination in the azygos vein and repositioning suggested. 4. Sclerotic appearance of the skeleton is probably related to renal disease. 5. Pericardial calcification [**3-28**] Echo: The left atrium is normal in size. The right atrial pressure is indeterminate. 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. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal technical quality. Global left ventricular function is probably normal, but a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. No pathologic valvular abnormality seen. Pulmonary artery systolic pressure could not be determined. EEG [**4-7**] IMPRESSION: This telemetry captured no pushbutton activations. The background activity was mostly of high voltage and in the low theta and delta frequency ranges, seen either in a generalized distribution or more pronounced over the left hemisphere; sometimes similar lower voltage activity was seen. These findings are most consistent with an encephalopathy. MR [**Name13 (STitle) 430**] [**4-5**] SCAN FINDINGS: There are focal areas of FLAIR signal hyperintensities within the bilateral frontal subcortical white matter. The largest located within the left frontal lobe measures approximately 11 mm in size and demonstrates central hypointensity on FLAIR images. These are likely secondary to chronic subcortical infarctions. There is no evidence of diffusion restriction to suggest acute infarction or abscess. However, the study is limited due to lack of IV contrast. There is mild prominence of the cerebral sulci, inappropriate for age likely representing mild cerebral atrophy. There is also prominence of the cerebellar fovea inappropriate for age consistent with mild cerebellar atrophy. There is no evidence of intracranial hemorrhage or mass lesion. The ventricles are normal in size. Minimal mucosal thickening is present within the right sphenoid sinus. IMPRESSION: Bilateral frontal subcortical FLAIR hyperintensities likely due to chronic sub-cortical infarctions. Mild cerebellar atrophy. [**4-5**] CT Chest/Abd/Pelvis CT CHEST WITH IV CONTRAST: The presence of extensive collateral veins in the chest, seen in the prior study, significantly limits the diagnostic value for pulmonary embolus. For example, the majority of the administered IV contrast refluxes into the azygos and hemiazygos veins as well as extensive collateral lumbar veins. Given these limitations, there is no evidence of large, central pulmonary embolus. A new left lower lobe pneumonia is identified likely contributory to reported respiratory status. There is impaction of the left lower lobe bronchus (2:47, 48; 301B:33). The previously seen diffuse ground- glass opacities or focal peribronchial opacities are again consistent with an infectious process, now seen to a lesser extent in the right upper/middle lobes. The trachea and right- sided bronchi are patent to the subsegmental level, as is the left upper lobe bronchus and its branches. There is no pleural or pericardial effusion. There is again seen extensive calcified thrombus in the left brachiocephalic vein as well as superior vena cava. Pericardial calcifications are again seen, and there is extensive calcification of the coronary arteries, especially the left anterior descending coronary artery. Extensive collateral vessels are seen again in the chest, likely due to prior instrumentation. CT ABDOMEN WITH IV CONTRAST: The kidneys are absent. A left pleural calcification is again seen (4:5). The liver, spleen, pancreas, and adrenal glands are unremarkable. The bowel is collapsed, and there is no evidence of obstruction. There is no intra-abdominal free air or fluid. Scattered mesenteric nodes do not meet pathologic size criteria. There is apparent decrease in degree of inflammatory fat stranding surrounding the cecum and proximal ascending colon, thought previously infectious in etiology. CT PELVIS WITH IV CONTRAST: Following 180-second delay, pelvic venous opacification is adequate, and there is no evidence of thrombosis. A right femoral line is identified, and the right femoral artery demonstrates extensive calcification. There is a bicornuate uterus. Osseous structures demonstrate sclerotic skeletal changes and vertebral endplate changes which may relate to end- stage renal disease. IMPRESSION: 1. New left lower lobe pneumonia. 2. Right upper/middle lobe likely infectious airspace opacities improved but not totally resolved. 3. Suboptimal study for PE given extensive collaterals, but no evidence of large/central PE. 3. Chronic-appearing thrombus in the left brachiocephalic and superior vena cava 4. Severe coronary artery calcifications due to end-stage renal disease. [**4-3**] CT Head NON-CONTRAST HEAD CT: There is no hemorrhage, edema, mass effect, or acute large vascular territory infarction. [**Doctor Last Name **]-white differentiation is preserved, although there are multiple small foci of hypoattenuation seen in the deep white matter. These appear chronic, with no surrounding edema or mass effect, although their etiology is unclear. The ventricles and sulci are slightly prominent for a patient of this age, suggesting an element age- inappropriate parenchymal atrophy. The osseous structures are normal, with no suspicious lytic or sclerotic lesions. There is mucosal thickening in the right maxillary sinus. The mastoid air cells are opacified. IMPRESSION: 1. No acute intracranial process, including no hemorrhage, edema, or mass effect. 2. Ventricular and sulcal prominence out of proportion to the patient's age. 3. Multiple white matter hypodensities are likely chronic but of uncertain etiology. 4. Mucosal thickening in the right maxillary sinus and opacification of the mastoid air cells. Brief Hospital Course: 22yo F with asthma COPD with stable hypoxia, ESRD on HD, CVID p/w AMS with delirium responsive to HD, now resolved. . Course summary: . Patient was initially admitted to the MICU [**3-23**] for concern of colitis as patient was hypotensive. Patient was transferred to medicine floor [**3-24**] and was found to be unresponsive after one dose of morphine on [**3-26**]. Patient was subsequently transferred to the MICU and worked up for altered mental status. During that interval, psychiatry was consulted and recommended discontinuing her psychiatric medications. Additionally, patient had a sleep study and was started on BiPap, as she was found to be hypercarbic likely secondary to obesity hypoventilation. Ms. [**Known lastname 81344**] mental status improved over her second MICU course and was transferred back to the medicine floor on [**3-31**]. At that time, patient's mental status had been noted to be improving, but would answer questions about [**2-4**] of the time. Through [**4-3**] patient's mental status declined progressively and on the AM of [**4-3**] patient was not responding to questions. Patient was awake and would move non-purposefully, and was not noted to be hypercarbic. Her oxygen requirements were increasing between [**3-/2125**] and [**4-3**] and was found to have a LLL pneumonia. Patient's respiratory status was concerning, given her not reponding to commands that she was transferred back to the MICU on the AM of [**4-4**]. She had a full neurological work-up, and it was unrevealing as what caused her state. Patient had CT head, MRI head, LP, and EEG that did not allude to why patient's mental status was worsened. Over the next four days, patient's mental status cleared and patient slowly became oriented. The cause of her altered mental status is unclear, but is currently attributed to either her prior psychotropic medications and/or delirum from pneumonia. Patient has been AO x 3 since [**2147-4-7**] and has been able to perform ADLs and ambulate without assistance. . The following are her medical issues addressed individually: . # Respiratory failure: Patient had a history of COPD, Asthma, and OSA, all likely contributing. Although patient responds to narcan, opiate overdose was unlikely causes given that pt only received 1 mg morphine on presentation. Given new fever perhaps this could be hypercarbic respiratory failure in the setting of pulmonary infection or chemical pneumonitis after emesis earlier during the day. Pt likely very hypercarbic at baseline given body habitus and obstructive/restrictive lung disease. Likely represents pt??????s baseline respiratory status. Baseline sats 80-90s, and pt requires 2L NC. Last PFT in [**9-/2146**]; moderate to severe proportionate decrease in flows and volumes with a strong bronchodilator response. Normal diffusion capacity. Features suggestive of poorly controlled asthma associated with obesity related ventillatory restriction. Patient intermittently refused BiPAP. Spiriva and Advair were continued. On [**4-3**], patient had an episode of acute respiratory distress and triggered on the floor for tachypnea. Due to an A-a gradient on her blood gas, she was started empirically on a heparin gtt given previous history of SVC clot. CTA chest was performed and was negative for PE. - Continue BiPap auto SV currently at [**2053-6-9**]. - Patient will need home oxygen . [**Hospital 25730**] Hospital Acquired Pneumonia: Patient had elevated WBC count and increasing oxygen requirement that was diagnosed by CXR on [**2147-4-3**]. Possible contributing to patient's mental status. Patient treated with 7 day course of Meropenem and Vancomycin. Patient is on basline 2L NC and is afebrile. # Altered mental status: Now resolved, patient AO x 3 and mentating well. This was likely multifactorial. It was thought not to be secondary to hypercarbic respiratory failure. She initially required restraints. The pscyhiatry service saw her and was considering delirium because of poor orientation. Their recommendation was to stop all of her psychiatric medications including pimozole, cogentin, and benzodiazepines. Instead Haldol was started prn. Because her symptoms could be consistent with absence seizures clinically, EEG was done with no evidence of seizure. CT head showed hypodensities which were poorly chracterized. Patient improved, but then on the evening of [**4-3**] was found to be unresponsive by nursing staff and was transferred back to the MICU. Of note, patient had received 2 mg of IV haldol for CT scan performed earlier that day. Acyclovir was started empirically to cover for HSV encephalitis given some question of temporal lobe abnormalities on previous EEG, and was continued until [**4-10**] when HSV PCR was negative. Neurology was consulted and continous EEG monitoring was reinitiated. EEG again showed wave forms consistent with encephalopathy, but no seizure activity. After multiple failed bedside attempts, LP was performed under flouro; glucose 74, protein 37, 3 WBC's, 0 WBC's, negative gram stain. MRI brain was performed and revealed Bilateral frontal subcortical FLAIR hyperintensities likely due to chronic sub-cortical infarctions and mild cerebeallar atrophy. Mental status resolved with antibiotics, BiPAP, and avoidance of sedating medications. - Avoid Benzodiazepines and cymbalta - See Psych as below. # Abdominal pain/Colitis: Resolved. Patient had a CT scan on admission that showed colitis and was treated with five day course of cipro and flagyl. Abd pain is resolved. CT scan from [**8-9**] showed similar findings. . # CVID : Patient has been on IVIG therapy in the past but stopped this treatment approximately 2 years ago. These were re-instituted on presentation. The infusions had to be held as pt spiked temperature, although there was doubt about whether this was related. Patient's last dose of IVIG was with HD on [**4-4**]. . # Hypotension: Patient was asymptomatic on admission with SBP in 60s. Patient's SBP remained in the 100s. - Fludrocortisone and midodrine were continued as per home regimen . # ESRD: On dialysis, s/p cadaveric transplant. rejection at age 13. - Tues/Thurs/Sat HD [**Last Name (un) 21610**] was continued. - Sevelamer was continued. . # SVC clot: Radiographic imaging and physical exam suggestive of extensive collaterals. Likely causing partial occlusion of SVC due to multiple lines and DVT. Not on any anticoagulation currently. . # Anxiety depression: Patient had a history of anxiety and depression, lives in a group home. Psychiatric medications were held as above in the setting of AMS. Psychiatry followed patient in house and recommended avoiding Klonopin and all benzodiazepines in the future, along with avoiding cymbalta as it is renally cleared. Psych has been in communication with patient therapist. There is no indication to start medications while she is an inpatient. - Follow up with outpatient psychiatrist Medications on Admission: Benztropine 2 mg TID Cymbalta 60 mg qAM, 30 mg qHS Klonopin 2 mg TID Pimozide 6 mg [**Hospital1 **] Loratadine 10 mg daily Fludrocort 0.1 mg qHS Midodrine 10 mg TID on non-HD days Midrondine 20 mg qAM, 10 mg after HD, and 10 mg qHS on HD days Protonix 40 mg daily Renagel 800 TID w/ meals Phenergan 25 mg q6 hours PRN Senna [**Hospital1 **] Doxepin 10 mg qHS Advair 500/50 [**Hospital1 **] Spiriva 18 mcg daily Albuterol PRN Miralax 17 g daily [**Doctor Last Name **]-Tin Discharge Medications: 1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Midodrine 5 mg Tablet Sig: Four (4) Tablet PO QAM (once a day (in the morning)): Tues, Thurs, Saturday before HD. . 4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): On Monday, Wednesday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**]. 10mg [**Hospital1 **] on non-HD days. . 5. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): on Tuesday, Thursday, Saturday. Give one dose after HD and then 3 hours post or pre HD dose, no dose near bedtime . 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - Colonial Heights - [**Hospital1 487**] Discharge Diagnosis: Primary: - Altered Mental Status, unclear etiology - Anxiety/Depression - Hospital Acquired Pneumonia - Infectious Colitis - Obstructive Sleep Apnea Secondary: CVID ESRD Asthma Discharge Condition: The patient was discharged hemodynamically stable, afebrile. Discharge Instructions: You were admitted to the hospital for evaluation of your abdominal pain with nausea. When you arrived, you had very low blood pressure and were admitted to the ICU because of this. During your hospital course, you became unresponsive and your mental status was altered. It is unclear why your mental status was altered, but it is suspected that it is related to your psychiatric medications along with a component of delirum from pneumonia. It is recommended that you avoid klonopin and cymbalta presently. Please take your medications as directed and continue BiPAP. If you have any confusion, shortness of breath, or anything concerning, please call your PCP or return to the ER. Followup Instructions: PCP Please see Dr. [**Last Name (STitle) **] in [**2-3**] weeks. Call [**Telephone/Fax (1) 76162**] to schedule an appointment. Psychiatry Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call to make an appointment. Completed by:[**2147-4-12**]

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icd9cm

[ [ [] ] ]

[ "93.90", "03.31", "99.14", "38.93", "39.95", "89.14" ]

icd9pcs

[ [ [] ] ]

21657, 21745

12803, 16542

303, 307

21966, 22029

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22764, 23037

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23,332

183,473

50860

Discharge summary

report

Admission Date: [**2148-1-9**] Discharge Date: [**2148-1-12**] Date of Birth: [**2088-3-3**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2181**] Chief Complaint: agitation Major Surgical or Invasive Procedure: Intubation Lumbar puncture History of Present Illness: 59 yo woman with metastatic breast CA, recent admission [**9-17**] for PE, presents initially with dyspnea and eventually intubated for acute mental status change(fidgety, dyskinesia) . ED initial VS T 99.5 P97 BP123/98 R20 99% on RA. Toxicology was initially consulted but did not think that she fit into any toxidrome. Patient received 4mg ativan, 2.5mg haldol and 50mg of benadryl. She got worse w/ benadryl. Patient was intubated in ED for airway protection prior to CTA, which showed no evidence of pulmonary embolism. CT head was obtained given new left sided weakness, which did not show any intracranial bleeding. EKG normal. LP was not done. . She says that she remembers going to physical therapy on Monday at 11am. Afterwards she took a nap and when she woke at 3pm she felt "useless" and "sleepy". She took an oxycodone and soon after found that she could not control her legs or arms. She called her neighbor who brought her in to the [**Name (NI) **]. She does not remember anything beyond this. She currently is having no trouble moving her arms or legs. She does have some residual weakness in her left leg ever since the pins were placed. She has had some word finding difficulties for 6 months. She has had no trouble with vision or other neurologic symptoms. . Her best friend and her neighbor, Ms [**Name (NI) 6483**] noted that she had been feeling well until this morning. She took her to the ED and noticed that she was working hard to breath, has twiching in one leg(cannot remember which) and appeared restless. Past Medical History: 1. Breast Cancer(patient of Dr. [**Last Name (STitle) 2036**]: metastatic to bone(multiple vertebral bodies, lytic lesions seen throughout the pelvis and lower lumbar spine ) Has lesions in brain which are not consistant with metastasis, consistant with glioma. Currrently on Xeloda and Zometa. Also uses large amount of pain medication: MS Contin 100 QAM and 60 QHS, oxycodone 5mg prn. 2. pulmonary embolism on coumadin since [**9-17**]. 3. recently treated with valtrex for HSV on positive anal swab([**7-18**]) found due to diarrhea after radiation treatment 4. left femur rod Social History: She is a real estate [**Doctor Last Name 360**]. Has an adopted daughter from [**Name (NI) **]. No tobacco, no etoh. Independent. Family History: Father died from MI at age 79 Mother died from Breast cancer in age 70's. Physical Exam: T99.2 P95 BP133/65 R18 PS 5/5 FiO2 0.3 propofol 80mcg/kg/min Gen- intubated, sedated, patient sit upright and tries to remove tubes/lines when sedation switched off HEENT- PERRLA, no facial/head trauma, moist mucus membrane, neck supple, JVD not appreciable CV- regular, no rubs/murmurs/gallop RESP- CTAB ABDOMEN- soft, does not appear tender, no bowel sounds NEURO- PERRLA, minimally withdraw to painful stimuli, stiff, upgoing toes bilaterally, no tremor, cannot elicit knee jerks Pertinent Results: EKG: NSR 94, nl axis, nl intervals, no ST/T wave changes . Imaging: [**1-8**] CT head: IMPRESSION: No intracranial hemorrhage. Note added at attending review: I think the abnormality in the right frontal lobe could relate to leptomengeal metastasis. The enhancing lesion in the right side of the sphenoid bone, either benign soft tissue or metastatic sisease is stable. There are two enhancing lesions in the frontal bones which may be slightly more sistinct than formerly. They probably reflect bone metastases. . [**1-8**] CT Chest: IMPRESSION: No evidence of pulmonary embolism. . [**2148-1-9**] CXR: No evidence of acute cardiopulmonary disease. . [**2148-1-11**] Brain MRI: No evidence of metastatic disease. Unchanged abnormal increased FLAIR signal within the parasagittal right frontal lobe, supporting the diagnosis of low intermediate grade glioma rather than metastatic disease. . Spinal fluid: Negative for malignant cells . [**2148-1-12**] 05:20AM BLOOD WBC-4.5 RBC-3.81* Hgb-12.8 Hct-36.1 MCV-95 MCH-33.6* MCHC-35.5* RDW-20.8* Plt Ct-202 [**2148-1-8**] 06:15PM BLOOD WBC-3.7*# RBC-4.08* Hgb-13.3 Hct-38.7 MCV-95 MCH-32.6* MCHC-34.4 RDW-20.8* Plt Ct-257 [**2148-1-8**] 06:15PM BLOOD Neuts-71.3* Lymphs-21.8 Monos-5.9 Eos-0.5 Baso-0.5 [**2148-1-12**] 05:20AM BLOOD Plt Ct-202 [**2148-1-12**] 05:20AM BLOOD PT-19.8* PTT-31.1 INR(PT)-1.9* [**2148-1-9**] 02:39AM BLOOD PT-29.5* PTT-35.9* INR(PT)-3.1* [**2148-1-9**] 02:39AM BLOOD Gran Ct-3490 [**2148-1-12**] 05:20AM BLOOD Glucose-103 UreaN-6 Creat-0.4 Na-141 K-3.6 Cl-107 HCO3-23 AnGap-15 [**2148-1-12**] 05:20AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.4 [**2148-1-8**] 06:15PM BLOOD Calcium-9.4 Phos-1.8* Mg-2.3 [**2148-1-9**] 02:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Ms. [**Known lastname 732**] is a 59 year old female with metastatic breast cancer with recent hospitalization for PE who presents with dyspnea and acute agitation. . #. Acute agitation, mental status changes: The differential diagnosis on admission was alcohol withdrawal, meningitis, encephalitis, brain tumors, non-convulsive seizures, and stroke. Urine and serum tox were negative on admission and CT was negative for intracranial bleed. Ms. [**Known lastname 732**] was intubated in the ED as above and admitted to the ICU where she was started on CTX/Vanco/Ampicillin/Acyclovir for possible meningitis or encephalitis. An LP was done while she was in the unit which showed 1 WBC. DFA was also sent which returned negative. Antibiotics were discontinued after results of the LP returned. She had an MRI head done to assess for encephalitis or tumor. The MRI showed no evidence of metastatic disease and presence of a low intermediate grade glioma - no change from prior. She was extubated and feeling well, back to baseline mental status so she was called out to the floor on [**2-10**]. At that time the patient's mental status was at baseline. She had a poor memory of the events of the past three days. Given the patient's leukopenia and immunosuppresion w/ chemotherapy, concern re: encephalitis and less likely meningitis. Patient had been treated for HSV recently as well. HSV PCR was negative and acyclovir was stopped on [**1-12**]. She was discharged to home mentating appropriately with a reduced dose of oxycontin and a taper of fluoxetine. . # Respiratory distress: Ms. [**Known lastname 732**] was intubated for agitation, no underlying lung pathology. She was rapidly weaned and extubated. On discharge she was able to breathe comfortably on room air. . # PE: Ms. [**Known lastname 732**] had been admitted for pulmonary embolism of RUL, RLL, LLL on [**2147-9-18**]. The CT on this admission showed no evidence of pulmonary embolism. INR on admission was 3.1. On the day of discharge it was 1.9. Coumadin 4mg was given nightly while in house and she was discharged on 2mg nightly. She continued to have appropriate oxygen saturation on room air. . #. Metastatic breast cancer: Ms. [**Known lastname 732**] is followed by Dr. [**Last Name (STitle) 2036**]. She receives Zomeda q3months and Xeloda. She was also noted to be leukopenic, NOT neutropenic, which was attributed to her chemotherapy. Pain control was continued with oxycodone 20mg [**Hospital1 **] which is a lower dose than she had been taking as an outpatient as she was interested in weaning down the dose. This regimen was effective while in house, however, patient reports increased difficulty with physical therapy. She will follow up with Dr. [**Last Name (STitle) 2036**] as an outpatient. . #. Depression: As an outpatient, she had been taking Fluoxetine, however she did not receive this during the initial days of her hospitalization. She expresses interest in coming off of this medication and was discharged with a weaning dose. . #. FEN: She was kept on a regular diet while in the hospital. She was also noted to be hypophosphatemic and was repleted as needed. . #. PPx: She was continued on coumadin and given a bowel regimen and proton pump inhibitor. . FULL code Medications on Admission: coumadin 4mg oxycontin 80 QAM and QHS oxycodone 5mg Q4-6prn Zometa Q 3 months Xeloda Discharge Medications: 1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Fluoxetine 10 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Mental status changes Breast cancer, metastatic to bone Secondary diagnosis: h/o pulmonary embolism Discharge Condition: Fair. The patient is at her baseline mental status. She is making voluntary movements with all limbs, denies pain, and is afebrile. Discharge Instructions: You were admitted for agitation and change in the way you were behaving. Scans including CT and MRI of your head showed no changes from prior scans. You were initially treated with antibiotics, however a spinal tap showed no signs of infection and antibiotics were stopped. Please take all medications as prescribed. Changes to your medications include: 1. Your oxycontin has been reduced to 20mg twice daily. 2. Your fluoxetine will be tapered over the next week. You will take 10mg for 7 days and then can stop the medication completely. If you begin to have symptoms of diarrhea, dizziness, headache, tremor, anxiety, or confusion you should restart the dose you had previously been taking. Please continue to take your coumadin. If you begin to experience any fevers, chills, limb shaking, urinary or fecal incontinence, or any other concerning symptoms please call your doctor or 911 immediately. Followup Instructions: You have the following appointments already scheduled: 1. ORHTO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-1-22**] 9:20 2. [**Name (NI) **] [**Name (NI) 65710**], PT Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2148-1-18**] 11:00 3. [**Name (NI) **] [**Name (NI) 65710**], PT Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2148-1-15**] 10:30 Please follow up with your primary doctor this week. Please follow up with Dr. [**Last Name (STitle) 2036**] as soon as possible.

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Discharge summary

report

Admission Date: [**2166-12-10**] Discharge Date: [**2166-12-17**] Date of Birth: [**2101-6-19**] Sex: M Service: MEDICINE Allergies: Benadryl / Morphine / Ativan / Compazine / Dilaudid Attending:[**First Name3 (LF) 30**] Chief Complaint: Neck Pain Major Surgical or Invasive Procedure: Anterior Cervical diskectomy History of Present Illness: 65Y M ESRD, CHF EF<20% with recuurent Listeria bacteremia X 2, had complained of neck pain for several weeks. Pt was seen in the ED treated with IV dilaudid. PT became sensitive and developed respiratory distress and failure to normal doses of IV narcotics in the ED. Pt eventually admitted to MICU, scheduled for C-spine MRI in the setting of unstable respiratory status. Pt coded in MRI holding underwen limited MRI studies which were inconclusive. Pt was subsequently intubated for final MRI w/ gado. MRI eventually was suspicious for osteomyelitis of C4 with inflammation of C3C4, C4C5. Pt wwas scheduled for bone biosy with tissue cx sent for micro and cyptococcal ag. Pt was stablized, extubated, received HD after MRI and transferred to the floor for pain control. Upon transfer, pt desated to 88% on RA with complaint of SOB but no CP. Pt's HR was 100, increased to RR 28, BP was 120/74. Pt immediately received O2. O2 was titrated SpO2 >96%. Pt also received lopressor 25mg po to control his rate. Pt was eventually stable on 2L. PT c/o shoulder pain o/n. Past Medical History: 1. Coronary artery disease: Myocardial infarction in [**2155**], MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous RCA stent patent at that time. 2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**] to 25% 3. Diabetes greater than 20 years; with triopathy. 4. Hypertension. 5. End stage renal disease on hemodialysis, q. Monday, Wednesday and Friday via right arteriovenous fistula. 6. Hypothyroidism. 7. Chronic obstructive pulmonary disease. 8. Hepatitis C. 9. Chronic pancreatitis. 10. Peptic ulcer disease. 11. Right perinephric hematoma; status post embolization. 12. Obstructive sleep apnea on CPAP. 13. Ruptured right groin abscess; recurrent right groin abscess in [**2162-12-4**]. 14. Peripheral [**Year (4 digits) 1106**] disease. 15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein 16. Status post 2nd and 3rd toe amps 17. Status post left CFA to AK [**Doctor Last Name **] with PTFE 18. Status post L inguinal hernia repair 19. Status post umbilical hernia repair 20. Ischemic left foot 21. A - Fib- not well documented. Followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of cardiology who notes he was previously on coumadin. Social History: Lives in [**Location 686**] with wife, has older children tobacco: 1 ppd x 60 yrs. quit 3 months ago, no EtOH. +Hx of narcotic abuse. Should avoid IV pain medications, especially dilaudid, morphine Family History: Non contributory Physical Exam: T 98.7 BP 140/74 HR 97 RR 16 SpO2 100 on 2L, FSBS: 113mg/dl Gen: AOX3 HEENT: perrlA, EOMI. mmm Neck: neck collar in place Lung: CTA b/l Heart: RRR nl S1S2 no M/R/G Abdomen: Soft, ND/NT. No rebound or guarding [**Location **]: Multiple toe amputations. Dopplerable DP pules b/l Pertinent Results: [**2166-12-10**] 11:56PM TYPE-ART TEMP-35.6 PO2-113* PCO2-48* PH-7.40 TOTAL CO2-31* BASE XS-4 [**2166-12-10**] 11:56PM LACTATE-0.8 [**2166-12-10**] 11:20PM GLUCOSE-70 UREA N-31* CREAT-4.8*# SODIUM-140 POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-28 ANION GAP-19 [**2166-12-10**] 11:20PM CK(CPK)-35* [**2166-12-10**] 11:20PM CK-MB-NotDone cTropnT-0.18* [**2166-12-10**] 11:20PM CALCIUM-9.7 PHOSPHATE-7.0* MAGNESIUM-2.2 [**2166-12-10**] 11:20PM WBC-6.4 RBC-3.91* HGB-12.2* HCT-38.3* MCV-98 MCH-31.3 MCHC-32.0 RDW-16.6* [**2166-12-10**] 11:20PM NEUTS-54 BANDS-0 LYMPHS-19 MONOS-18* EOS-7* BASOS-2 ATYPS-0 METAS-0 MYELOS-0 [**2166-12-10**] 11:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL [**2166-12-10**] 11:20PM PLT SMR-NORMAL PLT COUNT-232 [**2166-12-10**] 11:20PM PT-13.0 PTT-33.2 INR(PT)-1.1 [**2166-12-10**] 03:35AM GLUCOSE-116* UREA N-53* CREAT-6.0* SODIUM-139 POTASSIUM-5.5* CHLORIDE-92* TOTAL CO2-30 ANION GAP-23* [**2166-12-10**] 03:35AM CALCIUM-10.3* PHOSPHATE-8.4*# MAGNESIUM-2.5 [**2166-12-10**] 03:35AM CRP-5.1* [**2166-12-10**] 03:35AM WBC-5.8 RBC-4.19* HGB-13.0* HCT-40.2 MCV-96 MCH-30.9 MCHC-32.3 RDW-16.6* [**2166-12-10**] 03:35AM NEUTS-35* BANDS-0 LYMPHS-40 MONOS-17* EOS-5* BASOS-3* ATYPS-0 METAS-0 MYELOS-0 [**2166-12-10**] 03:35AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL [**2166-12-10**] 03:35AM PLT SMR-NORMAL PLT COUNT-238 [**2166-12-10**] 03:35AM PT-13.4* PTT-34.6 INR(PT)-1.2* [**2166-12-10**] 03:35AM SED RATE-5 [**2166-12-10**] 03:06AM TYPE-ART RATES-/24 O2 FLOW-5 PO2-99 PCO2-75* PH-7.22* TOTAL CO2-32* BASE XS-0 INTUBATED-NOT INTUBA [**2166-12-10**] 03:06AM O2 SAT-92 [**2166-12-9**] 06:13PM LACTATE-2.4* [**2166-12-9**] 06:10PM GLUCOSE-169* UREA N-48* CREAT-5.8* SODIUM-140 POTASSIUM-5.1 CHLORIDE-92* TOTAL CO2-31 ANION GAP-22* [**2166-12-9**] 06:10PM estGFR-Using this [**2166-12-9**] 06:10PM WBC-6.8 RBC-4.29* HGB-13.2* HCT-41.3 MCV-96 MCH-30.9 MCHC-32.0 RDW-16.7* [**2166-12-9**] 06:10PM NEUTS-55 BANDS-0 LYMPHS-27 MONOS-10 EOS-4 BASOS-1 ATYPS-3* METAS-0 MYELOS-0 [**2166-12-9**] 06:10PM PLT COUNT-242 [**2166-12-9**] 06:10PM NEUTS-55 BANDS-0 LYMPHS-27 MONOS-10 EOS-4 BASOS-1 ATYPS-3* METAS-0 MYELOS-0 CXR [**2166-12-10**]: no acute cardiopulmonary process. ET tube 2cm above carina. [**12-14**]: Right infrahilar consolidation has increased since [**12-11**] consistent with worsening pneumonia. mid and lower left lung atelectasis persists. [**12-15**]: some progressive clearing of the right perihilar and infrahilar consolidation, consistent with some improvement in the pneumonia . MRI C-spine [**2166-12-10**]: Discitis, osteomyelitis C4 with paraspinal phlegmon or abscess. Indicative of infectious etiology. However, rarely florid inflammatory response to renal spondyloarthopathy may demonstrate a similar picture. . US UE :Appropriate flow within the fistula with no surrounding fluid collections/abscess Brief Hospital Course: 65 yo male with a past medical history of CAD, dilated CHF (EF < 20%), Type 2 Diabetes Mellitus, ESRD on HD, COPD, and recent recurrent bacteremia (GBS bacteremia in [**7-10**] and Listeria Bacteremia in [**9-9**]) is being transferred to the floor after MICU admission for respiratory failure. . On [**2166-11-27**], patient complained of 3 weeks of neck pain. He [**Date Range 1834**] an outpatient MRI on [**12-9**] which demonstrated C4-C5 discitis with destructive osteomyelitis, including pre-vertebral involvement. No epidural abscess was seen at that time. He was then sent to the ED for further evaluation by neurosurgery, where he was found to have mild LUE weakness and unchanged decreased sensation at fingertips and toes. This study was limited by gado so they perform another MRI. Repeat MRI w/ gado on [**12-10**] demonstrated known C4-5 spondylodiscitis, and no evidence of an epidural component, but the study was limited by patient motion. . Overnight, patient triggered for decreased responsiveness and decreased SaO2 to 55% RA, increasing to 80% on 5L NC. He was noted to be snoring at the time. He had received significant amounts of dilaudid (4mg IV over the past few hours) and ativan prior to this episode. RR was [**11-16**]. ABG was 7.22/75/99 on 5L NC (PCO2 significantly above baseline). CXR showed clear lung fields. 0.2mg Narcan was administered with immediate improvement in mental status and oxygenation, improving to 98-100% on 5L, which was quickly weaned. He immediately c/o [**11-12**] pain and demanded additional pain medicine, and an additional 0.5mg IV dilaudid was given. He was also noted to intermittently refuse the hard c-collar. . Since the first two MRIs were limited (the first by lack of gado, the second by motion), a third MRI was done with anesthesia to definitively assess for epidural abscess. He was intubated for the MRI and given midazolam and fentanyl. He was initially extubated after the MRI but afterward has decreased respirations and was reintubated for respiratory distress. After he awoke, he complained of neck pain and was given fentanyl boluses, a total of 100mcg. His BP was down to 80s/40s and he was given a 500c bolus without improvement. A dopamine drip was ordered but the patient improved to 90s/50s and the drip was held. As he woke up, his BP improved to 120s/60s. He was transferred to the MICU. Pt was transferred from MICU after having HD. Patient's Spo2 reduced to 88% on RA after bed transfer, with complaint of SOB but no CP. Pt's HR was 100, increased to RR 28, BP was 120/74. Pt [**Name (NI) **]2 was titrated with NC to > 96%. Pt initially had increased oxygen requirements. Pain control was initially started with ketorolac and acetaminophen and subsequent to po percoicet. Patient problems of respiratory failure and hypotension resolved after all IV narcotics were stopped. Osteomyelitis/Discitis: Tissue biopsy and surgery results failed to confirm infectious etiology. Path results were consistent with cartilaginous degenerative changes and bone fragments.The neck pain was to be degenerative and inflammatory in etiology. A rare disorder in chronic renal patient was known as destructive renal spondyloarthopathy was suspected although there is no clear diagnosis of this phenomenon. It was decided to continue a 3 week course of at hemodialysis to prophylax against osteomyelitis given patient previous history of listeria bacteremia. Pneumonia: Chest xrays was concerning for worsening pneumonia although pt did no show any clinical signs of the disease. Endocarditis: Previous echo reports not consistent with endocarditis while patient was in house. No additional measure was taken to pursue. Pain control: For his neck pain, patient has been well-controlled on mild pain medications. He has previously been VERY sensitive to IV narcotics. Respiratory failure. Resolved Pt tolerated room air since all IV narcotics were stopped. Ambulated without shortness of breadth. Hypotension: Normalized since all IV narcotics were stopped. ESRD on HD: Pt continued to receive dialysis on regular schedule after additional HD to remove gadolinum contrast dye. DM: Pt remained euglycemic during the course of his stay with a sliding scale. Congestive Heart Failure EF < 20: Pt was restricted to low Na diet and 1500ml fluid restriction. Pt was continued on home medications. COPD: treatment was continued with Albuterol/Atrovent MDI prn SOB, dyspnea CAD: There was no evidence of active ischemia while in hospital. Management continued with home regimen and heart-healthy diet Medications on Admission: albuterol 1-2p q6h prn amiodarone 100 qd citalopram 20 qd RISS levoxyl 50 m-f/75 sat-sun lipitor 10 qd lisinopril 2.5 qd percocet q4-6h prn [**Name (NI) 4532**] 75 qd reglan 5 qd renagel 400 qd toprol xl 25 qd on non-HD days Meds on transfer Acetaminophen 650 Q6H PRN ALbuterol INH Q6H PRN Amiodarone 100mg PO Daily Atorvastatin 10mg daily Bisacodyl 10mg PO/PR daily Citalopram 20mg PO daily [**Name (NI) **] 75mg daily Colace 100mg po BID Reglan 5mg PO daily Toprol XL 25mg po daily percocet 1-2 tabs po Q4H prn Sevelamer 400mg PO TID meals Levothyroxine 50mcg PO dailiy Lisinopril 2.5 mg PO daily Insulin SC 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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. [**Name (NI) **]:*qs qs* Refills:*0* 3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Name (NI) **]:*15 Tablet(s)* Refills:*2* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name (NI) **]:*30 Tablet(s)* Refills:*2* 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name (NI) **]:*30 Tablet(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name (NI) **]:*30 Tablet(s)* Refills:*2* 7. Humulin N 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: Please continue your insulin according to your sliding scale. . 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name (NI) **]:*40 Tablet(s)* Refills:*2* 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Name (NI) **]:*15 Tablet(s)* Refills:*2* 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO three times a day. [**Name (NI) **]:*45 Tablet(s)* Refills:*2* 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). [**Name (NI) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). [**Name (NI) **]:*45 Tablet(s)* Refills:*2* 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): You will receive 1 gram of vancomycin at dialysis through [**2166-12-31**]. . 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. [**Month/Day/Year **]:*1 inh* Refills:*2* 16. Outpatient Lab Work Please send weekly results of the following Labs to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**]. Fax: ([**Telephone/Fax (1) 4591**] 1. CBC 2. Chem 10 3. Vancomycin Trough. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Cervical spinal inflammatory process NOS. 2. Right lower lobe pneumonia. 3. Acute respiratory failure. SECONDARY DIAGNOSIS: 1. Coronary artery disease: Myocardial infarction in [**2155**], MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous RCA stent patent at that time. 2. Chronic systolic heart failure-Ischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**] to 25% 3. Diabetes greater than 20 years; with triopathy. 4. Hypertension. 5. End stage renal disease on hemodialysis, q. Monday, Wednesday and Friday via right arteriovenous fistula. ` 6. Hypothyroidism. 7. Chronic obstructive pulmonary disease. 8. Hepatitis C. 9. Chronic pancreatitis. 10. Peptic ulcer disease. 11. Right perinephric hematoma; status post embolization. 12. Obstructive sleep apnea on CPAP. 13. Ruptured right groin abscess; recurrent right groin abscess in [**2162-12-4**]. 14. Peripheral [**Year (4 digits) 1106**] disease. 15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein 16. Status post 2nd and 3rd toe amps 17. Status post left CFA to AK [**Doctor Last Name **] with PTFE 18. Status post L inguinal hernia repair 19. Status post umbilical hernia repair 20. Ischemic left foot 21. A - Fib- not well documented. Followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of cardiology who notes he was previously on coumadin. Discharge Condition: Good. Patient is ambulating, tolerating oral intake, and has returned to his baseline condition. Discharge Instructions: You were admitted to the hospital because of your neck pain. An MRI was performed which was concerning for an infection of your bone or the tissue around your bone. You were admitted to the hospital for further evaluation of your neck pain and IV antibiotics. A biopsy of your neck bone was taken for analysis and did not demonstrate any infection. However given your history of prior infections and blood infections, we decided to treat you with a 3 week course of antibiotics. You will continue to be treated with an antibiotic called vancomycin which you will receive at dialysis. You should receive your last dose on [**2167-1-7**]. While evaluating your neck pain, we needed to perform an MRI with sedation. Unfortunately, you were very sensitive to the sedating medicine and developed difficulty breathing, requiring intubation and a short stay in the intensive care unit. You were extubated without difficulty and have been breathing on room air since then. Please continue close management of your heart failure with the following management: - Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. - Adhere to 2 gm sodium diet - Fluid Restriction:1500ml/ day Please continue to take all of your medications as prescribed. If you have any symptoms of fevers, chills, night sweats, headaches, worsening or changing neck pain, back pain, change in appetite,numbness, tingling sensation in your neck/ shoulders/ fingers, worsening cough or shortness of breath, leg swelling, or chest pain, please seek immediate medical attention. Followup Instructions: Please follow-up with your neurosurgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]. We have scheduled an appointment for you on [**1-7**] at 1pm. His office is lcoated at [**Last Name (NamePattern1) 439**]. You will also need an MRI prior to this appointment. Dr.[**Name (NI) 2845**] office will call you with an appointment time for your repeat neck MRI. Again, you should wear your cervical collar AT ALL TIMES until your appointment with Dr. [**Last Name (STitle) 548**]. Please also follow-up with your Infectious Disease Doctor, Dr. [**First Name8 (NamePattern2) 108567**] [**Last Name (NamePattern1) 4020**]. We have scheduled an appointment for you on Thursday [**1-8**] at 9:30am. Her office is located at [**Last Name (NamePattern1) 108568**]. If you need to reschedule, please call her office at [**Telephone/Fax (1) 457**]. Please also follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. We have scheduled an appointment for you on [**2167-1-8**] at 12pm. If you need to reschedule, please call his office at [**Telephone/Fax (1) 250**]. Please also continue with your previously scheduled appointments with the [**Telephone/Fax (1) 1106**] lab on [**2166-12-18**] at 1:45pm. If you need to rescehedule, please call them at [**Telephone/Fax (1) 1237**]. You will also have labwork drawn weekly at dialysis and faxed to your infectious disease doctor Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**]. Completed by:[**2166-12-19**]

[ "722.4", "425.4", "518.81", "357.2", "428.22", "327.23", "250.50", "458.29", "722.91", "440.20", "V45.82", "585.6", "486", "518.0", "362.01", "403.91", "250.40", "583.81", "730.28", "250.60", "250.80", "244.9", "414.01", "E849.7", "E937.9", "428.0", "427.31", "496", "577.1", "070.70", "731.8", "564.00" ]

icd9cm

[ [ [] ] ]

[ "96.04", "39.95", "96.71", "80.51" ]

icd9pcs

[ [ [] ] ]

13811, 13868

6329, 10910

322, 352

15334, 15433

3278, 6306

17042, 18595

2948, 2966

11572, 13788

13889, 13889

10936, 11549

15457, 17019

2981, 3259

273, 284

380, 1449

14036, 15313

13908, 14015

1471, 2716

2732, 2932

19,851

186,623

44300

Discharge summary

report

Admission Date: [**2125-7-24**] Discharge Date: [**2125-8-2**] Date of Birth: [**2061-2-21**] Sex: M Service: MEDICINE Allergies: Motrin / Codeine / Nortriptyline Attending:[**First Name3 (LF) 1162**] Chief Complaint: fevers, purulent drainage from HD cath site Major Surgical or Invasive Procedure: R femoral cath removed by IR L tunneled cath placed by IR History of Present Illness: 64 yo man with HIV, hepatitis C, ESRD on HD, DM2, who lives at a nursing home and was in his usual state of health but presented to [**Doctor Last Name 1263**] for HD on the day of admission and was noted to be febrile to 101 with rigors. He had blood cultures drawn off the line and a wound swab at HD (at [**Doctor Last Name 1263**]). He received HD (-2L), was given vanco 1gm iv and was referred to the ED. In the ED febrile to 101, HR 106, BP 124/58, 100% on 4L NC. He was noted to have pus leaking around catheter. He rec'd 750mg ceftriaxone (im), gentamycin 80mg iv, tylenol 325mg po and compazine 10mg im. He refused CVC placement in the ED and was transferred here for further management. . On arrival to our ED he noted nausea (baseline) with no emesis, no distinct pain, no subjective fevers, chills, HA, chest pain, SOB, cough, abdominal pain, constipation, diarrhea, LE pain. He is anuric at baseline. He denied rash or new skin ulcers. His HD cath was removed by IR fellow ([**Doctor Last Name 15785**]) on arrival and sent for culture. He was initially admitted to the MICU for further care and management. Past Medical History: 1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**]. 2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy, charcot foot, nephropathy, and ? mild retinopathy. 2) ESRD on Hemodialysis and graft infections, thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues, thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] / Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**] 3) [**Female First Name (un) 564**] esophagitis 4) Hepatitis C: genotype IB-> last viral load [**8-/2124**] 175,000 5) Congestive heart failure: echocardiogram [**10/2123**] w/ EF 60%. 6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and circumcision during hospitalization. 7) Hypertension 8) Hypercholesterolemia 9) LE Diabetic ulcers 10) Herpes zoster of the left mandibular distribution of the trigeminal nerve. [**2115**] 11) R suprapatellar abscess: [**2115**]. 12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**] 13) Obesity 15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative colonoscopies. 16) Anemia: [**2117**]. Started Epogen. 18) Colonic Polyps 19) Gastritis with large hiatal hernia. 20) Lipodystrophy 21) Charcot foot: dx in [**9-12**]. 22) Colonic AVM: seen on [**3-8**] colonoscopy on the ileocecal valve. Treated with thermal therapy. At that time was also offerred hormonal therapy, but this was deferred. 23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No abnormalities on CT chest in [**2121**]. 24) MRSA- grew out from culture from L anterior chest wound, s/p I+D 25) Peripheral neuropathy: on a narcotics contract 26) Diastolic CHF: [**2-/2125**] TTE: LV cavity is unusually small. Hyperdynamic LV systolic fxn (EF >75%), trivial MR, trivial/physiologic pericardial effusion 27) Thrombosis of dialysis line, on chronic anti-coagulation 28) Emphysema Social History: History of tobacco abuse (quit 20 years ago), alcohol abuse (quit >20 years ago) and heroin and cocaine abuse (quit >20 years ago). Has a fiance who visits him frequently and is involved in his care. Recently lost his home after several hospitalizations and has been in an extended care facility for 5-6 months, but hopes to return home to his fiance. He has not been ambulating for approximately one year. He has a wheelchair and a walker, but reports that he is starting to ambulate slowly with assistance. Family History: Non-contributory. Physical Exam: VS: T 102.8 HR 134 BP 154/85 RR 24 Sat 100% on RA Gen: NAD, comfortable obese man HEENT: PERRL, OP clear, no teeth and no dentures in place, MMM, Left pupil opacified Neck: supple, obese, no LAD, unable to assess JVP CV: decreased HS, tachy, reg rhythm, no m/r/g Resp: Decreased BS throughout, ? rales RLL, otherwise clear, no wheezes/rhonchi but limited by habitus Abd: soft, nontender, obese, decreased BS, no HSM Ext: Right fem HD cath site with dressing, 2+ edema bilat cool feet bilat, cool hands bilat, 1cm ulcer left foot; left foot with medial thickening below skin (non-tender, per pt unchanged) Neuro: CN II-XII intact, 5/5 strength bilat grips and feet Skin: right chest with 8mm open area with purulent drainage from old line site wound, ulcer left [**Last Name (un) 5355**] 1cm without discharge Pertinent Results: [**2125-7-24**] 01:15PM GLUCOSE-83 UREA N-27* CREAT-5.5* SODIUM-135 POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-31 ANION GAP-16 [**2125-7-24**] 01:15PM ALT(SGPT)-6 AST(SGOT)-11 ALK PHOS-79 AMYLASE-51 TOT BILI-1.2 [**2125-7-24**] 01:15PM LIPASE-12 [**2125-7-24**] 01:15PM WBC-22.2* RBC-3.03* HGB-9.7* HCT-30.5* MCV-101* MCH-32.0 MCHC-31.7 RDW-20.9* [**2125-7-24**] 01:15PM NEUTS-82* BANDS-13* LYMPHS-2* MONOS-2 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2125-7-24**] 01:15PM PLT COUNT-222 [**2125-7-24**] 01:15PM PT-21.3* PTT-53.8* INR(PT)-2.1* [**2125-7-24**] 10:50AM LACTATE-1.9 K+-15.8* [**2125-7-24**] 10:40AM GLUCOSE-101 UREA N-27* CREAT-5.5* SODIUM-137 POTASSIUM-6.0* CHLORIDE-94* TOTAL CO2-25 ANION GAP-24* [**2125-7-24**] 10:40AM ALT(SGPT)-9 AST(SGOT)-34 ALK PHOS-81 TOT BILI-1.3 Brief Hospital Course: A/P: 64yo man with HIV, Hepatitis C, DM2, ESRD on HD who presents with fever, rigors, purulent drainage from HD cath, tachycardia and growing staph aureus from his original catheter site. 1. Bacteremia--Patient was pan cultured, given empiric vancomycin and gent sent to the ICU for further monitoring. Given that he had frank purulent discharge at his HD access site this was thought to be the most likely source inducing sepsis and IR was able to remove the catheter and culture the tip. This catheter tip and his first set of blood cultures grew out MRSA. Serial cultures were obtained on [**7-26**] and 24 and have been negative or NGTD as of this dictation. A TTE was obtained which showed no signs of valvular vegetations and he had no peripheral stigmata suggestive of endocarditis. The patient defervesced on hospital day #3 and remained afebrile for the rest of the hospitalization. His gentamycin was stopped after two doses and he has remained on vancomycin for a 14 day course (last dose would be on [**8-6**]). The vancomycin dose has been titrated by level given his ESRD and his most recent dose was 1.5gm given after HD on [**8-1**]. His next dose is due on [**8-3**]. 2. ESRD on HD--patient had his prior R femoral line removed by IR and a subsequent Left groin temporary HD cath was placed for interim. The patient remained afebrile on vancomycin with subsequent negative blood cultures and a tunneled catheter was placed on [**7-31**] without complications. 3. HTN: The pt's BP was initially low on admission secondary to sepsis and his toprol was held and then added back at a lower dose. He is to resume his outpatient 4. DM: continue sliding scale insulin as that is what he is on at home. 5. Hyperlipidemia: Continued on atorvastatin. 6. HIV: last CD4 614 [**4-14**], likely not at risk for opportunistic infection but appears was inadvertently d/c'd on 400mg [**Hospital1 **] indinavir (rather than usual dose of 800mg [**Hospital1 **]) since mid [**Month (only) **]. He was continued on his prior regimen ofindinavir, stavudine, lamivudine. Consider rechecking CD4 when acute illness improved. 7. History of thrombosis--patient was previously on coumadin prior to arrival however this was held on admission for line placement and he was bridged with heparin IV by sliding scale. Coumadin was restarted at a dose of 3mg and then decreased to his prior home dose of 2mg po qhs. He will need his coags checked with HD on [**8-3**]. 8. AMS--patient had initial delirium thought to be secondary to infection. He responded to PRN zyprexa but has had some waxing and [**Doctor Last Name 688**] behavior issues with refusing medications and lab draws. He received one dose of Ativan 1mg IV and was very lethargic the next day so I would recommend avoiding this if possible. At the time of this dictation he is A&Ox3 and with a pleasant affect. 9. Code: Full. Medications on Admission: 1. Metoprolol Tartrate 50mg PO BID 2. Ritonavir 100 mg PO BID 3. Methadone 10 mg PO DAILY 4. Duloxetine 30 mg PO DAILY 5. Lamivudine 100 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Indinavir 400 mg PO Q12H-->not clear why this was changed from 800 8. Atorvastatin 10 mg PO DAILY 9. Bisacodyl 10 mg E.C. PO DAILY as needed 10. Sevelamer 800 mg PO DAILY 11. Stavudine 20 mg PO DAILY 12. Pantoprazole 40 mg PO DAILY 13. Magnesium Hydroxide 400 mg/5 mL 30ML PO DAILY as needed 14. Psyllium 1 Packet PO BID 15. Bismuth Subsalicylate 262 mg 2 Tablet PO DAILY as needed 16. B Complex-Vitamin C-Folic Acid 1 mg One PO DAILY 17. Insulin Lispro (Human) Per sliding scale 18. Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q6H PRN PAIN 19. Coumadin 2 mg PO at bedtime 20. nepro 8oz daily Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Doctor Last Name **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO BID (2 times a day). 3. Lamivudine 100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Doctor Last Name **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Stavudine 20 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO Q24H (every 24 hours). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Doctor Last Name **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Oxycodone 5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Acetaminophen 500 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 9. Methadone 10 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily). 10. Psyllium Packet [**Doctor Last Name **]: One (1) Packet PO BID (2 times a day). 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Doctor Last Name **]: One (1) Cap PO DAILY (Daily). 12. Indinavir 400 mg Capsule [**Doctor Last Name **]: Two (2) Capsule PO Q 12H (Every 12 Hours). 13. Sevelamer 400 mg Tablet [**Doctor Last Name **]: Two (2) Tablet PO DAILY (Daily). 14. Atorvastatin 10 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily). 15. Insulin Lispro (Human) 100 unit/mL Solution [**Doctor Last Name **]: One (1) Subcutaneous ASDIR (AS DIRECTED). 16. Olanzapine 5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO TID (3 times a day) as needed for hallucination/agitation. 17. Warfarin 2 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO at bedtime. 18. Heparin Flush Hickman (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) only on the IV port of the femoral line. lumen Daily and PRN. Inspect site every shift. 19. Metoprolol Tartrate 50 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO twice a day. 20. Vancocin 1,000 mg Recon Soln [**Doctor Last Name **]: One (1) Intravenous after each HD: Please draw a random level prior to the next dose. Last dose is [**2125-8-6**]. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: MRSA bacteremia ESRD HIV HCV Discharge Condition: stable Discharge Instructions: Patient is to continue of HD Tuesdays, Thursdays, and Saturdays. He is to receive Vancomycin IV with HD on those days to complete a 14 total day course. Followup Instructions: Patient should follow up with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 53939**] at [**Telephone/Fax (1) 64415**] in 1 week.

[ "362.01", "V09.0", "403.91", "070.54", "492.8", "V08", "250.50", "V58.61", "272.0", "285.21", "996.62", "428.32", "995.91", "585.6", "250.40", "038.11", "428.0", "357.2", "250.60" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

11899, 12070

5845, 8748

336, 396

12143, 12152

5022, 5822

12354, 12504

4157, 4176

9582, 11876

12091, 12122

8774, 9559

12176, 12331

4191, 5003

253, 298

424, 1548

1570, 3613

3629, 4141

56,930

109,803

9868+56074

Discharge summary

report+addendum

Admission Date: [**2116-3-20**] Discharge Date: [**2116-3-24**] Date of Birth: [**2065-10-8**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: shortness of breath and Fatigue Major Surgical or Invasive Procedure: 1. Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary; reverse saphenous vein single graft from the aorta to the posterior left ventricular coronary artery. 2. Endoscopic right greater saphenous vein harvesting. History of Present Illness: History of Present Illness:88 year old male who initially presented on [**2116-3-7**] to [**Hospital3 417**] Hospital via EMS with 2-3 days of nausea, vomiting, diarrhea, and diaphoresis. During the days up to admission, he also developed dyspnea on exertion and had progressively more difficulty climbing stairs, requiring rest, which was a change in baseline. In hindsight, he actually reports progressive dyspnea while walking for the past several months (4-6 months). Functionally, he feels he can no longer walk 1 block or do 1 flight of stairs due to his breathing. He also reported weakness and fatigue. He was admitted to [**Hospital3 417**] and an echocardiogram was done and found to have aortic stenosis with valve area 0.4cm2, he was then transferred to [**Hospital1 18**] for further evaluation and a cardiac surgery evaluation for an aortic valve replacement. Past Medical History: 1. CARDIAC RISK FACTORS: + Dyslipidemia 2. CARDIAC HISTORY: - Acute inferior ST-elevation MI treated with PCI to RCA in [**2106**] - NSTEMI [**2110**]: Coronary catheterization with balloon angioplasty to the posterior descending artery and placement of drug eluting stent to the posterolateral artery off PDA . -PERCUTANEOUS CORONARY INTERVENTIONS: . [**7-17**]: 1) 90% PLB lesion, 80% PDA lesion 2) Successful PCI of PLB with 2.5x28mm Cypher stent 3) Successful PTCA of PDA with 2.0x0mm balloon 4) Selective coronary angiography revealed the above findings. In addition, 60% D1 lesion and 40% distal LAD lesion beyond the D1 take-off was noted. Both of the above were unchanged since the last cardiac catherization in noted to be occluded at the ostium. This is a new finding since 8/[**2106**]. OM2 and OM3 were found to have diffuse, mild disease. 5) Left ventriculography revealed mild inferior and anterolateral hypokinesis with mildly reduced ejection fraction of 42%. 6) Normal LV filling pressure (LVEDP 13). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful placement of drug eluting stent in the RPL branch and PTCA to R-PDA. . [**8-13**]: 1. Resting hemodynamics post-intervention demonstrated slightly elevated biventricular filling pressures. The mean PCWP was 15 mmHg; prominent V waves were noted. The Fick cardiac index was normal. 2. Selective coronary angiography of this right dominant system demonstrated two vessel and branch coronary artery disease. The left main was normal. The mid-LAD had a tubular 50% stenosis. The D1 was 60% stenosed proximally. The left circumflex was normal. The small OM1 was 90% stenosed proximally. The larger OM2 and OM3 branches were normal. The dominant RCA had an ulcerated 80% proximal stenosis. The distal RCA was 70% stenosed, and a large posterolateral branch was thrombotically occluded. The R-PDA was normal. 3. Successful PTCA and stenting of the RPL were performed with a 2.5 x 23 mm Bx Velocity Hepacoat stent. The proximal RCA was successfully direct stented with a 3.5 x 33 mm Bx Velocity Hepacoat stent. Final angiography revealed normal flow, no dissection and 0% residual stenosis. FINAL DIAGNOSIS: 1. Two vessel and branch coronary artery disease. 2. Acute inferoposterolateral myocardial infarction, managed by PTCA and stenting of the RPL and RCA. 3. Mildly elevated biventricular filling pressures. . 3. OTHER PAST MEDICAL HISTORY: - Hiatal Hernia repair Social History: -Tobacco history: [**1-13**] ppd x 30 years -ETOH: 3 beers every night -Illicit drugs: None - Construction worker Family History: Father: Died 76 from MI Physical Exam: Physical Exam Pulse:92 Resp:18 O2 sat:96/2L B/P Right:112/74 Left:111/76 Height:5'[**15**].5" Weight:87.7 kgs General: No acute distress, AAOx3 Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [x] Murmur [x] systolic grade III/VI Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] mild bilat Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: dop Left: dop PT [**Name (NI) 167**]: dop Left: dop Carotid Bruit Right: none Left: none Pertinent Results: [**2116-3-24**] 08:52AM BLOOD WBC-7.3 RBC-3.35* Hgb-10.4* Hct-29.2* MCV-87 MCH-31.2 MCHC-35.8* RDW-12.8 Plt Ct-188# [**2116-3-24**] 08:52AM BLOOD Plt Ct-188# [**2116-3-24**] 08:52AM BLOOD UreaN-13 Creat-0.8 Na-137 K-4.2 Cl-100 [**2116-3-24**] 08:52AM BLOOD Mg-2.1 PA&Lat [**3-23**]: FINDINGS: Frontal and lateral radiographs of the chest show no pneumothorax. Inspiratory lung volumes are persistently low with bibasilar atelectasis greater on the left than the right. Background increased interstitial lung markings are unchanged. No large pleural effusion or focal consolidation is present. The pulmonary vasculature is not engorged. Patient is status post median sternotomy and CABG with wires intact. IMPRESSION: 1. No pneumothorax. 2. Stable postoperative appearance. Brief Hospital Course: The patient was admitted to the hospital for cath pre-operatively and found to have significant CAD and brought to the operating room on [**2116-3-20**] where the patient underwent CABGx3 (LIMA-LAD, v-om,c-Pl). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He required low dose vasopressin and phenylephrine. POD #1 pressors were weaned off. He extubated soon after the OR and remained alert and oriented and breathing comfortably. 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 On POD #1. Chest tubes and pacing wires were discontinued without complication. While on the floor he continued to progress well. His betablocker was increased due to tachycardia. On POD#3 he spiked temp to 101, work-up was negative. He 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 and deemed safe for discharge to home with VNA services. His wounds were healing well and his pain was controlled with oral analgesics. The patient was discharged in good condition with appropriate follow up instructions. Medications on Admission: ATORVASTATIN 80 mg Tablet daily LISINOPRIL 5 mg Tablet daily METOPROLOL SUCCINATE 50 mg Tablet Extended Release daily ASPIRIN 325 mg Tablet daily 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. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 5 days. Disp:*5 Tablet, ER Particles/Crystals(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p multiple leg surgeries right rotator cuff surgery hernia repair inguinal and umbilical stomach surgery r/t trauma from car accident Plan for left shoulder surgery for tendon tear Past Cardiac Procedures: PCI's: 2.5 x 23mm RPL, 3.5 x33mm to RCA; hepacoat stents [**8-/2106**] 2.5 x 28mm PLB cypher stent [**7-/2110**], PTCA to PDA; PROMUS 3.0 DES to RCA [**9-/2114**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace lower extremity edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**4-2**] @ 10am Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2116-4-23**] 1:15 Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 4475**] on [**2116-4-14**] 10AM **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2116-6-18**] 3:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2116-6-18**] 1:45 Completed by:[**2116-3-24**] Name: [**Known lastname 5778**],[**Known firstname **] Unit No: [**Numeric Identifier 5779**] Admission Date: [**2116-3-20**] Discharge Date: [**2116-3-24**] Date of Birth: [**2065-10-8**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1543**] Addendum: incorrect HPI information entered History of Present Illness: History of Present Illness: 50 year old gentleman with a known history of CAD including prior MIs and stents was referred for cardiac clearance prior to shoulder surgery. The patient describes a several month history of dyspnea and chest tightness after climbing [**1-13**] flights of stairs. He denies any symptoms occurring at rest. He does report intermittently lightheadedness but denies any syncope. He denies any lower extremity edema but does report gaining 18 lbs in [**3-15**] months and cannot attribute it to overeating. He denies any claudication. He does sleep elevated on 2 pillows and reports waking out of a sound sleep with coughing fits. Stress test was done on [**2116-2-25**]. The patient exercised for 7 minutes and 30 seconds. Negative for chest pain. EKG with inferoapical ischemic changes at 5 minutes and 30 seconds. nuclear imaging: septal hypokinesis. EF 54%. moderate anterior ischemia, small area of inferior ischemia. Denies claudication, edema, orthopnea, PND, lightheadedness. Cath today revealed significant progrssion of LAD disease, also diffuse LCx, origin 70% RCA and 70% proximal PDA. Csurg was asked to evaluate for revascularization Discharge Disposition: Home With Service Facility: [**Company 720**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2116-3-24**]

[ "V45.82", "414.01", "413.9", "412", "401.9", "305.1", "785.0", "V17.49", "272.4", "780.62", "V70.7" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12198, 12405

5835, 7169

342, 728

8750, 8941

5034, 5812

9729, 10969

4272, 4297

7366, 8263

8356, 8729

7195, 7343

3860, 4066

8965, 9706

4312, 5015

1714, 2676

270, 304

11025, 12175

4097, 4122

1654, 1694

4138, 4256

9,357

175,309

22121

Discharge summary

report

Admission Date: [**2183-8-24**] Discharge Date: [**2183-8-28**] Service: MED Allergies: Celebrex / Pseudoephedrine Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: Fever Major Surgical or Invasive Procedure: PICC line placed in L arm without complications. History of Present Illness: [**Age over 90 **]yo F s/p tracheostomy 3 weeks ago for respiratory failure who was brought from [**Hospital **] Rehab after developing a fever to 102.5 with thick and foul smelling secretions and decreased 02 sats to 87-89%. The staff were unable to place a PMV valve in her trach as well. Her vent settings were PS10/PEEP5/FiO230%. The patient reports feeling tired recently. She has also had abdominal pain for the past several weeks, worse on the L side. A KUB done that showed "dilated bowel loops." She describes her recent abdominal pain as sharp, intermittent, not associated with tube feeds, now resolved. She had a BM on the day PTA. ROS: No CP/SOB, + cough x several weeks, no N/V, reports normal BM's. Foley catheter in place. In the ED, she received vancomycin 1gr, flagyl 500mg, morphine 2mg IV. Past Medical History: Respiratory failure s/p trach placement 3 weeks ago H/o ARF AS HTN H/o fall B total hip replacements Aneia Dysphagia/GERD OA Osteoporosis S/p wrist fracture GERD Social History: No EtOH, no tobacco. Walks with a walker. Physical Exam: T100.0 HR79 BP116/52 RR18 O2sat98% 30%FiO2 Pleasant, elderly female, NAD, A+Ox3 EOMI, PERRL, OP-clear, MMM, neck supple, no lymphadenopathy Erythema and creamy discharge at trach stoma site. No fluctuance. Stoma site macerated. RR SEM at LLSB Decreased BS at L base, + rhonichi, no wheezes or crackles Obese, soft, NT, ND. +BS - hypoactive. G tube in place, site clean, dry, and intact. Extremities with no edema, 2+distal pulses. No rashes noted. Neruo grossly intact. Lines - L subclavian triple lumen catheter. Pertinent Results: [**2183-8-24**] 12:40AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [**2183-8-24**] 12:40AM URINE RBC-[**6-12**]* WBC-[**6-12**]* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2183-8-24**] 12:40AM WBC-14.9* RBC-3.38* HGB-11.3* HCT-33.3* MCV-98 MCH-33.3* MCHC-33.9 RDW-15.3 [**2183-8-24**] 12:40AM NEUTS-90.0* BANDS-0 LYMPHS-4.4* MONOS-3.6 EOS-1.6 BASOS-0.3 [**2183-8-24**] 12:40AM PLT COUNT-274 [**2183-8-24**] 12:40AM GLUCOSE-135* UREA N-41* CREAT-1.3* SODIUM-132* POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-28 ANION GAP-13 [**2183-8-24**] 12:40AM ALT(SGPT)-50* AST(SGOT)-35 LD(LDH)-187 ALK PHOS-110 AMYLASE-71 TOT BILI-0.5 [**2183-8-24**] 12:40AM LIPASE-30 [**2183-8-24**] 12:40AM TOT PROT-6.6 ALBUMIN-3.6 GLOBULIN-3.0 [**2183-8-24**] 12:41AM LACTATE-1.4 Brief Hospital Course: 1. The patient had a CXR suggestive of a LLL PNA, although it was unclear if this was a new process or a persistent old process. Sputum showed 3+GPC in pairs and clusters, and sensitivity showed MRSA. Blood cultures also grew MRSA. She was started on vancomycin on [**2183-8-23**], for a 14 day course. (Day of discharge is day 5 of 14 days.) At the time of discharge, the patient had been afebrile for several days. 2. Trach stoma infection/cellulitis. MRSA was grown from trach site and the patient was placed on vancomycin as above. Her trach was replaced on [**2183-8-26**] with improved fit. 3. The patient had a Foley catheter-related UTI. Her Foley was changed, and acinetobacter (pan sensitive) and enterococcus (sensitivities pending) was treated with ciprofloxacin, in addition to the vancomycin, for a 14 day course. On the day of discharge she was on day 3 of a 14 day course of ciproflox. 4. Abd pain was of unclear etiology, possibly a resolved partial SBO. The patient did not complain of abdominal pain during her admission. Tube feeds were restarted, which she tolerated well. 5. GI: Intermittent diarrhea. C. diff was negative. Lactulose was stopped while the patient had diarrhea. 6. Chest pain: Had very brief episode of CP on [**8-24**] evening --> EKG neg, enzymes neg. No interventions done. 7. A right shoulder anterior dislocation was seen on CXR. Ortho was consulted and recommended a splint for comfort. 8. Multiple foley catheters were placed during the patient's stay due to poor fit, the most recent on [**2183-8-26**]. She began to have hematuria after this placement, likely due to foley trauma. On [**2183-8-27**], the hematuria began to worsen, and SQ heparin was held while bleeding. The hematuria improved. 9. Lines: PIV. PICC line placed ([**8-27**]). 10. Prophylaxis: heparin SC (held on [**2183-8-27**]), PPI, compression stockings. 11. Full code. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (once a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 9. Calcium Carbonate 1250 mg/5 mL Suspension Sig: Ten (10) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID PRN as needed for constipation. 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 13. Naproxen 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for pain. 14. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 10 days. 15. Lorazepam 2 mg/mL Syringe Sig: [**1-3**] Injection Q4H (every 4 hours) as needed. 16. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. 17. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 7 days. Discharge Disposition: Extended Care Discharge Diagnosis: Pneumonia, Urinary tract infection, bacteremia, tracheostomy site cellulitis Discharge Condition: Stable Discharge Instructions: Return to hospital if develop fevers, difficulty breathing, change in mental status, chest pain or any other critical symptoms. Followup Instructions: No follow up necessary beyond regular appointments with PCP. ** On the day of discharge ([**2183-8-28**]), the patient is on day 5 of 14 of vancomycin, and day 3 of 14 of ciprofloxacin.**

[ "996.64", "424.1", "599.0", "682.1", "482.41", "519.01", "560.9", "518.83", "790.7" ]

icd9cm

[ [ [] ] ]

[ "96.72", "33.21", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

6224, 6239

2772, 4672

242, 293

6360, 6368

1930, 2749

6544, 6736

4695, 6201

6260, 6339

6392, 6521

1394, 1911

197, 204

321, 1135

1157, 1320

1336, 1379

63,320

188,305

19077

Discharge summary

report

Admission Date: [**2190-9-12**] Discharge Date: [**2190-9-14**] Date of Birth: [**2108-1-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: lethargy, hypoglycemic episode, concern for flash pulmonary edema Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Mr. [**Known lastname **] is an 82 yo M with history of CAD with NSTEMI s/p cath with DES to LAD in [**2183**], ESRD on HD, DM2, HTN, HL, Hep C, with recent admission for volume overload and NSTEMI s/p cath with no intervention 1 week ago who presented with lethargy, hypoglycemic overload and concern for flash pulmonary edema. Per wife, pt had been having low energy for past 5 days. On day of admission, he was slumped in a chair and sweaty and breathing more heavily than usual. He had been compliant with medications and dialysis as well as restricting salt in diet. He recently started taking glipizide and confirmed that he did not have enough to eat on day of admission. He was found to have blood sugar of 30 by EMS. Given D50. He did not recall what happened. Denied CP, palpitations, cough, fevers, chills, n/v. In ED, he was found to be breathing hard, SOB, BP was 190-180s, looked like he was flashing with fluffy CXR. He was given 300 plavix, started on heparin drip, started on nitro drip, given 80 lasix, and placed on bipap. His blood sugars were erratic (105 on admit, then dropped to 30) and he was started on started on D10 drip. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: DES to mid LAD in [**2183**], recent ([**8-/2190**]) cardiac catheterization which showed a distal lesion in his OM that was unable to be intervened upon due to the vessel being too small -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - CAD s/p NSTEMI in [**2183**] with DES to mid LAD - Type 2 diabetes mellitus - diet-controlled - ESRD on HD, secondary to HTN and FSGS - baseline creatinine of [**5-21**] - Bladder Cancer, biopsy positive [**12/2189**] for high grade papillary urothelial carcinoma with lamina propria invasion in multiple sites - Hypertension - Hypercholesterolemia - Hepatitis C - Glaucoma - s/p right nephrectomy for suspected cancer, found to be benign - s/p appendectomy - s/p hernia repair - s/p rotator cuff surgery in [**2182**] Social History: Mr. [**Known lastname **] lives in [**Location 2268**] with his son and grandson. [**Name (NI) **] is a retired court officer. Admits to distant history of tobacco use while he was in the service; about 1PPW x 5 years. Prior marijuana use admitted to other OMR providers. Denies other illicit drug use. No alcohol use. The patient is separated from his wife, has 2 sons and one is deceased. Family History: Father with cancer of unknown origin per patient. Brother with cirrhosis, another brother who recently had a massive CVA. Sister w/[**Name2 (NI) 499**] cancer in her 70s. Physical Exam: Gen: alert, oriented, NAD. HEENT: sclera anicteric, EOMI, neck supple, no JVD CV: RRR, II/VI holosystolic murmur, no thrills. No S3-4 RESP: mild crackles at bases bilaterally, no wheezes ABD: soft, NT, ND, + BS EXTR: trace edema, distal pulses intact NEURO: A/O, speech clear, seems to have good recall of meds and hospital course Pertinent Results: [**2190-9-12**] 08:30PM BLOOD WBC-8.6 RBC-2.82* Hgb-9.2* Hct-28.1* MCV-99* MCH-32.8* MCHC-33.0 RDW-15.4 Plt Ct-391 [**2190-9-14**] 04:29AM BLOOD WBC-7.3 RBC-2.46* Hgb-8.1* Hct-24.5* MCV-100* MCH-32.8* MCHC-32.9 RDW-15.2 Plt Ct-367 [**2190-9-12**] 08:30PM BLOOD PT-11.6 PTT-20.9* INR(PT)-1.0 [**2190-9-14**] 04:29AM BLOOD PT-13.5* PTT-33.7 INR(PT)-1.2* [**2190-9-12**] 08:30PM BLOOD Glucose-57* UreaN-33* Creat-8.3*# Na-137 K-4.9 Cl-97 HCO3-27 AnGap-18 [**2190-9-14**] 04:29AM BLOOD Glucose-91 UreaN-18 Creat-5.4*# Na-134 K-6.4* Cl-95* HCO3-32 AnGap-13 [**2190-9-12**] 08:30PM BLOOD cTropnT-0.93* [**2190-9-13**] 03:47AM BLOOD CK-MB-7 cTropnT-0.92* [**2190-9-13**] 05:50PM BLOOD CK-MB-4 cTropnT-1.02* Cardiology Report ECG Study Date of [**2190-9-12**] 9:12:22 PM Sinus rhythm. Probable anterior myocardial infarction with ST-T wave configuration suggesting acute/recent/in evolution process. Consider left ventricular hypertrophy. Borderline prolonged QTc interval is non-specific. Clinical correlation is suggested. Since the previous tracing of the same date precordial lead ST-T wave changes appear slightly less prominent but there may be no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 81 136 90 [**Telephone/Fax (2) 52073**]75 Cardiology Report ECG Study Date of [**2190-9-12**] 8:07:46 PM Sinus rhythm. Probable anterior myocardial infarction with ST-T wave configuration suggesting acute/recent/in evolution process. Consider left ventricular hypertrophy. Prolonged QTc interval is non-specific. Clinical correlation is suggested. Since the previous tracing of [**2190-9-5**] further ST-T wave abnormalities are present and the QTc interval appears longer. Intervals Axes Rate PR QRS QT/QTc P QRS T 77 122 88 [**Telephone/Fax (2) 52074**] -174 CHEST (PORTABLE AP) Study Date of [**2190-9-12**] 8:17 PM IMPRESSION: Findings compatible with mild pulmonary edema, small bilateral pleural effusions, right greater than left, and bibasilar atelectasis. Portable TTE (Complete) Done [**2190-9-13**] at 2:04:57 PM The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal septum and apex. The remaining segments contract normally (LVEF = 55-60 %).The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Small circumferential pericardial effusion. Pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2190-9-1**], regional left ventricular systolic dysfunction and pulmonary artery systolic hypertension are now seen. The pericardial effusion is similar. CLINICAL IMPLICATIONS: The patient has mild aortic stenosis. Based on [**2186**] ACC/AHA Valvular Heart Disease Guidelines, a follow-up echocardiogram is suggested in 3 years. CHEST (PA & LAT) Study Date of [**2190-9-13**] 2:58 PM IMPRESSION: Large bilateral pleural effusions and bibasilar atelectasis and mild volume. Brief Hospital Course: Mr. [**Known lastname **] is a pleasant 82 year-old gentleman with history of CAD with NSTEMI s/p cath with DES to LAD in [**2183**], ESRD on HD, DM2, HTN, HLD, Hepatitis C, with recent admission for volume overload and NSTEMI s/p cath with no intervention 1 week ago prior to admission who presented with lethargy, SOB, and volume overload. # Acute on Chronic Diastolic Heart Failure: Patient had an episode of flash pulmonary edema while in the ED and was briefly on BiPap with improvement in symptoms. Bipap was removed, per patient request, upon arrival to CCU and tolerated transition to nasal canula well. Nitroglycerin drip was weaned off slowly. He does have a history of ESRD and has had some frequent difficulty with blood pressure and fluid overload. Last ECHO on [**2190-9-1**] showed LVEF>55% with otherwise preserved global and regional biventricular systolic function. Echo during this hospitalization was largely unchanged with trivial pericardial effusion. CXR showed bilateral pleural effusions. Patient underwent one round of hemodialysis the following morning and was hemodynamically stable, monitored overnight, then discharged directly home. # Hypoglycemia: Patient has history of DM2, previously diet-controlled but started on glipizide about four days prior to admission. He was found to be hypoglycemic at home with FS of 30 by EMS, likely in the setting of not having eaten enough that day, per patient. He had been maintained on D10 drip in the ED. With normalization of his blood glucose, mental status improved. Glipizide was held on discharge, and patient was told to return to diet control for his diabetes. # ESRD: ESRD thought to be secondary to HTN and FSGS. Patient is on HD schedule of MWF at home; he uses tunneled dialysis catheter which had been placed on recent admission. Creatinine was 8.3 on admission. Patient was dialyzed once the morning after admission. He was continued on nephrocaps and sevelamir. # Coronary Artery Disease: Patient was recently admitted the week prior to admission with NSTEMI s/p cardiac catheterization that revealed distal lesion in his OM with no intervention. He does have a history of NSTEMI s/p cath DES to mid LAD in [**2183**]. EKG on this admission similar to EKG on previous admission. Trop T 0.93, CK 262 (trending down from Trop 7.67, CK 424 on [**9-5**]). There was initially some concern for cardiac ischemia in the ED, but EKGs showed J-point elevation similar to prior. Patient was continued on aspirin, simvastatin, home dose of labetalol. # Mental status: Upon arrival to the CCU, patient was alert and oriented but did not recall details of hypoglycemic event that [**Last Name (un) 4662**] him to the ED. Mental status appeared to be secondary to hypoglycemia, improved with D10 and normalization of blood sugars. # HTN: Patient is on labetalol 400 mg [**Hospital1 **] at home but continues to have episodes of acute pulmonary edema likely secondary to poorly controlled hypertension. He was hypertensive in the ED and started on nitro drip for blood pressure control, though he did miss [**First Name (Titles) **] [**Last Name (Titles) **] dose of home meds. Nitroglycerin drip was weaned successfully and pt was continued on home labetalol dose. He did undergo hemodialysis x1 for fluid removal. # Urinary sx: Patient complained of some irritation in bladder of unclear etiology. It was considered that pain may have been secondary to foley placement. Has had been given recent course of cipro for UTI and has a history of blood in his urine. Patient had recently been started on 3 day course of phenazopyradine 200 mg Tablet tid, which was not helping symptoms, so it was discontinued during this hospitalization. # ACCESS: PIV's, tunneled dialysis catheter # CODE: DNR/DNI per patient Medications on Admission: B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by Other Provider) - 1 mg Capsule - 1 Capsule(s) by mouth daily BRIMONIDINE - (Prescribed by Other Provider) - 0.1 % Drops - 1 drop OU as directed LABETALOL - 200 mg Tablet - 2 Tablet(s) by mouth twice a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily PHENAZOPYRIDINE - 200 mg Tablet - 1 Tablet(s) by mouth three times a day (for 3 days, prescribed [**9-10**]) SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 1 Tablet(s) by mouth three times a day SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily docusate Discharge Medications: 1. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 2. Brimonidine 0.1 % Drops Sig: One (1) Ophthalmic once a day. 3. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO twice a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Renvela 800 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Hypoglycemia Flash pulmonary edema causing shortness of breath End Stage Renal Disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because you experienced shortness of breath, lethargy/confusion, and hypoglycemic episode. While you were in the hospital your blood sugars were normalized. You were fluid overloaded so you received medications and dialysis to normalize your fluid levels with improvement of your breathing. Your condition improved and you were able to be discharged from the hospital in stable condition. . The following changes were made to your medications: - Please START taking Aspirin 81mg daily - Please STOP taking Glypizide as this may have lead to your hypoglycemic episode (i.e., episode of low blood sugar leading to confusoin and lethargy). - Please STOP taking Phenazopyridine - Please continue to take all of your other home medications as prescribed. . Please be sure to keep all follow-up appointments with your Primary Care Physician and other health care providers. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your Primary Care Physician and other health care providers. . Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2190-10-11**] 4:00 . [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2190-10-19**] 1:00 . Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2190-11-23**] 10:20

[ "412", "V45.82", "250.80", "518.4", "414.01", "070.70", "585.6", "272.0", "403.91", "365.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12753, 12811

7735, 10285

380, 395

12964, 12964

3963, 7388

14115, 14754

3423, 3596

12184, 12730

12832, 12943

11576, 12161

13115, 14092

3611, 3944

2187, 2443

7411, 7712

275, 342

423, 2079

12979, 13091

2474, 2997

2101, 2167

3013, 3407

31

128,652

10184

Discharge summary

report

Admission Date: [**2108-8-22**] Discharge Date: [**2108-8-30**] Date of Birth: [**2036-5-17**] Sex: M Service: Neurology HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old gentleman with a history of Hodgkin's disease was transferred here from [**Hospital3 **] Hospital because of intractable seizures and decreased mental status. He was in his usual state of health, active and playing golf, until [**8-17**] when he began to become "confused" and developed gait difficulties. According to the family, Mr. [**Known lastname **] was behaving in a way that was perceived to be nontypical by family members. [**Name (NI) **] was also having gait difficulties that were considered to be mild, according to the family members. Because of these symptoms, he was evaluated at [**Hospital3 **] Hospital on [**8-17**]. At that time, a head computed tomography was reported as normal. He was give a diagnosis of transient ischemic attacks and was d/c home. Over the next three days, Mr. [**Known lastname **] problems gradually worsened. On [**8-20**], he was at home when he developed a nonfocal onset of seizure which was later generalized. He was transferred to the nearest Emergency Department where he continued to have generalized seizures. He was given a Dilantin load and phenobarbital. His systolic blood pressure at that time ranged between 120 and 200s. A repeat head CT was reported to be normal. Despite the Dilantin load and the phenobarbiltal, the patient continued to have clinical seizured. Therefore, he was started on an Ativan drip and was admitted to the Intensive Care Unit. His Dilantin was also continued on therapeutic levels. Despite the Ativan drip and Dilantin therapeutic levels, Mr. [**Known lastname **] continued to be unresponsive and had intermittent seizures. The rate of the Ativan IV infusion was increased and the patient was intubated. A lumbar puncture was performed on [**8-20**] at [**Hospital3 **] Hospital and showed normal values. A MRI with diffusion- weighted imaging showed diffuse hyperintensity in the cerebral cortex (R > L) and both thalami. At this point, the patient remained intubated and unresponsive and was therefore transferred to [**Hospital1 18**] for further evaluation and care. PAST MEDICAL HISTORY: 1. Hodgkin's disease diagnosed in [**2106-4-11**] after developing a respiratory infection. This was diagnosed as nodular sclerosing Hodgkin's disease; stage III-B with positive [**Doctor Last Name **]-Sternberg cells. A bone marrow biopsy was done in [**2106-8-11**] which showed no bone marrow involvement. 2. Status post chemotherapy with bleomycin, Cytoxan, vincristine, and procarbazine two years ago. This had to be discontinued after three cycles because of interstitial lung disease and because of myelosuppression with episodes of neutropenic fever. Most recent surveillance computed tomography scan revealed gradual interval progression of Hodgkin's disease with slightly large mediastinal lymph nodes. 3. Borderline hypertension. 4. Colonic polyps. 5. Tuberculosis. 6. Cataracts. 7. Macular degeneration. MEDICATIONS ON ADMISSION: Aspirin, Prevacid, and Tylenol. Ativan drip and Dilantin were started at the outside hospital. ALLERGIES: CEFTIN (causes a rash). SOCIAL HISTORY: The patient was a retired chemistry teacher and lived in [**Hospital3 **]. He was married with no alcohol or intravenous drug use. FAMILY HISTORY: Family history was noncontributory. CONCISE SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the Intensive Care Unit of [**Hospital1 18**] on [**2107-8-23**]. A repeat LP on admission showed normal cells, glucose and protein. A CSF sample was also obtained for viral cultures and different viral and fungal Ab titers (including West Nile Virus, Arboviruses, HSV, HBVs). Routine cultures for bacterial, TB and other infectious agents were also normal. Cytology was normal. Despite the therapeutic levels of PTN and the IV infusion of Ativan, electroencephalogram (EEG) on admission showed epileptiform sharp spike activity suggestive of ongoing epileptict activity. Therefore, a Penotarbital infusion was started. The Pentobarbital infusion was titrated to obtain a burst- suppression pattern on bedside 24 h, EEG monitoring. In particular, the EEG showed sharp waves complexes every 6 to 10 seconds. Dilantin and Depakote were continued as well. At this point, pressors were started to compensate to the Pentobarbital- induced decreased cardiac function. Mr [**Known lastname **] condition did not improve and another magnetic resonance imaging examination ([**8-24**]) showed multicentric areas of T2 hyperintensity with more concentration in the right frontal as well as bilateral thalami. Laboratory studies throughout Mr. [**Known lastname **] admission included several blood cultures, urine cultures and extensive toxic metabolic workup. Another LP for cerebrospinal fluid analysis for infection, toxic metabolic and cytological analysis was also performed. In order to better elucidate the underlying pathology. A brain and meningeal biopsy was performed on [**8-24**] in the right frontal lobe. In regards to empiric treatment, after the brain biopsy, the patient received IV Solu- Medrol and high doses of antibiotics with broad coverage. The Infectious Disease team was also involved in the care of Mr. [**Known lastname **]. All the tests performed on his tissues and fuids obtained under request of the ID team, had thus far come back normal. Brain and meningeal biopsy were remarkable for an meningitic eosinophilic infiltrates and extensive ischemic cortical neuronal damage (red neurons). There was no evidence of an infectious [**Doctor Last Name 360**] on traditional staining and/or on electronic microscopy. Several attempts in decreasing the dose of Pentobarbital resulted in an increased epileptiform activity on bedside EEG monitor. Mr. [**Known lastname **] condition deteriorated even further. He had developed ileus, and his abdomen was hyperextended. He had been intubated throughout his entire stay in the Intensive Care Unit and was increasingly dependent on ventilatory support. At this point, the patient's poor clincal status and prognosis was thoroughly discussed with his closest family members. After a family meeting, it was decided that Mr. [**Known lastname **] would no longer benefit from aggressive support. Therefore, he was extubated and expired briefly thereafter. [**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**] Dictated By:[**Last Name (NamePattern1) 728**] MEDQUIST36 D: [**2108-9-25**] 15:05 T: [**2108-9-25**] 16:30 JOB#: [**Job Number 33975**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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3538, 6762

167, 2287

2309, 3137

3314, 3447

25,526

154,635

29575

Discharge summary

report

Admission Date: [**2104-1-9**] Discharge Date: [**2104-1-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]M with recent admission for PNA s/p 7 days vanco/cefepime, azithromycin who presented from nursing home with worsening SOB and confusion. He underwent HD prior to admission, and was noted to be hypoxic and confused. At that time 02 sats 80s on room air. In the ED, VS significant for 02 84%RA, which progressively worsened to being on BiPAP. ABG 7.52/38/71. He was given vanco/zosyn for asp PNA as well as ASA, and admitted to the MICU. . In the MICU, he was broadened to vanco/ceftaz, cipro, flagyl. He received HD. He was noted to have confusion [**1-10**] requiring seroquel, pulling off his 02, then haldol. EKG unchanged. He was weaned off BiPAP and transitioned to 02 . Currently history is provided by his son. [**Name (NI) **] seems more awake but still slightly agitated. . Review of Systems: 10 points review of systems negative except those listed above. Past Medical History: # HTN # ESRD HD [**2099**] (hypertensive nephropathy), receives HD qMWF # Alzheimer's Dementia on donepezil(recently discontinued [**3-5**] nocturnal wakenings) # [**Month/Day (2) 8974**] bacteremia treated with 8 weeks IV cefazolin [**10-9**] # Pseudomonas bacteremia [**11-8**] rx w/ Cipro at VA # C. difficile colitis [**11-8**] # Bladder CA s/p resection at 60, 83 y/o. Most recent resection [**2102-11-20**] - followed with yearly cystoscopies as he is now anuric # Aortic ulcerations [**3-10**], unchanged on [**2101-9-25**] abd CT # Temporary HD catheter line infection with [**Date Range 8974**] in [**3-10**], rx with nafcillin, cathether has since been removed # Additional episode of [**Date Range 8974**] bacteremia [**9-7**], unclear source. Rx'ed with nafcillin and 4 wks of outpt cefazolin # Chronic low back pain # Chronic diastolic CHF Social History: Prior supervisor of flight kitchen. No known alcohol or tobacco history. He lives with his daughter, [**Name (NI) **], who helps him with his food and medications. His wife also lives with them and has dementia. Family History: CAD Brothers (2), Mom ESRD (unknown etiology) Physical Exam: VS: T 98.3, HR 84 BP 167/50, RR 19, 92% 4L Gen: awake and lucid. answered yes and no. picking at things HEENT: MM dry, OP clear, anicteric sclera Neck: supple, Heart: RRR with holosystolic murmur at LLSB Lung: decreased BS bilat and laterally Abd: sfot ,NT, ND + BS no rebound or guarding Ext: thin, no edema, warm Skin: dry Neuro: awake and lucid, not oriented, mildly agitated picking at things. Recognizes son. not cooperative with the rest of the exam Pertinent Results: Admission Labs: 144 / 99 / 19 / 63 4.1 / 28 / 6.6 . Ca: 8.7 Mg: 2.0 P: 3.6 ALT: 13 AP: 87 Tbili: 0.5 Alb: 3.3 AST: 26 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 27 lactate 1.1 . 7.3 \ 12.4/ 280 /40.9 \ . . . Discharge labs: WBC 5.9 Hct 37.3 MCV 89 Plts 316 146 103 20 ----------------- Gluc 87 4.3 34 7.1 . Ca 8.9 Phos 3.9 Mg 2.3 . cardiac enzymes 0.09, 0.12, 0.11 with CKMB negative x3 prolactin 99 Flu: negative Blood cx: NGTD . EKG: NSR, low voltage, RBBB with LAFB, non specific changes. NO signficant change from prior. . CXR [**1-9**]: FINDINGS: An upright AP radiograph of the chest shows low lung volumes bilaterally with dense bibasilar consolidations. That at the left base appears progressed from most recent comparison and that at the right base is new. There are bilateral pleural effusions. A poorly marginated right upper lobe consolidation is also demonstrated. Superimposed upon these findings is increased interstitial markings, suggesting pulmonary vascular congestion. Cardiac, mediastinal and hilar contours are unchanged with redemonstration of atherosclerotic calcification of the aorta. IMPRESSION: Multifocal consolidations, progressed from the previous study, concerning for multifocal pneumonia with possible superimposed cardiac congestion. . CT Head: FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or vascular territorial infarction. The ventricles and sulci are enlarged, consistent with parenchymal volume loss. Periventricular white matter hyperdensities bilateral, reflecting the consequence of chronic microvascular infarction. Punctate calcified foci bilaterally are unchanged. There is no fracture. The right mastoid air cells are clear and there is opacification of the left mastoid air cells. IMPRESSION: 1. No acute intracranial abnormality. 2. Opacification of the left mastoid air cells, new [**1-11**] speech and swallow IMPRESSION: Aspiration of thins. Single episode of penetration of nectar residue. [**2104-1-12**] CT chest FINDINGS: There is no evidence of mediastinal or hilar lymphadenopathy. Moderate amount of pericardial effusion is noted. The lungs show diffuse ground-glass opacities and septal thickening with a number of linear atelectases in the right upper lobe. Further noted is bilateral high-density material in the distal bronchi in the right lower lobe and left lower lobe accompanied by consolidations with air bronchogram. Findings are suitable for bilateral aspirations (including apparent prior barium aspiration). Also seen bilateral pleural effusions of moderate size. There is a small loculated pleural effusion at the right upper chest. All findings are new as compared to the previous CT scan from [**2102**]. Two hypodense lesions are seen in the lateral limb of the left adrenal, one measuring 1.6 cm and an additional one measuring 1.9 cm. Both are of low attenuation. Findings are consistent with adenomas. IMPRESSION: 1. Bilateral moderate-sized pleural effusions. 2. Bilateral ground-glass opacities and septal thickening, findings which may be consistent with pulmonary congestion. 3. Bilateral right lower lobe and left lower lobe aspirations with consolidations with previously ingested barium. 4. Two small adenomas in the left adrenal. [**2104-1-17**] IMPRESSION: Abnormal EEG, apparently in wakefulness and drowsiness, due to the slow and disorganized background and bursts of generalized slowing. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features, including at the times of leg movements. Brief Hospital Course: [**Age over 90 **]yoM with Alzheimer's dementia, ESRD on HD, HTN and recent dx of multi-focal PNA treated with one week of vanco/cefepime and azithro, readmitted with confusion, SOB and hypoxia, admitted to MICU on BiPAP and quickly weaned, called out to floor where he was seen to have very waxing and [**Doctor Last Name 688**] mental status/delirium on top of dementia. 1. Mental status: Pt with known Alzheimer's dementia and poor short term memory who was seen to have waxing and [**Doctor Last Name 688**] delirium. At first thought to be due to a couple doses of Haldol and Zyprexa, but as time passed continued to have episodes of extreme somnolence in which he would minimally respond to sternal rub, lay in bed and moan responses to questions, and have myclonic jerks in his bilateral upper extremities. He would then spontaneously wake up the next day and be very alert and interactive, not oriented at all, but conversational, pleasant and as normal as his baseline was. He was never in cardiopulmonary distress during any of these episodes and vitals were completely stable through entire admission including oxygen saturation. Workup for this mental status included normal WBC's through admission, no fevers at all, BCx's negative x2, no UCx b/c pt is anuric HD dependent, negative DFA for influenza, normal BUN's and chemistries through admission, normal blood sugars, all normal LFT's and no h/o liver disease, negative lipase, negative cardiac enzymes and normal EKG's during somnolent episodes, stable ABG's without hypercarbia but slight metabolic alkalosis with elevated HCO3, head CT which showed no acute process. He had an EEG showing no focal epileptiform activity but with diffuse slow background called as encephalopathy due to metabolic causes, medications, or infections, but workup was negative as above. His mental status changes were thought to perhaps be due to worsening of his dementia with an element of hospital acquired delirium on top. No clear etiology was found for this pattern of extreme somnolence and decreased responsiveness for a day or so at a time, then complete turnaround, being alert, interactive, eating. In the future, would recommend monitoring his vital signs, labs, blood sugars, and being reasonable in his workup for the episodes of somnolence, unless there is obvious concern for something out of this baseline. Keep the pt NPO and have aspiration precautions while somnolent. On the day of discharge, the pt was seen to be sitting up, eating, totally conversant, vital signs stable. 2. Multifocal PNA: Pt with CXR concerning for multifocal PNA but later on CT called as aspirations. Nevertheless, pt was started on Vanc/Cefepime/Cipro/Flagyl and received 4d of Vanc/Cipro and 6d of Cefepime/Flagyl. It was never quite clear that the pt actually had a PNA, WBC's low and afebrile the entire time admitted and radiographic evidence of barium aspiration on chest CT. 3. Bilateral pleural effusions and pulmonary congestion: seen on chest CT, however suspicion for infected effusion low, and not thought to respiratorily compromise the pt as his oxygen sat was weaned to room air and normal, not tachypneic, ABG's were stable. If respiratory compromised in the future would consider tapping effusions if within goals of care, or pulling fluids off with HD. 4. HTN/HPL: Pt was continued on Amlodipine 10mg, Lisinopril 20 qday, Metoprolol 50 [**Hospital1 **], Minoxidil 5 [**Hospital1 **], ASA 81 qday, Simvastatin 40 qday, and aside from not being able to take pills while somnolent, these were not active issues this admission. 5. ESRD on HD: Pt receives HD on Mon/Wed/Fri, with volume being taken off given the CT findings of pulmonary congestion. 6. Nutrition: Seen by speech and swallow and had video swallow study, felt to be high risk for aspiration and recommended PO diet of nectar thick liquids, ground solids. Aspiration precautions with 1:1 for PO's, alternate bites and sips, encourage single sips of liquid as able, no mixed consistencies (liquids and solids), pills crushed in puree, and TID oral care. Family will need education re: how to feed pt. FEN: Nectar thick liquids and ground solids, NPO while somnolent. Prophy: subQ hep, Senna, Bisacodyl Access: LUE AV fistulas, PIV Code: FULL CODE Communications: 2 daughters, [**Name (NI) **] and [**Name (NI) 2184**] (?), also a son [**Name (NI) **] Medications on Admission: Simvastatin 40 mg QD Lisinopril 20 mg QD Metoprolol Tartrate 50 mg [**Hospital1 **] Minoxidil 5 mg [**Hospital1 **] Pantoprazole 40 mg Q24 Aspirin 81 mg QD Nephrocaps Memantine 5 mg QHS Calcium Acetate 667 mg x 2 TID with meals Docusate Sodium 100 mg [**Hospital1 **] Senna 8.6 mg [**Hospital1 **] Bisacodyl 10 mg Suppository [**Hospital1 **] PRN Polyethylene Glycol QD PRN Acetaminophen 1000 mg TID std Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO bid prn as needed for Constipation. 3. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 6. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Minoxidil 2.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 10. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Memantine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a day (at bedtime)). 12. Docusate Sodium 100 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO once a day. 13. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 3145**] Nursing Home - [**Location (un) 3146**] Discharge Diagnosis: HTN ESRD HD [**2099**] (hypertensive nephropathy), receives HD qMWF Alzheimer's Dementia on donepezil (discontinued [**3-5**] nocturnal wakenings) [**Month/Day (2) 8974**] bacteremia treated with 8 weeks IV cefazolin [**10-9**] Pseudomonas bacteremia [**11-8**] rx w/ Cipro at VA C. difficile colitis [**11-8**] Bladder CA s/p resection at 60, 83 y/o. Most recent resection Discharge Condition: Mental Status:Confused - always (pt with dementia and very waxing and [**Doctor Last Name 688**] delirium) Level of Consciousness:Lethargic and not arousable (pt waxes and wanes from day to day, some days somnolent and minimally arousable to sternal rub, other days very alert and interactive. Never oriented though, very demented) Activity Status:Bedbound (will need aggressive PT and should be able to get out of bed with [**Doctor Last Name 11807**]) Discharge Instructions: You were admitted to [**Hospital1 18**] with worsening confusion and hypoxia. You were admitted to the intensive care unit and received BiPAP and were quickly weaned from that and called out to the floor. You received broad spectrum antibiotics but it was unclear that you actually had a pneumonia. You were delirious through your course at [**Hospital1 18**] with waxing and [**Doctor Last Name 688**] mental status and increased somnolence. Followup Instructions: Please have your nursing home arrange follow up for you. You can arrange an appointment with your primary care physician [**Name9 (PRE) **],[**Name9 (PRE) 900**] by calling [**Telephone/Fax (1) 9075**]. Completed by:[**2104-1-18**]

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icd9cm

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65,374

121,962

44090

Discharge summary

report

Admission Date: [**2150-8-17**] Discharge Date: [**2150-8-24**] Service: MEDICINE Allergies: Percocet / Feldene Attending:[**First Name3 (LF) 983**] Chief Complaint: Lower extremity edema, pain and erythema Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 80687**] is a [**Age over 90 **] year old female with history of chronic venous stasis and lymphedema in bilateral lower extremities, Afib/DVT (>15 yrs ago) on coumadin, recently hospitalized in [**2150-5-1**] for GBS bacteremia secondary to GBS UTI and a cellulitis and leg ulcerations, treated with 2 weeks of ceftriaxone. She is now presenting with a recurrence of increased pain, swelling, redness of bilateral legs for [**3-5**] days, referred to the [**Hospital1 18**] ED by her VNA for increasing drainage from her legs. She denies subjective fevers, chest pain shortness of breath, cough, nausea/vomiting, abdominal pain, dysuria/frequency, dizziness, or loss of consciousness. According to her son [**Doctor First Name 3788**], HCP), she has not been elevating her legs like she has been told to. In the ED, vitals were: 100.9, 127, 161/69, 18, 99%. She was started on Vancomycin and LENIs were negative for DVT and given ~2L IVF for tachycardia to 130s, with response to 90s. Her INR was noted to be supratherapeutic at 5.1. She was initially assigned to the floor, but became hypotensive to SBP 80s prior to transfer and 2 more liters of IVF were givne. Central line was placed and she was started on levophed. Urinalysis noted to have many bacteria, large leuks, 34 WBC, so she was started on Ceftriaxone. Vitals upon transfer: 108 90/45, 16, 95% on 3L. In the ICU, her pressures have remained stable on small amounts of levophed. She is comfortable, pain-free, and otherwise stable. Past Medical History: -Chronic venous stasis/lymphedema bilaterally; followed by Dr. [**Last Name (STitle) 3407**] of vascular -PUD s/p "probable [**Doctor First Name 892**]-[**Doctor Last Name **] II surgery" in [**2103**] per GI note -Afib -CVD -DVT (> 15 years ago in the context of ovarian CA) -Ovarian cancer s/p TAH/BSO and XRT (per [**2146-8-29**] GI note in OMR) -Osteoporosis -Hiatal hernia -Spinal stenosis -> decompression laminectomy [**2132**] -Knee arthroscopy, synovectomy, meniscectomy [**2132**] -Cataract OS -Diarrhea thought [**3-4**] to bacterial overgrowth intermittently treated w/ augmentin ([**Hospital1 **] 1st 5 days of each month) -Ectopic pregnancy -Appendectomy -Tonsillectomy -Chronic venous stasis/lymphedema bilaterally; followed by Dr. [**Last Name (STitle) 3407**] of vascular -PUD s/p "probable [**Doctor First Name 892**]-[**Doctor Last Name **] II surgery" in [**2103**] per GI note -Afib -CVD -DVT (> 15 years ago in the context of ovarian CA) -Ovarian cancer s/p TAH/BSO and XRT (per [**2146-8-29**] GI note in OMR) -Osteoporosis -Hiatal hernia -Spinal stenosis -> decompression laminectomy [**2132**] -Knee arthroscopy, synovectomy, meniscectomy [**2132**] -Cataract OS -Diarrhea thought [**3-4**] to bacterial overgrowth intermittently treated w/ augmentin ([**Hospital1 **] 1st 5 days of each month) -Ectopic pregnancy -Appendectomy -Tonsillectomy Social History: She denies use of tobacco, alcohol, illicit drugs or herbal medications. She is widowed and lives alone in an apartment with VNA. Her son [**Name (NI) 11229**] lives near by. She relies on a walker for all mobility Family History: Venous disease, lymphedema Physical Exam: ADMISSION EXAM: VS:97.1 HR 108 BP 130/71 RR 19 98/O2xNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: bibasilar crackles, no wheezes, rales, rhonchi CV: irregularly irregular, normal S1/S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: very warm, with diffuse erythema along all surfaces of bilateral lower legs between ankles and knees, some mild skin breakdown but no openly weeping sores. [**3-5**]+ non-pitting edema. 1+ pulses, no clubbing, cyanosis. Back: significant kyphosis EXAM ON TRANSFER FROM ICU VS: Tm 97.4 Tc 97.3 HR 97 BP 104/54 RR 15 97/O2xNC General: Alert, oriented, no acute distress HEENT: MMM, OP clear, no LAD, no JVD Lungs: bibasilar crackles, good aeration, no w/r/r CV: irregularly irregular, normal S1/S2, no murmurs Abdomen: soft, non-tender, non-distended, +bowel sounds Ext: warm, [**3-5**]+ non-pitting edema, 1+DPs. +symmetric bilateral erythematous plaques extend from ankles to knees, not sharply demarcated, no fluctuance or induration, some crusting, no open lesions or e/o recent bleeding. Exquisitely tender to light touch, esp around L foot/ankle. Pertinent Results: [**2150-8-17**] 11:58PM GLUCOSE-116* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11 [**2150-8-17**] 11:58PM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-1.8 [**2150-8-17**] 11:58PM WBC-6.4 RBC-2.82* HGB-8.7* HCT-25.6* MCV-91 MCH-31.0 MCHC-34.1 RDW-15.6* [**2150-8-17**] 11:58PM NEUTS-75.3* LYMPHS-16.5* MONOS-6.6 EOS-1.4 BASOS-0.2 [**2150-8-17**] 11:58PM PLT COUNT-335 [**2150-8-17**] 11:58PM PT-52.1* PTT-36.9* INR(PT)-5.6* [**2150-8-17**] 06:10PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2150-8-17**] 06:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG [**2150-8-17**] 06:10PM URINE RBC-<1 WBC-34* BACTERIA-MANY YEAST-NONE EPI-0 [**2150-8-17**] 05:35PM LACTATE-1.3 K+-3.4* [**2150-8-17**] 05:28PM PT-48.0* PTT-45.6* INR(PT)-5.1* Brief Hospital Course: ICU Course: [**Age over 90 **] year old female with history of chronic venous stasis and lympedema in B/L lower extremities, AF/distant DVT on coumadin, with severe sepsis and suspicion for recurrent lower extremity cellulitis. # Severe sepsis: Patient admitted to the ICU from the ED on levophed for BP support. She was weaned off levophed overnight, with stable HR and SBP 90s-100s on maintenance IVF at 100/hr. No obvious infectious source identified for her suspected sepsis. Urosepsis was most likely, as patient had a UA in the ED with WBCs, leukesterase positive and with many bacteria. The first culture grew three equal colonies of GNR suspected to be fecal contamination, but notably this culture was drawn from her foley. Subsequent urine cultures (after starting antibiotics) were negative to date. Also concern for cellulitis(see below) Her leg pain and erythema after she was started on broad-spectrum antibiotics (vancomycin/ciprofloxacin) kmproved. When she completed her abx she had another fever and ID was consulted, recommending course of augmentin and doxycycline for 10 day course to be completed [**8-31**]. # Bilateral lower extremity lymphedema with superimposed cellulitis: In the MICU, it was unclear whether her leg edema and erythema was consistent with chronic venous stasis with worsening lymphedema vs. cellulitis. The patient however did note significant improvement with antibiotic therapy. She was treated empirically with vancomycin. Her legs were kept elevated to promote drainage, and wound care nursing was consulted. She spiked a fever when antibiotics were d/c and ID was consulted(noted above). Will completed 10 day course of Augmentin and doxycycline to be completed [**8-31**]. # Atrial fibrillation: She continues to have Afib with rate of 90-100 in the ICU. Continued metoprolol at increased dose of 37.5 TID. She has been on coumadin at home, originally for history of DVT (distant past) and for atrial fibrillation. Coumadin supratherapeutic at 5.6 on admission. Elevated INR likely secondary to infection. Held coumadin. CHADS2 score of 1 (age), so warfarin may not be indicated and deserves further discussion prior to discharge. When INR dropped to 2.1, her coumadin was restarted. When it dropped below 2, a heparin gtt was started to bridge until INR is [**3-5**]. On day of discharge, her INR was 1.8. Because this level was close to therapeutic and her CHADS2 score was low, the patient was d/c on coumadin 2.5mg daily with no further heparin. Will have biweekly INR checks at [**Hospital1 1501**] #Flash pulmonary edema: Pt developed transient respiratory distress twice in the ICU, in the context of holding home lasix and bolusing IV fluids to treat early sepsis. Symptoms responded well to IV lasix and morphine. EKG showed atrial fibrillation without ST or T changes. Serial enzymes negative. CXR without acute process, stable/improved pulmonary edema. She was restarted on home lasix. # Normocytic anemia: Stable at 26, down from 31 at admission, likely dilutional. No evidence of active bleeding at this time. # Deconditioning: Patient will be discharged to [**Hospital1 1501**] for PT/OT. Medications on Admission: -omeprazole 20 mg daily -metoprolol tartrate 25mg [**Hospital1 **] -warfarin 2.5 mg daily per INR -furosemide 20mg [**Hospital1 **] -acetaminophen PRN Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit Inhalation Q4H (every 4 hours) as needed for sob, wheeze. 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days: Please continue through [**8-31**]. 6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 8 days: Please continue through [**8-31**]. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: Urosepsis (bladder infection infecting your blood) cellulitis (leg infection) edema(swelling in your legs) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair-requiring physical therapy. Discharge Instructions: You were admitted for a bladder infection and leg infection that infected your blood. You were treated with antibiotics which are to continue on discharge. You are going to be discharged to a skilled nursing facility to continue physical rehabilitation Followup Instructions: 1. Please schedule follow up with your primary care physician after being discharged from the skilled nursing facility.

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icd9cm

[ [ [] ] ]

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icd9pcs

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47969+59050

Discharge summary

report+addendum

Admission Date: [**2198-3-5**] Discharge Date: [**2198-3-11**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Dilantin Kapseal Attending:[**First Name3 (LF) 1943**] Chief Complaint: Missed dialysis/Respiratory distress Major Surgical or Invasive Procedure: IV Fistulagram Intubation History of Present Illness: 63 y/o F w/ ESRD [**2-21**] IgA nephropathy s/[**Name Initial (MD) **] failed CRT [**2173**] on HD (MWF) through LUE AVF since [**2193**], p/t ED w/ n/v/diarrhea and at least one episode of bloody stools and ILI Sx w/ worsening SOB x 2-3d. Because she was not feeling well, she missed HD today. She was unable to provide further hx in ED. Initial ED VS: T 97.8 HR 80 170/78 18 94 % 2L Exam was notable for tachypenic ill-appearing F w/ nonfocal abd tenderness L basilar crackles and an irregularly irregular tachycardic heart rate to 145. CXR was consistent with B/L patchy infiltrates concerning for PNA vs. volume overload. Labs showed K of 6.5, Cr 8.6. Telemetry showed several runs of NSVTs and pt was symptomatic w/ nausea. She then began to have sustained runs of VTs; EKG showed hyperacute T waves in V3-V5, wide complex tachycardia, and LBBB w/ poor R-wave progression. She received a total of 5g IV calcium gluconate, 10u regular SC insulin, kayexalate and 1 amp IV glucose. Cardiology was consulted and felt arrhythmia was [**2-21**] hyperkalemia and renal was consulted for stat hemodialysis given hyperkalemia and VT. She did not become pulseless, but as she had increasing tachycardia and tachypnea, rapid sequence intubation with rocuronium (instead of succinylcholine given hyperkalemia) and etomidate was performed in the ED. As EJ blew during intubation, R- femoral CVL was placed for access. Pt was initially placed on lidocaine gtt for tachycardia which was changed to esmolol gtt. Pt also received CTX for presumed PNA on CXR. VS: afebrile, 145, 145/66 100% on AC 350 x 20,PEEP 5 FiO2 50% In the MICU, emergent HD was initiated. Past Medical History: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **] [**2195**]. 2. End-stage renal disease on hemodialysis secondary to IgA nephropathy s/p cadaveric kidney transplant in [**2173**] which has eventually failed, and started on hemodialysis in [**2193**]. 3. History of upper GI bleeding on [**2195-2-20**] with evidence of esophagitis, gastric ulcer, and bleeding duodenal vessel s/p clipping, cauterization and PPI. 4. Diastolic heart failure supported by an echocardiography from [**2195-12-21**]. Clinically asx. 5. History of malignant hypertension, which was complicated by seizure on [**2193-5-20**]. Not on antiepileptic meds. Denies h/o CVA. 6. Depression. 7. Rheumatic fever in childhood Social History: Single, lives by herself in [**Location (un) 686**], and has no children. She quit smoking 25 years ago (10-pack-years). She rarely drinks alcohol, and denies illicit drug use. She used to work part-time in a coffee shop, but currently does not work. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Her father died at the age of 80. Her mother died at the age of 64 from lung CA. She has a sister with breast CA. MI in uncle in his 60s. Physical Exam: On Admission: Vitals: Tm 99.1 Tcurr 97.2 BP: 154/65 P: 62 R: 18 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 8 cm, no LAD Lungs: Soft, dry inspiratory crackles on right, no wheezes, rales, ronchi CV: Regular rate and rhythm, Loud AV fistula thrill heard across precordium Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 1+ pitting edema to mid-shin Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: [**2198-3-5**] 01:20PM WBC-5.0 RBC-3.87* HGB-11.9* HCT-35.1* MCV-91 MCH-30.7 MCHC-33.9 RDW-18.3* [**2198-3-5**] 01:20PM NEUTS-86.5* LYMPHS-7.9* MONOS-4.4 EOS-0.4 BASOS-0.7 [**2198-3-5**] 01:20PM PLT COUNT-275 [**2198-3-5**] 01:20PM GLUCOSE-124* UREA N-81* CREAT-8.6* SODIUM-137 POTASSIUM-6.5* CHLORIDE-92* TOTAL CO2-23 ANION GAP-29* [**2198-3-5**] 01:20PM PT-21.3* PTT-27.3 INR(PT)-2.0* [**2198-3-5**] 03:10PM proBNP->[**Numeric Identifier **] [**2198-3-5**] 04:17PM freeCa-1.34* [**2198-3-5**] 03:17PM K+-6.5* [**2198-3-5**] 04:25PM TYPE-ART PO2-86 PCO2-59* PH-7.25* TOTAL CO2-27 BASE XS-2 [**2198-3-5**] 10:35PM TSH-4.5* Micro: [**3-5**] Blood Culture x 2- NGTD [**2198-3-6**] 2:40 am CATHETER TIP-IV Source: Rt Femoral. WOUND CULTURE (Final [**2198-3-8**]): No significant growth. [**2198-3-5**] 11:27 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2198-3-6**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2198-3-8**]): SPARSE GROWTH Commensal Respiratory Flora. [**2198-3-5**] 11:27 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [**2198-3-8**]** Respiratory Viral Culture (Final [**2198-3-8**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2198-3-6**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. [**2198-3-6**] Blood culture- NGTD STUDIES: [**2198-3-5**] EKG: Baseline artifact. Possible atrial flutter with variable block, predominantly 3:1. Leftward axis. Left bundle-branch block. Prominent precordial T waves. Since the previous tracing of [**2196-12-17**] the atrial tachyarrhythmia is new. The QRS complex is wider. Left bundle-branch block pattern is new. Clinical correlation is suggested. [**2198-3-5**] CXR: Portable upright AP chest radiograph is obtained. There is central pulmonary vascular congestion and mild pulmonary edema. Small right pleural effusion is noted. No pneumothorax is seen. IMPRESSION: Findings compatible with congestive heart failure/fluid overload. [**2198-3-6**] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 65%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2195-12-22**], the findings are similar. The acoustic texture of the left ventricular myocardium suggests an amyloid-type infiltration, as does the stiffness of the myocardium. Findings consistent with restrictive cardiomyopathy. [**2198-3-7**] R Neck Ultrasound: No focal fluid collection or abscess. Expansion and increased echogenicity of the right sternocleidomastoid muscle relative to the left, which may reflect myositis, of indeterminate etiology. Adjacent prominent cervical nodes may be reactive. However, followup imaging following resolution of symptoms is suggested to ensure resolution of findings. [**2198-3-9**] CXR: Small bilateral pleural effusions have both decreased. Substantial residual consolidation is present at the left lung base, and although there is no pulmonary edema, there is mild cardiomegaly and persistent, though improved, pulmonary vascular congestion. Brief Hospital Course: 63 F w/ ESRD [**2-21**] IgA nephropathy s/[**Name Initial (MD) **] failed CRT [**2173**] on HD (MWF) through LUE AVF since [**2193**], here w/ n/v/diarrhea and severe volume overload after missing session of HD from viral gastrointestinal illness.. 1. RESPIRATORY [**Name (NI) **] Pt was intubated [**2-21**] tachypnea and her increased WOB. Her respiratory failure was attributed to a likely viral illness with superimposed volume overload. She underwent emergent dialysis on [**3-5**] and again on [**3-6**] (removal of appx 3L of fluid) and was extubated on [**3-6**]. She was spiking temperatures and her CXR on [**3-7**] showed a new infiltrate and thus cefepime was added to her vancomycin for coverage of HCAP given her exposures at dialysis sessions. She was [**Month/Year (2) 20003**] out for flu with a viral respiratory panel. Her respiratory status improved greatly after several days of dialysis. Treatment for health-care associated pneumonia with vancomycin/cefepime was completed for 7 day course through [**3-11**] (and one more dose of Vanco on [**3-12**] during HD). 2. ESRD/HYPERKALEMIA- Patient presented w/ hyperkalemia [**2-21**] ESRD and her missed dialysis session. Her hyperkalemia did not improve w/ calcium gluconate, insulin, kayexalate, but improved after HD. Patien had underlying swelling of her left UE near the site of her AVF and had planned for a fistulogram as an outpatient. This was scheduled for her as inpatient prior to transfer to the floor. She received two dialysis sessions with 3L removed before being transferred to the floor with improvement in respiratory status. She had an IV fistulagram, and her fistula was dilated with a balloon. She will return to her normal dialysis schedule upon discharge. 3. Atrial fibrillation: Patient presented with AF with aberrancy in the 110s-130s in the ED. She was initially continued on the esmolol drip but this was weaned soon after she arrived on the floor. She was continued on her home amiodarone with good rate control. She underwent a TTE to rule out structural abnormality which showed a question of restrictive cardiomyopathy/stiffened myocardium suggestive of amyloidosis. Her coumadin was held as she was going for IR fistulogram with likely dilation planned. Once dilation was completes, she was restarted on coumadin per her home dosing with instructions to have INR checked the day after discharge. 4. Hypertension Medications on Admission: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Sensipar 60 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Coumadin 2 mg Tablet Sig: ASDIR Tablet PO ASDIR: 4mg on Monday and Friday, 2mg all other days. 10. Kayexalate Powder Sig: One (1) dose PO ASDIR: Take every Sunday and Monday. Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. warfarin 2 mg Tablet Sig: One (1) Tablet PO TUESWEDTHURSATSUN (). 3. warfarin 2 mg Tablet Sig: Two (2) Tablet PO MONFRI (). 4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS. 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO M W F SUN) Hold on dialysis days . 7. Sensipar 60 mg Tablet Sig: One (1) Tablet PO twice a day. 8. citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. sodium polystyrene sulfonate Powder Sig: Fifteen (15) grams PO every SUN MON. 12. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous HD PROTOCOL (HD Protochol) for 1 days. Disp:*1000 mg* Refills:*0* 13. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: - End-stage renal disease - Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 101213**], You were seen in the hospital because of shortness of breath. This shortness of breath was likely secondary to volume overload from missing dialysis. You had a breathing tube placed in the emergency room to help your breathing. Once the fluid was removed from your lungs with several days of dialysis, the breathing tube was able to be safely removed. While you were in the hospital, you also were treated for a pneumonia with IV antibiotics. You will receive Vancomycin for one more day (Monday [**2198-3-12**]) during your dialysis session. We made the following changes to your medications: - Started IV Vancomycin as above. You will receive this one more time with HD. - Started Carvedilol 3.125mg daily for your high blood pressure. - Increased your Citalopram from 40 mg daily to 60 mg daily. Please note that we discharged you on the same coumadin dose you were taking before you arrived. However, your INR is only 1.3 on discharge. You should call you [**Hospital 263**] clinic at [**Company 191**] on Monday ASAP at [**Telephone/Fax (1) 101218**] to get your INR checked and your coumadin dose adjusted. Because of your renal disease and heart failure, you should weigh yourself every morning, and call your doctor if weight goes up more than 3 lbs. It was a pleasure taking care of you during your hospital stay. Followup Instructions: Department: [**Hospital3 249**] POST [**Hospital 894**] CLINIC When: THURSDAY [**2198-3-15**] at 8:40 AM With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: COGNITIVE NEUROLOGY UNIT When: FRIDAY [**2198-3-16**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PHD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2198-6-13**] at 9:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Known lastname 16262**],[**Known firstname **] Unit No: [**Numeric Identifier 16263**] Admission Date: [**2198-3-5**] Discharge Date: [**2198-3-11**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Dilantin Kapseal Attending:[**First Name3 (LF) 11437**] Addendum: ISSUES FOR FOLLOW-UP: [] Patient to get reconnected with [**Hospital3 1946**] on Tuesday, [**3-13**]. [] F/u symptoms of shortness of breath [] F/u SPEP [**3-8**] for restrictive cardiomyopathy workup to r/o Amyloidosis [] F/u Blood cultures 2/14 and [**3-6**] Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11438**] MD [**MD Number(2) 11439**] Completed by:[**2198-3-12**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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30419

Discharge summary

report

Admission Date: [**2154-4-4**] Discharge Date: [**2154-6-17**] Date of Birth: [**2154-3-1**] Sex: M Service: NBB IDENTIFICATION: [**Known lastname 72312**] [**Known lastname 72313**] is a 109 day old former 29+ week infant who is being discharged from the [**Hospital1 18**] NICU. HISTORY OF PRESENT ILLNESS: [**Known lastname 72314**] [**Known lastname 72313**] was born at 29-1/7 weeks gestation at [**Hospital 8**] Hospital by emergent cesarean section for a nonreassuring fetal heart rate. His Apgars were 2 at one minute, 4 at five minutes, and 6 at 10 minutes. He was then transferred to [**Hospital3 **] for prematurity and respiratory distress. On day of life #33 at 33-6/7 weeks gestation, he was transferred to [**Hospital1 346**] for continuing care and is now ready for discharge home. His mother is a 36-year-old, gravida 2, para 1, now 2, woman. Her prenatal screens are blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen positive, and group B strep unknown. This pregnancy was complicated by insulin-dependent gestational mellitus, chronic hypertension, and thrombocytopenia (likely idiopathic thrombocytopenia). Rupture of membranes occurred at the time of delivery. His birth weight was 1140 gm, his birth length 35 cm, and birth head circumference 25 cm. At discharge his weight is 4000 gm, his length is 47 cm, and his head circumference is 36 cm. His discharge reveals a vigorous, nondysmorphic, term male infant. Anterior fontanel open and flat, sutures approximated, positive bilateral red reflex, oral mucosa without lesions. Neck supple and without masses. Clavicles intact. Comfortable respirations except for some mild nasal congestion. Lungs sounds clear and equal. Heart with regular rate and rhythm, no murmur. Pink and well perfused. Femoral pulses present. Abdomen soft, nontender, nondistended and with active bowel sounds. Cord healed. Testes descended bilaterally. No sacral anomalies. Hip exam was tight hips with limited, slightly decreased range of motion and some overall mild increased tone. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory Status: He was intubated at the time of birth and extubated to nasopharyngeal continuous positive airway pressure on day of life #11. He then weaned to nasal cannula oxygen on day of life #21 and weaned to room air of day of life #89 where he remains. He was treated with caffeine for apnea or prematurity until day of life #33. His last episode of bradycardia occurred on [**2154-6-7**]. He also received Lasix for chronic lung disease from day of life #67 until day of life #84. On exam he does have some mild nasal congestion but it does not interfere with feedings and there are no secretions. 2. Cardiovascular Status: He required pressor support until day of life #8 and he has been normotensive since that time. He was treated with Indocin for a patent ductus arteriosus on day of life #1. A follow-up echo showed no patent ductus and a structurally normal heart. He does have an intermittent grade [**1-26**] flow murmur. 3. Fluids/Electrolytes/Nutrition Status: Enteral feeds were begun on day of life #19 and he reached full volume feeding on day of life #26. At the time of discharge, he is eating 24-calorie per ounce breast milk or formula on an ad lib schedule, taking approximately 120-140 mL/kg/day. 4. Gastrointestinal Status: He was treated with phototherapy for physiologic hyperbilirubinemia from day of #1 until day of life #6. His peak bilirubin occurred on day of life #2 and was 6.0 total, and direct 0.4. He also has a mild direct hyperbilirubinemia due to prolonged hyperalimentation. His peak direct bilirubin was 2.3 on [**5-10**]. By discharge, this had resolved; bilirubin on [**6-16**] was total 0.3, direct 0.1. 5. Hematology: He is blood type O positive. He received 2 blood transfusions of packed red blood cells and 2 transfusions of platelets in the first few weeks of life. His last hematocrit on [**2154-5-20**] was 32.2 with a reticulocyte count of 5.9. He is on iron supplementation. 6. Infectious Disease Status: He was started on ampicillin and gentamicin at the time of delivery for sepsis risk factors. He completed a 7-day course of antibiotics for presumed sepsis and blood culture did remain negative. On [**2154-3-13**] he presented with hyperglycemia and thrombocytopenia. A blood culture at that time was positive for methicillin-resistant Staph aureus. At that time, he did have an indwelling PICC catheter and that was removed. He received 1-week treatment of gentamicin and 28 days of vancomycin, and he has remained off antibiotics since the completion of that course which was on [**2154-4-15**]. 7. Neurology: He had head ultrasounds done on day of life #3, day of life #7, day of life #30 and day of life #55, and they all showed no evidence of abnormality. 8. Audiology: A hearing screening was passed bilaterally on [**6-16**]. 9. Ophthalmology: His eyes were examined most recently, on [**2154-5-13**], revealing mature retinal vessels. A follow-up exam is recommended in 9 months. 10. Psychosocial: The parents live together. He has one 5- year-old sibling and the parents speak Portuguese. They have been very involved in the infant's care throughout his NICU stay. He is discharged home with his family. His primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) 40231**] [**Last Name (NamePattern1) 17425**] of [**Hospital6 53408**], ([**Telephone/Fax (1) 72315**]. CARE AND RECOMMENDATIONS AFTER DISCHARGE: Feedings at 24- calories per ounce and breastfeeding to maintain consistent weight gain. MEDICATIONS: 1. Ferrous sulfate (25 mg/mL) 0.3 mL by mouth daily to provide 2 mg/kg/day of elemental iron. IRON AND VITAMIN D SUPPLEMENTATION: 1. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months corrected age. A car seat position screening test will be done prior to discharge. A state newborn screening was sent of [**4-16**] and was within normal limits. He has received the following immunizations: Hepatitis B vaccine #1 and hepatitis B immunoglobulin on [**2154-3-2**]. Hepatitis B vaccine #2 on [**2154-4-1**], and on [**2154-5-3**] Pediarix and Hib and Prevnar. RECOMMENDED IMMUNIZATIONS: 1. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 4 criteria: 1. Born at less than 32 weeks. 2. Born between 32 and 35 weeks with 2 of the following: Daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings. 3. Chronic lung disease. 4. Hemodynamically significant congenital heart disease. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. 3. This infant has not receive Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. FOLLOW-UP APPOINTMENTS: 1. Early Intervention of [**Hospital1 8**] and [**Hospital1 3494**], ([**Telephone/Fax (1) 72316**]. 2. Care Group [**Hospital6 407**], ([**Telephone/Fax (1) 72317**]. 3. Infant follow-up program at [**Hospital3 1810**], ([**Telephone/Fax (1) 72318**]. 4. Follow-up can be considered with pulmonary service due to history of chronic lung diseae (Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], [**Hospital3 1810**]). DISCHARGE DIAGNOSES: 1. Status post prematurity at 29 weeks gestation. 2. Status post perinatal depression. 3. Status post respiratory distress syndrome. 4. Status post hypertension. 5. Status post presumed sepsis. 6. Status post methicillin-resistant Staph aureus bacteremia. 7. Status post phsyiologic hyperbilirubinemia. 8. Status post direct hyperbilirubinemia due to PN cholestasis. 9. Status post chronic lung disease. 10. Status post apnea of prematurity. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2154-6-16**] 02:26:16 T: [**2154-6-16**] 14:27:36 Job#: [**Job Number 72319**]

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icd9cm

[ [ [] ] ]

[ "99.55", "99.21", "96.6" ]

icd9pcs

[ [ [] ] ]

8304, 9028

2135, 5723

7821, 8283

6714, 7797

5757, 5960

332, 2107

5996, 6687

18,643

133,660

16979+56814

Discharge summary

report+addendum

Admission Date: [**2143-4-9**] Discharge Date: [**2143-4-15**] Date of Birth: [**2113-8-11**] Sex: F Service: Inpatient [**Hospital1 139**] Medicine HISTORY OF PRESENT ILLNESS: Patient is a 29-year-old female with a history of recurrent acute pancreatitis approximately once a month since undergoing laparoscopic cholecystectomy [**2142-2-16**], who is presenting now with worsening right upper quadrant pain x4 days. The patient was previously seen by Dr. [**Last Name (STitle) 3315**] and Dr. [**Last Name (STitle) 47768**] in [**2142-5-10**] for similar symptoms. She has had multiple studies including CT and MRCP, which showed pancreatic dilatation in the past. An ERCP was performed on [**2142-5-14**], which demonstrated mild diffuse common bile duct dilatation and a sphincterotomy was performed without resolution of symptoms. The patient was referred for further workup including a small bowel follow-through, which was negative and a CFTR study, which was negative. The patient was recently admitted to [**Hospital 1281**] Hospital for severe abdominal pain, nausea, vomiting, fevers, and chills. During that hospitalization, her amylase and lipase were not elevated. CT scan of the abdomen showed no pancreatic ductal dilatation. Patient was started on pancreatic enzymes and given Carafate. After discharge approximately three weeks ago, the patient has progressively gotten worse with symptoms much worse over the last three days after a large meal. She states that she is unable to tolerate p.o. and has subjective fevers, chills, nausea, vomiting, diarrhea, dizziness, and fatigue. Her pain is characterized as a knife and sharp cramping and it is a [**2149-8-18**] up from her baseline of [**2149-3-14**]. She had bright red blood per rectum approximately four days ago. She has had a cough productive of greenish sputum for which she has been taking Levaquin x1 week. PAST MEDICAL HISTORY: 1. History of dilated common bile duct status post sphincterotomy in [**2142-5-10**], which did not improve her pain. 2. Status post laparoscopic cholecystectomy in [**2142-5-10**]. 3. History of pancreatitis with multiple hospital admissions most recently one month at [**Hospital 1281**] Hospital, complicated by pancreatic ductal dilatation. 4. Hypothyroidism. 5. Anxiety. 6. Fibromyalgia. 7. Migraines. 8. Asthma. 9. Endometriosis diagnosed by exploratory laparotomy. 10. Manic depression. 11. Status post appendectomy. 12. Status post right ovarian cystectomy. 13. Status post knee surgery. 14. History of systolic dysfunction with an EF of 40-45% and echocardiogram performed at [**Hospital 1281**] Hospital in [**2142-5-10**] showing anteroseptal hypokinesis. ALLERGIES: Latex which causes scars. Sulfa and Demerol, which causes hives. Vicodin, codeine, Percocet, and vancomycin. MEDICATIONS: 1. Lithium 300 mg p.o. t.i.d. 2. Wellbutrin 150 mg p.o. b.i.d. 3. Ambien 10 mg p.o. q.h.s. 4. Levaquin x1 week. 5. Klonopin 0.5 mg p.o. prn. 6. Fioricet prn. 7. Ovcon 35 p.o. q.d. 8. Synthroid 0.5 mg p.o. q.d. SOCIAL HISTORY: The patient does not drink and quit smoking 10 years ago, but previously smoked two packs per day. She is currently on [**Social Security Number 47769**]social security due to her disability and is married with one child. FAMILY HISTORY: She has uncles with diabetes, grandparents with cancer, father with cardiovascular accident at age 26, and mother and father with [**Name2 (NI) **]. PHYSICAL EXAM: Vital signs: 97.3, 91/63, 100, 16, and 98% on room air. In general, the patient is awake and alert in no apparent distress, lying in bed. HEENT exam: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Mucous membranes are moist. Chest was clear to auscultation bilaterally. Heart is regular rate and rhythm. Abdominal examination is soft, mild right upper quadrant tenderness to palpation, mild right lower quadrant tenderness with palpation, no rebound, no guarding, and no hepatomegaly, and positive bowel sounds. Rectal exam: Small amount of reddish stool, which is guaiac positive, although the patient is also menstruating and it is difficult to separate whether the bleeding is coming from her stool or from menstruation. Extremities: No lower extremity edema. LABORATORIES ON ADMISSION: Show a white count of 14.6. Her amylase is 60, lipase is 26. Remainder of laboratories are within normal limits. HOSPITAL COURSE: 1. Right upper quadrant pain: The patient had been seen at [**Hospital **] Clinic on the day of admission. They felt that her symptoms were possibly related to pancreatitis and was sent over to the ED for admission. However, on admission her amylase and lipase were within normal limits. From previous hospital records obtained from [**Hospital 1281**] Hospital, it is known that the patient has had prior episodes of pancreatitis, which have presented with elevated amylase and lipase. The patient has had multiple recurrent attacks of acute pancreatitis, although it is unclear whether the patient has such chronic pancreatitis that she has burned out her pancreas and that her amylase and lipase do not elevate even though she has pancreatitis. The patient underwent a right upper quadrant ultrasound to evaluate for biliary duct dilatation. It showed no intra or extrahepatic biliary ductal dilatation. There was mild prominence of the common bile duct with normal tapering. There was no stone or filling defect in the common bile duct. She had normal kidneys, normal spleen, and normal pancreas. Given her recent history of cough, a chest x-ray was obtained to determine if she possibly had a right lower lobe pneumonia, which was producing this right upper quadrant pain. However, chest x-ray showed no evidence of pneumonia. In addition, she had been started on levofloxacin for possible pneumonia. There was also question raised of whether this was cholangitis, however, the patient was afebrile and there was no evidence for biliary duct dilatation on right upper quadrant ultrasound. A GI consult was obtained for assistance with deciphering the cause of her right upper quadrant pain. They recommended MRCP for further elucidation of the patient's biliary duct anatomy. MRCP showed no biliary duct dilation in the liver. Her common bile duct was 8 mm, which was dilated, but yet normal for someone who has undergone cholecystectomy. She had small bilateral pleural effusions. Further hospital records from [**Hospital 1281**] Hospital were also obtained. A CT scan obtained at [**Hospital 1281**] Hospital on [**2143-3-3**] showed prominence of part of the pancreatic tail without acute changes. The appearance was stable. There was diffuse fatty change of the liver. GI felt that this prominence of the pancreatic tail was normal and did not represent pancreatitis. The GI fellow called Dr. [**First Name (STitle) **] [**Name (STitle) 47769**], who had previously been involved in the patient's ERCP. He stated given a completely normal MRCP, there was no indication for sphincterotomy. In addition, she had previously received a sphincterotomy, which should not lead to resolution of her abdominal pain. There was no indication for ERCP. A gastric emptying study was obtained to determine if there was any evidence for gastroparesis, however, gastric emptying was normal. Given thus far extensive negative workup, GI consult recommended further outpatient management. The patient should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] from the [**Hospital 13721**] Clinic or Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) 2161**] for outpatient secretin test. They recommended advancing her diet to low fat low residue as tolerated. The patient should be started on Viokase with meals, when she is taking good p.o. She should also be restarted on her pancreatic enzymes (Lipram three tablets p.o. with meals) when the patient is taking better p.o. She should also be on ranitidine 150 mg p.o. b.i.d., which will help increase the pH in order to activate her pancreatic enzymes. 2. Anemia: The patient was admitted with a hematocrit of 42. She was noted to have started menstruation, and there was a question of whether her positive guaiac stools were due to menstruation or actual blood in her stool. A repeat hematocrit was checked, which was found to be 29 down from 42. The patient then also became hypotensive with a systolic blood pressure in the 60s. She was given a liter of fluid and transfused 2 units of packed red blood cells. Her blood pressure improved, although still running in the high 80s to low 90s. Her hematocrit remained stable throughout the remainder of the hospitalization at 32-34. The patient was restarted back on her oral contraceptives. GI consult felt that her stools were not guaiac positive and that the blood was coming all from menstruation. 3. Shortness of breath: Given her drop in systolic blood pressure down to the 60s, the patient was given a liter of normal saline. She was also continued on maintenance fluid given her NPO status as well as borderline blood pressure. However, on the morning of [**4-11**], the patient desaturated down to 70% on room air. She was noted to have very shallow breathing. The patient also complained of shortness of breath at that time. She was placed on a nonrebreather, which improved her O2 saturation. However, ABG on nonrebreather showed a pH of 7.36, pCO2 of 42, a pO2 of 61, and a bicarb of 25. There was concern that the patient might have had a PE given her multiple risk factors including a mother, who had a blood clot in her leg in her 40's, the patient currently taking oral contraceptives, immobility, and lack of Heparin subq due to concern for possible bleed. It was also noted that the patient had received approximately 5 liters of fluid, and had a prior history of systolic dysfunction with an EF of 40-45% on an echocardiogram from an outside hospital. The patient was sent to the MICU for management. She was continued on nonrebreather, but did not require any intubation. The patient was given 60 mg of Lasix IV to which she diuresed approximately 2 liters. Chest CTA was negative for PE, but did show bilateral lower lobe patchy opacities. The patient did not have any fevers to suggest pneumonia and was not started empirically on antibiotics especially considering that the patient recently completed a one week course of levofloxacin by her PCP for bronchitis. The patient continued to be diuresed and eventually was able to get back on room air. A lower extremity noninvasive showed no DVT. An echocardiogram was ordered, but unfortunately, had not been performed at the time of this dictation. The patient was transferred back to the [**Hospital1 **] for further management. 4. ID: The patient had been started on a week long course of levofloxacin for possible bronchitis. Throat culture obtained from the PCP's office was growing Moraxella catarrhalis. Chest CTA obtained to rule out PE showed infiltrates, which was thought to possibly represent focal areas of consolidation. The patient had low-grade fevers, but a normal white blood count. Given the low likelihood of pneumonia, the patient was not treated with any antibiotics and remained afebrile throughout the remainder of the hospitalization. 5. Hypothyroidism: The patient was continued on a regular home dose of Synthroid. TSH was within normal limits. 6. Psych: The patient was continued on a regular home dose of Wellbutrin as well as lithium. She was also given Klonopin prn. 7. Migraines: The patient has a history of chronic migraines, and was taking Fioricet with increased frequency at home. Given the risk for addiction to Fioricet, the patient was taken off Fioricet during the hospitalization to give her a break. She was treated with Tylenol and Toradol prn for her pain. The remainder of the [**Hospital 228**] hospital course as well as discharge diagnoses and medications will be dictated at a later time. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**] Dictated By:[**Name8 (MD) 4993**] MEDQUIST36 D: [**2143-4-14**] 11:07 T: [**2143-4-17**] 05:48 JOB#: [**Job Number 47770**] Name: [**Known lastname 8816**], [**Known firstname **] Unit No: [**Numeric Identifier 8817**] Admission Date: [**2143-4-9**] Discharge Date: [**2143-4-18**] Date of Birth: [**2113-8-11**] Sex: F Service: [**Hospital1 248**] MEDICINE ADDENDUM: Please refer to the previously dictated discharge summary by Dr. [**Last Name (STitle) **] for a full account of the patient's hospitalization course up until [**2143-4-14**]. HISTORY OF THE PRESENT ILLNESS: Briefly, the patient is a 29-year-old female with a history of recurrent acute pancreatitis, status post cholecystectomy, endometriosis, migraine headaches, hypothyroidism, bipolar disorder who is admitted for right upper quadrant pain and nausea. The patient also had abdominal pain, nausea and vomiting, fevers and chills. The patient had recently been discharged from an outside hospital just prior to presentation. During her hospitalization course, the patient had initially received 2 units of packed red blood cells due to a decrease in hematocrit. Her hematocrit then stabilized. However, with her fluid resuscitation she went into flash pulmonary edema. She was given Lasix and her oxygen saturations normalized without intubation. HOSPITAL COURSE FROM [**2143-4-14**] TO [**2143-4-18**]: CARDIOVASCULAR: The patient underwent an echocardiogram on [**2143-4-16**]. This revealed an ejection fraction of 35-40% with moderate left ventricular wall hypokinesis. An EKG revealed a normal sinus rhythm at 77 beats per minute, no ST or T wave changes. Due to the patient's significant family history for coronary artery disease as well as these abnormal echocardiogram findings, the patient underwent a stress MIBI test on [**2143-4-17**] which was negative for any evidence of ischemia. However, the patient developed shortness of breath and chest pain and thus the procedure was stopped at six minutes. The EKG was within normal limits and the postprocedure ejection fraction was measured at 53%. After much discussion, and with evaluation by cardiology, the patient was then started on an ACE inhibitor, namely Lisinopril 2.5 mg q.d., for her low ejection fraction. The patient was on birth control pills which were initially stopped when the low ejection fraction was discovered. However, these were resumed when the stress MIBI test revealed no ischemic changes. Also, as part of her cardiac workup, the patient had cardiac enzymes which were cycled times three and found to be negative. She had a cholesterol panel drawn which was significant for a high triglyceride of 188. Otherwise, they were within normal limits. Also, iron studies were performed which were within normal limits, [**First Name8 (NamePattern2) **] [**Doctor First Name **] was negative, HIV was negative, and the TSH was found to be normal at 2.5. The patient will have follow-up with cardiology as an outpatient. 2. FLUIDS, ELECTROLYTES, AND NUTRITION/GI: The GI service was consulted regarding the patient's continued abdominal pain. Her amylase and lipase were within normal limits on admission, as were her liver function tests. The patient was started on Bentyl 10 mg and titrated up to 20 mg p.o. one half an hour before meals. This provided minimal relief of her symptoms. Her pain did improve, however, by the time of discharge with morphine sulfate immediate release on an p.r.n. basis as well as Tylenol. She was provided with Boost for nutritional supplementation at discharge. She was continued on her Viokase and Lipram for pancreatic supplementation. She was instructed to follow-up with Dr. [**Last Name (STitle) 8818**]. She was also started on Zofran with significant relief of her nausea. 3. GYNECOLOGIC: The patient is known to have a significant history of endometriosis. Upon phone consultation with her gynecologic provider, [**Name10 (NameIs) **] was determined that she has a mild case of endometriosis diagnosed on laparoscopy two years prior. She was cycled on continuous oral contraceptive pills. Her postpartum course had been uncomplicated, i.e., no evidence of cardiomyopathy or other significant cardiac failure. She was placed back on her birth control pills after a stress MIBI test was negative for ischemic changes and instructed to follow-up with her gynecologist. The patient was instructed to maintain her oral contraceptive pills while taking the Lisinopril due to the potential teratogenic effects if she were to become pregnant. 4. PSYCHIATRY: The patient was continued on her Wellbutrin and Klonopin p.r.n. without any exacerbations of her depression or manifestations of bipolar disorder. 5. ENDOCRINE: The patient was continued on her Synthroid at a regular dose for her history of hypothyroidism. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: 1. Flash pulmonary edema. 2. Low ejection fraction on echocardiogram. 3. Right upper quadrant pain. DISCHARGE MEDICATIONS: 1. Lithium 300 mg p.o. t.i.d. 2. Ambien 2 mg p.o. q.h.s. 3. Clonazepam 0.5 mg p.o. t.i.d. 4. Levothyroxine 50 micrograms p.o. q.d. 5. Tylenol q. four to six hours p.r.n. 6. Colace 100 mg p.o. b.i.d. 7. Wellbutrin 150 mg sustained release p.o. b.i.d. 8. Calcium carbonate 500 mg p.o. b.i.d. 9. Ovcon-35 one tablet p.o. q.d. 10. Amylase, lipase, protease, 30,000, 8,000, 30,000 units one tablet p.o. t.i.d. with meals. 11. Zofran one tablet p.o. q. four to six hours p.r.n. nausea. 11. Lisinopril 2.5 mg p.o. q.d. 12. Morphine sulfate 15 mg immediate release one to two tablets q. four hours p.r.n. 13. Ranitidine one tablet p.o. b.i.d. FOLLOW-UP: 1. The patient is to follow-up with Dr. [**Last Name (STitle) 8818**] in GI on [**2143-4-22**]. 2. Dr. [**Last Name (STitle) **] in Cardiology on [**2143-4-22**]. [**First Name8 (NamePattern2) 46**] [**Doctor First Name 258**], M.D. [**MD Number(2) 8819**] Dictated By:[**Name8 (MD) 3684**] MEDQUIST36 D: [**2143-4-19**] 02:23 T: [**2143-4-19**] 17:42 JOB#: [**Job Number 8820**]

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

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19816

Discharge summary

report

Admission Date: [**2142-8-7**] Discharge Date: [**2142-8-21**] Date of Birth: [**2071-3-30**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Iodine; Iodine Containing Attending:[**First Name3 (LF) 1835**] Chief Complaint: left sided paresis Major Surgical or Invasive Procedure: Posterior fossa resction of brain lesion Right Iintra Jugular Cenral Venous Catheter Arterial line Right parietal mass resection History of Present Illness: 71 F h/o colon ca c/o LLE weakness x3 weeks and LUE weakness x2 days. Pt fell at home on day of admission. Came to ED and was admitted to OMED. Pt reports having HA, N&Vx1, diplopia. Denies dizziness, CP, SOB, BRBPR, difficulty with urination or stool, LE edema. Past Medical History: -Colon CA: T3N2, dx 2 yrs ago, s/p resection ([**5-23**] LN+), mets to liver and brain, last CEA 7.4 -Chemo: last [**11-18**] -HTN -GERD Social History: no tob/EtOH, lives w/ husband Family History: No h/o strokes or cancer. Physical Exam: 98.3 F - 92 - 167/98 - 16 - 97 RA WD/WN F in NAD NC/AT, anicteric sclera, MMM, supple neck RRR, CTA B soft, ND/NT, no HSM warm, no CCE Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Unable to shoulder shrug on left XII: Tongue midline without fasciculations. Motor: Normal bulk and tone on right. Paretic left upper extremity No pronator drift on right, paretic on left LLE: IP 4+ Q 5 AT/[**Last Name (un) 938**]/G=0 Sensation: Intact to light touch. Reflexes: B T Br Pa Ac Right 2+ 2+ Left 2+ 2+ Toes downgoing on left mute on right Coordination: normal on finger-nose-finger on right unable to assess on left Gait: unable to test Pertinent Results: [**2142-8-7**] 12:00PM BLOOD WBC-9.4 RBC-5.33 Hgb-16.2* Hct-47.1 MCV-88 MCH-30.3 MCHC-34.3 RDW-12.9 Plt Ct-289 [**2142-8-9**] 05:20AM BLOOD WBC-13.4* RBC-4.84 Hgb-14.7 Hct-43.1 MCV-89 MCH-30.3 MCHC-34.0 RDW-12.5 Plt Ct-253 [**2142-8-7**] 12:00PM BLOOD Neuts-82.2* Lymphs-13.4* Monos-3.2 Eos-0.4 Baso-0.8 [**2142-8-7**] 12:00PM BLOOD Plt Ct-289 [**2142-8-7**] 12:00PM BLOOD Glucose-148* UreaN-13 Creat-0.8 Na-138 K-3.5 Cl-92* HCO3-31 AnGap-19 [**2142-8-7**] 12:00PM BLOOD LD(LDH)-373* TotBili-0.6 [**2142-8-7**] 12:00PM BLOOD Calcium-10.9* Phos-3.9 Mg-1.9 Iron-76 [**2142-8-7**] 12:00PM BLOOD calTIBC-352 Hapto-209* Ferritn-763* TRF-271 Brief Hospital Course: Pt initally admitted to OMED(medicine service)with left sided weakness and known colon CA for workup, MRI of the head revealed a lesion is centered within the left lateral recess of the fourth ventricle. It exhibits a moderate degree of surrounding edema, with moderate compression of the adjacent medulla and pons and a smaller right parietal ring-enhancing lesion.Neurosurgery consulted on [**2142-8-8**] for surgical option seen and assessed by [**Doctor Last Name **]. After long discusion of benefists and risks of surgery patient and family deceided persue with posterior fossa tumor resection and external ventriculostomy drain on [**2142-8-10**] under general anesthesia.Central line was placed in the OR.Post surgery patient stayed in PACU overnight for hemodynamic monitoring and hourly neuro checks. Patient did well without any intraop complications. Able to extubate in early AM on [**2142-8-11**] and transferred to ICU for management of ventriculostomy drain and post craniotomy care. Patient neuro exam post op was as preop except hemiparesis got better. Patient able to gradually increase her the movementn on the left upper arm, grip got stronger. trasnferred from ICU to neuro-stepdown and removed external ventriculostomy drain on [**8-14**]. After she recovered from first surgery Dr [**Last Name (STitle) **], and Dr [**Last Name (STitle) 4253**] discussed regarding resection of right temporal lesion with patient and family. On [**2142-8-18**] patient underwent right temporal mass resection under general anesthesia.Did well. Continued on dexamethasone tapered to 2mg [**Hospital1 **], until seen in Brain tumor clinic.On [**8-19**] brief episode of bradycardia (HR:30's) reported by RN, pateient denied any chest pain, ECG without any changes, flat cardiac enzimes. Patient eating well, voiding without difficulty after surgery. Physical therapy consulted for safety and rehab needs. Pyhsical thepray recommended to rehab since she still has a residual on the left sided weakness. [**2142-8-21**] replaced for low potassium (2.9), and low Phosphorus. Repeated levels of Na: 132 K: 4.3, P:2.1. Na is bordeline low please check electrolytes tomorrow and fluid restrict 1000ml per day until sodium is better, continue to replace phosphorus. Patient ready to disposition rehab today. Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): can be discontinued when off steroids. 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO QD (). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours): [**2142-8-22**] Take Decadron 2mg twice a day until seen in Brain tumor clinic. Discuss further dosing at the follow up. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: posterior fossa lesion right temporal mass colon ca Discharge Condition: neurologically stable Discharge Instructions: You may return to your regular activities. You may resume your regular diet. Take medications as directed. 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. Do not get the wound wet. Use an occlusive dressing when taking a shower. Retrun to the hospital if you experience: * Fever (>101.5 F) * Severe pain * Vomiting and inability to eat * Drainage or pus from your wound * Other symptoms concerning to you DR[**Doctor Last Name 9034**] office number is [**Telephone/Fax (1) 2992**] for any question or concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] and Dr [**Last Name (STitle) 4253**] in Brain [**Hospital 341**] clinic on [**2142-9-10**] at 1100 in [**Hospital Ward Name 23**] Building [**Location (un) 6749**]. Brain [**Hospital 341**] Clinic phone number [**Telephone/Fax (1) 1844**]. Sture removal [**2142-9-1**]. Is you still in rehab can be removed there if not call Dr[**Name (NI) 9034**] office at [**Telephone/Fax (1) 2992**] for sture removal.appointment Neurology recommends outpatient studies: Carotid duplex,HgbA1c,lipid panel,[**Doctor First Name **],ESR,CRP,Lyme,B12,antiphospholipids, outpatient echo; if symptoms persist would send CSF for cell count, protein, oligoclonal bands. Completed by:[**2142-8-21**]

[ "276.1", "401.9", "198.3", "V10.05", "348.4", "197.7", "275.42", "196.0", "276.8" ]

icd9cm

[ [ [] ] ]

[ "02.2", "38.91", "01.59", "38.93" ]

icd9pcs

[ [ [] ] ]

6436, 6510

2923, 5241

331, 462

6605, 6629

2263, 2900

7361, 8099

981, 1008

5264, 6413

6531, 6584

6653, 7338

1023, 1167

273, 293

490, 757

1419, 2244

1182, 1403

779, 918

934, 965

62,515

155,001

34639

Discharge summary

report

Admission Date: [**2140-1-25**] Discharge Date: [**2140-1-28**] Date of Birth: [**2078-10-9**] Sex: M Service: MEDICINE Allergies: Tenormin Attending:[**First Name3 (LF) 4765**] Chief Complaint: Transferred from outside hospital for chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 61 yo M with CAD, s/p MI and RCA stent [**2130**], LAD stent [**2138**], transferred from OSH for cath for resting angina. CP on [**1-22**] peaked at 7/10, did not resolve with SL nitro, not associated with EKG changes and pt ruled out for MI. Pain consistently described as pressure, diffuse over chest. No associated SOB, N/V, radiation. Occasional diaphoresis. . Today, pt cathed by Dr [**Last Name (STitle) 7047**]. Revealed patent stents. 70-80% PDA lesion crossed, ballooned then lost poition. Reattempt caused nonflow limiting spiral dissection and could not be recrossed to stent. Pt started on integrillin and cath aborted with pt pain free. . On the [**Hospital Unit Name 196**] floor, pt developped angina [**4-25**] with new 2mm STE inferiorly. Pain reduced with to [**2-24**] with SLN x 3. SBP dropped to 70s and pt became lightheaded. Gave about 250 cc bolus and BP normalized. STE mostly resolved with addition of nitro and heparin gtts, cont integrillin. Transferred to CCU for closer monitoring . ROS: Currently slight pain [**1-27**], no nausea, lightheadedness or diaphoresis. No SOB, abd pain. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: RCA and LAD as per HPI 3. OTHER PAST MEDICAL HISTORY: Prostate CA s/p radical prostatectomy Depression prior hernia repairs prior tonsillectomy Social History: Manager at office, married, wife is [**Name2 (NI) 79457**] care nurse at [**Hospital 6451**] Hospital. -Tobacco history: quit 1000, 25-30 py hx. -ETOH: none -Illicit drugs: Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mom with HL/HTN. Physical Exam: VS: T=...BP=118/62 HR=72 RR=27 O2 sat= 97 GENERAL: WDWN obese male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD (to jaw when lying supine) CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Right USB soft systolic murmur. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. Strong distal pulses. Right groin bandaged, no hematoma or tenderness. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: on admission: [**2140-1-25**] 09:41PM WBC-6.3 RBC-4.57* HGB-13.3* HCT-39.4* MCV-86 MCH-29.2 MCHC-33.9 RDW-12.8 [**2140-1-25**] 09:41PM GLUCOSE-94 UREA N-9 CREAT-0.9 SODIUM-141 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 [**2140-1-25**] 09:41PM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.0 [**2140-1-25**] 09:41PM CK(CPK)-181 [**2140-1-25**] 09:41PM CK-MB-3 cTropnT-<0.01 [**2140-1-25**] 09:41PM PT-11.8 PTT-26.3 INR(PT)-1.0 [**2140-1-25**] CCATH: COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated one vessel coronary artery disease. The LMCA had no angigraphically apparent obstruction. The LAD had widely patent stents and no angiographically apparent flow-limiting stenosis. The LCX had a stable 50% stenoiss of the OM1 branch that appeared stable from prior. The RCA stents had a proximal 30% in-stent restenosis. There was a 70-80% stenosis in the mid RPDA. 2. Limited resting hemodynamics revealed normotension. 3. PTCA of the RPDA was performed. Attempts at placing a stent was unsuccessful due to coronary dissection. Final angiography showed normal flow to the distal vessel. (See PTCA comments.) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. PTCA of the RPDA. . On discharge: [**2140-1-28**] 07:30AM BLOOD WBC-5.9 RBC-4.35* Hgb-12.7* Hct-37.1* MCV-85 MCH-29.2 MCHC-34.2 RDW-12.7 Plt Ct-178 [**2140-1-28**] 07:30AM BLOOD Glucose-94 UreaN-13 Creat-1.0 Na-142 K-4.5 Cl-107 HCO3-28 AnGap-12 [**2140-1-28**] 07:30AM BLOOD CK(CPK)-145 [**2140-1-28**] 07:30AM BLOOD CK-MB-4 cTropnT-0.20* [**2140-1-28**] 07:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2 . Cardiac enzymes: [**2140-1-25**] 05:30PM BLOOD CK-MB-3 [**2140-1-25**] 09:41PM BLOOD CK-MB-3 cTropnT-<0.01 [**2140-1-26**] 04:19AM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-0.13* [**2140-1-26**] 11:39AM BLOOD CK-MB-14* MB Indx-5.5 cTropnT-0.32* [**2140-1-26**] 07:47PM BLOOD CK-MB-9 cTropnT-0.23* [**2140-1-26**] 09:42PM BLOOD CK-MB-8 cTropnT-0.23* [**2140-1-27**] 07:15AM BLOOD CK-MB-5 cTropnT-0.14* [**2140-1-28**] 07:30AM BLOOD CK-MB-4 cTropnT-0.20* Brief Hospital Course: Pt is pleasant 61 yo M w/ CAD, prior stents to the LAD and RCA who was transferred to [**Hospital1 18**] for cath after presenting w/ unstable angina at OSH. He was admitted to [**Hospital1 827**] on [**2140-1-25**] and underwent cardiac catheterization. This procedure was complicted by coronary artery dissection, and after the procedure the Pt was monitored in the cardiac intensive care unit. He was subsequently transferred to the floor, and discharged from the hospital on [**2140-1-28**] in good condition, ambulatory, with stable vitals signs, chest pain free, tolerating food and medicines by mouth, and alert and oriented X 3. His brief hospital course was notable for: . #CAD/cardiac Catheterization: Pt underwent scheduled cardiac cath on [**2140-1-25**] and was found to have LCx w/ stable 50% stenosis of OM1, RCA w/ 30% instent restenosis and 70-80% stenosis in the mid-RPDA. PTCA of the RPDA was performed but stents could not be placed as the PTCA was complicated by a dissection of the mid-distal PDA. The procedure was then terminated. The patient was left on integrillin and sent to the inpatient cardiology service. On the floor on [**2140-1-25**] he developed angina [**4-25**] with new 2mm STE inferiorly. Pain reduced to [**2-24**] with SLN x 3. SBP dropped to 70s and pt became lightheaded. Gave about 250 cc bolus and BP normalized. STE mostly resolved with addition of nitro and heparin gtts, cont integrillin. He was transferred to CCU for closer monitoring. . In the CCU on [**1-26**] Imdur was started and nitro gtt was stopped. The patient remained pain free, on integrillin and heparin gtt with a plan to discontinue these medications when his cardiac enzymes trend down. The Pt was transferred to the floor on [**2140-1-26**] where the integrillin and heparin drips were ultimately discontinued as he was chest pain free with downtrending cardiac enzymes. He remained chest pain free, asymptomatic and was discharged on [**2140-1-28**] with outpatient follow-up scheduled with Dr.[**Last Name (STitle) **], the Pt's primary cardiologist. . At the time of discharge, Pt was given prescriptions for Plavix 75 mg qD, and Imdur 30 mg qD. The team considered adding Metoprolol but deffered as Pt had hx of intolerance to beta blockers and was not hypertensive or tacchycarding on the last 48 hours of his hospitalization. . All other chronic medical issues for this patient were stable during this hospitalization. Medications on Admission: ASA 325mg daily Diovan 160mg daily Norvasc 10mg daily Zocor 80mg daily Celexa 40mg daily Trazadone 100mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: angina Secondary: hypertension, hyperlipidemia Discharge Condition: Good, vital signs stable, ambulatory, tolerating food and medicine by mouth, alert and oriented X 3 Discharge Instructions: You were admitted to [**Hospital1 69**] on [**1-25**], for a planned cardiac catheterization. Initially, you had presented to an outside hospital on [**1-22**], with a complaint of chest pain. After evaluation at that hospital it was determined that you were not having a heart attack and you were scheduled for a catheterization here. You underwent the catheterization as scheduled, and the procedure was complicated by dissection of one of your coronary arteries. After this procedure, you were monitored on the cardiology service and in the cardiac intensive care unit. On [**2140-1-28**] you are being discharged to home, in good condition, ambulatory, with stable vitals signs, tolerating food and pills by mouth, and alert and oriented X 3. . The following changes have been made to your outpatient medication regimen: STARTED Clopidogrel 75 mg daily STARTED Isosorbide Mononitrate 30 mg daily . No further changes were made to your outpatient medication regimen. Please continue to take all medications as you had prior this admission. Followup Instructions: You have a follow-up appointment scheduled with your cardiologist Dr. [**Last Name (STitle) **] on [**2140-2-4**] at 9:30 am. Please attend all outpatient follow-up appointments as scheduled.

[ "V10.46", "414.01", "311", "413.9", "401.9", "414.12", "272.4", "V45.82", "412", "414.2" ]

icd9cm

[ [ [] ] ]

[ "37.22", "00.66", "88.56", "00.40" ]

icd9pcs

[ [ [] ] ]

8378, 8384

5070, 7520

318, 343

8484, 8586

2978, 2978

9679, 9874

1973, 2105

7682, 8355

8405, 8463

7546, 7659

4159, 4221

8610, 9656

2120, 2959

1582, 1643

4235, 4600

4617, 5047

230, 280

372, 1488

2992, 4142

1674, 1766

1510, 1562

1782, 1957

61,144

187,912

54889

Discharge summary

report

Admission Date: [**2189-7-8**] Discharge Date: [**2189-7-18**] Date of Birth: [**2137-9-8**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: trauma s/p MVC Major Surgical or Invasive Procedure: [**2189-7-9**] Examination under anesthesia and closed treatment of pelvic ring fracture History of Present Illness: 51 F passenger side of Jeep involved in MVC rollover confused at scene and intubated at OSH for decreased mental status. Past Medical History: none Social History: Involved in accident with her husband, son and son's girlfriend [**Name (NI) **] patient's family drinks alcohol socially Family History: Non-contributory Physical Exam: On admission: HR: 114 BP: 104p Resp: 20 O(2)Sat: 100 Normal HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light midface stable C. collar placed Chest: Left-sided chest wall crepitus rhonchorous breath sounds bilaterally Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Rectal: Decreased rectal tone Extr/Back: +2 DP bilaterally +2 radial pulse bilaterally obvious degloving of the left proximal wrist elbow no active bleeding no obvious deformity of the right upper extremity or bilateral lower extremities Skin: Warm and dry, No rash Neuro: Sedated and not moving any extremities Pertinent Results: [**2189-7-8**] admission imaging CT Head: No evidence of acute intracranial hemorrhage CT Cspine: negative CT OF THE CHEST: Patient is intubated with the endotracheal tube terminating approximately 4 cm above the carina. An NG tube is seen coursing through the esophagus with its tip terminating in the stomach. No mediastinal, axillary, or hilar lymphadenopathy. Substantial subcutaneous emphysema is noted at the left chest tube insertion site. Small left pneumothorax is seen. There are small bilateral pleural effusions. Opacity in the left upper lobe measuring 1.7 x 1.0 cm is identified (2:11) which could be related to contusion. Additional areas of ground-glass opacity (2:27) in the right lung as well as (2:22 and 2:25), potentially sequela of trauma. CT ABDOMEN: Liver, gallbladder, and spleen are unremarkable. Bilateral kidneys enhance and excrete contrast symmetrically. Cyst seen at the superior pole of the left kidney. There is an outpouching of the left renal vein inferiorly concerning for pseudoaneurysm (2:59). It measures 1.5 x 1.8 x 1.3 cm. There is also a small amount of retroperitoneal fluid tracking along the pararenal fat planes bilaterally concerning for hemorrhage. Additionally, the right adrenal gland is enlarged measuring 3.0 x 3.6 cm. The small and large bowel are unremarkable. The pancreas is normal in appearance. CT OF THE PELVIS: There is a trace amount of pelvic free fluid. Bladder and uterus are normal in appearance. No pelvic or inguinal adenopathy is noted. BONES: Multiple fractures are noted including the left-sided superior and inferior pubic rami (2:112), right pubic symphysis. In addition, a fracture of the sacral ala is present on the left (2:89) as well as S1 on the right. Fracture of the left L1, L2, bilateral L3, L4 and right L5 transverse processes identified. In addition, rib fractures of the left first, second, third, fourth, fifth, sixth, seventh, eighth and eleventh left ribs are present as well as the left scapula (2:13) and right second rib. There are posterior and anterolateral left rib fracures at 5 consecutive levels. IMPRESSION: 1. Left renal vein pseudoaneurysm, presumably acute. 2. Enlargement of the right adrenal gland conpatible with hemorrhage in the trauma setting. 3. Retroperitoneal hematoma seen bilaterally, likely due to combination of right adrenal hemorrhage, left renal vein pseudoaneurysm, transverse process fractures. 5. Multiple fractures as described above, noting 5 consecutive levels of posterior and anterolateral fractures on the left raising possibility of flail chest. Lumbar transverse process and left scapular fractures. 4. Left-sided chest tube with small pneumothorax. 5. Left upper lobe pulmonary contusion. [**2189-7-8**] 06:51PM WBC-13.3* RBC-2.54* HGB-8.4* HCT-25.7* MCV-101* MCH-33.2* MCHC-32.7 RDW-13.7 [**2189-7-8**] 06:51PM PLT COUNT-197 [**2189-7-8**] 06:51PM PT-12.2 PTT-26.1 INR(PT)-1.1 [**2189-7-8**] 06:51PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2189-7-8**] 06:51PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2189-7-8**] 06:51PM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE EPI-1 RENAL EPI-<1 [**2189-7-8**] 06:51PM URINE HYALINE-4* [**2189-7-8**] 06:51PM URINE MUCOUS-RARE [**2189-7-8**] 06:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2189-7-8**] 06:51PM LIPASE-148* [**2189-7-8**] 06:51PM UREA N-8 CREAT-0.8 [**2189-7-8**] 07:08PM freeCa-0.90* [**2189-7-8**] 07:08PM HGB-8.7* calcHCT-26 O2 SAT-94 CARBOXYHB-3 MET HGB-0 [**2189-7-8**] 07:08PM GLUCOSE-126* LACTATE-1.2 NA+-135 K+-3.1* CL--115* [**2189-7-8**] 07:08PM PO2-104 PCO2-46* PH-7.21* TOTAL CO2-19* BASE XS--9 COMMENTS-GREEN TOP [**2189-7-8**] 10:06PM TYPE-ART PO2-510* PCO2-38 PH-7.31* TOTAL CO2-20* BASE XS--6 [**2189-7-8**] 11:05PM PLT COUNT-148* [**2189-7-8**] 11:05PM WBC-10.6 RBC-3.76*# HGB-12.0# HCT-36.0# MCV-96 MCH-31.8 MCHC-33.2 RDW-15.8* [**2189-7-8**] 11:05PM CALCIUM-6.6* PHOSPHATE-2.5* MAGNESIUM-1.6 [**2189-7-8**] 11:05PM GLUCOSE-138* UREA N-9 CREAT-0.9 SODIUM-139 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12 Labs on discharge: [**2189-7-17**] 09:00AM BLOOD WBC-12.6* RBC-3.02* Hgb-9.3* Hct-29.2* MCV-97 MCH-30.9 MCHC-31.9 RDW-16.7* Plt Ct-431 [**2189-7-16**] 06:00AM BLOOD Glucose-96 UreaN-13 Creat-0.4 Na-141 K-3.9 Cl-101 HCO3-36* AnGap-8 [**2189-7-16**] 06:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0 [**2189-7-17**] 06:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2189-7-17**] 06:30AM URINE RBC-1 WBC-12* Bacteri-MOD Yeast-NONE Epi-1 TransE-<1 [**2189-7-17**] 06:30AM URINE CastGr-1* [**2189-7-17**] 06:30AM URINE AmorphX-RARE [**2189-7-17**] 06:30AM URINE Mucous-RARE Brief Hospital Course: The patient was admitted to the trauma ICU for close management of her multiple traumatic injuries. She remained intubated until HD#2 and required multiple blood transfusions initially. After extubation she required Bipap for a short period of time as well as some diuresis and her respiratory status improved so she was transferred to the floor on [**2189-7-13**]. Her hospital course is summarized by systems below: Neuro: She had altered mental status upon arrival and was intubated for airway protection. She was extubated on HD2 and was initially delirious and agitated. She required antipsychotics and intermittent benzodiazepines for inital concern for alcohol withdrawal. However, her mental status began to improve and after further questioning of the patient and her family no significant alcohol history was found. Benzos were discontinued at that time and she was started on [**Hospital1 **] seroquel which helped with her agitation. By the time of discharge she was alert with intermittent confusion and lethargy, but calm and cooperative. Her cognitive function was evaluated by occupational therapy who recommended ongoing cognitive therapy after discharge for her traumatic brain injury/concussion. CV: She was initially hypotensive on admission likely due to traumatic shock. She required initially resuscitation with multiple units of RBC's and fluids. Her hemodynamics stablized within 28 hours and she was extubated. While her blood pressure was stable after extubation, she was persistently tachycardia which was thoguht to be due to agitiation/delirium and given that her hematocrit was stable and she had no signs of infection. She was started on lopressor and clonidine and transferred to the floor. On the floor she remained hemodynamically stable and her clonidine was discontinued on [**2189-7-16**]. Pulm: She had extensive bilat rib fractures, a L chest tube was placed for pneumothorax. It was kept to suction. She was initially ventilated and weaned to extubation on HD2. After extubation fluid overload was evident on chest xray and clinically and she was diuresed intermittently with lasix, to which she responded well. When alert, pulmonary toileting and incentive spirometry were encouraged. Her supplemental oxygen was weaned as tolerated and she remained without respiratory compromise. On [**7-17**] she had a chest xray which showed moderate left sided pleural effusion but decrease in size from prior xrays with no evidence of infiltrates or pneumothorax. GI: She was kept NPO, with an OG tube. tube feeds were started while in the ICU. After extubation her diet was advanced as tolerated as her mental status improved. She was also started on a bowel regimen given the administration of narcotics for pain managment. GU: Her UOP was closely monitored as a foley catheter was inserted on admission. Her UOP responded appropriately to initial resuscitation and her foley catheter was removed on [**2189-7-14**] at which time she voided without difficulty. On [**7-16**] a u/a was positive for infection and she was started on 5 days of cipro starting [**7-17**]. MSK: She had extensive pelvic fractures, for which orthopedic surgery took her to the operating room on [**2189-7-9**] to stress the pelvis and check the stability. Her pelvis was determined to be stable (see operative note by Dr. [**Last Name (STitle) 1005**] for details). She was then made weightbearing as tolerated on bilateral lower extremities and mobilized out of bed with physical therapy. She also had multiple spinous process fractures for which no intervention was needed aside from pain control. She had a large degloving injury to her L forearm. Plastic surgery was consulted and did a bedside washout and closure. [**Hospital1 **] wet-to-dry dressing changes were performed thereafter, and f/u was scheduled for after discharge for future management of the injury and possible split thickness skin graft. Prophylaxis: She was placed on pneumoboots and SC heparin for DVT prophylaxis. Social work was involved with the patient's course and her family throughout her hospitalization given the circumstances around the accident. Ms. [**Known lastname **] is currently afebrile with stable vital signs. She is tolerating a regular diet and voiding adequate amounts of urine. She is without respiratory compromise. Her mental status is improving and she remains alert and oriented, with intermittent confusion. She is being discharged to rehab to continue her recovery. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Heparin 5000 UNIT SC TID 3. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain 4. Quetiapine Fumarate 12.5 mg PO BID:PRN agitiation 5. Senna 1 TAB PO BID 6. Docusate Sodium 100 mg PO BID 7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 8. Ipratropium Bromide Neb 1 NEB IH Q6H 9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days 10. Valsartan 320 mg PO DAILY 11. Rosuvastatin Calcium 20 mg PO DAILY 12. Potassium Chloride 40 mEq PO DAILY Hold for K > 13. Hydrochlorothiazide 25 mg PO DAILY Hold for sBP<100 14. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p MVC: 1. Concussion 2. Stable pelvic fractures 3. Multiple rib fractures (Left [**1-11**], 11 rib fractures. Posterior and anterior fractures at 5 levels, Right 2nd rib fracture) 4. Left upper lobe pulmonary hematoma 5. Small left apical pneumothorax 6. L1-L5 transverse process fractures of the spine 7. Left scapula fracture 8. Left renal vein pseudo aneurysm 9. Left forearm degloving injury 10. Acute blood loss anemia 11. Acute respiratory failure 12. Traumatic shock 13. Urinary tract infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after being involved in a motor vehicle accident. You sustained multiple injuries including broken ribs, collapse in your lung, broken pelvis, broken left scapula, breaks in the bony prominences of your spine, and a left forearm "degloving injury". You also sustained a concussion from your accident. You were taken to the operating room by the orthopedic surgeons to evaluate your pelvic fractures which were determined to be stable. You may bear weight as tolerating on your legs. Your left arm wound will require daily dressing changes with a wet to dry dressing. Keep your left arm dry and do not get wound wet. Please follow up with the Plastic surgeons at the appointment scheduled for you regarding further treatment for you left arm wound. You sustained rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. You should take your pain medicine as as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating, take half the dose and notify your physician. [**Name10 (NameIs) **] is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. Symptomatic relief with ice packs or heating pads for short periods may ease the pain. Do NOT smoke. Return to the ED right away for any acute shortness of breath, increased pain or crackling sensation around your rips (crepitus). Narcotic pain medication can cause constipation. Thefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. If your doctor allows, non steriodal anti-inflammatory drugs are very effective in controlling pain (i.e. Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. Followup Instructions: Department: SPINE CENTER When: MONDAY [**2189-7-20**] at 4:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *You will need Xrays prior to this visit so please arrive 15 mins early to [**Hospital Ward Name **] CENTER [**Location (un) 551**] Radiology Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2189-7-30**] at 2:30 PM With; Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage *You will need a chest x-ray prior to this appointment. Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology 30 minutes prior to your appointment. Department: ORTHOPEDICS When: TUESDAY [**2189-8-4**] at 9:20 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2189-8-4**] at 9:40 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "293.0", "958.4", "883.0", "276.69", "881.02", "861.21", "850.5", "285.1", "599.0", "902.42", "868.01", "811.09", "E816.1", "860.0", "807.08", "881.00", "808.2", "805.6", "807.4", "518.51", "805.4" ]

icd9cm

[ [ [] ] ]

[ "79.09", "96.71", "86.59", "38.93" ]

icd9pcs

[ [ [] ] ]

11465, 11535

6305, 10798

316, 407

12083, 12083

1471, 1506

14450, 16076

740, 758

10853, 11442

11556, 12062

10824, 10830

12268, 14427

773, 773

262, 278

5715, 6282

435, 557

1516, 5695

788, 1452

12098, 12244

579, 585

601, 724

72,269

154,757

37862

Discharge summary

report

Admission Date: [**2114-6-28**] Discharge Date: [**2114-7-1**] Date of Birth: [**2040-4-22**] Sex: M Service: NEUROSURGERY Allergies: Mobic / adhesive tape Attending:[**First Name3 (LF) 2724**] Chief Complaint: Lower back pain Major Surgical or Invasive Procedure: [**2114-6-28**] T-11 - L3 Posterior fusion History of Present Illness: This 74-year-old gentleman had previously undergone a retroperitoneal resection and L1 vertebrectomy with anterior reconstruction. The discovery was made of an incidental posterior local recurrence involving the lamina and compressing the dural tube. The anterior construct was solid, however, the facet was completely destroyed. Past Medical History: htn,OA,asthma,benign cyst removed from chest,benign cyst from testicle,s/p fx L elbow. Social History: married Family History: nc Physical Exam: On examination, his motor strength is [**4-5**] in hip flexion, extension, quadriceps, hamstrings, dorsiflexion, and plantar flexion bilaterally. His sensory examination is intact. There is no clonus. His abdominal incision is well healed. discharge exam: he is pleasant and cooperative with mild pain he has paraspinal muscle spasms noted Incision is c/d/i Motor is full Sensory is full Pertinent Results: Thoracic/Lumbar X-ray [**2114-6-29**] - intact hardware. Brief Hospital Course: Patient was admitted to Neurosurgery on [**2114-6-28**] and underwent the above stated procedure. Please review dictated operative report for details. Patient was remained intubated due to significant blood loss and fluid resuscitation. As a result, he was transferred to ICU for further management. He was weaned off of respiratory support throughout the evening and was extubated without incident. POD #1, he had a thoracolumbar x-ray after he ambulated which demonstrated intact hardware. He was transferred to floor in stable condition. Chronic pain was consulted for further recommendations given his poor pain management. Now DOD, patient is afebrile, VSS, and neurologically stable. Patient's pain is well-controlled and the patient is tolerating a good oral diet. Pt's incision is clean, dry and intact without evidence of infection. After clearance per physical therapy, patient was discharged home on [**2114-7-1**] with instructions to return on [**7-8**] for wound check and follow-up with Dr. [**Last Name (STitle) 739**] in 6 weeks with T and L spine AP/lateral films. Medications on Admission: Lactulose Albuterol Pantoprazole Zofran PRN Ativan PRN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO BID (2 times a day). 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 7. oxycodone 10 mg Tablet Extended Release 12 hr Sig: Three (3) Tablet Extended Release 12 hr PO BID (2 times a day) for 2 weeks. Disp:*30 Tablet Extended Release 12 hr(s)* Refills:*0* 8. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) for 2 weeks. Disp:*10 Patch 72 hr(s)* Refills:*0* 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: Renal cell metastatis s/p transpedicular resection of L1 with instrumented reconstruction from T11-L3. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? If you are required to wear one, wear your cervical collar or back brace as instructed. ?????? You may shower briefly without the collar or back brace; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. Followup Instructions: ?????? Please return to the office on [**2114-7-8**] for removal of your steri-strips of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**] to be seen in 6 weeks. ?????? You will need standing AP and lateral x-rays of your T and L spine prior to your appointment. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 13016**] Date/Time:[**2114-7-3**] 2:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2114-7-3**] 2:00 Completed by:[**2114-7-1**]

[ "715.90", "401.9", "198.4", "285.1", "493.90", "327.23", "E870.0", "189.0", "998.2", "197.0", "198.5" ]

icd9cm

[ [ [] ] ]

[ "80.99", "81.05", "81.63", "84.52" ]

icd9pcs

[ [ [] ] ]

3855, 3861

1373, 2467

301, 345

4007, 4007

1292, 1350

5587, 6535

860, 864

2572, 3832

3882, 3986

2493, 2549

4158, 5564

879, 1123

1139, 1273

246, 263

373, 707

4022, 4134

729, 818

834, 844

14,237

146,480

16987

Discharge summary

report

Admission Date: [**2174-12-26**] Discharge Date: [**2175-5-4**] Date of Birth: [**2124-1-12**] Sex: F Service: MEDICINE Allergies: Augmentin / Sulfa (Sulfonamides) / Penicillins / Heparin Agents Attending:[**First Name3 (LF) 6169**] Chief Complaint: Fever Major Surgical or Invasive Procedure: [**2175-3-4**]: Chest Tube Placement Tracheostomy History of Present Illness: The patient is a 50 year old female with multiple myeloma, s/p autologous stem cell transplant, transfusion dependent, presenting with fevers and upper respiratory congestion. The patient was in her usual state of health until two days prior to admission when she began sneezing. She came to the outpatient clinic for platelet and blood transfusions over the weekend. The night prior to admission, she developed a frontal headache, runny nose, nasal congestion, watery and red eyes and had difficulty sleeping. She presented for a scheduled visit at the clinic for platelet transfusion today. She developed a temperature to 100.5 after one unit of blood transfusion. She was also transfused one unit of platelets. The patient was admitted for febrile neutropenia. Past Medical History: Multiple Myeloma -Diagnosed with IgG multiple myeloma in [**2162**]. She was followed expectantly with stable asymptomatic disease -[**9-/2170**] she developed back pain, anemia and an IgG level to the mid 3000 range. Bone marrow biopsy demonstrated approximately 40-50% plasma cellularity. MRI revealed an expansile lesion in the left iliac crest. She was treated with pulse Decadron until [**10/2170**] but developed hypercalcemia. -She received high-dose Cytoxan for stem cell priming. On [**2171-3-8**], she underwent an autologous bone transplant and attained a CR. -[**2-/2173**], she was noted to have a rising IgG level with progressive bone pain -bone marrow biopsy performed in [**4-/2173**] showed 90% plasma cell cellularity with amyloidosis by [**Country 7018**] red staining comprising approximately 40% of the marrow core. -[**2173-5-25**], she was started on protocol 04-130 with Velcade and Revamid--and completed 8 cycles. -[**10/2174**], found to have progressive disease by skeletal survey. She was restarted on Velcade/Revlamid to cytoreduce prior to allogeneic stem cell transplantation. -[**12-12**], secondary to poor response to therapy, changed to Melphalan, Revlamid, Prednisone Social History: Lives with husband and two children (daughter, 14 y/o, and son, 16y/o). Denies significant tobacco use - smoked about [**2-7**] ppd x2-3 years, quit 20y ago. Occasional alcohol, no IVDU. Does not work outside the home. Family History: M - skin cancer M - multiple sclerosis F - Alzheimer's Physical Exam: Admission Physical Exam: VS-100.7, 119, 22, 127/78 Gen-congested, red weeping eyes HEENT-bilateral injection, red eyes right>left, mouth sores on posterior pharynx Neck-supple, nontender Car-tachycardic, no murmur Resp-CTAB Abd-s/nt/nd/nabs no HSM Ext-no edema, ecchymoses over both forearms. . Pertinent Results: . [**2174-12-25**] 09:30AM WBC-0.4* RBC-3.21* HGB-10.0* HCT-27.2* MCV-85 MCH-31.1 MCHC-36.8* RDW-14.5 [**2174-12-25**] 09:30AM GRAN CT-70* [**2174-12-26**] 10:10AM ALT(SGPT)-82* AST(SGOT)-31 LD(LDH)-152 ALK PHOS-123* TOT BILI-1.1 [**2174-12-26**] 10:10AM ALBUMIN-3.6 CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-1.9 [**2174-12-26**] 10:10AM GLUCOSE-145* UREA N-17 CREAT-0.6 SODIUM-133 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-28 ANION GAP-12 [**2174-12-26**] 08:45PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 . [**12-27**]: CT sinus-IMPRESSION: 1. Mucosal thickening of the paranasal sinuses as described above. 2. Preseptal periorbital soft tissue edema and postseptal extraconal fat stranding, most consistent with a cellulitis. . [**12-28**]: MR head/brain: IMPRESSION: 1. Features consistent with invasive fungal sinusitis involving primarily the bilateral ethmoid sinuses and the nasal cavity, which are filled with presumably necrotic non-enhancing material, and extension into and post- septal involvement of the medial aspect of the right orbit. 2. Possible transgression of the cribriform plates with evidence of reactive pachymeningeal enhancement in bifrontal regions. 3. Mucosal thickening in sphenoid sinus and right maxillary fluid, with no definite direct extension of the ethmoid process. 4. No foci of abnormal enhancement noted in the brain. 5. Unremarkable cranial MRA. . [**1-1**]: MR orbit: CONCLUSION: Findings of some concern for progression of fungal infection with secondary mucosal abnormalities as noted above. . [**1-3**] CT sinus: IMPRESSION: Extensive sinus disease with increased density consistent with the history of fungal sinusitis. . [**1-24**] CT sinus: IMPRESSION: Persistent opacification of multiple paranasal sinuses with worsening of opacity within the sphenoid sinus. Although no definite bony erosion is identified, increased subcutaneous air as well as air adjacent to the lamina papyracea on the left raises the question of breach of this structure, as well as transmission of infection via emissary veins, the latter mechanism being invoked to account for the tiny amount of left extraconal gas adjacent to the left lamina papyracea. . [**2175-2-26**] CT sinus: IMPRESSION: Minimally increased aeration of the paranasal sinuses since the prior of [**2175-1-24**]. No definite osseous erosions are present. The subcutaneous air within the left nasolacrimal duct persists. Please correlate clinically. . [**3-1**] MR head/orbit: IMPRESSION: 1. There is marked distention of the left nasolacrimal duct suggesting distal obstruction. Currently, it is distended with fluid. Previously it was air filled. 2. There is extensive opacification of the paranasal sinuses with minimal aeration of the sphenoid sinus, the maxillary sinuses, and up to the ethmoid air cells as seen on the CT from [**2-15**]. The left maxillary sinus air-fluid level is no longer seen. 3. There is bilateral periosteal-based enhancement at the lateral aspect of the lamina papyracea both pre-septal and post-septal, unchanged from [**1-1**] and likely related to the fungal infection. 4. The diffuse pachymeningeal enhancement seen previously has improved. 5. The visualized marrow signal intensity is more abnormal than previously, perhaps related to progression of the patient's myeloma, perhaps related to marrow proliferation secondary to infection. . [**3-4**] CT chest: IMPRESSION: 1. Large layering right-sided pleural effusion with associated compressive atelectasis/ collapse of a large part of the right lower lobe, and portions of the right middle lobe and right upper lobe. There are high-density areas within this pleural effusion dependently concerning for hematoma. 2. Multiple bilateral patchy focal opacities in the lungs with associated ground-glass opacity consistent with an infectious/inflammatory process. Follow-up is recommended to demonstrate resolution. 3. Probable splenomegaly. 4. Small pericardial effusion. 5. Diffuse osseous abnormality consistent with multiple myeloma. . [**3-5**] CT chest: IMPRESSION: 1. Decrease in size of large right-sided pleural effusion with improvement in previously noted atelectasis and collapse. Again high-density area within this pleural effusion is concerning for hematoma. 2. New right-sided pleural drainage tube with small right apical pneumothorax. 3. Multiple patchy focal opacities within the lungs are again identified, likely consistent with an infectious/inflammatory process. Followup is again recommended to ensure resolution. 4. Diffuse osseous abnormality consistent with multiple myeloma. . Brief Hospital Course: 50 year old female with relapsed Stage 3A IgG kappa multiple myeloma, presented with neutropenic fever, hospital course complicated by GI bleed, invasive fungal sinusitis, and transfer to the [**Hospital Unit Name 153**] for pleural effusion/hemothorax then underwent an allo-BMT [**2175-3-14**]. Thereafter she had a PEA cardiac arrest and was transferred to the ICU-east. Hospital course organized by ICU-East events then summary of prolonged hospital course: . # Invasive fungal sinusitis: The patient's upper respiratory symptoms rapidly progressed to right eye swelling and discoloration. ENT evaluation revealed necrotic turbinate and microbiology and pathology preliminary evaluations demonstrated hyphae. She was started on high dose Ambisome and posaconazole for invasive fungal sinusitis. Risk factors for this condition include prolonged neutropenia, steroid-induced hyperglycemia and history of multiple transfusions. She was also changed briefly to GM-CSF [**Hospital1 **] in an effort to improve killing of zygomycetes. A sinus CT on [**1-24**] showed worsening disease. After that, pt seemed to stabilize until mid-[**Month (only) 404**], when pt began to develop worsening swelling around medial epicanthal disease. Serial CT sinus and MRI orbit/head showed continued sinus infection, but no significant bony erosion on posaconazole and ambisome combination therapy. . # Multiple myeloma: The patient's most recent regimen was Melphelan, Revlamid and Prednisone. She was tapered off the Prednisone and her Revlamid was held. She continued to be neutropenic, and was continued on GM-CSF. She was platelet transfusion dependent. Last bone marrow showed 95-100% plasma cells with amyloid. Given one dose IVIG. On [**1-5**] she was started on cytoxan/prednisone chemotherapy. She remained pan-cytopenic after therapy and continued to be transfusion dependant. Neupogen and epogen did little to increase her counts. On [**2175-1-25**] she was started on Doxil/velcade therapy as she has not received doxil previously. On [**2175-2-10**], pt remained neutropenic on G-CSF, repeat bone marrow biopsy done, appears that marrow remains fibrotic with collagen deposition, not nearly as cellular as previous marrow. Decided to proceed forward with bone marrow transplant anticipating brother's arrival [**2175-3-1**]. On [**3-1**]- repeat MRI sinus/orbit with marked distention of L nasolacrimal duct and continued extensive sinus disease, but no extensive bony erosion, pt decided to continue with BMT. However, in prep for BMT on [**2175-3-4**], pt developed hemothorax [**3-10**] right sublavian central line placement and was sent to the [**Hospital Unit Name 153**] ([**3-5**]). This resolved and she successfully underwent BMT on [**2175-3-14**]. Continued cyclosporine for GVH ppx . #. Respiratory failure. Increased work of breathing led to re-intubation. Largest contributor was pneumonia. Also could be chest wall weight given edema, ? aspiration due to vomiting. underwent tracheostomy on [**5-1**]. . # Pseudomonal pneumonia: Had pseudomonas on sputum culture from [**4-22**]. Sensitivities indicated resistance to meropenem and cipro. continued on ceftaz and tobramycin. tobra was dosed by level. . #. Enterococcal and coag-neg staph bacteremia. Blood cultures positive from [**4-18**] showing enterococcus sensitive to vancomycin. Has since had lines changed (new R IJ; R SC, R a line, L PICC d/c'd on [**4-20**]). Cath tip from A line grew coag negative staph but PICC/CVL cath tip cultures negative. Continued vancomycin. Dose by vanc troughs (goal 15-20) . #. Altered MS: Previous work-up negative, including MRI with no parenchymal involvement of mucor, HSV-6 negative, HSV 1,2 negative from CSF. Head CT [**4-3**] negative. EEG with diffuse encephalopathy, no epileptiform features. Continued supportive care . #. Renal Failure: Potentially due to over-diuresis but patient is grossly edematous and total body overloaded. Previous meds thought to potentially be related are gancyclovir and acyclovir which were d/c'd without much improvement. Continued cyclosporin gtt (dosed by level as tends to be renal toxic). other meds too were renally dosed. . #. Hypercalcemia:Possibly related to malignancy versus medication additions versus side effect of renal failure. Calcium slowly improved. Gave pamidronate 60 mg IV X 1 on [**4-13**], usually dosed monthly . #. Hyperphosphatemia: resolved. Continued sevelamer. Likely secondary to renal insufficiency. . #. Pancytopenia: counts improved after restarting GCSF. Discontinued acyclovir/ aztreonam as dropping counts may have been related to meds. Continued to transfuse for HCT >25, PLT >10. Transfused Plt>50 for active bleeding. . # Cardiac Arrest [**4-3**]: PEA vs asystole. Most likely due to hypoxia due to supraglottis/vocal cord occlusion from black debris/clots as noted by anesthesia during intubation vs worsening CHF. No h/o CAD to suggest ACS. Difficult to determine the length of her arrest; was found asystolic with return of rhythm in 3 minutes, but unknown how long she was down prior to that. Initial concerns of anoxic brain injury were alleviated when her mental status improved significantly - she was awake and alert and conversing, albeit slowly. . # Leg blisters: Has blistering along inner thighs bilaterally. Improved. Etiology unclear-potentially contact from foley tape? On zinc/vitamin C for wound healing. . # Hyperglycemia: Continued ISS, titrated to goal 80-150 . # FEN: TPN. Replete lytes prn. . # PPX: PPI, no heparin as plts are low, hold bowel regimen for now as some diarrhea, pneumoboots. . # Code: DNR/I . # Communication: Husband [**Telephone/Fax (1) 47788**] . Medications on Admission: Famvir 500 mg po bid Levoquin 500 mg po qd Prednisone 40 mg po qd X1 (today) Prednisone 20 mg po qd X 1 (in am) Compazine 10 mg po q6 prn Ativan 0.5 mg po q6 prn Tylenol prn Discharge Medications: none Discharge Disposition: Home with Service Discharge Diagnosis: Multiple Myeloma Invasive Fungal Sinusitis GI bleed Hemothorax Renal Insufficiency Discharge Condition: pt died Discharge Instructions: none Followup Instructions: none Completed by:[**2175-6-2**]

[ "288.00", "380.15", "E930.8", "117.9", "285.22", "428.0", "585.9", "999.8", "916.2", "535.01", "511.8", "584.9", "560.1", "512.1", "349.82", "482.1", "785.52", "038.0", "427.5", "518.81", "599.0", "693.0", "203.00", "995.92", "E928.9", "427.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "44.43", "03.31", "00.17", "38.91", "99.15", "00.91", "22.11", "38.93", "88.73", "31.1", "41.05", "33.24", "99.60", "34.04", "34.91", "41.31", "99.14", "99.25", "99.05", "99.04", "99.28" ]

icd9pcs

[ [ [] ] ]

13610, 13629

7671, 8118

330, 382

13756, 13765

3055, 7648

13818, 13852

2669, 2725

13581, 13587

13650, 13735

13382, 13558

8135, 13356

13789, 13795

2765, 3036

285, 292

410, 1178

1200, 2413

2429, 2653

27,347

146,376

6716

Discharge summary

report

Admission Date: [**2176-3-10**] Discharge Date: [**2176-3-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: lethargy, N/V Major Surgical or Invasive Procedure: none History of Present Illness: 87 yo F with a history of hypertension and recent weight loss, who was brought by EMS to the [**Hospital1 18**] ED after her sister called having diarrhea with black stools, and some blood, and having body aches; "not able to drink, too weak to speak." . Ms [**Known lastname 13060**] is an uncertain and likely quite unreliable historian, but does affirm that she has been feeling poorly recently and that she has had some nausea and vomiting. She denies any shortness of breath or chest pain; she denies current abdominal pain; she denies current fever or chills and does not remember any febrile symptoms recently. . In the ED, her vitals were initially T 99, HR 87, BP 151/68, O2 sat 96% but within a half hour of arrival her T was 103, then 100.9 one hour after that. A CXR was significant for a patchy opacity in the R middle and lower lobes; UA was negative; had "brown stool, guiaic +++". She was given levaquin 750 mg IV X 1, CTX 1 gm X 1, and flagyl 500 mg IV X 1. . . Past Medical History: 1. Hypertension 2. Guaiac positive stool - pt has been refusing colonoscopy 3. Weight loss- PCP concerned about an underlying malignancy but pt did not desire extensive workup. 4. Numbness in feet- Concern for peripheral neuropathy. 5. S/P removal of melanoma- Pt is unclear regarding the date of this removal. 6. S/P umbilical hernia repair 7. Arthritis 8. S/P multiple falls 9. Macular degeneration . Social History: Pt is a retired middle school English teacher. She lives with her sister [**Name (NI) **], and has a regular caretaker, [**Name (NI) **], who helps her with ADLs including getting dressed. No ETOH, tobacco, or drugs. Her PCP is [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. Pt reaffirms with us today that she wishes to be DNR/DNI, which is also reflected in past notes. Family History: NC Physical Exam: BP 168/62 HR 88 RR 27 O2 sat 98% 2L NC Gen - Thin/cachectic elderly woman, staring up at ceiling HEENT - Dry mucus membranes and tongue, no lesions of OP Neck - No JVP appreciated CV - RRR, low-pitched systolic murmur heard best at L sternal border Lungs - +egophony, diminished breath sounds in middle of R lung field, crackles at bases bilaterally, R>L Abd - Non-tender, non-distended, some masses ?stool Ext - No edema, WWP Neuro - Oriented to place but not time; tangential, vague, confabulates some answers; pleasant Skin - Multiple keratoses, most strikingly on lower legs bilaterally Pertinent Results: [**2176-3-19**] 07:40AM BLOOD WBC-7.6 RBC-3.11* Hgb-10.3* Hct-29.6* MCV-95 MCH-33.1* MCHC-34.8 RDW-13.2 Plt Ct-472* [**2176-3-17**] 08:12AM BLOOD WBC-9.6 RBC-3.61* Hgb-12.1 Hct-34.6* MCV-96 MCH-33.5* MCHC-34.9 RDW-13.0 Plt Ct-456* [**2176-3-12**] 07:05AM BLOOD WBC-15.4* RBC-3.34* Hgb-11.5* Hct-35.0* MCV-97 MCH-34.4* MCHC-35.5* RDW-13.5 Plt Ct-203 [**2176-3-10**] 01:30PM BLOOD WBC-13.5*# RBC-4.16* Hgb-14.8 Hct-42.1 MCV-94 MCH-35.7* MCHC-35.1* RDW-14.1 Plt Ct-245 [**2176-3-17**] 08:12AM BLOOD Neuts-80.3* Bands-0 Lymphs-14.1* Monos-2.8 Eos-2.6 Baso-0.1 [**2176-3-19**] 07:40AM BLOOD Plt Ct-472* [**2176-3-19**] 07:40AM BLOOD Glucose-105 UreaN-15 Creat-0.6 Na-140 K-4.2 Cl-101 HCO3-34* AnGap-9 [**2176-3-11**] 03:54AM BLOOD ALT-10 AST-20 LD(LDH)-272* AlkPhos-49 Amylase-54 TotBili-0.6 [**2176-3-11**] 03:54AM BLOOD Lipase-12 [**2176-3-19**] 07:40AM BLOOD Phos-3.2 Mg-2.0 [**2176-3-10**] 01:57PM BLOOD Lactate-2.7* [**2176-3-11**] 11:37AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013 [**2176-3-11**] 11:37AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2176-3-11**] 11:37AM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 [**2176-3-11**] 11:37AM URINE CastGr-3* [**2176-3-10**] 1:30 pm BLOOD CULTURE **FINAL REPORT [**2176-3-13**]** Blood Culture, Routine (Final [**2176-3-13**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. 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 PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2176-3-11**]): REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 25581**], R.N. ON [**2176-3-11**] AT 0400. GRAM NEGATIVE RODS. VIDEO FLUOROSCOPIC SWALLOWING EVALUATION: In collaboration with the speech and pathology department, an oropharyngeal swallowing evaluation was performed. Barium of various consistencies was administered orally to the patient under continuous video fluoroscopy. ORAL PHASE: There is moderate reduction in bolus formation, bolus control, and anterior to posterior tongue movement. Premature spillover was noted. Moderate residue remained in the oral cavity following the swallow. PHARYNGEAL PHASE: There is moderate delay of the pharyngeal swallow. Palatal elevation and upper esophageal sphincter relaxation were grossly within normal limits. There is mild reduction in laryngeal elevation, laryngeal valve closure and absence of the epiglottic deflection. Mild amount of residue remained within the valleculae and piriform sinuses. ASPIRATION/PENETRATION: There was no penetration or aspiration seen on the examination. IMPRESSION: Moderate oral and mild-to-moderate pharyngeal dysphagia. No evidence of aspiration. For further details, please refer to the speech and pathology report from the same day. AP CHEST RADIOGRAPH: Lungs demonstrate patchy opacity within the right mid and lower lung zone. The heart, mediastinum, and hila are within normal limits. No pneumothorax or pleural effusion is detected. The aorta shows atherosclerotic calcification. A left apical granuloma is stable. IMPRESSION: Patchy opacity within the right mid and lower lung zones consistent with pneumonia or aspiration. Brief Hospital Course: PNEUMONIA - treated with IV antibiotics and then with po levofloxacin to finish a 14 days course. Swallow eval as above. Aspiration precautions and pulmonary toilet/ O2 as needed recommended. E coli bacteremia - pansensitive and treated with levofloxacin. Repeat blood cultures negative. Delirium - likely from the above issues. Improved with Rx of infections. Per sister close to baseline at discharge. GUIAIC-POSITIVE STOOL: History of guiaic positive stool for which patient has refused work-up, and guiaic positive stool now, in setting of weight loss. Defer work up to PCP. Hypertension: Initially meds held and restarted prior to discharge (Toprol XL, amlodipine). Dose of toprol increased. Malnutrition: nutrition followed pt for caloric count and supplements were added. po intake was inconsistent likely due to delirium. Should get [**2-13**] assistance with meals and nutrition consult recommended at rehab to ensure patient has appropriate po intake. PT evaluated patient and recommended rehab. CODE: DNR/DNI (confirmed with patient, noted in past notes) Sister [**Name (NI) **] aware of transfer to rehab. Medications on Admission: ocuvite tab, 2 tablets PO BID acetaminophen-codeine 300-30, 1 tab PO q4-6hrs PRN pain amoxicillin 500 mg, 4 tabs PO before any dental procedure hydrocortisone 2.5% rectal cream [**Hospital1 **] norvasc 10 mg PO daily toprol XL 50 mg PO daily Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Tablet(s) 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Amoxicillin 500 mg Tablet Sig: Four (4) Tablet PO prior to dental procedure. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Ocuvite Oral 8. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. 9. Metoprolol XL (Toprol XL) 150 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: multilobar pneumonia E coli septicemia delirium hypertension, essential, benign Malnutrition Discharge Condition: stable Discharge Instructions: You were admitted with multilobar PNA that required initial ICU care. You were also found to have blood infection. Both will require that you complete the prescribed course of antibiotics. Physical theray has recommended rehab for further Physical therapy as we discussed. Followup Instructions: You will need to follow up with Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 250**] within 1 -2 weeks of discharge from rehab. The physicians at rehab will care for your further medical needs.

[ "578.1", "263.9", "276.8", "401.9", "486", "995.91", "780.09", "038.42" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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276, 283

8978, 8987

2771, 6583

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7758, 8001

9011, 9286

2159, 2752

223, 238

311, 1292

1314, 1720

1736, 2124

636

142,160

443

Discharge summary

report

Admission Date: [**2133-9-3**] Discharge Date: [**2133-9-13**] Service: MEDICINE Allergies: Codeine / Penicillins Attending:[**First Name3 (LF) 1974**] Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Bone biopsy--left humerus History of Present Illness: 82M with h/o prostate CA who p/w increasing pain of left arm. Sveral months PTA, pt hit his arm. He went to local ER and was told he had a mild fracture, treated with sling and pain control. however, the pain worsened over the last few months. Pt came in to [**Hospital1 18**] for further evaluation. In [**Name (NI) **], pt noted to have displaced left humerus fracture, likely pathologic. ROS of notable for increased LE edema. Past Medical History: Prostate CA s/p resection, unknown status CAD s/p CABG x 4 in [**2123**] with no further caths per family Vfib arrest, s/p ICD placement with 2 subsequent firings CHF, unknown EF%, followed by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 3236**] at [**Hospital1 3793**] Hospital (cards) Afib s/p pacemaker hypercholesterolemia glaucoma Social History: Lives at home with son and daughter heavily involved in care. Tob: 1 ppd x many years, quit 6y ago Etoh: none Illicits: none Family History: non contributory Physical Exam: T=99.0, BP=100/70, HR=82 irreg, RR=20, O2=98% 3LNC, 88% RA elderly man lying in bed, in NAD PERRL <EOMI, MMM, OP clear JVP 10cm, no LAD irreg irreg, no m/r/g lungs rales lower [**12-8**] b/l Abd benign EXT: LUE with limited ROM, 2+ radial pulses b/l Pertinent Results: [**2133-9-3**] 07:00PM WBC-9.8 RBC-3.98* HGB-13.7* HCT-40.7 MCV-102* MCH-34.4* MCHC-33.6 RDW-13.4 [**2133-9-3**] 07:00PM NEUTS-79.8* LYMPHS-11.7* MONOS-6.3 EOS-0.1 BASOS-2.1* [**2133-9-3**] 07:00PM PLT COUNT-240 [**2133-9-3**] 07:00PM PT-19.3* PTT-29.5 INR(PT)-1.8* [**2133-9-3**] 07:00PM CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.1 [**2133-9-3**] 07:00PM CRP-191.6* PSA-<0.1 LEFT ARM FILM: Pathologic fracture of the proximal humerus as described above. A large lytic lesion is present involving the humeral head and proximal humerus. This is concerning for metastatic disease. Taking into account the recent chest x-ray that did not demonstrate evidence of malignancy, this is concerning for metastasis from a renal cell carcinoma and abdominal CT is recommended for further evaluation. CHEST CT: 1. 2.6 x 2.4 cm left lower lobe lesion, likely lung carcinoma. This lesion would be amenable to a CT-guided biopsy if clinically desired. 2. Extensive pleural thickening and calcification likely from asbestos exposure. 3. Rounded pulmonary nodule in the right upper lobe, suspicious for metastasis. 4. Bony destruction of T9 and T10 vertebrae with tumor extension into the bony spinal canal. There is a high risk for compression fracture in the future given the extent of these lesions. 5. Two suspicious enhancing areas within the right lobe of the liver raise the question of metastases, though the appearance is not typical. 6. Likely bilateral renal cysts, incompletely characterized. 7. Mild aneurysmal dilatation of the distal aspect of the abdominal aorta. Left common iliac artery aneurysm. Roughly 50% stenosis of the right superficial femoral artery. Bilateral atrial enlargement. Brief Hospital Course: 1) RESP: Initially, pt admitted to floor for workup of malignancy. However, on day#1, he developed increasing agitation. He was not clearing secretions and was intubated for airway protection. He was then transferred to [**Hospital Unit Name 153**]. Pt was in ICU for about 6 days. As his agitation and myoclonuse improved, he was extubated, and then transferred back to floor. . 2) HUMERUS FRACTURE: AS this represented likely pathologic fracture, a needle biopsy was done. Pt also had malignancy w/u with torso CT. This showed lung masses and abdominal mets. The pathology from humerus revealed likely metastatic lung carcinoma. Pt was seen by ortho onc but was not a surgical candidate. . 3) ONC: Pt was seen by onc, rad onc, neurosurg, and ortho onc regarding likely lung CA with mets to bone including spine. However, based on discussions with family, pt was made CMO given very poor prognosis. A few days after this change, on [**9-13**], the pt was found unresponsive and pronounced dead at 7:15AM. The family was called and declined autopsy. . 4) CV: His CAD, CHF, afib were not active issues during this hospitalization. EP service was consulted to turn off ICD given pt made CMO, however, this was not completed as there was concern that the family did not want to tell pt this was to be done. Medications on Admission: Coumadin 1.25mg per day, 6d/week; 2.5mg per day, 1d/week Colace 100mg [**Hospital1 **] Toprol XL 25mg per day Lasix 120mg po qday (recent increase from 80mg per day) Lescol XL (statin) 80mg qd Losartan 25mg qd Xalatan 1 drop OU QHS Tylenol 1000mg tid prn Morphine elixir 10mg/5ml, [**12-10**] teaspoon q3h prn:pain in LUE Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Metastatic lung cancer Pathologic left humurous fracture Discharge Condition: Expired Discharge Instructions: none. Followup Instructions: none.

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icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "00.17", "92.29", "77.42" ]

icd9pcs

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297, 732

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1136, 1263

26,013

120,646

46947

Discharge summary

report

Admission Date: [**2112-5-10**] Discharge Date: [**2112-5-19**] Date of Birth: [**2038-1-21**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1055**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Pericardial window History of Present Illness: 74 y/o F w/ PMH of ?Sarcoidosis[home O2], CAD s/p CABG (EF=60-70%), HCV Cirrhosis s/p liver tx, DM w/ CRI, HTN and stable pericardial effusion who presents from clinic with worsening SOB and LE edema times 2 days. Additionally reports 20 sec episode of fleeting CP. [**Company 191**] VS -> 148/70, 54, 22 99% 4LNC. ECG without acute changes. Pt referred to ED for further eval. . Pt states that since her discharge in [**Month (only) 547**] her breathing has slowly improved and actuallly feeling well last week. Over the past 2 days progressive worseding of DOE. At times unable to ambulate across the room. SOB improved with O2, but has had a higher requirement these past few days. No cough. No sputum production. No URI Sx. No CP with exertion. No F/C/S. No abd pain, N/V/D. Slight worsening LE edema. No recent travel or sick contacts. [**Name (NI) **] long car/train/plane rides, no extended periods of being bedbound. Past Medical History: - CAD/CABG [**2108**] - Dr. [**Last Name (STitle) **] - Hep C/Liver Tx [**2105**] - no s/s rejection. On immunosuppression - DM/CRI - HTN - HYPERCHOL - Chronic Lung Dz: Per Dr. [**Last Name (STitle) **] Note [**2112-2-22**]: " normal FEV1 and FVC at 113% of predicted. Her last diffusing capacity was measured two years ago at 42% of predicted. Recent chest CT scan showed stable mediastinal lymphadenopathy, a moderate pericardial effusion, and apical emphysema. - mild PulmHTN - emphysema - sarcoidosis Social History: Completes adl's at baseline (using 3L NC oxygen) Lives in [**Hospital1 3597**] by herself. Stopped smoking 5-6 years ago before transplant, but smoked for 40 years. No alcohol. No drugs. Does have home o2. HCP is daughter [**Name (NI) 402**] [**Last Name (NamePattern1) **] in [**Name (NI) 3146**], MA. Family History: dm, heart failure and colon cancer on mother's side. Physical Exam: Gen: lying comfortably in bed in nad, speaking in complete sentences Heent: eomi, perrl, op clear, mmm, no JVD Chest/Lungs: CTAB with rare r-basilar. No wheeze Cardiac: rrr, nl s1/s2, no murmur or rub. Pulsus < 5 Abdomen: soft, nt, nd , NABS Ext: WWP, no c/c/e, 1+ pulses Skin: no rashes Neuro: AO3, CNs intact, appropriate, non-focal stength/sensation Pertinent Results: D-Dimer: [**2106**] 139 110 25 / 124 AGap=15 ------------- 5.0 19 1.5 \ CK: 74 MB: Notdone Trop-*T*: <0.01 Ca: 9.3 Mg: 2.2 P: 3.7 proBNP: 3575 95 5.3 \ 13.1 / 255 ------- 37.8 N:60.1 L:30.2 M:6.6 E:2.2 Bas:0.9 . [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with elevated d-dimer. REASON FOR THIS EXAMINATION: Please use visipique- d/w radiology resident; r/o pe CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Elevated D-dimer. COMPARISON: [**2112-3-22**]. TECHNIQUE: Contrast-enhanced axial CT imaging of the chest with multiplanar reformats was reviewed. CTA CHEST WITH CONTRAST: No filling defects are present within the pulmonary arteries. The aorta and great vessels of the mediastinum are unchanged. There is a moderate-to-large pericardial effusion that is unchanged in size. Enlarged mediastinal lymph nodes are unchanged. Previous bypass surgery and right RCA and LAD stents are present. There are emphysematous changes of the lungs and small bibasilar atelectasis and bilateral pleural plaques. Previously identified nodules are not as well discerned on today's study. The trachea and airways are patent to the subsegmental level. The upper images of the abdomen demonstrate previous liver transplant and marked splenomegaly. IMPRESSION: 1. No evidence for PE. 2. Chronic pericardial effusion, moderate-to-large in size. . MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.3 cm Left Ventricle - Fractional Shortening: 0.31 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% (nl >=55%) Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm) Aorta - Ascending: 2.7 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.43 Mitral Valve - E Wave Deceleration Time: 178 msec TR Gradient (+ RA = PASP): *44 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s) Pericardium - Effusion Size: 2.5 cm INTERPRETATION: Findings: This study was compared to the prior study of [**2112-3-24**]. LEFT ATRIUM: Mild LA enlargement. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. TVI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic function. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[**12-7**]+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. Significant PR. PERICARDIUM: Moderate to large pericardial effusion. Effusion echo dense, c/w blood, inflammation or other cellular elements. Effusion is loculated. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Sgnificant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a moderate to large sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. The effusion appears loculated. In the subcostal view, the RV appears compressed - this suggests either localized tamponade or technical artifact. Overt echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures/pulmonary hypertension. Compared with the prior study (images reviewed) of [**2112-3-24**], the effusion appears similar in size. The apopearance of compression of the distal RV free wall in the subcostal view appears more prominent. IMPRESSION: Large, loculated pericardial effusion. Pulmonary hypertension. Possible, localized tamponade. . [**2112-5-13**] 8:45 am FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [**2112-5-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2112-5-16**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2112-5-19**]): NO GROWTH. ACID FAST SMEAR (Final [**2112-5-16**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2112-5-13**]): NO FUNGAL ELEMENTS SEEN. . Surgical report: INDICATIONS FOR SURGERY: [**First Name8 (NamePattern2) **] [**Known lastname 99571**] is a 74-year-old woman who is status post a liver transplant as well as coronary artery bypass graft in the past several years. She has an Apparently loculated and by echo characteristics complex pericardial effusion which may have some mild tamponade physiology. PROCEDURE: The patient was positioned supine and then prepped and draped in the usual sterile fashion. An 8 cm incision centered around the xiphoid was made in the midline of the abdomen. We used electrocautery to divide the subcutaneous tissue and fascia. I needed then to remove some of the fascia closure stitches from the previous [**First Name8 (NamePattern2) 8314**] [**Last Name (NamePattern1) **] abdominal incision from her liver transplant. I carried the skin incision up over the xiphoid somewhat for retraction purposes. I then entered the space extraperitoneally just underneath the xiphoid. With blunt dissection, the diaphragmatic muscles slips off the anterior chest wall. I was able to visualize the pericardium. This was grasped with a [**Doctor Last Name **] clamp and then incised carefully with the knife so as not to injure any underlying grafts or right ventricle. Upon entry into the chest, a very clear yellow fluid was evacuated. A portion of this was sent for microbiology and the remainder for cytology. In addition, a 2x2 cm window was cut out of the inferior pericardium and this was sent to microbiology as well as pathology. Then, I tried to develop a space in the peritoneal cavity for this fluid to drain into. Because of the massive previous adhesions from the liver transplant, it was not possible to have free flowing space into the peritoneal cavity. However, we were able to create a suitable drainage pocket in the peritoneum around the left lateral segment of the transplanted liver and more laterally towards the spleen. A single 28 French angled chest tube was placed into the hole in the pericardium and secured with silk sutures. Then, a Surgicel gauze was placed on the raw surface of the transplanted liver where there was some mild oozing from the liver capsule. Hemostasis otherwise was quite good at the completion of the procedure. We then closed the fascia with running #1 Prolene with a couple interspersed buried retention sutures on the fascia given her immunosuppression. The skin was closed with staples. I was present and scrubbed for the entire procedure. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 25080**] Brief Hospital Course: This patient was transfered to my service and accidentally discharged before I saw her. I did not care for this patient at all. After I learned of her discharge, I spoke with her nurse and was told she was doing very well and that she had no concerns. I reviewed her vitals and they were all normal. She has close follow up scheduled in near future. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 74 F on home O2 for sarcoidosis as well has h/o stable pericardial effusion and s/p liver Tx who presented with 2 days of worsening SOB after having been off oxygen for one week. Patient's dyspnea was likely multifactorial as patient has known interstitial lung disease, known pericardial effusion, and mild pulmonary hypertension. Pt did note LE swelling, which has resolved overnight, as well as small bilateral pleural effusions noted on chest CT, which prompted an echo to be performed, which showed signs of early tamponade. Cardiology was consulted, and recommended CT surgery evaluation for pericardial window. Given that patient's symptoms were improved after prior percardiocentesis, patient was taken to the OR for pericardial window. Per report, the pericardial window was complicated by surgical adhesions from prior liver transplant. The window was performed with both cardiac and thoracic surgery, and window was placed into the peritoneal cavity. Patient had an uncomplicated postoperative course, with chest tube removal and transfer to the floor two days prior to discharge. Her SOB improved significantly after window placement. She also had repeat PFTs performed prior to her pericardial window. This showed no significant change from baseline. A pericardial biopsy was performed, and initial pathology showed reactive changes. She had fluid cultures performed as well, which showed no growth to date. Patient did not have a pulsus on exam prior to or after her surgery, and she remained hemodynamically stable throughout. Her oxygen requirement at discharge was her baseline of 2L. . Patient had three negative sets of cardiac enzymes. Her echo showed no new RWMA and a preserved EF. She was continued on her metoprolol, atorvastatin, and aspirin. Patient was placed on insulin sliding scale for control of her diabetes. She was followed by liver transplant service. Her Prograf levels were stable, and she was continued on her Bactrim per home dose. She was on pantoprazole and heparin SC for prophylaxis. She was seen by physical therapy who recommended discharge home. Because of patient's home situation with mold on her ceiling, she was felt unable to go home. She was seen by social work, and after discussion, patient made the decision to go to her daughter's house temporarily. She was discharged home with services. Medications on Admission: 1. Tacrolimus 1 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. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). sliding scale insulin as needed Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: 1. Pericardial effusion 2. Sarcoidosis Discharge Condition: Stable Discharge Instructions: If you develop increased shortness of breath, fever, chills, chest pain, nausea, or vomiting, call your primary care doctor or go to the emergency room. You were diagnosed with a pericardial effusion. This was drained. You should follow up in three weeks to have your staples removed. Followup Instructions: 1. Please follow up with your PCP. [**Name Initial (NameIs) 2169**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-6-21**] 1:30 2. Please follow up with Dr. [**Last Name (STitle) **]. Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2112-6-22**] 9:10 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2112-6-22**] 9:30 3. Please follow up with Dr. [**Last Name (STitle) 914**] in cardiac surgery. The appointment time is [**2112-6-27**] at 1:00 p.m. The number to call to change the appointment is [**Telephone/Fax (1) 170**]. 4. Your staples need to be removed at the end of the month. You can follow up on [**2112-5-30**] at [**Hospital Ward Name 121**] 2 at 11:00 a.m. to remove your stapless. 5. Please follow up with Dr. [**Last Name (STitle) **] in Cardiology. This appointment is on [**2112-8-19**] at 2:40 pm. 6. Follow up with Dr. [**Last Name (STitle) 497**]. Your appointment is Wednesday, [**5-25**], [**2111**] at 2:00 pm.

[ "492.8", "428.0", "V42.7", "423.9", "585.9", "401.9", "583.81", "V45.81", "250.40", "135" ]

icd9cm

[ [ [] ] ]

[ "99.04", "37.12" ]

icd9pcs

[ [ [] ] ]

15094, 15169

10827, 13591

292, 313

15252, 15261

2579, 2815

15594, 16735

2135, 2189

14324, 15071

2852, 2893

15190, 15231

13617, 14301

15285, 15571

2204, 2560

8111, 10804

8078, 8078

233, 254

2922, 8045

341, 1268

1290, 1798

1814, 2119

52,453

187,278

3756+55502

Discharge summary

report+addendum

Admission Date: [**2173-2-12**] Discharge Date: [**2173-3-3**] Date of Birth: [**2120-3-3**] Sex: F Service: SURGERY Allergies: Lisinopril Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD Major Surgical or Invasive Procedure: [**2173-2-12**]: Cadaveric kidney transplant - Midline catheter [**2173-2-19**] R SVC/brachiocephalic balloon angioplasty with stent History of Present Illness: 52 y/o female with lupus nephritis on hemodialysis since [**2167**]. She currently dialyzes M-W-F using tunneled catheter (placed [**10-19**]) She had multiple failed accesses on her left arm. She had her dialysis run today which was uneventful, but is unsure of her dry weight. The patient reports she makes about 2 cups of urine daily. She denies fevers, chills, recent sick contacts. However, per report in OMR she had respiratory symptoms and cough on [**2-5**] and blood cultures were sent from [**Location (un) **] which came back as one set positive for Staph coag negative and she received a loading dose of 1 gram Vanco on [**2-5**] and 750 mg IV post HD this last week. She does not have chest pain or shortness of breath and denies problems with dialysis runs. Appetite is good, no nausea, vomiting or diarrhea. No abdomninal surgeries, had 1 C section . Past Medical History: 1. ESRD [**1-12**] WHO Stage IV Lupus nephritis (bx at [**Hospital1 112**] [**2166**]) on HD since [**11/2168**]) c/b E coli line sepsis [**8-/2170**] - Followed by Nephrology and currently on Transplant list. Dialyzed through catheter in RIGHT chest wall after AV fistula was deemed unsalvagable earlier this year. Last HD on Wednesday. 2. HTN - Medical admission for hypertensive urgency [**2-/2171**] 3. Thyroid nodule - 1.3 cm, observed on imagining for the first time in [**2159**], followed up by Endocrinology. TFTs unremarkable. Previously refused FNA of nodule. 4. Antiphospholipid antibody (not syndrome). C/b AV fistula thrombosis [**2171-7-10**]. Managed off of anticoagulation, but may require coumadin in peri-transplant period. No dvt or abortion history. 5. SLE - Followed by Dr. [**Last Name (STitle) 1667**] in Rheumatology. Managed with Plaquenil prophylaxis therapy. Diagnosed around year [**2162**]. 6. Hypercholesterolemia 7. LEFT Ankle Pain (although some notes document pain was on RIGHT side) - seen in ED [**2171-7-13**] - joint aspirate negative. cx guided bx cx negative , followed up in [**Hospital **] clinic with Dr. [**First Name (STitle) **]. 8. 4 children, 3 vaginal births, 1 section, last 22 yrs ago. 9. osteonecrosis of the distal fibula (Right); Hosp [**2086-9-29**] [**2173-2-12**] Cadaveric renal transplant into right iliac fossa. Social History: The patient was born in [**Country 2045**] and immigrated to the United States in [**2144**]. She was widowed in 6/[**2169**]. She is on disability since she has been on dialysis over the last three years. She walks without a cane and takes care of her ADLs. She lives alone in [**Location (un) **], but she has one son who is at BC. Her other three children are still in [**Country 2045**] and her husband died two years ago. She denies any tobacco, ethanol or illicit drug use. Family History: Significant for a maternal uncle with hypertension; otherwise denies any family history of heart disease, cancer or diabetes. Mother died of unclear causes when patient was 7 yo. Father died of unclear causes in [**2152**]. Pertinent Results: [**2173-3-3**] 05:33AM BLOOD WBC-4.9 RBC-3.22* Hgb-9.5* Hct-28.9* MCV-90 MCH-29.4 MCHC-32.7 RDW-16.8* Plt Ct-208 [**2173-3-3**] 05:33AM BLOOD PT-26.8* PTT-31.0 INR(PT)-2.6* [**2173-3-3**] 05:33AM BLOOD Glucose-103* UreaN-23* Creat-2.8* Na-141 K-3.6 Cl-109* HCO3-25 AnGap-11 [**2173-2-19**] 01:52AM BLOOD ALT-3 AST-16 AlkPhos-139* TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2173-3-3**] 05:33AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7 [**2173-3-1**] 05:00AM BLOOD calTIBC-217* Ferritn-1201* TRF-167* [**2173-3-3**] 05:33AM BLOOD tacroFK-12.0 Brief Hospital Course: On [**2173-2-12**], she underwent cadaveric renal transplant into right iliac fossa. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. A ureteroneocystostomy was performed over a stent. Induction immunosuppression was administered (solumedrol, cellcept and ATG). Please refer to operative note for complete details. Postop, minimal urine was produced. She developed neck and head swelling requiring reintubation and transfer to the SICU for management. Initially, head/neck swelling was felt to be due to ATG and ATG was held. Bilateral upper extremity LENIS were done to evaluate for DVT. There were no DVTs. Given h/o SVC syndrome, an MRV of the head and neck was done to assess for thrombosis/stenosis large vessels. This demonstrated the following: Occlusion of the bilateral bracheocephalic veins. 2. Bilateral internal jugular veins are small in caliber but patent and drain via collaterals. 3. Bilateral subclavian veins are patent and drain via collaterals. 4. Superior vena cava patent, however supra-azygos portion is small in caliber. 5. Nonocclusive fibrin sheath around tip of right internal jugular catheter within the SVC. 6. Small bilateral pleural effusions and dependent atelectasis. 7. Hemosiderosis probably related to transfusion therapy. On [**2-19**], she underwent IR the following procedures: Ultrasound-guided right brachial vein access. 2. Removal and exchange of the right internal jugular vein tunneled hemodialysis catheter. 3. Right upper extremity and SVC venography. 4. Venoplasty of the right subclavian vein, brachiocephalic vein, and SVC up to 10 mm x 4 cm. 5. Post-venoplasty venography. 6. Stent placement from the right subclavian vein to the upper SVC (12 mm x 4 cm and 14 mm x 4 cm Luminexx self-expanding stent). 7. Post-stent placement venography. 8. Placement of a double-lumen non-tunneled midline via the right brachial vein. 9. Exchange of the left groin central venous catheter for a non-tunneled VIP hemodialysis catheter. 10. Repositioning of the existing Dobbhoff tube with the tip in the duodenum Post procedure, she was started on IV heparin then transitioned to coumadin on [**2-21**] for 2.5mg. She received coumadin 2.5 again on [**2-22**], 5mg on [**2-23**] and [**2-24**], 7.5mg [**2-25**] & [**2-27**], 4mg on [**2-27**] then 2mg on [**2-28**]. Coumadin was held for inr of [**3-14**] on [**3-1**] then resumed on [**3-2**] for 1mg. After review of INRs and doses, coumadin was set at 4mg daily. Facial and neck swelling resolved. ATG was resumed for a total of 4 doses. Cellcept was continued and steroids were tapered per protocol. Prograf was initiated on postop day 2 with daily dose adjustments for goal trough level of 10. Urine output continued to average 300cc per day. Creatinine ranged 3-4.5. Intermittent hemodialysis was performed. Renal biopsy was performed on [**2-16**] demonstrating no rejection. Gradually, urine output increased to approximately 1 liter per day with creatinine decreasing to a low of 2.4 then stabilizing around 2.8. Renal ultrasound demonstrated stable appearing small AV fistula, which did not appear to cause any vascular steal as perfusion continued to appear appropriate. Resistive indices were normal. There was no hydronephrosis and no perinephric collection. The previously placed L groin temporary dialysis access was removed. Nutritionally, she was slow to advance as course was complicated by airway swelling that resolved. A bedside swallow evaluation was done and she was found to be safe for a regular diet. Appetite was poor and a feeding tube was recommended by the Dietician. The patient refused a feeding tube. In addition, she developed a mild ileus that resolved. Gradually, po intake increased. Supplements were given. On [**2-23**], she developed intense right shoulder pain. EKG and cardiac enzymes were negative. Xrays were negative. Ortho was consulted and MRI was recommended. MRI was done on [**2-26**] showing the following: High-grade partial-thickness partial-width bursal surface tear predominantly through the anterior and mid fibers of the supraspinatus tendon with delaminating intrasubstance component on a background of mild tendinosis. 2. High-grade partial-thickness partial-width articular surface tear through the mid and posterior fibers of the infraspinatus tendon on a background of mild tendinosis. 3. SLAP tear. Likely additional tear of the inferior and inferior-posterior labrum. 4. Slit-like partial-width, partial-thickness articular surface tear through the superior fibers of the subscapularis tendon on a background of mild tendinosis. 5. No joint effusion or bursitis. A sling was applied and OT/PT were consulted. She will follow up with the sports orthopedist on [**3-17**]. NSAIDs were contraindicated given renal transplant. Dilaudid was used for pain. She was ambulating independently with her right arm in a sling. Rehab was deemed necessary as she required assist with ADLs. She will be discharged to [**Hospital 100**] Rehab [**Telephone/Fax (1) 16882**] with twice weekly transplant labs and daily INRs for coumadin management. Medications on Admission: Hydroxychloroquine 200 mg daily, Hydroxyzine 10 mg q 12 hrs, Metoprolol 25 mg [**Hospital1 **], Renvela 3200 mg TID w/meals, Warfarin 2mg daily (last dose 9 PM [**2-11**]) for antiphospholipid syndrome, Tylenol PRN, Cetirizine(zyrtec) 5 mg daily, Colace 100 mg [**Hospital1 **] . Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DOSE SUNDAY AND WEDNESDAY (). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): PCP [**Name Initial (PRE) 1102**]. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold for sbp <110 . 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for sbp <110 or HR <60. 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4 PM: daily inr goal 2-2.5. 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for R shoulder pain. 13. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 14. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Outpatient Lab Work Daily INR until inr stable goal 2-2.5 16. Outpatient Lab Work Labs every Monday and Thursday for cbc, chem 10, ast, alk phos, albumin, and trough prograf (tacrolimus)level. UA Fax results to [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 697**] attention Transplant RN coordinator Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: ESRD secondary to lupus nephritis now s/p cadaveric kidney transplant Delayed renal graft function, resolving Antiphospholipid syndrome on Warfarin R SVC stenosis R brachiocephalic stenosis R shoulder bursal bursal surface tear, R intraspinatus tendon tear, Slap tear, subscapularis tear Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, constipaton, inability to take or keep down food, fluids or medications. Monitor facial swelling and report if this increases significantly or if the patient has respiratory difficulties due to swelling Labwork to be drawn every Monday and Thursday Patient may shower, pat incision dry and leave open to air Patient should wear right arm sling Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-3-4**] 10:00 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-3-8**] 9:30 Dr. [**Last Name (STitle) 2719**] ([**Telephone/Fax (1) 2007**] [**2173-3-17**], 1:00pm Sports Orthopedics-please call to schedule f/u in 2 weeks for R shoulder Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-3-9**] 9:00 Completed by:[**2173-3-3**] Name: [**Known lastname 2645**],[**Known firstname 2646**] Unit No: [**Numeric Identifier 2647**] Admission Date: [**2173-2-12**] Discharge Date: [**2173-3-3**] Date of Birth: [**2120-3-3**] Sex: F Service: SURGERY Allergies: Lisinopril Attending:[**First Name3 (LF) 2648**] Addendum: Of note, she was treated with renally dosed IV Vancomycin thru [**2-26**] for preop staph coag negative blood cultures (1 week prior to transplant obtained at outpatient HD). Subsequent blood cultures remained negative. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**] Completed by:[**2173-3-3**]

[ "453.77", "790.7", "041.10", "996.81", "998.6", "710.0", "V58.61", "560.1", "582.81", "733.49", "276.8", "459.2", "403.91", "289.81", "731.3", "E878.0", "788.5", "241.0", "784.2", "585.6", "840.7", "E928.9", "584.5", "287.5" ]

icd9cm

[ [ [] ] ]

[ "38.95", "55.24", "00.42", "96.04", "55.69", "96.6", "00.46", "39.50", "39.95", "96.72", "99.71", "00.93", "39.90" ]

icd9pcs

[ [ [] ] ]

13441, 13663

4013, 9153

273, 408

11557, 11557

3459, 3990

12217, 13418

3215, 3440

9484, 11136

11246, 11536

9179, 9461

11737, 12194

229, 235

436, 1304

11572, 11713

1326, 2701

2717, 3199

3,369

143,327

25977

Discharge summary

report

Admission Date: [**2109-12-10**] Discharge Date: [**2110-2-13**] Date of Birth: [**2080-7-13**] Sex: M Service: SURGERY Allergies: Pertussis Vaccine,Fluid Attending:[**First Name3 (LF) 5880**] Chief Complaint: Fever Major Surgical or Invasive Procedure: [**1-7**]: Flexible Bronchoscopy [**1-9**]:Roux-en-Y duodenojejunostomy, Gastrostomy, Feeding jejunostomy. [**1-28**]: Bedside Trach [**2-7**]: Bedside EGD History of Present Illness: (History from medical record and patient's mother) This is a 29 y.o. non-verbal gentleman with a history of cerebral palsy, seizures, recurrent UTIs and SMA Syndrome, recent [**Hospital 19601**] transferred from [**Hospital **] Rehab on [**2109-12-10**] with fevers s/p recent admission to [**Hospital1 18**] ([**Date range (1) **]/05). He was discharged from [**Hospital1 18**] to [**Hospital6 **] on valproate 450 q6 (increased from prior dose), and a 2 week course of meropenem 1 gram q8 (given urine cultures showed klebsiella resistant to all antibiotics save meropenem. He was doing well at rehab until 3 days prior to admission when he was noticed to have fevers to 102.0 despite IV vancomycin and Imipenem empirically. Urine culture with yeast and started on fluconazole. His PICC line was replaced in the left UE (from right UE). He was then noted to have edema at the left [**Last Name (LF) **], [**First Name3 (LF) **] U/S was performed on [**2109-12-5**] demonstrating a DVT. He was started on lovenox and coumadin. Vitals at [**Hospital1 **], BP:140/70, HR:100, RR:20, temp 102 rectally. Vanco was started on [**12-9**]. WBC noted to be 7.5 with 7% bandemia. He is transferred to [**Hospital1 18**] for further evaluation of fevers. ROS (limited by non-verbal status): NEGATIVE: No diarrhea and able to tolerate J-tube with isocal at 80cc, no CP, SOB, pain, wt loss (in fact the patient has gained weight and was 100 pounds on admission), mild nausea and dry heaves x 1 day. Past Medical History: 1) Cerebral palsy with mental retardation 2) Seizure disorder 3) History of H. pylori gastritis 4) Recent right clavicular fracture on [**2109-9-14**] 5) History of multiple surgeries to the lower extremities for flexion contractures 6) Recurrent Klebsiella UTI, treated with Bactrim, Rocephin and Tequin. 7) SMA Syndrome: Followed by Dr. [**Last Name (STitle) **] (surgery) SBO initially felt secondary to obstipation brought about by codeine use for pain managment secondary to clavicular fracture. A barrium swallow on [**2109-9-21**] was suggestive of partial obstruction at the second portion of the duodenum. However, he continued to have high NG residuals and radiographic features c/w partial SBO despite clearance of stools, which led to a consideration of SMA syndrome. A CT on [**2109-10-2**] showed stable distension of the stomach and duodenum, with proximal duodenal distension without apparent dilatation of the distal duodenum. A repeat EGD on [**2109-10-17**] was performed, at which time duodenal narrowing was not appreciated. A subsequent gastrograffin study, however, showed high grade partial obstruction of the duodenum. Suspected gastric outlet obstruction/partial SBO due to SMA syndrome suggested on radiographic studies, although duodenal narrowing not appreciated on repeat EGD. The patient had had minimal improvement with conservative management, with continued weight loss and inability to tolerate POs. NG tube was maintained, and TPN was continued per nutrition recs. GI consulted, CT angio of abdomen was done. The patient underwent EUS on [**11-11**], duodenal biopsies taken, unable to visualize pancreas, decision made for pancreatic MRI to be done. Surgery consulted, thought clinical picture c/w SMA, plan to have patient undergo surgical decompression in the near future once his nutritional status has improved (goal weight of 105 pounds). The patient was continued on a PPI [**Hospital1 **] for GI protection given his history of fundus ulcers. The patient had a G/J tube placed under IR on [**11-13**], and tube feeds were started 24 hours after placement. Biopsies from duodenum showed mild inactive duodenitis. 8) ARDS [**9-/2109**] at [**Hospital **] Hospital; admitted with abdominal pain, ? hematemesis and suspected SBO. A CT chest and abdomen was performed and reportedly showed multifocal pneumonia with bilateral pleural effusions, no abdominal mass. His clinical picture evolved into an ARDS picture requiring intubation on [**2109-9-22**]. He was treated with Zosyn for presumed aspiration pneumonia; sputum cultures grew [**Female First Name (un) 564**] Albicans. He self-extubated on [**2109-10-6**], and has been stable from a respiratory standpoint since that point. 9) Left LE DVT, diagnosed on [**2109-12-5**], initially treated with lovenox, then switched to coumadin. 10) Pancreatic Head Cystic Lesion, followed q1 year Social History: Mr. [**Known lastname 6164**] is a resident of [**Hospital1 **] Meadows in [**Location (un) **]. Patient reportedly ambulates with assist and wears a helmet for safety in the nursing home. Family History: Not available. Physical Exam: On admission: Temp 102 rectally, HR:144, BP:150/92, RR:12, O2:99 RA Gen: Cachectic gentleman with flexion contractures in all extremities, screaming. Non-verbal. CV: Reg tachy. No murmurs Pulm: (exam limited by effort). No wheezes or rales ABD: Soft with J and G tubes without evidence of infection. Ext: contracted in flexion. 1+ DP and radial. Neuro: MAE. Babinski normal. Pertinent Results: [**1-15**] Single contrast upper GI study from G-tube: FINDINGS: The scout film demonstrated surgical clips overlying the left upper quadrant, as well as IVC filter and J-tube and G tube. 60 cc of water soluble contrast (COnray) was administered from the G-tube into the stomach, however, the contrast pooled in the stomach, and the stomach did not empty even with semi- upright and right lateral decubitus position. IMPRESSION: Limited study, which showed pooling of contrast in the stomach, which did not show adequate emptying. At the end of the study, part of the administered contrast was drained and the G- tube was reconnected to drainage bags. [**1-21**] CT chest/abd/pelvis: IMPRESSION: 1. Patchy bilateral ground-glass opacities. This is a nonspecific finding and may represent pulmonary edema secondary to volume overload or ARDS. Infection cannot be fully ruled out. 2. Moderate-sized bilateral pleural effusions. 3. A small amount of low-attenuation free intraperitoneal fluid with linear peritoneal enhancement. The enhancement is nonspecific, and likely due to inflammatory changes from recent surgery. Infection can not be fully ruled out, but is considered less likely. [**1-21**] Left lower extremity ultrasound: Impression: There is persistent thrombus seen within the left common femoral and proximal superficial femoral veins, but this has partially recanalized since the prior examination. Some flow is seen within the common femoral and proximal superficial femoral veins. Normal respiratory ariation is seen in the common femoral waveform. Normal color flow with normal waveforms are seen in the mid and distal superficial femoral vein, deep femoral, and popliteal veins. Of note, there appears to be a duplicated superficial femoral venous system, with no flow seen in the duplicated vein through the mid and distal portions. IMPRESSION: Partial recanalization of the previously seen thrombus within the left common femoral and proximal superficial femoral veins. [**1-31**] Gall bladder ultrasound: INTERPRETATION: Serial images over the abdomen show prompt uptake of tracer into the hepatic parenchyma. At 6 minutes, the gallbladder is visualized with tracer activity noted in the small bowel at 6 minutes. Note is made of reflux of tracer into a dilated stomach. IMPRESSION: 1. No evidence of cholecystitis. 2. Significant tracer reflux into a dilated stomach. [**2-7**] Bedside EGD: showed "patent duodenojejunal anastomosis, stenosis of the first part of the duodenum, fluids in stomach, gastrostomy tube in gastric wall in antrum, and findings do not account for patients symptoms. Recommendations: Consider SBFT to rule out distal obstruction" Brief Hospital Course: 1) Fevers/Respiratory. Has recurrent resistant uti on meropenem and vanco and picc. CXR on admission normal. Yeast in urine on fluc. Foley changed. Yeast also in blood. ID consulted recommended caspofungin for fungemia, meropenem/vancomycin/ flagyl for possible GI process. Developed ARDS picture due to sepsis, pressors and vented with high peep. Right chest tube was placed by thoracic surgery on [**12-17**] after attempted CVL placement resulted in a pneumothorax. Vancomycin was d/c'd on [**12-25**]. He spiked after vanco d/c'd and it was restarted [**12-28**]. Echo obtained to rule out endocarditis and was negative. Flagyl d/c'd [**12-27**] after 3 negative cdiff stool samples.Chest tube removed [**12-26**]. Patient extubated [**12-27**] but could not handle secretions and re-intubated. On [**1-6**] percutaneous tracheostomy tube was placed due to neuromuscular weakness with prolonged ventilatory requirement and copious secretions. He has since been doing very well with the trach and his vent settings have been weaned. Patient was off antibiotics for a week or so, preparing for discharge when he again spiked a fever and leukocytosis. On [**1-23**] urine culture grew psuedomonas and [**1-24**] sputum grew psuedomonas and klebsiella. [**1-24**], [**1-26**], [**1-29**], [**2-1**] Cdiff stools were all negative, and repeat urine culture [**1-28**] was also negative for growth. Infectious disease again came onboard and patient started a two-week course of zosyn and meropenem which he completed. He has been afebrile for over a week upon discharge. 2) SMA Syndrome. Plan was to increase weight to ~105-110 pounds and then perform blind pouch decompression of duodenum. On [**12-23**] patient developed acute bleeding from G-J tube and subsequent anemia for which he received several units of blood. Emergent EGD showed large clot but no active source of bleeding. IR took for embolization- used gel to embolize. Patient stable enough to take to OR by Dr. [**Last Name (STitle) **] on [**1-9**] for Roux-en-Y duodenojejunostomy, Gastrostomy, Feeding jejunostomy. Please see operative report for details, but in general findings were as follows: "The duodenum was somewhat scarred to the retroperitoneum and the kidney was very thickened and fibrotic and dilated. There was a gastrojejunal tube going into the stomach and down to the jejunum through a previously placed site by radiology. The bowel was fairly delicate. No other abnormalities were noted." Patient tolerated the procedure well. The abdominal incision was partially opened 2 weeks ago when there was concern for infection and a vac dressing was initially applied which was present for about one week before switching to wet to dry dressings. The wound is granulating very well and the wet to dry dressings [**Hospital1 **] will need to be continued at rehab until healing is complete. All staples have been removed. 3) DVT. The pt had been on lovenox but was on coumadin with INR goal of [**1-17**] on admission. He was started on sc heparin and bled as described above. HIT antibodies were tested and returned negative. Now has IVC filter in. His heparin was restarted and he has not re-bled. His platelets occassionaly drift down as well as his hct but they have been stable recently and attributed mostly to medication side effects. 4) Nutrition: He is NPO. Currently J tube feeding with G tube drainage (J-tube is RED). J tube feeds are Probalance [**1-17**] strength at 80 an hour. Keep the Gtube clamped throughout the day, check for residual once daily. Do not refeed residuals and reclamp the Gtube. Only modify this plan if the patient experiences persistent abdominal distension/vomiting. 5) Seizure Disorder. Did not seize until [**12-26**]. CT was negative. Neuro consult obtained for management, depakote increased. Patient has since had several seizures over the course of the admission and has been followed by neurology service throughout. Head CTs were obtained after both major seizures ([**12-26**], [**1-21**]) and did not demonstrate any mass effect, hemorrhage or acute change. The pt. was recently changed from a PO dilantin order to IV. This enables his tube feeds to continue while he is being medicated. He is currently to get 100mg IV bid. He will continue to need daily dilantin and albumin levels checked and the dilantin level needs to be "corrected" for the current albumin level. The pt. had another seizure on [**2-10**], was evaluated by the neurology department and at that time they recommended no changes to his current medication regimen. The pt. then underwent another EEG which did not show any new activity since his previous EEG. Neurology agreed that the patient will not likely achieve seizure-free state and recommended continuing his current dose of dilantin to achieve a level of 15-20. 6) Dispo. [**Hospital **] rehab with instructions for tube feeding and refeeding of G tube drainage. The patient has been stable and afebrile, nutritionally managed on tube feeding via his J tube. He has been weaned to trach collar. The patient will follow up with Dr. [**Last Name (STitle) **] in his office. Medications on Admission: Free water flushes 250ml q4h Imipenem 500 mg IV q8 Prevacid 30 [**Hospital1 **] Promethazine 12.8 q8 Depakote 650 po6 Kcl 40 mEq daily Isocal HN @ 80cc/hour Coumadin Vanco 1 gram daily Fluconazole 100 mg [**Hospital1 **] Trazadone 25 qhs Discharge Medications: 1. Metoclopramide 5 mg/mL Solution Sig: Two (2) ml Injection Q6H (every 6 hours). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**] Drops Ophthalmic PRN (as needed). 10. Acetaminophen 650 mg Suppository Sig: [**12-16**] Suppositorys Rectal Q4-6H (every 4 to 6 hours) as needed for fever. 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) AS DIRECTED Injection ASDIR (AS DIRECTED): PER ISS OF FACILITY. 12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane PRN (as needed). 13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 15. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 16. Phenytoin Sodium 50 mg/mL Solution Sig: 100 mg Intravenous Q12H (every 12 hours): - 2 ml for a total of 100 mg twice a day. 17. Lorazepam 2 mg/mL Syringe Sig: [**12-16**] Injection Q4H (every 4 hours) as needed for seizures. Disp:*10 * Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Superior mesenteric artery syndrome, Cerebral Palsy, seizure disorder Discharge Condition: Good Discharge Instructions: Please take medications as directed, please follow-up with Dr. [**Last Name (STitle) **]. Please refer to the page 1 sheet for further instructions. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**1-17**] weeks. You will need to call ahead of time to make an appointment. His office phone number is ([**Telephone/Fax (1) 6449**].

[ "557.1", "285.1", "117.9", "318.1", "578.9", "453.8", "263.9", "038.8", "780.39", "507.0", "518.82", "584.9", "995.92", "343.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.07", "38.93", "96.04", "43.19", "46.39", "99.15", "31.1", "96.72", "45.91", "99.04", "97.23", "39.79", "45.13", "34.04", "38.7" ]

icd9pcs

[ [ [] ] ]

15347, 15420

8253, 13395

290, 447

15533, 15539

5547, 8230

15736, 15931

5115, 5132

13683, 15324

15441, 15512

13421, 13660

15563, 15713

5147, 5147

245, 252

475, 1977

5161, 5528

1999, 4892

4908, 5099

21,448

148,695

45775

Discharge summary

report

Admission Date: [**2126-7-27**] Discharge Date: [**2126-7-29**] Date of Birth: [**2069-5-31**] Sex: M Service: MEDICINE Allergies: Penicillins / Enalapril Attending:[**First Name3 (LF) 3984**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 57 yo M with h/o ETOH abuse and multiple admissions for ETOH withdrawal. He was admitted here as recently as [**Month (only) 216**] and Declined referral to detox programs, eventually leaving AMA. He also has a h/o tachycardia induced cardiomyopathy, felt to be resolved with EF 55% in [**2123**], and stage 3 fibrosis of the liver secondary to hepatitis C and ETOH. He preseneted to the ED with chest pressure for 1.5 days. His initial vitals were 98.3 104 154/90 20 100% 3L. There were no ST changes on his ECG. He denied shortness of breath or diaphoresis. He smelled strongly of ETOH. The initial plan was to rule him out for MI in the ED with the hope of discharging him; however he [**Last Name (un) 4996**] to have symptoms of ETOH withdrawal requiring significant doses of ativan. He receieved ASA 325, thiamine 100 po, MVI and folate PO, KCL repletion with 100 po, haldol 5mg IV x 2, lorazepam 2 mg IV x 2, diazepam 10mg IV x 3 and 5mg po x1, and zofran. . Currently states he feels slightly short of breath. He complains fo substernal left sided chest pressure. He also has some abdominal pain Review of systems: see metavision Past Medical History: Atrial fibrillation Tachycardia induced cardiomyopathy (since resolved) ETOH abuse with cirrhosis Hypertension 2.5-cm cystic lesion in pancreatic tail ([**2121**]) Colonic polyposis s/p knee replacement Hepatitis B/C/ETOH, grade 3 fibrosis Social History: Homeless, lives on the street in [**Location (un) **] Corner. Smokes 2ppd for 44yrs. Drinks listerine, 1 medium bottle per day for the past [**2-19**] years. Denies current IVDU. Previously did IV cocaine in the remote past. Denies taking painkillers. Family History: Positive for coronary artery disease (details unknown) and hypertension. His father had an aortic aneurysm. There is a history of cancer of the brain and the breast. Physical Exam: General Appearance: No acute distress Eyes / Conjunctiva: PERRL, no nystagmus Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2126-7-27**] 04:30PM GLUCOSE-85 UREA N-9 CREAT-0.6 SODIUM-142 POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-20* ANION GAP-22* [**2126-7-27**] 04:30PM estGFR-Using this [**2126-7-27**] 04:30PM cTropnT-<0.01 [**2126-7-27**] 04:30PM proBNP-111 [**2126-7-27**] 04:30PM ALBUMIN-3.4* [**2126-7-27**] 04:30PM VIT B12-308 [**2126-7-27**] 04:30PM ASA-NEG ETHANOL-343* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2126-7-27**] 04:30PM WBC-6.5# RBC-2.99* HGB-10.6* HCT-30.2* MCV-101* MCH-35.6* MCHC-35.3* RDW-15.4 [**2126-7-27**] 04:30PM NEUTS-61.2 LYMPHS-30.1 MONOS-6.1 EOS-1.9 BASOS-0.6 [**2126-7-27**] 04:30PM PLT COUNT-192# Brief Hospital Course: 56 yo presenting to ED w/ c/o Chest pressure, tachycardia and an admission ETOH level of 343. Pt. being admitted w/ ETOH withdrawal and transferred to [**Hospital Unit Name 153**] for further monitoring and management. SW was asked to see Mr. [**Known lastname 14879**] who was insisting on leaving AMA on [**2126-7-29**]. Per social work, "he was angry because someone had ??????stolen?????? his canes, which he had also said about other belongings, but he then acknowledged that they had been found. The resource RN located an extra cane, which the pt accepted, understanding, as well, that he was leaving AMA, as there was concern about his continuing to be detoxing; he was continuing to score on the CIWA. Mr. [**Known lastname 14879**] understood and accepted that he was leaving AMA." . # ETOH withdrawal: treated with valium for ciwa >10. Also received thiamine, folate and MVI. He was hydrated and social work was consulted. . # Chest pain: Attributed to atypical chest pain, non-cardiac etiology. ECG without ischemic changes or injury,and cardiac enzymes negative. . # tachycardia: beleived to be [**12-19**] hypovolemia and/or withdrawal. Treated with IVF and continued home metoprolol, diltiazem . # Hypokalemia: likely [**12-19**] ETOH. He received 80 PO and 20 IV repletion. He was likely diuresing [**12-19**] etoh as well as [**12-19**] hctz and lasix. . # anemia: near his baseline. macroocytic. iron studies in [**Month (only) 116**] showed iron 203, TIBC 239, transferrin 184, ferritin 278. B12 was 407, folate 15.6. Likely [**12-19**] bone marrow suppresion from ETOH but B12 was low normal. . #Back pain: chronic back pain for about 13yrs; no surgical intervention per neurosurg (see last d/c sum). declined pt last admission. pain was controlled on last admission without narcotics. lidocaine patch was given. . #Hepatitis B/C: lfts elevated but actually improved from baseline. Has h/o grade 3 fibrosis. He had RUQ U/S last admission which showed diffuse fatty infiltrate but no e/o focal lesions or ascites. It was attempted to set the pt up with an EGD as an outpatient, but no contact information. Outpatient management. . #Thrombocytopenia: stable. . #Atrial fibrillation: continued metoprolol and diltiazem. . Transitions of care: Homelessness/EtoH abuse: has repeatedly declined referrals and left AMA Medications on Admission: One Multivitamin by mouth daily Toprol XL: one 25mg tablet by mouth daily Omeprazole: one 20mg tablet by mouth daily HCTZ: one 50 mg tablet by mouth daily Folic Acid: one 1mg tablet by mouth daily Vitamin B1: one 100mg tablet by mouth daily Diltiazem XR: one 120mg tablet by mouth daily Furosemide: one 20mg tablet tablet by mouth daily Discharge Medications: One Multivitamin by mouth daily Toprol XL: one 25mg tablet by mouth daily Omeprazole: one 20mg tablet by mouth daily HCTZ: one 50 mg tablet by mouth daily Folic Acid: one 1mg tablet by mouth daily Vitamin B1: one 100mg tablet by mouth daily Diltiazem XR: one 120mg tablet by mouth daily Furosemide: one 20mg tablet tablet by mouth daily Discharge Disposition: Home Discharge Diagnosis: ethanol withdrawal > PATIENT LEFT AMA. Discharge Condition: fair Discharge Instructions: Patient left AMA despite being warned of risks for decompensation [**12-19**] ETOH withdrawal. He was instructed to report back to ED should he have any further chest pain, shortness of breath, fevers, chills or sweats. Followup Instructions: Patient left AMA despite being warned of risks for decompensation [**12-19**] ETOH withdrawal. He was instructed to report back to ED should he have any further chest pain, shortness of breath, fevers, chills or sweats. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2126-7-30**]

[ "724.5", "303.91", "571.2", "427.31", "211.3", "276.52", "401.9", "786.59", "287.5", "070.54", "276.8", "291.81", "785.0", "281.9", "070.32" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

6643, 6649

3559, 5799

296, 302

6731, 6737

2891, 3536

7005, 7381

2037, 2205

6281, 6620

6670, 6710

5919, 6258

6761, 6982

2220, 2872

1471, 1488

245, 258

330, 1451

5820, 5893

1510, 1751

1767, 2021

1,974

192,753

47505

Discharge summary

report

Admission Date: [**2123-7-10**] Discharge Date: [**2123-7-13**] Date of Birth: [**2051-4-3**] Sex: F Service: MEDICINE Allergies: Darvon Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Transfer from [**Hospital 8**] hospital for respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 100449**] is a 72 year-old female with a history of progressive supranuclear palsy, hypertension and hypothyroidism, status post esophagectomy for cancer in [**2104**], and with chronic reflux disease, who presents from home with respiratory distress. She was most recently admitted to [**Hospital1 18**] in [**3-/2123**] for fever, at which time she was diagnosed with a pneumonia, probable aspiration, and was treated with Levofloxacin and Flagyl. * According to her husband, she was noted to have increasing difficulty swallowing over the past 3-4 days, and difficulty handling secretions. She ate little over the past few days. Last night, while drinking Ensure, she developed progressive shortness of breath, and EMS were called. Per records, she was noted to have thick yellow secretions. * At OSH ED, T 102.7, HR 140s, RR 40s, 88% on NRB. ABG 7.17/58/75 on 100% face mask. She was intubated. She received Zosyn x1, albuterol, and was placed on propofol. Her blood pressure subsequently dropped to 80s systolic, and peripheral dopamine was initiated. She was hydrated with 2.5 L of NS. She was transferred to [**Hospital1 18**] for further care. Past Medical History: PMH - 1. Progressive Supranuclear Palsy 2. HTN 3. Urinary incontinence 4. Hypothyroidism 5. h/o esophageal CA ([**2104**]) 6. chronic cough [**3-4**] reflux - had extensive w/u by pulmonary, speech/swallow, ENT Social History: SH - Lives at home with her husband, has 24-hour care and caregiver. [**Name (NI) **] five daugters, two with her currently. No tobacco, EtOH, or illicits. Wheelchair and bed-bound, able to stand with maximal assistance. Family History: FH - NC Physical Exam: VITALS: T 97.1 HR 109 BP 105/63 RR29 VENT: AC 500x14, PEEP 5, Fi02 50%, sat 100% GEN: Intubated, not on sedation. HEENT: Anicteric. NECK: JVP not elevated. No carotid bruits. RESP: Rhonchorous breath sounds bilaterally. Exam limited to the anterior chest. CVS: RRR. Normal S1, S2. No S3, S4. Systolic murmur at apex radiating to axilla. GI: BS NA. Abdomen soft and non-tender. EXT: Without edema. Good pedal pulses. Pertinent Results: OSH labs: WBC 20, no differential. . RELEVANT IMAGING DATA: [**2123-7-10**] CXR: ETT in good position. NG tube curled up and coming proximally. Patchy opacities in left lung field, with loss of left hemidiaphragm. * EKG at OSH: Sinus tachycardia, IVCD, LAD, LAFB, no prior for comparison, non-specific ST-T changes. Brief Hospital Course: Patient was transferred from the OSH intubated and sedated. She was hypotensive and required pressors. She was found to have evidence of severe aspiration on CT scan. Given the rapid progression of her supranuclear palsy, palliative care was consulted and care was withdrawn with the full knowledge and support of the family on [**2123-7-13**]. Patient expired soon thereafter. Pronounced dead at 5:27 PM on [**2123-7-13**]. Medications on Admission: Zosyn 3.375 gm IV X1 Dopamine drip Carbi/Levodopa 1 tab TID Detrol 2 [**Hospital1 **] Fosamax 70 QWednesday Levothyroxine 75 mcg PO QD Ranitidine 150 mg PO BID Robitussin with Codeine prn Colace 100 mg PO BID Cozaar 25 mg PO QD Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "785.52", "518.81", "401.9", "244.9", "530.81", "V10.03", "038.9", "507.0", "333.0", "276.2", "995.92" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "96.04", "00.17" ]

icd9pcs

[ [ [] ] ]

3580, 3589

2841, 3273

337, 343

3648, 3665

2500, 2818

3729, 3883

2037, 2046

3551, 3557

3610, 3627

3299, 3528

3689, 3706

2061, 2481

234, 299

371, 1547

1569, 1782

1798, 2021

74,821

134,184

34571

Discharge summary

report

Admission Date: [**2141-9-15**] Discharge Date: [**2141-9-25**] Date of Birth: [**2108-4-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: aortic dissection Major Surgical or Invasive Procedure: Resuspension of aortic valve,Ascending Aorta and hemiarch replacement, reimplantation of innominate artery [**2141-9-15**] History of Present Illness: This 33 year old white male presented with the 2-day history of chest pain at an outside hospital. Subsequent investigation with a CT scan showed type A aortic dissection involving the whole of the ascending and extending onto the arch and the left common iliac artery. He was emergently transferred from the outside hospital. Prior to transfer, he was hypotensive with blood pressure in the 70s and was intubated emergently at the outside hospital and was transferred here. He was also noted to have signs of pericardial effusion with tamponade physiology and ST-segment changes indicating the coronary artery involvement. He was transferred in critical condition and was taken straight to the Operating Room for emergency repair. Past Medical History: multiple sclerosis depression glaucoma Social History: Mr. [**Known lastname 79362**] is married and lives at home with his wife. [**Name (NI) **] is currently unemployed. He has a history of smoking/alcohol/substance abuse: Smokes [**12-3**] PPD, has requested more percocet recently, occasional alcohol. Family History: unremarkable Physical Exam: admission: none available Pertinent Results: [**2141-9-24**] 04:35AM BLOOD WBC-12.1* [**2141-9-23**] 03:37AM BLOOD WBC-12.8* RBC-3.34* Hgb-10.2* Hct-29.9* MCV-90 MCH-30.5 MCHC-34.1 RDW-13.8 Plt Ct-329 [**2141-9-15**] 08:14AM BLOOD WBC-9.7 RBC-3.12*# Hgb-10.1*# Hct-28.5*# MCV-91 MCH-32.3* MCHC-35.4* RDW-13.6 Plt Ct-80*# [**2141-9-24**] 04:35AM BLOOD Na-136 K-4.1 Cl-102 [**2141-9-23**] 03:37AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-141 K-4.2 Cl-104 HCO3-27 AnGap-14 [**2141-9-15**] 03:38PM BLOOD UreaN-38* Creat-2.3*# Na-145 K-4.5 Cl-116* HCO3-23 AnGap-11 [**2141-9-20**] 03:47AM BLOOD ALT-985* AST-153* LD(LDH)-487* AlkPhos-83 Amylase-46 TotBili-2.5* Brief Hospital Course: He was taken emergently to the Operating Room where resuspension of the aortic valve, replacement of the ascending and hemiarch and reimplantation of the innominate artery were undertaken. He weaned from bypass on Propofol and Neo Synephrine. He was kept sedated and intubated overnight after surgery. he was stable and awoke over a day or two. He was extubated but had no movement of the upper extremities. neurology was consulted and an MRI revealed bilateral watershed and thalamic infarcts. Over the next days he gradually regained some movement of the upper extremeties. Beta blockers and calcium blockers were given for blood pressure control, with good effect. Physical Therapy worked with him. Rehabilitation screening was completed and he was discharged to [**Hospital6 **] in [**Location (un) 246**] for further recovery. At discharge he had 3/5 strength and movement of the right hand and arm and minimal movement of the left hand and shoulder. Cognitve function was intact. Arrangements were made for outpatient follow up. Medications on Admission: baclofen 40mg TID Tamsulosin 0.4mg HS Citalopram 20mg daily Tizanidine 4mg TID trazadone 50mg HS prn Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. tizanidine 4 mg Capsule Sig: One (1) Capsule PO three times a day. 7. baclofen 40 mg Tablet Sig: one (1) Tablet PO three times a day. 8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS:PRN as needed for insomnia. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 12. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 14. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One Dose). 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: type A aortic dissection s/p aortic valve resuspension, graft ascending aorta/hemiarch, reimplantation of innominate artery [**2141-9-15**] multiple sclerosis glaucoma depression Discharge Condition: Alert and oriented x3 Moving lower extremities, 3/5 strength right upper extremity, very slight movement of left fingers Incisional pain managed with oral medications Incisions: Sternal - healing well, no erythema or drainage Edema: 1+ 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. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2141-10-16**] at 1:30pm Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**] ([**Telephone/Fax (1) 15916**]) in [**1-4**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2141-9-25**]

[ "998.11", "434.91", "285.1", "441.02", "423.9", "997.02", "453.87", "443.22", "441.01", "423.3" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.44", "39.61", "38.93", "38.45", "35.11" ]

icd9pcs

[ [ [] ] ]

4920, 4992

2281, 3326

338, 463

5215, 5453

1648, 2258

6292, 6912

1573, 1587

3478, 4897

5013, 5194

3352, 3455

5477, 6269

1602, 1629

281, 300

491, 1224

1246, 1287

1303, 1557

72,540

173,755

6735

Discharge summary

report

Admission Date: [**2142-2-1**] Discharge Date: [**2142-2-8**] Date of Birth: [**2057-2-22**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3556**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: CVL Placement x4 PICC line placement ([**2142-2-6**]) History of Present Illness: 84 yo male with vascular dementia vs Alzheimer's, HL, DM II, CVA with right temporoparietal bleed who presents to the ED with AMS. At [**Hospital3 **] he was reported to have AMS and SBPs in the 80s. Per his wife he was increasingly lethargic at the nursing home. For the last 3-4 days he would not open his mouth to eat and "went down [**Doctor Last Name **] quickly." He was changed to a soft diet and was pouching his food. Prior to that time he was chewing normally. He had poor PO intake for multiple months and especially the last 3 weeks. He's had at least a 25 lb weight loss since [**Month (only) 216**] per his wife. Wife says he used to weight 200 lbs and now he weighs 158. Prior to [**Month (only) 205**] was walking at home with a cane and he stopped walking in the middle of [**Month (only) 216**]. At baseline does not have comprehensible speech. Per his wife he also had 4 UTIs in [**Month (only) 359**]. . In the ED, initial vs were: T 98.5, HR 124, BP 124/76, RR 16, SpO2 96% on unknown amount of oxygen. In the ED the patient was initially minimally responsive and non verbal. He was found to have a UTI with >1000 WBC and few bacteria for which he received Ciprofloxacin. He also had hypernatremia to 160 and received 1L of NS and then a second liter of NS with 40 of potassium since he was hypokalemic to 2.3. His mental status improved while in the ED and he became more alert but remained not oriented and non comprehensible. He initially was not hypotensive in the ED but became hypotensive to SBP of 80s prior to transfer and an IJ was placed. His lactate 2.2. His Trop was 0.05 and his EKG was notable for new septal q waves. He was given Aspirin 600 mg PR. His INR was 1.8. HCT was 29 (recent baseline 37). His left eye was notable for erythema and tearing which is chronic. He had a pressure ulcer on his left heel. . On arrival to the ICU, vitals were T axillary 100.4, BP 103/52 (dropped pressures to 80s soon after arrival with MAPs in 50s), RR 31, SpO2 92% on 50% shovel mask. Labs were notable for stable lactate (2.3), troponin increasing to 0.14 (from 0.05), K 4.4, bicarb improved from 16 to 21, creatinine to 2.3 (from 1.2), HCT up from 29 in ED to 39, WBC up to 14 from 8.6. He was originally groaning but opened his eyes more and became more interactive during the first hour. . Review of systems: Unable to obtain given AMS. Past Medical History: -Dementia, vascular vs. Alzheimer's -Hypercholesterolemia for which he takes Crestor. -Diabetes type 2, followed by Dr. [**Last Name (STitle) 3845**] [**Name (STitle) **]: right temporoparietal bleed [**2130**], with gait abnl, impairment in attention and executive functioning -Obstructive sleep apnea. Does not tolerate CPAP -Weight loss. -Polydypsia -Melanoma. right thigh in [**2115**]. -SCC on left cheek -baseline neuro exam in [**2139**] oriented to self only, poor attn, left hemineglect and hemianopsia, increase tone throughout, hyperesthesia from calf to toe Social History: Mr. [**Known lastname **] was born and raised in [**Location (un) 669**]. He then moved to [**Location (un) **] after marrying his wife. [**Name (NI) **] has two sons. [**Name (NI) **] ran an appliance business for many years until his stroke. He did not smoke nor does he drink alcohol. He cannot transfer out of bed on his own anymore. Speech does not make sense at baseline. Family History: Mother died at age 67 of breast cancer, father died at age 69 of CAD. Father had first MI in his 50s. Physical Exam: Physical Exam On Admission: Vitals: T axillary 100.4, BP 103/52 (dropped pressures to 80s soon after arrival with maps in 50s), RR 31, SpO2 92% on 50% shovel mask. General: Groaning and initially not opening his eyes. Knows his wife's name. Otherwise speaking nonsense. HEENT: extremely dry mucus membranes, erythema of left eye Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: ulcer on left heel, 1+ DP pulses, extremities warm, no clubbing, cyanosis or edema Neuro: oriented to self and wife's name, otherwise speaking nonsense, able to move all extremities, pupils equal and reactive, shoulder shrug intact, symmetric palate raise, CN XII intact. Brisk 3+ UE reflexes R>L, patellar reflexes +3 . Physical Exam On Discharge: General: NAD, reclining in bed HEENT: mucus membranes moist, erythema of left eye Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: ulcer on left heel, 1+ DP pulses, extremities warm, no clubbing, cyanosis or edema Neuro: oriented to self, otherwise speaking non sense, able to move all extremities, pupils equal and reactive, shoulder shrug intact, symmetric palate raise, CN XII intact. Pertinent Results: Admission Labs: [**2142-2-1**] 06:35PM BLOOD WBC-8.6 RBC-3.06*# Hgb-9.4*# Hct-29.4* MCV-96 MCH-30.6 MCHC-31.9 RDW-14.0 Plt Ct-141* [**2142-2-1**] 06:35PM BLOOD PT-19.6* PTT-37.4* INR(PT)-1.8* [**2142-2-1**] 06:35PM BLOOD Glucose-174* UreaN-43* Creat-1.2 Na-160* K-2.3* Cl-134* HCO3-16* AnGap-12 [**2142-2-1**] 06:35PM BLOOD cTropnT-0.05* [**2142-2-1**] 06:50PM BLOOD Lactate-2.2* Discharge Labs: [**2142-2-8**] 05:16AM BLOOD WBC-14.7* RBC-3.56* Hgb-10.5* Hct-31.4* MCV-88 MCH-29.3 MCHC-33.3 RDW-14.7 Plt Ct-197 [**2142-2-7**] 04:25AM BLOOD Neuts-90.6* Lymphs-6.5* Monos-2.4 Eos-0.3 Baso-0.1 [**2142-2-7**] 04:25AM BLOOD PT-13.7* PTT-25.6 INR(PT)-1.2* [**2142-2-8**] 05:16AM BLOOD Glucose-158* UreaN-18 Creat-1.0 Na-140 K-3.4 Cl-111* HCO3-21* AnGap-11 [**2142-2-8**] 05:16AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0 Brief Hospital Course: 84 yo male with vascular dementia vs Alzheimer's, HL, DM II, CVA with right temporoparietal bleed who presents to the ED with AMS in the setting of poor PO intake and was found to have hypernatremia, UTI, acute renal failure and hypotension. Hypernatremia treated with IV fluids D5W and NS and gradually resolved over first 3 days. UTI treated with vancomycin and meropenem with subsequent decrease in urinary WBCs. Urine culture only showed Diphtheroids, felt likely contaminant. Renal failure resolved gradually and serum creatinine normalized to baseline. Mental status gradually improved to baseline by around hospital day 3. Hypotension proved largely treatment resistant. Patient was ~16.5 L positive in fluid balance for total hospital stay but presented severely dehydrated with ~7 L free water deficit. Developed mild respiratory distress with pulmonary edema that responded to Lasix/albumin. Nevertheless continued to require IV pressor support. Trial of hydrocortisone for possible relative AI was not effective. Ultimately, given severity of patient's underlying dementia and inability to wean pressor support, family meeting was held and decision was made to make Mr. [**Known lastname **] [**Last Name (Titles) 3225**]. . Management by problem: # Shock: Intermittently hypotensive, likely reflective of sepsis. He was minimally responsive to IV fluids and pressors. He was placed on a Norepinephrine drip and then started on Midodrine without being able to wean off pressors. He had a 17 L positive fluid balance for LOS and appeared to be developing worsening pulmonary edema and pleural effusion. Trial of hydrocortisone did not show clear improvement in his pressures. He was treated for infection as below. . # Pulmonary edema: Net 17 L positive fluid balance. Taking into account ~7L free water deficit and dehydration on admission, still likely total body volume overloaded. . # Urinary tract infection: Culture demonstrated Corynebacteria. He was treated with Vancomycin and Meropenem with improvement in his UA. . # Altered mental status: Likely hypernatremia, hyperglycemia, and UTI all contributing with the largest contribution from metabolic abnormalities. He has a history of CVA in [**2130**]. No known fall to suggest subdural hematoma. His MS improved, likely to near baseline by the time of discharge with electrolytes and glucose now WNL. . # Hypernatremia: Likely due to poor PO intake over many weeks with a slow increase, and thus needed to be corrected slowly. Normalized during his stay with IV fluids. . # CAD: New q waves on EKG with trop leak potentially reflective of renal failure. CK and CK-MB did not suggest infarct. Echo on [**2142-2-2**] did not suggest any acute ischemia. Sick sinus and tachy-brady syndrome in setting of severe AS may have contributed to his hypotension. His beta blocker and ACE-I were held. . # Hyperglycemia: His FBGs were significantly elevated on admission and normalized with Insulin and hydration. He was placed on Lantus and Humalog sliding scale. His home Glipizide was held. . # Left Heel Ulcer: Appeared unchanged since admission. Podiatry saw over weekend and suggest no need for debridement of heel ulcer and no evidence of osteo. They recommended continued off loading with Multipodus boots and dry dressing changes. . # Elevated INR: The patient was not on Coumadin at home. His INR resolved from 1.8 to 1.2 with unclear explanation. Checked LFTs which were normal. Albumin 2.[**4-8**] suggest anabolic liver defect possibly due to poor nutrition. . # Acute on chronic renal failure: Creatinine 1.2 on arrival to ED and up to 2.3 on floor, now back to baseline after hydration. . # Hypothyroidism: Substituted Levothyroxine 100 mcg IV daily for 200 mcg PO daily. . # Prophylaxis: Heparin SC . # Goals of Care: Discussed with family and made [**Day Month 3225**] on [**2142-2-8**] . Medications on Admission: -Seroquel 37.5 mg q am -seroquel 25mg qhs -Crestor 40mg daily -Folic Acid 1 mg daily -Hydrochlorothiazide 25 mg daily -lorazepam 0.25mg q am -KCL 10meq daily -MVI daily -glipizide 1 tab by mouth [**Hospital1 **] -misoprostol 200mcg [**Hospital1 **] -lantus 10 units at bedtime-colace 100mg [**Male First Name (un) **] -verapamil 40mg q 8 hrs -senna 8.5mg qhs -meds crushed in apple sauce -levothyroxine 200mcg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. Disp:*30 Tablet(s)* Refills:*0* 2. haloperidol lactate 5 mg/mL Solution Sig: One (1) 0.5-1.0 mg Injection every four (4) hours as needed for anxiety or agitation. Disp:*30 * Refills:*0* 3. morphine 5 mg/mL Solution Sig: One (1) 2-4 mg Injection Q1H (every hour) as needed for discomfort: Titrate dose to comfort. Disp:*30 * Refills:*0* 4. lorazepam 2 mg/mL Syringe Sig: One (1) 0.5-1.0 mg Injection Q3H (every three hours) as needed for anxiety or agitation. Disp:*30 * Refills:*0* 5. Patient is [**Male First Name (un) 3225**] 6. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Vascular Dementia Hypernatremia Urinary Tract Infection Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname **], it was a pleasure caring for you during your hospitalization in the [**Hospital1 18**] [**Hospital Ward Name 332**] Intensive Care Unit. You were admitted because your family and care givers noticed a change in your mental status in the days prior to hospitalization. You were found to have infections in your urine and likely in your lungs as well as elevated levels of sodium and sugars in your blood. You were treated with antibiotics and IV fluids. Because of your infections and dehydration, your blood pressure was very low and you required medications to treat this. Your body did not completely respond to these treatments and ultimately the decision was made to focus on treating your symptoms as it did not seem we would be able to cure the underlying cause of your illness. You were discharged with ongoing treatments aimed at keeping you as comfortable as possible. Followup Instructions: Hospice Care at [**Hospital3 2558**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "348.30", "290.40", "276.0", "585.9", "599.0", "584.9", "995.92", "038.9", "244.9", "707.14", "E849.9", "250.80", "486", "272.0", "437.0", "E928.8", "285.9", "276.8", "414.01", "V49.86", "783.7", "785.52" ]

icd9cm

[ [ [] ] ]

[ "00.14", "38.97" ]

icd9pcs

[ [ [] ] ]

11293, 11363

6228, 8276

293, 349

11473, 11473

5393, 5393

12541, 12710

3769, 3874

10570, 11270

11384, 11452

10129, 10547

11609, 12518

5790, 6205

3889, 3903

4800, 5374

2733, 2763

231, 255

377, 2713

5409, 5774

3917, 4772

11488, 11585

2785, 3357

3373, 3753

15,243

135,360

43778

Discharge summary

report

Admission Date: [**2155-5-27**] Discharge Date: [**2155-6-4**] Date of Birth: [**2084-1-8**] Sex: F Service: MEDICINE Allergies: Cephalosporins Attending:[**First Name3 (LF) 2387**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: 1. Transesophageal echocardiogram ([**2155-5-29**]) 2. Thoracentesis ([**2155-5-29**]) 3. Midline IV ([**2155-5-28**]) History of Present Illness: Ms. [**Known lastname 4643**] is a 71 year-old female with a history of CAD/CHF, recent MVR, among others, presenting with shortness of breath. Recent hospitalization ([**Date range (1) 94068**]) with the following, brief course: Initially with respiratory failure (O2 sat in mid 70's with SBP in 200's; emergently intubated). This was felt to be multi-factorial (CHF, flash pulmonary edema, pneumonia); completed 10 days of levofloxacin. Extubated on [**4-22**] without event. Also had troponin leak in setting of CHF and renal failure but remained chest pain free during hospitalization. She underwent cardiac catheterization on [**4-24**] without intervention. Given severe mitral degenerative disease with MS and MR, felt to be contributing to recurrent bouts of CHF requiring hospitalization, underwent MVR on [**2155-5-5**]. Pre-operatively, underwent tooth extraction ([**2155-4-28**]) per oral surgery recommendation. Post-operatively, was volume overloaded requiring reintubation once and mask ventilation the second time. Experienced complete heart block after receiving lopressor; after this did not resolve, a permanent pacemaker was placed on [**2155-5-13**]. Was discharged on [**2155-5-26**] to rehab. Awoke this morning and felt short of breath. This did not wake her out of sleep and did not come on suddenly. She notified staff and was given 100mg lasix PO at 7am. Also dose with amiodarone 400mg (known medication) and her home dose of NPH (18 units). Was found to be 85% on 2.5L NC (after started at 97% on room air) and was therefore sent to [**Hospital1 18**] for further evaluation. Vitals in the ED showed, T 103.6 (rectal), HR 95, 137/86 --> 182/79, RR 34, 100% on NRS. . A PIV could not be placed, so given nitropaste, captopril 6.35mg SL. Placed on CPAP with 5 PEEP (off at 9:45am). A femoral line was placed and 80mg IV lasix was given (9am). Nitro gtt started. Blood and urine cultures were drawn and vancomycin, 1gram and ceftazidime 1gram were given. Urine output of 225mg in the ED. Currently, the patient is feeling well. Her SOB is much improved. Other than the mild SOB, she had no complaints. She denies chest pain or pressure, palpatations, subjective fever or any other issues. Of note, the patient reports having arrived at [**Location (un) **] yesterday late in the day and she does not belive that she received her PM doses of medications. There is no recording of her having gotten her PM dose of glipizide, lasix, metolazone. Past Medical History: 1. Coronary artery disease: a. MI ([**2128**]) s/p PTCA b. MI ('[**45**]) c. CABG ('[**45**]) --> LIMA to LAD --> SVG to PDA (occluded as of '[**45**]) --> SVG to diagonal (occluded as of '[**45**]) d. PCI ([**4-6**]) --> LAD with 70% stenosis just prior to a large first diagonal s/p stenting of LAD/D1 (3.0x20 mm Taxus (DES) e. PCI ([**7-8**]) --> RCA with 60% stenosis s/p stenting (Cypher 3.5x8mm and 3.0x33 overlapping) f. PCI ([**4-8**]) --> LAD with 70% stenosis after insertion of the LIMA graft s/p stenting (2.5x13mm Cypher DES) g. Cath ([**2155-4-24**]) --- no interventions h. s/p pacemaker ([**2155-5-13**]) for complete heart block CURRENT ANATOMY: a. LMCA had an ostial 30% stenosis b. LIMA --> LAD (patent) - LAD/D1 stent (patent) - LAD stent distal to LIMA graft (patent) - SVG to PDA (occluded as of '[**45**]) - SVG to diagonal (occluded as of '[**45**]) c. LCX diffusely diseased d. Very small OM1 and a small bifurcating OM2 with an ostial 40%stenosis e. RCA is dominant vessel and showed a distal 50% stenosis. - RCA proximal stent (patent) OTHER PAST HISTORY: 1. Diabetes mellitus: A1c ([**2151-9-3**]): 8.8* 2. Hypertension 3. Hyperlipidemia: ([**2151-9-3**]): TC 206, TG 411, HDL 48, LDL 118 4. Congestive heart failure: - Ejection Fraction: 40% (nl >=55%) - E/A Ratio: 1.31 5. History of MR/MS s/p MVR (25-mm Mosaic porcine tissue valve) on [**2155-5-5**] 6. History of atrial fibrillation: ? diagnosed during last hospitalization 7. Chronic kidney disease: baseline SCr 1.1-1.3 8. Restless leg syndrome PAST SURGICAL HISTORY 1. s/p hysterectomy 2. s/p spinal cyst removal 3. s/p appendectomy 4. s/p cataracts removal Social History: Significant for the absence of current tobacco use (quit >40 years ago). There is no history of alcohol abuse (prior occasional use). Previously lived with daughter and grandson. [**Name (NI) **] PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] victim of [**Name Initial (NameIs) **] abuse by the daughter. Recently discharged from [**Hospital1 18**] and is coming from [**Hospital **] Health Care. Worked as a book-keeper. Her HCP is [**Name (NI) **] [**Name (NI) 94069**] (attorney/friend); #[**Telephone/Fax (1) 94070**]. Before prior admission, patient was ambulatory and driving. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 99.5 (oral), BP 114/42, HR 68, RR 13-->28, O2 97% on 2L NC Gen: Elderly female, mildly overweight, lying in bed (at 30 degrees) in no distress; breathing comfortablely. Oriented to person, "[**Hospital1 18**]" and "[**2155-5-4**]". 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 10cm. CV: RR, normal S1, S2. Soft II/VI sytolic murmur, best heard at lower sternal border. No thrills, lifts. No S3 or S4. Chest: Midline sternal incision looks intact with no erythema, tenderness or dehiscence. Decreased breath sounds at right base; no crackles heard. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No clubbing, cyanosis; trace edema. No distal stigmata of endocarditis. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMIT LABS: 134 95 46 ---------- < 333 5.7 26 2.0 . Trop-T: 0.43 CK: 48 MB: Notdone WBC: 7.9 N:91.5 L:5.0 M:2.0 E:1.1 Bas:0.4 Poiklo: 1+ HCT 29.9 (MCV 92) PLT: 272 PT: 21.4 PTT: 36.3 INR: 2.1 UA: 1.012/7.0; Urobil 1; Bld Mod; Prot 30; Ket 15; RBC 0; WBC 0-2; Bact Few. Otherwise negative. Lactate 1.7 EKG ([**2155-5-20**]): Sinus rhythm. A-V conduction delay. Left bundle-branch block. Compared to the previous tracing of [**2155-5-16**] ventricular ectopy is absent and the rate has slowed. Otherwise, no diagnostic interim change. EKG ([**2155-5-27**]): Sinus rhythm (92 bpm). LBBB and left axis. Long PR (246ms). No clear diagnostic ST-T changes. 2D ECHO ([**2155-5-21**]): The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Septal motion is dysnchronous, but the remaining segments appear to contract well. EF ~40%. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic valve stenosis is seen. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present with normal gradient and mobile leaflets. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . 2D ECHO ([**2155-5-28**]) Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed. Tissue synchronization imaging demonstrates significant LV dyssynchrony with the lateral wall contracting 85 ms later than the septum. There is mild global right ventricular free wall hypokinesis. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. ETT ([**2151-6-17**]): This 67 year old woman was referred to the lab for evaluation of her CAD (s/p MI [**28**], cabg [**29**]). The patient exercised for 9.5 minutes of a [**Hospital1 **] modified [**Doctor First Name **] protocol and was stopped for fatigue. Poor functional capacity. The patient was asymptomatic throughout. The rhythm was sinus with rare isolated APBS and VPBS. The ST segment was uninterpretable for ischemic changes secondary to digoxin therapy and complete LBBB. ST elevations were noted on resting EKG in V1-V4 (consistent with baseline EKG, Q wave leads). Sinus brady at rest in the setting of beta blockade therapy. Appropriate hemodynamic response to imposed demands. IMPRESSION: Uninterpretable ST segment for ischemic changes in the absence of anginal symptoms CARDIAC CATH ([**2155-4-24**]): 1. Selective coronary angiography in this right dominant system revealed three vessel coronary artery disease. The LMCA was patent. The LAD was patent with patent stents in the diagonal branch and proximal LAD. The LCx was widely patent. The OM that had previous PTCA was patent. The RCA was patent. The previously placed stents in the RCA were patent. 2. Arterial conduit angiography demonstrated a patent LIMA-LAD. 3. The known occluded vein grafts were not engaged. 4. Left ventriculography demonstrated an ejection fraction of 44%. There was [**3-8**]+ mitral regurgiation and global hypokinesis. The mitral valve was very calcified. HEMODYNAMICS: Resting hemodynamics demonstarted an elevated RVEDP of 17 mmHg. There was pulmonary arterial hypertension with a pulmonary artery pressure of 52/17 mmHg. Pulmonary capillary wedge pressure was 22 mmHg. There was a mean gradient of 9.3 mmHg across the mitral valve. There was no gradient across the aortic valve. Cardiac index was perserved at 2.5 l/min/m2. There was moderate mitral stenosis with a mitral valve area of 1.4 cm2. CXR: Pending. On my read, right sided pleural effusion, which is unchanged from yesterdays exam. No obvious change from prior study. Brief Hospital Course: 1. Dyspnea: Given the patient's history of heart failure (presumed diastolic given preserved EF), this may have been secondary to CHF with possible flash pulmonary edema. The recent MVR was done, in part, to help reduce the frequency of flashes and CHF exacerbations. Is is possible that she had hypertension (possibly from fever/catecholamine release) causing an acute flash. CXR did not show overt pulmonary edema and oxygen requirement was significantly lower after a short time on CPAP; this was even before any significant diuresis took place. She was initially treated with IV lasix with continuation of metolazone/aldactone PO. Once her pulmonary edema improved, she was transitioned back to PO lasix with good effect. Given her elevated SCr, her ACEI was held. A TEE was performed and showed that the mitral valve prosthesis (MVR) was well seated with normal leaflet/disc motion and transvalvular gradients. There was trivial MR. [**Name13 (STitle) **] ACEi was continued to be held given her worsening ARF. Her Metolazone 5mg [**Hospital1 **] was held the day of admission given that she appeared mildly dry and her Cr rose slightly (2.5 on day of discharge). This should be restarted once her Cr is rechecked and returns to her baseline (1.3-1.5) or if pulmonary edema reaccumulates. . 2. CAD: History of multivessel diseasea, s/p CABG and multiple cath and stents (see PMH). Chest pain free during stay with negative cardiac enzymes. Regarding risk factor management, an A1c was checked and at goal (5.9). Lipid panel showed LDL 56 and HDL 32. Given the transaminitis, the patient's statin was held. The aspirin, beta-blocker were continued. ACEI was held, as above. Her Lipitor 40mg qD should be restarted once her LFTs are rechecked in 1 week and return to normal. Her ACEi should be restarted once her Cr returns to baseline (1.3-1.5). Her creatinine was 2.6 at day of discharge. . 3. Rhythm: In NSR, s/p pacemaker placement during last admission (for complete heart block). It was somewhat unclear as to why the patient presented on amiodarone and coumadin; possibility of afib during last hospitalization, although there is no mention of this the discharge summary. The amiodarone was stopped in the setting of elevated LFTs. The coumadin was also stopped; initially given that she may have had procedures, later given that she did not appear to have recurrance of afib. These should not be restarted without consultation with her cardiologist Dr. [**Last Name (STitle) **]. . 4. Fever: The two most likely etiologies were infection and drug induced. Regarding the former, there were no clear sources, but she did have multiple suspect areas (sternal wound, recent pacer, MVR, pleural effusion, among others). Wound and pacer did not look infected. Cultures were drawn in the ED and thereafter and showed no growth. A TEE showed no vegetations. She was initially started on ceftriaxone and vancomycin. When she developed eosinophelia and rash, in addition to elevated LFTs, there was thought given to the possibility of drug fever. The antibiotics, amiodarone and atorvastatin were stopped. In addition, viral studies (EBV/CMV/Hep) were sent and negative. She defervesced on HD#2 after discontinuing her Abx and she remained afebrile throughout the rest of her hospitalization. . 5. Anemia: Mild anemia with hemolysis labs showing low haptoglobin and elevated LDH. No schistos were seen on smear. Heme felt this was due to hemolysis from her MVR. Got one unit of pRBCs on [**5-28**] and her hematocrit was followed daily and remained stable. . 6. Transaminitis: Unclear etiology. [**Month (only) 116**] have been secondary to medications (amiodarone, ceftriaxone?), infection, transient hypotension. As above, possible offending agents were stopped and viral studies were sent. Her LFTs trended down throughout her hospitalization (peak ALT/AST 1000). She should not be re-exposed to a PCN/cephalosporin given her new allergy. . 7. Hyperlipidemia: On statin as oupatient; this was stopped, as outlined above. Pls restart once LFTs return to normal. . 8. Hypertension Aggresively treated HTN, given possiblity that she has flash pulmonary edema in the setting of acutely elevated BPs. Beta-blocker and diuretics were continued while ACE was held. Captopril 25mg tid should be restarted once her Cr returns to baseline. . 9. Diabetes mellitus: Continued home regimen with HISS. Held oral Glipizide 10mg [**Hospital1 **] given her ARF. This should likely not be restarted until her ARF resolves back to her baseline. Please continue with Insulin NPH 18 qAM, 6 qPM and Insulin SS until you are able to restart her oral Glipizide medication once her ARF resolves. . DISPO - Full Code. Pt is to be transferred to rehab and f/u with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (her cardiologist) 2-4 weeks after discharge. Medications on Admission: 1. ASA 325mg daily 2. Amiodarone 400mg daily (through [**5-30**]), then 200mg daily 3. Toprol XL 100mg daily 4. Aldactone 25mg daily 5. Lasix 80mg [**Hospital1 **] 6. Metolazone 5mg [**Hospital1 **] 7. Captopril 25mg TID 8. Lipitor 40mg daily 9. Coumadin 1mg QHS 10. Glipizide 10mg [**Hospital1 **] 11. Insulin NPH 18/8 12. Folate 1mg daily 13. Zoloft 50mg daily 14. Iron 300mg daily 15. Senna 16. Colace 17. Protonix 40mg daily 18. Percocet PRN Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO qAM. 5. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous qAM. 6. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: 6 (six) units Subcutaneous qPM (at dinnertime). 7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Per standard sliding scale units Subcutaneous three times a day: please begin to cover at FS of 120. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. midline care per standard midline care protocol Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare - [**Location (un) 1887**] Discharge Diagnosis: Primary: 1. Fever 2. Transaminitis due to Cephalosporin allergy 3. Acute pulmonary edema Secondary: 1. Coronary artery disease 2. s/p Mitral valve repair 3. Chronic kidney disease 4. Diabetes mellitus 5. Hypertension 6. Hyperlipidemia Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted with congestive heart failure and pulmonary edema. You were diuresed and doing better. You were given an Anbitiotic called Ceftriaxone (a Pencillin derivative). You developed an allergic reaction to it and you should not be prescribed a Pencillin or Cephalosporin antibiotic in the future. Please inform your doctors of this [**Name5 (PTitle) **] allergy. Please weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight > 3 lbs. Adhere to 2 gm sodium diet and maintain a fluid Restriction of less than 2 liters of fluid daily. If you develop fevers, chest pain, shortness of breath, difficulty breathing, or any other concerning symptoms, please tell your doctors [**Name5 (PTitle) **] report to the nearest ER. Followup Instructions: 1. You have an appointment with Dr. [**Last Name (STitle) **] on [**2155-6-18**] at 2:15pm at [**Hospital6 2910**], [**Doctor Last Name 3649**] 430. 2. Please follow up with a counselor or with psychiatry. With a provider's guidance, you may consider increasing your Zoloft dosing. ([**Telephone/Fax (1) 24780**] ([**Hospital1 18**] psychiatry appointment phone number). Completed by:[**2155-6-4**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "88.72", "34.91" ]

icd9pcs

[ [ [] ] ]

17434, 17522

10721, 15608

294, 415

17802, 17841

6405, 10698

18644, 19047

5300, 5382

16105, 17411

17543, 17781

15634, 16082

17865, 18621

5397, 6386

234, 256

443, 2922

2944, 4674

4690, 5284

44,685

189,219

13310+56455

Discharge summary

report+addendum

Admission Date: [**2175-12-1**] Discharge Date: [**2175-12-12**] Date of Birth: [**2103-5-26**] Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccine Attending:[**Doctor First Name 3290**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 72 F with history of COPD (does not use home O2), non small cell Lung CA of lingula s/p resection, hyperparathyroidism who presents s/p fall. She was in her usual state of health until yesterday when she got up from her couch in her socks, slipped and fell on her left arm. Did not hit her head, no LOC. She reported to the ED where she was found to have a left proximal humeral fracture and left superior rami fracture. Ortho evaluted pt- the superior rami fracture is managed medically. The proximal humeral fracture might be surgically managed but pt declines at this time. . In the ED, initial vs were: T 97.3 P103 BP 104/65 R 20 97% O2 sat. Patient was given 4mg zofran, morphine (4mg IV x2, 15mg PO), 500mg tylenol, 1mg IV dilaudid. Prior to transfer, vitals were: HR 90, BP 118/60, RR 18, 94%RA. . On the floor, pt reports hip and shoulder pain. Has some nausea from the dilaudid. Otherwise feels comfortable. T 95.7, BP 110/60, HR 70, 16, 95% RA. Past Medical History: 1. Severe COPD/Bronchitis (multiple hospitalizations) 2. Asthma/COPD - never intubated. FEV1/FVC = 39% 3. GERD - pt cannot tolerate H2 blockers or PPIs; s/p fundoplication [**2172**] 4. Barrett's esophagus [**1-10**] GERD; esophagitis confirmed [**1-16**] EGD 5. Lingular non-small cell lung CA, s/p resxn [**2166**] 6. H/o sinusitis 7. h/o allergic rhinitis 8. constipation, 9. hyperparathyroidism, 10. hyperkalemia 11. vitamin D deficiency 12. osteopenia 13. Right middle lobe pulmonary nodule - stable for 3 years Social History: Lives in [**Location 40525**] by herself. No children, not married. 40 year smoking history, smoking 1-2 packs per day. Retired guidance counselor of middle school in [**Location (un) **]. Family History: Mother died of a stroke at 77. Father died of lung CA age 70. + tobacco use. Physical Exam: ADmission Exam: Vitals: T 95.7, BP 110/60, HR 70, 16, 95% RA. General: Alert, oriented, comfortable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP around 8, no LAD Lungs: few scattered crackles bilaterally in lower bases, no wheezes, no rhales CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Left arm in a sling. No bruising. Pertinent Results: CXR: IMPRESSION: Left fifth posterior rib defect from prior thoracotomy. No acute fracture is seen. Shoulder: Impacted left humeral head fracture. C-spine: Incomplete views of the cervical spine on the lateral projection. No significant malalignment is seen, however, CT examination is recommended for further evaluation. Hip: IMPRESSION: Stepoff at the left superior pubic ramus raises the concern for a pelvic fracture. A CT examination can be considered for further evaluation. Brief Hospital Course: 72 year-old F with history of COPD, non small cell Lung CA of lingula s/p resection, hyperparathyroidism who presents s/p mechanical fall found to have left proximal humeral fx and left superior pubic rami fracture. . # Left proximal humeral fx: Orthopedic team evaluated patient. Patient declined surgery as she has several comorbitities putting her at risk. Pain was controlled with narcotics. Arm supported with sling. She has a sling for comfort and is not allowed to do heavy lifting. She might re-consider ORIF vs hemiarthoplasty in future if patient reconsiders surgery. She was to follow-up with orthopedic surgery in late [**Month (only) 404**]. She does not require dvt prophylaxis with lovenox for her upper extremity fracture per ortho. She was seen by PT/OT while in the hospital. She received MS Contin 15mg [**Hospital1 **] while in the hospital and this should be tapered off as her pain improves. . # Left pubic ramus fracture: Medicaly managed. No ROM restrictions . #Pneumonia: She developed a fever up to 101.5, despite 1 g of Tylenol. UA was clean, but CXR showed a RLL pneumonia. She was started on Levoflox/Flagyl on [**2175-12-3**], but continued to deteriorate requiring more oxygen. She was switched to Vanc/Zosyn/Levoflox and required ICU transfer for monitoring where she was stable on 35-50% shovel mask. She was continued on ceftriaxone and azithromycin and completed an 8 day course on [**2175-12-11**]. She was also started on a 7-day prednisone taper 60-40-40-20-20-20-20 mg out of concern for wheezing and concomitant COPD exacerbation which completed on [**2175-12-11**]. CXR on HD#7 showed worsening R pleural effusion. Ultrasound showed small effusion with some organization. On [**12-6**], she was satting 95% on RA she was transferred to the floor. At the time of transfer to rehab her 02 sat was 93% on 1-2L/min nasal cannula. Continue to wean oxygen as tolerated to maintain SpO2 > 93%. Recommend continuing scheduled nebulizer or MDI treatments while patient requires supplemental oxygen. . # Osteopenia: Patient has several risk factors for fractures including hyperparathyroidism, repeated prednisone use for COPD exacerbations, vit D deficiency. She was on calcium and vitamin D at home. She was continued on vitamin D and calcium. She has been approved by her insurance for reclast but has not yet received a dose. Please recommend that patient address starting Reclast with her primary care provider after discharge. . # COPD: She was also started on a 7-day prednisone taper 60-40-40-20-20-20-20 out of concern for wheezing and concomitant COPD exacerbation which completed on [**2175-12-11**]. She had no cough, no fevers, or wheezing on discharged. Her O2 requirement gradually decreased during her hospitalization. She is being discharged on her home inhalers. . # She was on lovenox for DVT prophylaxis and sent to rehab on hep sc which can be stopped once she is ambulating regularly. . # Acute Renal Failure: Her creatinine climbed up to 1.2 and later her ARF resolved and her creatinine was 1.2. This ARF may be secondary to dye as well as pre-renal azotemia as the patient was clinically dry at the time of her renal failure. . # Constipation: She had no BM for 8 days. She then moved her bowels on [**2175-12-10**]. She is being dicharged on colace, senna, and miralax. . # Pulmonary Nodule: Per Pulm notes has been stable for 3 years. . #Communication was with the patient and her brother Father [**Name (NI) **] [**Name (NI) 6359**] . [**Name (NI) 40526**] fathers [**Name2 (NI) 40527**] [**Location (un) 16221**], [**Numeric Identifier 40528**] ([**Telephone/Fax (1) 40529**]. . # Code status: Full Medications on Admission: FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts(s) nasally once daily FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 Puffs(s) inhaled twice a day LEVALBUTEROL TARTRATE [XOPENEX HFA] - 45 mcg/Actuation HFA Aerosol Inhaler - 2 puffs(s) inhaled up to four times daily as needed for shortness of breath or wheezing POLYETHYLENE GLYCOL 3350 [MIRALAX] - once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule - 1 capsule(s) inhaled once a day ACETAMINOPHEN - (OTC) - 325 mg Tablet - 2 Tablet(s) by mouth every 6 hours as needed for fever or pain CALCIUM CARBONATE-VIT D3-MIN [CALTRATE PLUS] - 1 Tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Tablet - 2 Tablet(s) by mouth once a day LORATADINE-PSEUDOEPHEDRINE [CLARITIN-D 24 HOUR] - 240 mg-10 mg Tablet Sustained Release, 1 tab daily SODIUM BICARB-SODIUM CHLORIDE [NEILMED SINUS RINSE COMPLETE] - Packet - once a day Discharge Medications: 1. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours): One left arm/shoulder pain improves this should be tapered off. 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hrs on and 12 hrs off. 3. fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 4. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puff Inhalation four times a day as needed for shortness of breath or wheezing. 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool and can stop when no longer on pain meds. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2) Tablet PO once a day. 10. loratadine-pseudoephedrine 10-240 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day as needed for congestion. 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day: while not moving a lot at rehab. 12. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Left proximal humeral fracture Left pubic rami fracture Healthcare acquired pneumonia COPD exacerbation Discharge Condition: Alert and oriented x3 Ambulatory Status with assistance On supplemental oxygen 1-3L/min per nasal cannula Discharge Instructions: It was a pleasure providing care for your during your hospitalization. You were admitted for a fracture in your left arm and in your pelvis. The decision was made to treat you with pain medications and physical therapy instead of surgery. You developed a pneumonia and you have completed your course of antibiotics. You developed an exacerbation of your COPD and you completed your course of steroids. The following medications were started: -ducosate sodium 100mg twice a day as stool softener while on pain meds -senna 1 tab twice a day as needed for constipation -miralax 17g once a day as needed for constipation -morphine sustained release (MS Contin) 15mg twice a day for pain -lidocaine patch applied daily to arm as needed for pain After rehab you will likely start a medication called Reclast for your osteopenia (weak bones). It is important that you discuss this medication with your primary care provider. . There were no other changes to your medications as you completed your antibiotics and steroids in the hospital. Please take the following medications as previously prescribed. -FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 Puffs(s) inhaled twice a day -LEVALBUTEROL TARTRATE [XOPENEX HFA] - 45 mcg/Actuation HFA Aerosol Inhaler - 2 puffs(s) inhaled up to four times daily as needed for shortness of breath or wheezing -POLYETHYLENE GLYCOL 3350 [MIRALAX] - once a day as needed for constipation -TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule - 1 capsule(s) inhaled once a day -CALCIUM CARBONATE 600mg twice a day -CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Tablet - 2 Tablet(s) by mouth once a day -LORATADINE-PSEUDOEPHEDRINE [CLARITIN-D 24 HOUR] - 240 mg-10 mg Tablet Sustained Release, 1 tab daily -SODIUM BICARB-SODIUM CHLORIDE [NEILMED SINUS RINSE COMPLETE] - Packet - once a day Please follow up with your primary care doctor within 1 week of discharge from rehab. Followup Instructions: Please follow up with your primary care provider within one week of discharge from rehabilitation. . Department: ORTHOPEDICS When: THURSDAY [**2175-12-28**] at 10:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2175-12-28**] at 10:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: FRIDAY [**2175-12-29**] at 10:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: FRIDAY [**2175-12-29**] at 11:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Known lastname 917**],[**Known firstname **] Unit No: [**Numeric Identifier 7337**] Admission Date: [**2175-12-1**] Discharge Date: [**2175-12-12**] Date of Birth: [**2103-5-26**] Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccine Attending:[**Doctor First Name 376**] Addendum: See BRIEF HOSPITAL COURSE Brief Hospital Course: Pulmonary nodule: Final report of CTA chest suggests interval increase in density of known right lower lobe pulmonary nodule. Three month follow up imaging in recommended. Patient was instructed to follow up with her primary care provider regarding this follow up. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**] Completed by:[**2175-12-12**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13529, 13737

13239, 13506

291, 298

9538, 9646

2712, 3199

11608, 13216

2048, 2126

7854, 9297

9411, 9517

6920, 7831

9670, 11585

2141, 2693

247, 253

326, 1284

1306, 1826

1842, 2032

15,379

160,009

11399+56301

Discharge summary

report+addendum

Admission Date: [**2171-11-9**] Discharge Date: [**2171-11-18**] Date of Birth: [**2104-5-20**] Sex: F Service: Surgery, Gold Team HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old woman with a history of asthma who was originally admitted to [**Hospital3 **] Hospital on [**11-1**] with a 24-hour history of severe upper abdominal pain, nausea, and vomiting which was evaluated by ultrasound and CT scan of the abdomen. On admission to the hospital with elevated lipase, amylase, bilirubin, and ultrasound results significant for gallstones. A CT scan of the abdomen revealed pancreatitis with poor perfusion of the neck of the pancreas. She was initial treated on the surgical floor; however, she had some respiratory distress requiring transfer to the Surgical Intensive Care Unit. She was treated aggressively, however, not requiring intubation. On admission, she was started and continued throughout her admission on Unasyn. A follow-up CT scan of the abdomen on [**11-4**] showed progression of the pancreatitis with a marked decrease of visualization in the body of the pancreas, consistent with necrosis. On hospital day five she began to become febrile at which time another CT scan of the abdomen was performed which showed a necrosis of the neck and body of the pancreas, enlarging intra-abdominal fluid, peripancreatic fluid with enhancing rim, and large pleural effusions. She was started on hyperalimentation peripherally and then converted to central total parenteral nutrition. She was transferred to the [**Hospital1 188**] where she had persistent fevers, worsening abdominal pain, and the above-mentioned CT results. PAST MEDICAL HISTORY: (Past medical history was significant for) 1. Asthma. 2. A tonsillectomy. 3. Right inguinal hernia. ALLERGIES: She had no known drug allergies. MEDICATIONS ON ADMISSION: No medications on admission. SOCIAL HISTORY: She is an occasional drinker. No tobacco. REVIEW OF SYSTEMS: Her review of systems was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: On admission, the person dictating was not the person who initially examined the patient; however, the patient was found to be febrile with a temperature of 101.3, blood pressure of 128/61, heart rate of 107, respiratory rate of 18, oxygen saturation of 94% on room air. She was alert and conversant with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 15 and anicteric sclerae, pink conjunctivae, moist mucous membranes. No jugular venous distention. Lungs were clear to auscultation bilaterally, decreased breath sounds at the bases. She had a soft, obese, and tender abdomen which was tender in the epigastrium with positive rebound, positive cough tenderness, positive shake tenderness, and positive bowel sounds. On rectal examination she was heme-negative. No mass was palpate, soft stool, positive external hemorrhoids. She had no clubbing, cyanosis or edema, and her pulses were palpable bilaterally. LABORATORY DATA ON PRESENTATION: Her laboratories on admission were white blood cell count 17.1, hematocrit 33, platelets 390; 81% neutrophils, 6% bands. Sodium of 133, potassium of 4.4, chloride of 98, bicarbonate of 31, BUN of 13, creatinine 0.4, glucose of 284. PT was 13.2, PTT was 24.1, INR of 1.2. AST 39, ALT 50, alkaline phosphatase 107. Calcium 7.6, magnesium 1.6, phosphate 2.5, albumin 2.3, total bilirubin 1.1, amylase 1.4. RADIOLOGY/IMAGING: CT scan as above. Chest x-ray showed large bilateral effusions and positive central line in the superior vena cava. No pneumothorax. HOSPITAL COURSE: She was admitted to the hospital to the Surgical Intensive Care Unit and started on vancomycin, ciprofloxacin, Flagyl, as well as continued on total parenteral nutrition. She had pan cultures. She was started on a insulin sliding-scale, and her electrolytes were repleted. The patient did well and was transferred out of the Surgical Intensive Care Unit to the floor. On the following day, [**11-10**], the patient did well on the floor. She required oxygen to maintain her oxygen saturations above 92%. She was given some albuterol nebulizers and was started on meter-dosed inhaler albuterol inhaler which improved her sensation of shortness of breath, and her oxygen saturations quickly improved. She was kept n.p.o. and on total parenteral nutrition allowing for the inflammation within her pancreas to resolve. Her vital signs remained stable throughout her hospital course. On [**11-16**], total parenteral nutrition was stopped, and she was started on clear liquids and was tolerating them without any abdominal pain. On [**11-17**] she began tolerating a soft regular diet, and on [**11-18**] she was discharged to home in stable condition. Prior to discharge she had a CT scan of the abdomen to [**Month (only) 11197**] for progression versus resolution of her abdominal findings, for which she was to follow up for the results with Dr. [**Last Name (STitle) 1305**] in the future. The patient was afebrile on admission, and the fever continued until hospital day six. Pan cultures were sent on admission, all of which came back negative for infection, and the patient's fever resolved on triple therapy antibiotics. MEDICATIONS ON DISCHARGE: 1. Dilaudid 2 mg one to two tablets q.4-6h. p.r.n. for pain. 2. Zantac 150 mg 1 tablet p.o. b.i.d. She was started on Lopressor in the hospital; however, she was to follow up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 11197**] for the need for antihypertensive medication in the future. DISCHARGE DIAGNOSIS: Necrotizing pancreatitis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**] Dictated By:[**Last Name (NamePattern1) 2649**] MEDQUIST36 D: [**2171-11-18**] 13:10 T: [**2171-11-21**] 10:43 JOB#: [**Job Number 36448**] (cclist) Name: [**Known lastname 6757**], [**Known firstname 6758**] Unit No: [**Numeric Identifier 6759**] Admission Date: [**2171-11-9**] Discharge Date: Date of Birth: [**2104-5-20**] Sex: F Service: HOSPITAL COURSE: The patient required sliding scale regular insulin while on total parenteral nutrition, as well as for a couple of days thereafter. However, once started on American Diabetes Association diet, the patient no longer required insulin to keep her blood sugar within normal range. Hence, the patient was not discharged on any diabetic medications. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1255**], M.D. [**MD Number(1) 1256**] Dictated By:[**Last Name (NamePattern1) 5543**] MEDQUIST36 D: [**2171-11-18**] 13:13 T: [**2171-11-20**] 10:02 JOB#: [**Job Number 6760**]

[ "790.2", "574.51", "493.90", "577.0" ]

icd9cm

[ [ [] ] ]

[ "99.15" ]

icd9pcs

[ [ [] ] ]

5645, 6193

5297, 5623

1870, 1900

6211, 6836

1982, 3614

177, 1670

1693, 1843

1917, 1961

44,863

139,400

41638

Discharge summary

report

Admission Date: [**2117-9-20**] Discharge Date: [**2117-10-8**] Date of Birth: [**2061-4-25**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: Respiratory failure, [**First Name3 (LF) 7816**]-[**Location (un) **] Paralysis Major Surgical or Invasive Procedure: Plasmapheresis endotracheal intubation and mechanical ventilation Tracheostomy placement History of Present Illness: 56 yo male admitted to [**Hospital3 **] Hospital [**9-15**] with 10 days of supposed Campylobacter diarrhea associated with low grade temp. He developed bilateral facial numbness approximately 5 days prior to presentation, followed by paresthesia of bilateral fingers, distal lower extremities and the trunk. This was associated with generalized weakness which prompted ED visit. By time of presentation, his diarrhea had subsided. His symptoms progressed to include muscle weakness of upper and lower extremities. Lumbar puncture showed elevated protein at 58 consistent with [**First Name9 (NamePattern2) **] [**Location (un) **], and CSF glucose of 52. He was electively intubated on [**9-17**] following decrease in forced vital capacity and NIF. Neurology was consulted and pt was started on IVIG. However, he developed a rash on day 2, and then anaphylactic reaction on day 4 (spiked temp and developed rigors). Immunology Consultation suggested transfer to [**Hospital1 18**] for plasmapheresis. On day of transfer, pt developed temp of 101.1. . While in ICU, pt also developed an aspiration pneumonia for which he was started on zosyn on [**9-19**]. . Review of systems: Per records, 10 pound weight loss in 10 days preceeding admission. Had been having hourly bowel movements for 3-4 days initially, decreased to daily bowel movements since admission. Past Medical History: - hypothyroidism - GERD - dyslipidemia - prior back surgery for ruptured disk [**2085**] Social History: wife is a pharmacist. He works in an autoparts store. Prior to this episode, was very active, did 120 push-ups/day and worked out frequently. - Tobacco: quit in [**2101**] - Alcohol: social - Illicits: denies Family History: Father died at 70 from complications of head and neck surgery. Mother died at 82 following complication from hip fracture. Physical Exam: On Admission: General: sedated, opens eyes on command but does not follow any other commands HEENT: pupils equal and reactive, MMM 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, diffusely tender to palpation R>L, non-distended, bowel sounds present, difficult to assess rebound, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: diffusely areflexic On Discharge: General: Awake and alert. Following commands. Appears improved generally from yesterday. HEENT: pupils equal and reactive, MMM. Extubated. Neck: supple, JVP not elevated, no LAD Lungs: Trached. Breath sounds improved although still rhoncorous diffusely CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: to move both feet and calves on command, able to shrug shoulder, squeezes both hands, bicep muscles contract, able to lift left forearm off the bed Pertinent Results: On Admission: [**2117-9-21**] 04:19AM BLOOD WBC-26.0* RBC-3.43* Hgb-11.2* Hct-30.5* MCV-89 MCH-32.6* MCHC-36.7* RDW-12.6 Plt Ct-282 [**2117-9-20**] 07:36PM BLOOD Neuts-94.2* Lymphs-1.9* Monos-2.8 Eos-0.8 Baso-0.3 [**2117-9-20**] 07:36PM BLOOD PT-11.9 PTT-30.9 INR(PT)-1.0 [**2117-9-20**] 07:36PM BLOOD Glucose-133* UreaN-18 Creat-0.6 Na-134 K-4.4 Cl-98 HCO3-28 AnGap-12 [**2117-9-20**] 07:36PM BLOOD ALT-48* AST-67* LD(LDH)-346* AlkPhos-63 TotBili-0.4 [**2117-9-20**] 07:36PM BLOOD Calcium-8.6 Phos-3.1 Mg-2.3 On Discharge: [**2117-10-7**] 08:30AM BLOOD WBC-9.6 RBC-3.67* Hgb-11.3* Hct-34.6* MCV-94 MCH-30.9 MCHC-32.8 RDW-13.1 Plt Ct-408 [**2117-10-6**] 05:20AM BLOOD Neuts-79.5* Lymphs-7.8* Monos-9.0 Eos-2.9 Baso-0.7 [**2117-10-7**] 08:30AM BLOOD Glucose-121* UreaN-25* Creat-0.6 Na-147* K-3.9 Cl-107 HCO3-29 AnGap-15 [**2117-10-6**] 05:20AM BLOOD ALT-78* AST-48* LD(LDH)-157 AlkPhos-91 TotBili-0.5 [**2117-10-7**] 08:30AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.7* Studies: . MR [**Name13 (STitle) 430**] [**9-21**] - IMPRESSION: 1. No evidence of acute hemorrhage, infarct or abnormal enhancement. 2. Bilateral mastoid and ethmoid fluid. Clinical correlation is recommended. . CXR [**10-4**] - IMPRESSION: Tracheostomy tube is in standard position. A feeding tube is seen to course through the diaphragm into the stomach, however, distal end is beyond the view of radiograph. Both lungs are well expanded and only remarkable for very minimal bibasilar opacities likely atelectasis. No pleural effusion. Heart size is normal. Mediastinal and hilar contours are within normal limits. No discrete opacities to suggest pneumonia. Brief Hospital Course: Mr. [**Known lastname 90506**] is a 56 y/o male who developed paralysis c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7816**] [**Location (un) **] after several days of campylobacter diarrhea. . ACTIVE ISSUES: . # [**First Name9 (NamePattern2) 7816**] [**Location (un) **]: The patient initially developed facial numbness and extremity tingling following a campylobacter infection. The numbness subsequently began to ascend into the trunk and the patient presented to [**Hospital3 **] ED. The patient was admitted and an LP showed elevated protein at 58 and glucose of 52. He was electively intubated on [**9-17**] following decrease in forced vital capacity and NIF. Neurology was consulted and pt was started on IVIG. However, he developed a rash on day 2, and then anaphylactic reaction on day 4. Transferred to [**Hospital1 18**] on [**2117-9-20**] for plasmapheresis. At [**Hospital1 18**], the patient underwent 5 rounds of plasmapheresis. Neurology was consulted and followed the patient throughout his hospitalization. His muscle strength remarkably improved over the first week of admission and he was able to be extubated on [**9-25**]. The patient made some progress over the following days although remained bed-bound. The patient had difficulty clearing secretions and required frequent chest PT and nasopharyngeal suctioning. Given that the patient would likely require agressive respiratory care and a desire to have the patient start rehabilitation closer to home, Mr. [**Known lastname 90506**] [**Last Name (Titles) 8783**]t tracheostomy on [**2117-10-1**]. He will be discharged to an extended care rehabilitation facility from the MICU. He vocalizes well with Passe-Muir Valve. . # Aspiration Pneumonia/leukocytosis: On day of transfer to [**Hospital1 18**], the paitent had developed a fever to 101.1 and a leukocytosis. CXR here revealed a likely aspiration PNA and the patient was started on vancomycin and zosyn. The leukocytosis improved and the patient became afebrile. The vancomycin was stopped on [**9-22**]. Zosyn was continued to complete a 7 day course. Cultures remained negative. The patient had 2 other likely aspiration events with resultant leukocytosis after stopping zosyn. He failed speech and swallow eval and had a post-pyloric dobhoff placed. He continued on tube feeds. His WBC trended down and he remained afebrile for 72 hours prior to transfer. . #. Back pain: The patient has chronic back pain which has been exacerbated by an inability to reposition due to paralysis. Pain initially controlled with tramadol and gabapentin in addition to tylenol. Regimen changed to lidocaine patch and IV tylenol with IV morphine for breakthrough after the patient lost NG tube post-extubation. Following dobhoff placement, the PO medications were continued and he was able to obtain adequate pain control with lidocaine patch, gabapentin and PRN tylenol. . #. Delirium: Following extubation, the patient had a waxing/[**Doctor Last Name 688**] mental status. Believed to be due to an inverte sleep-wake cycle and started on Zolpidem at night. On day #3 post extubation the patient's delerium had significantly improved, though he remains intermittently confused. This should continue to be monitored, with possible culprits including zolpidem, gabapentin, pain medications. . CHRONIC ISSUES: . # Hypothyroidism: Continue on home synthroid. We did not check a TSH at this admission but this should be monitored now that he is over his acute illness. . # GERD: Protonix changed to ranitidine. . # dyslipidemia: pt was continued on home simvastatin dose. . # anemia: patient was noted to be anemic on this admission. It is unclear what his baseline is. He remained stable and did not require any transfusions. This should be worked up as an outpatient. . TRANSITIONAL ISSUES: Pt is full code. . Pt has follow scheduled with Dr. [**Last Name (STitle) 90507**] (neurology) at [**Hospital3 **] Hospital, who cared for him when he initially presented. . He was also noted to have microscopic hematuria on this admission, thought to be secondary to foley placement. This should be followed as an outpatient. . Patient has trach in place and is regaining strength. He still requires suctioning approximately every 4 hours. His cuff can be deflated when patient is upright, but should be inflated when supine or sleeping. . He was noted to have very mild hypernatremia on several days, which resolved with free water flushes of his tube feeds. This should be monitored q3-4 days until stabilized. Medications on Admission: simvastatin levoxyl protonix Discharge Medications: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 10. ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg PO Q8H (every 8 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: [**Location (un) 7816**]-[**Location (un) **] Syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 90506**], It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred with paralysis believed to be due to [**Hospital1 7816**]-[**Location (un) **] syndrome. In the hospital you were treated with 5 rounds of plasmapheresis and received antibiotics for a pneumonia. Your muscle strength improved while you were here and we were able to extubate you. However, due to increased tracheal secretions and a desire to start rehabilitation you underwent tracheostomy prior to discharge. See below for changes to your home medication regimen: 1) Please CHANGE Protonix to Famotidine 20mg daily 2) Please START Docusate 3) Please START Miralax 4) Please START Enoxaparin 40mg sub-cutaneous daily Please continue all other home medications as prescribed. See below for instructions regarding follow-up care. Followup Instructions: After discharge from rehabilitation, please follow-up with your primary care physician. . We have also schedule a follow up appointment with neurology at [**Hospital3 **] Hospital: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 **] HEALTH CARE/ NEUROLOGY Address: 40 [**Location (un) **] WAY [**Apartment Address(1) 40744**], [**Location (un) **],[**Numeric Identifier 33731**] Phone: [**Telephone/Fax (1) 90508**] When: Tuesday, [**12-21**], 9:30 AM *Please ask your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] to send Dr. [**Last Name (STitle) 90507**] and intake form. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2117-10-8**]

[ "E879.6", "357.0", "335.22", "293.0", "780.52", "338.29", "272.4", "724.5", "507.0", "244.9", "518.81", "867.0", "276.0", "285.9", "530.81", "599.72" ]

icd9cm

[ [ [] ] ]

[ "38.97", "96.6", "31.1", "99.71", "96.72" ]

icd9pcs

[ [ [] ] ]

10703, 10775

5252, 5462

384, 475

10883, 10883

3604, 3604

11935, 12785

2225, 2350

9872, 10680

10796, 10862

9818, 9849

11059, 11912

2365, 2365

4129, 5229

9077, 9792

1682, 1866

265, 346

5477, 8580

503, 1663

3618, 4115

10898, 11035

8596, 9056

1888, 1979

1995, 2209

23,364

156,049

49488

Discharge summary

report

Admission Date: [**2168-12-25**] Discharge Date: [**2168-12-29**] Date of Birth: [**2091-2-18**] Sex: M Service: MEDICINE Allergies: Nsaids/Anti-Inflammatory Classifier / Vancomycin / Flagyl Attending:[**First Name3 (LF) 613**] Chief Complaint: AMS Major Surgical or Invasive Procedure: left percutaneous nephrostomy with 8 French nephrostomy tube History of Present Illness: History of Present Illness: 77 yo m w/ cc AMS w/ obstructive uropathy and infected kidney stone p/w obstructive nephrolithiasis, fever, and coffee ground emesis, transferred to [**Location (un) 86**] [**Hospital1 **] from [**Location (un) 620**] for urology c/s. This AM, patient was altered, confused and not responding verbally (AOX3, conversive at baseline). CT scan at [**Hospital1 18**] [**Location (un) 620**] showed 11mm stone on left kidney w/ rise in Cr to 1.7, which decreased to 1.4 after 2L ivf at [**Location (un) 620**]. NGT lavage w/ coffee grounds cleared on lavage. Prtonix, IVF, CTX administered in ED> Transfer for stone eval given level of infection and obstruction. [**2086-10-28**] obstructing renal stone and bacteremia. . In the ED inital vitals were, 101 86 145/71 20 100% 3L Nasal Cannula. He developed supraventricular tachycardia to 140 bpm in ED. Given adenosine 6mg once, which broke rhythm to normal sinus. Had been given dose of CTX at rehab earlier in the day. No abx . On arrival to the ICU, vitals 99.8, hr 78, BP 133/78, RR 20, 94 RA. On 3L NC for comfort. Past Medical History: * Hemorrhagic frontal CVA secondary to heparin ~16 years ago * Coronary artery disease s/p quadruple CABG in [**2152**] (LIMA-LAD, SVG-PL/PDA, SVG-OM), also later BMS to ostial SVG-PL/pDA and PTCA of LIMA-LAD * s/p dual chamber [**Company 1543**] pacemaker in [**2157**] * Anxiety * Depression * Type 2 diabetes mellitus complicated by peripheral neuropathy * Ulcerative colitis (last colonoscopy at [**Hospital1 18**] [**Location (un) 86**] in [**2162**] with erythema and ulcers in rectum/sigmoid) * BPH * Barrett's esophagus * s/p Neck surgery * h/o thrombocytopenia * h/o DVT complicated by PE 19 years ago * h/o Body dysmorphia, controlled with medication - H/o DVT complicated by PE about 19 years ago -h/o thrombocytopenia . Medications: * Cholecalciferol 1000 units daily * Polyethylene glycol 17 grams daily PRN constipation * Mesalamine 1600mg four times daily * Simvastatin 20mg daily * Methylphenidate 20mg twice daily * Seroquel 25mg qHS * Escitalopram 20mg daily * Docusate 100mg twice daily * Senna 8.6mg twice daily PRN constipation * Ramipril 10mg twice daily * Tamsulosin ER 0.4mg qHS * Omeprazole 40mg daily * Levothyroxine 25mcg daily * NPH 6 units qAM * s/p Erythromycin/daptomycin X 4 weeks Social History: Most recently at [**Hospital 582**] Rehab. Previously lived with wife who helps with ADLs at their home in [**Location (un) 37666**]. Homebound but ambulates with walker. Wife previously stated she would have him walk 50 laps around the house daily. 25 pack year, quit 25 years ago. Denies alcohol and illicit drugs. Former contractor, no children. Family History: - Father died in 80s [**1-5**] DM - Mother died in 70s [**1-5**] alcoholism - Brother died in 40s of esophageal hemorrhage Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2168-12-25**] 08:05PM BLOOD WBC-6.8# RBC-3.81* Hgb-10.3* Hct-30.8* MCV-81* MCH-26.9* MCHC-33.3 RDW-16.8* Plt Ct-101* [**2168-12-25**] 08:05PM BLOOD Neuts-59 Bands-32* Lymphs-4* Monos-3 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2168-12-25**] 08:05PM BLOOD PT-13.4* PTT-23.4* INR(PT)-1.2* [**2168-12-25**] 08:05PM BLOOD Glucose-245* UreaN-28* Creat-1.4* Na-141 K-3.9 Cl-110* HCO3-22 AnGap-13 [**2168-12-25**] 08:05PM BLOOD Calcium-8.4 Phos-2.0* Mg-1.7 [**2168-12-25**] 08:19PM BLOOD Lactate-1.9 Brief Hospital Course: 77 yo m w/ cc AMS w/ obstructive uropathy and infected kidney stone p/w obstructive nephrolithiasis, fever, and coffee ground emesis, transferred to [**Location (un) 86**] [**Hospital1 **] from [**Location (un) 620**] for urology c/s. # Left Obstructive Nephrolithiasis with infected stone: Patient managed in the MICU overnight for emergent placement of left nephrostomy tube; he was transferred to the medicine floor on the following morning. Left nephrostomy tube by IR placed without incident. Blood and urine cultures from outside hospital showed klebsiella oxytoca sensitive to cipro. Initially broad coverated with dapto and vancomycin. These were stopped in favor of cipro which was continued as an outpatient until lithotripsy could be performed by urology. # Ulcer/gastritis: Had some coffee ground emesis prior to admission. Underwent endoscopy by GI which showed an ulcer and gastritis, non-bleeding. Ulcer was biopsied. Continued on omeprazole 40mg [**Hospital1 **]. # [**Last Name (un) **]: Likely combination of pre-renal and obstructing renal stone. Resolved with IVF. # Supraventricular Tachycardia in ED: Was given adenosine and broke. EKG c/w likely AVNRT. No further episodes. EP interrogated pacemaker. # Anemia, acute blood loss: Hematocrit at baseline around 30, trended down over the course of admission. Possibly related to gastritis or ulcer. Stable on discharge. # HTN: Held ramipril due to [**Last Name (un) **] #CAD s/p CABG - Held aspirin in the possible upper GI bleed. Consulted GI... #Ulcerative colitis - Continued mesalamine #Type 2 diabetes - Continued on Humalog sliding scale #Anxiety/depression - Continued Lexapro Medications on Admission: * Cholecalciferol 1000 units daily * Polyethylene glycol 17 grams daily PRN constipation * Mesalamine 1600mg four times daily * Simvastatin 20mg daily * Methylphenidate 20mg twice daily * Seroquel 25mg qHS * Escitalopram 20mg daily * Docusate 100mg twice daily * Senna 8.6mg twice daily PRN constipation * Ramipril 10mg twice daily * Tamsulosin ER 0.4mg qHS * Omeprazole 40mg daily * Levothyroxine 25mcg daily * NPH 6 units qAM ? * Erythromycin/daptomycin X? 4 weeks Discharge Medications: 1. cholecalciferol ([**Last Name (un) **] D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO once a day. 3. mesalamine 800 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO four times a day. 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. methylphenidate 20 mg Tablet Sig: One (1) Tablet PO twice a day. 6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 7. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 10. ramipril 10 mg Capsule Sig: One (1) Capsule PO twice a day. 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. insulin lispro 100 unit/mL Solution Sig: One (1) inj Subcutaneous ASDIR (AS DIRECTED). 15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): until followup with urology. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Infected nephrolithiasis obstructive uropathy UGIB acute blood loss anemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 103545**], It was a pleasure caring for you at [**Hospital1 18**]. You were admitted with an infected kidney stone. You were given a nephrostomy tube and treated with antiobiotics. You will need to followup with urology for a lithotripsy procedure. Medication Changes: START cipro 500mg [**Hospital1 **] until you see your urologist Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: UROLOGY PRACTICE ASSOCIATES Address: [**Street Address(2) 18723**], [**Location (un) **],[**Numeric Identifier 18724**] Phone: [**Telephone/Fax (1) 18725**] Appointment: Friday [**2169-1-6**] 11:00am [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "45.16", "55.03" ]

icd9pcs

[ [ [] ] ]

7836, 7913

4319, 5986

323, 385

8031, 8031

3781, 3781

8597, 9059

3128, 3252

6504, 7813

7934, 8010

6012, 6481

8215, 8574

3267, 3762

280, 285

441, 1508

3798, 4296

8046, 8191

1530, 2746

2762, 3112

73,831

197,368

36226

Discharge summary

report

Admission Date: [**2177-5-29**] Discharge Date: [**2177-6-13**] Date of Birth: [**2104-2-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: Transfer from OSH for possible trach by thoracics. Major Surgical or Invasive Procedure: Patient transferred to [**Hospital1 **] intubated History of Present Illness: 73 year old man with history of obesity, diabetes, unspecified chronic lung disease who initially presented to [**Hospital3 12594**] on [**5-22**] with acute respiratory distress. Prior to presentation he was reportedly sick for a couple of days and became short of breath on [**5-21**] almost to the point of developing stridor. Also complaining of pain with swallowing, right ear pain and right neck pain. In the ED ENT performed an indirect laryngoscopy which revealed edema and exudate of the posterior trachea. In the ED he was placed on BiPAP. He was given Unasyn and Ceftriaxone in the ED for swelling and crusting of his right ear, and started on steroids for concern of laryngeal edema. The patient was admitted to the ICU. He had warmth and edema on the right side of his face and neck along with induration that obscured the angle of the mandible. A gram stain revealed +1 WBC, +1 GPC, +1, GNR and +1 Yeast; throat Cx returned positive for group A strep. He was felt to have acute pharyngitis with angioedema, right external cellulitis (sparing ear canal and TM), right upper cervical lymphadenitis, right supraglottitis with a probable soft tissue infection of the right neck. Needle aspirate was attempted of right soft pallate without any pus. His antibiotics were changed to Vanc/zosyn and for a time clindamycin IV ([**Date range (1) 82121**]) and bactroban to right ear; IV steroids were continued. Initial labs were significant for a WBC of 24 and a HCT of 43; ABG: 7.29/56/78 on 30% BiPAP. A CT scan on [**5-22**] revealed swelling in the retropharyngeal area. At that time there was a concern for a LLL infiltrate on CXR. On [**2177-5-23**] he began to retain C02 and later had an ABG of 7.11/144 (attributed to underlying lung disease and increased amounts of morphine); at that time he went to the OR for an ET tube placed by ENT. A trach was attempted but his trachea was in his thorax so an ET tube was sutured into his retropharyngeal area. A repeat CT on [**5-24**] showed extensive infiltrate and/or hematoma in the retropharyngeal area. CT on [**5-26**] showed decreased swelling. During his MICU stay he underwent acute renal failure (Cr to 3.5). Renal was consulted and it was felt to be dehydration. Cr resolved to 1.4 with fluids. The infiltrate in the LLL was resolving per CXR on [**5-29**]. ENT felt that he was ready to be extubated with anesthesia present in case of stridor. He was attempted to be extubated twice but was unable to do so. He was transferred to [**Hospital1 **] for thoracics surgery consult for placement of a tracheostomy as he had been intubated for 7 days. Past Medical History: Diabetes mellitus Obesity COPD/Emphysema CRI (Cr: 1.5) Hypertension Peripheral vascular disease Transient ischemic attack Carotid endarterectomy Appendectomy Hernia repairs Chronic low back pain Tonsillectomy Social History: Quit smoking in [**2174**] Lives alone Denied any EtOH abuse Works as gas station clerk Lives Alone Family History: Noncontributory Physical Exam: VS - Temp 100.6 F, BP 137/45, HR 79, R 14, O2-sat 100% on 100%Fio2 GENERAL - Obese, intubated, sedated HEENT - Right ear erythema and induration with crusting of previously serous fluid. right facial erythema and inducation. Right sub-mandibular induration. Patient grimaces to pressure on right side. NECK - Thick neck, Trach attemp scar. Induration or right neck. LUNGS - CTA bilat, no r/rh/wh, HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - + Edema, LE. + scrotal edema. NEURO - Sedated indubated. Moving all four extremities. pupils reactive to light. Pertinent Results: Labs at Admission: [**2177-5-29**] 08:32PM BLOOD WBC-20.9* RBC-3.37* Hgb-10.6* Hct-29.6* MCV-88 MCH-31.5 MCHC-35.9* RDW-14.7 Plt Ct-218 [**2177-5-30**] 05:47AM BLOOD Neuts-73* Bands-5 Lymphs-7* Monos-2 Eos-5* Baso-0 Atyps-0 Metas-3* Myelos-5* [**2177-5-29**] 08:32PM BLOOD PT-12.6 PTT-25.3 INR(PT)-1.1 [**2177-5-29**] 08:32PM BLOOD Glucose-169* UreaN-47* Creat-1.2 Na-139 K-3.8 Cl-111* HCO3-20* AnGap-12 [**2177-5-29**] 08:32PM BLOOD ALT-26 AST-21 LD(LDH)-323* AlkPhos-35* TotBili-0.4 [**2177-5-29**] 08:32PM BLOOD Albumin-2.1* Calcium-6.1* Phos-3.4 Mg-2.3 [**2177-5-30**] 05:47AM BLOOD Vanco-25.6* [**2177-5-29**] 09:37PM BLOOD freeCa-1.09* [**2177-5-29**] 08:52PM BLOOD Lactate-0.6 [**2177-5-29**] 09:37PM BLOOD Type-ART Rates-16/ Tidal V-550 PEEP-8 FiO2-100 pO2-274* pCO2-47* pH-7.38 calTCO2-29 Base XS-2 AADO2-407 REQ O2-70 -ASSIST/CON Imaging Studies: CXR ([**5-29**]): The OGT shows a normal course, the tube is visible distally into the lower third of the esophagus. More distally, the tube is not visible. The endotracheal tube also shows normal course, its tip appears to project approximately 3.5 cm above the carina, the definite tip position is difficult to determine because of projection effects. Moderate cardiomegaly with retrocardiac atelectasis. Suspicion of moderate left sided pleural effusion. No evidence of focal parenchymal opacities suggesting pneumonia. No evidence of pneumothorax. MRI Neck ([**5-30**]): Diffuse oropharyngeal mucosal enhancement and subcutanous edema, consistent with cellulitis with a 1.6 X 1.0 cm right mylohyoid muscle collection and other smaller microabscesses. Incidental note of partially imaged right pleural effusion. CT [**2177-6-3**] 1. Abscess adjacent to the right mylohyoid muscle is not clearly defined on this noncontrast study. Extensive edema centered in the right submandibular space is similar to [**2177-5-30**]. 2. Opacification and air-fluid levels in all sinuses may represent sinusitis in the correct clinical context. 3. Borderline enlarged cervical nodes are likely reactive. 4. Saber sheath trachea, possibly secondary to collapse of the tracheal cartilage, as there is no evidence of COPD on CT chest performed concurrently. MRI [**2177-6-10**] (follow-up) FINDINGS: Again soft tissue edema is identified in the right side of the oro- and hypo-pharynx. A 14 x 11 mm hyperintense area on T2-weighted images is seen in this region indicative of a small fluid collection. Since the previous study, the endotracheal tube has been removed and the soft tissue edema is considerably decreased with slight decrease in size of a fluid collection. No new fluid collections are seen in the neck. There is no lymphadenopathy or new mass lesion identified. Soft tissue changes are seen in both mastoid air cells. IMPRESSION: Gadolinium-enhanced imaging could not be performed. Compared to the previous MRI of [**2177-5-30**], there is considerable decrease in swelling of the oropharyngeal and hypopharyngeal soft tissues with slight decrease in size of the previously noted fluid collection. No significant new abnormalities. Brief Hospital Course: A 73 yo man with history of obesity, diabetes mellitus, chronic obstructive pulmonary disease who developed respiratory distress and right sided cellulitis/soft tissue infection now transferred to [**Hospital1 **] for failure to extubate and possible trach placement by thoracics. # Cellulitis/soft tissue infection: He received 7-days of broad spectrum antibiotics at an outside hospital prior to transfer. Per ENT notes his infection was improving. Although S. aureus and Group A strep grew from culture data, the referring hospital's ID team felt that it was likely a polymicrobial infection that required broad spectrum coverage. From an ENT stand point they had wanted to extubate him and were considering changing him to oral antibiotics. On admission to our hospital and ICU, he was seen by ID who recommended continuing vancomycin and Zosyn. Cultures were sent from sputum, ear discharge, blood and urine. No microbe was isolated. An MRI of the neck soft tissue showed diffuse oropharyngeal mucosal enhancement and subcutanous edema, consistent with cellulitis with possible right mylohyoid abscess. ENT was consulted, as well as thoracic surgery. ENT recommended conservative management and repeat imaging. He received a total 21 days of vancomycin and Zosyn, with improvement demonstrated by repeat neck MRI. Follow-up is arranged with ENT as per attached form. # Chronic obstructive pulmonary disease: He is not on home medication for COPD. Unclear [**Name2 (NI) 11149**]. He has a smoking history, unclear how long, quit a few years ago. There is no record of home oxygen requirement. After extubation, he continued to have a high oxygen requirement, and ABG demonstrated chronic CO2 retention. He did not tolerate bipap, but this should be readdressed with a formal sleep study as he did become intermittently hypoxic overnight requiring additional O2. - He does need frequent/vs continuous oxygen saturation monitoring and supplemental oxygen. - At discharge, he was on 15L of High Flow / 60% FiO2 estimated + supplemental NC - His last ABG on the day of transfer was 7.50/ pCO2=50/ pO2=93 - We were diuresing him with lasix (he also takes home lasix 40mg QD), please consider additioanl doses beyond his home dose as he is still edematous at the time of transfer electrolyte repletion should be assessed and monitored daily. # Extubation: Patient has been difficult to extubate initially secondary to sedation then later due to lack of a cuff leak. He may not have a cuff leak given his body habitus. Initially it was thought that he may require a trach given his upper airway swelling. Thoracic surgery and ENT were consulted as above, and felt that tracheostomy was necessary due to prolonged intubation. However, bronchoscopy revealed a very narrowed trachea (saber-sheath), and operative report obtained from outside hospital showed that his trachea was under the manubrium. After discussion with thoracic surgery, this would make tracheostomy very difficult and not easily reversible. Thus, he remained intubated until [**6-6**] when he was fortunately successfully extubated with a high subsequent O2 requirement. # Delirium: After extubation he was delirious likely from orientation/ICU stay and toxic-metabolic etiology. Further infectious work-up was negative. # Diabetes: We held his oral anti-hyperglycemics. He was covered with insulin sliding scale during this admission with adequate BS control. Current sliding scale attached. # Hypertension: Blood pressures were not elevated initially, and anti-hypertensives were held. However, he later became hypertensive requiring the initiation and uptitration of hydralazine, lisinopril, and amlodipine. Please consider further up-titration as necessary. # Chronic kidney disease: His baseline creatinine is approximately 1.3-1.5. 1.2 on admission. Acute renal failure from OSH resolved. We continued hydration with IVF as needed and initially held his home ACEI--this was restarted prior to d/c. Creatinine increased to 2.0 and was responsive to IV fluids, improving to 1.6 prior to discharge. # Decubitus ulcer: This was present on admission and unchanged [**Last Name (un) 22034**] this hospitalization. Wound care information is presented in the discharge/page 1. # FEN: He received tube feeds while intubated, diet was advanced after extubation. - He will need repeat speech/swallow evaluation within [**1-24**] weeks # Access: He had a PICC placed on [**2177-6-4**] at [**Hospital1 18**] in interventional radiology. This was left in place at the time of transfer. # PPx: He was given Subcutaneous heparin and pneumoboots for prophylaxis, in addition to PPI for gastritis prophylaxis. # Code: He was full code throughout this hospitalization Medications on Admission: Amlodipine 5mg daily Furosemide 40mg daily Gabapentin 200mg [**Hospital1 **] DiaBeta 5mg daily Lisinopril 10mg daily Glyburide (unsure dose) HCTZ 12.5mg daily Prilosec 20mg daily ASA 81mg daily Naprosyn PRN Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Hydralazine 10 mg Tablet Sig: Four (4) Tablet PO every six (6) hours. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. Hydralazine 10 mg Tablet Sig: Forty (40) mg PO Q6H (every 6 hours). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 12. Morphine Sulfate 2-8 mg IV Q4H:PRN pain 13. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fever. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day: hold sbp<100. Tablet(s) 15. Outpatient Lab Work Daily Chemistry Panel, follow-up with facility staff physician 16. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 17. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a day. 18. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) Units Subcutaneous at bedtime. 19. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale units Injection qAC + qHS: 0-50mg/dL 4 oz. Juice ; 51-150 mg/dL 0 Units ; 151-200 mg/dL 8 Units ; 201-250 mg/dL 10 Units ; 251-300 mg/dL 12 Units; 301-350 mg/dL 14 Units; 351-400 mg/dL 16 Units ; > 400 mg/dL Notify M.D. . Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: primary: cellulitis leading to upper airway obstruction, chronic obstructive pulmonary disease, acute on chronic kidney failure, hypertension secondary: diabetes Discharge Condition: Medically Stable for transfer to Rehab, with O2 requirement of 60% FiO2, 15L hi-flow Discharge Instructions: You were transferred to [**Hospital1 18**] because you had a breathing tube because of an infection in your neck. You were given three weeks of antibiotics to treat this, and improvement has been seen by MRI. Because of your oxygenation status, you are being transferred for further recovery to a rehabilitation hospital. Please review your current medication list. Your medications will be continued at your rehabilitation hospital, and you should see your primary care physician to address any medication changes after discharge. Followup Instructions: An appointment has been made for you with Ear, Nose, and Throat Surgery: Dr. [**Last Name (STitle) **] 2:50pm on [**278-6-19**], Suite 6E [**Telephone/Fax (1) 41**] Completed by:[**2177-6-13**]

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Discharge summary

report

Admission Date: [**2188-8-5**] Discharge Date: [**2188-8-14**] Date of Birth: [**2129-7-12**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: nausea Major Surgical or Invasive Procedure: pericardiocentesis History of Present Illness: This is a 59 year old Chinese woman with minimal known past medical history who initially presented yesterday ([**8-5**]) with four days of naseau and vomiting and no bowel movements. . Pt was in her usual state of health until one month ago. She reportedly worked as temp in a candy shop for 3 days, and had extreme fatigue that was thought out of her usual condition. She stopped working afterwards, and later developed a productive cough, which gradually worsened in the past month. There was no hemoptysis. Patient was evaluated by her PCP at [**Hospital3 **] on [**7-21**], and again on [**7-30**]. A PPD was placed on [**7-30**], and was read on [**8-1**] as nonreactive (completely negative). In the past week, patient developed shortness of breath, malaise, and could only ambulate to the bathroom. She c/o nausea, bilious vomiting, intolerable to po intake. Her family also endorsed night sweats in the past week, and an 8lbs weight loss in the past 2 weeks. Of note, patient immigrated to US 10 months ago from southern [**Country 651**]. She recently visited her daughter in [**Name (NI) 6607**] two months ago. During workup in the ED she had a CXR which showed a large cardiac silloute and fluid overload with possible RML infection. Her EKG showed diffusely low voltages but no ST depressions. LFTs showed mild transaminitis (60s) with alk phos 120 with dir bili 0.6. . She was initially treated for CHF, but did not respond well with diuresis. On the second day, an RUQ ultrasound in the ED showed a possible pancreatic head mass (otherwise negative). Surgery recommended an abdominal CTA with pancreatic protocol to further evaluate. Overnight she was stable and breathing comfortably on room air. She was hypertensive to 140s-170s. Vitals otherwise were stable. On CT, circumferetial pericardial effusion was seen. Patient was found to have a pulsus paradoxus of 20 mmHg. She was stat intubated, underwent a pericardiocentesis in the cath lab, and admitted to CCU. Past Medical History: beta thalessemia atrophic gastritis Social History: Mandarin/[**Name (NI) **] speaking. Immigrated from [**Country 651**] 10 months ago. Currently living with daughter, son in law, and 3 grandchildren. Recently returned from 3 month visit in [**Country 6607**]. Works in a candy factory Denies Smoking, Drinking or Recreational drug use. Family History: beta thalessemia Physical Exam: ADMISSION EXAM: VS: T96.7 BP137/92 HR87 RR18 95% RA GEN: AOx3, dry mucosal membrane. HEENT: PERRLA. no LAD. flat jvp. neck supple. Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, bilateral crackle / rhonchi Abd: Soft, NT/ND, +BS, no hepatosplenomegaly. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. . DISCHARGE EXAM: VS: Tmax: 99.2 Tc: 98.0 HR: 77 (77-85) BP: 139/90 (128-143/60-90) RR: 18 SpO2: 95% RA Pulsus of 8. GEN: Patient was lying flat in bed in no acute distress or pain. Moist mucosal membrane. HEENT: PERRLA. Conjunctival pallor. Neck supple. Cards: 7cm JVP. RRR S1/S2 normal. not distant. no murmurs/gallops/rubs. Pulm: Clear to auscultation bilaterally Abd: Soft, NT/ND, +BS, no hepatosplenomegaly. Extremities: No edema. Radial pulses, DPs, PTs 2+. Skin: No rashes or bruising Neuro: CNs II-XII intact. 4-/5 strength in IP. Full strength in quads, hamstrings, tib anteriors, gastrocs. 1+ biceps, triceps, patellar reflexes, 0 ankle reflexes bilaterally. Babinskis mute bilaterally. Sensory exam intact to light touch and proprioception. Pertinent Results: ADMISSION LABS [**2188-8-5**] WBC-10.9 RBC-4.99 Hgb-11.2* Hct-34.0* MCV-68* MCH-22.5* MCHC-33.0 RDW-16.1* Plt Ct-371 [**2188-8-5**] Neuts-85.2* Lymphs-8.2* Monos-5.8 Eos-0.6 Baso-0.3 [**2188-8-5**] Glucose-138* UreaN-20 Creat-0.6 Na-138 K-4.1 Cl-102 HCO3-21* AnGap-19 [**2188-8-5**] ALT-78* AST-69* AlkPhos-123* TotBili-2.4* DirBili-0.6* IndBili-1.8 [**2188-8-5**] Calcium-9.6 Phos-3.8 Mg-2.1 [**2188-8-6**] calTIBC-244* Hapto-195 Ferritn-806* TRF-188* [**2188-8-6**] Type-ART pO2-77* pCO2-41 pH-7.39 calTCO2-26 Base XS-0 [**2188-8-6**] calTIBC-244* Hapto-195 Ferritn-806* TRF-188* [**2188-8-5**] Lactate-2.8* [**2188-8-5**] Lactate-2.9* [**2188-8-6**] Lactate-3.9* [**2188-8-6**] Lactate-1.3 Na-139 K-3.9 Cl-107 calHCO3-24 . DISCHARGE LABS [**2188-8-11**] WBC-9.3 RBC-5.01 Hgb-11.4* Hct-34.7* MCV-69* MCH-22.7* MCHC-32.8 RDW-16.5* Plt Ct-330 [**2188-8-11**] Glucose-112* UreaN-9 Creat-0.7 Na-142 K-3.9 Cl-104 HCO3-28 AnGap-14 [**2188-8-9**] ALT-241* AST-97* AlkPhos-98 TotBili-1.4 [**2188-8-11**] Calcium-9.5 Phos-3.4 Mg-2.2 [**2188-8-7**] HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2188-8-7**] HCV Ab-NEGATIVE . . PERTINENT STUDIES # [**8-5**], Abd US IMPRESSION: 1. No cholelithiasis or evidence of acute cholecystitis. 2. Possible pancreatic lesion. Correlate with nonemergent pancreatic CT or MRI. . # [**8-5**], Portable CXR FINDINGS: There are diffuse bilateral interstitial alveolar opacities. There is a markedly tortuous aorta. The cardiac silhouette is enlarged. Small bilateral pleural effusions are evident. There is no pneumothorax. The osseous structures are unremarkable. . IMPRESSION: Excessive volume overload likely due to cardiogenic etiology. Repeat radiography after appropriate diuresis recommended to assess for underlying infection. In particular, there is slight confluent opacity in the right perihilar region which likely reflects confluent edema; however, an underlying pneumonia cannot be entirely excluded. . # [**2188-8-6**] ECHO (pre-pericardiocentesis) FOCUSED STUDY: The right ventricular cavity is unusually small. There is a large pericardial effusion which ranges in size from 2.4 to 3.5 cm. The effusion appears circumferential. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . # [**2188-8-6**] ECHO (post-pericardiocentesis) Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2188-8-6**], the large pericardial effusion has resolved. The heart rate has normalized. The right ventricular cavity is larger and function is normal. . # [**2188-8-7**], ECHO The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Trivial pericardial effusion without echocardiographic evidence of tamponade. Mild pulmonary artery systolic hypertension. . # TTE ([**2188-8-11**]) The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a very small pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [**2188-8-7**], the pericardial effusion is minimally larger, but remains very small. . . # [**2188-8-7**] ECG Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing the rate is slower. . # [**2188-8-7**] CT chest w/ contrast IMPRESSION: 1. Right lower lobe mass with centrilobular nodules and interlobular septal thickening is concerning for primary lung malignancy with lymphangitic carcinomatosis. 2. Extensive infiltrative mediastinal lymphadenopathy. 3. Small, malignant pericardial effusion following percardiocentesis. No tamponade. 4. Lytic metastasis, D11 vertebral body with invasion of the spinal canal and impingement on thecal sac anteriorly. 5. Probable left adrenal metastasis. . # [**2188-8-8**] C/T/L spine MRI Evaluation of the cervicothoracic spine demonstrates osseous metastases at C2, C7 and T11. A posterior element lesion is also noted at T4. Due to motion artifact, axial images are markedly limited. At T11, there is marked motion artifact, but suggestion of left sided anterior epidural disease . There is no significant cord compression or myelomalacia present at this time, however.There is bulging of the posterior vertebral body into the canal and mild compression deformity at this level. Evaluation of the lumbar spine demonstrates no evidence for osseous metastatic disease. No epidural disease is seen. There are multilevel disc bulges. Posterior element hypertrophy is also present at multiple levels. IMPRESSION: Osseous metastatic disease at C2, C7, T4 and T11 as described. At T11, there is mild compression deformity and small amount of epidural tissue, particularly on the left, without significant cord compression at this time. Degenerative changes in the lumbar spine. . # [**2188-8-10**] ECG Sinus rhythm. T wave inversions and poor R wave progression in the anterior precordial leads are consistent with prior anterior wall myocardial infarction of indeterminate age. Compared to the previous tracing of [**2188-8-7**] the R wave progression is less prominent. . Brief Hospital Course: 59F Chinese immigrant with no significant past medical history admitted with four days of nausea and was noted to have pericardial effusion with tamponade physiology s/p pericardiocentesis with cytology showing adenocarcinoma. Further workup showed metastatic lung adenocarcinoma to the spine c/b T11 compression fracture without cord compression. # Cardiac tamponade secondary to adenocarcinoma: Pt developed shortness of breath, and tachycardia, with a pulsus >20 mmHg on hospital day 2. CT abdomen showed circumferential fluid in pericardium. Bedside ECHO showed RV collapse consistent with tamponard physiology. Due to shortness of breath and inability to lie flat, pt was intubated and sent to cath lab for pericardiocentesis, which drained ~700 cc sanguous fluid. Patient was admitted to CCU for further management. Post-procedure ECHO showed minimal residue fluid accumulation. Interval changes measured by ECHO and daily pulsus did not show evidence of reaccumulation of pericardial fluid. Pt remained asymptomatic for the remainder of her hospital course with a baseline pulsus of <14. # metastatic adenocarcinoma-lung primary: Pt's presenting chest x-ray showed diffuse reticulonodular pattern, concerning for TB, or carcinomatosis. As part of the workup, pt underwent bronchoscopy with BAL. Of note, both pericardiofluid and BAL showed positive adenocarcinoma on cytology, but negative AFB. Pathology stain of the pericardiofluid and BAL showed adenocarcinoma of lung primary. Patient was seen by heme/onc who recommended further outpt testing for typing and an MR head for complete staging. Pt declined at this time. Hem/onc f/u appt to be set up in approximately 2 weeks, where pt will discuss potential treatment. Lung metastastes were noted at multiple vertebral bodies, adrenals, and liver on imaging. # Compression fracture at T11 without cord compression. Spinal MRI was obtained due to patient's complaints of lower back pain. There was evidence of compression fracture at T11 on both chest CT and spinal MRI, without significant cord compression. There was also evidence of osseous metastatic disease at C2, C7, and T4. Pt had normal neural exam including intact sphincter tone. Pt was evaluted by Neurosurgery, who felt that there was no imminent risk of cord compression. Pt was also evaluated by rad-onc who felt that radiation treatment was not indicated at this time. Pt was fitted with a TLSO brace to be used when upright or out of bed. Pain management included lidocaine patch, ibuprofen and gabapentin. Tylenol was avoided due to patient's transaminitis. Patient will have bisphosphonate therapy arranged through her Oncologist as an outpatient. . # Post-obstructive pneumonia: Pt developed fever to 101.6 on hospital day 3. Chest CT revealed bilateral pleural effusion and density in RLL concerning for post-obstructive pneumonia. Given patient continued high O2 requirement, and history of cough, the suspicion for pneumonia was high. BAL, sputum culture, blood culture, urine culture showed no growth. Patient was treated with Vancomycin and Zosyn for a total of 5 days. Her oxygen requirements remained stable. . # Transaminitis Patient presented with transaminitis and indirect bilirubinemia. No evidence of biliary obstruction was found on abdominal US. Hepatitis panel was also negative. Initial DDx include hepatic congestion secondary to cardiac tamponarde or metastasis of adenocarcinoma. Of note, there was a ~ 7 mm hypoenhancing foci in right hepatic lobe on the abdominal CT, and marked gallbladder wall edema consistent with congestive heart failure. Patient's liver enzymes peaked on HD3 and has been down trending since then, suggesting the transaminitis is largely caused by hepatic congestion. . # Disclosure of medical information Pt initially expressed wishes to disclose medical news to family only, but later wanted to know herself. Given the special culture background, social worker was involved, and family meeting was held in the presence of patient's family, CCU team and social worker. Agreement was reached that medical information will be released to patient with presence of her husband for emotional support. . CHRONIC ISSUES # beta thalassemia Patient presented with microcytic anemia, consistent with her reported history of beta thalassemia. Her HCT remained stable throughout this admission. . TRANSITIONAL ISSUES Patient declared a full code at admission, but changed to DNR/DNI on [**2188-8-13**]. Pt and husband initially considered returning to [**Country 651**], given that their son-in-law did not want them returning to the house. However, after much conversation, pt's daughter agreed to let them return home. Patient has follow up appointment with hem/onc in approximately 2 weeks regarding potential treatment. As patient and husband are [**Name (NI) 8230**] speaking only, they were given the name and number for the [**Name (NI) 8230**] hem/onc patient nagivator to help facilitate further care. They were also given prescriptions for 2 weeks for pain medications to be filled at the free pharmacy, however the patient decided to leave prior to getting authorization for the lidocaine patches. Patient continued to refuse head MRI during hospitalization, which made complete staging of her disease impossible. Language and social barriers are likely to continue to be problem[**Name (NI) 115**] with this patient and she would benefit from close contact with the [**Name (NI) 8230**] patient nagviator to ensure she receives adequate care. Medications on Admission: Unclear Chinese Medication (two items) Discharge Medications: 1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please wear patch for 12 hours/day, and then take off for 12 hours. Disp:*14 Adhesive Patch, Medicated(s)* Refills:*1* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*42 Tablet(s)* Refills:*1* 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*14 Capsule(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. lung adenocarcinoma 2. cardiac tamponade 3. thoracic compression fracture without spinal cord compression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) - should wear spine brace while sitting up or ambulating. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because of abdominal pain, vomiting and constipation. You were found to have fluid around your heart (tamponade) which had to be drained to help you breath. The fluid was found to be caused by a lung cancer, which has spread to your spine and liver. The cancer has caused a fracture in your lower spine, which is contributing to your pain. You should wear the back brace whenever you are sitting up or standing. Please follow-up with your primary care doctor, as well as the cancer doctors. The following changes were made to your medications: 1. Please start taking Gabapentin 300mg by mouth daily 2. Ibuprofen 600mg my mouth three times a day 3. Lidocaine patch daily for up to 12 hours Followup Instructions: Name: [**Name6 (MD) 27839**] [**Name8 (MD) **], MD Specialty: Internal Medicine When: Tuesday [**8-19**] at 2:30p Location: [**Hospital3 8233**] Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**] Phone: [**Telephone/Fax (1) 8236**] Please call ([**2188**] immediately to schedule an appointment with the cancer doctors - Thoracic Oncology with Dr. [**Last Name (STitle) **], or Dr. [**Last Name (STitle) 3274**] or Dr. [**Last Name (STitle) **]. Please call ([**Telephone/Fax (1) 89355**] if questions about spinal brace. Please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Last Name (NamePattern1) 8230**]-speaking patient advocate and cancer navigator, for social work questions. Completed by:[**2188-8-16**]

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Discharge summary

report

Admission Date: [**2203-3-31**] Discharge Date: [**2203-4-7**] Date of Birth: [**2147-5-13**] Sex: M Service: MEDICINE Allergies: Atorvastatin Attending:[**First Name3 (LF) 5141**] Chief Complaint: Transferred by MedVac from [**Hospital 105679**] Hospital, [**Location (un) **], [**Country 4754**], for acute renal failure, small bowel obstruction, and new brain mets. Major Surgical or Invasive Procedure: EGD - [**4-5**] (twice) duodenal stent placement - [**4-5**] History of Present Illness: 55M with HIV on HAART as well as widely metastatic pancreatic cancer (diagnosed early [**2203**]), previously on gemcitabine last chemotherapy [**2202-3-9**], transferred directly from [**Country 4754**] by air ambulance after a complicated course in [**Country 4754**]. The patient received 3 weeks of chemotherapy and then opted to travel to [**Country 4754**] and [**Location (un) **] for a final vacation. His disease progressed extraordinarily rapidly in [**Country 4754**], and patient presented to [**Hospital 105679**] hospital w/ intractable vomiting, lethargy and ARF, found to have SBO from new duodenal lesion and new liver and brain mets. Was sepsis culture negative during that course. [**Location (un) 105679**] in [**Country 4754**] was going to attempt to stent duodenal obstruction, but patient's symptoms reportedly improved slightly. Pt had a prolonged flight from [**Country 4754**]. Main complaints are currently dry mouth/throat, mild back pain. Pt states has had a BM today, and has been passing gas. . In the ED inital vitals were, Pulse: 93, RR: 19, BP: 118/77, O2Sat: 95. Denies F/CP/SOB/AB. The patient comes accompanied with no CDs of images from [**Country 4754**], thus was sent for CT abd/pelvis in ED. EKG: sinus 89 NA/NI TWI I, III, V3-4 (new from prior) Pt started on Vanc, unasyn (has been on pip-taz and cipro at OSH). Renal c/s: no need for emergent dialysis but will see in ICU tmrw PIVx1, with NGtube in place. Vitals on transfer: 126/75 P89 RR18 97%3L . On arrival to the ICU, afebrile 99 115/70 92% 3L. Patient cachectic appearing, w/ NGT in nare. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - HIV INFECTION: Dx [**9-/2183**], manifested by periodontal disease and minor dermatologic problems; nadir CD4~ 160s, on ARVs - CHRONIC HEPATITIS B: Dx [**9-/2185**] asymptomatic, mildly increased transaminases; viral hepatitis serologies show positive HBsAg/HBcAb and undetectable VL on truvada - CAD s/p inferolateral MI '[**01**]: Inferior/inferolateral hypokinesis, EF 45-50%, mild RV free wall hypokinesis, normal valves. Cath [**2201**], 99% mid right coronary artery thrombus status post drug-eluting stent x1. - PAD, s/p L SFA stent '[**02**] with residual moderate right SFA/significant left infrapopliteal disease. - PERIODONTAL DISEASE: s/p tooth extractions - LIPODYSTROPHY SYNDROME - HYPERLIPIDEMIA - CIGARETTE SMOKING: one pack per day for many years; patient quit with use of hypnosis in 2/95 but relapsed; [**2-/2190**]: nicotine nasal spray unsuccessful; [**1-20**]: chantix unsuccessful - ALCOHOL USE: "one case of beer" per week, now not drinking - H/O SKIN CANCERS: recurrent; followed in dermatology clinic - H/O WARTS: - H/O LATERAL EPICONDYLITIS - H/O FACIAL CYSTS - H/O BRONCHITIS - H/O SCABIES - H/O CELLULITIS - H/O LOW BACK PAIN: LS spine shows L4-5 and L5-S1 disc herniations - H/O DERMATITIS: eczema and tinea pedis - H/O GONORRHEA - H/O HEPATITIS A - S/P CHOLECYSTECTOMY Past Oncological History (per [**2203-3-7**] summary by Dr. [**Last Name (STitle) 16095**]: The patient initially presented with jaundice and abdominal pain at the end of [**2202**]. [**2203-2-11**] CTA of the abdomen and pelvis revealed a 3.3 cm pancreatic head mass, highly worrisome for pancreatic adenocarcinoma invading the adjacent duodenal wall and obstructing the common bile duct without adjacent major vascular involvement and multiple rim enhancing round hypodensities in both lobes of the liver, the largest 15 mm across, suggesting metastatic involvement, intra and extrahepatic biliary ductal dilation, multiple nearby retroperitoneal lymph nodes noted, 19 mm left adrenal nodule, likely adenoma, likely bone islands, no concerning lytic or sclerotic osseous lesions identified. He underwent ERCP on [**2203-2-12**], which revealed a narrowing consistent with external compression seen at the junction of the duodenal bulb and D2 with severe post-obstructive dilation of the common bile duct measuring 20 mm secondary to a singular, irregular stricture of malignant appearance that was 3 cm long seen at the distal common bile duct. A metal biliary stent was placed and cytology samples were obtained from the common bile duct using a brush. The brushings were positive for malignant cells consistent with an adenocarcinoma. He received Gemcitabine 1740 mg IV Days 1, 8 and 13. ([**2203-2-23**], [**2203-3-2**] and [**2203-3-7**])(1000 mg/m2). Social History: Patient has a supportive partner. [**Name (NI) **] previously worked as a concierge at a hotel. He has recently continued to smoke. He has had no interest in alcohol in the last few months and reports no illicit drug use. Family History: IDDM in mother, dad died from lung cancer. Physical Exam: Admission Physical Examination: afebrile 99 115/70 92% 3L General: Alert, oriented, cachectic HEENT: Sclera anicteric, MM extremely dry, temporal wasting Neck: supple, JVP flat Lungs: Crackles scattered b/l CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, moderately distended, bowel sounds present, no rebound tenderness or guarding, hepatomegaly GU: foely in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Physical Exam: Vitals: 98.4 120/60 86 22 94% 2L General: alert, oriented, cachectic HEENT: NC, AT, MMM, OP clear, temporal wasting, mild epistaxis related to nasal cannula Neck: supple, no LAD CV: RRR, nl S1 S2, no MRG Resp: bilateral basilar rales, no wheezes or ronchi Abd: soft, non-tender, non-distended, no rebound or guarding Ext: warm, well-perfused, no cyanosis clubbing or edema. RLE strength limited, right footdrop Pertinent Results: ADMISSION LABS: [**2203-3-31**] 04:30PM BLOOD WBC-29.8*# RBC-2.96*# Hgb-9.2*# Hct-27.2*# MCV-92 MCH-31.1 MCHC-33.9 RDW-13.6 Plt Ct-319 [**2203-4-1**] 02:45AM BLOOD WBC-32.3* RBC-2.76* Hgb-8.5* Hct-25.0* MCV-90 MCH-30.9 MCHC-34.2 RDW-13.9 Plt Ct-275 [**2203-3-31**] 04:30PM BLOOD Neuts-94.7* Lymphs-3.6* Monos-1.5* Eos-0.1 Baso-0.2 [**2203-3-31**] 04:30PM BLOOD PT-15.6* PTT-25.8 INR(PT)-1.5* [**2203-3-31**] 04:30PM BLOOD Glucose-245* UreaN-158* Creat-9.0*# Na-148* K-4.5 Cl-103 HCO3-23 AnGap-27* [**2203-4-1**] 02:45AM BLOOD Glucose-244* UreaN-156* Creat-9.1* Na-146* K-3.8 Cl-102 HCO3-26 AnGap-22* [**2203-3-31**] 04:30PM BLOOD ALT-46* AST-33 CK(CPK)-43* AlkPhos-60 TotBili-0.4 [**2203-3-31**] 04:30PM BLOOD Lipase-1098* [**2203-3-31**] 04:30PM BLOOD cTropnT-0.65* [**2203-3-31**] 04:30PM BLOOD Albumin-3.0* Calcium-8.9 Phos-10.2*# Mg-3.1* [**2203-4-1**] 02:45AM BLOOD Calcium-8.5 Phos-9.9* Mg-3.2* [**2203-4-1**] 02:46AM BLOOD Vanco-15.3 [**2203-3-31**] 10:11PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2203-3-31**] 10:11PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2203-3-31**] 10:11PM URINE RBC-8* WBC-7* Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 [**2203-3-31**] 10:11PM URINE Hours-RANDOM UreaN-612 Creat-43 Na-55 K-25 Cl-17 [**2203-3-31**] 10:11PM URINE Osmolal-417 [**Hospital3 **]: [**2203-3-31**] 04:30PM BLOOD ALT-46* AST-33 CK(CPK)-43* AlkPhos-60 TotBili-0.4 [**2203-4-2**] 08:20AM BLOOD ALT-35 AST-33 LD(LDH)-604* CK(CPK)-71 AlkPhos-55 TotBili-0.4 [**2203-3-31**] 04:30PM BLOOD Lipase-1098* [**2203-3-31**] 04:30PM BLOOD CK-MB-3 cTropnT-0.68* [**2203-3-31**] 04:30PM BLOOD cTropnT-0.65* [**2203-4-2**] 08:20AM BLOOD CK-MB-3 cTropnT-0.51* [**2203-4-1**] 02:46AM BLOOD Vanco-15.3 [**2203-4-2**] 08:20AM BLOOD Vanco-31.7* [**2203-4-3**] 07:15AM BLOOD Vanco-24.6* [**2203-4-5**] 06:15AM BLOOD Vanco-19.5 [**2203-4-6**] 06:15AM BLOOD Vanco-16.2 [**2203-4-3**] 08:17AM BLOOD Type-[**Last Name (un) **] pO2-67* pCO2-52* pH-7.37 calTCO2-31* Base XS-2 [**2203-4-3**] 08:17AM BLOOD Lactate-1.6 [**2203-3-31**] 10:11PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2203-3-31**] 10:11PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2203-3-31**] 10:11PM URINE RBC-8* WBC-7* Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 [**2203-3-31**] 10:11PM URINE Hours-RANDOM UreaN-612 Creat-43 Na-55 K-25 Cl-17 [**2203-3-31**] 10:11PM URINE Osmolal-417 Discharge Labs: [**2203-4-7**] 06:40AM BLOOD WBC-19.6* RBC-2.89* Hgb-9.1* Hct-25.3* MCV-88 MCH-31.4 MCHC-35.8* RDW-15.2 Plt Ct-162 [**2203-4-7**] 06:40AM BLOOD Neuts-90.4* Lymphs-5.0* Monos-3.4 Eos-1.1 Baso-0.1 [**2203-4-7**] 06:40AM BLOOD WBC-19.6* Lymph-5* Abs [**Last Name (un) **]-980 CD3%-80 Abs CD3-780 CD4%-19 Abs CD4-182* CD8%-63 Abs CD8-613 CD4/CD8-0.3* [**2203-4-7**] 06:40AM BLOOD Glucose-130* UreaN-143* Creat-8.8* Na-139 K-2.8* Cl-95* HCO3-24 AnGap-23* [**2203-4-7**] 06:40AM BLOOD Calcium-6.8* Phos-9.4* Mg-2.4 Microbiology: [**2203-3-31**] 4:30 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Aerobic Bottle Gram Stain (Final [**2203-4-2**]): GRAM POSITIVE COCCI IN CLUSTERS. [**2203-3-31**] URINE CULTURE - NEGATIVE [**2203-3-31**] BLOOD CULTURE - NEGATIVE [**2203-4-2**] BLOOD CULTURE - NEGATIVE [**2203-4-3**] BLOOD CULTURE - NEGATIVE [**2203-4-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST - NEGATIVE [**2203-4-4**] BLOOD CULTURE - PENDING [**2203-4-5**] BLOOD CULTURE - PENDING [**2203-4-6**] BLOOD CULTURE - PENDING Imaging: CT abdomen and pelvis ([**3-31**]): 1. No signs of small-bowel obstruction are seen. 2. Known pancreatic carcinoma with interval increase in the size of liver metastasis. 3. New ascites. 4. New omental stranding is seen. This might be secondary to third spacing; still, omental involvement (peritoneal diseaes) cannot be excluded. 5. Multifocal ground-glass opacities are seen in the visualized lung fields might represent infectious or inflammatory process. 6. Bilateral enlargement of the kidneys that appear swollen with no obvious cause (though the exam is limited). No hydronephrosis. 7. Bilateral small-moderate pleural effusions with associated compressive atelectasis. Renal ultrasound ([**4-1**]): 1. No evidence of renal artery stenosis, hydronephrosis or perinephric fluid collections. 2. Nonspecific, slightly elevated resistive indices may relate to medical renal disease. 3. Small amount of free fluid in the pelvis. MR head ([**4-1**]): 1. No evidence of metastatic disease, although exam was somewhat limited due to the lack of contrast. 2. Small right centrum semiovale cavernoma. 3. Mild chronic small vessel ischemic disease. CXR ([**4-2**]): Stable cardiac and mediastinal contours. There is a bilateral air space process with layering pleural effusions. These findings together favor moderate pulmonary edema with bibasilar compressive atelectasis rather than diffuse pneumonia. No pneumothorax. Calcific density contiguous to the greater tuberosity of the right humerus may be related to remote trauma or the presence of calcific tendinitis. Clinical correlation is advised. LE ultrasound ([**4-3**]): FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**] imaging was performed of bilateral common femoral, right superficial femoral, right popliteal, right peroneal, and right posterior tibial veins. Normal compressibility, flow, and augmentation was demonstrated. IMPRESSION: No evidence of DVT in the right lower extremity. KUB ([**4-5**]): SINGLE SUPINE FRONTAL ABDOMINAL RADIOGRAPH: The left lateral abdomen is excluded from the study. There is no evidence of nasogastric tube in either the visualized distal esophagus or the stomach. The stomach is mildly gas-distended. There is overall paucity of bowel gas in the visualized abdomen. IMPRESSION: No nasogastric tube in the stomach or the distal esophagus. EGD [**4-5**]: Impression: - Feeding tube was located in the upper esophagus. Given location, the tube was removed. - Esophagitis - Retained fluids in stomach - Friability, erythema and congestion in the first part of the duodenum and second part of the duodenum compatible with obstruction - Otherwise normal EGD to third part of the duodenum Recommendations: - Protonix 40mg IV BID. - NG tube to suction. - Consider attempted placement of a duodenal stent by advanced endoscopy team. EGD with advanced endoscopy ([**4-5**]): Impression: - Limited exam of esophagus and stomach were unremarkable - Erythema and congestion of the mucosa with contact bleeding were noted in the first and second part of the duodenum with near complete obstruction of the duodenal lumen. - Fluoroscopy also revealed a previously placed metal biliary stent. - A 450 cm JAG wire was passed through the narrowed duodenal segment into the third part of the duodenum under fluoroscopic vision. - A WallFlex TM Duodenal 22mmX120mm (LOT: [**Numeric Identifier 105709**], REF: 6503) metal stent was placed successfully over the guide wire under endoscopic and fluoroscopic guidance. - Otherwise normal EGD to third part of the duodenum Recommendations: - Return to floor - Start clear liquids and then advance slowly to liquid diet tomorrow. Brief Hospital Course: ========================== BRIEF CLINICAL SUMMARY ========================== 55M with HIV on HAART as well as widely metastatic pancreatic cancer (diagnosed early [**2203**]), previously on gemcitabine last chemotherapy [**2202-3-9**], transferred directly from [**Country 4754**] by air ambulance after a complicated course in [**Country 4754**]. Patient to have multi-disciplinary approach to palliative care and eventual return to home. ========================== ACTIVE ISSUES ========================== # ARF / Anion Gap alkalosis: BUN 158, Cr 9.0, from baseline 1.0. Differential is broad. Unlikely to be post-renal secondary at this point since draining urine with foley, although patient stated that foley was difficult and required urology [**3-17**] prostate enlargement. Likely combination of intrinsic renal disease secondary to ATN and hypotension at OSH with pre-renal etiology in setting of prolonged course of nausea and vomiting, profound volume depletion. Patient presented with an anion gap metabolic acidosis secondary to GI acid losses and contraction alkalosis. Potassium was not elevated. Na 149 on admission. He was both free water and total body water depleted on presentation. Although the patient had elevated calcium and phosphorus, and was at risk for precipiation, binders were initially of little use as the patient was NPO. Renal consultation sought, they found no indication for emergent dialysis. As volume status normalized, urine lytes and consistent hypokalemia despite renal failure raised concern for type 1 RTA. UOP increased to roughly 1 L/day. Foley removed [**4-6**] prior to discharge, patient voided normally. Started aluminum hydroxide for phosphate binding with good effect. The Renal team recommended using potassium supplementation to avoid hypokalemia given persistent renal wasting. . # Metastatic Pancreatic Adenocarcinoma: Discussed patient with Dr. [**Last Name (STitle) 16095**] on evening of admission. Patient with very rapidly progressing pancreatic adenocarcinoma, worsening liver mets, although no brain mets despite prior report from OSH. Further treatment unlikely to be helpful at this time. Previously treated with dexamethasone for concern of brain mets, however after MR imaging this was discontinued. Inter-disciplinary meeting with oncologist and palliative care on [**4-1**], and patient and partner brought up to speed on prognosis. He remained full code, wished to pursue treatment for all conditions noted. Although discharged home with hospice, if his renal function normalized he would be interested in palliative chemotherapy to reduce tumor burden. . # SBO/GOO: Patient presented with intractable nausea and vomiting, which was thought related to small bowel obstruction and also potentially from cerebral edema. CT scan in ED showed no clear e/o obstruction. Seemed as if prior obstruction had resolved given BM and flatus, however there continued to be concern for functional ileus or obstruction due to peritoneal carcinomatosis. EGD performed [**4-5**] for possible GI bleeding revealed 95% obstruction of duodenum, the likely cause of these symptoms. This was stented successfully, and the patient was able to tolerate liquid diet prior to discharge. NGT removed [**4-5**]. . # GIB: The patient presented with coffee grounds in NGT output on [**4-1**]. He received 2 units PRBCs with good response, and NG lavage was negative. IV PPI was started. He had multiple guaiac positive and melanotic stools over the next several days with persistently negative NG lavage. EGD revealed no source of bleeding and his Hct remained stable following transition. However, the location of his tumor adjacent to the duodenum put him at high risk for future bleeding due to erosion into the vasculature of the small bowel. No intervention could lower this risk. His ASA and Plavix were held for several days due to concern for bleeding, but following consultation with his Cardiologist, his ASA was restarted the day following discharge. Oral PPI continued. . # GPC bacteremia / ? PNA: Patient treated for sepsis at OSH for CXR suggestive of L lung base consolidation. Urine and blood cultures negative from OSH. Received IV vanc and Unasyn at OSH. Per culture [**3-31**] growing GPC in clusters. Started vanco/Zosyn [**4-2**]. CXR [**4-3**] showed no consolidation. Antibiotics were discontinued [**4-6**] given multiple negative cultures. . # CAD: Tropinemia most likely secondary to cardiac demand (ischemia, as evidenced by TWI on EKG) in background of ARF. Patient had no LAD disease on prior cardiac cath. Unlikely to be ACS as having no typical anginal symptoms. Continued ASA and Plavix through [**4-3**], then discontinued for several days given concern for GI bleeding. Restarted ASA the day following discharge per Cardiology recommendations. . # Anemia: Hct 27.2 from most recent [**Location (un) 1131**] of 36. Most likely from marrow suppression in setting of malignant disease, anemia of chronic disease. Despite concern for GI bleeding, the patient had good response to transfusion without further Hct drop. . # Hyperglycemia: Pt w/ blood sugars > 250 on admission. Likely secondary to use of steroids used for possible brain met. Patient maintained on insulin sliding scale. Blood glucose normalized and this was discontinued. . # HIV: Patient previously with very well-controlled HIV. Truvada on hold given renal failure, Kaletra on hold given risk of resistance. Contact[**Name (NI) **] outpatient PCP/HIV provider for guidance. HAART held on discharge, however given CD4 < 200 he will be started on pentamidine for PCP [**Name Initial (PRE) 1102**]. . # Sacral pressure ulcer: From long-term hospitalization. Wound care team consulted, provided assistance for management on discharge. . # RLE edema: b/l LE edema, R>L, concerning for DVT given long hospitalization. Patient could receive heparin due to concern for GIB, Venodynes used instead. RLE ultrasound negative for DVT. Edema likely due to ATN and prolonged bedrest. . # Persistent leukocytosis: WBC as high as 48 during admission. [**Month (only) 116**] be partially due to use of dexamethasone, however this remained elevated throughout admission regardless of antibiotic use. Patient remained afebrile. . # Goals of Care: continually addressed while in ICU, patient remained full code. Transitioned to hospice care on discharge. However, should renal function normalize he would be interested in pursuing further chemotherapy. . ABX Hx (per records from St James' [**Location (un) **]): Pip/Tazo started [**3-22**], continued through [**4-6**] Cipro started [**3-26**], d/c on transfer [**3-30**] Metronidazole started [**3-29**], d/c on transfer [**3-30**] Clarithromycin started [**3-22**], d/c on transfer [**3-30**] vanco started [**3-31**], continued through [**4-6**] =============================== TRANSITIONAL ISSUES: =============================== - Pentamidine should be started for PCP [**Name Initial (PRE) 1102**]. This was not administered prior to discharge. Medications on Admission: CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - One Tablet(s) by mouth every day LISINOPRIL - 20 mg Tablet - Take one Tablet(s) by mouth once a day LOPINAVIR-RITONAVIR [KALETRA] - 200 mg-50 mg Tablet - 2 Tablet(s) by mouth twice a day LORAZEPAM - 2 mg Tablet - [**2-14**] Tablet(s) by mouth nightly as needed for insomnia OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth Daily ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth Every 8 hours as needed for Nausea OXYCODONE - 5 mg Tablet - Take one Tablet(s) by mouth every four hours as needed for pain POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 1 scoop by mouth daily as needed for nausea PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea to start following the first day of chemotherapy ROSUVASTATIN [CRESTOR] - 10 mg Tablet - Take one Tablet(s) by mouth once a day TEMAZEPAM - 7.5 mg Capsule - Take one to two Capsule(s) by mouth at bedtime as necessary Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice daily take this every day; add the senna and the miralax as needed LOPERAMIDE [LO-PERAMIDE] - 2 mg Tablet - 1.5 Tablet(s) by mouth daily NICOTINE - 21 mg/24 hour Patch 24 hr - Apply topically as directed every 24 hours SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth twice daily take this as needed for constipation Discharge Medications: 1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID (3 times a day) as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 2. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours). Disp:*120 vial* Refills:*0* 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours). Disp:*120 vial* Refills:*0* 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q2H (every 2 hours) as needed for dyspnea. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 7. aluminum hydroxide gel 600 mg/5 mL Suspension Sig: Five (5) ML PO three times a day as needed for with meals: With meals. Disp:*300 ML(s)* Refills:*0* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 10. 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* 11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for nausea, anxiety, insomnia. Disp:*30 Tablet(s)* Refills:*0* 12. potassium chloride 20 mEq Packet Sig: One (1) Packet PO TID (3 times a day). Disp:*90 Packet(s)* Refills:*2* 13. pentamidine 300 mg Recon Soln Sig: One (1) Recon Soln Inhalation once a month. 14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Hospice of the [**Location (un) 1121**] Discharge Diagnosis: primary: acute kidney injury small bowel obstruction bacteremia . secondary: metastatic pancreatic cancer coronary artery disease peripheral vascular disease 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: It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred here from a hospital in [**Country 4754**], where you had been treated for pneumonia, nausea, vomiting, and fever. You were initially admitted to our ICU given your fever, low blood pressure, and acute kidney injury. The testing done in [**Country 4754**] and at this facility determined that you had experienced worsening of your pancreatic cancer, with new metastases in the liver. You had recently completed a course of chemotherapy, but given your kidney injury and infection, it was not possible to continue this treatment. The rapid progression of your disease despite chemotherapy did not support further treatment. Our Renal team saw you and did not recommend dialysis for your kidney failure. During your stay, you were treated with antibiotics for infection, IV fluids and bowel decompression for your bowel obstruction, and pain and nausea medications. You received a duodenal stent to keep your bowel open and to allow you to eat and drink. While here you were started on multiple medications. Please follow the dosages that are attached. The medications are: - Albuterol and iprotropium nebulizers to help with your breathing. - metoprolol to control your heartrate - ondansetron and olanzapine as needed to help with nausea - docusate and senna to help with constipation - aluminum hydroxide to prevent your phosphate from getting too high - pantoprazole to lower the acid in your stomach and prevent bleeds - lorazepam as needed to help with anxiety - potassium chloride to prevent low potassium levels - pentamidine once a month to prevent lung infections - oxycodone as needed for pain You should NOT take your HIV meds for the time being. If your condition improves, you can discuss possibly restarting these medications in the future with Dr. [**Last Name (STitle) 4844**]. Please follow-up with your providers as listed below. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2203-4-8**] at 10:00 AM With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2203-4-11**] at 11:00 AM With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2203-4-12**] at 11:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "45.13", "46.86" ]

icd9pcs

[ [ [] ] ]

24567, 24637

13980, 20886

443, 505

24839, 24839

6620, 6620

26978, 27876

5603, 5647

22662, 24544

24658, 24818

21084, 22639

25014, 26955

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5694, 6150

20907, 21058

2151, 2553

233, 405

533, 2132

6636, 9123

24854, 24990

2575, 5344

5360, 5587

6175, 6601

42,232

138,632

50986

Discharge summary

report

Admission Date: [**2160-9-22**] Discharge Date: [**2160-10-2**] Date of Birth: [**2112-6-13**] Sex: M Service: SURGERY Allergies: Cogentin / Trilafon Attending:[**First Name3 (LF) 668**] Chief Complaint: End-stage renal disease. Major Surgical or Invasive Procedure: [**2160-9-22**]: Kidney transplant. History of Present Illness: 48 yo M with ESRD [**1-23**] diabetic nephropathy on HD through L AV fistula 3x/wk presents for kidney transplant. Pt was initially evaluated for transplant in '[**6-27**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and was activated on the kidney transplant list in [**2158-11-21**]. On hemodialysis MWF, last received [partial] treatment this morning. He currently feels well and has no complaints. He endorses having a few days of nasal congestion and mild cough productive of minimal white sputum, for which he is taking cough drops, but denies fever or chills, SOB, or difficulty breathing. He denies nausea, vomiting, diarrhea, or constipation. He has no history of kidney stones or urinary tract infections. He denies current or past dysuria, hematuria, or kidney infections. Past Medical History: ESRD [**1-23**] diabetic nephropathy maintained on HD three times a week through his L AV fistula, Type II DM, HTN, hyperlipidemia, schizophrenia, foot ulcers Past Surgical History: Left AV fistula placement ([**2154**]), L AV fistula angioplasty x 1 ([**2158**]), pilonidal cyst excision when a teenager Social History: Used to smoke 1 cigarette a month- quit 10 years ago, denies alcohol and illicit drug use, NH resident at [**Hospital 4542**] Rehab in [**Location (un) 38**] ([**Telephone/Fax (1) 105939**]). Family History: Uncle with kidney stones, otherwise - no Fam Hx of kidney disease. Physical Exam: T 96.3F, P 58, BP 179/70, RR 16, O2sat 96% RA, FS191 Gen - alert and cooperative, AO x 3, no jaundice HEENT - normocephalic, atraumatic; ears and nose of normal outer appearance; moist oral mucosa Heart - RRR, no M/R/G, S1/S2 normal, no JVD, no carotid bruit appreciated Lungs - CTAB Abd - bowel sounds present, soft, nontender, nondistended but obese Extrem - warm, well-perfused, sensory and motor intact all extremities, no pedal edema, pedal pulses equal and strong, L forearm: radial thrill palpated and bruit appreciated, no local erythema Pertinent Results: On Admission: [**2160-9-22**] WBC-5.7 RBC-3.53* Hgb-11.7* Hct-34.6* MCV-98 MCH-33.2* MCHC-33.8 RDW-13.9 Plt Ct-200 PT-12.8 PTT-57.6* INR(PT)-1.1 Glucose-191* UreaN-63* Creat-6.9* Na-139 K-5.0 Cl-97 HCO3-29 AnGap-18 Albumin-4.7 Calcium-8.9 Phos-4.2 Mg-2.4 Renal transplant duplex US [**2160-9-23**]: 1. Mild lower pole renal pelvis fullness. 2. Expected slightly elevated RIs and slightly delayed upstroke on the waveforms, right after renal transplant. Labs at discharge: [**2160-10-2**] WBC-4.3 RBC-3.19* Hgb-10.0* Hct-29.5* MCV-93 MCH-31.5 MCHC-34.0 RDW-14.5 Plt Ct-192 Glucose-160* UreaN-56* Creat-3.7* Na-136 K-4.2 Cl-96 HCO3-32 AnGap-12 Calcium-10.2 Phos-4.7* Mg-2.8* [**2160-10-2**] tacroFK-11.3 Brief Hospital Course: On [**2160-9-22**], patient underwent cadaveric renal transplant in right iliac fossa with end-to-side neoureterocystostomy over a 6-French double-J stent. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the retroperitoneum. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details. Postop, he remained in the PACU for management of low bp and urine output. Neo was required for low sbp. He was transferred to the SICU for continued management. U/S on [**9-23**] showed mild hydro, mildly increased RIs, mildly delayed aterial upstrokes. Urine output was 5-10cc/hr. CVVH was started for hyperkalemia after femoral CVL was exchanged for a temporary line. On [**9-24**] he was febrile to 101.6 likely from ATG. However, he was pan-cultured. The L femoral line was removed. He was transiently hypoxic, likely from atelectasis. CXR showed bilateral infiltrates, poor respiratory status likely [**1-23**] fluid overload. He was given 1 unit of PRBC for hct of 25.1 from 31. On [**9-25**] Hemodialysis was done with 2 units of PRBCs given for hct of 25.2. He was weaned to O2 via nasal cannula. Urine output was less than 500cc/day. Creatinine remained elevated, dropping after HD as expected. JP drainage decreased and JP was removed on [**9-26**]. Incision was intact with staples and remained without redness/drainage. Diet was advanced and tolerated. Immunosuppression consisted of ATG x 4 doses (125mg each dose), Cellcept 1 gram [**Hospital1 **], steroids were tapered to off and prograf was started on postop day 1. Doses were adjusted per trough levels. He was assisted to ambulate. PT recommended return to his home skilled nursing facilty. The patient was also followed by Transplant Nephrology, who monitored his need for hemodialysis. On HD 11 the patient was noted to have increased urine output to 1040 mls. And creatinine did not rise as quickly interdialytically. He was given PO lasix and the nephrologists plan is to follow labs and volume status to determine need for future hemodialysis. On [**10-2**], the creatinine was noted to have fallen to 3.7, which was the first drop in this value without dialysis intervention. He is also continuing to make greater than a liter of urine daily. Medications on Admission: modafanil 100 mg PO daliy, omeprazole 20 mg PO daily, ASA 325 mg, advair 100-50 1 puff [**Hospital1 **], fibra-lax 625 mg PO BID, hydralazine 50 mg PO BID 3x/wk and TID 4 x/week, renvela 2400 mg TID, Ca acetate 1334 mg TID, metoclopramid 5 mg QID, atenolol 100 mg PO daily, simvastatin 20 mg PO daily, amlodipine 10 mg PO daily (hold in dialysis days), pregabalin 25 mg PO daily, sensipar 60 mg PO daily, sertraline 200 mg daily, folic acid 0.8 mg daily, trazadone 100 mg PO qhs, risperidone 1.5 mg PO qhs, tylenol, lantus 25 units SQ daily, bowel regimen (Milk of mag, biscodyl, fleet enema, Mg citrate) Discharge Medications: 1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) 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. risperidone 1 mg/mL Solution Sig: 1.5 mg PO HS (at bedtime). 5. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. insulin regular human 100 unit/mL Solution Sig: follow printed sliding scale Injection four times a day. 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Tablet(s) 11. Outpatient Lab Work Stat Labs every Monday and Thursday for: cbc, chem 10, ast, t.bili, urinalysis and trough prograf level. Fax results to [**Telephone/Fax (1) 697**] (Do not give am Prograf prior to lab draw. give after lab draw) Labs to be drawn by US labs, specimens tested at Quest Lab, Crown Colony, [**Telephone/Fax (1) 105940**] 12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day: Hold for SBP < 110 or HR < 60. 13. Valcyte 450 mg Tablet Sig: One (1) Tablet PO twice a week: q Monday and Thursday. Will readjust based on kidney function. 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO twice a day: Brand name medically necessary. Do not switch between brands. 16. tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO Q12H (every 12 hours): [**Last Name (un) **] brand. Do not switch between brands. 17. pregabalin 25 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 19. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. 20. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-26**] hours as needed for pain: maximum 3 grams daily. Discharge Disposition: Extended Care Facility: [**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**] Discharge Diagnosis: ESRD Delayed renal graft function Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You will return to [**Male First Name (un) 4542**] Skilled Nursing in [**Location (un) 38**] The [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**] should be called if you develop any of the following: fever (temperature of 101), shaking chills, nausea, vomiting, inability to take any of your medications, increased incision/abdominal pain, abdominal distension, constipation/diarrhea, decreased urine output, edema, weight gain of 3 pounds in a day, incision redness/drainage/bleeding You will need to have blood drawn every Monday and Thursday for lab monitoring You may shower No heavy lifting/straining (nothing heavier than 10 pounds) Followup Instructions: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2160-10-7**] 10:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Date/Time:[**2160-10-7**] 11:30 Completed by:[**2160-10-2**]

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icd9cm

[ [ [] ] ]

[ "38.95", "55.69", "00.93", "39.95" ]

icd9pcs

[ [ [] ] ]

8255, 8354

3116, 5442

303, 340

8446, 8446

2387, 2387

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1737, 1805

6098, 8232

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5468, 6075

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1820, 2368

239, 265

2861, 3093

368, 1183

2401, 2842

8461, 8573

1205, 1365

1528, 1721

21,642

103,101

1867

Discharge summary

report

Admission Date: [**2138-11-21**] Discharge Date: [**2138-11-23**] Date of Birth: [**2062-7-21**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 76-year-old male with severe coronary artery disease involving three vessels, hypercholesterolemia, diabetes mellitus, status post coronary artery bypass graft in [**2132**], and multiple follow-up catheterizations who presented to [**Hospital1 190**] for elective percutaneous transluminal coronary angioplasty and stent of the right coronary artery. Since the patient's 4-vessel coronary artery bypass graft in [**2132**] he has had recurrent exertional angina that is relieved by rest and nitroglycerin. He has had six catheterizations since the surgery, but no interventions. His most recent catheterization was in [**2138-4-13**] that showed an ejection fraction of 73%, mild inferobasal hypokinesis, severe 3-vessel disease with 60% to 80% proximal left anterior descending artery occlusion, and complete distal left anterior descending artery occlusion, diffuse left circumflex disease with middle stenosis of approximately 50%, with 90% stenosis at third obtuse marginal, and significant right coronary artery disease with serial 70% stenoses proximal and midway through the vessel as well as total occlusion of the distal third of the right coronary artery. These findings represented essentially no change since the prior study performed in [**2136**]. Also, the patient had a stress thallium in [**2138-4-13**] that showed defects in an inferoapical distribution as well as with upper septal defects. This was worse than the prior test which was performed one year earlier. Therefore, he was admitted for elective catheterization and right coronary artery intervention. During his cardiac catheterization an right coronary artery stent was placed that resulted in a perforation of the middle right coronary artery. He remained hemodynamically stable. A [**Doctor First Name **]-Med covered stent was placed with filling of the perforation. Subsequently, a small guide wire perforation was noted in the distal posterior descending artery. This was treated with reversal of heparin and prolonged balloon inflations. A post procedure echocardiogram was performed that showed no pericardial effusion. The patient was brought to the holding area where approximately half an hour after the procedure he experienced substernal chest pain, and electrocardiogram at that time revealed ST elevations in leads V1 through V3. He was brought back to the catheterization laboratory where he underwent an additional catheterization. A total right coronary artery stent occlusion was seen. A stent thrombectomy was performed with Angio-Jet and proximal and distal stents were placed. The patient tolerated this procedure well and given the complicated procedure he was admitted to the Coronary Care Unit for observation and for monitoring for possible development of tamponade in the setting of coronary vessel rupture. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Hypertension. 3. Coronary artery disease, status post 4-vessel coronary artery bypass graft involving left internal mammary artery to the left anterior descending artery, saphenous vein graft to first obtuse marginal, saphenous vein graft to the distal right coronary artery, and saphenous vein graft to the acute marginal. 4. Gastroesophageal reflux disease. 5. Hypercholesterolemia. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d., Zocor 80 mg p.o. q.i.d., Imdur 30 mg p.o. q.d., Elavil 75 mg p.o. q.h.s., Glucophage 850 mg p.o. t.i.d., glyburide 10 mg p.o. b.i.d., atenolol 25 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He smoked 15 years ago but has not smoked since. No ethanol history. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were afebrile, blood pressure 122/55, pulse 78, respirations 14, oxygen saturation 98% on 3 liters. In general, an elderly gentleman in no acute distress, lying in bed. HEENT revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Neck had no jugular venous distention. Pulmonary revealed lungs were perfectly clear to auscultation. Heart had a regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops. The abdomen was soft, nontender, and nondistended, positive bowel sounds. His extremities had no clubbing, cyanosis or edema, and good pulses bilaterally. The groin was notable for absence of hematoma. LABORATORY DATA ON PRESENTATION: White blood cell count 7.3, hematocrit 37.5, platelets 278. Sodium 136, potassium 4.8, chloride 98, bicarbonate 28, BUN 16, creatinine 0.8, glucose 135. RADIOLOGY/IMAGING: Electrocardiogram showed normal sinus rhythm, inferior Q wave consistent with an old inferior myocardial infarction. There was diffuse T wave flattening. The ST elevations seen in leads V1 through V3 that were present on the electrocardiogram immediately after catheterization were completely resolved. IMPRESSION: This is a 76-year-old male with severe 3-vessel disease and a history of coronary artery bypass graft in [**2132**] who presented for elective catheterization, where he received a stent to the right coronary artery complicated by right coronary artery bleed, placement of [**Doctor First Name **]-Med stent and distal posterior descending artery bleed treated with percutaneous transluminal coronary angioplasty. Post catheterization course complicated by chest pain found to be secondary to stent thrombosis. A thrombectomy was performed and additional stents were placed with complete resolution of symptoms and electrocardiogram changes. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR: (a) Coronaries: The patient had no further angina at rest of evidence of stent instability following the second cardiac catheterization. An electrocardiogram was done that showed complete resolution of the ST elevations that had been seen in V1 to V3 in association with a stent thrombosis. Aspirin was continued. Plavix was given at the time of catheterization and was continued at 75 mg p.o. q.d. and should be continued for 30 days. ReoPro was given for 18 hours after catheterization. We held his Imdur and Norvasc. He was given Lopressor after catheterization, and this was tolerated well so it was switched back to his home dose of atenolol 25 mg p.o. q.d. (b) Pump: There were no signs or symptoms of congestive heart failure or tamponade post procedure. (c) Rate and rhythm: The patient was in a normal sinus rhythm and there were no acute issues from a rate and rhythm perspective. 2. PULMONARY: The patient was weaned off oxygen quickly after his cardiac catheterization and did well from a pulmonary standpoint. There were no acute issues. 3. ENDOCRINE: The patient was treated with a regular insulin sliding-scale and once he was tolerating p.o. food he was restarted on his oral hypoglycemics. 4. GASTROINTESTINAL: The patient was treated with Protonix for his known gastroesophageal reflux disease. 5. CODE STATUS: He was full code. 6. DISCHARGE DISPOSITION: The patient was stable in the Coronary Care Unit, and on the second day after admission was transferred to the Cardiology Medicine floor. DISCHARGE STATUS: He was discharged to home. CONDITION AT DISCHARGE: Discharge condition was good. DISCHARGE FOLLOWUP: He was instructed to follow up with his primary care cardiologist, Dr. [**Last Name (STitle) 10439**], in one week. MEDICATIONS ON DISCHARGE: 1. Glyburide 10 mg p.o. b.i.d. 2. Glucophage 850 mg p.o. b.i.d. 3. Elavil 75 mg p.o. q.h.s. 4. Atenolol 25 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. for 30 days. 6. Aspirin 325 mg p.o. q.d. 7. Zocor 80 mg p.o. q.d. Imdur and Norvasc were both held given good blood pressure control. DISCHARGE DIAGNOSES: 1. Stent of right coronary artery complicated by stent thrombosis and thrombectomy. 2. Hypertension. 3. Diabetes mellitus. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2138-11-26**] 12:35 T: [**2138-11-27**] 12:52 JOB#: [**Job Number 10440**] (cclist)

[ "250.00", "530.81", "V45.81", "998.2", "414.01", "996.72" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "36.06", "99.20", "36.01", "37.22" ]

icd9pcs

[ [ [] ] ]

7124, 7320

7840, 8238

7530, 7819

3471, 3695

5701, 7100

7335, 7366

7387, 7504

163, 3006

3028, 3444

3712, 5673

29,125

185,825

28176

Discharge summary

report

Admission Date: [**2188-5-12**] Discharge Date: [**2188-5-18**] Date of Birth: [**2169-9-9**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 943**] Chief Complaint: Tylenol overdose Major Surgical or Invasive Procedure: central venous line placement picc placement History of Present Illness: Ms. [**Known lastname **] is an 18 yo F w/ h/o seizure disorder who presented with ingestion after suicide attempt. Patient reports taking 1 teaspoon of Potassium Ferricyanide (Kodak product for developing film), and 48 extra strength Tylenol tablets. Patient may have been upset about her boyfriend breaking up with her. They currently live together but did not wish to elaborate. . In the ED vital signs on presentation T 95.3 BP 97/34 HR 96 RR 18 oxygen sat 100%. Labs significant for ALT 378, AST 443, T bili 1.8, ALB 4.5, INR 1.3. ABG 7.29/35/68. Lactate 5.5. UA negative for UTI. HCG negative. Serum tylenol level 248.8. Serum tox negative for benzos, barbiturates, TCAs, EtOH. ASA 4. Urine tox negative for opiates, cocaine, amphetamines, methadone. . The patient was treated with cyanide antidote kit - but only sodium thiosulfate for elevated lactate. Nausea was treated with zofran. N-acetylcysteine started. Liver and toxicology team were consulted. Past Medical History: 1. thyroid nodule 2. ADHD/anxiety 3. Seizure disorder s/p subdural and orbital fracture following a seizure - diagnosis given after syncopal episode, reportedly a passerby saw her seize. 4. Syncopal episode Social History: She is a student at [**First Name4 (NamePattern1) 1663**] [**Last Name (NamePattern1) 1688**],just finished her first year, undercleared major.. She lived with her grandmother for much of her high school education. She and her grandmother seem to have a very positive relationship. She smokes cigarettes on occasion. No alcohol or drug use. Family History: Notable for hypertension in father. Mother with schizophrenic disorder. Physical Exam: per Dr. [**Last Name (STitle) 6812**] VS: 98.1 115/53 90 100% 2L 16 HEENT: pleasant, pale female, NAD, speaking full sentences NC, AT, PERRLA, anicteric, EOMsI, NECK: no JVD, supple CV: RRR, nl s1, s2, PULM: CTAB/L, no w/r/r, no back pain ABD: decrease BS, snd, diffuse tenderness with voluntary guarding EXTR: no edema, no cyanosis NEURO: no focal deficits appreciated Pertinent Results: Admission labs: 141 105 8 -------------< 102 3.5 16 0.9 . CK: 45 MB: Notdone Ca: 9.7 Mg: 1.9 P: 4.3 ALT: 378 AP: 102 Tbili: 1.8 Alb: 4.5 AST: 443 [**Doctor First Name **]: 39 Serum ASA 4 Serum Acetmnphn 248.8 Serum EtOH, Benzo, Barb, Tricyc Negative Iron: 44 . 15.0 10.4 >----< 334 40.9 N:83.7 L:10.5 M:5.8 E:0.1 Bas:0.1 . PT: 14.2 PTT: 25.6 INR: 1.3 . Trends: Hct 40 - 30 Plt 334 - 132 . Coags: [**2188-5-12**] 12:20PM BLOOD PT-14.2* PTT-25.6 INR(PT)-1.3* [**2188-5-12**] 05:29PM BLOOD PT-19.5* PTT-29.6 INR(PT)-1.9* [**2188-5-12**] 10:48PM BLOOD PT-22.3* PTT-35.4* INR(PT)-2.2* [**2188-5-13**] 01:46AM BLOOD PT-25.2* PTT-106.3* INR(PT)-2.5* [**2188-5-13**] 05:56AM BLOOD PT-28.8* PTT-74.5* INR(PT)-3.0* [**2188-5-14**] 03:00PM BLOOD PT-55.9* PTT-42.7* INR(PT)-6.8* [**2188-5-14**] 06:18PM BLOOD PT-55.2* PTT-43.5* INR(PT)-6.7* [**2188-5-14**] 08:14PM BLOOD PT-46.7* PTT-40.2* INR(PT)-5.4* [**2188-5-15**] 10:53AM BLOOD PT-33.1* PTT-35.5* INR(PT)-3.6* [**2188-5-15**] 06:20PM BLOOD PT-31.8* PTT-36.4* INR(PT)-3.4* [**2188-5-16**] 02:06AM BLOOD PT-21.5* PTT-31.8 INR(PT)-2.1* [**2188-5-17**] 05:17AM BLOOD PT-16.8* PTT-29.6 INR(PT)-1.5* . Liver enzymes: [**2188-5-12**] 12:20PM BLOOD ALT-378* AST-443* AlkPhos-102 TotBili-1.8* [**2188-5-12**] 05:29PM BLOOD ALT-453* AST-460* AlkPhos-93 TotBili-2.6* [**2188-5-12**] 10:48PM BLOOD ALT-478* AST-433* AlkPhos-89 TotBili-2.9* [**2188-5-13**] 01:46AM BLOOD ALT-495* AST-404* AlkPhos-87 TotBili-2.7* [**2188-5-13**] 05:56AM BLOOD ALT-536* AST-414* AlkPhos-83 TotBili-2.9* [**2188-5-13**] 12:19PM BLOOD ALT-627* AST-474* AlkPhos-87 [**2188-5-13**] 06:01PM BLOOD ALT-988* AST-878* AlkPhos-91 TotBili-5.2* [**2188-5-13**] 09:55PM BLOOD ALT-1503* AST-1398* AlkPhos- TotBili-5.0* [**2188-5-14**] 03:09AM BLOOD ALT-2241* AST-2086* AlkPhos-103 TotBili-4.9* [**2188-5-14**] 09:00AM BLOOD ALT-3934* AST-3871* AlkPhos-108 TotBili-5.1* [**2188-5-14**] 03:00PM BLOOD ALT-5137* AST-5187* AlkPhos-109TotBili-4.5* [**2188-5-14**] 08:14PM BLOOD ALT-5170* AST-4400* AlkPhos-122* TotBili-4.7* [**2188-5-14**] 11:49PM BLOOD ALT-5170* AST-3567* AlkPhos-124* TotBili-4.3* [**2188-5-15**] 03:00AM BLOOD ALT-3885* AST-2813* AlkPhos-124* TotBili-4.1* [**2188-5-15**] 06:00AM BLOOD ALT-4383* AST-2358* AlkPhos-89 TotBili-4.3* [**2188-5-15**] 10:53AM BLOOD ALT-4123* AST-1818* AlkPhos-126* TotBili-5.2* [**2188-5-15**] 06:20PM BLOOD ALT-3456* AST-1128* AlkPhos-129* TotBili-4.7* [**2188-5-16**] 02:06AM BLOOD ALT-2973* AST-695* AlkPhos-135* Amylase-24 TotBili-5.2* [**2188-5-17**] 05:17AM BLOOD ALT-1874* AST-178* AlkPhos-125* TotBili-5.3* . Thyroid: TSH-0.39, Free T4-1.9* . HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE AFP-3.5 . Tylenol level: [**2188-5-12**] 05:29PM BLOOD Acetmnp-161.3* [**2188-5-13**] 05:56AM BLOOD Acetmnp-81.0* [**2188-5-14**] 03:09AM BLOOD Acetmnp-12.7 . Imaging: RUQ ultrasound: liver normal ECHO: The left atrium is normal in size. 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) 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 pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal biventricular size and function. No structural valvular disease. Brief Hospital Course: 18 year old woman history of syncope of unclear etiology, presumed seizure, low baseline blood pressure and presenting with tylenol, cyanide, iron overdose. She ingested significant quantities of tylenol. Hospital course by problem: . # Tylenol overdose - We trended the liver enzymes and liver function tests. She was started on a NAC gtt and monitored in the ICU. She was followed by the liver, toxicology, and liver transplant teams. Supportive care was provided and her enzymes trended as above. Her ALT/AST peaked in the 5000 range. Her INR also peaked around 6.0. Given concerns for irreversible liver damage, a full transplant evaluation was started. All values improved with the NAC and supportive care so a transplant was not necessary. On [**5-17**], her ALT/AST were much improved and her INR was less than 1.5. The NAC was stopped and it was determined that she was medically cleared for psych treatment. Recommend monitoring AST, ALT, alk phos, T Bili, INR every other day for one week to monitor trend. Liver enzymes will remain elevated for at least 4 weeks after the tylenol ingestion. . # Psych: Patient had a suicide attempt as above. Psych followed patient. We provided emotional support as well as a 24 hour sitter. She remained depressed and with thoughts of hurting herself. She was quite anxious at times and had heart rates into the 120s with anxiety. This improved with PO ativan. She will be referred to inpatient psych at [**Last Name (un) 3671**] Behavioral, care of Dr. [**Last Name (STitle) 68469**]. Patient was transferred on Section 12 per psychiatry. . # Sinus tachy and borderline hypotension: both have been documented in the past. Her BP remained stable in SBP low 90s. Her heart rate increased to 120s particularly with multiple visitors or discussions about her disease. It improved with ativan. We do not feel there is an underlying medical ailment which causes this tachycardia. . # Thyroid nodule - TSH, fT4 as above. We recommend outpatient evaluation. . # CN overdose - elevated lactate on admission thought [**12-21**] CN overdose. This improved and she received sodium thiosulfate in the ED. Toxicology assisted with management, no futher interventions are indicated. . # h/o syncope and possible seizure: History is unclear. Pt is not currently taking any anti-seizure medications. Recommend f/u with PCP. . # UTI - She received cipro x3 days. . # Dispo status: medically cleared. requires inpatient psych per psych. Medications on Admission: Keppra 1000 mg in the morning and 1500 mg in the afternoons - stopped it, has not had recurrent seizures Ortho Tri-Cyclin daily. . ALLX: PCN Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety for 1 months. Disp:*60 Tablet(s)* Refills:*0* 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Last Name (un) 3671**] Behavioral Care - [**Hospital1 **] Discharge Diagnosis: - suicidal ideation/attempt - tylenol overdose - hepatic failure - urinary tract infection - anxiety Discharge Condition: tearful, anxious, sad. stable Discharge Instructions: You came in after an overdose on tylenol. We provided supportive care and treated your liver failure. Your symptoms improved. We discharged you to a psychiatric facility for treatment of your thoughts of harming yourself. Please take your medications as recommended. Please followup with your PCP after your psychiatric hospitalization. . Please call your PCP or return to the ED if you have thoughts of hurting yourself. Followup Instructions: Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2188-6-10**] 10:40 . Please followup with psychiatry and your PCP after discharge from psychiatric center.

[ "276.2", "989.0", "E950.0", "345.90", "314.01", "241.0", "570", "599.0", "965.4", "E950.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8959, 9046

6052, 6259

288, 334

9191, 9224

2409, 2409

9699, 9919

1930, 2003

8738, 8936

9067, 9170

8573, 8715

9248, 9676

2018, 2390

231, 250

6287, 8547

362, 1325

2425, 6029

1347, 1556

1572, 1914

59,797

124,058

33833

Discharge summary

report

Admission Date: [**2124-10-3**] Discharge Date: [**2124-10-11**] Date of Birth: [**2078-8-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Variceal Bleed Major Surgical or Invasive Procedure: EGD with variceal banding and injection Intubation History of Present Illness: 46M with ETOH cirrhosis complicated by portal hypertension and prior esophageal variceal bleeding transferred from [**Hospital1 3325**] ED after presenting with massive hematemesis starting 2 hours prior to arrival. Mother called EMS. Describes amount of blood as "a lot." In the ambulance on the way to [**Hospital1 46**] had 300-400 cc hematemesis. Tachycardic to 140s but normotensive and mentating appropriately. Hct 21.1 plts 115 INR 1.3. Given 2U pRBC, ceftriaxone 1 g IV, started on protonix/octreotide gtt. [**Location (un) 7622**] to [**Hospital1 18**]. In ED initial V/S 132 118/65 10 100%NRB. Hct 24.0 plts 113 INR 1.7. Given 4U pRBC, 1L NS. Remained normotensive. Had 600 cc additional hematemesis in the ED. Vital signs prior to transfer 123 123/79 17 100%RA. Upon arrival in the ICU, had another episode of ~500 cc bright red emesis. Feels lightheaded and mild shortness of breath, and complains of LUQ pain and nausea. No fever, chills, syncope, chest pain, cough, hematochezia, or melena. Past Medical History: -ETOH hepatitis/cirrhosis, portal hypertension, esophageal varices. No history of hep ancephalopathy, no Hx of SBP. -Subacute pancreatitis -Hypertension -Appendectomy -Repeated surgeries for facial trauma -Unknown surgery on bilateral shoulders Social History: Heavy EtOH abuse, with binge drinking episodes. Previously drank a six-pack daily, with whiskey. Reports last etoh intake 1 week ago. Smokes 1 pack/week. Denies IVDU. Family History: CAD, father deceased at 64, grandfather deceased at 61, both from MI Physical Exam: On admission: V/S: T 98.7 HR 120 BP 130/84 RR 15 O2sat 100%2L GEN: Awake, alert, conversing appropriately HEENT: anicteric, pale conjunctiva, dried blood around the mouth NECK: no JVD CV: reg tachy no m/r/g PULM: CTAB ABD: soft nondistended mildly tender to deep palp LUQ no rebound, guarding +BS EXT: warm, dry +PP . Pertinent Results: [**2124-10-3**] 01:55PM BLOOD WBC-5.4 RBC-3.09* Hgb-7.7* Hct-24.0* MCV-78*# MCH-25.0* MCHC-32.2 RDW-17.8* Plt Ct-113*# [**2124-10-3**] 03:59PM BLOOD WBC-4.3 RBC-3.26* Hgb-9.3* Hct-27.3* MCV-84 MCH-28.6# MCHC-34.1 RDW-17.5* Plt Ct-68* [**2124-10-3**] 06:48PM BLOOD WBC-5.4 RBC-3.06* Hgb-8.6* Hct-25.6* MCV-84 MCH-28.0 MCHC-33.4 RDW-17.1* Plt Ct-90* [**2124-10-5**] 04:13AM BLOOD WBC-6.0 RBC-3.32* Hgb-9.7* Hct-27.4* MCV-83 MCH-29.0 MCHC-35.2* RDW-17.4* Plt Ct-60* [**2124-10-5**] 11:44AM BLOOD WBC-6.0 RBC-3.32* Hgb-9.4* Hct-27.8* MCV-84 MCH-28.4 MCHC-33.9 RDW-17.3* Plt Ct-68* [**2124-10-8**] 07:00AM BLOOD WBC-3.5* RBC-3.25* Hgb-9.2* Hct-27.5* MCV-85 MCH-28.5 MCHC-33.6 RDW-18.6* Plt Ct-80* . [**2124-10-3**] 01:55PM BLOOD PT-18.4* PTT-30.9 INR(PT)-1.7* [**2124-10-3**] 01:55PM BLOOD Plt Smr-LOW Plt Ct-113*# [**2124-10-3**] 03:59PM BLOOD PT-18.7* PTT-32.2 INR(PT)-1.7* [**2124-10-3**] 03:59PM BLOOD Plt Ct-68* [**2124-10-8**] 07:00AM BLOOD PT-16.9* PTT-32.4 INR(PT)-1.5* [**2124-10-8**] 07:00AM BLOOD Plt Ct-80* . [**2124-10-3**] 01:55PM BLOOD Glucose-152* UreaN-16 Creat-0.7 Na-145 K-4.9 Cl-110* HCO3-22 AnGap-18 [**2124-10-3**] 03:59PM BLOOD Glucose-197* UreaN-17 Creat-0.8 Na-146* K-5.0 Cl-112* HCO3-22 AnGap-17 [**2124-10-7**] 04:40AM BLOOD Glucose-101* UreaN-7 Creat-0.6 Na-137 K-3.3 Cl-104 HCO3-25 AnGap-11 [**2124-10-8**] 07:00AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-141 K-3.1* Cl-108 HCO3-26 AnGap-10 . [**2124-10-3**] 01:55PM BLOOD Calcium-8.2* Phos-3.6 Mg-1.6 [**2124-10-3**] 03:59PM BLOOD Albumin-3.2* Calcium-7.4* Phos-3.2 Mg-1.5* [**2124-10-7**] 04:40AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.8 [**2124-10-8**] 07:00AM BLOOD Albumin-2.6* Calcium-8.1* Phos-3.3 Mg-1.8 . [**2124-10-4**] 03:44PM BLOOD Type-ART pO2-132* pCO2-41 pH-7.42 calTCO2-28 Base XS-2 Intubat-INTUBATED [**2124-10-5**] 04:40AM BLOOD Type-ART Temp-36.9 pO2-104 pCO2-42 pH-7.46* calTCO2-31* Base XS-5 . [**2124-10-4**] 01:31PM BLOOD Glucose-103 Lactate-1.5 Na-141 K-3.7 Cl-109 [**2124-10-4**] 03:44PM BLOOD Glucose-103 Lactate-1.6 Na-141 K-3.6 Cl-109 . [**2124-10-3**] 03:59PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . LABS ON DISCHARGE . [**2124-10-11**] 05:34AM BLOOD WBC-3.8* RBC-3.22* Hgb-9.2* Hct-27.2* MCV-85 MCH-28.5 MCHC-33.7 RDW-20.1* Plt Ct-75* [**2124-10-11**] 05:34AM BLOOD PT-18.5* PTT-34.6 INR(PT)-1.7* [**2124-10-11**] 05:34AM BLOOD Glucose-94 UreaN-9 Creat-0.6 Na-139 K-3.7 Cl-108 HCO3-24 AnGap-11 [**2124-10-11**] 05:34AM BLOOD ALT-34 AST-51* LD(LDH)-172 AlkPhos-157* TotBili-2.2* [**2124-10-11**] 05:34AM BLOOD Albumin-3.0* Calcium-8.1* Phos-4.1 Mg-1.9 . IMAGING . Chest x-ray ([**2124-10-7**]) FINDINGS: In comparison with the study of [**10-6**], the hemidiaphragms are quite sharply seen. There may still be some pleural effusion, which is hidden behind the apex of the hemidiaphragm on this upright view. Mild atelectatic changes are seen at the left base, but no evidence of vascular congestion or acute pneumonia. . MICROBIOLOGY . Urine cx x 2 = no growth Blood cx x 6 = pending at time of discharge . Brief Hospital Course: 46 yo M with a pmh of alcohol abuse, alcoholic cirrhosis admitted to the MICU for massive hemetemisis from known severe esophageal varices s/p banding and injection, received large amounts of pRBC, platelet, and FFP transfusions as well as a TIPS procedure, who is currently hemodynamically stable. . #Esophageal variceal bleed - EGD [**10-3**] showed 3 cords of grade II varices in the mid- and lower esophagus, one of which had an ulcerated area consistent with recent rupture. Two were treated with banding and one with sodium morrhuate injection. Given 11U pRBC, 4U FFP, 2 bags platelets (last pRBC transfusion was on [**10-4**]). Underwent TIPS on [**10-4**]. Treated with octreotide/protonix gtt and ceftriaxone for SBP prophylaxis. Carafate and nadolol started [**10-5**]. His HCT stabilized at 25-28 for the remainder of the admission. . # Fever: Spiked fevers prior to leaving the MICU on [**10-6**] to 101.6. He was pan-cultured and concern was for aspiration pneumonia vs. mediastinitis s/p EGD. He had been covered by ceftriaxone and spiked through it, so he was switched to vanc and unasyn. He had a temp to 100.5 the following night, so we pan cultured and broadened to vanc and Zosyn. His bump in LFTs was likely due to the recent TIPS. He was initiated on Vanc and Zosyn for an 8 day course (last day = [**2124-10-14**]) to be administered with the assistance of VNA. . # Confusion: Resolved upon transfer from the unit. Possibly due to encephalopathy in the setting of the bleed vs. infection. On lactulose and antibiotics. . #. ETOH Cirrhosis: Extensive EtOH abuse. Pt admitted to recent alcohol use prior to admission. He stated that he needs help and wants to get sober. Social work is getting him help for placement. Openly remoresful and actively seeking help. He will be discharged with information about local detox options close to home. . Medications on Admission: 1. Lactulose 30 ML PO TID as needed for constipation. 2. Nadolol 20 mg DAILY 3. Omeprazole 40 mg twice a day 4. Sucralfate 1000 mg four times a day. 5. Folic Acid 1 mg DAILY 6. Multivitamin DAILY 7. Thiamine 100 mg DAILY Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 4 days: last day = [**10-14**]. Disp:*7 grams* Refills:*0* 9. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every eight (8) hours for 4 days: last day = [**10-14**]. Disp:*18 grams* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Primary Diagnoses: Variceal Bleed Pneumonia Secondary Diagnosis: Alcohol Cirrhosis 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 a large bleed from your stomach. When you arrived, a breathing tube was placed to help you breath and to protect against blood getting into your lungs. You had a procedure done with a camera looking into your stomach to find the veins that were bleeding and elastics were placed on them to stop the bleed. You were given blood to help stabilize your blood level. . You were given antibiotics to protect against infection. Before leaving the ICU you had a temperature while on antibiotics, so we gave you different antibiotics. You were treated for a pneumonia. . Your blood counts were stable and you no longer had fevers. You were actively seeking help to enter relapse prevention program and we were happy to have social work meet with you to help set that up. You were in good condition upon discharge. YOU MUST MAKE THE APPOINTMENT TO GO TO OUTPATIENT [**Hospital **] REHAB. YOU ARE IN DANGER OF BECOMING VERY SICK OR DYING IF YOU CONTINUE TO DRINK ALCOHOL. . In summary, we made the following changes to your medications: We ADDED Vancomycin 100mg IV twice a day for 8 days total (end [**2124-10-14**]) We ADDED Zosyn 4.5g IV every 8 hours for 8 days total (end [**2124-10-14**]) Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (STitle) 14244**] office will call you for an office visit and an abdominal ultrasoun appointment. The endoscopy procedure that is scheduled for the end of [**Month (only) **] is not needed You have an appointment with your PCP [**Last Name (NamePattern4) **] [**2124-10-18**] at 3:30pm. The phone number is [**Telephone/Fax (1) 25821**]. You can get your disability forms filled out there.

[ "285.1", "286.7", "456.20", "571.1", "537.89", "348.30", "456.8", "507.0", "401.9", "571.2", "572.3", "303.91", "458.29", "577.0" ]

icd9cm

[ [ [] ] ]

[ "88.64", "38.91", "39.1", "38.93", "96.71", "99.29", "96.04", "42.33" ]

icd9pcs

[ [ [] ] ]

8394, 8463

5377, 7256

329, 381

8590, 8590

2309, 5354

9998, 10440

1885, 1956

7527, 8371

8484, 8528

7282, 7504

8741, 9787

1971, 1971

9816, 9975

275, 291

409, 1415

8549, 8569

1985, 2290

8605, 8717

1437, 1684

1701, 1869

18,190

127,881

8374

Discharge summary

report

Admission Date: [**2141-3-14**] Discharge Date: [**2141-3-21**] Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1283**] Chief Complaint: Increasing fatigue and pre-syncope Major Surgical or Invasive Procedure: [**2141-3-15**] Aortic Valve Replacement(21mm Pericardial valve) and Two Vessel Coronary Artery Bypass Grafting(left internal mammary to left anterior descending and vein graft to obtuse marginal). History of Present Illness: This is an 84 year old year old female with known aortic stenosis and coronary artery disease since [**2133**], who recently complained of worsening presyncopal episodes and progressive dyspnea on exertion and fatigue. Her most recent echocardiogram showed an aortic valve area of 0.76cm2 with a peak of 64 and mean of 38mmHg. There was no aortic insufficiency, mild mitral regurgitation and an LVEF of 65%. Cardiac catheterization in [**2141-1-9**] confirmed severe aortic stenosis and three vessel disease. Based on the above, she was referred for cardiac surgical intervention. Past Medical History: Aortic Valve Stenosis, Coronary Artery Disease, Mild COPD, Hypertension, Insulin Dependent Diabetes Mellitus, Dyslipidemia, Mild Chronic Renal Insufficiency, Esophagitis, Recurrent UTI, Osteoporosis, Obesity, s/p Nephrectomy, Colon Cancer - s/p Colectomy, s/p Total Hip Replacments, s/p Chole, s/p Appendectomy, s/p Vein Stripping, s/p Cataract Surgery Social History: Remote history of tobacco. Admits to only rare ETOH. She lives alone. Family History: Brother died of MI at age 50. Father died of MI at age 62. Physical Exam: Vitals: T 97.3, BP 160/66, HR 66, RR 20, SAT 97 on room air General: Elderly female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, 4/6 systolic ejection murmur throughout precordium, radiating to carotids Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, 1+ edema, Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [**2141-3-21**] 07:10AM BLOOD Hct-31.5* [**2141-3-20**] 05:46AM BLOOD WBC-7.5 RBC-3.28* Hgb-10.0* Hct-29.7* MCV-91 MCH-30.6 MCHC-33.7 RDW-15.5 Plt Ct-130* [**2141-3-20**] 05:46AM BLOOD Plt Ct-130* [**2141-3-18**] 05:07AM BLOOD PT-11.8 PTT-27.8 INR(PT)-1.0 [**2141-3-20**] 05:46AM BLOOD Glucose-78 UreaN-18 Creat-1.0 Na-136 K-5.0 Cl-105 HCO3-25 AnGap-11 [**2141-3-21**] 07:10AM BLOOD UreaN-19 Creat-1.1 K-5.5* Brief Hospital Course: Mrs. [**Known lastname 20585**] was admitted on [**3-14**]. Due to operative emergencies, surgery was postponed to the following day. On [**3-15**], Dr. [**Last Name (STitle) 1290**] performed an aortic valve replacement and coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She weaned from inotropic support without difficulty. She maintained stable hemodynamics as beta blockade was resumed. Her CSRU course was otherwise uneventful and she transferred to the SDU on postoperative day three. She remained in a normal sinus rhythm. Beta blockade was slowly advanced as tolerated. She remained fluid overloaded and continue to require diuresis. Over several days, she continued to make clinical improvements and was eventually cleared for discharge on postoperative day 7. Medications on Admission: Atenolol 50 qd, Avapro 150 qd, Diltiazem XT 120 qd, Evista 60 qd, Lasix 20 qd, Metformin 750 [**Hospital1 **], Zocor 20 qd, Aspirin 81 qd, Nitrofurantoin 100 qd, Lantus, Humalog SS, MV Discharge Medications: 1. 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* 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 7. Metformin 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 8. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous once a day. 9. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Aortic Valve Stenosis and Coronary Artery Disease - s/p AVR and CABG, COPD, Hypertension, Insulin Dependent Diabetes Mellitus, Dyslipidemia, Mild Chronic Renal Insufficiency, Esophagitis, Recurrent UTI, Osteoporosis, Obesity Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-13**] weeks. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20458**] in [**2-11**] weeks. Local cardiologist, Dr. [**Last Name (STitle) **] in [**2-11**] weeks. Completed by:[**2141-3-27**]

[ "414.01", "585.9", "250.00", "403.90", "496", "V10.05", "424.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "35.21", "39.61", "36.11", "38.93" ]

icd9pcs

[ [ [] ] ]

4863, 4931

2482, 3477

269, 469

5200, 5207

2049, 2459

5526, 5796

1558, 1618

3712, 4840

4952, 5179

3503, 3689

5231, 5503

1633, 2030

195, 231

497, 1079

1101, 1455

1471, 1542

20,259

130,781

20910

Discharge summary

report

Admission Date: [**2196-6-8**] Discharge Date: [**2196-6-18**] Date of Birth: [**2156-12-21**] Sex: F Service: MEDICINE Allergies: Cephalosporins / Dilaudid / Metoclopramide Attending:[**First Name3 (LF) 2641**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Intubation Central line placement Bronchoscopy History of Present Illness: This is a 39 year-old female with a history of diabetes type I on an insulin pump, anemia, hypothyroidism, gastroparesis, GERD, who was transferred from [**Hospital **] Hospital for further management of hypoxic respiratory failure. She arrived at [**Hospital **] Hospital on [**5-23**] for 1 day of nausea and vomiting and was found to be febrile to 99 at that time. She was admitted for likely gastroparesis and eventually had a complete fever work-up that included a negative chest x-ray, blood cultures, and urine culture. She was discharged on [**5-24**] and represented that day with continued nause, vomiting, and fever. She was readmitted and had a complete febrile work-up that included CT abdomene/pelvis, chest x-ray, blood culture's, urine cultures, all of which were unremarkable. She was intubated on [**5-25**] for progressive respiratory failure. Workup continued to be negative. Extubation was attempted on [**6-5**], but she was re-intubated due to inspiratory stridor. A CT neck showed soft tissue swelling obliterating the airway surrounding the ETT tube. She was transferred to [**Hospital1 18**] for further management. Past Medical History: 1. Type I diabetes diagnosed at age 27. She is usually managed on an insulin pump. 2. Hashimoto's thyroiditis. 3. Gastroparesis 4. History of bulemia 5. Anxiety on clonazepam 6. History of diabetic foot ulcer. Social History: She is married and lives with her husband. She has a 10 month old child. She denies any alcohol, tobacco, or other drugs. Family History: Non-contributory. Physical Exam: Vitals: Temperature:98.8 Pulse:79 Blood Pressure:125/89 Respiratory Rate:12 Oxygen Saturation:100% on AC 500x12, PEEP5, 50% GENERAL: Intubated, sedated, not responsive to command, retracts to pain HEENT: Anicteric sclera bilat. Pupils minimally reactive NECK: No elevated JVP appreciated. CARDIAC: Regular, s1,s2. No murmurs RESPIRATORY: Clear to auscultation anteriorly. ABDOMEN: Soft. Nondistended. No hepatosplenomegally. Mildly hypoactive bowelsounds. EXTREMITIES: No edema bilaterally. Pulses diminished but symmetric. NEURO: Sedated. Retracts to painful stimuli SKIN: No rashes Pertinent Results: Hematology: WBC-29.9 HGB-8.5 HCT-26.8 PLT COUNT-323 NEUTS-75 BANDS-13 LYMPHS-6 MONOS-5 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 . Chemistries: SODIUM-137 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-22 UREA N-41* CREAT-1.3 GLUCOSE-231 CALCIUM-7.7 PHOSPHATE-3.6 MAGNESIUM-2.4 . Liver Function: ALT(SGPT)-249 AST(SGOT)-147 LD(LDH)-241 ALK PHOS-230 AMYLASE-28 TOT BILI-0.9 LIPASE-12 ALBUMIN-2.6 . Coagulation: PT-13.8 PTT-24.3 INR(PT)-1.2 . Thyroid: TSH-3.3 . Imaging: 1. Nexk CT: Increased soft tissues within the pharynx. This may be secondary to soft tissue swelling as indicated in the patient's history, and some may be secondary to secretions above the ETT balloon. No retropharyngeal fluid is identified. Dependent atelectasis is present within the visualized portions of the lung apices. 2. Chest CT: Bilateral lower lobe consolidations mostly in dependent portion, with small pleural effusion and diffuse ground-glass opacity in bilateral upper and lower lobes, consistent with ARDS with pulmonary edema given the history. Ground-glass opacity is somewhat more prominent in right upper lobe, and superimposed infection cannot be totally excluded. Brief Hospital Course: This is a 39 year-old female with diabetes type I, hypothyroidism, gastroparesis who was transfered for hypoxic respiratory failure. . 1. Hypoxic Rspiratory Failure: She arrived intubated and sedated from [**Hospital 5279**] Hospital. On arrival a chest x-ray showed perihilar and bibasilar opacities, which appeared conistent with pulmonary edema but also possibly consistent with a pneumonia. There was no evidence of ARDS. She was known to have gram-positive cocci in her sputum at the outside hospital. A bronchoscopy with BAL was performed and a sputum sample eventually grew out MRSA. She was treated with vancomycin to cover her MRSA pneumonia. . A CT scan was performed on [**6-8**] to evaluate the soft tissue swelling seen on CT at the outside hospital. The CT showed increased soft tissues within the pharynx which was felt to be secondary to prolonged intubation/trauma. She was treated with steroids for this swelling at the outside hospital, and these were continued. It was decided that patient should receive one more trial off the vent before committing her to a tracheotomy. She did well on minimal vent settings but it was decided to delay extubating the patient until the morning of [**6-10**]. Overnight, the patient became hypoxic, dropping to the 80's. A chest x-ray showed that the ET tube was displaced to very high in the trachea. The cuff was deflated and the patient was extubated. She was placed in supplemental oxygen by shovel mask and her sats immediately improved. She was weaned down until she was maintaining her oxygen saturation above 90% on 6L by nasal cannuala. As she was doing well without evidence of stridor, the steroids were stopped. She did well and was weaned from supplemental oxygen. At the time of discharge, she was oxygenating well on room air. She Will need to complete a 14 day course of vancomycin for her MRSA pneumonia on [**2196-6-21**]. . 2. Enterobacter bacteremia: She was initially covered broadly with vancomycin, ciprofloxacin, and falgyl. She had positive blood cultures at [**Hospital **] Hospital for gram negative rods. Subsequently, zosyn was added. The cultures grew out enterobacter cloacae. It was unclear the source of her bacteremia. Her stool cultures were negative. Her central line was removed and the tip was culture negative. She was transitioned to on levofloxacin for her bacteremia. She had no positive cultures during this admission. Once she was more stable, an abdominal CT was performed to look for an abscess. This study was negative. However, the study was limited due to inadequate po contrast intake by the patient; it did show a question of a cecal cystic lesion verse normal loop of bowel. This study will need to be repeated once she is tolerating po's. She will complete a 14 day course of levofloxacin for her bacteremia on [**2196-6-21**]. . 3. Diabetes type I: She was intially maintained on an insulin drip for tight glycemic control. She was followed by [**Last Name (un) **] during the admission. She was initially maintained on D5W, which was increased to D10W as the patient was persistently borderline hypoglycemic while on insulin drip. Once she began to take PO's, the insulin drip was stopped and patient was started on glargine with a humalog sliding scale. While her po intake was minimal she was maintained on supplemental IV dextrose to suppress ketosis. While she was on the IV dextrose, she required up to 26 units of glargine for glycemic control. As she starting taking some foods, her glargine was decrease. At the time of discharge her glargine was 10. Her blood glucose were under good control. The day prior to discharge, she was nauseated and not taking pos. Therefore, she received 1L of D5, and her sugars were elevated to 400 the day of discharge. . 4. Gastroparesis: She has a history of gastroparesis secondary to long-standing type I diabetes. Once she was extubated, she was nauseated with emesis. She was intially treated with erythromycin for pro-motility as she had a bad reaction to reglan in the past. She continued to remained nauseated so she was treated with phenergan, anzemet, zofran, and ativan. She intermittently was able tolerate pos. Her nausea was accompanied by abdominal pain for which she was treated with morphine. She was transitioned to a PCA for better pain control. She continued to have nausea despite an agressive anti-emetic regimen. It was felt that her symptoms were secondary to gastroparesis. However, other causes were looked for including adrenal insufficiency and bowel obstruction. She had a normal cortisol stimulation test. A abdominal plain film showed non-specific bowel gas patterns that may represent an early obstruction. A NG tube was placed for decompression given the signs of early obstruction the day of transfer. The GI service was consulted and they felt that her symptoms were all gastroparesis. They recommended erythromycin and zelnorm. She should eventually have a tissue transglutaminase to rule out celiac disease. . 5. Transaminitis: Per report, She had elevated LFTs at the outside hospital. A right upper quadrant ultrasound was performed and was negative for any acute pathology. Her LFTs trended down during this admission. . 6. Hypothyroidism: She was maintained on her levothyroxine. While she was not taking adequate pos, she was on IV levothyroxine. . 7. F/E/N: She was NPO while intubated and recived tube feedings for nutrition. After extubation, patient was started on sips and had a speech and swallow evaluation. She was cleared to advance her diet as tolerated. She only tolerated some clear liquids. At the time of transfer, she was NPO given her NG tube. . 8. Prophylaxis: PPI, Heparin SQ. . 9. Access: Her central line was removed given the concern for a line infection. She had a double lumen PICC place. . 10. CODE: FULL . 11. Dispo: She was transfered back to [**Hospital **] Hospital per the patient's and husband's request so that she would be closer to home once her respiratory status was stable. anti-GBM is pending. Medications on Admission: Meds: Vitamin D [**Numeric Identifier 1871**] Unit [**Unit Number **] one time a week Cozaar 25mg 1 time per day Procrit - Multidose 20000u/ml 20, 000 units SQ every other week Levoxyl 150mcg 1 1 time per day Iron 325(65)mg twice a day Zoloft 100mg 1 per day,2 TABS Freestyle as directed Clonazepam 0.5mg Humalog 100 U/ml 1 as directed pump Zofran 8mg 1 as directed Prevacid 30mg 1 1 time per day Lorazepam 0.5mg 1 to 2 tablets twice daily if needed . on transfer: Cipro 400" Vanco 1g qD Flagyl 500q8 Levophed gtt Propofol gtt Solumedrol 40q6 (started [**6-5**]) Pepcid FeSo4 325' Insulin 35 lantus qhs Synthroid 150' Losartan 25' Zoloft 200' Zelnorm 6" MS [**First Name (Titles) **] [**Last Name (Titles) **] Discharge Medications: 1. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for headache. 4. Ondansetron HCl 2 mg/mL Solution Sig: One (1) ML Intravenous Q12H (every 12 hours) as needed for nausea. 5. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day). 7. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous once a day. 8. Humalog 100 unit/mL Cartridge Sig: asdir Subcutaneous once a day: see attached sheet for sliding scale. 9. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. 10. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO bid (). 11. Levofloxacin 500 mg IV Q24H 12. Vancomycin HCl 750 mg IV Q 12H 13. Dolasetron Mesylate 25 mg IV Q8H:[**Last Name (Titles) **] nausea 14. Promethazine HCl 25 mg IV Q6H:[**Last Name (Titles) **] 15. Lorazepam 0.5-1 mg IV Q3-4H:[**Last Name (Titles) **] anxiety, nausea hold for sedation. 16. Levothyroxine Sodium 75 mcg IV DAILY 17. Pantoprazole 40 mg IV Q12H 18. Erythromycin 500 mg IV Q6H Discharge Disposition: Extended Care Facility: [**Hospital 5279**] Hospital Discharge Diagnosis: MRSA pneumonia Gastroparesis Enterobacter bacteremia Diabetes type I Hypothyroidism Discharge Condition: Stable. She was oxygenating well on room air. She continued to have nausea and vomiting. She was unable to tolerate pos. Discharge Instructions: You are being transfered to [**Hospital **] Hospital for further care as you have requested to be closer to home. Followup Instructions: You should have a anti-Tissue Transglutaminase Antibody, IgA to rule out celiac disease given your abdominal symptoms. Completed by:[**2196-6-18**]

[ "790.7", "518.81", "V09.0", "041.85", "482.41", "536.3", "250.63", "244.9", "300.00", "478.25", "794.8", "V45.85" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11902, 11957

3759, 9843

323, 372

12085, 12211

2591, 3736

12373, 12523

1946, 1965

10604, 11879

11978, 12064

9869, 10581

12235, 12350

1980, 2572

264, 285

400, 1553

1575, 1788

1804, 1930

12,003

101,374

51064

Discharge summary

report

Admission Date: [**2135-2-14**] Discharge Date: [**2135-2-20**] Service: MEDICINE Allergies: Ativan / Compazine Attending:[**First Name3 (LF) 2751**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD x3 with clipping History of Present Illness: 86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial gastrectomy [**2072**], sarcoidosis, afib not on coumadin, hematemesis with anastamotic ulcer on EGD in [**2128**] p/w nausea and vomiting last night. She was in her usual state of health during the day, went out for Chinese food for dinner around 5 pm. Initially felt well afterwards, around 10 pm felt nauseated and started vomiting. Was up all night with abdominal pain and nausea, vomited about five times last night. This morning around 6 am vomited bright red blood. Not sure how much it was, no coffee grounds. Also may have had a dark stool this AM but she is not sure. Denies any diarrhea currently, but had diarrhea last week. She does get nauseated about once a week, used to be followed in [**Hospital **] clinic for this and was thought to be related to GERD and possible ulcer disease, has been on a [**Hospital1 **] PPI and PRN promethazine at home, takes promethazine about weekly. Unable to take last night due to nausea. No h/o liver disease. No h/o liver disease. Denies chest pain, shortness of breath, lightheadedness, joint pain, rashes, sick contacts. . In the ED, initial VS were HR 82, BP 162/98, RR 14, sat 99% 3L NC. EKG showed sinus rhythm 82 bpm, prolonged PR interval, PVCs and new lateral ST depressions. Pt given IV NS, protonix 80 mg bolus and started on drip, zofran 4 mg, and morphine. Pt appeared dry on exam, rectal exam with no stool in the vault. NG lavage not done given presence of bright red blood in vomit. Hct 36 so no blood products were given, coags wnl. Access with PIV x 2. Received 2.5 L of IV NS. GI called from [**Location **], recommended EGD. Admitted to ICU for active vomiting of blood noted in ED. VS on transfer temperature 97.8. HR 86 RR 20 BP 152/81, afib, sat 100% 2L. . On arrival to ICU, pt feels nauseated and abdominal pain in lower part of abdomen which started last night as well, nonradiating, feels like cramping. No fever since episodes started but did have a fever to 101 about 2 weeks ago for which she was treated with amoxicillin. Has had 4 episodes total of blood in vomit, although unable to quantify amount of blood. . Review of systems: (+) Per HPI, also + for cough for the last few weeks, recently treated for presumed PNA with 10 day course of amoxicillin, suspected that cough may be related to pulmonary sarcoidosis per daughter (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. HTN 2. Hypercholesterolemia 3. systolic CHF, etiology unclear 4. Bleeding gastric ulcer s/p partial gastrectomy in [**2072**]. 5. Hematemesis 6-7 years ago. No source was found on EGD. 6. Lap cholecystetomy in [**2124**] complicated by liver laceration and PE 7. Post-op PE requiring brief intubation and s/p IVC filter and anticoagulation in [**2124**] 8. S/p appendectomy 9. Iron deficiency anemia 10. OA of left knee requiring knee replacement 11. S/p fall complicated by displacement of anterior arch of C1 one year ago; wore hard collar for one year and is now s/p surgical fixation in [**7-11**] at [**Hospital3 **] 12. L TKR due to non [**Hospital1 **] of femur fx [**3-12**] at OSH 13. h/o depression 14. atrial fibrillation 15. hematemesis bleeding ulcer noted at billroth II anasthamosis in [**2128**] (gastrin level wnl and H. pylori negative) 16. sarcoidosis dx [**2129**] with pulmonary symptoms and lymph node bx Social History: - Tobacco: denies, prior 10 pack year history per OMR - Alcohol: denies currently, h/o EtOH abuse quit 35 years ago, detox x 3 in the past - Illicits: pt denies, but per OMR h/o prescription drug abuse (opiates) Family History: Her father died of renal cancer; brother with lung cancer; no hx of CAD; no hx of colon cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.7 HR 86 BP 143/74 sat 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, tacky mucous membranes, no oropharyngeal lesions Neck: supple, JVP not elevated, no LAD Lungs: crackles at bases bilaterally, no wheezes, rhonchi CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic murmur best heard at apex Abdomen: soft, mild ttp throughout, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2135-2-14**] 07:05AM BLOOD WBC-15.5* RBC-4.02* Hgb-11.7* Hct-36.9 MCV-92 MCH-29.1 MCHC-31.6 RDW-14.9 Plt Ct-167 [**2135-2-14**] 12:55PM BLOOD WBC-10.6 RBC-2.90*# Hgb-8.7*# Hct-26.4*# MCV-91 MCH-29.9 MCHC-32.9 RDW-15.0 Plt Ct-148* [**2135-2-14**] 07:25PM BLOOD Hct-24.0* [**2135-2-15**] 02:53AM BLOOD WBC-14.9* RBC-3.22* Hgb-9.6* Hct-28.8* MCV-89 MCH-29.9 MCHC-33.5 RDW-14.8 Plt Ct-113* [**2135-2-15**] 09:22AM BLOOD Hct-26.0* [**2135-2-15**] 03:30PM BLOOD Hct-28.9* [**2135-2-16**] 04:24AM BLOOD WBC-8.6 RBC-2.66*# Hgb-8.1*# Hct-23.6*# MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8 Plt Ct-84* [**2135-2-14**] 07:05AM BLOOD PT-10.9 PTT-29.9 INR(PT)-1.0 [**2135-2-16**] 04:59AM BLOOD PT-13.1* PTT-29.2 INR(PT)-1.2* [**2135-2-14**] 07:05AM BLOOD Fibrino-390 [**2135-2-14**] 07:05AM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-140 K-4.3 Cl-102 HCO3-25 AnGap-17 [**2135-2-15**] 02:53AM BLOOD Glucose-124* UreaN-25* Creat-0.6 Na-141 K-3.8 Cl-110* HCO3-22 AnGap-13 [**2135-2-16**] 04:24AM BLOOD Glucose-67* UreaN-21* Creat-0.5 Na-141 K-3.6 Cl-112* HCO3-21* AnGap-12 [**2135-2-14**] 07:05AM BLOOD ALT-20 AST-43* LD(LDH)-432* AlkPhos-120* TotBili-0.3 [**2135-2-15**] 02:53AM BLOOD ALT-14 AST-24 AlkPhos-77 [**2135-2-14**] 07:05AM BLOOD Lipase-19 [**2135-2-14**] 07:05AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.8 [**2135-2-15**] 02:53AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.9 [**2135-2-16**] 04:24AM BLOOD Calcium-6.5* Phos-2.6* Mg-1.7 [**2135-2-16**] 03:10AM BLOOD Digoxin-0.5* [**2135-2-16**] 04:34AM BLOOD freeCa-1.00* [**2135-2-14**] 08:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2135-2-14**] 08:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [**2135-2-14**] 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 MICRO: Urine ([**2-14**]): no growth EKG ([**2-14**]): Rate 82. Sinus rhythm. First degree A-V block. Leftward axis. Poor R wave progression. Lateral ST-T wave abnormalities. Compared to the previous tracing of [**2134-3-27**] first degree A-V block is now present. CXR ([**2-14**]): IMPRESSION: 1. No evidence of intra-abdominal free air. 2. Stable cardiomegaly. 3. No evidence of decompensated congestive heart failure or pneumonia. Hand ([**2-16**]) Xray: PND EGD [**2-14**]: Impression: Normal mucosa in the esophagus Blood in the stomach body Dieulafoy lesion in the Anastomotic site (endoclip) Both the limbs were identified and no source of bleeding was noticed in those. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: BRIEF HOSPITAL COURSE: 86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial gastrectomy [**2072**], hematemesis in [**2128**] [**2-3**] anastamotic bleed, afib not on coumadin p/w nausea and vomiting, hematemesis . ACTIVE ISSUES: # Hematemesis/Acute blood loss Anemia: Patient was initially admitted to the ICU for frequent episodes of hematemesis with stable blood pressures and heart rate in the ED. Initially Hct was 36 in setting of dehydration and decreased to 26 after fluid repletion. GI was consulted and EGD was done on day of admission which showed likely Dieulafoy's lesion near anastatmotic site from prior gastric bypass surgery, and three clips were placed. Followup Hct was 24 after EGD, transfused 2 units of PRBC. She was scoped again the following day which again showed bleeding Dieulafoy lesion and 2 clips were placed and lesion injected. Followup Hct suggested continued bleeding so she was transfused 2 more units PRBC. Third EGD was done on [**2-16**] which showed no bleeding at anastamotic site and areas suggestive of ischemia around the anastamotic site. Patient was evaluated by the surgical team who recommended no acute intervention and transfusion goal of Hct >30 and platelets >70, IR was made aware of patient who recommended no acute intervention. Throughout course in MICU patient's blood pressure, urine output remained stable and patient was continued on protonix 40 mg IV BID. She received total of 6 units PRBC in MICU and antihypertensives were held. Her Hct remained stable and she was transitioned to orals. H. pylori was also sent and was negative. . # Afib: Pt history with atrial fibrillation, not on coumadin. At home she is on rate control with atenolol and on digoxin, however this was held in setting of acute bleed. She had one episode of afib w/ RVR to 140s [**2-15**] around the EGD procedure. The patient was given 2.5mg metoprolol IVx2 and 5mg IV x1. Pt was otherwise in sinus during MICU stay. Her digoxin was continued. Her beta blocker was started as Metoprolol on [**2-17**], and she remained stable. Aspirin is being held in light of GI bleeding. . #Hand pain/ swelling: Patient has chronic pain at baseline, on [**2-16**] noted to have swollen and tender MCP joints. Pt with history of sarcoidosis and inflammatory appearance of joints, started short course of prednisone 20 mg x 4 days and standing tylenol. Pseudogout was also a consideration. Hand xrays ordered and showed nothing acute. . # Nausea/vomiting/abd pain: Pt has had episodes in the past of nausea and vomiting usually post-prandial and is on PPI [**Hospital1 **] as symptoms thought to be [**2-3**] GERD or recurrence of ulcers in the past, viral gastroenteritis was also on differential. It is possible that symptoms were also related to lesion at anastamotic site. Zofran and IV morphine given with symptomatic improvement. This was transitioned to oral oxycodone, and then this was weaned because of fall risk. Abdominal exam remained benign. # leukocytosis: Initally WBC 15.5, improved without intervention. [**Month (only) 116**] have been in setting of stress vs gastroenteritis given sx of nausea, vomiting. No fevers during stay in MICU, but was recently treated for cough and fever with amoxicillin. # Cough: has been ongoing for about 2 weeks, no change with antibiotics and CXR with no acute process making PNA or CHF exac less likely. [**Month (only) 116**] be related to viral bronchitis vs re-occurance of sarcoidosis (had pulmonary sarcoid in the past, follows in pulmonology). Being worked up as outpatient # HTN: Held atenolol, lisinopril in setting of acute bleed. Restarted low dose BB first on [**2-17**]. ACE-I held and restarted at a lower dose (10mg daily, instead of 30mg daily). Should be revaluated by PCP. . # chronic pain: pt with chronic pain in setting of multiple knee and neck surgeries. She is on an oxycodone regimen per her PCP, [**Name10 (NameIs) **] IV morphine in ICU since pt had increased pain and was NPO. I did not give her more oxycodone since this increases risk of falls, and she at times felt light-headed after taking it when walking with walker (though proved to be stable on evaluation). she was instructed not to drive on this medication. # chronic systolic CHF: She appeared euvolemic on exam. Most recent EF is 50% from dobutamine stress test. Beta blocker and ACEI held in setting of bleed, but restarted gradually once her bleeding resolved. # depression: continued effexor # Communication: Patient, daughter/hcp [**Name (NI) **] cell:[**Telephone/Fax (1) 106059**] home: [**Telephone/Fax (1) 106060**] # Code status: DNR, ok to intubate Medications on Admission: alendronate 70 qweek atenolol 25mg qam 50 qpm dig 0.125 qd lidoderm patch for back or knee lisionpril 30mg qday omeprazole 20mg [**Hospital1 **] pravastatin 40mg qd ropinirole 1mg qhs effexor 150 mg qd vit d -allergies: ativan, compazine and advair Discharge Medications: 1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. 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* 7. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed due to gastric ulcer Acute blood loss anemia Atrial fibrillation Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted after vomiting blood. You were found to have a GI bleed with anemia. In the ICU, you underwent EGD showing bleeding ulcers. These were successfully clipped. After 6 blood transfusions your bleeding stopped. It is very important that you take the twice daily Protonix to prevent bleeding. You were also found to have mild arthritis in your hand, most likely felt to be "Pseudogout." You completed a short course of Prednisone. Please see the medication sheet on discharge. Please note that your Lisinopril dose was decreased to 10mg daily. Please minimize the use of any opiate medications you receive from your physicians as this can cause an increased risk of falls. Oxycodone will only be prescribed by your PCP. Followup Instructions: PCP: [**Name10 (NameIs) 106056**],[**Name11 (NameIs) 1569**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 35502**] - within 1 week You should [**2135-2-22**] call to make an appointment for follow up.

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Discharge summary

report

Admission Date: [**2157-9-24**] Discharge Date: [**2157-10-14**] Date of Birth: [**2099-10-19**] Sex: M Service: MEDICINE Allergies: Sulfonamides / Shellfish Attending:[**First Name3 (LF) 51811**] Chief Complaint: diarrhea and lack of urination Major Surgical or Invasive Procedure: Right IJ venous central line placement and removal PICC placement [**2157-10-12**]. History of Present Illness: Pt is a 57 yo man with pmh sig for HIV/AIDS (last CD4 90's in [**7-/2157**], VL>100k in [**5-/2157**], self d/c'd HAART in [**5-/2157**]) presenting with worsening watery diarrhea with several episodes containing flecks of blood, last for the past two weeks, and associated with anuria for past two weeks. Pt states that he was diagnosed with cryposporidium diarrhea 6 weeks prior to presentation, was treated with azithromycin and Humatin, diarrhea resolved but recurred two weeks prior to presentation worse than previously. He was seen by his PCP who instructed him to continue azithromycin and humatin but he stopped taking these two medications secondary to the anorexia he was experiencing. Over this time he had no abdominal pain or fever, and lost > 20 pounds of weight. ROS negative for headache, sob, dysuria, palpitations, chest pain. Pt had been frrling "dizzy" but had no syncopal episodes. Past Medical History: AIDS/HIV POSITIVE HYPERTENSION LEFT FOOT NUMBNESS HERPES ZOSTER [**4-/2152**] DIVERTICULOSIS SINUSITIS [**11/2146**] ALLERGY TO SULFA [**11/2146**] TINEA PEDIS JOINT PAIN TINEA CORPORIS Social History: Pt lives in [**Location (un) 4398**] with his long term partner. [**Name (NI) **] is homosexual. He denies tobacco use, drug use, though PCP notes recent use of crystal meth in OMR. he denies alcohol use. He is on disability and previously worked at [**Company 5620**]. He has a cat at home but does not change the litter box, has no other pets, has travelled to Europe, Carribean, and most of the USA while in the armed forces > 20 years ago. Family History: Non contributory Physical Exam: VSS, Afebrile Gen: Slim caucasian male, appearing comfortable, non-dyspneic HEENT: PEARL, EOMI, anicteric, clear oropharynx Neck: IJ line in place, no LAD CVS: RR, normal rate, no m/r/g Lungs: CTA b/l Abd: NABS, soft, NT/ND Extr: No c/c/e Pertinent Results: [**2157-9-24**] 11:20AM BLOOD WBC-6.4 RBC-3.39*# Hgb-10.7*# Hct-28.1* MCV-83# MCH-31.5 MCHC-37.9*# RDW-15.7* Plt Ct-144* [**2157-9-24**] 05:30AM BLOOD Neuts-76* Bands-1 Lymphs-8* Monos-14* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2157-9-24**] 06:30PM BLOOD PT-16.1* PTT-33.8 INR(PT)-1.6 [**2157-9-24**] 02:45AM BLOOD Glucose-194* UreaN-176* Creat-8.1*# Na-121* K-2.6* Cl-84* HCO3-<5 [**2157-9-24**] 03:50AM BLOOD ALT-17 AST-29 AlkPhos-97 Amylase-56 TotBili-0.3 [**2157-9-24**] 03:50AM BLOOD Albumin-3.1* Calcium-6.5* Phos-9.0*# Mg-1.7 [**2157-9-25**] 12:16AM BLOOD Calcium-7.4* Phos-0.4* Mg-2.1 [**2157-9-24**] 04:29PM BLOOD TSH-0.39 [**2157-9-24**] 08:34AM BLOOD Cortsol-59.6* [**2157-9-24**] 03:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2157-9-24**] 05:58AM BLOOD pO2-189* pCO2-15* pH-7.16* calHCO3-6* Base XS--21 [**2157-9-27**] 04:45AM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-39* pCO2-26* pH-7.47* calHCO3-19* Base XS--2 [**2157-9-24**] 04:19AM BLOOD Lactate-2.3* [**2157-9-24**] 05:58AM BLOOD Lactate-1.2 Stool - multiple studies sent, positive only for Cryptosporidium oocytes On discharge: [**2157-10-13**] 05:00AM BLOOD WBC-7.5 RBC-3.08* Hgb-10.0* Hct-30.1* MCV-98 MCH-32.5* MCHC-33.2 RDW-21.1* Plt Ct-622* [**2157-10-6**] 07:00AM BLOOD Neuts-55 Bands-3 Lymphs-34 Monos-3 Eos-4 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2157-10-13**] 05:00AM BLOOD Glucose-82 UreaN-7 Creat-0.8 Na-136 K-4.3 Cl-104 HCO3-25 [**2157-10-13**] 05:00AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9 [**2157-10-13**] 05:00AM BLOOD ALT-45* AST-42* LD(LDH)-321* AlkPhos-466* TotBili-1.2 LFTs at peak: [**2157-10-10**] 06:45AM BLOOD GGT-203* [**2157-10-6**] 07:00AM BLOOD ALT-31 AST-32 LD(LDH)-361* AlkPhos-700* TotBili-0.7 CD4: [**2157-10-10**] 05:30PM BLOOD WBC-5.8 Lymph-36 Abs [**Last Name (un) **]-2088 CD3%-78 Abs CD3-1633 CD4%-8 Abs CD4-161* CD8%-68 Abs CD8-1423* CD4/CD8-0.1* Anemia workup: [**2157-10-6**] 07:00AM BLOOD VitB12-204* Folate-5.0 [**2157-9-29**] 04:38AM BLOOD calTIBC-95* Ferritn-691* TRF-73* [**2157-9-29**] 04:38AM BLOOD Iron-52 [**2157-9-24**] 04:29PM BLOOD TSH-0.39 Hepatitis serology: [**2157-9-24**] 02:23PM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE [**2157-9-24**] 02:23PM BLOOD HCV Ab-NEGATIVE Vanco trough: [**2157-10-13**] 01:08PM BLOOD Vanco-20.1* IMAGING STUDIES: [**9-25**] Renal US: Normal. No hydronephrosis. [**9-30**] CXR: Again, note is made of right IJ line terminating in the right atrium. The heart is normal in size. The mediastinal and hilar contours are within normal limits. Again, note is made of bilateral small pleural effusions. Otherwise, bilateral lungs are clear. There is no evidence of parenchymal consolidation. There is no suspicious lesion in the skeletal structures. [**10-1**] CXR: Right CVL has been removed - no PTX. There is no significant interval change vs prior with no evidence of interval development of consolidation or CHF. [**10-1**] RLE US: No DVT. [**10-2**] CT CHEST/ABD/PELVIS: 1. There is no evidence of pneumonia or mediastinal lymphadenopathy. 2. Pathy nodular opacity in the left upper lobe and multiple pleural based nodules. Follow up chest CT is recommended. 3. Thrombus in the right IJ vein was not completely evaluated. Recommend ultrasound of the IJ for further evaluation. 4. Mildly dilated fluid filled loops of small bowel without evidence of obstruction. This findings are consistent with diarrhea. 5. Multiple small mesenteric and retroperitoneal lymph nodes that do not meet the criteria for pathology by size, but are increased in number. 6. High-riding or inguinal testicle. [**10-4**] RUE US: IMPRESSION: 1) Occluding thrombus in the right cephalic vein. 2) Eccentric thrombus within the right internal jugular vein without significant flow impairment. [**10-4**] TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60%). 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 (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. No definite vegetations seen. The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested. [**10-7**] CTA: 1. No evidence of pulmonary embolism. 2. Progression of the left upper lobe focal consolidation, and a new ground glass opacity in the left lower lobe. Infection, such as PCP is high on the differential. 3. Small left pleural effusion. [**10-7**] CXR: IMPRESSION: Small pleural effusion. No definite evidence of pneumonia in the chest radiographs. [**10-11**] CT ABD/PELVIS: Unremarkable CT of the abdomen and pelvis. Specifically, no abnormalities are detected in the liver. Brief Hospital Course: ICU course: Mr. [**Known lastname 95543**] was placed on sepsis protocol which he met by tachycardia, hypotension resistant to fluid boluses, and hypothermia. His WBC was normal with no bands and lactate was only slightly above normal but quickly normalized. He was ruled out for coricosteroid insufficiency with high morning cortisol. He had acute renal failure, a combined non gap and gap acidosis, which responded quickly to extensive fluid resuscitation and bicarbobate administration (both po and iv). Pts electrolytes were very difficult to manage and required q4 chemistry checks over the first several days with aggressive replacement especially of potassium, calcium, magnesium, and phosphate. While in the ICU patient began to appear much better both clinically and subjectively. When he left the ICU his length of stay fluid balance was approximately 6 liters positive, and his creatine had improved very quickly. His hematocrit and platelet count were low which at the time was felt to be secondary to aggressive hydration. His diarrhea volume did not change over the course of the ICU stay and ranged from 5 liters perday to 11 liters per day. When pt was admitted it was felt that the two most likely diagnoses would be either cryptosporidium or clostridium difficile and so he was started on tx for both. When C. dif toxin was negative his Flagyl was discontinued. As his stool cultured was positive for cryptosporidium, he was treated with azithromycin and paromomycin, and as infectious disease consult felt that the only way to completely treat this episode would be by restarting his HAART and reconstituting his CD4 count, he was started on HAART as dictated by his Primary Infectious Disease Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. On the floors: 1) Cryptosporidium diarrhea: His diarrhea resolved over the course of the first week on the floors, and he was no longer having diarrhea at discharge. Intake and ouptut were matched with large amounts of IVF initially, however as his diarrhea lessened, IVF were decreased. He had developed lower extremity edema during his ICU time, probably secondary to massive hydration with low albumin, and this edema gradually resolved during his stay on the floors with decreased IVF and improved nutrition with decreased diarrhea. He was continued on azithromycin/paromomycin, and HAART throughout his stay. 2) Anemia: He was noted to be anemic, with occassional guaiac positive stools in the ICU. On the floors his guaiac positive stools resolved with resolution of his diarrhea. His anemia persisted, however, and he was found to be B12 deficient, likely from malabsorption. He was given 3 IM cyanocobalamin injections, and should continue to receive an IM injection monthly. 3) Electrolytes: His electrolytes were extremely difficult to control at first, requiring large amounts of IV supplementation. As his diarrhea resolved, his electrolytes gradually normalized, and on discharge he was only on PO supplementation for Calcium (500 mg TID), Vitamin D, and Magnesium Oxide 200 mg qd, with normal electrolyte values. The supplementation can likely be discontinued by Dr. [**Last Name (STitle) **], provided he remains free of diarrhea. 4) Fevers: The patient developed fevers during his last 2 weeks of hospitalization, accompanied by oxygen desaturation to 88% with ambulation. At this time, his R IJ line was pulled, and blood cultures were sent. A CT of the chest at that time revealed a patchy nodular opacity in the left upper lobe and multiple pleural based nodules, as well as thrombus in the right IJ vein, as well as multiple small mesenteric and retroperitoneal lymph nodes. Blood cultures very quickly grew out MRSA on [**10-1**], and he was started on vancomycin. He continued to spike low grade fevers, however, and continued to have mild hypoxia. A repeat CT scan was done to further evaluate the pulmonary nodules as well as to assess for PE, which was negative for PE, but concerning for PCP/other pneumonia. He was started empirically on clindamycin and primaquine at this time, however these were stopped when induced sputum for PCP came back negative, and he was restarted on dapsone 100 mg qd for prophylaxis (bactrim allergy). CMV VL was also sent at that time, which came back negative. A TTE to rule out vegetations was negative. LFTs were sent to evaluate for source of infection, and were notable for an ALP of 700, with elevated GGT to 203. Therefore, a CT abd was done to r/o lymphoma, which was unremarkable. His fever curve trended down, and he had been afebrile for 72 hours by the day of discharge. It is felt that his persistent low grade fevers were related to impaired clearance of his MRSA infection secondary to persistent clot in his IJ (original source of infection), which eventually resolved. Prior to discharge, after being afebrile x 48 hours, he had a PICC placed for 2 more weeks of IV vancomycin, to complete a 4 week course. He should likely have a repeat CT chest in the next month or two to assess for resolution of his pulmonary nodules with HAART treatment. 5) LFTs: He was noted to have acute elevation of his ALP to 700 on [**10-6**], and GGT 200. He denied RUQ pain, and had no tenderness on exam. His transaminases were normal at this time, but they became mildly elevated over the next couple of days to 45 and 42 ALT and AST. The only new medications that had been started were HAART, and vancomycin. CMV VL was negative. A CT abdomen did not reveal any abnormalities. His LFT elevation continues to remain a mystery. It is possibly secondary to HAART, or vancomycin. His vanco trough on 1000 mg q12 hours was found to be mildly elevated at 22, and his dose was therefore decreased to 750 mg q12 hours on discharge. His ALP began trending down, and was at 466 on discharge. His total bili peaked at 1.3. He should have weekly CBC, chem 7, and LFTs as an outpatient. 6) AIDS: On admission, his CD4 count was found to be 52. HAART was initiated on [**9-29**], and his CD4 count on [**10-10**] had risen to was 161. 7) Hemorrhoids: Mr. [**Known lastname 95543**] complained of a painful hemorrhoid. On physical exam, he has a large external hemorrhoid, without evidence of bleeding or thrombosis, that persisted for the duration of his hospitalization. Colorectal surgery recommended ice packs, [**Last Name (un) **] baths, as well as a topical lidocaine ointment, with the hopes that as his diarrhea resolves the hemorrhoid will also resolve. He also had an area of sacral desquamation from lying in bed for so long. He was encourage to shift positions and walk around as much as possible. This area was covered with duuderm, and never appeared to be infected. 8) Thrush: Mr. [**Known lastname 95543**] complained of a "scratchy" throat in the last few days of his hospitalization. On exam, he had multiple small white plaques on his posterior orpharynx. He was treated for thrush with nystatin swish and swallow, and sent home on this regimen. Diflucan was not given secondary to concern for interference with his multiple other antibiotics. Dr. [**Last Name (STitle) **] can start this medication at her discretion should his thrush persist. 9) Prophylaxis: He was maintained on Dapsone 100 mg Qday for PCP prophylaxis, secondary to a bactrim allergy. For PE he was given heparin SQ TID, however his platelets were noted to be dropping, therefore this was discontinued and HIT antibody assay was sent, which came back negative. He was given pneumoboots for DVT prophylaxis. Medications on Admission: none Discharge Medications: 1. Paromomycin Sulfate 250 mg Capsule Sig: Four (4) Capsule PO bid (). Disp:*240 Capsule(s)* Refills:*2* 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 3. Stavudine 40 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). Disp:*60 Capsule(s)* Refills:*2* 4. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qd (): To be taken with tenofovir. Disp:*30 Capsule(s)* Refills:*2* 5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 6. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q12H (every 12 hours) as needed for PAIN FROM HEMORRHOID. Disp:*1 tube* Refills:*1* 7. Pramoxine-Zinc Oxide in MO 1-12.5 % Ointment Sig: One (1) Appl Rectal TID (3 times a day). Disp:*1 tube* Refills:*1* 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QD (once a day): Please dose with meals. Disp:*30 Capsule(s)* Refills:*2* 9. Atazanavir Sulfate 150 mg Capsule Sig: Two (2) Capsule PO QD (once a day): Please dose after meals. Disp:*60 Capsule(s)* Refills:*2* 10. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). Disp:*60 Capsule(s)* Refills:*2* 11. Magnesium Oxide 400 mg Tablet Sig: 0.5 Tablet PO QD (once a day). Disp:*15 Tablet(s)* Refills:*2* 12. Dapsone 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). Disp:*450 ML(s)* Refills:*2* 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 15. Vancomycin HCl 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q12H (every 12 hours) for 14 days: 750 mg total. Disp:*42 Recon Soln(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: Cryptosporidum diarrhea MRSA bacteremia Right IJ vein thrombus Pulmonary nodules Thrush Elevated LFTs Discharge Condition: Good, stable. Discharge Instructions: Take all of your medications as directed. Start taking your vancomycin early tomorrow morning. From then on, you need to take it every 12 hours for the next two weeks. Follow up with Dr. [**Last Name (STitle) **] at your appointment listed below for weekly blood tests. Drink plenty of fluids, even if you don't feel thirsty. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2157-10-18**] 10:00

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

16979, 17057

7488, 15081

319, 405

17202, 17217

2329, 3462

17595, 17828

2037, 2055

15136, 16956

17078, 17181

15107, 15113

17241, 17572

2070, 2310

3476, 4629

249, 281

433, 1343

1365, 1555

1571, 2021

4647, 7465

29,315

187,236

33250

Discharge summary

report

Admission Date: [**2174-5-3**] Discharge Date: [**2174-5-11**] Date of Birth: [**2117-3-30**] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain due to scoliosis Major Surgical or Invasive Procedure: Anterior/posterior lumbar fusion with instrumentation L4-S1 History of Present Illness: Ms. [**Known lastname 4587**] has a long history of back and leg pain. She has attempted conservative therapy including physical therapy and has failed. She now presents for surgical intervention. Past Medical History: HTN, anxiety/panic d/o, etoh abuse Social History: +EtOH Family History: N/C Physical Exam: NAD RRR CTA B Abd soft NT/ND BUE- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; reflexes intact at biceps, triceps and brachioradialis BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact distally; reflexes deminished at quads and achilles; +sciatica Pertinent Results: [**2174-5-11**] 05:55AM BLOOD WBC-14.6*# RBC-3.53*# Hgb-11.1* Hct-32.3* MCV-91 MCH-31.3 MCHC-34.2 RDW-17.9* Plt Ct-442* [**2174-5-10**] 05:45AM BLOOD WBC-7.0 RBC-2.80* Hgb-9.2* Hct-26.9* MCV-96 MCH-32.8* MCHC-34.2 RDW-16.9* Plt Ct-327 [**2174-5-9**] 06:50AM BLOOD WBC-5.7 RBC-2.39* Hgb-8.2* Hct-24.2* MCV-102* MCH-34.5* MCHC-34.0 RDW-14.1 Plt Ct-336 [**2174-5-7**] 04:59PM BLOOD WBC-5.3 RBC-2.22* Hgb-8.3* Hct-22.4* MCV-101* MCH-37.4* MCHC-37.0* RDW-13.9 Plt Ct-188 [**2174-5-4**] 05:40AM BLOOD WBC-9.3# RBC-2.56* Hgb-9.1* Hct-26.4* MCV-103* MCH-35.6* MCHC-34.6 RDW-13.6 Plt Ct-91*# [**2174-5-10**] 05:45AM BLOOD Glucose-361* UreaN-5* Creat-0.8 Na-136 K-4.8 Cl-104 HCO3-26 AnGap-11 [**2174-5-9**] 06:50AM BLOOD Glucose-112* UreaN-4* Creat-0.8 Na-140 K-3.8 Cl-105 HCO3-29 AnGap-10 [**2174-5-6**] 01:50PM BLOOD Glucose-119* UreaN-4* Creat-0.9 Na-141 K-3.1* Cl-104 HCO3-28 AnGap-12 Brief Hospital Course: Ms. [**Known lastname 4587**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for an L4-S1 staged anterior/posterior fusion. She was informed and consented for the procedure and elected to proceed. Please see Operative Note for procedure in detail. POD2 nursing staff began noticing confusion. She was started on a CIWA scale without the confusion clearing. She was placed in restraints due to her inability to follow her bedrest status. She subsequently experienced acute delerium due to alcohol withdrawl and was transfered to the SICU for close observation. Her staged posterior fusion was postponed until the delerium cleared. All lab values for infection or organic pathology were negative. Upon completion of her posterior fusion she was able to work with physical therapy. Her strength and balance improved and her delerium cleared. She was given a social work consult for alcohol abuse. Please see their note in OMR. Upon discharge her posterior incision was slightly erythematous and she started a 10 day course of Keflex. She was discharged in good condition and will follow up in clinic in 10 days. Medications on Admission: Lisinopril-HCTZ 20/25mg 2 pills daily. Clonazepam 0.5mg [**Hospital1 **]. Trazadone 100mg qhs. Oxycodone 5/325mg 2 tabs q 8hr. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0* 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Lumbar spondylosis and scoliosis Post-op delerium Alcohol withdrawl Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic if you notice any redness or discharge from the incision site. Call the clinic for any additional concerns. Followup Instructions: Please follow up in the Spine Clinic during your previously scheduled appointments. Completed by:[**2174-5-23**]

[ "737.30", "560.1", "E878.8", "291.0", "721.3", "300.01", "303.91", "401.9", "997.4", "571.1" ]

icd9cm

[ [ [] ] ]

[ "81.62", "77.89", "81.06", "81.08", "84.51", "84.52", "80.51" ]

icd9pcs

[ [ [] ] ]

4404, 4410

2121, 3297

310, 372

4522, 4529

1218, 2098

4784, 4899

697, 702

3474, 4381

4431, 4501

3323, 3451

4553, 4761

717, 1199

236, 272

400, 600

622, 658

674, 681

7,591

133,517

26677

Discharge summary

report

Admission Date: [**2165-9-29**] Discharge Date: [**2165-10-6**] Date of Birth: [**2117-4-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Lung Cancer Major Surgical or Invasive Procedure: Right upper lobe resection and mediastinal lymph node dissection. History of Present Illness: 46-year-old gentleman with locally advanced lung cancer who status post chemotherapy and XRT neoadjuvant therapy. The patient is admitted for a planned right thoracotomy, right upper lobectomy, radical mediastinal nodal dissection. Of note the patient's surgery was recently postponed due to a fever and cough. His fever workup performed in the hospital was unremarkable and has since resolved and he now returns for the planned procedure. Past Medical History: PMH: RUL NSS lung ca, +PPD PSH: bronch and mediastinoscopy [**2165-5-23**] Social History: married , lives w/ wife and 4 children one PPD smoker-quit [**4-25**], no ETOH Air conditioning repair man- no known TB or asbestos exposure Immigration to the US from [**Country **] [**2140**] Family History: father died in military combat -mother and siblings alive and well. Physical Exam: Alert, oriented, in no acute distress Afebrile Regular rate and rhythm, S1 S2 wnl Lungs with mild rhonchi bilaterally right>left Abdomen soft, non distended, non tender No clubbing, cyanosis, or edema Pertinent Results: [**2165-9-29**] 07:30PM BLOOD WBC-6.5 RBC-3.89* Hgb-10.2* Hct-30.1* MCV-77* MCH-26.1* MCHC-33.8 RDW-20.9* Plt Ct-310 [**2165-10-1**] 02:57AM BLOOD WBC-10.0 RBC-3.30* Hgb-8.7* Hct-25.2* MCV-76* MCH-26.3* MCHC-34.5 RDW-20.6* Plt Ct-250 [**2165-10-5**] 06:45AM BLOOD WBC-5.1 RBC-3.68* Hgb-10.1* Hct-30.2* MCV-82 MCH-27.5 MCHC-33.5 RDW-18.8* Plt Ct-270 [**2165-9-29**] 07:30PM BLOOD PT-11.6 PTT-21.8* INR(PT)-1.0 [**2165-9-29**] 07:30PM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-143 K-3.7 Cl-106 HCO3-26 AnGap-15 [**2165-10-3**] 07:30AM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-140 K-4.8 Cl-98 HCO3-35* AnGap-12 ~~~~~~~~~~~~~~~~~~~~~~Radiology CHEST (PRE-OP PA & LAT) [**2165-9-29**] 8:01 PM IMPRESSION: PA and lateral chest compared to [**2165-9-19**]: The irregular right perihilar opacification seen on the previous study has coalesced, though it may contain central pneumatocele or bullae with thickened walls. Sequence of changes is consistent with developing radiation fibrosis which may also explain a region of consolidation projecting over the mid thoracic spine seen on the lateral view, but this area could represent a bacterial infection. Clinical correlation is needed. Left lung is clear. The heart is normal size. Slight rightward mediastinal shift is longstanding. A right upper lobe mass is smaller than it was on [**9-3**] but size measurements are not practical, still at least 5 cm in greatest diameter. Right apical pleural thickening and fullness in the right paratracheal mediastinum are concerning for local tumor extension, but best evaluated by CT scanning. ~~~~~~~~~~~~~~~~~~~~~~~~ MR [**Name13 (STitle) **] W &W/O CONTRAST [**2165-9-29**] 8:09 PM FINDINGS: The vertebral body heights, alignment, and intervertebral disc spaces are preserved. The vertebral body bone marrow signal is normal. No disc herniations are identified. There is no abnormal signal or enhancement identified within the cord. Within the right upper lobe in the right peritracheal region, there is a large heterogeneously enhancing mass with an apparent necrotic center. In addition, more inferiorly, there are areas of lung consolidation. The reader is refereed to the chest CT and chest x-ray reports for further descriptions regarding these findings. There is also abnormal soft tissue in the subcarinal region, which probably represents lymphadenopathy. There does not appear to be involvement of the adjacent vertebral bodies. IMPRESSION: 1. No evidence of abnormality within the thoracic spine. 2. Large necrotic right upper lobe mass with lung consolidation inferiorly and probable subcarinal lymphadenopathy. For further description of these findings, the reader is referred to the chest CT and chest x-ray reports. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CHEST (PORTABLE AP) [**2165-10-4**] 8:47 PM IMPRESSION: No significant change compared with earlier the same day. Two right-sided chest tubes with suspected small right apical pneumothorax unchanged. Prominence of the right paratracheal soft tissues again noted ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CHEST (PA & LAT) [**2165-10-6**] 9:00 AM Compared with one day earlier, there is new blunting of the right costophrenic angle, without significant interval change. Again seen is an elevated right hemidiaphragm and shift of the mediastinum to the right, with pleural fluid/thickening tracking along the right chest wall, right apex, and medial aspect of the upper right mediastinum. Focal lucency and fluid level at the right lung apex is compatible with a small hydropneumothorax, unchanged. There is considerable subcutaneous emphysema along the right chest wall, also unchanged. The left lung remains grossly clear, with minimal atelectasis/scarring at the left base. ~~~~~~~~~~~~~~~~~~~~~~~~~~~Pathology Lung Cancer Synopsis Tumor Size Greatest dimension: 4 cm. MICROSCOPIC Histologic Type: Large cell undifferentiated carcinoma. Histologic Grade: G4: Undifferentiated. EXTENT OF INVASION Primary Tumor: pT2: Tumor greater than 3 cm. Lymph nodes: Location: Level 4R, hilar, level 9, level 7, lobar. Number examined: 6. Number involved: 0. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Distant metastasis: pMX: Cannot be assessed. Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 2.5 mm. Specified margin: Visceral pleura. Venous invasion (V): Absent. Lymphatic Invasion (L): Absent. Additional Pathologic Findings: Radiation/chemotherapy effect.. Comments: The tumor shows extensive necrosis. Brief Hospital Course: The patient was admitted pre-operatively and underwent a pre-op chest x-ray and an MRI of the spine to assess cord invasion of the tumor. He continued to have a cough prior to surgery, but was otherwise afebrile and felt well. A right upper lobectomy and mediastinal lymph node dissection was performed via a thoracotomy on [**9-30**] without complication. Dr. [**Last Name (STitle) 1352**], [**First Name3 (LF) **] orthopedic spine surgeon was available for intraoperative collaboration however the tumor was not invading the spinal structures and dissection was completed without the need for a spine specialist. The patient was transferred to the floor post-operatively with a chest tube and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain in place. He recovered well and he was encouraged to get out of bed on POD1 and incentive spirometry was encouraged. He had an epidural placed pre-operatively that ceased to work for pain relief and he was converted to a PCA for pain control on POD1. Post-operatively he was noted to have slightly increasing subcutaneous emphysema. The chest tubes were left in place on water seal and his subcutaneous emphysema and a small stable pneumothorax remained stable and eventually decreased somewhat. His chest tubes were clamped POD4. He complained of moderately increasing right chest wall pain on POD4&5 and his pain medications were adjusted accordingly when chest x-rays revealed no underlying pathology. His chest tubes were discontinued POD5 without complication. He was noted to have a gradual development of a post-operative anemia and was transfused on POD2 for a HCT of 21.2. He developed a fever in the midst of his transfusion and this was stopped immediately and investigated for a transfusion reaction. The work-up was negative and he received the full 2 units at a later time without further complication. Cultures taken at that time were also negative for an infectious source. He was started on oxycontin for a longer acting pain relief and this seemed to alleviate his pain except on his first movements from a stationary position. He continued to be ambulatory frequently and used an incentive spirometer as directed. He was discharged to home on POD6 in good condition. He will follow-up with Dr. [**Last Name (STitle) 952**] in 2weeks with a follow-up chest x-ray. Medications on Admission: isoniazid 300qhs, pyridoxine 50qd, Tylenol prn Discharge Medications: 1. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*1 Large bottle* Refills:*1* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 months. Disp:*120 Capsule(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed for constipation. Disp:*1 bottle* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*1* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for prn pain. Disp:*100 Tablet(s)* Refills:*0* 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours) as needed for pain for 3 weeks. Disp:*30 Tablet Sustained Release(s)* Refills:*0* 10. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day: Take to prevent constipation while on pain medicine. Disp:*60 Capsule(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Lung cancer Discharge Condition: Good Discharge Instructions: Please call Dr. [**Last Name (STitle) 952**] at the thoracic office ([**Telephone/Fax (1) 170**]) with any questions or problems. Please call if you are experiencing any increasing shortness of breath, if your pain significantly increases or changes in character, if you have any fevers or chills, or have any other symptoms that concern you. Followup Instructions: Please call Dr.[**Name (NI) 1816**] office for an appointment in 2weeks. [**Telephone/Fax (1) 170**]. A chest x-ray should be done at that time. You have this previously scheduled appointment. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2165-10-9**] 2:00

[ "285.1", "162.3", "E878.6", "276.1", "530.81", "998.81" ]

icd9cm

[ [ [] ] ]

[ "99.04", "32.4", "40.3" ]

icd9pcs

[ [ [] ] ]

9907, 9965

6091, 8451

341, 409

10021, 10028

1512, 6068

10420, 10763

1207, 1276

8548, 9884

9986, 10000

8477, 8525

10052, 10397

1291, 1493

290, 303

437, 880

902, 979

995, 1191

21,267

149,523

12118

Discharge summary

report

Admission Date: [**2181-1-8**] Discharge Date: [**2181-1-10**] Date of Birth: [**2136-12-24**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 44 year-old male dentist with no prior history of cardiac disease who presented to [**Hospital6 3872**] after approximately one week history of dyspnea on exertion. He experienced no chest pain at that time. His electrocardiogram on admission to the outside hospital revealed some ST changes. He ruled in for a myocardial infarction by enzymes with a cardiac troponin I of 13. The patient was transferred to [**Hospital1 346**] where he underwent cardiac catheterization, which revealed pulmonary artery pressures of 70/36. He had a right coronary artery 100%, proximal left anterior descending coronary artery lesion 100%, circumflex lesion as well as a diffusely diseased obtuse marginal. He had left ventricular ejection fraction of 10%. Intra-aortic balloon pump was inserted at that time. Cardiothoracic surgery consult was obtained and the patient was taken to the Operating Room on [**2181-1-9**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please see operative report for full details of the surgical procedure. The patient underwent a coronary artery bypass graft times four with a plication of his left ventricular aneurysm. The patient had left internal mammary coronary artery graft to the left anterior descending coronary artery, saphenous vein to the obtuse marginal and a sequential saphenous vein graft to the posterior descending coronary artery and the PL. Chest was closed with attempted chest closure. In the Operating Room the patient became profoundly hypotensive with systolic blood pressure dropping to the 40s. He did not have ST changes on the cardiac monitor. His pulmonary artery pressures rose. Transesophageal echocardiogram showed an akinetic left ventricular with no response to epinephrine initially. The chest was reopened. The patient was placed back on cardiopulmonary bypass to stabilize him. Attempt to come off bypass pump three additional times were unsuccessfully due to hemodynamic instability, elevated pulmonary artery pressures and diminished systemic blood pressure. The patient at that time was on multiple inotropics and vasopressors as well as an intra-aortic balloon pump. The decision was made at that time to consult Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 411**] for placement of ventricular assist device. An Aveomed BVS left ventricular assist device was placed in the Operating Room at that time. The ventricular assist device flows were fairly consistent at about 4.5 liters per minute. His chest was left open at that time. The patient separated from bypass and transferred to the Cardiothoracic Care Unit on low dose Levophed as well as Dobutamine at 2.5 micrograms per kilogram per minute. Over the course of the night the patient had one episode where he had significant clot and blood accumulation in the chest with bulging of his chest dressing and hemodynamic instability with systemic hypotension as well as significantly elevated right sided heart pressures with a CVP up to the 30s. He also decreased VAD flows requiring correction necessitating opening of the esmarch and evacuation clot and blood in the chest around the heart. During that time the patient had some hemodynamic instability with hypotension and systolic pressure to the 60s. It was treated with very low doses of intravenous calcium chloride and intravenous fluid boluses of normal saline as well as packed red blood cells. The patient subsequently recovered fairly quickly from this episode after the chest was reexplored. The esmarch was then closed. The patient was briefly placed on intravenous nitroprusside. Due to hypertension with a mean arterial pressure of greater then 100, which caused decreased flows of the VAD to the 2.5 liter per minute range. The patient quickly responded to the afterload reduction. The VAD flows increased and the patient became hemodynamically stable. Throughout the course of the night the patient remained hemodynamically stable with a fairly high volume requirement as determined by the assessments of the VAD bladders as well as the flow on the ventricular assist device and systemic blood pressure. The patient remains on Dobutamine at 2.5 micrograms per kilogram per minute. It was felt due to the patient's age, patient's lack of comorbities and the patient significantly decreased heart function that he be assessed at [**Hospital 8503**] for heart transplants. During the course of the night the patient had a left femoral arterial line removed due to an enlarging hematoma in that area. Manual compression was felt for thirty minutes. The hematoma was significantly decreased in size at the end of this and the patient has clear doppler signals both dorsalis pedis pulse as well as posterior tibial in the left foot. Also due to inability to adequately time and trigger the intra-aortic balloon pump, because of the left ventricular assist device, the intra-aortic balloon pump was also removed, which was in the right femoral artery as well as the right femoral venous line were both discontinued during the night. Manual pressure was held to that groin as well for approximately thirty minutes with no outward sign of bleeding and the patient also continued with strong doppler signals in the right foot as well. The patient is presently hemodynamically stable. He has also evidenced that he has awoken up after his surgical procedure. He had followed commands. He had moved all four extremities to command. Once his neurologic status was assessed he was placed on intravenous cisatracurium to paralyze him to decrease any work load on the heart as well as respiratory effort and oxygenation need. He was also placed on intravenous morphine and intravenous propofol drips for sedation while he was being paralyzed. The patient's condition right now is as follows: The patient's blood pressure is running from 80 systolic to one teen systolic. He has ventricular assist device flows in the 4 to 5 liter per minute range. Neurologically the patient is completely sedated. His pulmonary status is stable on full ventilatory support. His FIO2 is down to 50% and he is on sinus PEEP with an adequate blood gas and adequate oxygenation. His chest remains open. He has bilateral pleural chest tubes in as well as two mediastinal chest tubes. He has VAD cannulas also and esmarch to the chest with an Ioban dressing covering the esmarch. His abdominal examination is benign. He is obese, nondistended with no bowel sounds audible. The patient's extremities are warm with doppler signals in both feet. The patient is being transferred to [**Hospital 4415**] Intensive Care Unit to await transplant. He is being transferred to the care of Dr. [**Last Name (STitle) 37994**] cardiothoracic surgeon at [**Hospital 10908**]. Please contact the Cardiothoracic Surgery Service here at [**Hospital1 69**]. We can be reached at [**Telephone/Fax (1) 170**] either Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] can be of assistance. If we can be of any help with this matter feel free to contact us for any questions or concerns regarding Mr. [**Known lastname **]. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2181-1-10**] 11:57 T: [**2181-1-10**] 12:03 JOB#: [**Job Number 37995**]

[ "428.0", "414.01", "401.9", "998.12", "414.10", "414.8", "250.00", "458.2", "410.11" ]

icd9cm

[ [ [] ] ]

[ "37.66", "88.57", "36.15", "37.61", "39.52", "37.23", "39.61", "36.13", "88.53" ]

icd9pcs

[ [ [] ] ]

184, 7688

28,241

119,238

33965

Discharge summary

report

Admission Date: [**2164-7-16**] Discharge Date: [**2164-7-21**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: angina and palpitations Major Surgical or Invasive Procedure: [**2164-7-16**] AVR ( [**Street Address(2) 17167**]. [**Male First Name (un) 923**] Epic porcine)/cabg x3 (LIMA to LAD, SVG to ramus, SVG to PDA) History of Present Illness: 83 yo female presented to [**Hospital3 **] in [**5-17**] with angina and palpitations. Ruled out for MI with equivocal troponins. Echo showed worsening AS, and she was transferred here for a cath at that time. This revealed 3VD. Seen again in clinic [**6-28**] for surgical consultation. Past Medical History: Aortic stenosis CAD elev. lipids HTN mild COPD mild memory impairment [**Last Name (un) **]. joint dz. mild PVD right shoulder pain panic attacks osteoporosis overactive bladder chronic low back pain cecal AVM with bleed [**7-16**] diverticulitis PSH; TAH, tomsillectomy;bil cataract [**Doctor First Name **] with IOLs, left knee [**Doctor First Name **] Social History: lives with husband retired quit smoking [**2154**];35 pack/yr hx no ETOH use Family History: brother with MI at 63 Physical Exam: 5'0" 150# HR 56 reg 116/76 NAD right thigh and calf ecchymotic PERRLA, EOMI, anicteric sclera, OP unremarkable neck supple, full ROM, no JVD CTAB RRR IV/VI SEM radiates throughtout precordium to carotids abd soft, NT, ND, no HSM or CVA tenderness, +BS 1+ BLE edema, no varicosities noted healed left knee scars moves BLE [**5-14**] strengths; moves LUE [**5-14**], RUE [**4-14**] neuro exam otherwise nonfocal 1+ bil. DP/PTs 2+ bil. radials 1+ right fem, 2+ left fem murmur radiates to carotids Pertinent Results: [**2164-7-20**] 05:35AM BLOOD WBC-9.5 RBC-3.89* Hgb-10.4* Hct-31.3* MCV-80* MCH-26.7* MCHC-33.2 RDW-15.3 Plt Ct-143* [**2164-7-21**] 01:24PM BLOOD WBC-5.2 RBC-1.55*# Hgb-4.3*# Hct-11.6*# MCV-74* MCH-27.5 MCHC-36.9*# RDW-16.1* Plt Ct-70*# [**2164-7-21**] 01:24PM BLOOD PT-150* PTT-150* INR(PT)-22.8* [**2164-7-21**] 01:24PM BLOOD Plt Smr-VERY LOW Plt Ct-70*# [**2164-7-20**] 05:35AM BLOOD Plt Ct-143* [**2164-7-21**] 01:24PM BLOOD Fibrino-95* [**2164-7-21**] 01:24PM BLOOD Glucose-423* UreaN-9 Creat-0.3* Na-138 K-3.2* Cl-92* HCO3-40* AnGap-9 [**2164-7-20**] 05:35AM BLOOD Glucose-90 UreaN-15 Creat-0.5 Na-142 K-4.0 Cl-105 HCO3-27 AnGap-14 [**2164-7-21**] 01:24PM BLOOD CK-MB-NotDone cTropnT-0.31* [**2164-7-21**] 01:24PM BLOOD Calcium-7.0* Phos-3.3 Mg-GREATER TH Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Biventricular systolic function is preserved. There is a well seated, well functioning bioprosthesis in the aortic position ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] #19 supraanullar tissue). Visualization of the leaflets is limited. No significant AI is appreciated. The aortic contours of the ascending aorta appear intact, The study is otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2164-7-16**] 12:10 [**Known lastname **],[**Known firstname **] [**Medical Record Number 78449**] F 83 [**2080-9-24**] Radiology Report CHEST (PA & LAT) Study Date of [**2164-7-20**] 2:39 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2164-7-20**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 78450**] Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 83 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions Final Report INDICATION: Status post CABG. COMPARISON: [**2164-7-18**]. FRONTAL AND LATERAL CHEST RADIOGRAPH: The patient is status post CABG and median sternotomy wires are intact. The cardiomediastinal silhouette is stable. The pulmonary vasculature is normal. There are small bilateral pleural effusions which have not appreciably changed and no pneumothorax. IMPRESSION: Unchanged small bilateral pleural effusions. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name **] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: FRI [**2164-7-20**] 6:11 PM Imaging Lab Brief Hospital Course: Admitted [**7-16**] and underwent AVR/cabg x3 with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition on phenylephrine and propofol drips.Extubated later that day. She awoke with garbled speech which slowly cleared over the next couple of days. Neuro consult done. CT scan of head ruled out CVA. Transferred to the floor on POD #3 to begin increasing her activity level. Chest tubes and pacing wires removed per protocol. Was making good progress and was ready for discharge to home the next day when she experienced sudden cardiac arrest on the afternoon of POD #12. Full ACLS protocol was performed, but she was unable to be resuscitated. Expired at 1:50 PM on [**7-21**]. Medications on Admission: lovastatin 20 mg daily omeprazole 20 mg daily ditropan 5 mg [**Hospital1 **] ECASA 81 mg daily toprol XL 25 mg daily lisinopril 20 mg daily Discharge Disposition: Home With Service Facility: . Discharge Diagnosis: AS CAD s/p AVR/cabg x3 HTN mild COPD elev lipids DJD chronic bacl pain mild memory impairment mild PVD osteoporosis overactive bladder cecal AVM diverticulitis Discharge Condition: expired Completed by:[**2164-8-9**]

[ "424.1", "293.9", "401.9", "496", "112.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "35.21", "36.12", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

6027, 6059

5135, 5836

292, 440

6262, 6299

1804, 4266

1248, 1271

4306, 4333

6080, 6241

5862, 6004

1286, 1785

229, 254

4365, 5112

468, 758

780, 1138

1154, 1232

7,326

177,167

26033

Discharge summary

report

Admission Date: [**2118-12-1**] Discharge Date: [**2118-12-23**] Date of Birth: [**2055-10-21**] Sex: F Service: MEDICINE Allergies: Meperidine / Iodine Attending:[**First Name3 (LF) 1055**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: - EGD/Colonosocpy - Angiography - PICC line placement History of Present Illness: 63 yo with hx of HTN, fibromyalgia, and breast cancer who was admitted here 12/20-12-29 for acute pulmonary edema in setting of NSTEMI s/p 2 stents in LCX and D1 complicated by strep viridins tricuspid endocarditis. She was discharged with PICC line to complete course of PCN and on coumadin, [**First Name3 (LF) **] and [**First Name3 (LF) 4532**]. Last night around 6pm first passed bright red blood about a cup with clots of blood with some left sided abd pain, then passed 5 more movements with blood, minimal stool if any over night and 4 more bloody movements this am until she presented for evaluation. She also noted today that she had similar substernal chest pressure although less intense for an hour today that resolved w/o intervention. Some minimal shortness of breath, no fevers, chills, or other complaints. Given bleeding took other home meds except [**First Name3 (LF) **] and coumadin today. Otherwise has been complaint with home meds since d/c. Of note she has never had hx of GI bleed or ulcers, but did have a colonoscopy over 5 yrs ago with evidence of polyps which she has not followed up. . In ED no more bloody BMs, rec'd 10mg SC vitamin K, 2uFFP, 1uPRBC and NGT attempts unsuccessful. Past Medical History: 1. CAD s/p 2 drug eluding stents in LCX and D1 2. CHF ef 30-40% 3+TR, 1+MR, e/a 0.45 3. PVD s/p bifem bypass 4. s/p Right mastectomy, Breast Ca 20yrs ago 5. Hypertension 6. Fibromyalgia 7. Strep Viridans Endocarditis 8. PFO Social History: Quit smoking 3-4 years ago, previous 40 pack yr smoking hx, no etoh, lives in SC, daughters are next of [**Doctor First Name **] Family History: Heart Disease Physical Exam: VS: T 96.3 P 59 BP 129/39 R18 Sat 100%RA GEN: aao, nad HEENT: assymetric pupils, +pallor conjuctiva, injected sclera CHEST: CTAB no wheezes or crackles CV: RRR, slight SEM at RLSB ABD: soft, +tenderness to palpation of her left side to deep palpation, +BS, rectal with bright red blood with small clots, no stool in vault, +ext hemorrhoid EXT: no edema, left PICC in place on left axilla Pertinent Results: Admission Labs: [**2118-12-1**] 04:00PM PT-22.6* PTT-33.0 INR(PT)-3.7 [**2118-12-1**] 04:00PM PLT COUNT-331 [**2118-12-1**] 04:00PM WBC-8.5 RBC-3.09* HGB-8.4* HCT-25.3* MCV-82 MCH-27.1 MCHC-33.1 RDW-15.7* [**2118-12-1**] 04:00PM CK-MB-NotDone cTropnT-<0.01 [**2118-12-1**] 04:00PM CK(CPK)-48 [**2118-12-1**] 04:00PM GLUCOSE-165* UREA N-27* CREAT-1.3* SODIUM-141 POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14 [**2118-12-1**] 04:11PM HGB-8.7* calcHCT-26 [**2118-12-1**] 08:00PM PT-19.0* PTT-31.4 INR(PT)-2.5 [**2118-12-1**] 08:00PM PLT COUNT-305 [**2118-12-1**] 08:00PM ANISOCYT-1+ MICROCYT-1+ [**2118-12-1**] 08:00PM NEUTS-59.7 LYMPHS-31.9 MONOS-4.1 EOS-3.0 BASOS-1.2 [**2118-12-1**] 08:00PM WBC-7.7 RBC-2.52* HGB-7.0* HCT-20.6* MCV-82 MCH-27.8 MCHC-34.0 RDW-16.3* [**2118-12-1**] 08:00PM LIPASE-16 [**2118-12-1**] 08:00PM ALT(SGPT)-10 AST(SGOT)-10 ALK PHOS-62 AMYLASE-35 TOT BILI-0.2 . Discharge/Interval Data: [**2118-12-23**] 04:58AM BLOOD WBC-7.8 RBC-3.57* Hgb-10.6* Hct-30.5* MCV-86 MCH-29.6 MCHC-34.6 RDW-17.7* Plt Ct-271 [**2118-12-15**] 05:05AM BLOOD Neuts-67 Bands-0 Lymphs-24 Monos-5 Eos-2 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2118-12-13**] 05:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [**2118-12-23**] 04:58AM BLOOD Plt Ct-271 [**2118-12-22**] 04:58AM BLOOD QG6PD-8.3 [**2118-12-20**] 05:40AM BLOOD Ret Aut-5.3* [**2118-12-15**] 01:30PM BLOOD Ret Aut-3.5* [**2118-12-23**] 04:58AM BLOOD Glucose-84 UreaN-16 Creat-1.3* Na-143 K-3.4 Cl-109* HCO3-27 AnGap-10 [**2118-12-23**] 04:58AM BLOOD LD(LDH)-1109* TotBili-1.0 DirBili-0.3 IndBili-0.7 [**2118-12-22**] 04:58AM BLOOD LD(LDH)-1283* TotBili-1.4 DirBili-0.3 IndBili-1.1 [**2118-12-21**] 03:25AM BLOOD LD(LDH)-1454* CK(CPK)-72 TotBili-2.7* DirBili-0.4* IndBili-2.3 [**2118-12-20**] 05:40AM BLOOD LD(LDH)-1289* TotBili-1.1 [**2118-12-19**] 05:47AM BLOOD LD(LDH)-1336* TotBili-1.5 [**2118-12-17**] 04:37AM BLOOD ALT-20 AST-66* LD(LDH)-1580* AlkPhos-70 TotBili-1.9* [**2118-12-16**] 05:07AM BLOOD LD(LDH)-1691* TotBili-1.4 [**2118-12-15**] 05:05AM BLOOD LD(LDH)-1898* TotBili-1.7* [**2118-12-14**] 04:54AM BLOOD LD(LDH)-2135* CK(CPK)-227* TotBili-2.6* [**2118-12-13**] 05:10AM BLOOD LD(LDH)-2100* CK(CPK)-230* TotBili-2.7* DirBili-0.4* IndBili-2.3 [**2118-12-12**] 05:21AM BLOOD LD(LDH)-1855* CK(CPK)-228* TotBili-2.2* DirBili-0.4* IndBili-1.8 [**2118-12-9**] 12:58PM BLOOD CK(CPK)-150* [**2118-12-7**] 04:50AM BLOOD ALT-13 AST-23 LD(LDH)-210 AlkPhos-56 TotBili-0.6 [**2118-12-1**] 08:00PM BLOOD ALT-10 AST-10 AlkPhos-62 Amylase-35 TotBili-0.2 [**2118-12-21**] 03:25AM BLOOD cTropnT-<0.01 [**2118-12-20**] 05:42PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-20**] 11:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-9**] 12:58PM BLOOD CK-MB-3 cTropnT-<0.01 [**2118-12-7**] 03:38AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-6**] 11:26AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-6**] 03:12AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2118-12-5**] 05:55AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-4**] 05:05PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-4**] 09:01AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-4**] 04:07AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-4**] 01:37AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-2**] 04:41AM BLOOD CK-MB-NotDone cTropnT-0.01 [**2118-12-2**] 12:05AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2118-12-21**] 03:25AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.8 [**2118-12-20**] 05:40AM BLOOD Hapto-<20* [**2118-12-19**] 05:47AM BLOOD Hapto-<20* [**2118-12-16**] 05:07AM BLOOD Hapto-<20* [**2118-12-15**] 01:30PM BLOOD calTIBC-213* VitB12-379 Folate-8.5 Hapto-<20* Ferritn-1461* TRF-164* [**2118-12-15**] 01:30PM BLOOD PEP-NO SPECIFI IgG-959 IgA-309 IgM-42 IFE-NO MONOCLO [**2118-12-1**] 04:11PM BLOOD Hgb-8.7* calcHCT-26 [**2118-12-7**] 09:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative . Microbiology: Blood cultures: [**12-2**], [**12-3**], [**12-16**] - No growth Urine cultures: [**12-9**], [**12-10**], [**12-13**] contaminated, [**12-12**] No growth H.Pylori - negative . Imaging: CXR [**2118-12-1**]: 1. Left-sided PICC with tip at brachiocephalic/SVC junction. 2. Stable cardiomegaly with stable to slightly improved mild congestive heart failure. . EKG [**12-1**]: Sinus bradycardia. Non-specific intraventricular conduction delay. Left ventricular hypertrophy with associated ST-T wave changes. Q waves in the inferior leads consistent with prior infarction. Compared to the previous tracing Q waves in the inferior leads are more apparent. . GI BLEEDING STUDY [**2118-12-2**] GI BLEEDING STUDY Reason: LOCALIZE GI BLEED HISTORY: 63-year-old on Coumadin, now passing blood clots per rectum. DECISION: INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for 90 minutes were obtained. Dynamic blood pool images show focal uptake of tracer in the region of the hepatic flexure within the initial 10 minutes of the study. Tracer was then seen throughout the transverse colon, and passing into the descending colon. Blood flow images show normal flow. Bleeding was first noticed at approximately eight minutes. IMPRESSION: Findings consistent with bleeding originating in the region of the hepatic flexure. This was communicated to Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 3646**] at the completion of the study. . C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2118-12-4**] 7:04 PM Reason: please eval for site of bleeding Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 63 year old woman with BRBPR and blood loss anemai. REASON FOR THIS EXAMINATION: please eval for site of bleeding CLINICAL INFORMATION: 63-year-old woman with lower GI bleed, had positive nuclear scan, needs mesenteric arteriogram. PROCEDURE/FINDINGS: The procedure was performed by Dr. [**First Name (STitle) 379**] [**Name (STitle) **] and Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **], the attending radiologist was present and supervising throughout the procedure. After the risks and benefits were explained to the patient, written informed consent was obtained. The patient was placed supine on the angiographic table. Preprocedure timeout was performed to confirm the patient's name, procedure and the site. The right groin was prepped and draped in the standard sterile fashion. The right common femoral artery was accessed with a 19-gauge needle after local administration of 1% lidocaine. A 0.035 Bentson guidewire was advanced into the abdominal aorta under fluoroscopic guidance. The needle was exchanged for a 4-French sheath. The inner dilator was removed. The sheath was connected to a continuous sidearm flush. A 4 French catheter was advanced over the wire into abdominal aorta. The guidewire was removed. The catheter was used to subsequently engage the origin of celiac axis and superior mesenteric arteries. Selective celiac and SMA arteriogram were performed at anterior-posterior and lateral projections. There was no evidence of extravasation of contrast. No inferior mesenteric artery was identified secondary to aortic bypass graft. Based on the diagnostic findings, no further intervention was needed at this moment. The catheter and the sheath were removed. Hemostasis was achieved by direct manual pressure for 20 minutes. The patient tolerated the procedure well and there were no immediate complications. IMPRESSION: Selective celiac axis, superior mesenteric arteriogram demonstrated no extravasation of contrast. . GI BLEEDING STUDY [**2118-12-4**] GI BLEEDING STUDY Reason: P/W BRBPR-PLEASE ASSESS GI BLEED HISTORY: bright red blood per rectum INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for 30 minutes were obtained. Dynamic blood pool images show prompt appearance of tracer activity in the right upper quadrant in a similar distribution to the prior study. Blood flow images show tracer within the expected course of the abdominal vasculature. Bleeding was first noticed at approximately 3 minutes. IMPRESSION: Tracer activity demonstrated in the right upper quadrant beginning at approximately 3 minutes, in a similar location compared to the prior study. Patient was promptly taken to angiography when the bleeding was identified. . EKG [**12-4**]: Sinus bradycardia Short PR interval Nonspecific intraventricular conduction defect Inferior infarct - age undetermined LVH with ST-T changes No change from previous . EKG [**12-7**]: Sinus bradycardia Short PR interval Nonspecific intraventricular conduction defect Inferior infarct - age undetermined LVH with ST-T changes No change from previous . EKG [**12-10**]: Atrial fibrillation with a mean ventricular response, rate 118. Compared to the previous tracing of [**2118-12-9**] cardiac rhythm is now atrial fibrillation. . RENAL U.S. [**2118-12-12**] 11:54 AM RENAL U.S. Reason: obstruction [**Hospital 93**] MEDICAL CONDITION: 63 year old woman with CAD s/p MI, CHF, massive LGIB s/p 19 units of prbcs, now with ARF cr 0.8->1.9 in setting of labile HTN. Also with ongoing hematuria. REASON FOR THIS EXAMINATION: obstruction INDICATION: CAD, status post MI with acute renal failure in the setting of labile hypertension, ongoing hematuria. No prior studies are available for direct comparison. FINDINGS: The right kidney measures 10.9 cm. The left kidney measures 11.1 cm. There is a small roughly 4-mm nonobstructing stone within the interpolar region of the right kidney. There is no hydronephrosis. A small approximately 1 cm anechoic cyst is demonstrated within the right parapelvic region. The bladder is unremarkable. IMPRESSION: 1. No evidence of hydronephrosis. 2. Non-obstructing right renal stone. . INDICATIONS FOR CONSULT: Investigation of transfusion reaction CLINICAL/LAB DATA: The patient is a 63 year old female with a history of hypertension, coronary artery disease (NSTEMI with stent placements in [**10-31**]) peripheral vascular disease, pulmonary edema, breast cancer and a recent diverticular bleed at the splenic flexure who was admitted for a GI bleed and falling hematocrit. The patient has received 21 non-reactive red blood cell transfusions, 5 non-reactive plasma transfusions and two non-reactive platelet trasnfusions. On [**12-12**], the patient received a unit of packed red blood cells (Hct was 28.2 to 29.3 on that date). Her vitals pre transfusion (14:45) were: temp=97.9, pulse=60, resp=18, BP=106/palp. At 18:30, after the patient had received 375 cc, the patient was witnessed to have hematuria, which was also present before the transfusion, per the resident caring for the patient. Her vitals at that time were: temp=98.6, pulse=60, resp=16, BP=154/80. The patient had received percocet 30 minutes prior to the transfusion. Fever, chills/rigors, respiratory distress, chest pain, nausea and vomiting and back pain were not described. No clerical errors were detected. LAB DATA: RECIPIENT ABO/RH: B POSITIVE UNIT (04FS82305) ABO/RH: B POSITIVE Antibody screen: NEGATIVE Plasma color pre and post transfusion: Icteric, copper-colored LABS: post transfusion= 30.1 Other labs from [**2118-12-12**]: WBC=11.9, PLT=232 BUN=23, Creat=1.9, LD=1855, CK=228, total bili=2.2, indirect=1.8, direct bili=0.4, haptoglobin=<20. Urine: color=red with 6-10 WBC and [**5-6**] RBC, prot/creat=1.6, DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: The patient experienced isolated hematuria 3 hours and 45 minutes after receiving 375 cc of B positive compatable blood. This hematuria was present pre-transfusion. The post transfusion antibody screen and DAT were negative and the post transfusion plasma had an icteric, copper color. No fever, chills, respiratory distress, hypotension or other signs of hemodynamic instability were noted after the transfusion. The possiblility of an immune intravascular hemolytic transfusion reaction with this clinical picture is highly unlikely. Non immune causes of hemolysis include mechanical (heart valve, roller pump), osmotic, intrisnic red cell defect. Repeat testing of antibody screen and direct antiglobulin test (DAT) would be warrented if continued hemolysis occurs without other found causes. . BAS/UGI AIR/SBFT [**2118-12-15**] 9:38 AM BAS/UGI AIR/SBFT Reason: obstruction, mass - cause for dysphagia [**Hospital 93**] MEDICAL CONDITION: 63 year old woman with massive LGIB, CAD s/p MI, now with hemolytic anemia, ARF, also with dysphagia to solids REASON FOR THIS EXAMINATION: obstruction, mass - cause for dysphagia HISTORY: 63-year-old woman with massive lower GI bleed, CAD, hemolytic anemia, acute renal failure, now with upper dysphagia to solids. FINDINGS: Barium passes freely through the esophagus. There is no aspiration into the airway and no significant retention in the valleculae or piriform sinuses. No structural abnormalities are detected in the region of the pharynx and cervical esophagus. There is a small axial hiatal hernia and a small amount of gastroesophageal reflux was observed during the exam. No definite Schatzki ring was observed, however, the barium tablet delayed significantly at the gastroesophageal junction before passing into the stomach. No esophageal mucosal abnormalities were identified. IMPRESSION: No abnormalities identified in the hypopharynx and upper esophagus. Small axial hiatal hernia with associated gastroesophageal reflux. Although no Schatzki ring was identified, there was delayed passage of the 12.5 mm barium tablet across the gastroesophageal junction. . EKG [**12-20**]: Sinus rhythm. Left atrial abnormality. Compared to the previous tracing of [**2118-12-10**] cardiac rhythm now sinus mechanism. Multiple other abnormalities persist without major change. . . . Gastroenterology: 1. Colonoscopy [**2118-12-4**]: Indications: Gastrointestinal bleeding with positive tagged RBC scan at hepatic flexure Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. A physical exam was performed. The patient was placed in the left lateral decubitus position and the colonoscope was introduced through the rectum and advanced under direct visualization until the cecum was reached. The appendiceal orifice and ileo-cecal valve were identified. Careful visualization of the colon was performed as the colonoscope was withdrawn. The procedure was not difficult. The quality of the preparation was poor. Visualization of the whole colon was poor. The patient tolerated the procedure well. The digital exam was normal. There were no complications. Limitations: Poor preparation of the whole colon due to bleeding. Findings: Protruding Lesions Many semi-pedunculated non-bleeding polyps of benign appearance and ranging in size from 4mm to 8mm were found in the hepatic flexure. Three semi-pedunculated polyps of benign appearance and ranging in size from 4mm to 7mm were found in the transverse colon. A single mixed 7 mm non-bleeding polyp of benign appearance was found in the sigmoid colon. Excavated Lesions Multiple severe diverticula with extensive openings were seen in the sigmoid colon , transverse colon, hepatic flexure and ascending colon. Other Extensive amount of blood was seen throughout the entire colon. The cecum, appendiceal orifice, and ileocecal valve were identified. Bilious, non-bloody fluid was seen coming from the ileocecal valve suggesting that bleeding is localized distal to the ileocecal valve. There was also fresh blood seen at the hepatic flexure and less blood in general at the cecum/ascending colon. A large adherent blood clot of was visualize at the hepatic flexure. The blood clot was mobilized with irrigation and with the colonoscope. Multiple diveriticula were seen beneath the clot, but no active bleeding was seen. There were also six polyps of [**3-4**] mm in size at the hepatic flexure. None of the polyps was actively bleeding. Impression: 1. Diverticulosis of the sigmoid colon , transverse colon, hepatic flexure and ascending colon 2. Polyps in the hepatic flexure, transverse colon, and sigmoid colon 3. A large adherent blood clot of was visualize at the hepatic flexure. There were multiple diverticula and polyps underneath and nearby the clot, respectively. Source of bleeding is most consistent with diverticular bleed at the hepatic flexure. Recommendations: Angiogram +/- selective embolization of arteries supplying hepatic flexure. Patient will need repeat colonoscopy for polypectomies after acute GI bleeding has resolved. Additional notes: The attending physician was present throughout the entire procedure. . . . 2. EGD: Indications: Dysphagia Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered Conscious sedation anesthesia. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The vocal cords were visualized. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Patchy erythema of the mucosa with no bleeding was noted in the antrum. These findings are compatible with gastritis. Duodenum: Normal duodenum. Impression: Erythema in the antrum compatible with gastritis Otherwise normal egd to second part of the duodenum Recommendations: Follow-up biopsy results Check H. pylori serology Esophageal manometry Additional notes: The attending was present for the entire procedure . Brief Hospital Course: Patient is a 63 yo woman w/ CAD, labile HTN, CHF (mildly depressed EF, 1+AR, 2+MR), Afib, PVD, FM, breast CA in remission, s/p NSTMI in [**10-31**] c/b pulmonary edema, s/p 2 stents to D1 and LCx (failed), also c/b strep viridans endocarditis admitted with massive GI bleed. Patient was d/ced on [**2118-11-24**] w/PICC line to complete course of PCN. Patient had episode of GI bleed w/BRBPR in setting of taking [**Date Range **], Coumadin. Patient's hct on admission was 25->20. Patient received a total of 19 units of pRBCs , 2 units of FFP, and reversed with 10 mg SC Vit K for this episode of GI bleeding. At that time patient also had substernal chest pressure x 1 hr that resolved spontaneously. Patient is s/p 2 positive tagged cell scan at hepatic flexure and colonoscopy showing a clot at the hepatic flexure. Angiogram was negative, last bleed on [**2118-12-5**]. Surgical evaluation felt that patient was not a surgical candidate at the time. Patient was then stabilize in terms of GI bleeding and maintained a stable Hct >30. She was transferred to the regular medicine floor at that time. On the floor, the patient had labile HTN with BP ranging 180s-200s. Her blood pressure medications were held in the setting of GI bleed. Patient was restarted on most of her outpatient meds including ACEI. She dropped her pressures to the 140s range. She subsequently had an increase in Cr. to a max of 2.4 on [**2118-12-13**]. Renal consultation was placed and it was felt that the initiation of an ACE along with relative hypotension was the cause for this increase. ACEI was discontinued and the patient's medications where tapered for a goal SBP of 160s. Upon discharge the patient's Cr. was 1.3 and she is scheduled for renal follow up regarding the possibility of using an ACEI in the future. Patient also started to develop brown urine around this time. Her Hct drifted below 30 without any evidence of ongoing GI bleeding (although she remained guaiac +). Patient was transfused several more units of blood over the following days to a total of 25 units since admission. With these transfusions, however, the patient did not substantially increase her Hct and persistently remained with a Hct ~25-26. Her urine remained dark and the workup for hemolysis began since patient had elevated LDH to [**2112**], haptoglobin <20 and elevated bilirubin to ~2.5. Patient never experienced any fevers, chills, flank pain however and her Cr. continued to improve. Hematology was consulted since the etiology for this hemolysis remained unclear. DDx included delayed transfusion reaction (immune vs. non immune), G6PD deficiency given patient had received 1x Sulfa for +U/A. Urine hemosiderin was persistently negative suggesting an extravascular process. [**Doctor Last Name 17012**] body preparation was negative and G6PD assay was within normal limits. Her blood smear remained inconclusive with rare schistocytes, bite cells and spherocytes. It was also postulated that the patient may be hemolyzying due to sulfa drugs since she also received lasix with her blood transfusion. A trial of lasix however did not induce further hemolysis. Upon discharge, the patient's Hct is stable ~30 with clear urine. She is scheduled for follow up with Hematology at [**Hospital3 **]. . In terms of her individual medical problems: . 1. Lower GI bleed: Patient bled in the setting of a supra therapeutic INR and while taking [**Hospital3 **] post MI and hx of A.fib. She did not have a history of bleeding had a colonoscopy with polyps over 5 yrs ago without any follow up. She was guaiac negative prior to starting heparin on last admission. Her bleed was found to be secondary to diverticula located at the hepatic flexure. Her last bleed was on [**12-5**] without any further episodes. Her hematocrit was maintained >30 given her recent history of myocardial infarction, this required a total of 19 units of blood while she was monitored in the intensive care unit. She was also treated with Vit K and 2 units of FFP. Two tagged red cell scans localized the bleed to the hepatic flexure. She also had colonoscopy confirming diverticular disease. Patient is advised to return to the ED immediately with any blood per rectum. She will likely need surgical intervention should this occur again. At the time of admission, however the patient was felt to be nonoperable. Interventional Radiology also performed angiography but was unwilling to perform embolization due to the risk of necrosis. Importantly, patient was taken off Coumadin and continued on [**Month/Day (4) **]/[**Month/Day (4) **] as per Cardiology consultation. Patient has been tolerating a diet for several days prior to discharge. She is also continued on a bowel regimen to maintain soft stool. . 2. CAD s/p NSTEMI: Patient was considered high risk for ischemia given her massive LGIB and recent MI. She experience one episode of CP with the bleed without EKG changes, CE negative. Patient then remained stable throughout admission. Later on patient experience chest tightness with shortness of breath in the setting of Hct ~25. There were no new EKG changes and CE were negative x 3. Upon discharge she is chest pain free. She is to continue taking [**Last Name (LF) **], [**First Name3 (LF) **], beta blocker. She is scheduled for Cardiology follow up as an outpatient. . 3. Labile HTN: Patient with severe HTN with hx of flash pulmonary edema and hypertensive emergencies. She was initially taken off all outpatient meds given her large GI bleed. Once stabilized and transferred to the floor, her usual medications were restarted including CCB, ACEI, Hydral PO, clonidine patch, Imdur. Her blood pressures varied b/w 120s-190s. At this stage her Cr. began to increase and it was felt that relative hypotension was the cause along with initiation of the ACEI. As such, permissive hypertension was allowed with goal SBP ~ 160. Upon discharge, however, with recovery of her Cr, she was controlled more closely with BP ~130-140. She is discharged on Toprol, Amlodipine, and Imdur. Her clonidine path, Hydral and ACEI and Aldactone were all discontinued. She will be evaluated in the nephrology clinic about the possibility of re adding and ACEI. She may also still need po Hydralazine for optimum control. Patient received a renal MRI/MRA to rule out stenosis that was negative on the right and unable to assess on the left due to artifact from aorto-[**Hospital1 **] iliac stenting. . 4. Atrial Fibrillation/Flutter: Patient had transient episode during her last admission, spontaneously converted to sinus rhythm and was started on Coumadin, and sent out on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor and was to have an outpatient EP study. Given her massive GI bleed Coumadin was discontinued. Patient also had some short runs of SVT to 150s on [**12-13**]. Beta blocker was up titrated per EP recommendations. She did not experience any further episodes. She is scheduled for EP follow up to determine the need for ongoing anticoagulation. She is currently in Sinus Rhythm. 5. ARF. Cr peak at 2.4 trending down to 1.3 on Discharge. Her Cr began to rise prior to her episode of hemolysis. Likely secondary to starting ACEI as well as relative hypotension, ?exacerbated by hemolysis. Her dose of Statin was temporarily decreased to 40 mg daily (Atorvastatin) since this could have been exacerbating her renal failure. She is not longer taking and ACEI. . 6. Hemolytic Anemia. Evidence of hemolysis with increased LDH, low hapto, increased T. bili, ?delayed transfusion rx vs. G6PH deficiency, drug reaction, infectious (Bactrim for UTI). Patient s/p transfusion reaction screen - no evidence of immune mediated hemolysis however could be false negative. Other work up was also negative including [**Doctor Last Name 17012**] body smear, urine hemosiderin, non specific blood smear. Upon discharge the etiology remains unclear. Hct currently stable ~30. She is scheduled for Hematology follow up. The patient should have a micro coombs assay sent as outpatient as the clinical suspicion for a COOMBS + alloimmune hemolytic anemia remaisn high as the patient seemed to only hemolyze in the setting of red cell transfusion. Said another way, we think the negative DAT ( coombs test) may be a false negative. 7. CHF: Evidence of both systolic and diastolic dysfunction with mildly reduced EF. No active issues during this admission, no evidence of fluid overload. Lasix was given between blood transfusions to prevent overload. Patient was continued on beta blocker and Imdur. . 8. Strep Viridans endocarditis/thrombus: Unclear based on [**Doctor Last Name 113**] results (no vegetations) on prior admission, surveillance cultures negative. She was started on Penicillin to complete a course of antibiotics on last admission and d/ced home with PICC. Upon admission to the MICU, PCN was discontinued. Surveillance cultures were negative and as such she was not restarted on penicillin. Patient is scheduled for ID follow up as an outpatient. . 9. Shortness of Breath. Patient experienced intermittent episodes of shortness of breath, primarily wit ambulation/exertion and SVT. Beta blocker was up titrated with good control. Likely [**12-29**] to deconditioning and long hospital stay. She was r/out for MI. O2 sats remained good. . 10. Dysphagia. Patient complained of dysphagia to solids. Barium swallow was performed which showed showing distal narrowing and delayed emptying at the level of the GE junction (see results section). EGD was performed that did not show any lesions/masses, not consistent with achalasia. + gastritis. H. pylori testing was negative. Her dysphagia was thought to be secondary to a [**Month/Day (2) **] disorder. Patient was continued on a soft mechanical diet. An esophageal manometry study is scheduled as an outpatient. . 11. Thrombocytopenia: Likely secondary to massive red cell transfusion. Resolved spontaneously. . F/E/N: Cardiac diet/soft mechanical, monitored and replaced lytes as needed . Prophylaxis: Venodynes, no heparin, [**Hospital1 **] PPI then tapered to daily, bowel reg prn . Patient was a full code throughout. . Access: PICC, 1 PIV (Note: Post-mastectomy, can only use left arm) Medications on Admission: - [**Hospital1 **] 75mg qd - Lipitor 80mg qd - [**Hospital1 **] 325mg qd - Pantoprazole 40mg qd - Warfarin 5mg qd - Lasix 20mg qd - Lisinopril 40 [**Hospital1 **] - Toprol xl 100mg qd - Hydralazine 50mg q6hrs - Spironolactone 25mg qd - Imdur 120mg qd - Norvasc 10mg qd - Clonidine 0.1mg/24hr patch(Tues) - Ipratropium 2puffs qid - Sertraline 25mg qd - Penicillin G Potassium 3,000,000 units q4hrs - Oxycontin 10mg q12 - Oxycodone-Acetaminophen 5-325 mg prn PO Q4-6H Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*150 Tablet(s)* Refills:*0* 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 10. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0* 11. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 12. 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* 13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*qs 1* Refills:*2* 15. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: 1. Lower GI bleed 2. Coronary Artery Disease s/p Non ST Elevation Myocardial Infarction 3. Atrial Fibrillation/SVT 4. Hypertension 5. Congestive Heart Failure 6. Thrombocytopenia 7. Acute Renal Failure 8. Hemolytic Anemia Discharge Condition: Good - BP under better control, chest pain free, no further hemolysis, renal function stable and improved Discharge Instructions: Please take all of your medications as directed Please go to your local clinic/doctor's office to get your blood drawn (Complete Blood Count and Chemistry Panel) and have the results sent/faxed to your Primary Care Doctor. Please return to the hospital or contact your physician if you have any headache/dizziness, chest pain/pressure, difficulty breathing or any other complaints. ***If you see any evidence of bleeding in your stool immediatedly go to the nearest emergency room Followup Instructions: You have the following appointments scheduled. It is very important that you see a doctor shortly after your discharge. We have made an appointment for you to see a general medicine doctor here at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**]. You should also follow up with you own primary care doctor, please make sure to see them within one week of discharge. Please take your discharge summary with you to this appointment so that they know what happened in the hospital. 1. Gastroenterology: Provider: [**Name10 (NameIs) 2166**] ROOM GI ROOMS Date/Time:[**2118-12-28**] 12:00 to perform a [**Year/Month/Day **] study. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7217**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2118-12-28**] 12:00 2. Infectious Diseases - Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2118-12-29**] 11:00 AM 3. Gastroenterology: [**2119-1-3**] 02:30p Dr. [**First Name (STitle) **] [**Doctor Last Name **]. To follow up your [**Doctor Last Name **] study. Phone ([**Telephone/Fax (1) 8892**] 4. Hematology: Date: [**2119-1-23**] 09:30a Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] L. Phone: ([**Telephone/Fax (1) 31457**] 5. General Medicine [**2119-1-26**] 01:30p Dr. [**Last Name (STitle) 11183**],[**First Name3 (LF) **] - [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]. [**Hospital 191**] MEDICAL UNIT 6. Cardiology: Date: [**2119-1-9**] 04:00p Dr. [**Last Name (STitle) **] CARDIOLOGY Phone: ([**Telephone/Fax (1) 9530**] 7. Kidney specialist. [**2119-1-26**] 03:00p Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] K. RENAL DIV-Phone: ([**Telephone/Fax (1) 773**] Completed by:[**2118-12-23**]

[ "V10.3", "787.2", "287.5", "283.9", "V45.82", "285.1", "599.7", "410.72", "041.09", "427.31", "584.9", "562.12", "401.9", "729.1", "211.3", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.05", "45.23", "99.07", "99.04", "45.13", "88.47" ]

icd9pcs

[ [ [] ] ]

33109, 33187

20475, 30708

310, 366

33453, 33561

2459, 2459

34093, 35897

2020, 2035

31224, 33086

14939, 15050

33208, 33432

30734, 31201

33585, 34070

2050, 2440

243, 272

15079, 20452

394, 1609

2475, 8050

1631, 1857

1873, 2004

25,030

102,205

49182

Discharge summary

report

Admission Date: [**2117-9-5**] Discharge Date: [**2117-9-5**] Date of Birth: [**2078-4-17**] Sex: F Service: MEDICINE Allergies: Prochlorperazine Attending:[**First Name3 (LF) 4765**] Chief Complaint: Endocarditis: Heart Block Major Surgical or Invasive Procedure: Temporary pacing wire: placement of quadripolar catheters for pacemaker function History of Present Illness: This is a 39 y/o female with MMP and multiple episodes of bacteremia who presented obtunded from nursing home. The patient was noticed to have decreased mental status after hemodialysis yesterday which worsened on the day of presentation. The patient was febrile to 101 and brought to the ED. An EKG done showed AV block, inferior ST elevations. An echo showed significant aortic valce vegetation(1cm), thickened anterior MR leaflet (no frank vegetation, inferior wall motion abnormality and thickening. The patient was transferred to the CCU. Past Medical History: 1. ESRD due secondary to diabetes, on hemodialysis three times weekly. She had a failed renal transplant ([**2104**]) 2. Diabetes mellitus type I with retinopathy, nephropathy and peripheral vascular disease, diagnosed as a child, brittle 3. CVA ([**2113**], [**2116**]) with hydrocephalus status post VP shunt (removed in [**12-10**] as CSF grew out coag negative staph), right basal ganglia hemorrhage 4. Hypercholesterolemia 5. Hypertension 6. Unclear history of grand mal seizure during dialysis 7. MRSA line tip infection with right atrial thrombus (line tip pulled [**2116-6-16**]) 8. Diffuse lymphadenopathy of unknown etiology. 9. Chronically elevated alkaline phophatase 10. History of naphthelene induced coma from inhaling moth balls 11. H.O VRE bacteremia (completed linezolid in 11/[**2116**]). 12. Status post parathyroidectomy 13. Status post multiple amputations (right BKA, left digit, left metatarsal) 14. Exploratory laparotomy and appendectomy for appendicitis in [**2116-3-8**] 15. Prior history of tracheostomy Social History: Ms [**Known lastname **] usually lives in JP with her daughter and granddaughter, although she came from rehab. Her sister-in-law, [**Name (NI) 1060**], helps her with management of her multiple medications. No tobacco or alcohol use. Her baseline is such that she can feed herself, knows when to take medicines and when to go to dialysis. Family History: Family history of diabetes mellitus in children. Physical Exam: VS: T 104, HR 60-108, R 30-33, BP 88-101/40-60 General: Obtunded HEENT: no conjunctival lesions NECK: multiple scars, trachea midline Heart: 4/6 systolic murmur, [**3-14**] diastolic murmur Lungs: difficulty due to shallow breathing Abdomen: multiple surgical scars Neurologic: unable to assess Pertinent Results: [**2117-9-5**] 09:49AM PT-15.8* PTT-31.3 INR(PT)-1.7 [**2117-9-5**] 09:49AM PLT COUNT-307 [**2117-9-5**] 09:49AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL TARGET-OCCASIONAL BURR-OCCASIONAL [**2117-9-5**] 09:49AM NEUTS-89.0* BANDS-0 LYMPHS-6.7* MONOS-3.7 EOS-0.3 BASOS-0.3 [**2117-9-5**] 09:49AM WBC-17.7*# RBC-4.34# HGB-11.3* HCT-38.0 MCV-88# MCH-25.9* MCHC-29.6* RDW-18.1* [**2117-9-5**] 09:49AM cTropnT-5.83* [**2117-9-5**] 03:31PM CK-MB-7 cTropnT-4.45* [**2117-9-5**] 03:31PM CK(CPK)-107 [**2117-9-5**] 03:31PM GLUCOSE-195* UREA N-47* CREAT-6.3* SODIUM-136 POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-23 ANION GAP-23* [**2117-9-5**] 08:05PM GLUCOSE-275* UREA N-48* CREAT-6.5* SODIUM-131* POTASSIUM-7.1* CHLORIDE-91* TOTAL CO2-13* ANION GAP-34* [**2117-9-5**] 08:34PM TYPE-[**Last Name (un) **] PO2-19* PCO2-52* PH-7.01* TOTAL CO2-14* BASE XS--20 Brief Hospital Course: This is a 39 y/o female with multiple medical problems who was admitted with endocarditis and found to be in complete heart block. In the emergency department the patient was in sepis: hypotensive, lethargic and febrile to 104. Infectious disease was initially [**Last Name (un) 4221**]. They agreed with the plan to place the patient on gentamycin and vancomycin. In addition, they suggested adding daptomycin and ceftriaxone. They also recommended further imaging to rule out septic emboli. While in the CCU, after multiple attempts for central access a temporary pacer was placed through the left femoral groin. Cardiac surgery evaluated the patient for surgery, but they recommended hemodynamic stabilization and administration of intravenous antibiotics. Renal was also [**Last Name (un) 4221**]. At the time, there was no acute indication for hemodialysis. They recommended renal dosing of antibiotics. At approximately 7 or 8pm in the evening the patient went into pulseless electrical asystole X 3-5 minutes. The patient was coded. It was suspected that the patient went into hyperkalemic arrest (K+ 7.1). The patient received epi/ bicarb/ insulin/ D50/ calcium with return of rhythm. The health care proxy was notified and she informed us that the patient would not have wanted repeated resuscitations. The patient code was reversed to DNR. The patient later passed. Medications on Admission: Prozac 30 Aspirin Colace Folate Protonix Metoprolol Norvasc Atorvastin ISS Reglan Vancomycin Glargine Sevelamer Benadryl Discharge Medications: Patient died within 24 hours of admission Discharge Disposition: Expired Discharge Diagnosis: Patient went into pulseless electrical asystole. Patient had been full code for cardiac interventions, but the code was later reversed to DNR/DNI. Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2117-11-15**]

[ "276.7", "995.92", "421.0", "038.9", "410.92", "V49.75", "403.91", "785.51", "250.41", "426.0", "427.5" ]

icd9cm

[ [ [] ] ]

[ "99.07", "38.93", "00.17", "99.69", "96.04" ]

icd9pcs

[ [ [] ] ]

5333, 5342

3709, 5096

301, 383

5533, 5538

2772, 3686

5590, 5625

2392, 2442

5267, 5310

5363, 5512

5122, 5244

5562, 5567

2457, 2753

236, 263

411, 961

983, 2018

2034, 2376

29,876

100,856

13447

Discharge summary

report

Admission Date: [**2190-10-8**] Discharge Date: [**2190-10-15**] Date of Birth: [**2122-5-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2190-10-11**] Coronary Artery Bypass Graft x 3 (LIMA to Diag, SVG to LAD, SVG to RCA) History of Present Illness: 68 y/o male with three month h/o exertional dyspnea andjaw pain. Had a positive stess test. Referred for cardiac cath which revealed severe three vessel coronary artery disease. Transferred to [**Hospital1 18**] for surgical management. Past Medical History: Hypertension, Hypercholesterolemia, Diabetes Mellitud, Anxiety, s/p hernia repair Social History: Remoted smoking history. Occasional ETOH use. Family History: Non-contributory Physical Exam: Neuro: A&O x 3, MAE, non-focal Puml: CTAB -w/r/r Cor: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, -edema Pertinent Results: [**10-11**] Echo: PRE-CPB The left atrium is moderately dilated. The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 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. Mild (1+) mitral regurgitation is seen. POST-CPB Normal biventricular systolic function. Mild mitral regurgitation. Thoracic aorta intact. [**10-13**] CXR: Patient has been extubated. Multiple lines and tubes have been removed. There are low lung volumes with bilateral bibasilar atelectasis worse in the right lower lobe. Bilateral pleural effusions are small. Patient is post-median sternotomy and CABG. Cardiac size is top normal. The stomach is moderately dilated. [**2190-10-8**] 07:22PM BLOOD WBC-8.9 RBC-4.14* Hgb-14.1 Hct-38.7* MCV-94 MCH-34.1* MCHC-36.4* RDW-13.6 Plt Ct-256 [**2190-10-14**] 12:55PM BLOOD WBC-10.4 RBC-3.26* Hgb-10.6* Hct-30.8* MCV-95 MCH-32.4* MCHC-34.3 RDW-13.2 Plt Ct-192 [**2190-10-8**] 07:22PM BLOOD PT-12.3 PTT-25.5 INR(PT)-1.1 [**2190-10-11**] 11:59AM BLOOD PT-14.1* PTT-71.8* INR(PT)-1.2* [**2190-10-8**] 07:22PM BLOOD Glucose-138* UreaN-24* Creat-1.1 Na-139 K-3.9 Cl-105 HCO3-28 AnGap-10 [**2190-10-14**] 12:55PM BLOOD Glucose-107* UreaN-13 Creat-1.0 Na-143 K-3.7 Cl-108 HCO3-28 AnGap-11 [**2190-10-14**] 12:55PM BLOOD Calcium-7.8* Phos-1.5*# Mg-2.1 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 20825**] was transferred to [**Hospital1 18**] following his cath. He received medical management over several days while be worked-up prior to surgery. On [**10-11**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned off sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics. He was gently diuresed towards his pre-op weight. Later on post-op day one he was transferred to the SDU for further care. Chest tubes were removed on post-op day two. Epicardial pacing wires were removed on post-op day three. He did have some post-op confusion which resolved by time of discharge. He continued to slowly improve while working with physical therapy. On post-op day four he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Atenolol 25mg qd, Aspirin 325mg qd, Celexa 20mg qd, Protonix 40mg qd, MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Hypertension, Hypercholesterolemia, Diabetes Mellitud, Anxiety, s/p hernia repair Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 1295**] in [**2-20**] weeks Dr. [**First Name (STitle) **] in [**1-19**] weeks Completed by:[**2190-10-15**]

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