ChanBeDu/relevant_section_length · Datasets at Hugging Face

64,581

108,761

41109

Discharge summary

report

Admission Date: [**2194-4-25**] Discharge Date: [**2194-5-7**] Date of Birth: [**2150-11-9**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3227**] Chief Complaint: left frontoparietal tumor Major Surgical or Invasive Procedure: [**4-25**] Left Craniotomy History of Present Illness: 43-year-old gentleman who initially presented with a dominant generalized tonic-clonic seizure. Workup revealed a left frontal mass. The patient underwent biopsy of this mass for tissue diagnosis. Pathology analysis revealed gemiscytic astrocytoma (WHO II) without oligo component. Past Medical History: None Social History: He lives alone and is unemployed. His mother is deceased. He has a step father - [**Name (NI) **] [**Name (NI) **] - who he would like making his decisions if he is not able to make decisions for himself. He has a brother but reports him as "not a nice person". The pts father lives on [**Location (un) **] but is aparently nonverbal due to esophageal CA. He stopped smoking and drinking several months ago. He does not have a PCP. Family History: His mother is deceased. His father has esophageal CA. Physical Exam: O: T: af BP: 184/102 HR: 96 R 16 O2Sats100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**5-18**] EOMis NCAT Neck: Supple. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**4-17**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-19**] throughout. No pronator drift Sensation: Intact to light touch. Discharge exam: PERRLA, EOMs full, VF full Expressive aphasia with word finding difficulty. Naming and Repetition intact. Right-Sided Facial droop Rightward tounge deviation Motor: D B T Gr IP Q H AT [**Last Name (un) 938**] G Right 1 3 5 5- 5 5 5 5- 3 5 Pertinent Results: fMRI The expected activation areas during the functional paradigms were demonstrated, during the movement of the right hand, there is no evidence of areas close to the left frontal neoplasm. During the movement of the tongue and language paradigms, areas of activation were demonstrated anterior to the mass lesion in the frontal lobe [**4-26**] MRI Brain: CONCLUSION: Preoperative localization for tumor surgery. The cortical infiltration is compatible with a glioma. The focus of enhancement suggests the lesion may be higher than grade II. [**4-25**] Head CT: IMPRESSION: 1. Status post left temporal tumor resection with pneumocephalus and tiny blood products post-surgical at the surgical bed. 2. Persistent vasogenic edema in the left frontotemporal region. 3. Mild interval worsening of hypodensity at the left frontal white matter near surgical bed, could be mild interval worsening edema; however, cannot exclude focal ischemia. 4. No large acute hemorrhage. [**4-25**] MRI Brain (post op):IMPRESSION: Status post resection of left temporal and posterior frontal mass. Small residual area of enhancement at the superior aspect of the surgical cavity is identified. No significant increase in edema is seen, but slow diffusion is seen at the margin of the surgical cavity with a small focus more deeper to the margin of the surgical cavity which could be related to ischemia or could also be due to postoperative change. No territorial infarcts are seen, however. [**4-26**] Head CT: IMPRESSION: No evidence of new hemorrhage. Increased parafalcine air likely represents redistribution of moderate pneumocephalus. Vasogenic edema and blood products at the resection site appear stable. There is persistent extension of hypodensity into the left frontal lobe, which may represent vasogenic edema. [**4-30**] CTA Chest: 1. Very extensive, acute pulmonary embolism with associated pulmonary arterial and right ventricular hypertension. 2. Incidental finding of left thyroid nodule, ultrasound evaluation, when clinically appropriate, is suggested. [**4-30**] Lower Extremity Venous Ultrasound: No evidence of deep venous thrombosis in bilateral lower extremity. [**5-1**] Transthoracic echocardiogram: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size is normal with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**5-1**] Ct Head: Stable appearance of the left parietal lobe resection bed, with minimal post-surgical blood products and surrounding frontoparietal edema. Stable minimal rightward shift of midline structures and effacement of the left cerebral hemispheric sulci. No new intracranial hemorrhage. LABS: [**2194-4-25**] 07:42PM GLUCOSE-157 UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17 [**2194-4-25**] 07:42PM WBC-16.5* RBC-4.60 HGB-14.2 HCT-39.3* MCV-85 MCH-31.0 MCHC-36.3* RDW-12.9 [**2194-4-25**] 07:42PM PLT COUNT-190 [**2194-4-26**] INR - 1.1 [**2194-5-1**] PT - 14.4 PTT- 55.9 INR - 1.2 [**2194-5-2**] PT - 15.2 PTT- 81.1 INR - 1.3 [**2194-5-3**] PT - 30.5 PTT- 83.6 INR - 3.0 [**2194-5-4**] PT - 34.5 PTT- 30.0 INR - 3.5 [**2194-5-5**] PT - 31.7 PTT- 31.4 INR - 3.2 [**2194-5-6**] PT - 36.0 PTT- 32.6 INR - 3.7 [**2194-5-7**] PT - 33.7 PTT- 32.5 INR - 3.3 Brief Hospital Course: Patient presented electively for a left sided craniotomy for resection of mass on [**2194-4-25**]. Surgery was without complication but upon awakening the patient was right hemiplegia. A CT was performed immediately which showed no hemorrhage or obvious infarct. An MRI was performed that night which demonstrated no evidence of CVA. Over the ensuing days, the patient's neurologic examination improved. The initial deficit was attributed to a temporary supplemental area syndrome. On [**4-29**] PT and OT were ordered for assistance with discharge planning. They recommended rehab. The patient worked with case management trying to make a plan with regards to his insurance. On [**4-30**] the patient remained neurologically stable. While ambulating with physical therapy in the afternoon the patient became hypotensive with decreased oxygen saturations and complained of anxiety. LENI's and a CTA were ordered to evaluate for DVT and PE. CTA revealed multiple PEs in all segmental arteries. A medicine consult was obtained and patient was transferred to SDU. He was started on a heparin gtt with a bolus of 3000 units and then 1800 units/hr for a goal PTT of 60-100. A head CT was done to evaluate for hemorrhage before heparin was initiated and showed stable postop findings. Echocardiogram and EKG were ordered to evaluate for further clots and abnormalities, results as decribed in Pertinent Results section. Lower extremity dopplers were negative for DVT. He c/o intermittent chest pain with deep inspiration, at times [**8-24**] and described as a cramping pain. On [**5-1**] he continued on the heparin gtt with close monitoring of PTT and was trasitioned to Coumadin. He received his first dose of Coumadin 5mg on [**5-1**], followed by 5mg on [**5-2**], and 3mg on [**5-3**]. Heparin gtt was stopped on [**5-3**] when his INR reached 3.0. Coumadin was held on [**5-4**] for an INR of 3.5 and resumed on [**5-5**] at a dose of 2.5mg QHS. His Coumadin was held again on [**5-6**] for an INR of 3.7 and [**5-7**] for an INR of 3.3. His INR is likely impacted by the interaction between Dilantin and Coumadin and so on [**5-7**] a transition to Keprra 100mg [**Hospital1 **] was started. Dilantin will need to be tapered over 4 days to off. Dexamethasone taper was also started on [**5-7**] with a plan for a 2 week taper to off. The patient's right-sided strength improved during his hospital stay and he worked with PT, OT and Speech Therapy. At the time of discharge he was tolerating a regular diet, ambulating with a walker, afebrile with stable vital signs. Medications on Admission: Keppra Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Left frontoparietal Tumor Global Aphasia - expressive aphasia Dysarthria Bilateral Pulmonary Emboli Rash 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 taper Dilantin to off over 4 days and Continue on Keppra 1000mg [**Hospital1 **] for Seizure prophylaxis. Follow INR closely (daily) as Dilantin potentiates the effect of Coumadin and impacts the INR. - Check incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You are tapering off of Dilantin and being transitioned to Keppra 1000mg [**Hospital1 **] for seizure prevention. You should continue the Keppra until intructed by Dr. [**First Name (STitle) **]. ?????? You are on steroid medication which will taper to off over 2 weeks. 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. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????You have dissolving sutures and may get your surgical site wet 10 days from your surgery. Followup as below in Brain [**Hospital 341**] Clinic for a wound check. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2194-5-19**] at 9:30am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain. Completed by:[**2194-5-7**]

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icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

9046, 9116

6406, 8989

333, 362

9265, 9265

2627, 3183

11659, 12314

1172, 1228

9137, 9244

9015, 9023

9448, 11636

1243, 1392

2326, 2608

268, 295

390, 675

1685, 2310

5484, 6383

4125, 5475

9280, 9424

697, 703

719, 1156

31,359

132,451

19858

Discharge summary

report

Admission Date: [**2197-7-31**] Discharge Date: [**2197-8-16**] Service: MEDICINE Allergies: Coumadin / Heparin Agents Attending:[**First Name3 (LF) 134**] Chief Complaint: Ascites Major Surgical or Invasive Procedure: Thoracentesis Cardiocentesis History of Present Illness: 89 yo M history of CHF, afib, CAD, HTN, CRI, PAH, CMY (EF 25%), transferred from OSH with large ascites and significant left sided pleural effusion. Patient states that he had been in subacute rehab and was transferred to [**Hospital3 417**] for CT scan on Friday which was read this morning and he was subsequently transferred here for further management of his ascites and pleural effusion. . Patient complains of left-sided headache above his eye. Intermittent lightheadedness and dizziness, SOB on exertion and increased abdominal girth. He does note, however, that he still has a good appetite. Past Medical History: CHF Right-sided heart failure Cardiac amyloidosis Mild pulmonary hypertension Moderate MR Hyperlipidemia CRI (baseline Cr 2.0) CAD s/p MI and s/p angioplasty in [**2191**] CLL diagnosed [**2169**] glaucoma Undescended testicle Hernia repair Social History: Lives with his wife. quit tobacco 30y ago but had 20-40 pack year history. Very rare alcohol. Pt is a WW2 veteran who was in the infantry. Has 2 adopted sons. Family History: brother with copd, sister with liver ca, father died age [**Age over 90 **], mother died of cirrhosis in her 70s. Physical Exam: VS - T: 95.3 BP: 102/60 P:69 R:20 O2 94%RA Gen: elderly, cachectic 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: no JVD. CV: Distant hear sounds, III/VI holosystolic murmur. RR, normal S1, S2. No thrills, lifts. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, scattered bilateral crackles and expiratory wheezes Abd: protruberant, + ascites and fluid wave, hepatosplenomegaly, erythema around umbilicus. Ext: 2+ pitting pedal edema. cool to touch Skin: extensive bruising, irritated skin tag on back Pertinent Results: Admission Labs: [**2197-7-31**] 05:31PM WBC-4.7 RBC-4.46* HGB-13.1* HCT-40.5 MCV-91 MCH-29.3 MCHC-32.3 RDW-17.2* [**2197-7-31**] 05:31PM PLT COUNT-187 [**2197-7-31**] 05:31PM ALT(SGPT)-11 AST(SGOT)-23 LD(LDH)-214 ALK PHOS-225* TOT BILI-0.8 [**2197-7-31**] 05:31PM ALBUMIN-3.7 CALCIUM-9.4 PHOSPHATE-4.9* MAGNESIUM-3.1* [**2197-7-31**] 05:31PM GLUCOSE-90 UREA N-56* CREAT-2.2* SODIUM-140 POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-30 ANION GAP-17 [**2197-7-31**] 05:31PM PT-17.5* PTT-32.9 INR(PT)-1.6* Admission Echo: Biventricular hypertrophy with echogenic myocardium, restrictive filling pattern, thickened valvular structures, and a large circumferential pericardial effusion without overt echo signs of tamponade (which may be masked in the setting of severe pulmonary hypertension and right ventricular hypertrophy). Findings consistent with amyloid cardiomyopathy. Compared with the prior study (images reviewed) of [**2197-1-23**], the pericardial effusion is slightly larger. The estimated pulmonary artery pressures are higher. Post Pericardial Effusion Drainage: There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. LV systolic function appears depressed. Right ventricular systolic function appears depressed. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [**2197-8-1**], a small circumferential pericardial effusion has reaccumulated; no evidence of cardiac tamponade. Brief Hospital Course: Patient is a 89 yo M history of CHF, afib, CAD, HTN, CRI, PAH, CMY (EF 25%), transferred from OSH with large ascites and significant left sided pleural effusion for therapeutic intervention. . #. CAD - h/o cardiac cath with occluded RCA, unable to recanulize - on ASA, BB and statin, no ACEI [**1-13**] hypotension . #. Pump - h/o CHF predominantly right-sided failure secondary to probable cardiac amyloidosis - not biopsy-proven. EF 40%, Severe biventricular diastolic dysfunction with low cardiac output. Major volume overload, pleural effusion and ascites on admission with pericardical effusion that responded well to pericardiocentesis. Echo revealed a large pericardial effusion that was also noted in [**1-18**], although appeared larger. Though no echocardiographic signs of tamponade were seen, it was thought that tamponade could be masked in setting of RV hypertrophy and pulmonary htn. The pt was taken to cath lab and was found to have hemodynamics midly suggestive of tamponade with cvp 22, PA 67/29, wedge 28, pericardium 14, with mild improvement in CI from 1.42 to 1.48 after resolving tamponade. Follow-up ECHO after pericardiocentesis did not reveal reaccumulation. Patinet initially on Lasix gtt for peripheral volume overload after the pericardiocentesis with good diuresis and transitioned to PO lasix with continued improvemnet. Patient was also continued on BB and Aldactone. ACE was held in setting of hypotension. Patient remained normotensive while in house and was discharged in stable condition. Patient was discharged on Lasix 40 mg [**Hospital1 **] and was getting Lasix 80 mg [**Hospital1 **] in house. If patient appears to be getting volume overloaded patient can be transitioned back to Lasix 8- mg [**Hospital1 **]. Patient was close to his dry weight upon discharge. . #. Rhythm - irreg, irreg, chronic afib - on BB, ASA - no coumadin [**1-13**] allergy/sensitivity . Pleural effusion: Thoracentesis was done which revealed a transudate with WBC 615, RBC 1475 though gram stain showed no PMNs, no microorganisms. The patient was sent to CCU for pericardial drain management . Ascites: Patinet with ascites in absence of liver disease, likely due to poor cardiac output. This was not intervened on as it was not bothersome to the patient and it actually responded slightly to aggressive diuresis. . #.Renal Failure - likely acute on chronic. This improved with improved cardiac output after pericardiocentesis and diuresis. Patient's nadir with respect to Cr was 1.5 and was discharged at 1.6 suggesting good diuresis. Patient was close to his dry weight upon discharge. . . After discussion with the patient and the medical staff, all were in agreement that Mr. [**Known lastname 15905**] was a suitable candidate for discharge. Medications on Admission: Milk of Magnesia 10 ml PO HS Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN Multivitamins 1 CAP PO DAILY Aspirin 325 mg PO DAILY Oxazepam 10 mg PO HS Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY Pilocarpine 1% 1 DROP BOTH EYES Q6H Carvedilol 12.5 mg PO BID Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **] Senna 2 TAB PO HS Docusate Sodium 100 mg PO BID Simvastatin 20 mg PO DAILY with supper at 1800 Erythromycin 0.5% Ophth Oint 0.25 in OU HS Furosemide 80 mg po BID Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 14. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) **] Center - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: CHF, pericardial effusions . Secondary Diagnoses: CHF Right-sided heart failure Cardiac amyloidosis Mild pulmonary hypertension Moderate MR Hyperlipidemia CRI (baseline Cr 2.0) CAD s/p MI and s/p angioplasty in [**2191**] CLL diagnosed [**2169**] glaucoma Undescended testicle Hernia repair Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating with assistance. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1200 cc . 1. Please take all medication as prescribed. 2. Please attempt to make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Please call Dr. [**Last Name (STitle) **] @ [**Telephone/Fax (1) 4022**] to make a follow-up appointment. . Please call your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 25694**] to make a follow-up appointment.

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icd9cm

[ [ [] ] ]

[ "37.21", "34.91", "88.56", "37.0", "88.53" ]

icd9pcs

[ [ [] ] ]

8668, 8749

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73,583

155,552

19498

Discharge summary

report

Admission Date: [**2150-5-12**] Discharge Date: [**2150-5-19**] Date of Birth: [**2103-2-20**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Subglottic stenosis. Major Surgical or Invasive Procedure: [**2150-5-12**]: Cricotracheal resection, bronchoscopy with bronchoalveolar lavage. History of Present Illness: Mrs. [**Known lastname **] is a 47-year-old woman who has had idiopathic subglottic stenosis which has been dilated several times with subsequent recurrence. She presents for definitive resection. Past Medical History: GERD s/p laparoscopic Nissen Fundoplication on [**2148-5-31**] Social History: She is married and lives with her family. She denies tobacco or alcohol use. Family History: non-contributory Pertinent Results: [**2150-5-15**] WBC-8.4 RBC-4.39 Hgb-12.5 Hct-37.6 Plt Ct-344 [**2150-5-14**] WBC-9.8 RBC-3.96* Hgb-11.1* Hct-33.6 Plt Ct-311 [**2150-5-18**] Glucose-96 UreaN-10 Creat-0.8 Na-137 K-4.6 Cl-102 HCO3-28 [**2150-5-15**] Glucose-96 UreaN-6 Creat-0.6 Na-135 K-4.5 Cl-101 HCO3-26 [**2150-5-12**] Glucose-132* UreaN-11 Creat-0.7 Na-137 K-4.0 Cl-105 HCO3-22 [**2150-5-18**] Calcium-9.7 Phos-4.2 Mg-2.0 Tissue Path: Tracheal ring, reconstruction/resection (A-B): Focal calcification and ossification of tracheal cartilage. Chronic inflammation and fibrosis of submucosal tissue. Focal squamous metaplasia of respiratory epithelium CXR: [**2150-5-12**]: No evidence of pneumothorax exists. Lungs are clear without evidence of new infiltrates or pulmonary congestion. A linear density in retrocardiac position is suggestive of a plate atelectasis in the posterior segment of the left lower lobe. No other abnormalities are seen and the lateral pleural sinuses are free [**2150-5-14**]: The patient's head obscures the lung apices. The imaged portion of the lungs is unremarkable except for two linear opacities at the left lung base consistent with areas of atelectasis. There is no appreciable pleural effusion or pneumothorax. Cardiomediastinal silhouette is stable. Brief Hospital Course: Mrs. [**Known lastname **] was admitted following her Cricotracheal resection, bronchoscopy with bronchoalveolar lavage. She was extubated in the operating, neck guard suture in place and JP drain in left side of neck. She was admitted to the SICU for airway monitoring. Respiratory: aggressive pulmonary toilets and nebs were administered. She titrated off supplemental oxygen with oxygen saturations 96% RA. Bronchoscopy: On POD6 interventional pulmonology performed Flexible Bronchoscopy. The Anastomosis site appeared widely patent with no necrosis or dehiscence but did reveal mucosal flap with no airway obstruction and neck sutures removed. She was transferred back to the floor for airway monitoring for a few hours. Speech: immediately postoperative her voice was mildly hoarse but improved over the hospital course. Cardiac: hemodynamically stable. Sinus tachycardic 120's was started on low-dose beta-blocker with heart rate 70-80's. Systolic blood pressure 120-140. GI: PPI was continued Nutrition: initially NPO maintained on IV fluids. Once voice improved on POD3 she was started on sips advanced slowly to regular which she tolerated. Renal: Foley was removed POD4. Renal function normal with good urine output. Pain: Morphine & IV NSAIDS were converted to PO with good pain control. Drains: Neck JP was removed on POD4. Neuro: no mental status changes. Anxious requiring low-dose anxiolytics. Disposition: She was seen by physical therapy once of bedrest who deemed her safe for home. She will follow-up next week for flexible bronchoscopy with Dr. [**Last Name (STitle) **] next week. Medications on Admission: none Discharge Medications: 1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking narcotics. Discharge Disposition: Home Discharge Diagnosis: Subglottic stenosis. GERD s/p s/p laparoscopic Nissen Fundoplication on [**2148-5-31**] 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: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Develops stridor or hoarsness -Chest pain -Neck incision develops drainage, increased redness or pain -You may shower. Wash incision with mild soap, Pat dry. -No tub bathing or swimming for 4 weeks -No driving while taking narcotics. Take stool softners with narcotics Followup Instructions: NOTHING TO EAT OR DRINK AFTER MIDNIGHT [**2150-5-29**] for Flexible Bronchoscpy. You may take your home medications with sip of water Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2150-5-29**] 10:00am [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2150-5-29**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2150-5-29**] 11:00 Completed by:[**2150-5-21**]

[ "V45.89", "300.00", "519.19", "785.0", "V10.82" ]

icd9cm

[ [ [] ] ]

[ "31.5", "33.23", "33.24", "31.79" ]

icd9pcs

[ [ [] ] ]

4256, 4262

2175, 3795

343, 429

4395, 4395

891, 2152

5008, 5647

854, 872

3850, 4233

4283, 4374

3821, 3827

4546, 4985

282, 305

457, 656

4410, 4522

678, 742

758, 838

73,440

102,309

30973

Discharge summary

report

Admission Date: [**2161-11-23**] Discharge Date: [**2161-11-25**] Date of Birth: [**2128-4-28**] Sex: F Service: CARDIOTHORACIC Allergies: Iodine; Iodine Containing / Zofran Attending:[**First Name3 (LF) 492**] Chief Complaint: weakness, confusion Major Surgical or Invasive Procedure: paracentesis History of Present Illness: Ms. [**Known lastname 73200**] is a 33 year old female with end stage metastatic melanoma admitted for weakness and confusion/somnolence. Patient has had slowly declining functional status over the past few weeks and has been more somnolent and dozing off during conversations. She is appropriate when awake, but frequently falls asleep. Today, she presented to [**Hospital 5871**] Hospital for confusion and weakness. At [**Location (un) 5871**], she was noted to be tachycardia and to have a positive UA, so was given vancomycin and Zosyn. She had a head CT which was negative and CXR which was normal. Her lactate was noted to be 5.8. She was noted to be in ARF and so was given 500 cc of NS. She was sent to [**Hospital1 18**]. . In the ED, vitals were T96.6, HR 130, BP 100/63, RR 18, 97% on 3LNC. Hr blood pressure was 98/54 at its lowest and her HR was 128 at it's highest. She was given 3LNS for dehydration and ARF. She underwent V/Q scan for workup of tachycardia, shortness of breath, and metastatic melanoma which was found to be low prob. Bilateral LENIs were also negative. She cannot get a CTA due to iodine allergy. She got a CT abd/pelvis which showed new significant ascites from [**2161-8-7**]. CXR showed low lung volumes, but lung cuts on abdomen CT showed moderate plerula effusions with atelectasis. Labs were notable for acute renal failure and newly elevated LFTs. . Upon arrival to the floor, patient denies shortness of breath, though is speaking in short sentences. She denies chest pain, abdominal pain, fevers, chills, headache, change in vision. Her husband notes increased somnolence over one week. Patient reports lightheadedness and thirstiness over the past few days. Past Medical History: Metastatic melanoma. Patient was diagnosed with melanoma 2 years ago when she noted an enlarging groin node found to be positive for metastatic melanoma. Patient underwent lymphadenectomy and was found to have positive inguinal, pelvic, ileac, and peri-aortic nodes. She began IL-2 chemotherapy in [**8-13**] with disease progression. She then began ipilimumab on the compassionate use protocolat [**Hospital1 1012**] with disease progression on her week 12 scans. She then enrolled in the RAF-265 clinic trial on [**2161-4-7**],but had disease progression. She was then treated with two cycles of DTIC unsuccesfully. She is now being treated by NIH Surgery Branch for adoptive cellular immunotherapy. She is now approximately 1.5 months out from conditioning regimen and 1 month out from receiving TIL. Social History: She is former English professor [**First Name (Titles) **] [**Last Name (Titles) 73201**] [**Location (un) **]. She does not smoke. She does have an occasional glass of wine or beer. . Family History: She has no family history of melanoma, no family history of cancer. Physical Exam: Gen: cachectic, tachypneic HEENT: temporal wasting, o/p clear CV: Tachycardic, no m/r/g Pulm: diminished breath sounds at bases bilaterally Abd: soft, NT, distended, + fluid wave, bowel sounds present Ext: 2+ bilateral pitting edema Neuro: somnolent, falling asleep mid-sentence Pertinent Results: Admission Labs: . .. \ 11.4 / 8.6 ------ 63 .. / 32.5 \ . Diff: 85%N, 11.7%L, 2.9%M, 0.1%E, 0.3%B . . 128 | 99 | 48 / -------------- 78 4.9 | 18 | 1.3 \ . (baseline Cr 0.7) . ALT 105 AST 475 AP 359 T. bili 0.8 Alb 2.6 . Micro: UA. 21-50 WBCs, small LE, protein 30, [**3-11**] epis, 21-50 hyaline casts . Lactate 5.3 . [**2161-11-22**]. LENIs. no DVT of right or left leg. subcutaneous edema. prominent right groin lymph nodes. . CXR. [**2161-11-22**]. No PNA. . CT abd/pelvis. [**2161-11-22**]. IMPRESSION: Extremely limited examination secondary to lack of intravenous and oral contrast and extensive intra-abdominal pelvic ascites. 1. Moderate bilateral pleural effusions with associated atelectasis. 2. Large volume of intra-abdominal and pelvic ascites. 3. Right-sided double-J ureteral stent with moderate associated hydronephrosis. 4. Extensive retroperitoneal lymphadenopathy, incompletely assessed on this evaluation. 5. Probable normal appendix visualized in the right lower quadrant. No CT findings suggestive of bowel obstruction or perforation. . Renal ultrasound [**2161-11-20**]. IMPRESSION: 1. Persistent moderate hydronephrosis of the right kidney and right hydroureter suggestive of stent malfunction. This stent appears to be in the appropriate location. 2. Thick-walled bladder with sediment identified in the posterior aspect. Significant post-void residual of 187 cc. 3. Increased echogenicity of the kidneys bilaterally with an appearance suggestive of medullary nephrocalcinosis. The three most likely causes of this are hyperparathyroidism, medullary sponge kidney, and renal tubular acidosis. 4. Small amount of ascites. . EKG. NSR at 126 bpm. Normal axis. Normal pr, qrs, qt inerval. q wave in III. No ST elevations or depressions. EKG unachanged except for rate from [**2161-3-31**]. Brief Hospital Course: In summary, Ms. [**Known lastname 73200**] is a 33 year old female with metastatic melanoma admitted with somnolence, liver failure, renal failure, new chylous ascites and persistent tachycardia of unclear etiology, who ultimately was made comfort measures only and passed away on a morphine drip with family at bedside. Fatigue/somnolence. Patient admitted with symptoms of fatigue and somnolence which appeared to me multifactorial. Patient was hydrated for dehydration. Patient was taking standing opioids at home and presented with renal and liver failure, so impaired clearance of toxins and meds likely contributed to her mental status. Detrol, compazine, and opiods (initially) were withheld and mental status mildly improved. She had a head ct without contrast (patient has contrast allergy) which was reportedly negative. Tachpnea/Hypoxia. Patient did not report subjective shortness of breath on admission, but appeared tachypneic and had new oxygen requirement of 4LNC. Patient noted to have new significant ascites with bilateral pleural effusions and atelectasis which may have contributed. VQ scan was low prob for PE, though echo shows increased TR gradient and pulmonary artery pressures. No evidence of pneumonia. Patient did not have significant relief of tachypnea with therapeutic paracentesis. Ureteral stent. Patient presents with positive UA though urine culture was negative. She was treated with vancomycin and zosyn. Given that cultures were negative, positive UA was likely the effect of the ureteral stent which had been placed at NIH one month prior. Urology evaluated the stent who felt it was working well, though CT abd/pelvis showed persistent hydronephrosis suggesting the possibility of stent malfuction. Chylous Ascites. Patient had mild ascites in [**8-14**], and was admitted with significant worsening of ascites over two months. No history of cirrhosis, though patient has been receiving various chemotherapies (though exact medications unclear). [**Name2 (NI) **] evidence of portal vein thrombus on [**Name (NI) 5283**] sono with doppler. SAAG suggestive of exudative secondary to malignancy. Diagnostic para consistent with chylous ascites, likely due to infiltration of melanoma into lymphatics. Elevated LFTs. Noted to have newly elevated LFTs, likely secondary to liver infiltration of lymphatics. Abdominal ultrasound did not show portal vein thrombus. Hepatitis serologies were pending at time of death. Thrombocytopenia. New thrombocytopenia in setting of elevated LFTs and worsening ascites were though to possibly be due to liver failure. She was noted to have mild splenomegaly on abdominal ultrasound. She had received chemotherapy (unclear which medications) > 1 month ago making marrow supression less likely. Also concern for DIC or TTP-HUS, though DIC labs were normal. Renal failure. Patient recently had right sided ureteral stent placed and presented with elevated Cr of 1.3 that did not respond to > 5 L of IVF. Moderate hydronephrosis noted on abodinal CT suggestive of a non-functioning stent, though urology evaluated the patietn and felt it was working but recommended further imaging studies. Melanoma. Patient has end stage metastatic melanoma and failed multiple chemotherapy regimens. She was receiving experimental chemotherapy from NIH with 11 percent tumor reduction. However, patient's presentation suggested worsening disease with multiorgan failure and no reversible etiology. After discussion with family, decision was made to make patient DNR/DNI and then comfort measures only. She was placed on a morphine drip for comfort. Her husband was at the bedside when she passed away. Medications on Admission: Cipro completed on Tuesday for UTI Morphine 15-30 mg prn MS contin 30 mg [**Hospital1 **] Compazine PRN Ranitidine Scopolamine Detrol [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] Colace 100 mg [**Hospital1 **] Senna Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: metastatic melanoma multiorgan failure Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]

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icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

9379, 9388

5371, 9068

323, 337

9471, 9480

3528, 3528

9536, 9658

3144, 3214

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263, 285

365, 2088

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2110, 2924

2940, 3128

79,032

178,712

9211+56010

Discharge summary

report+addendum

Admission Date: [**2173-12-17**] Discharge Date: [**2173-12-22**] Date of Birth: [**2111-12-10**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Re-do sternotomy , AVR (23mm porcine) History of Present Illness: This is a 61yo male s/p AVR in [**2162-6-17**] for aortic valve endocarditis. He has known bioprosthetic aortic valve stenosis which has been followed by serial echocardiograms. He has also had worsening symptomatology. Current symptoms inlude dyspnea on exertion, fatigue and peripheral edema. His most recent echocardiogram showed severe aortic bioprosthetic stenosis with a peak of 74mmHg and a mean of 44.mmHg. His aortic root and ascending aorta were dilated with both measuring 4.3cm. Given the progression of his disease, he has been referred for surgical management. Recent liver workup by Dr. [**Last Name (STitle) 497**] showed no evidence to suggest advanced chronic liver disease. He was previously seen in [**Month (only) **] and [**Month (only) 359**] and now presents for PATs. He has been cleared to proceed for redo operation. Past Medical History: Past Medical History: - Congestive Heart Failure(chronic, diastolic) - History of aortic valve endocarditis(Enterococcus) - History of IV drug abuse, on Methadone maintenance - Hepatitis B and C - History of Hepatitis A - Dyslipidemia - Hypertension(resolved with bariatric surgery) - Diabetes Mellitus(resolved with bariatric surgery) - History of Splenic Infarct(endocarditis) - Low Testosterone - Nephrolithiasis - Ventral Hernia Past Surgical History: - s/p AVR(25mm tissue) [**2162-6-17**] - [**Hospital1 18**] Dr. [**Last Name (STitle) 1537**] - Excision of a neurofibroma on the thoracic spine - s/p Bariatric surgery with Roux-en-Y bypass [**2171-2-17**] - Right total knee replacement Past Cardiac Procedures: Surgery: Aortic Valve Replacement [**2162-6-17**] Type of valve: 25mm [**Last Name (un) 3843**]-[**Doctor Last Name **] bovine valve Social History: Race: Caucasian Last Dental Exam: Edentulous Lives with: Wife in [**Name2 (NI) 47**] Occupation: Carpenter Cigarettes: Smoked no [X] yes [] Hx: ETOH: None Illicit drug use: former IV drug abuser with heroin 25 years ago Family History: Denies premature coronary artery disease Physical Exam: Pulse: 65 O2 sat: 100% B/P 109/64 Height: 68" Weight: 200lb General: WDWN male in no acute distress Skin: Warm, dry and intact. Keloid scarring noted in sternotomy and prior thoracotomy incision HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Edentulous. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X]; healed back scars Heart: RRR, Nl S1-S2, IV/VI harsh holosystolic murmur Abdomen: Soft [X], bowel sounds + with large ventral hernia and healed scar Extremities: Warm [X], well-perfused [X] 1+ LE Edema on L with faint erythema, trace edema on R; healed Right knee scar Varicosities: None [X] Neuro: Grossly intact [X],nonfocal exam;MAE [**5-20**] strengths Pulses: Femoral Right:2 Left:1 DP Right:1 Left:1 PT [**Name (NI) 167**]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit Pertinent Results: Due to patient's history of gastric bypass surgery, only mid-esophageal window images were obtained. No transgastric views were attempted. PRE-CPB: The left atrium is markedly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. A bioprosthetic aortic valve is present. The prosthetic aortic valve leaflets are thickened. The transaortic gradient is higher than expected for this type of prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results at time of study. POST-CPB: There is a porcine prosthetic valve in the aortic position. The valve appears well seated with normal leaflet mobility. There is no evidence of aortic stenosis or aortic insufficiency. There are no paravalvular leaks. Biventricular function is preserved. The tricuspid regurgitation remains moderate. There is no evidence of aortic dissection. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2173-12-17**] 14:48 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2173-12-17**] where the patient underwent re-do sternotomy AVR (23Porcine). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. he developed a junctional rhythm and hos lopressor dose was held then decreased without further episode of junctional rhythm. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Lovastatin 10mg daily, Lisinopril 10mg daily, Aldactone 50mg daily, Methadone 80mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 4. methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO DAILY (Daily). 5. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 8. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Re-do sternotomy /AVR (23 porcine)[**2173-12-17**] Congestive Heart Failure(chronic, diastolic), History of aortic valve endocarditis(Enterococcus), History of IV drug abuse, on Methadone maintenance, Hepatitis B and C, History of Hepatitis A, Dyslipidemia, Hypertension(resolved with bariatric surgery), Diabetes Mellitus(resolved with bariatric surgery), History of Splenic Infarct(endocarditis), Low Testosterone, Nephrolithiasis, Ventral Hernia s/p AVR(25mm CE tissue) [**2162-6-17**] - [**Hospital1 18**] Dr. [**Last Name (STitle) 1537**], Excision of a neurofibroma on the thoracic spine, Bariatric surgery with Roux-en-Y bypass [**2171-2-17**], Right total knee replacement Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage 1+ lower extremity Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2174-1-19**] 1:30[**Hospital 31652**] [**Hospital **] medical office building [**Last Name (NamePattern1) **], [**Hospital Unit Name **] WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2173-12-30**] 10:30 [**Hospital **] medical office building [**Last Name (NamePattern1) **], [**Hospital Unit Name **] Cardiologist: Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**] [**Telephone/Fax (1) 6256**] - the office will call you with an appointment Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3658**] in [**4-20**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2173-12-21**] Name: [**Known lastname 5491**],[**Known firstname **] Unit No: [**Numeric Identifier 5492**] Admission Date: [**2173-12-17**] Discharge Date: [**2173-12-22**] Date of Birth: [**2111-12-10**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[**First Name3 (LF) 741**] Addendum: Patient had a brief episode of rapid atrial fibrillation on the day of discharge. Potassium and magnesium were checked and repleted and the patient was hemodynamically stable throughout episode. Lopressor was kept at 25 mg [**Hospital1 **] with HR in 60's BP 110/70's. No further episodes of atrial fibrillation. Patient was discharged home with VNA services on POD#5 in sinus rhythm. Discharge Disposition: Home With Service Facility: [**Location (un) 2333**] Area VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2173-12-22**]

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icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

10833, 11021

4958, 6219

298, 338

8039, 8214

3303, 4935

9055, 10810

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6358, 7227

7334, 8018

6245, 6335

8238, 9032

1690, 2089

2401, 3284

239, 260

366, 1212

1256, 1667

2105, 2327

75,188

176,512

11133

Discharge summary

report

Admission Date: [**2192-10-3**] Discharge Date: [**2192-10-19**] Date of Birth: [**2121-3-15**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: Sudden Onset Headache, and vomiting. Major Surgical or Invasive Procedure: [**10-3**]: Emergent perioperative EVD placement [**10-3**]: Emergent Angiogram [**10-16**]: VP shunt placement History of Present Illness: Mr. [**Known lastname 19419**] is a 71 y/o male with previously observed right frontal meningioma who was seen by Dr. [**Last Name (STitle) **] in [**2192-8-27**]. A possible left temporal AVM was noted on MRI at that time, and he was scheduled for a CT angio later this month. However, at approximately 0130 this am, he noted a sudden onset headache with associated nausea and vomiting. He also sustained a ground-level fall, and his wife took him to an outside hospital where a head CT revealed an intraventricular hemorrhage which involved the left temporal [**Doctor Last Name 534**], 4th, 3rd, and left lateral ventricles. He was transferred to [**Hospital1 18**] for neurosurgical care. A CT angio at [**Hospital1 18**] revealed the hemorrhage is stable, and left mesial temporal flow voids suggestive of AVM is noted as well. Past Medical History: benign prostatic hypertrophy,meningioma, s/p electrohydraulic lithotripsy of bladder stones Social History: resides at home with wife Family History: Non-contributory Physical Exam: On Admission: T: 99.1 BP: 183/64 HR:81 R16 O2Sats 98% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**3-28**] bilaterally EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert but confused. Orientation: Oriented to person and place only Language: slurred speech 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 voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Moves all 4 extremities symmetrically with 5/5 strength over right side and left leg, but left arm is 4+/5 in all muscle groups. Patient did not cooperate with pronator drift test Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On Discharge: The patient is oriented to himself and to the month. His left pupil is slightly smaller than the right but both are reactive. His face is symmetric and his tongue is midline. There is evidence of thrush in the oropharynx which is significantly improved since he has been on nystatin. The patient is following commands with all extremities. His right side is full strength and he has mild weakness on the left side. The incision is clean, dry, intact and there are sutures in place. His abdomen has 2 incisions that have steri-strips in place. Pertinent Results: Labs on Admission: [**2192-10-3**] 04:35AM BLOOD WBC-23.1*# RBC-4.58* Hgb-13.8* Hct-40.8 MCV-89 MCH-30.1 MCHC-33.8 RDW-14.3 Plt Ct-449* [**2192-10-3**] 04:35AM BLOOD Neuts-89.9* Lymphs-6.9* Monos-2.8 Eos-0.1 Baso-0.2 [**2192-10-3**] 04:35AM BLOOD PT-12.3 PTT-20.7* INR(PT)-1.0 [**2192-10-3**] 09:32AM BLOOD Fibrino-262 [**2192-10-3**] 04:35AM BLOOD Glucose-154* UreaN-22* Creat-1.1 Na-143 K-4.2 Cl-105 HCO3-27 AnGap-15 [**2192-10-3**] 09:32AM BLOOD Mg-1.7 Labs prior to Discharge [**10-17**]: Na 136 Cl 104 BUN 13 Glu 85 K 4.9 CO2 26 Cr 0.8 Ca: 8.7 Mg: 2.1 P: 3.1 WBC 21.3 Hgb 11.6 Hct 34.3 Plts 736 PT: 15.1 PTT: 22.7 INR: 1.3 Imaging: CTA([**10-3**]) 10 mm left PCA saccular aneurysm. 6.4 x 3.8 cm right frontal mass with adjacent vasogenic edema. Left midline shift. Intraventricular hemorrhage. Head CT ([**10-3**]): 1. Unchanged appearance of intraventricular hemorrhage with mild-to-moderate hydrocephalus. 2. Unchanged appearance of right frontal extra-axial mass with mass effect and vasogenic edema. Head CT([**10-3**]): Status post left-sided central ventricular drain placement with slight interval improvement in dilatation involving the frontal horns bilaterally, otherwise unchanged examination. Head CT([**10-5**]): IMPRESSION: In comparison with a prior examination, no significant changes are demonstrated, persistent effacement of the sulci and mass effect, related with the frontal extra-axial mass lesion. Left frontal ventriculostomy, apparently unchanged, persistent intraventricular hemorrhage. Followup CT is recommended if clinically warranted. Head CT([**10-6**]): IMPRESSION: No significant change. Persistent sulcal effacement and mass effect related to the right frontal extra-axial mass lesion. Left frontal ventriculostomy and persistent intraventricular hemorrhage. Head CT([**10-9**]): CONCLUSION: No evidence of new hemorrhage. Decrease in the volume of intraventricular hemorrhage since the study of [**2192-10-6**]. Unchanged large right frontal mass most likely a meningioma with extensive mass effect and midline shift. Head CT ([**10-15**]): IMPRESSION: Interval decrease in intraventricular hemorrhage. Otherwise, no significant change. Head CT ([**10-15**]): IMPRESSION: 1. Post-surgical changes, with a small amount of pneumocephalus overlying the left frontal lobe, as well as air within the left frontal [**Doctor Last Name 534**] of the lateral ventricle. 2. Intraventricular hemorrhage, unchanged from 5:09 p.m., but decreased in extent from [**2192-10-9**]. No new foci of hemorrhage. 3. Stable large right frontal extra-axial mass, with calcifications and associated vasogenic edema. Minimal increased leftward subfalcine herniation. Brief Hospital Course: The patient is a 71 y/o male with previously observed right frontal meningioma who was seen by Dr. [**Last Name (STitle) **] in [**2192-8-27**]. A possible left temporal AVM was noted on MRI at that time, and he was scheduled for a CT angio later this month. However, at approximately 0130 on the date of admission, he noted a sudden onset headache with associated nausea and vomiting. He also sustained a ground-level fall, and his wife took him to an outside hospital where a head CT revealed an intraventricular hemorrhage which involved the left temporal [**Doctor Last Name 534**], 4th, 3rd, and left lateral ventricles. He was transferred to [**Hospital1 18**] for neurosurgical care. A CT angio at [**Hospital1 18**] revealed the hemorrhage is stable, and left mesial temporal flow voids suggestive of AVM is noted as well. Due to a rather expeditious neurological decline, he was taken for an emergent placement of an intraventricular drainage catheter, followed by a emergent angiogram to further identify the lesion. Unfortunatley there was an aneurysm identified, however within the AVM itself, and thereby ineligible for coil embolization. He was continued to be evaluated in the ICU for the next several days with multiple attempts at EVD clamping trials. Unfortunately due to persistantly elevated ICPs with clamping of the EVD, he was determined to be an appropriate candidate for VP shunt placement. On [**10-16**] he underwent an uneventful shunt placement. Post-operatively he was transferred to the neuro step-down unit where his treatment continued. He was getting out of bed with physical therapy. Patient got CT angiography on [**10-18**] to evaluate AVM for radiosurgery planning. He was seen by Radiation oncology on [**10-18**] for evaluation and will be treated in a few weeks. The patient was deemed a suitable candidate for rehab and was discharged on [**2192-10-19**]. **The patient needs to be on telemetry at rehab since he still has an AVM and an aneurysm that have not been secured.** Medications on Admission: doxazosin 8 mg finasteride Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day) as needed for htn. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: AVM w/ intranidal aneurysm, intra-ventricular hemorrhage, Large superior right extra-axial lesion Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions - Please return to the office in 7 days for removal of your sutures or the rehab may remove them on [**2192-10-26**]. - Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. - You will need a CT scan of the brain without contrast. - Radiation oncology will call you with an appointment. Completed by:[**2192-10-19**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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24617

Discharge summary

report

Admission Date: [**2172-1-25**] Discharge Date: [**2172-2-4**] Date of Birth: [**2111-5-16**] Sex: F Service: MEDICINE Allergies: Penicillins / Colchicine / Bactrim Attending:[**First Name3 (LF) 896**] Chief Complaint: Hypotension, SOB, chest pressure Major Surgical or Invasive Procedure: Place of central venous catheter (right IJ). History of Present Illness: 60 yo female with PMH significant for CAD, COPD on home o2 (2L), systolic HF with EF of 30%, PE, and NF1, adrenal insufficiency due to chronic steroid use, and hypothyroidism who presented to the ED with CP and SOB. In the ED, initial vs were: T 98.2 P 73 BP 106/44 R 20 O2 sat. 100% on 12L. Attempts at peripheral IVs failed, she became hypotensive to 75/40 RIJ placed for access, [**First Name3 (LF) **] cultures were drawn from the line, she was given 1L NS without increase in BP, levophed was started at 0.05, and titrated up to 0.08, and back to 0.05 on transfer. Patient was given an additional 1L NS. Vancomycin 1g x1 and Zosyn 4.5g x1 were given followed by levofloxacin 750mg IV x1 and flagyl 500mg IV x1 as well as solumedrol 125mg IV x1. Her CVP was monitored (initially 9, increased to 24 on levo). She had low urine output with 30cc draining after placement of foley (no voiding overnight). Her creatinine was 3.5 up from 1.1. Vitals on transfer: 96.9, 61, 109/44, 18, 97% RA. Total UOP of 105 in the ED. On the floor, the patient reports 5/10 chest pain which she states is not new for her. She called an ambulance for [**6-24**] chest pressure in the center of her chest. She took all her morning meds but no SL nitro. She reports this pain does not feel nearly as severe as the pain she had in the past with her MIs. She also reports while in the ambulance she felt like she could not take a complete breath in. She reports she has a chronic non productive cough. For the past 3 days she's had 3 loose stools but not [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 62155**]. She has 3 pillow orthopnea and PND. She denies urinary sx, jaw pain, arm pain, back pain, sweatiness. Review of systems: (+) Per HPI, + chronic cough (-) Denies fever, chills, headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath or wheezing. Denies palpitations. Denies nausea, vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies rashes or skin changes. Past Medical History: 1. Coronary artery disease s/p revascularization, with STEMI [**3-19**], BMS x 2 in [**2165**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, in [**2165**] and [**2170**] (RCA) 2. Congestive heart failure with LVEF 30% 3. Moderate COPD on home oxygen 4. Pulmonary embolism [**2158**] 5. Neurofibromatosis Type 1 6. Malignant nerve sheath tumor (s/p removal from left anterior chest wall [**6-18**] and radiation [**2172**]) 7. Depression 8. Hypothyroidism 9. Adrenal insuficiency [**12-18**] chronic steroid use for COPD exacerbation 10. Hypercalcemia 11. Alcoholism per omr (patient denies current ETOH abuse) 12. Schizoaffective disorder 13. Gout Social History: Ms. [**Known lastname 805**] lives with her boyfriend in a trailer in [**Name (NI) 3146**]. Boyfriend has MR [**Name13 (STitle) 62156**] to seizures. She is on disability, used to work as a nursing aide. She is no longer taking stray cats. No other pets. Tobacco: Quit smoking in past few months. Smoked for >30 years. ETOH: <1 drink a week Drugs: none. At last admission, the patient was screened for inpatient rehab, but could not afford co-pay and was not accepted at state facilities. The patient was discharged with home nursing, home physical therapy and [**Name13 (STitle) **] follow-up. Family History: Mother / sister / nephew / son with Neurofibromatosis. Father w/COPD. Sister w/COPD. Mother w/ asthma. Mother died of MI at age 72 Father died of MI at age 86 Physical Exam: Vitals: T:97.6 BP:125/62 P:15 R:15 O2: 94% RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear Neck: supple, JVP difficult to assess given large neck Lungs: Expiratory wheeze in right lower lung and mild crackles in right lung base CV: distant heart sounds, no appreciated murmur Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm hand, mildly cold feet, DP pulses +1, no edema Skin: Diffuse neurofibromas Pertinent Results: Admission Labs: [**2172-1-25**] 01:00PM [**Year/Month/Day 3143**] WBC-19.5*# RBC-4.00* Hgb-10.7* Hct-34.1* MCV-85 MCH-26.8* MCHC-31.5 RDW-19.1* Plt Ct-880*# [**2172-1-25**] 01:00PM [**Year/Month/Day 3143**] PT-12.3 PTT-22.1 INR(PT)-1.0 [**2172-1-25**] 01:00PM [**Year/Month/Day 3143**] Glucose-111* UreaN-46* Creat-3.5*# Na-141 K-3.4 Cl-95* HCO3-26 AnGap-23* [**2172-1-25**] 07:40PM [**Year/Month/Day 3143**] Calcium-8.0* Phos-4.0# Mg-1.7 [**2172-1-25**] 01:13PM [**Year/Month/Day 3143**] K-3.3* [**2172-1-25**] 02:35PM [**Year/Month/Day 3143**] Lactate-2.0 Transfer Labs: [**2172-1-28**] 04:23AM [**Month/Day/Year 3143**] WBC-10.0 RBC-2.88* Hgb-7.6* Hct-24.5* MCV-85 MCH-26.5* MCHC-31.1 RDW-18.7* Plt Ct-455* [**2172-1-28**] 04:23AM [**Month/Day/Year 3143**] Glucose-170* UreaN-22* Creat-1.0 Na-145 K-3.6 Cl-117* HCO3-20* AnGap-12 [**2172-1-28**] 02:40PM [**Month/Day/Year 3143**] Calcium-8.4 Mg-1.7 Cardiac Biomarkers: [**2172-1-25**] 01:00PM [**Year/Month/Day 3143**] cTropnT-0.03* [**2172-1-25**] 07:40PM [**Year/Month/Day 3143**] CK-MB-2 cTropnT-0.02* [**2172-1-26**] 05:25AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-<0.01 proBNP-729* Urine: [**2172-1-25**] 07:31PM URINE Hours-RANDOM UreaN-445 Creat-93 Na-50 K-46 Cl-55 [**2172-1-25**] 02:15PM URINE [**Year/Month/Day **]-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2172-1-25**] 02:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014 [**2172-1-25**] 02:15PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-4 Imaging: Portable TTE (Focused views) Done [**2172-1-27**] at 4:20:38 PM Conclusions Porr image quality. The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is probably mildly depressed(LVEF= 40 -45%). Distal LV/apical akinesis to dyskinesis is suggested. A left ventricular mass/thrombus cannot be excluded. There is no ventricular septal defect. The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2171-1-2**], the LVEF appears improved. If indicated, a repeat TTE with echo contrast (Definity) or cardiac MRI may better assess regional/global LV systolic function and exclude apical thrombus. Chest X-Ray, study Date of [**2172-1-26**] 10:35 AM Right internal jugular line tip is at the level of mid low SVC. Cardiomediastinal silhouette is stable, but there is new consolidation in the left lower lung, worrisome for interval progression of infectious process. Loculated pleural effusion along the left pleural surface is unchanged. Right basal consolidation has slightly improved in the interim. BILAT LOWER EXT VEINS Study Date of [**2172-1-26**] 10:36 AM IMPRESSION: Limited assessment of the calf veins without evidence of DVT. Microbiology: [**2172-1-25**] 2:15 pm URINE Site: CLEAN CATCH URINE CULTURE (Final [**2172-1-27**]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2172-1-28**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: 1. SIRS / sepsis / septic shock: Most likely etiology of her shock was sepsis secondary to pneumonia. She had a low grade fever with hypotension and an elevated white count. She initialy required low doses of levophed and placed on stress dose steroids. After initial broad coverage, her antibiotics were switched to levofloxacin with course completed before discharge. 2. Congestive heart failure, systolic, acute on chronic. Likely produced in the setting of acute illness with IVF administration. Improved with furosemide diuresis. 3. Coronary artery disease and chest pain. Had intermittant chest pains which were somewhat different from her chronic chest pain. Troponins were checked and ECG was unchanged from her prior. She was continued on her home regimen including aspirin, clopidogrel, metoprolol (initially held), and lisinopril (initially held). 4. Acute on chronic renal failure: Creatinine 1.1 on [**2172-1-18**] and was 3.5 on admission. This was all likely pre-renal in the setting of hypotension. She was volume resuscitated with 6L and her creatinine normalized to 1.0 prior to transfer to the floor. Also of note, she recently had AIN thought due to bactrim. Her ACE-I was held and then resumed on the floor. Her Cr normalized to 0.9 while on the floor. 5. Neurofibromatosis Type 1. History of malignant nerve sheath tumor (s/p removal from left anterior chest wall [**6-18**] and radiation [**2172**]). Stable. No new manifestations. Innumerable fibromas on exam. 6. Hypothyroidism: TSH of 12, free T4 normal. Continued 150mcg po daily. Medications on Admission: -aspirin 325 mg po daily -*clopidogrel 75 mg po daily -rosuvastatin 5 mg po daily -fluticasone-salmeterol 500-50 mcg/dose po BID -*metoprolol succinate 100 mg po daily -docusate sodium 100 mg po BID -senna 8.6 mg po BID as needed for constipation -bisacodyl 5 mg 2 tabs po daily prn constipation -levothyroxine 150 mcg po daily -tiotropium bromide 18 mcg daily -albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution every 4 hrs as needed for SOB/wheeze -*Zyrtec 10 mg po daily -omeprazole 40 mg po daily -Percocet 5-325 mg 1 tab PO every 4-6 hours -nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: [**Month (only) 116**] repeat x 3, if need more than once, call your physician [**Name Initial (PRE) 2227**]. -prednisone 20 mg po daily -Vitamin D-3 1,000 unit daily -multivitamin po daily -nicotine 14 mg/24 hr Patch daily -atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO once a day: NEW MED. -Lasix 20 mg [**11-17**] Tablet PO once a day -lisinopril 5 mg po daily -*ranitidine 150 PO BID *Rx bottles brought in by boyfriend Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/wheeze. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 14. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. atovaquone 750 mg/5 mL Suspension Sig: Two (2) ml PO DAILY (Daily). 17. bismuth subsalicylate 262 mg Tablet, Chewable Sig: Two (2) Tablet PO TID (3 times a day) as needed for diarrhea. 18. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 21. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 22. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED). 23. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 24. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**] Discharge Diagnosis: 1. Bacterial pneumonia 2. SIRS / sepsis / septic shock 2. Acute on chronic systolic congestive heart failure 3. Acute Renal Failure 4. COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with low [**Location (un) **] pressure, high white [**Location (un) **] cell count, hypoxia (low oxygen levels) and acute renal failure. You were admitted to the intensive care unit and treated for a presumed pneumonia. You were also treated on the medical floor for congestive heart failure. Your kidney function recovered. It will be important for you to record your weight frequently to get a sense of how much fluid you have in your body. Followup Instructions: Rehabilitation will coordinate follow-up with your primary care doctor.

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2106-3-28**] Discharge Date: [**2106-4-6**] Date of Birth: [**2032-12-4**] Sex: F Service: NEUROLOGY Allergies: Aspirin Attending:[**First Name3 (LF) 618**] Chief Complaint: right hip pain Major Surgical or Invasive Procedure: open reduction with internal fixation right hip History of Present Illness: 73yo RH F who is POD#1 from R hip repair after a mechanical fall caused a fracture. Perioperatively, she has been treated with a beta blocker and now postoperatively she has been started on lovenox for DVT prophylaxis. She was completely normal per her daughter today around 4-5pm, apart from pain, which was controlled with oxycodone (last dose 3pm and no further narcotics). At 8:30pm, however, the ortho PA was paged by the patient's nurse after she was found to have a new left facial droop and was thought to be disoriented and "confused", with slurred speech. We are consulted for concern of an acute infarction. The patient has had no nausea/vomiting and denies headache (in fact, she denies any difficulty or impairment). She denies dysarthria, though her son-in-law attests that her speech is markedly different from baseline. Past Medical History: PMH: No prior history of MI/CAD or stroke No h/o HTN Osteoporosis COPD MV prolapse s/p TAH Seen by neurology in [**2102**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] for RLS (neuro exam with mild peripheral neuropathy only) Social History: non smoker, social alcohol Family History: NC Pertinent Results: Admission labs: Chol 89 Triglyc 491 HDL 47 CHol/HDL 1.9 LD32 GLUCOSE-121* UREA N-19 CREAT-1.0 SODIUM-141 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14 WBC-6.5 RBC-4.11* HGB-12.4 HCT-36.4 MCV-88 MCH-30.2 MCHC-34.1 RDW-14.1 NEUTS-69.6 LYMPHS-24.0 MONOS-3.7 EOS-1.3 BASOS-1.4 PLT COUNT-195 PT-12.0 PTT-26.9 INR(PT)-1.0 [**2106-4-5**]: WCC7.3 Hgb 10.3 Hct 29 Plt360 INR 2.4 Na 136 K 3.8 Cl 100 Co2 28 BUN 16 Cr0.6 CT/CTA: 1. No obvious infarcts are noted on the non-contrast CT. However, MRI with diffusion-weighted imaging is more sensitive for the detection of acute infarcts. 2. Short segment focal stenosis in the pericallosal artery and right middle cerebral artery M2 segment which could be stenoocclusive or thromboembolic. 3. Mild atherosclerotic calcification in bilateral cervical internal carotid arteries, close to their origins, with no flow-limiting stenosis. 4. Multilevel degenerative disease of the cervical spine, not adequately evaluated on the present study. 5. Biapical pleural scarring. MRI/MRA: Limited study due to motion artifact. There are multiple acute infarcts in the distal right MCA territory, possibly embolic in etiology. TTE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A small secundum atrial septal defect is present withbidirectional shunting (small amount). Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. CT chest and abdomen 1. No central or segmental pulmonary embolism. 2. Small bilateral pleural effusions with associated atelectasis. Some small opacities in the right lower lobe are nonspecific, and could be regions of focal atelectasis. 5-mm pulmonary nodule in the right upper lobe. In the absence of known malignancy, followup in one year is recommended. Postoperative appearance to the right hip and surrounding soft tissues and muscles consistent with recent surgery. CXR [**2106-4-1**] Small bilateral pleural effusions with left basilar atelectasis. Brief Hospital Course: Mrs.[**Known lastname 95459**] presented to the Emergency Department complaining of right hip pain after a fall. She was evaluated by the Orthopaedics department and found to have a right intertrochanteric hip fracture. She was admitted, consented, and medically cleared for surgery. On [**2106-3-29**], she was prepped and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. She was then transferred to the floor for further recovery. On the floor, she remained hemodynamically stable with her pain controlled. On [**3-30**], she had acute onset dysarthria, left facial droop and left arm/leg weakness. On exam, she also had left-sided neglect and anosognosia and was inattentive, falling asleep frequently. CT and MRI showed right MCA infarction and the patient was transferred to the ICU for further monitoring. Metoprolol was discontinued and blood pressure allowed to autoregulate. She was started on aspirin 325mg daily, as her previously documented "allergy" consisted only of GI upset. She was also started on zocor for secondary stroke prevention. FLP was normal and HbA1c 5.7. She had an uneventful ICU course and by the next morning, her dysarthria and neglect had improved, leaving her with UMN pattern of weakness, affecting her face/arm/leg. Transferred to the floor. TTE from [**3-30**] was unremarkable for source of cardioembolism. TEE showed small secundum ASD with bidirectional flow, no source of thrombi and no significant aortic arch atheroma. Cardioembolic event thought most likely etiology of stroke in presence INR 2.0, so new goal INR 2.5-3.5. CTA of the neck showed "Short segment focal stenosis in the pericallosal artery and right middle cerebral artery M2 segment" thought to be stenoocclusive or thromboembolic. She was covered with lovenox 60mg [**Hospital1 **] and started on coumadin 5mg qhs on [**3-31**], with the plan on continuing for 3-6 months and then transition to aspirin. LENIs were negative for DVT. Lovenox ceased on [**2106-4-2**] as INR therapeutic. INR supraptherapeutic to maximum 6.1 on [**2106-4-3**]. Coumadin held. Today ([**2106-4-5**]) INR 2.4 and restarting coumadin at 2mg daily. Please continue to monitor INR. There was an episode of hypotension overnight [**2106-3-31**] responsive to fluid treatment.Repeat head CT was unchanged. Abdominal CT was negative for retroperitoneal bleed. Stools negative for blood. Hct dropped to 22.0 and transfused 2 units rbc. Conincident with hypotensive episode, increased oxygen requirement occurred with concern for PE in context of perioperative stroke. CTA chest negative for PE. CT did show R upper lobe lung nodule which requires follow up scan at 1 year. Hematocrit now stable. Urinary tract infection was diagnosed on [**2106-4-4**] and treatment commenced with ciprofloxacin. Switched from tablets to suspension following episode of vomiting. To complete 3 days course (day 2 today). Repeat CT chest in 1 year for right upper lobe lung nodule. Neurology and orthopedic follow up arranged. Medications on Admission: Actenol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Please restart actonel weekly (?dose 30mg qw) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Right hip fracture Multiple infarcts in R MCA territory likely cardioembolic (AF) Post operative anaemia-transfused rbc Discharge Condition: Improved: No neurologic deficit. R hip wound healing. Discharge Instructions: Keep the incision clean and dry. You may apply a dry sterile dressing as needed for drainage or comfort. If you have any redness, increased swelling, pain, drainage, shortness of breath, or a temperature greater than 100.5, please call your doctor or go to the emergency room for evaluation. You may bear weight on your right leg. Resume all the medication you took prior to admission and take all medication as prescribed by your doctor. Feel free to call the orhtopedic office with any questions or concerns regarding the fracture or the neurology service regarding the stroke. Followup Instructions: 1. NEUROLOGY: Neurology Dr [**Last Name (STitle) **] Tuesday [**2110-5-4**].30 am [**Hospital Ward Name 23**] 8 [**Numeric Identifier 108659**] Please bring referral from PCP. 2. ORTHOPEDICS: Please call Dr.[**Name (NI) 4016**] office @ [**Telephone/Fax (1) 1228**] for a follow up appointment in 4weeks after hospital discharge. 3. PCP: [**Name10 (NameIs) 357**] follow up with Dr. [**Last Name (STitle) 2204**] one week after discharge from Rehab. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Name: [**Known lastname 17773**],[**Known firstname 1463**] Unit No: [**Numeric Identifier 17774**] Admission Date: [**2106-3-28**] Discharge Date: [**2106-4-6**] Date of Birth: [**2032-12-4**] Sex: F Service: NEUROLOGY Allergies: Aspirin Attending:[**First Name3 (LF) 608**] Addendum: Prior to discharge the patient experienced an episode of chest heaviness. Cardiac enzymes and EKG were negative for MI. The discomfort settled quickly and she continued well. There were no further problems and she was discharged to the rehab facility the following day. Pertinent Results: [**2106-4-6**] WC 7.5 Hct 28.2 Plt 419 PT 22.1 INR 2.2 Gluc 105 BUN 19 Cr 0.6 Na 136 K 3.8 Cl 99 HCO3 28 Cardiac Enzymes negative EKG No acute changes suggestive of MI Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Actonel 30 mg Tablet Sig: One (1) Tablet PO once a week. 10. Bactrim Suspension Sig: One (1) DS twice a day for 3 days. Disp:*qs * Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2106-4-21**]

[ "496", "E878.8", "434.11", "733.00", "599.0", "518.89", "820.21", "997.02", "424.0", "285.1", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "79.35", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

11590, 11777

4312, 7574

282, 332

8682, 8738

10556, 10736

9373, 10537

1536, 1540

10759, 11567

8539, 8661

7600, 7609

8762, 9350

228, 244

360, 1199

1575, 4289

1221, 1476

1492, 1520

14,669

144,417

53926+59564

Discharge summary

report+addendum

Admission Date: [**2107-12-17**] Discharge Date: [**2107-12-29**] Date of Birth: [**2069-2-12**] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old female with a history of diabetes type 1, hypertension and end-stage renal disease secondary to diabetes. The patient started on hemodialysis and then peritoneal dialysis. Recently had returned back to hemodialysis due to a peritoneal dialysis catheter infection. The patient had a left AV fistula thrombectomy one week prior to admission. The patient made no urine prior to the procedure. The patient denied any diarrhea, sore throat, colds, pains, coughs or dizziness, any rashes or visual changes, headaches, or any problems with shortness of breath, chest pain, no weakness, chills or fevers. PAST MEDICAL HISTORY: Includes diabetes x 20 years, type 1, the patient has hypertension diagnosed for about 10 years, hypercholesterolemia, and end-stage renal disease, now on peritoneal dialysis and hemodialysis. MEDICATIONS: Include enalapril 40 [**Hospital1 **], Klonopin 1 in the am and 2 in the pm; Mirapex 0.25 in am and 0.5 in pm, Periactin 4 prn, Norvasc 5 in am and 10 in pm, PhosLo 3 tabs with meals, Prozac 40 qd, Restoril 60 q hs, Toprol XL 100 [**Hospital1 **], trazodone 200 hs, Zyprexa 5 and 10, am and pm, Humalog sliding scale, NPH 10 and 20, compazine prn and Chromagen FO 460 which is a vitamin. ALLERGIES: Cipro, Diflucan, Keflex, sulfa, tetracycline and Cozaar. PHYSICAL EXAM: Unremarkable. Temperature 100.7, blood pressure 190/80, pulse rate 92, satting 100% on room air. LABORATORY: The patient had a white count of 5.9, hematocrit 29.5, platelets 276, BUN 26, creatinine 4.1. Last hemodialysis had been in the morning of admission. HOSPITAL COURSE: The patient underwent a cadaveric kidney transplant without complications. On postoperative day #1, the patient remained afebrile. Vital signs were stable. Urine output was low. White count was noted to be 16.7, hematocrit 29.8, and the creatinine was 4.5, up from 4.3 on admission. On postop day #2, the patient had a temperature increase to 101 overnight. Otherwise, vital signs were stable by the morning. Blood cultures were sent, as were urine cultures and a chest x-ray, all of which turned out to be negative. On postoperative day #3, the patient again had a temperature increase to 101 overnight. Otherwise, vital signs were stable. The patient continued to make lower volumes of urine with the creatinine trending upward into the 7 range. The patient's phosphate was also noted to be increasing into the 10 and 11 range. The patient's potassium also increased when she was given Kayexalate. The patient was started on peritoneal dialysis on postoperative day #4, as the phosphate was noted to be at 12.9 and creatinine was up to 7.8. That night, the patient was also noted to be somewhat paranoid likely due to a combination of medications, benzodiazepine withdrawal, and a psych consult was called. The patient was started on Klonopin, Restoril and Mirapex, but later on postoperative day #5 the patient was noted to be unresponsive. She responded well to flumazenil. CT of the head was negative. The patient was also started on Prograf and potassium level was 3.9. On day #6, the patient continued to be afebrile, vital signs stable, still on peritoneal dialysis, and the labs were improving. An FK level was drawn which was drawn after the dose was given and was noted to be very high at 18.4; therefore, no dose changes were made. The labs were improved, as her creatinine was down to 6.9, phos was down to 9.1 and K was at 2.8. She was given some potassium was replacement. On the overnight period between postop day #6 and #7, the patient was noted to be hiding the pills in her mouth and; therefore, the subsequent FK level was irrelevant on postop day #7. The patient continued to be on peritoneal dialysis. The JP was DC'd. The patient's creatinine continued to improve to 6.8, potassium 3.3 and the phos at 8.1. On postoperative day #8, the patient continued to be afebrile with vital signs stable. Urine output had begun to increase. The patient's FK level was now at 9.3 on a 4 and 4 dosing. The patient was restarted on Zyprexa, and trazodone and the Prozac was continued. The Klonopin and Restoril were being held pending recommendations from psychiatry. On postoperative day #9, the patient continued to improve. Peritoneal dialysis cycling was decreased, and the patient's urine output continued to increase. On postoperative day #10, the patient was noted to have a slightly swollen arm on the left. The patient with radial and ulnar pulses. Palpable pulse over the AV graft. The patient was taken to ultrasound which ruled out any DVT. The patient was now off peritoneal dialysis. FK level was at 13.5 on a dose of 7 and 7. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 02-919 Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2107-12-29**] 12:00 T: [**2107-12-29**] 11:22 JOB#: [**Job Number 110605**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 18124**] Admission Date: [**2107-12-17**] Discharge Date: [**2107-12-29**] Date of Birth: [**2069-2-12**] Sex: F Service: TRANSPLANT ADDENDUM: HOSPITAL COURSE: Postop day eleven the patient continued to be afebrile with vital signs stable. The patient was seen by Psychiatry and felt to be ready for discharge to home with either a VNA Service or a rehab facility for assistance with medications. The patient's ...... level continued to be 13.5 on a 7 and 7 regimen and potassium, creatinine and phosphate continued to be stable. On postoperative day twelve the patient continued to be afebrile and vital signs were stable. Sugars were under good control. The patient's laboratories continued to hold. The patient was felt ready for discharge to an assisted facility for compliance of medications due to her situation at home. The patient was felt to be better served under these circumstances. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To a nursing facility. DISCHARGE DIAGNOSES: 1. Status post cadaveric renal transplant. 2. Gastroparesis. 3. Reflux. 4. Anemia. The patient is to follow up with Dr. [**First Name (STitle) **] in the Transplant Center on a regular basis. [**First Name8 (NamePattern2) 399**] [**Last Name (NamePattern1) 400**], M.D. [**MD Number(1) 401**] Dictated By:[**Name8 (MD) 2182**] MEDQUIST36 D: [**2107-12-29**] 12:04 T: [**2107-12-29**] 12:17 JOB#: [**Job Number 18125**]

[ "250.41", "585", "583.81", "311", "272.0" ]

icd9cm

[ [ [] ] ]

[ "55.69" ]

icd9pcs

[ [ [] ] ]

6225, 6687

5388, 6129

1518, 1782

182, 812

835, 1502

6154, 6204

8,698

113,608

45742

Discharge summary

report

Admission Date: [**2164-12-20**] Discharge Date: [**2164-12-25**] Date of Birth: [**2084-10-17**] Sex: F Service: CARDIOTHORACIC Allergies: Protamine Attending:[**First Name3 (LF) 1267**] Chief Complaint: DOE/CHF Major Surgical or Invasive Procedure: [**2164-12-20**] - Aortic Valve Replacement (19mm St. [**Male First Name (un) 923**] Mechanical Valve) History of Present Illness: The patient is an 80-year-old woman with diabetes and renal failure who presented with recurrent congestive heart failure. She was noted to have severe aortic stenosis. Catheterization showed normal coronary arteries. It was elected to proceed with aortic valve replacement with mechanical valve. Past Medical History: 1)History of GIB of unknown cause; numerous diverticula on C-scope 2) L colectomy with transverse colostomy for GIB (D/C [**11-12**]) 3) Diastolic CHF (EF 65-75%) 4) s/p trach placement after prolonged intubation in ICU (at time of colectomy) 5) Severe AS ([**Location (un) 109**] 0.7cm2, pk gradient 91mmHg, mean gradient 55mmHg on [**6-13**] TTE 6) HTN 7) Elevated cholesterol 8) Diabetes type 2 9) CKD - baseline creat 2.5-3 10) Bilat total knee replacment 11) Multiple skin lesions removed by general and plastic surgery 12) Hypothyroid Social History: Lives at home with husband, [**Name (NI) **] 3 sons and 1 daughter. Is a non-smoker, no alcohol use, no history of illicit drug use. Retired, former manager. No h/o IVDU. Family History: No colon CA, otherwise unremarkable. Has 3 sons and 1 dtr. Physical Exam: 63 sr 18 150/61 68" 222lbs GEN: NAD SKIN: Unremarkable HEENT: Unremarkable NECK: Supple, FROM LUNGS: CTA HEART: RRR, Loud SEM, NlS1-S2 ABD: Soft, NT/ND, NABS EXT: 2+ LE edema, Pulses palp except nonpalp DP. NEURO: Nonfocal, unsteady gait Pertinent Results: [**2164-12-24**] 08:15AM BLOOD WBC-4.5 RBC-3.25* Hgb-10.1* Hct-31.3* MCV-96 MCH-30.9 MCHC-32.1 RDW-16.3* Plt Ct-183 [**2164-12-20**] 11:06AM BLOOD WBC-9.2# RBC-3.11*# Hgb-9.8*# Hct-29.3*# MCV-95 MCH-31.4 MCHC-33.2 RDW-17.1* Plt Ct-177 [**2164-12-20**] 11:06AM BLOOD Neuts-62.2 Lymphs-36.5 Monos-0.5* Eos-0.7 Baso-0.1 [**2164-12-25**] 05:42AM BLOOD PT-16.1* PTT-70.5* INR(PT)-1.4* [**2164-12-24**] 08:15AM BLOOD PT-13.9* PTT-35.5* INR(PT)-1.2* [**2164-12-23**] 01:10PM BLOOD PT-12.9 INR(PT)-1.1 [**2164-12-22**] 06:38AM BLOOD PT-13.7* PTT-30.9 INR(PT)-1.2* [**2164-12-20**] 12:12PM BLOOD PT-14.8* PTT-47.3* INR(PT)-1.3* [**2164-12-20**] 11:06AM BLOOD PT-15.7* PTT-48.0* INR(PT)-1.4* [**2164-12-24**] 08:15AM BLOOD Glucose-109* UreaN-45* Creat-5.0*# Na-137 K-3.9 Cl-101 HCO3-27 AnGap-13 [**2164-12-20**] 12:12PM BLOOD UreaN-21* Creat-2.9* Cl-105 HCO3-28 [**2164-12-24**] 08:15AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.5 [**2164-12-24**] 09:00AM BLOOD PTH-290* Cardiology Report ECG Study Date of [**2164-12-24**] 7:58:44 AM Sinus rhythm. Compared to previous tracing of [**2164-12-20**] no diagnostic change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Intervals Axes Rate PR QRS QT/QTc P QRS T 79 124 104 422/455 57 20 71 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2164-12-24**] 2:59 PM CHEST (PORTABLE AP) Reason: evaluate effusion - in HD please check with RN that pt on fl [**Hospital 93**] MEDICAL CONDITION: 80 year old woman with s/p avr REASON FOR THIS EXAMINATION: evaluate effusion - in HD please check with RN that pt on floor INDICATION: Followup. FINDINGS: Comparison to [**2164-12-22**]. The right-sided sheath in the jugular vein has been removed. All other invasive and monitoring devices are in unchanged position. The effusions are small and limited to the very area of the pleural sinuses. In unchanged manner, the silhouette of the heart is enlarged. Slight aortic calcification. Subtle signs of fluid overload. IMPRESSION: Cardiomegaly with signs of fluid overload, unchanged extent of bilateral pleural effusions. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: MON [**2164-12-24**] 5:14 PM RADIOLOGY Preliminary Report [**Numeric Identifier **] PICC W/O PORT [**2164-12-24**] 12:01 PM Reason: no IV access [**Hospital 93**] MEDICAL CONDITION: 80 year old woman with s/p AVR w/ chronic renal failure, on HD REASON FOR THIS EXAMINATION: no IV access PICC LINE PLACEMENT INDICATION: IV access needed for antibiotics. The procedure was explained to the patient. A timeout was performed. RADIOLOGISTS: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 4686**] performed the procedure. Dr. [**Last Name (STitle) 4686**], the Attending Radiologist, was present and supervised the entire procedure. TECHNIQUE: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guidewire and a 5 French double-lumen PICC line measuring 35 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the right brachial venous approach. Final internal length is 35 cm, with the tip positioned in SVC. The line is ready to use. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**] DR. [**First Name (STitle) **] [**Name (STitle) **] PreliminaryApproved: MON [**2164-12-24**] 4:48 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 2995**] [**Hospital1 18**] [**Numeric Identifier 97470**] (Complete) Done [**2164-12-20**] at 10:14:31 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2084-10-17**] Age (years): 80 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Congestive heart failure. Dizziness. Hypertension. Left ventricular function. Pulmonary hypertension. ICD-9 Codes: 428.0, 402.90, 786.05, 440.0, 424.1 Test Information Date/Time: [**2164-12-20**] at 10:14 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 45% to 55% >= 55% Aorta - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: *3.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *40 mm Hg < 20 mm Hg Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. No masses or vegetations on aortic valve. Moderate-severe AS (area 0.8-1.0cm2). Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50%). 3. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated. Right ventricular systolic function is borderline normal. 4. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Trace aortic regurgitation is seen. The annulus is heavilyb calcified and measures 19 mm. 6. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. POST-CPB: On infusions of epinephrine and levophed. Well-seated mechanical valve in the aortic position. No AI. AS gradient 20 peak, 13 mean at Cardiac Output of 7 L/min. Preserved LV systolic function on inotropic support. Mild inferior hypokinesis. LVEF=50%. Flow seen in LMCA and RCA. Protamine reaction with hypotension and CCO=8-9 L/min. Rx'd epi boluses. LV SAX shows underfilled LV with good systolic function. Aorta intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2164-12-20**] 16:50 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2164-12-20**] for surgical management of her aortic valve disease. She was taken directly to the operating room where she underwent an aortic valve replacement using a 19mm St. [**Male First Name (un) 923**] Mechanical valve. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. On postoperative day one, she underwent dialysis to remove volume. On postoperative day two, she awoke neurologically intact and was extubated. Coumadin was started for anticoagulation. She was later transferred to the step down unit for further recovery. The physical therapy service was consulted for assistance with her postoperative strength and mobility. The renal service continued to follow her and she continued with hemodialysis as prior to surgery. She was started on heparin while her INR was subtherapeutic. The heparin should continue until her INR is 2. She is due for HD Wednesday [**12-26**]. Medications on Admission: lasix 100", fluticasone 50', diovan 160", levothyroxine 75', hydrazaline 50"', Labetolol 400", Procrit [**Numeric Identifier 961**] q mon, protonix 40', simvastatin 20', iron 325' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1000 (1000) units/hr Intravenous ASDIR (AS DIRECTED): goal PTT 60-80 do NOT bolus discontinue when INR > 2.0 . 4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. PICC line PICC line care per protocol 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Warfarin 1 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO DAILY (Daily) as needed for mech AVR: please dose based on INR result - goal INR 2.5-3.0 with PT/INR checked daily until off heparin and then mon/wed/fri for continued dosing . She has received 3mg coumadin [**12-22**] and [**12-23**] 5mg coumadin [**12-24**] and [**12-25**] Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital/Radius Discharge Diagnosis: Aortic stenosis s/p avr s/p Aortic valvuloplasty CHF (Diastolic dysfunction LVEF 65% Diabetes mellitus CRI baseline creatinine 3.0 Hypothyroid GIB Obesity s/p vein stripping 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 [**Telephone/Fax (1) 170**] Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**First Name (STitle) 437**] after discharge from rehab Follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] after discharge from rehab [**Telephone/Fax (1) 608**] Follow up with Dr [**Last Name (STitle) 4883**] [**Telephone/Fax (1) 20422**] Please call all providers for appointments. Scheduled Appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2165-3-20**] 10:40 Dialysis - please refer back to [**Location (un) **] [**Location (un) **] when dc from rehab Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-1-3**] 9:20 Completed by:[**2164-12-25**]

[ "428.0", "272.0", "428.32", "416.8", "244.9", "403.91", "V43.65", "424.1", "250.40", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95", "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

13521, 13583

10864, 11883

287, 392

13801, 13808

1829, 3272

14577, 15446

1489, 1549

12113, 13498

4316, 4379

13604, 13780

11909, 12090

13832, 14554

8988, 10841

1564, 1810

240, 249

4408, 8939

420, 718

740, 1284

1300, 1473

4,985

120,917

3851+55509

Discharge summary

report+addendum

Admission Date: [**2107-12-29**] Discharge Date: [**2108-1-24**] Date of Birth: [**2043-6-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14964**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p CABGx5 [**12-30**](LIMA-LAD, SVG-Diag, SVG-ramus-OM, SGV-RCA) s/p tracheostomy [**1-18**] #8 Shiley s/p PEG [**1-18**] History of Present Illness: Mr. [**Known lastname 17283**] has a h/o MI several years ago, w/episode lasting 20 hours on day of admission. Pt ruled in for NSTEMI. Past Medical History: HTN hypercholesterolemia colon CA-s/p hemicolectomy and chemotherapy CAD DM Pertinent Results: [**2108-1-23**] 04:16AM BLOOD WBC-12.2* RBC-3.63* Hgb-10.6* Hct-32.7* MCV-90 MCH-29.4 MCHC-32.6 RDW-14.4 Plt Ct-434 [**2108-1-23**] 04:16AM BLOOD Plt Ct-434 [**2108-1-23**] 04:16AM BLOOD PT-14.1* PTT-62.3* INR(PT)-1.3 [**2108-1-23**] 04:16AM BLOOD Glucose-60* UreaN-33* Creat-1.1 Na-135 K-4.2 Cl-101 HCO3-27 AnGap-11 [**2108-1-24**] 02:11AM BLOOD PT-15.3* PTT-85.7* INR(PT)-1.5 Brief Hospital Course: Mr. [**Known lastname 17283**] is a 64 yo gentleman who was admitted on [**12-29**] with unstable angina. Cardiac catheterization showed LM and significant vessel disease. An intra-aortic balloon pump was inserted due to ongoing angina and marginal hemodynamics. He was taken to the operating room with Dr. [**Last Name (STitle) 70**] on [**12-30**] for a CABGx5. His ejection fraction in the operating room was 20%. Postoperatively he was hemodynamically unstable for several days, requiring inotropes and IABP. On [**1-1**] he was taken to the cardiac catheterization lab due to marginal hemodynamics which showed that all of his bypass grafts were patent. He also had moderate hypoxia and an interventional pulmonary consult was obtained. It was recommended that the patient receive bronchodilators. His hypoxia gradually resolved and his ventilator was weaned. He was started on an ACE inhibitor in an attempt to wean his inotropes, but it was discontinued due to an elevated creatinine. By POD#9 his inotropes were weaned and the patient was able to diurese. He was extubated from mechanical ventilation on POD#11, but required intermittent BiPAP and was re intubated on POD#14 due to hypoxia and work of breathing. The patient underwent CT scan to evaluate for pulmonary emboli which showed 2 small pulmonary emboli which were thought to be clinically insignificant, but it was recommended that he be anticoagulated. He had bilateral lower extremity venous dopplers preformed which were negative for evidence of DVT. On POD#19 he self extubated and after several hours was re intubated for hypoxia and work of breathing. On POD#19 he underwent bedside tracheostomy and PEG placement. He continued to wean on the ventilator. On POD#21 he underwent a transthoracic echocardiogram which showed his ejection fraction had improved to 30% with no significant valvular abnormalities. On [**1-21**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained due to the patients continued elevated blood sugar. It was recommended that the patient be started on Lantus insulin which was started without difficulty. Medications on Admission: aspirin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 8. Carvedilol 6.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1000 (1000) units/hour Intravenous infusion: until INR>2.0 goal PTT 50-70. 11. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection DAILY (Daily). 12. Coumadin 1 mg Tablet Sig: as directed Tablet PO once a day: titrate for INR 2.0-3.0 5mg per PEG [**1-24**]. 13. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-18**] Puffs Inhalation Q4H (every 4 hours). 17. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 18. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection tid: for blood sugar <60 give [**12-18**] amp D50 121-150 4 units SC 151-160 8 units SC 161-200 12 units SC 201-250 14 units SC 251-300 16 units SC 301-350 18 units SC 351-400 20 units SC. 19. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection bedtime: for blood sugar <60 give [**12-18**] ampD50 BS 201-250 6units SC BS 251-300 10unitsSC BS 301-350 12unitsSC BS 351-400 14unitsSC . Discharge Disposition: Extended Care Facility: Northeast [**Hospital 17284**] Rehab Discharge Diagnosis: CAD s/p urgent CABG post op respiratory failure s/p tracheostomy s/p PEG post op pulmonary emboli HTN post op atrial fibrillation ^chol h/o colon CA s/p colectomy Discharge Condition: good Discharge Instructions: do not lift anything heavier than 10 pounds for 1 month Followup Instructions: follow up with Dr. [**Last Name (STitle) 17285**] in [**12-18**] weeks follow up with Dr. [**Last Name (STitle) 70**] ([**Telephone/Fax (1) 170**]) in [**3-20**] weeks follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3512**]) when ready for discharge from rehab follow up with the [**Last Name (un) **] center ([**Telephone/Fax (1) 2378**]for diabetes management when ready for discharge from rehab Completed by:[**2108-1-24**] Name: [**Known lastname 2722**],[**Known firstname 140**] Unit No: [**Numeric Identifier 2723**] Admission Date: [**2107-12-29**] Discharge Date: [**2108-1-24**] Date of Birth: [**2043-6-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Addendum: The patient was discharged to Northeast [**Hospital 2725**] Hospital in [**Location (un) 437**] and had a question of respiratory distressed and was transferred back to [**Hospital1 8**] 6 hours later. He was stable on readmission, diuresed, and was screened by [**Hospital3 14**] and is being discharged today in stable condition. Discharge Disposition: Extended Care Facility: Northeast [**Hospital 2726**] Rehab [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2727**] MD [**MD Number(1) 2728**] Completed by:[**2108-1-26**]

[ "416.8", "414.01", "427.31", "401.9", "E878.8", "518.0", "518.81", "415.11", "428.30", "272.0", "410.71", "V10.05", "250.00", "428.0" ]

icd9cm

[ [ [] ] ]

[ "36.14", "89.64", "45.13", "43.11", "36.15", "96.04", "88.56", "37.22", "37.61", "88.72", "31.1", "99.20", "00.13", "97.44", "96.72", "39.61", "99.04", "88.42", "33.24", "38.91", "38.93", "37.23" ]

icd9pcs

[ [ [] ] ]

7054, 7273

1143, 3296

333, 458

5703, 5709

741, 1120

5814, 7031

3354, 5410

5517, 5682

3322, 3331

5733, 5791

283, 295

486, 623

645, 722

18,996

159,330

17058

Discharge summary

report

Admission Date: [**2165-2-28**] Discharge Date: [**2165-3-8**] Date of Birth: [**2130-8-4**] Sex: M Service: MEDICINE Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 45**] Chief Complaint: Fever/Chest Pain Major Surgical or Invasive Procedure: TEE PICC placement History of Present Illness: 34 y/o M with a PMH of ESRD secondary to membranous glomerulonephritis on HD via AV fistula, MSSA Aortic Valve endocarditis (from line infection) necessitating AV replacement ([**2161-9-18**]) with post-op course complicated by aortic root abscess/dehiscence requiring re-do AVR/homograft ([**2161-9-29**]). He was treated initially with a course of nafcillin, subsequently on suppressive dicloxacillin through 11/[**2162**]. He was readmitted [**8-25**] with MSSA bacteremia and presumed prosthetic valve endocarditis. He was treated initially with Naf/gent but dropped counts on Nafcillin so was transitioned to Cefazolin. He was treated with rifampin for six week course. He was transitioned to cephalexin 500 mg orally twice daily as suppressive therapy [**10-25**]. He reports intermittent chest pain with associated numbess of his limbs and nausea. His baseline blood pressure has been 80-90 systolic. . On [**2165-2-1**] he underwent a fistulogram and balloon angioplasty of his AVF for suspected stenosis. He reports the development of fever to 103 with nausea and diarrhea last week which resolved without intervention. He reports having blood cultures drawn in HD which were negative per pt. . He came to the ED today [**2-19**] to fever and CP that started yesterday, with temp to 103. CP improved with improved temps. He again today had CP, fever, and dyspnea and in the ER. VS were: T100.2 BP 90/31 HR 102. ECG demonstrated STE in superior leads and ST depression in lateral leads. He received vancomycin 1 gm IV. . The patient was evaluated on the medical floor and reported resolution of chest pain. Denied shortness of breath. He was taken to [**Hospital Ward Name 121**] 7 for scheduled HD. During HD session the patient developed chest pain with ECG demonstrating worsened ST depressions anteriolaterally and small STE in V1-V2. His blood pressure decreased to 60s systolic during his symtoms. He was given morphine 0.5mg IV X1 with subsequent improvement in his symptoms and ECG. BP improved to 90s systolic. He did not have fluid removed during HD. Cardiology was consulted and MICU evaluation obatined. He was tranfered to the MICU for concern of endocarditis. Past Medical History: # ESRD on HD M/W/F, [**2-19**] FSGS on renal bx in [**2158**] - L AVF stenosis s/p percutaneous angioplasty [**2164-10-21**] and [**2165-2-1**] - followed by Dr. [**Last Name (STitle) **], on transplant list # Aortic valve endocarditis with MSSA s/p bioprosthetic AVR [**2161-9-18**] - presumed secondary to HD line infection - c/b peri-valvular abscess that recurred after his initial AVR requiring homograft valve and aortic root replacement with reimplantation of his coronary arteries ([**2161-9-29**]) - Completed 6 week course of nafcillin on [**2161-11-12**] - then dicloxacillin through [**11-24**]. - recurrent MSSA bacteremia with presumed recurrent endocarditis in [**8-25**] treated with 6 weeks of rifampin and cefazolin with 2 wks of gent - On cefalexin 500 [**Hospital1 **] since for suppressive therapy # CHF, H/O systolic and diastolic dysfunction, EF >55% 8/08 # PFO, with left to right shunt on TTE [**2161-9-29**] # Bilateral subclavian vein, left IJ and left brachiocephalic thromboses s/p brachiocephalic vein stent. # Hypertension # Hyperlipidemia # Chronic fatigue syndrome # Pyloric stenosis in childhood, surgically repaired # [**2-/2165**] admission for fever/chest pain, Enterococcus bacteremia. Treated with Ampicillin and Streptomycin Social History: Originally from [**Male First Name (un) 1056**]. Has 3 sons. Drinks 2-3 drinks/month, continues to smoke 1ppd x10 years, no illicits. Works part-time as a teacher. Family History: mother - breast ca at 45, survivor, aunt - died of MI at 50, no other family hx of renal disease, no DM or other CA in the family Physical Exam: Vitals: (In HD) T 101.4 BP: 92/30 HR 87 RR 20 O2: 100% on 3LNC General: Pleasant, NAD, awake and appropriate HEENT: Anicteric sclera, MMM, OP clear NECK: Supple, No LAD CV: RRR, loud murmur systolic and diastolic murmurs throughout chest loudest along left sternal border. RESP: CTAB, no wheezes, rales, or rhonchi ABD: NABS. Soft, NT, ND, no hepatosplenomegaly EXT: no edema, 2+ pulses PT/DP SKIN: L AVF without erythema; small possible splinter hemorrhage on right pinky nail NEURO: A&Ox3. CN II-XII intact Pertinent Results: ADMISSION LABS . [**2165-2-28**] 09:30AM BLOOD WBC-8.4# RBC-3.16* Hgb-10.2* Hct-32.4* MCV-103* MCH-32.2* MCHC-31.3 RDW-15.2 Plt Ct-133* [**2165-3-1**] 03:33AM BLOOD WBC-4.1# RBC-3.35* Hgb-10.5* Hct-33.9* MCV-101* MCH-31.5 MCHC-31.1 RDW-15.1 Plt Ct-83* [**2165-2-28**] 09:30AM BLOOD PT-14.2* PTT-25.1 INR(PT)-1.2* [**2165-3-1**] 03:33AM BLOOD PT-14.9* PTT-31.1 INR(PT)-1.3* [**2165-3-2**] 03:37PM BLOOD Fibrino-569* [**2165-2-28**] 10:05AM BLOOD Glucose-83 UreaN-88* Creat-14.4* Na-140 K-4.2 Cl-100 HCO3-20* AnGap-24* [**2165-3-1**] 03:33AM BLOOD Glucose-93 UreaN-88* Creat-13.6* Na-137 K-4.6 Cl-96 HCO3-25 AnGap-21* [**2165-2-28**] 10:05AM BLOOD ALT-23 AST-23 CK(CPK)-135 AlkPhos-89 TotBili-0.5 [**2165-2-28**] 10:05AM BLOOD Albumin-4.5 Calcium-9.8 Phos-5.1* Mg-2.2 [**2165-3-5**] 07:10AM BLOOD Albumin-3.6 Calcium-9.4 Mg-2.3 Iron-31* [**2165-3-5**] 07:10AM BLOOD calTIBC-231* TRF-178* [**2165-3-6**] 06:25AM BLOOD Ferritn-373 [**2165-3-5**] 08:32AM BLOOD PTH-588* [**2165-2-28**] 09:52AM BLOOD Lactate-1.0 . DISCHARGE LABS . [**2165-3-8**] 06:48AM BLOOD WBC-4.5 RBC-2.68* Hgb-8.2* Hct-26.7* MCV-100* MCH-30.7 MCHC-30.9* RDW-15.2 Plt Ct-125* [**2165-3-7**] 07:15AM BLOOD WBC-4.3 RBC-2.63* Hgb-8.2* Hct-25.9* MCV-99* MCH-31.3 MCHC-31.8 RDW-15.7* Plt Ct-110* [**2165-3-1**] 03:33AM BLOOD Neuts-76.0* Lymphs-18.5 Monos-4.7 Eos-0.5 Baso-0.3 [**2165-3-2**] 03:37PM BLOOD PT-14.0* PTT-28.2 INR(PT)-1.2* [**2165-3-8**] 06:48AM BLOOD Glucose-79 UreaN-51* Creat-9.8* Na-145 K-4.9 Cl-102 HCO3-33* AnGap-15 [**2165-3-7**] 07:15AM BLOOD Glucose-102* UreaN-66* Creat-10.7* Na-141 K-4.1 Cl-100 HCO3-27 AnGap-18 [**2165-3-8**] 06:48AM BLOOD Calcium-9.0 Phos-5.9*# Mg-2.0 [**2165-3-7**] 07:15AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 . CARDIAC ENZYMES . [**2165-2-28**] 10:05AM BLOOD CK-MB-2 [**2165-2-28**] 10:05AM BLOOD cTropnT-0.05* [**2165-2-28**] 10:05AM BLOOD ALT-23 AST-23 CK(CPK)-135 AlkPhos-89 TotBili-0.5 [**2165-2-28**] 03:10PM BLOOD CK-MB-3 cTropnT-0.06* [**2165-2-28**] 03:10PM BLOOD CK(CPK)-108 [**2165-3-1**] 03:33AM BLOOD CK-MB-6 cTropnT-0.17* [**2165-3-1**] 03:33AM BLOOD CK(CPK)-149 [**2165-3-1**] 02:18PM BLOOD CK-MB-5 cTropnT-0.21* [**2165-3-1**] 02:18PM BLOOD CK(CPK)-118 . . [**2165-2-28**] 3 BLOOD CX'S POSITIVE FOR ENTEROCOCCUS: MICRO: [**2-28**] BCx: ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml of gentamicin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin = 1.0 MCG/ML : Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 8 S VANCOMYCIN------------ 1 S . From [**2165-2-28**] to [**2165-3-7**] there were 8 subsequent NEGATIVE blood cultures. . . IMAGING . [**2165-2-28**] EKG Sinus tachycardia. Left axis deviation. Non-specific intraventricular conduction delay. Left ventricular hypertrophy. Poor R wave progression could be due to left ventricular hypertrophy. Non-specific ST-T wave changes could be due to left ventricular hypertrophy and/or ischemia. Compared to tracing #1 sinus tachycardia is present and ST segment depression is more pronounced. TRACING #2 . [**2165-2-28**] EKG Sinus rhythm. Possible right atrial abnormality. Non-specific intraventricular conduction delay. Prominent QRS voltate suggestes left ventricular hypertrophy. Non-specific ST-T wave changes. Compared to the previous tracing of [**2163-12-29**] RSR' pattern is less prominent in lead V1. ST segment depression is more pronounced in leads V4-V6. TRACING #1 . [**2165-2-28**] ECHO Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Thickened AVR leaflets. Increased AVR gradient. No masses or vegetations on aortic valve. AR vena contracta is >0.6cm. Severe (4+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or vegetation on mitral valve. Normal mitral valve supporting structures. No MS. Mild to moderate ([**1-19**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. No TS. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF 60%). [Intrinsic left ventricular systolic function is likely depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. A bioprosthetic aortic valve prosthesis is present. The prosthetic aortic valve leaflets are thickened. The transaortic gradient is higher than expected for this type of prosthesis. No definite masses or vegetations are seen on the aortic valve. The aortic regurgitation vena contracta is >0.6cm. Severe (4+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**1-19**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2163-9-14**], the aortic regurgitation is fiurther increased, and the bioprosthetic leaflets appear thicker, although no definite vegetation is evident. . [**2165-2-28**] CXR SINGLE AP VIEW OF THE CHEST: The patient is status post median sternotomy with a left brachiocephalic stent. The cardiac silhouette is normal in size. The mediastinal and hilar contours are within normal limits. The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. IMPRESSION: No acute cardiopulmonary abnormality. . [**2165-3-1**] EKG Sinus rhythm. Right bundle-branch block. Nn-specific lateral ST-T wave changes. Compared to the previous tracing of [**2165-2-28**] the overall rate as decreased. The lateral ST-T wave changes are not as apparent on the current tracing. Criteria for left ventricular hypertrophy are not quite met on the current tracing. TRACING #1 . [**2165-3-1**] TEE Findings This study was compared to the prior study of [**2163-9-15**]. LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Aortic valve homograft (AVR). Thickened AVR leaflets. Moderate to severe (3+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on mitral valve. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. . Conclusions The left atrium is normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. No aortic plaque was identified to 47 centimeters from the incisors. The thoracic aorta appears normal/without atheroma to 47cm from the incisors. A well-seated aortic valve homograft is seen with thickened leaflets, but no discrete mass, vegetation, or abscess. Aortic stenosis was not assessed. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened but without discrete mass or vegetation. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Thickened aortic homograft leaflets without discrete vegetation or abscess. Moderate to severe aortic regurgitation. Mild mitral regurgitation with mildly thickened mitral valve leaflets. Compared to the previous TEE (images reviewed) of [**2163-9-15**], the aortic valve homograft leaflets appear diffusely thicker and the severity of aortic regurgitation has increased. The mtral valve leaflets appear minimally thicker (?technique) and mild mitral regurgitation is now identified. If clinically suggested, the absence of a vegetation on 2D TEE does not exclude endocarditis. . [**2165-3-1**] UPPER EXTREMITY NON INVASIVE FINDINGS: Transverse and sagittal images with [**Doctor Last Name 352**] scale and color Doppler imaging were obtained of the left AV fistula and the native left basilic vein in the left forearm. Non-occlusive thrombus is identified within the left basilic vein below the level of the antecubital fossa. Vascular flow is identified adjacent to this non-occlusive clot. No discrete fluid collections are seen in the left forearm. The AV fistula appears patent although a region of focal narrowing which demonstrates a thrill on color Doppler imaging is seen in the draining vein portion of the fistula. This narrowing is in the mid upper arm. IMPRESSION: 1) Non-occlusive thrombus seen within the left basilic vein within the left forearm. No discrete subcutaneous fluid collection identified. 2) Area of stenosis in the AV fistula seen in the mid upper arm. . [**2165-3-1**] CT CHEST/ABD/PELVIS CT CHEST WITHOUT INTRAVENOUS CONTRAST: No axillary or mediastinal lymph nodes meet size criteria for pathologic enlargement. There has been interval placement of a left subclavian venous stent. The patient has had an aortic valve replacement. Ascending aortic graft is again seen. The patient is status post a median sternotomy. No mediastinal abscess or fluid collection is seen. There is no pericardial effusion. There is mild left ventricular dilation. Central airways are patent to the level of subsegmental bronchi. A 10 x 7-cm ground-glass nodule is seen in the right lower lobe and there are some nodules with a suggestion of a tree-in-[**Male First Name (un) 239**] configuration proximally (series 2, image 32). There is mild dependent bibasilar atelectasis. There is no large effusion, or pneumothorax. A 2mm nodule in the right upper lobe is unchanged since [**2161-11-18**]. CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Evaluation of the solid organs is limited without intravenous contrast. The liver, gallbladder, pancreas, adrenals and kidneys appear unremarkable. The spleen is enlarged, measuring a maximum of 16cm. Splenic calcifications are noted. Abdominal loops of bowel appear unremarkable. There is no large ascites. No intra-abdominal lymphadenopathy is seen. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder and distal ureters, and rectosigmoid appear normal. No pelvic fluid collection is seen. MUSCULOSKELETAL: There is no suspicious osteolytic or osteoblastic lesion. IMPRESSION: 1. No abscess is seen within the chest, abdomen or pelvis. 2. Ground-glass nodule in the right lower lobe and additional nodular opacificaiton, suggests infeciton. Follow-up chest CT after treatment to assess for expected resolution is recommended. 3. Status post median sternotomy. Interval aortic valve replacement. . [**2165-3-2**] EKG Sinus tachycardia. Right bundle-branch block. Non-specific inferior and lateral ST-T wave changes may be due to left ventricular hypertrophy and/or ischemia. Clinical correlation is suggested. Compared to tracing #1 no change. TRACING #2 . [**2165-3-2**] CXR FINDINGS: Again seen are the sternotomy wires and left brachiocephalic stent. There are new bilateral patchy areas of alveolar airspace disease in the mid lungs predominantly. The heart is upper limits normal in size. One of the sternal wires inferiorly is seen to be broken as visualized previously. IMPRESSION: New bilateral alveolar infiltrates. . [**2165-3-3**] EKG Same findings as tracing #2 and no change. TRACING #3 . [**2165-3-3**] CXR CHEST, SINGLE AP PORTABLE VIEW: Lordotic positioning. Heart size is at the upper limits of normal. The mediastinum is slightly prominent, but likely accentuated by technique. A stent is seen over the upper mediastinum. The patient is status post sternotomy. There is asymmetric perihilar opacity, corresponding to the findings on the [**2165-3-1**] chest CT and similar to the [**2165-3-2**] chest x-ray. There is also very faint opacity in the left mid zone, which is unchanged. There is a focal nodular-type density (12.4 mm) in the right upper zone, projecting over the right third posterior rib. This corresponds to a small faint nodular opacity that can be seen in retrospect on the [**2165-3-1**] CT scan. As before, repeat CT scan following resolution of the acute process is recommended to confirm resolution of the nodular opacities. IMPRESSION: 1. Right greater than left opacities unchanged compared with one day earlier. 2. Doubt CHF. No upper zone redistribution. 3. Nodular opacity in right upper zone may represent an inflammatory/infectious process. However, repeat chest CT scanning when acute process has resolved is recommended to exclude underlying lesion. Please see report from [**2165-3-1**] CT scan. . . [**2165-3-5**] EKG Sinus rhythm. Incomplete right bundle-branch block. Left ventricular hypertrophy. Consider left atrial abnormality. Prolonged QTc interval is non-specific. ST-T wave abnormalities are primary and may be due to left ventricular hypertrophy or possible ischemia. Clinical correlation is suggested. Since the previous tracing of [**2165-3-4**] the QTc interval may be longer but there may be no significant change. . [**2165-3-7**] TAGGED WBC SCAN INTERPRETATION: Following the injection of autologous white blood cells labeled with Tc-[**Age over 90 **]m/In-111, images of the whole body obtained show no abnormal foci of tracer uptake. Tracer activity in the liver and spleen is within normal range. IMPRESSION: No scintigraphic evidence for an infectious source. . Brief Hospital Course: 34yoM with h/o ESRD on HD secondary to glomerulonephritis, awaiting transplant, history of recurrent MSSA endocarditis of aortic valve necessitating AV replacement [**2161-9-18**] with post-op course complicated by aortic root abscess requiring re-do AVR/homograft on [**2161-9-29**], then readmitted with recurrent MSSA bacteremia [**8-/2163**] and finally transitioned to chronic suppressive Keflex since [**10/2163**], who presented with fevers, nausea, and chest pain after having a LUE fistulogram and balloon angioplasty [**2165-2-1**]. He was admitted to MICU and found to have [**3-20**] Enterococcus bacteremia. . # Enterococcal Bacteremia: 3 positive blood cultures for enterococcus as above in results section. The pt had TTE showing worsening AR with thickened leaflets but no obvious vegetations, then had TEE which did not show any vegetations. After being desensitized in the MICU, pt was started on Ampicillin on [**2165-3-2**] for 6-8wk course with ID consulting, had PICC line placed before discharge. After having a normal audiology exma, he was also given 2 doses of Streptomycin for synergy with Ampicillin while admitted with plan to continue as outpt. Two levels were drawn to monitor Strepto kinetics which were pending at time of discharge (pt received 500mg IM strepto, had level drawn just before HD 2 days later, then had a dose of 500mg IV strepto after HD, with another level drawn 1 hour later). . Transplant surgery was consulted to evaluate the LUE fistula as a source of the enterococcal bacteremia but they did not feel it to be the source. The fistula was normal appearing, not erythematous or tender. The TEE was negative for endocarditis. Pt had CT chest which showed nodular opacity however ID did not feel this to be clinically relevant PNA, or the source. No other clear source was identified, so pt underwent a tagged WBC scan, which did not clearly identify any source either. . Pt was discharged with home service to continue his Ampicillin/Streptomycin, will need to follow up with ID, who had also recommended pt have full course of Rifampin for consolidation therapy after the Amp/Strepto course. Pt was also instructed to get audiology exam 1 and 2 weeks after discharge to monitor for Strepto toxicity and given phone number to set this up. Also given order to have weekly CBC/diff, LFT's drawn at HD and faxed to ID for monitoring of ABx sides. Pt should also f/u with Dr. [**Last Name (STitle) 914**] for evaluation of whether his aortic valve will need to be replaced again after ABx course is done. . # Coronaries: Pt noted to have chest pain during an HD session with ST elevations and depression noted on EKG's. Cards was consulted but given normal recent stress perfusions scan, did not feel this to be an ACS as daily EKG's were monitored and the changes were not dynamic and persisted even when pt was chest pain free. Enzymes peaked at trop 0.21, MB's were all negative, and CK peaked at 149 then went down to 118 by discharge. Pt was started on ASA 325 and continued home dose statin. He did not have any chest pain or cardiac symptoms through the rest of his admission. Antihypertensives Labetalol and Lisinopril were held when pt thought to be hypotensive sbp's in the 80-90's. . # Hypotension: There was initial concern that the pt was hypotensive, and he later endorsed that his "bp's run in the 80-90's" and he was seen to mentate well, get up and walk around and be completely normal with sbp 80-90. However later a bp cuff placed on his thigh showed normal bp's, so there may be some element of stenosis of his UE arteries. Labetalol and Lisinopril were held during admission but could reasonably be added back as needed. . # ESRD on HD: No indication for AV fistula redo per Transplant surgery. He received HD with Epo, and was continued on Sevelamer, Lanthanum, VitB, Nephrocaps. Pt was discharged to f/u HD at [**Location (un) **] in [**Location (un) **]. . # Anemia: From ESRD. Received Epo with HD. . # CXR with focal nodular opacity: 12.4mm in RUL projecting over 3rd R posterior rib, recommend repeat CT after acute process resolved. As above, ID did not feel this to be clinically relevant PNA. Pt will likely need f/u imaging. Medications on Admission: -ASA 325 mg daily -labetalol 200mg [**Hospital1 **] Monday, Wednesday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**] and none on his dialysis days (Tuesday, Thursday, Saturday) -lisinopril 30 mg daily 4 days a week and 20 mg on dialysis days (TuThSa) -atorvastatin 20 mg daily -sevelamer (Renagel) 2400 mg TID with meals -lanthanum carbonate (Fosrenol) [**Telephone/Fax (1) 1999**] mg TID with meals -cephalexin 500 mg [**Hospital1 **] (indefinitely) -omega-3 fish oil 2 capsule daily -vitamin B complex [**Hospital1 **] -renal vitamins -zinc -vitamin C -vitamin E -antioxidants Discharge Medications: 1. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) dose Intravenous twice a day for 46 days: Start date [**2165-3-2**]. Will need total of 56 days. . Disp:*92 doses* Refills:*0* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. B Complex Vitamins Capsule Sig: One (1) Cap PO twice a day. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Outpatient Lab Work Please have a CBC with differential, ALT, AST, ALKP, total bilirubin drawn once a week at dialysis and have the results faxed to the [**Hospital **] clinic attn: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13895**]. Fax [**Telephone/Fax (1) 17715**]. 10. other Sig: see below see below see below for 7 doses: Streptomycin 1 gram Recon Soln Five Hundred (500) mg IV As directed for 7 doses: Administer after HD on HD days (Tu, Th, Sat). 1st dose Saturday [**2165-3-9**]. Disp:*7 dose supply* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: Primary diagnoses this admission: 1. Enterococcus bactermia 2. Worsening of aortic regurgitation, cannot rule out endocarditis 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**] with fevers, chills, and chest pain, and found to have an infection in your blood stream with Enterococcus. You had an esophageal echocardiogram which showed some worsening of your aortic heart valves but was unable to say whether you had endocarditis or not. You will need to be treated with 6 to 8 weeks of antibiotics, which will be determined by the infectious disease specialists, with whom you will need to follow up closely. The following changes were made to your medication regimen: 1. START Ampicillin 2g IV q12 hrs for the next 6-8 weeks. On the day of discharge, [**2165-3-8**], you were on day 9 out of 42 or 56, depending on how long ID wants to continue. 2. START Streptomycin 500 mg intramuscularly, after each HD session on Tues/Thurs/Sat for the next 7 HD sessions 3. STOP Labetalol. This was held out of concern for your low blood pressure during admission 4. STOP Lisinopril. This was held out of concern for your low blood pressure during admission. 5. DECREASE Sevelamer from 2400 to 800 three times a day 6. STOP Keflex Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: - Please follow-up with infectious disease service, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2165-3-20**] at 9:50 AM. You will also need serial audiology exams at 1 week and 2 weeks after discharge. We tried to schedule these appointments for you but the Audiology office is only open on Monday, Wednesday, and Thursday from 8am to 4:30pm. They can be reached at [**Telephone/Fax (1) 47965**]. You should call them to schedule an appointment and ask them to fax the results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13895**] at fax number [**Telephone/Fax (1) 17713**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2165-3-14**] 10:00 Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2165-5-3**] 10:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-6-21**] 10:00 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2165-3-20**] 9:50 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] Completed by:[**2165-3-17**]

[ "425.4", "585.6", "745.5", "272.4", "428.42", "428.0", "996.61", "403.91", "V42.2", "038.0", "V49.83", "305.1", "421.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95", "88.72" ]

icd9pcs

[ [ [] ] ]

25936, 25992

19780, 23984

297, 317

26164, 26164

4690, 19757

27507, 28833

4014, 4146

24623, 25913

26013, 26142

24010, 24600

26309, 27484

4161, 4671

241, 259

345, 2528

26178, 26285

2550, 3817

3833, 3998

29,348

127,366

33266

Discharge summary

report

Admission Date: [**2148-6-20**] Discharge Date: [**2148-7-15**] Date of Birth: [**2089-10-23**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine Attending:[**First Name3 (LF) 3561**] Chief Complaint: Transfer from SICU to MICU for hypoxic respiratory failure, ARDS Major Surgical or Invasive Procedure: right vats tracheostomy peg History of Present Illness: This is a 58 yo F with h/o interstitial lung disease who is being transferred from the SICU service for hypoxic respiratory failure and ARDS. The pt was admitted on [**6-20**] for a scheduled VATS/RML and RLL wedge resection to help ascertain the etiology of her pulmonary fibrosis. She had been increasingly more DOE over the past 6 mos with her sxs being unresponsive to steroids. Per op report, procedure was without immediate complications and she was extubated in the PACU without any difficulty sating 94% on 2L NC, RR 18. The plan was for d/c home on POD 1; however, she was noted to be SOB with exertion and desated to 89% on 3L which improved to 95% on 4L NC. This was partially attributed to uncontrolled pain and splinting. The following morning, the pt fell while ambulating to the bathroom and several hours later triggered for RR 40-55 and O2 sat 50-60% on 6L NC. Placed on 100% NRB with improvement in sats to mid 80s then placed on BIPAP with improvement in sats to 98%. CXR revealed increasing opacities with pleural effusions bilaterally suggestive of infection vs. CHF. Given acute hypoxic respiratory failure and distress, pt was emergently intubated and transferred to the SICU for further care. . Bronch post-intubation showed no mucous plugs, no significant secretions, but significant TBM. BAL performed CTA chest did not show evidence for PE but did reveal significant b/l consolidations and septal thickening suggestive of pulmonary edema, ARDS, or alveolar hemorrhage. WBC from 10K on admission to 19K, fever to 101F on [**6-23**], left antecub PIV d/c'd and noted to have frank pus, culture with coag neg staph. RIJ placed. She was started on IV vancomycin and ciprofloxacin and started on ARDSnet ventilation. As the pt continued to overbreathe/remain dysynchronous from the vent and was reportedly agitated with no improvement after boluses of propofol, fentanyl, and versed, she was paralyzed on [**6-24**]. Briefly dropped pressures in setting of propofol boluses on [**6-24**] requiring neo gtt. On [**6-25**], RIJ changed over wire to [**Location (un) 109**] with SGC, SVR 879, CI 3.03. Pulmonary consulted who agreed that likely diagnosis being UIP with superimposed ARDS in the post-op setting. Vent mode changed to PCV [**2-10**] elevated PIPs to 36. Most recent ABG 7.31/51/99 on PCV. Paralytics weaned off, neo gtt being weaned down. Now being transferred to MICU for further care. Past Medical History: HTN Pulmonary fibrosis - ddx included NSIP, IPF, hypersensitivity pneumonititis, path on [**6-20**] c/w usual interstitial pneumonia (IPF) s/p VATS/RML and RLL wedge resection on [**6-20**] Anxiety Detached retina and legally blind in the R eye Elevated triglycerides Glucose intolerance Social History: Of Irish descent. The patient worked in a manufacturing factory making cardboard boxes. She has a boyfriend and family that are involved in her care. No prior h/o tobacco. Family History: Mother had [**Name2 (NI) **]. Sister with [**Name (NI) 13483**] thyroiditis. Physical Exam: T 98.6 BP 129/70 HR 107 RR 26 Vent settings: PCV FiO2 50% PEEP 5 RR set at 26 I/O: 2211/700 Gen - sedated, intubated HEENT - pupils sluggishly reactive to light b/l, right IJ line in place with Swan d/c'd CV - tachycardic, no m/r/g appreciated Lungs - limited by anterior exam. no breath sounds over right lower base, otherwise scattered bronchial sounds on right Abd - Soft, NT, ND, normoactive BS Ext - no LE edema Neuro - pupils sluggishly reactive to light b/l, no purposeful mvmt, sedated Skin - no rashes, scar with small area of surrounding erythema over left antecub fossa Pertinent Results: ON ADMISSION: [**2148-6-23**] 02:33AM BLOOD WBC-19.0*# RBC-3.63* Hgb-11.1* Hct-31.8* MCV-88 MCH-30.6 MCHC-34.9 RDW-14.3 Plt Ct-394 [**2148-6-23**] 02:33AM BLOOD Neuts-89* Bands-2 Lymphs-4* Monos-4 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2148-6-23**] 02:33AM BLOOD PT-14.5* PTT-30.0 INR(PT)-1.3* [**2148-6-23**] 02:33AM BLOOD Fibrino-1024* [**2148-6-22**] 01:00PM BLOOD Glucose-174* UreaN-13 Creat-0.9 Na-139 K-4.1 Cl-100 HCO3-27 AnGap-16 [**2148-6-23**] 02:33AM BLOOD ALT-46* AST-79* AlkPhos-88 [**2148-6-23**] 02:33AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3 . [**Last Name (un) **] STEM [**2148-6-28**] 03:42AM BLOOD Cortsol-36.9* [**2148-6-28**] 03:16AM BLOOD Cortsol-33.8* [**2148-6-28**] 02:27AM BLOOD Cortsol-18.7 . WORK-UP [**2148-6-25**] 04:10PM BLOOD ANCA-NEGATIVE B [**2148-7-5**] 11:49PM BLOOD Lactate-1.5 . CXR [**7-8**]:AP chest radiograph compared to [**2148-7-7**], there is worsening edema and bibasilar atelectasis. The cardiomediastinal contour is partially obscured. Tracheostomy remains in place. Attention is recommended to the unusual course of the tip of the left IJ central venous catheter, which may be related to patient position, on subsequent non-rotated film. . CT CHEST [**2148-6-28**]: 1. There is a gradient in the degree of clearing of lungs with the lowest improvement at the bases and near complete resolution at the apeces. The differential includes ARDS and the acute exacerbation of the underlying interstitial lung disease. 2. Findings of background interstitial lung disease with traction bronchiectasis and subpleural lines. The recent pathology suggested UIP. . RIGHT LOWER AMD MIDDLE LOBE WEDGE RESSECTION [**2148-6-20**]: 1. Lung, wedge biopsy, right lower lobe: Patchy severe interstitial fibrosis with honeycomb change, focal moderate interstitial chronic inflammation and focal fibroblastic foci. The findings are consistent with usual interstitial pneumonia (UIP) in the proper clinical setting. Focal pleural adhesions are seen. There is focal acute inflammation of the mucous filled space lined by bronchial epithelium in the honeycomb areas. 2. Lung, wedge biopsy, right middle lobe: Patchy severe interstitial fibrosis with honeycomb change, focal moderate interstitial chronic inflammation and focal fibroblastic foci. The findings are consistent with usual interstitial pneumonia (UIP) in the proper clinical setting. Focal pleural adhesions are seen. There is focal acute inflammation of the mucous filled space lined by bronchial epithelium in the honeycomb areas. Brief Hospital Course: 58 yo F h/o interstitial lung disease s/p VATS with RML/RLL wedge resection with path significant for UIP admitted to the MICU s/p VATS due to hypoxic respiratory failure. Despite aggressive measure the patient continued to deteriorate. A family meeting was held with the attending present. A decision was made to focus on the comfort of the patient. The patient expired on [**2148-7-15**]. Respiratory Failure: Respiratory failure was attributed to ARDS and superimposed UIP post-operatively. The patient remains difficult to ventilate on and off paralytics. Patient was weaned off of paralytics but continued to be dysynchronus with the ventilator despite multiple attempts at tailoring the ventilator settings. She was covered empirically with broad spectrum antibiotics. She eventually had a tracheostomy placed due to the inability to wean her off of the ventilator. . Fever/hypotension/Leukocytosis: Patient remains febrile. On vanc/[**Last Name (un) 2830**]/cipro for presumed HAP and broad coverage. Two catheter tips grew out coag negative staph and [**Female First Name (un) **] for which she was covered with vancomycin and fluconazole. multiple ultrasounds were negative for DVTs. Interstitial lung disease - Non-steroid responsive as an outpatient. Surgical pathology was consistent with UIP. She was continued on steroids. Medications on Admission: expired Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2148-7-16**]

[ "401.9", "515", "516.8", "112.5", "999.31", "369.4", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.71", "33.23", "45.13", "96.6", "32.20", "33.24", "96.04", "43.11", "31.1", "38.93" ]

icd9pcs

[ [ [] ] ]

8020, 8029

6585, 7929

348, 377

8080, 8089

4041, 4041

8145, 8183

3343, 3421

7987, 7997

8050, 8059

7955, 7964

8113, 8122

3436, 4022

244, 310

405, 2827

4055, 6562

2849, 3138

3154, 3327

29,643

107,287

53369

Discharge summary

report

Admission Date: [**2127-7-3**] Discharge Date: [**2127-7-13**] Date of Birth: [**2050-4-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2127-7-7**] Three Vessel CABG(LIMA to LAD, SVG to OM, SVG to Ramus) [**2127-7-3**] Cardiac Catheterization History of Present Illness: This 77 year old man has a history of mild hyperlipidemia and prior tobacco abuse, quit 35 years ago. Approximately six months ago the patient began to notice occasional episodes of mid sternal chest discomfort occurring with light exertion and emotional stress. He underwent stress testing which was notable for a partially reversible distal inferoseptal defect. He has continued to have angina with his last episode occurring about four days ago, responsive to SL nitroglycerin. He denies increased fatigue or dyspnea on exertion. He has now agreed to proceed with cardiac catheterization. Past Medical History: - Possible Hypertension (although patient denies) - Borderline hyperlipidemia - [**2092**] Throat cancer, s/p surgery, chemo and radiation - History of Hematuria approximately one year ago - diagnosed with enlarged prostate (treated with medication) - Cataract surgery bilaterally - Tonsillectomy Social History: Patient is married with four children. He lives with his wife and was a former air traffic controller. Patient drinks one beer/day. Tobacco - quit 35 years ago Family History: No family history of premature CAD Physical Exam: Admission Vitals: 190/90, 68, 18, 97% RA Gen: 77 yo man in NAD HEENT: PERRL, EOMI Neck: supple, no LAD, no JVD Cardiac: RRR, nl S1, S2 Chest: CTAB, no crackles, wheezes, rhonchi Abd: + BS, NT, ND, No hepatosplenomegaly Ext: No edema, cyanosis Neuro: AAO x3 Psych: Very anxious Pulses: 2+ radial and DP pulses bilaterally Pertinent Results: [**2127-7-3**] 02:14PM BLOOD WBC-5.6 RBC-3.92* Hgb-12.0* Hct-33.5* MCV-86 MCH-30.6 MCHC-35.8* RDW-13.1 Plt Ct-183 [**2127-7-3**] 02:14PM BLOOD PT-13.5* PTT-33.2 INR(PT)-1.2* [**2127-7-3**] 02:14PM BLOOD Glucose-120* UreaN-17 Creat-1.0 Na-128* K-4.1 Cl-97 HCO3-23 AnGap-12 [**2127-7-3**] 02:14PM BLOOD ALT-13 AST-17 AlkPhos-86 TotBili-0.6 [**2127-7-3**] 02:14PM BLOOD %HbA1c-5.9 [**2127-7-3**] CArdiac Cath: 1. Selective coronary angiography of this right dominant system demonstrated 2 vessel coronary artery disease. The LMCA showed a 70% ostial stenosis with dampened blood pressure when the artery was engaged. LAD showed moderate diffuse disease. LCx showed a 70% lesion in OM1. The RCA showed mild diffuse disease. 2. Limited resting hemodynamic measurements revealed elevated LVEDP (21 mmHg) and elevated systemic arterial pressure (193/82 mmHg). There was no transaortic valve gradient on careful pullback of the catheter from the LV to the aorta. 3. Left ventriculography showed EF of 71%, no mitral regurgitation and normal LV systolic function. Regional wall motion was normal. [**2127-7-4**] Carotid Ultrasound: Bilateral 70-79% stenosis. The right-sided stenosis is slightly more severe than the left. Both vertebral arteries have normal antegrade flow. [**2127-7-10**] 06:50AM BLOOD WBC-14.9* RBC-3.77* Hgb-11.1* Hct-32.5* MCV-86 MCH-29.5 MCHC-34.2 RDW-14.7 Plt Ct-139* [**2127-7-8**] 05:53AM BLOOD PT-13.9* PTT-31.3 INR(PT)-1.2* [**2127-7-9**] 07:05AM BLOOD Glucose-139* UreaN-17 Creat-1.0 Na-134 K-4.5 Cl-101 HCO3-24 AnGap-14 Brief Hospital Course: Mr. [**Known lastname 1794**] was admitted and underwent cardiac catheterization which revealed a severe left main lesion and severe two vessel coronary artery disease. Cardiac surgery was consult for surgical evaluation and he underwent preoperative workup. Carotid ultrasound was notable for 70-79% bilateral stenoses of both internal carotid arteries and asymptomatic. Vascular surgery evaluated him and there was no indication for intervention at this time. On [**7-7**] he was taken to the operating room and underwent coronary artery bypass grafting. See operative report for further details. He received perioperative vancomycin because he was in the hospital pre operatively. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Post operative night he had atrial fibrillation that was treated with amiodarone, which he converted back to normal sinus rhythm. His CVICU course was otherwise uneventful and he transferred to the floor on postoperative day one. He was started on beta blockers and diuretics. Physical therapy worked with him for strength and mobility. His urinary catheter was reinserted for failure to void, he was restarted on Terazosin, foley was removed POD 3 and he had no further issues. POD#5 serous drainage at the inferior pole of his sternal incision was noted, along with a right forearm IV area that appeared erythematous. Mr [**Known lastname 1794**] was placed on Vancomycin per DrKhabbaz and his discharge was postponed . He continued to progress and was ready for discharge home POD 6 with services on Ciprofloxacin, with plan for wound check Tuesday [**7-15**] at 11am. Plan for follow up on carotids with Dr [**Last Name (STitle) 57956**] (vascular surgery) in 6 months with repeat carotid duplex. Medications on Admission: Terazosin 5mg daily every evening Hyzaar 50-12.5mg one tablet every morning Metoprolol Tartrate 50mg one tablet twice a day Simvastatin 20mg one tablet every morning Aspirin 81mg daily every morning Nitroglycerin SL as needed Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 8. Losartan-Hydrochlorothiazide 50-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0* 10. 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 With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Post operative atrial fibrillation Carotid stenosis Hypertension Hyperlipidemia History of Throat Cancer Discharge Condition: Good Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. 6)Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 2093**] in 1 weeks Dr. [**Last Name (STitle) 3321**] in 3 weeks Dr [**Last Name (STitle) 57956**] (vascular surgery) in 6 months - please call to schedule appointment for office visit with physician and for carotid duplex ultrasound. Wound check appointment Tuesdat [**7-15**] at 11am [**Hospital Ward Name 121**] 6

[ "411.1", "682.3", "433.30", "V10.20", "401.9", "272.4", "E878.2", "414.01", "997.1", "427.31", "788.20", "996.62" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.53", "36.12", "36.15", "88.55", "39.61" ]

icd9pcs

[ [ [] ] ]

6967, 7022

3555, 5408

331, 443

7206, 7219

1984, 3532

7628, 8055

1583, 1619

5685, 6944

7043, 7185

5434, 5662

7243, 7605

1634, 1965

281, 293

471, 1065

1087, 1386

1402, 1567

56,462

196,546

7505

Discharge summary

report

Admission Date: [**2163-8-2**] Discharge Date: [**2163-8-9**] Date of Birth: [**2082-9-15**] Sex: F Service: SURGERY Allergies: Aspirin / Demerol / Penicillins / Dilaudid Attending:[**First Name3 (LF) 2597**] Chief Complaint: 5.6 cm aneurysm of the infrarenal aorta Major Surgical or Invasive Procedure: Retroperitoneal tube graft AAA repair History of Present Illness: She was found to have an abdominal aortic aneurysm by CT scan and she has been asymptomatic from the aneurysm, it was an incidental find. CT angiogram showed diffusely aneurysmal infrarenal aortic segment with a large amount of mural thrombus extending right up to the renal arteries. There is also ectasia and mural thrombus in the suprarenal aorta. The aneurysm extends down to the aortic bifuration. It is about 5.2cm in maximal diameter. The iliac arteries are somewhat calcified and moderately ectatic Past Medical History: 1. Asthma/COPD, 2. HTN 3. rectal CA (s/p radiation and colectomy with colostomy) 4. multiple SBOs 5. Osteoarthritis Past surgical hx: 1. Abdominoperineal resection 2. Appendectomy 3. Ovarian cyst removal 4. Lysis of Adhesions 5. Colostomy 6. Hernia repair 7. Tonsillectomy 8. Adenoidectomy Social History: A former smoker, she used to smoke 2 packs a day for about 60 years. She quit 7 years ago. No alcohol. She is a retired nurse. Family History: Mother had an abdominal aortic aneurysm. No rectal cancer in her family and no other types of cancer in her family. Physical Exam: Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness, obese, incision C/D/I EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: OPERATIVE REPORT ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: 700 cc. COMPLICATIONS: None. INDICATIONS: This 88 year-old lady has a 5.6 cm aneurysm of the infrarenal aorta. She has a history of a previous sigmoid colectomy and with colostomy as well as abdominal radiation for cancer of the rectum. She has had multiple small-bowel obstructions. PROCEDURE: Under adequate general endotracheal anesthesia, the patient was placed in the right lateral decubitus position and after positioning the patient appropriately the left flank and abdomen were prepped and draped in the usual sterile fashion. An oblique incision was made across the flank into the left abdomen in the 11th interspace. The intercostal and oblique muscles were divided and with some difficulty due to the postop changes the retroperitoneal space was entered posterior to the left kidney. The [**Last Name (un) 24412**] retractor was placed after raising the kidney and mobilizing the peritoneum anteriorly. The aorta was exposed. We started the dissection at the left renal artery which was carefully delineated. Working superior to the renal artery, the crus of the diaphragm was incised and the celiac and superior mesenteric arteries were identified. The best area for clamping seemed to be above the renal arteries, since the aneurysm extended right up to the renal arteries. Dissection was then carried distally. The inferior mesenteric artery was ligated. The ureter was mobilize to the right with the peritoneum. There were marked inflammatory changes in the pelvis which made dissection of the iliac arteries hazardous and so no attempt was made to completely expose them. The patient was then heparinized. The left and right renal arteries and superior mesenteric artery were all encircled with vessel loops. With these vessels controlled, a clamp was placed on the aorta just above the renal arteries or below the superior mesenteric artery. Flow was then reestablished into the superior mesenteric artery. A longitudinal aortotomy was then made. A large amount of thrombus and atheromatous debris was removed. A large aortic crossclamp was used on the distal aorta to control backbleeding while the proximal anastomosis was done. Some bleeding lumbar branches were oversewn with silk suture ligatures after removal of calcific plaque over them. It became apparent that the aneurysm actually terminated at the level of the renal arteries. The aorta was transected proximally except for the posterior wall. An 18-mm Dacron graft was then taken. An end-to-end anastomosis was fashioned between the graft and aorta with a running continuous suture of 3-0 Prolene using the graft inclusion technique. The sutures came close to but did not impinge on the orifices of the renal arteries which were carefully visualized. Once this was done, the graft was copiously flushed and clamped distal to the anastomosis and flow was reestablished into both renal arteries. Warm ischemia time was 18 minutes. Attention was turned distally. We opened the aorta the rest of the way down after removing the clamp. There was very brisk backbleeding from both iliac vessels. Balloon occlusion was done from within the aortic sac using 4 mm [**Doctor Last Name **] embolectomy catheters on 3-way stopcocks. Calcific plaque at the bifurcation was then removed. The middle sacral artery was oversewn with a silk suture ligature. The distal end of the graft was trimmed and a second end-to-end anastomosis was fashioned with running continuous suture of 3-0 Prolene, again using the graft inclusion technique. Prior to completing this anastomosis, the iliac vessels and aorta were copiously flushed. Flow was reestablished by compressing both femoral arteries in the groin as best as possible. There was some drop in the blood pressure with restoration of flow to about 85 mm systolic which responded rapidly to blood replacement. Flow was allowed down into the left lower extremity first and then the right lower extremity with no further hemodynamic instability. Heparin was then reversed with protamine. Doppler interrogation demonstrated good flow in both renals and the superior mesenteric artery and there were good pulses in the iliac vessels. The aorta was closed over the graft with 3-0 Prolene. All packs and retractors were then removed. The viscera was allowed to fall back into their normal position. We had entered the pleural cavity posteriorly. A 28 chest tube was placed just in the interspace above our incision and connected to the Pleur-Evac and sutured to the skin. The intercostals were reapproximated with #1 PDS. The transversus abdominis and internal oblique were approximated as 1 layer with a #1 PDS. The part of the latissimus dorsi and the external oblique and anterior rectus sheath were all closed as a single layer with a running continuous suture of double-stranded #1 PDS. 2-0 Vicryl was used to close the subcutaneous tissue and the skin was closed with skin staples. A dry sterile dressing was applied. The patient was returned to the supine position and palpation of her extremities demonstrated palpable dorsalis pedis pulses. She was then taken to the recovery room still intubated but in stable condition. All counts were reported correct. GLUCOSE-142* UREA N-9 CREAT-0.5 SODIUM-141 POTASSIUM-3.8 CHLORIDE-113* TOTAL CO2-20* ANION GAP-12 CHEST (PORTABLE AP) [**2163-8-8**] 9:07 AM AP UPRIGHT RADIOGRAPH OF THE CHEST: The right IJ line is in unchanged position with the tip projecting over the mid SVC. There is significant increase in opacity in the left mid and lower lung fields, most likely representing collapse and/or pleural effusion. Note is made of a narrowed left main stem bronchus which may indicate luminal obstruction causing collapse. The right lung remains clear. There has been interval removal of the NG tube. IMPRESSION: 1. Increase in left-sided pleural effusion and/or left lower lobe collapse. 2. Removal of NG tube. Cardiology Report ECG Study Date of [**2163-8-3**] 11:18:32 PM Sinus rhythm with PVCs Early R wave progression Extensive ST-T changes are nonspecific Low QRS voltages in precordial leads Since previous tracing of [**2163-6-29**], ventricular premature complex seen Intervals Axes Rate PR QRS QT/QTc P QRS T 97 144 88 348/402.57 67 -5 26 Brief Hospital Course: Pt admitted Underwent a retroperitoneal tube graft AAA repair. there were no complications. pt extubated in teh OR. To the PACU. Once recovered from anesthesia sent to the VICU in stable condition. Pt kept on bedrest day 1 / chest tube removed pt diet advanced day 2 / allowed OOB home meds day 3 PT consult day 4 pt remained afebrile in stable condition for rest of hospital course / pt did not have any post operative complications Medications on Admission: lopressor, hydorcodone, colace, advair Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 4 weeks. Disp:*40 Tablet(s)* Refills:*0* 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Discharge Disposition: Extended Care Facility: [**Location (un) **] - [**Location (un) 620**] Discharge Diagnosis: Abdominal Aortic Aneurysm Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-19**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**1-14**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please Call ([**Telephone/Fax (1) 18181**] to make an appointment. Completed by:[**2163-8-9**]

[ "441.4", "493.20", "V10.06", "401.9", "V44.3" ]

icd9cm

[ [ [] ] ]

[ "38.44", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

9864, 9937

8289, 8730

340, 379

10007, 10016

1959, 8266

12756, 12918

1395, 1512

8819, 9841

9958, 9986

8756, 8796

10040, 12303

12329, 12733

1527, 1940

261, 302

407, 919

941, 1233

1249, 1379

11,701

132,469

11711+56272

Discharge summary

report+addendum

Admission Date: [**2102-4-24**] Discharge Date: [**2102-5-2**] Date of Birth: [**2030-2-24**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [**2102-4-25**] - Coronary Artery Bypass Grafting x2 (Internal mammary to the left anterior descending artery, vein to the posterior descending artery). Aortic Valve Replacement (21mm [**Company 1543**] Mosaic Tissue Valve) History of Present Illness: This is a 72-year-old female who developed exertional chest pain. She had a history coronary artery disease. Workup revealed 2-vessel coronary artery disease involving the left anterior descending artery and the distal right coronary artery. Also she had an echocardiogram which demonstrated that she had an aortic valve area of 0.9 cm2. It was noted that she had some ascending aortic calcifications and a CAT scan was obtained of her chest which confirmed a heavily calcified ascending aorta. It was recommended that she undergo coronary artery bypass grafting and replacement of her aortic valve. There is also a possibility that we may have to replace the ascending aorta. After the risks and benefits were explained to her, she agreed to proceed. Past Medical History: MI CAD PVD Aortic stenosis HTN Hyperlipidemia Obesity Diabetes Social History: Retired office worker. Lives alone. Drinks 2 drinks per week. 50 pack year history of smoking quitting three years ago. Family History: None Physical Exam: Admission: VS:112 SR 132/80 GEN: 72 y/o female somewhat SOB HEENT: Unremarkable LUNGS: CTA HEART: RRR, Holosystolic murmur [**1-17**] ABD: Benign EXT: Warm, dry no C/C/E. Well perfused. NEURO: Nonfocal, bilateral carotid bruits Discharge: VS: T97 HR 93 BP 120/52 RR 20 O2sat 95% RA Gen: NAD Neuro: A&Ox3, nonfocal exam Pulm: diminished bases CV: RRR, S1-S2. Sternum stable, incision CDI Abdm: soft, NT/ND/NABS Ext: warm, 1+ pedal edema Pertinent Results: [**2102-4-27**] ECHO PRE-BYPASS: 1. The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). No aortic regurgitation is seen. 6. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. A bioprosthetic valve is wellseated in the aortic position. Leaflets open well. Trace AI is seen, mean gradient across the valve is 16 mm of Hg. 2. Biventricular function is preserved. 3. Other findings are unchanged. [**2102-4-27**] CXR The median sternotomy sutures, ____ replaced aortic valve. The cardiomediastinal contours are unchanged. A minimal hematoma at the place of previous chest tube is demonstrated in the left lower lobe. No pneumothorax or increased pleural effusion is demonstrated. There is no evidence of congestive heart failure. [**2102-5-1**] 07:45AM BLOOD WBC-7.9 RBC-3.46* Hgb-9.9* Hct-28.6* MCV-83 MCH-28.7 MCHC-34.7 RDW-15.0 Plt Ct-266 [**2102-4-25**] 12:35PM BLOOD WBC-18.5*# RBC-3.31*# Hgb-9.4*# Hct-27.1*# MCV-82 MCH-28.5 MCHC-34.7 RDW-15.1 Plt Ct-232 [**2102-4-27**] 02:54AM BLOOD PT-12.6 PTT-29.7 INR(PT)-1.1 [**2102-4-25**] 12:35PM BLOOD Fibrino-243 [**2102-5-1**] 07:45AM BLOOD Glucose-78 UreaN-11 Creat-0.7 Na-135 K-4.2 Cl-98 HCO3-29 AnGap-12 [**2102-4-25**] 02:03PM BLOOD UreaN-16 Creat-0.6 Cl-112* HCO3-24 [**2102-4-28**] 07:55AM BLOOD Mg-2.1 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2102-4-24**] for surgical management of her aortic valve and coronary artery disease. She underwent a CT scan which showed a heavily calcified aorta. On [**2102-4-25**], Ms. [**Known lastname **] was taken to the operating room where she underwent coronary artery bypass grafting to two vessels and an aortic valve replacement using a 21mm [**Company **] mosaic porcine valve. Femoral cannulation was used due to her heavily calcified aorta. Please see operative not for further details. Postoperatively she was taken to the intensive care unit for monitoring. She was transfused for postoperative anemia. On postoperative day one, Ms. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. On postoperative day two, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Over the next several days the patients physical activity progressed slowly and on POD seven it was deciced she was stable and ready for discharge to rehabilitaion at [**Location (un) 29789**] country manor. She will follow-up with Dr [**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Toprol XL 300' Vytorin 10/40' Diovan/HCTZ 80/12.5' Glucophage 1000" Lantus 50 HS ASA 81' Norvasc 5' MVI/Calcium Chromium Dr[**First Name4 (NamePattern1) 37061**] [**Last Name (NamePattern1) 37062**] Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*qs Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Lantus 100 unit/mL Solution Sig: 50 Units Subcutaneous at bedtime. 8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous Qdinner. Discharge Disposition: Extended Care Facility: [**Location (un) **] manor Discharge Diagnosis: AS/CAD s/p AVR(tissue)CABGx2 [**4-25**] MI PVD HTN Dyslipidemia Obesity Diabetes Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Take lasix for 1 week then stop. Take with potassium. Weigh yourself daily. Monitor and replete electrolytes as needed. 8) Call with any questions or concerns. [**Telephone/Fax (1) 170**] [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 1295**] [**Telephone/Fax (1) 6256**] in 2 weeks. Follow-up with Dr. [**Last Name (STitle) 37063**] after discharge from rehab [**Telephone/Fax (1) 37064**] Call all providers for appointments. Completed by:[**2102-5-2**] Name: [**Known lastname 6626**],[**Known firstname **] E Unit No: [**Numeric Identifier 6627**] Admission Date: [**2102-4-24**] Discharge Date: [**2102-5-2**] Date of Birth: [**2030-2-24**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 674**] Addendum: medication correction Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*qs Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous Qdinner. Discharge Disposition: Extended Care Facility: [**Location (un) **] manor [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2102-5-2**]

[ "V45.82", "278.00", "443.9", "424.1", "412", "250.00", "272.8", "401.9", "427.31", "414.01", "276.6" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.15", "39.63", "39.61", "35.21", "99.04", "36.11" ]

icd9pcs

[ [ [] ] ]

9515, 9703

4168, 5602

337, 563

6962, 6969

2067, 4145

1584, 1590

8654, 9492

6858, 6941

5628, 5828

6993, 7811

7862, 8631

1605, 2048

281, 299

591, 1345

1367, 1431

1447, 1568

46,439

132,850

36874

Discharge summary

report

Admission Date: [**2200-11-10**] Discharge Date: [**2200-11-18**] Date of Birth: [**2132-8-11**] Sex: M Service: ORTHOPAEDICS Allergies: Avodart / Niacin Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: [**2200-11-10**] anterior fusion L3-S1 stage 1 Anterior fusion T10-L3 stage 2 on [**11-10**] via thoracotomy stage 2 T10-S1 posterior fusion [**11-11**] stage 3 History of Present Illness: Dr. [**Known lastname 3761**] has a long history of back and leg pain. He has attemptede conservative therapy but has failed. He now presents for surgical intervention. Past Medical History: Dyslipidemia Hypertension Ischemic Heart Disease s/p MIx3, stent x3. Cardiac cath [**2-/2200**] showed no flow limiting epicardial vessels, patent LAD, occluded PDA. hearing loss severe GERD renal insufficiency Cr 1.4-1.6 at baseline Social History: Denies Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles + axial back pain Pertinent Results: [**2200-11-15**] 05:15AM BLOOD WBC-6.2 RBC-3.79*# Hgb-12.2*# Hct-33.7*# MCV-89 MCH-32.1* MCHC-36.1* RDW-15.7* Plt Ct-114* [**2200-11-14**] 03:39AM BLOOD WBC-6.5 RBC-2.87* Hgb-9.3* Hct-25.5* MCV-89 MCH-32.3* MCHC-36.4* RDW-16.1* Plt Ct-97* [**2200-11-13**] 01:27AM BLOOD WBC-8.2 RBC-3.37* Hgb-10.6* Hct-30.2* MCV-90 MCH-31.5 MCHC-35.1* RDW-17.0* Plt Ct-117* [**2200-11-12**] 01:36AM BLOOD WBC-6.0 RBC-2.91* Hgb-9.5* Hct-26.6* MCV-92 MCH-32.7* MCHC-35.7* RDW-15.6* Plt Ct-146* [**2200-11-15**] 05:15AM BLOOD Glucose-114* UreaN-15 Creat-0.6 Na-129* K-3.6 Cl-97 HCO3-25 AnGap-11 [**2200-11-13**] 01:27AM BLOOD Glucose-121* UreaN-17 Creat-0.7 Na-136 K-3.9 Cl-107 HCO3-24 AnGap-9 [**2200-11-11**] 08:17PM BLOOD Glucose-163* UreaN-17 Creat-1.0 Na-136 K-4.4 Cl-105 HCO3-25 AnGap-10 [**2200-11-11**] 04:10AM BLOOD Glucose-136* UreaN-14 Creat-1.0 Na-134 K-4.2 Cl-104 HCO3-25 AnGap-9 [**2200-11-15**] 05:15AM BLOOD Calcium-7.3* Phos-1.9* Mg-1.9 [**2200-11-13**] 01:27AM BLOOD Calcium-7.1* Phos-2.0* Mg-2.0 [**2200-11-11**] 08:17PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7 Brief Hospital Course: Dr. [**Last Name (STitle) 83277**] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2200-11-10**] and taken to the Operating Room for L3-S1 interbody fusion through an anterior approach. In addition, he underwent a fusion T11 to L3 through a thoracotomy. Chest tube placement was performed in the OR. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 he returned to the operating room for a scheduled T10-S1 decompression with PSIF as part of a staged 3-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was low and he was transfused multiple units PRBCs. He was transfered to the SICU for hemodynamic monitoring. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop day one when it was removed. He was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#3 from the second procedure. He was fitted with a TLSO brace for comfort. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Acetaminophen Aciphex Atenolol Atorvastatin Diazepam Ezetimibe Fexofenadine Furosemide Gabapentin Metoclopramide Methocarbamol Multivitamins Nasacort AQ Nitroglycerin SL Omeprazole Ondansetron Prochlorperazine Ranexa Senna Zolpidem Tartrate Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for rash. 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). 9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for angina. 10. metoclopramide 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. methocarbamol 500 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for spasm. 12. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 13. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 15. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. 19. Atrovent Nasal 20. amitriptyline 10 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital 11292**] Health Care Discharge Diagnosis: Scoliosis, spondylosis and spinal stenosis Acute post-op blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Lumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Out of bed w/ assist Thoracic lumbar spine brace: when OOB Treatments Frequency: Please continue to inspect the incisions daily Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days Completed by:[**2200-11-18**]

[ "V45.82", "403.90", "338.18", "285.1", "414.00", "585.9", "721.3", "389.9", "412", "737.30", "530.81", "722.52", "272.4" ]

icd9cm

[ [ [] ] ]

[ "81.05", "03.90", "86.3", "84.52", "78.59", "81.63", "81.04", "80.51", "84.51", "54.19", "77.79", "81.06" ]

icd9pcs

[ [ [] ] ]

6288, 6347

2597, 4339

301, 464

6466, 6473

1519, 2574

8613, 8694

962, 967

4631, 6265

6368, 6445

4365, 4608

6497, 6596

982, 1500

8446, 8520

8542, 8590

6632, 6825

244, 263

6861, 7316

7328, 8428

492, 664

686, 922

938, 946

21,509

166,544

17539

Discharge summary

report

Admission Date: [**2141-2-8**] Discharge Date: [**2141-2-14**] Date of Birth: [**2107-9-2**] Sex: M Service: GOLD SURGERY CHIEF COMPLAINT: Gastroesophageal reflux disease. HISTORY OF THE PRESENT ILLNESS: The patient is a 33-year-old relatively healthy gentleman who flew up from Bermuda for laparoscopic Nissen fundoplication. The patient has been suffering from gastroesophageal reflux disease for five years which has been treated by multiple conservative therapies. Originally, a proton pump inhibitor had provided some relief but over the last year it has become ineffective and the patient suffers with daily pain. The patient underwent upper endoscopy and manometry studies which were all normal. The patient is now presenting for definitive treatment. PAST MEDICAL HISTORY: Knee injury, status post knee surgery six weeks ago. ADMISSION MEDICATIONS: None currently. The patient stopped proton pump inhibitor two weeks ago. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient use to smoke one pack per day for five years, quit two years ago. He drinks approximately two beers per day. He is from Bermuda. He is a diving instructor. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Pulse 73, blood pressure 172/76. General: He is healthy, well appearing. HEENT: The sclerae were anicteric. Neck: Supple. Chest: Clear to auscultation. Heart: Regular rate with no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. Extremities: There was no extremity edema. HOSPITAL COURSE: The patient was taken to the Operating Room and underwent an attempted laparoscopic Nissen fundoplication. The intraoperative note accounts in full detail the events. The end result was a conversion to an open procedure secondary to perisplenic bleeding, a splenectomy, and an open Nissen fundoplication. The patient required intraoperative resuscitation and received 4 units of packed red cells, 4 liters of crystalloid, but remained hemodynamically unchanged during the procedure. Postoperatively, the patient was transferred to the Surgical Intensive Care Unit for close monitoring. The patient had been extubated intraoperatively and remained stable overnight in the Intensive Care Unit. Postoperatively, his hematocrit was 33. His other laboratories were within normal limits. He was left n.p.o. with nasogastric tube in place. On postoperative day number one, there were no events, no further transfusions, and his hematocrit remained stable. He continued to make adequate amounts of urine and his abdomen remained soft and tender with no evidence of continued bleeding. On postoperative day number two, the patient spiked a fever to 102.3. His white count had slightly been elevated and his hematocrit remained stable. A chest x-ray was taken which was not significant for any infiltrate. Blood cultures were sent as well. Following that one temperature spike, the patient remained stable and has subsequently been afebrile. He has been encouraged to be out of bed, use incentive spirometry and deep breathe and cough. The patient was transferred to the floor on postoperative day number three and from there has remained there for the remainder of his recovery. His diet was started on postoperative day number five which he has tolerated. Subsequent to that, he had a bowel movement. His wound remained clean, dry, and intact. He has had no nausea or vomiting. No other episodes of temperatures. The patient is stable and ready for discharge to the hotel where he will remain for a week. He will follow-up with Dr. [**Last Name (STitle) 468**] in the office prior to flying back to Bermuda. On postoperative day number five, he received his vaccinations for Pneumococcal meningococcus, and Hemophilus influenza. He was instructed that if he was to develop fevers, chills, headache, neck pain, or any other signs of illness, he should seek medical attention early due to his post splenectomy status. DISCHARGE CONDITION: The patient is in stable condition, ready for discharge. DISCHARGE DIAGNOSIS: 1. Gastroesophageal reflux disease. 2. Status post laparoscopic Nissen conversion to open procedure. 3. Status post splenectomy secondary to perioperative hemorrhage. 4. Status post vaccinations for splenectomy. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 468**] on Monday, [**2141-2-20**], and will remain in the area as instructed by Dr. [**Last Name (STitle) 468**] before flying back to Bermuda. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2141-2-14**] 10:17 T: [**2141-2-14**] 19:38 JOB#: [**Job Number 48937**]

[ "285.1", "V64.4", "998.11", "530.81" ]

icd9cm

[ [ [] ] ]

[ "44.66", "41.5" ]

icd9pcs

[ [ [] ] ]

4033, 4091

4112, 4806

1578, 4011

888, 1017

161, 787

1242, 1560

810, 864

1034, 1227

18,681

174,535

47455

Discharge summary

report

Admission Date: [**2195-5-1**] Discharge Date: [**2195-5-8**] Date of Birth: [**2164-10-29**] Sex: M Service: MEDICINE, [**Hospital1 **] CHIEF COMPLAINT: Nausea and vomiting. HISTORY OF PRESENT ILLNESS: This is a 30-year-old male with a history of HIV/AIDS, not on therapy, HIV nephropathy, and anemia, who presented with hypocalcemia and acute renal failure from an outside hospital. The patient was in his usual state of health until approximately four weeks prior to admission when he began experiencing daily nausea and vomiting and decreased urine output. The patient denied any fever, chills, chest pain, dyspnea or anorexia. In the Emergency Department, the patient was noted to have acute renal failure with a creatinine of 29 (baseline is approximately 4), hyperphosphatemia at 15.6, acidosis with a bicarb of 14, free calcium 0.59, and pH of 7.3. In the Emergency Department, the patient was treated with 1 L normal saline, 1 L D5W, with 3 amps of Bicarb, 6 amps of Calcium Gluconate. Renal was consulted immediately. PAST MEDICAL HISTORY: 1. HIV diagnosed in [**2194-3-31**]. CD4 count was 89 at that time. HIV nephropathy diagnosed by biopsy showing collapsed focal segmental glomerulonephrosis. 2. Hepatitis C. 3. Anemia. 4. Status post AV fistula placed in [**2194-5-31**]. MEDICATIONS: The patient currently was on HAART therapy but has discontinued it approximately nine weeks prior to admission. SOCIAL HISTORY: The patient lives with mother and three nephews. [**Name (NI) **] smokes approximately one pack per week and occasionally drinks alcohol. ALLERGIES: NO KNOWN DRUG ALLERGIES. PHYSICAL EXAMINATION: Vital signs: On admission the patient was afebrile [**Company 100372**]-max of 99.1??????, blood pressure 106/52, heart rate 94, respirations 16, oxygen saturation 100% on room air. General: The patient was a thin male in no acute distress. HEENT: Anicteric sclerae. Mild thrush. Heart: Regular, rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No costovertebral angle tenderness. Extremities: No edema. His left AV fistula had a bruit. Neurological: Normal. The patient exhibited no asterixis. LABORATORY DATA: Hematocrit 34, platelet count 167; creatinine 29.9, BUN 94, potassium 4.3, glucose 58, calcium 4.0, phosphate 15.6, magnesium 1.7; urinalysis 50 ketones, 500 protein, large blood, no signs of urinary tract infection; urine electrolytes revealed a FEna of 3.5%; initial ABG was with a pH of 7.3, CO2 34, O2 113. Electrocardiogram was normal sinus rhythm at 70 with left axis deviation and increased QTC interval. HOSPITAL COURSE: The patient was admitted to the MICU for stabilization of acute renal failure and hypocalcemic crisis. 1. Hypocalcemia: As noted above, the patient presented with a very low calcium. Electrocardiograms were followed serially until QTCs stabilized to approximately 450. The patient's calcium as checked on a q.6 hour basis and replaced with intravenous Calcium Gluconate as required. Towards the end of his admission, he received p.o. supplementation as well with TUMS. At the time of discharge, his free calcium was consistently approximately 0.99. He will continue TUMS supplementation approximately five times a day, 1000 mg. 2. Acute renal failure: The patient's acute renal failure was most likely secondary to baseline HIV nephropathy exacerbated by noncompliance with HAART therapy. The patient exhibited no signs of uremic confusion, fluid overload or electrolyte abnormalities that were correctable by hemodialysis at the initial presentation; therefore, urgent hemodialysis was deferred until later in the course of the patient's admission. Work-up of the acute renal failure revealed atrophy of the kidneys consistent with irreversible nephropathy. The Renal Team followed the patient throughout his course and determined late in his course that hemodialysis would be necessary, as his creatinine did not improve dramatically. The patient's AV fistula was examined with AV fistulogram and noted to be revisable. Transplant Surgery was consulted, and the patient underwent revision. A central line was placed for the interim while the AV fistula was maturing. The patient began hemodialysis during the last week of his admission. He will continue his hemodialysis as an outpatient at the kidney center. The patient also received Calcitriol and Phosphate binders as per the recommendation of the Renal Team. 3. HIV: The patient was restarted on his HAART medications. His primary care physician was [**Name (NI) 653**], and sufficient follow-up was made. The patient was also seen by Case Management to be certain that the patient could continue HAART medications. The patient continued on prophylactic Bactrim 4.Hepatitis C: No significant elevation in LFTs was noted during admission. Hepatitis C was a nonactive issue. 5. Anemia: The patient's hematocrit was followed on a daily basis. He had a nadir of 24. The patient's Epogen dose was increased to 10,000 U. He did not require transfusion, as he was not symptomatic and was not tachycardiac. 6. Coagulopathy: The patient had elevated coagulation factors with a PTT of 150 following placement of a central line. After applying sufficient pressure, coagulation was obtained. The patient did not require FFP or DDAVP. The patient's transient coagulopathy was thought to be secondary to acute renal failure. DISCHARGE DIAGNOSIS: 1. Acute renal failure leading to end-stage renal disease requiring hemodialysis. 2. Uremic coagulopathy. 3. HIV. 4. Hepatitis C. 5. Anemia secondary to renal failure. DISCHARGE MEDICATIONS: Bactrim single strength p.o. q.d., Efazirenz 600 mg p.o. q.h.s., Stavudine 20 mg p.o. q.d., Lamivudine 50 mg p.o. q.d., TUMS 1000 mg with meals and between meals (5-6 times per day). FOLLOW-UP: The patient will follow-up at the Kidney Center on [**Last Name (LF) 766**], [**2195-5-11**], for next hemodialysis. The patient is also instructed to follow-up with Dr. [**Last Name (STitle) 100373**] as scheduled on Thursday, [**2195-5-14**]. CONDITION ON DISCHARGE: The patient was tolerating a regular diet. He was hemodynamically stable. He is undergoing dialysis. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 100374**] Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. MEDQUIST36 D: [**2195-5-11**] 12:50 T: [**2195-5-12**] 20:47 JOB#: [**Job Number 100375**]

[ "112.0", "070.54", "275.41", "996.73", "585", "584.8", "582.81", "042", "V15.81" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "39.42", "39.50" ]

icd9pcs

[ [ [] ] ]

5729, 6172

5531, 5705

2706, 5510

1666, 2688

172, 194

223, 1054

1076, 1448

1465, 1643

6197, 6655

46,198

153,560

838

Discharge summary

report

Admission Date: [**2102-7-12**] Discharge Date: [**2102-7-19**] Date of Birth: [**2024-1-14**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 64**] Chief Complaint: left hip pain Major Surgical or Invasive Procedure: left total hip replacement - revision History of Present Illness: Mr. [**Known lastname 5849**] was working in his cellar on [**2101-10-1**] when he tripped and fell on a step and sustained a left subcapital hip fracture. As you know, this was treated with an uncemented Osteonics Omnifit hemiarthroplasty on [**2101-10-2**]. This was performed through an anterolateral approach. His postoperative course was uneventful. Over the ensuing months, he did receive treatment from an orthopedic surgeon in [**State 108**], whereby he was given viscosupplementation injections of the left knee. He did not have any improvement of his knee pain at that time. Subsequently, in [**2102-3-13**], he was admitted with pneumonia. At that time, his hip was painful and an x-ray revealed subluxation of the hemiarthroplasty. Aspiration was positive for infection. The aspiration white cell count on [**2102-4-11**] was 35,500 with 97% polys. The patient was then taken to the operating room by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who performed a resection of the hemiarthroplasty, irrigation and debridement, and spacer with antibiotic cement. Tissue culture on [**2102-4-12**] revealed coagulase negative Staphylococcus as well as propionibacterium acnes. The patient was then subsequently treated with intravenous antibiotics and the spectrum was widened to include vancomycin, ceftriaxone, and azithromycin. He was discharged on an antibiotic regimen of vancomycin and ceftriaxone and demonstrated improvement in his fevers and pain. He completed five weeks of intravenous vancomycin. He developed Clostridium difficile infection on [**2102-5-16**] which was treated with Flagyl. For this reason, IV antibiotics were discontinued at five weeks rather than six weeks. Mr. [**Known lastname 5849**] now presents for assessment for reimplantation of the hip. Past Medical History: CAD s/p DES to RCA in [**11-20**] Prostate cancer s/p radical prostectomy [**2093**] Hypertension Hypothyroidism dx early [**2082**] Glaucoma s/p bilateral ankle surgery carpal tunnel s/p surgical release [**2100**] s/p L hernia repair [**2086**] Social History: Pt lives with wife in [**Name (NI) 1468**], recently from nursing home. He denies current tobacco use or illicit drug use. Admits to occasional glass of wine. Used to own a sub shot. Family History: nc Physical Exam: well-appearing, well nourished 78 year old male alert and oriented no acute distress LLE: -dressing-c/d/i -incision-c/d/i, +edema and ecchymosis, no drainage -+AT, FHL, [**Last Name (un) 938**] -SILT -brisk cap refill -calf-soft,nontender -NVI distally Brief Hospital Course: ICU course: Pt transfered to the ICU for post op care in setting of hypotension. He was put on low dose pressors for hypotension thought to be hypovolemic in nature [**Last Name (un) **] surgery and blood loss. He was noted to have anemia and was transfered a total of 5 UPRBC over the course of 2 days. Pt quickly improved, weaned off pressors, and BP and HCT stabalized. He was given Vancomycin 1g [**Hospital1 **] for septic arthritis. He was tranfered to the ortho service in stable condition. The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: ****** Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Mr [**Known lastname 5849**] is discharged to rehab in stable condition with prescriptions for lovenox and hydromorphone. Medications on Admission: tylenol, ASA, colace, flovent, levoxyl, losartan, lovenox, metoprolol succinate, morphine, neurontin, miralax, plavix, simvastatin, tramadol, brimonidine, timolol, travaprost eye gtts, vit B12 Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily). Disp:*21 syringe* Refills:*0* 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Left hip osteomyelitis/septic arthritis 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for an additional three weeks. You may restart your plavix once you have finished lovenox. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing as tolerated on the operative extremity. Posterior hip precautions. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2102-8-11**] 11:40 Completed by:[**2102-7-19**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2139-2-2**] Discharge Date: [**2139-2-9**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1257**] Chief Complaint: Fever, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old male with COPD on home O2 (2-3L) and frequent PNA who presented yesterday to the ER from his nursing home with fever, hypoxia and altered mental status. Sats were in the 50s and came up to 90s with NRB by EMS. In the ED his rectal temp was 102. A CXR demonstrated a LLL PNA. Labs notable for acute on chronic kidney injury and hyperkalemia. He also had a positive UA. Of note, he was recently admitted for hematuria and had bladder fulgeration on [**2139-1-28**]. Has also been getting PO vanc for C. Difficile infection. In the ER he was given vanc, zosyn, flagyl. EKG without ischemic changes or peaked T-waves, no QRS widening. He received insulin/glucose, calcium and kayexelate. His saturation was up to 92% on 4L, however he was admitted to the ICU given the high oxygen requirement. ROS positive for cough productive of green phlegm, and chronic chest pain, abdominal (suprapubic), and rectal pain, which are all unchanged. Has burning sensation when he urinates. Constipated. Otherwise negative. Past Medical History: 1. prostate ca s/p XRT [**2119**] 2. bladder ca, papillary urothelial carcinoma, high grade (dx in [**2133-3-20**]), nonmetastatic (negative cystoscopy [**8-24**]) -most recent cystoscopy and bladder resection in [**2138-7-20**] 3. lumbar fracture L5 -- w/multiple steroid injections, previously on chronic opioid therapy 4. COPD on [**1-22**] L of home O2 (PFTs [**12-27**]: FVC 89% predicted, FEV1 82% predicted and FEV1/FVC 93% predicted) 5. PUD with GIB in [**2120**] 6. hx of rheumatic fever 7. hx of CVA 8. s/p appendectomy 9. s/p lap chole in [**2122**] 10. chronic LE edema 11. tachy-brady syndrome s/p pacer [**39**]. afib-aflutter - was on coumadin, however this was stopped [**2139-1-19**] given hematuria. 13. Parkinsons Disease 14. LGIB secondary to rectal ulcer:[**Date range (3) 96242**] with rectal ulcer s/p sigmoidoscopy and cauterization. 15. stage III chronic kidney disease 16. Melanoma, s/p removal Social History: Patient is currently at [**Hospital 169**] Center with the help of a caretaker, [**Name (NI) 3065**]. [**Name2 (NI) **] smoked [**1-23**] ppd for 30 years, quit 10 years ago. He currently does not drink EtOH. Family History: Non-contributory Physical Exam: Admission physical exam VITALS: 98.9, 61, 134/45, 17, 93% on 2-4L. GENERAL: Elderly male appearing younger than his stated age, breathing comfortably in bed, telling jokes. NECK: No JVD. COR: Irregularly irregular rhythm. Heart sounds are distant. LUNGS: Diffuse rhonchi and coarse upper airway sounds. ABD: Distended, tympanitic. Normoactive bowel sounds and non-tender, without rebound or guarding. EXTR: Heals are wrapped in kerlix. No edema. PSYCH: Patient's affect is full. He is cooperative and answering questions appropriately. Occasionally loses his train of thought and repeats things he already said. GU: Foley catheter in place, urethral meatus without ulceration. Pertinent Results: CHEST X-RAY FINDINGS [**2139-2-3**]: Patient's condition required examination in sitting semi-upright position using frontal AP and left lateral projection. Comparison is made with the next previous chest single AP chest view examination of [**2139-1-24**] as well as a more recent single chest view of [**2139-2-2**]. Moderate cardiac enlargement and elongation of generally widened thoracic aorta as before. Unchanged position of previously described left-sided permanent pacer with dual intracavitary electrode system. Already on examination of [**1-24**], the patient had bilateral plate atelectasis but no conclusive evidence for pleural effusions. On [**2-2**], the portable single view examination demonstrated an increased density on the left base obscuring the diaphragmatic contour and suggesting the presence of an increased atelectasis. Today's AP and lateral chest views again demonstrate the presence of a diffuse density in the left base, most likely representing atelectasis or pneumonic infiltrate. On the lateral view, one can identify an increased density along a major fissure supporting the assumption that pleural effusion has developed. The patient's respiratory effort appears limited as the diaphragmatic contours are relatively high and the basal lung vasculature is markedly crowded. Most likely diagnosis is increasing CHF probably with superimposed left basal atelectasis or infection. No pneumothorax is present. Renal ultrasound [**2139-2-2**] IMPRESSION: Mild right pelvicaliectasis and extrarenal pelvis similar to the CT from [**2139-1-25**], but slightly more prominent compared to the US from [**2139-1-2**]. [**2139-2-3**] VIDEO SWALLOW EXAMINATION: TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There is trace penetration of thin liquids, but no gross aspiration. For full details, please refer to speech and swallow division note in the OMR. IMPRESSION: Trace penetration of thin liquids with no evidence of aspiration. Labs: [**2139-2-2**] 12:25PM WBC-8.5 RBC-2.90* HGB-8.5* HCT-26.3* MCV-90 MCH-29.2 MCHC-32.3 RDW-14.9 [**2139-2-2**] 12:25PM NEUTS-83.9* LYMPHS-9.3* MONOS-5.7 EOS-0.9 BASOS-0.2 [**2139-2-2**] 12:25PM GLUCOSE-117* UREA N-56* CREAT-3.2* SODIUM-138 POTASSIUM-6.3* CHLORIDE-103 TOTAL CO2-26 ANION GAP-15 [**2139-2-2**] 01:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2139-2-2**] 01:00PM URINE HOURS-RANDOM CREAT-108 SODIUM-64 POTASSIUM-54 CHLORIDE-49 [**2139-2-2**] 12:25PM cTropnT-0.09* [**2139-2-2**] 08:10PM CK-MB-4 cTropnT-0.08* [**2139-2-2**] 08:10PM CK(CPK)-303 [**2139-2-6**] 06:30AM BLOOD WBC-7.8 RBC-2.74* Hgb-7.9* Hct-26.7* MCV-98 MCH-28.9 MCHC-29.6* RDW-14.7 Plt Ct-287 [**2139-2-2**] 12:25PM BLOOD WBC-8.5 RBC-2.90* Hgb-8.5* Hct-26.3* MCV-90 MCH-29.2 MCHC-32.3 RDW-14.9 Plt Ct-292 [**2139-2-2**] 12:25PM BLOOD Neuts-83.9* Lymphs-9.3* Monos-5.7 Eos-0.9 Baso-0.2 [**2139-2-4**] 07:10AM BLOOD PT-14.8* PTT-32.1 INR(PT)-1.3* [**2139-2-2**] 12:25PM BLOOD PT-14.2* PTT-30.1 INR(PT)-1.2* [**2139-2-6**] 06:30AM BLOOD UreaN-35* Creat-2.2* Na-142 K-4.5 Cl-108 HCO3-29 AnGap-10 [**2139-2-2**] 12:25PM BLOOD Glucose-117* UreaN-56* Creat-3.2* Na-138 K-6.3* Cl-103 HCO3-26 AnGap-15 [**2139-2-2**] 12:25PM BLOOD ALT-17 AST-36 LD(LDH)-292* AlkPhos-67 TotBili-0.2 [**2139-2-2**] 12:25PM BLOOD cTropnT-0.09* [**2139-2-2**] 08:10PM BLOOD CK-MB-4 cTropnT-0.08* [**2139-2-2**] 08:10PM BLOOD CK(CPK)-303 [**2139-2-3**] 05:21AM BLOOD Calcium-7.4* Phos-4.3 Mg-1.9 [**2139-2-2**] 12:25PM BLOOD Albumin-3.1* [**2139-2-3**] 05:21AM BLOOD VitB12-474 [**2139-2-3**] 05:21AM BLOOD TSH-0.90 [**2139-2-2**] 12:35PM BLOOD Lactate-1.0 [**2139-2-2**] 12:25 pm BLOOD CULTURE x 2 Blood Culture, Routine (Pending): [**2139-2-2**] 1:29 pm URINE Site: CATHETER **FINAL REPORT [**2139-2-3**]** URINE CULTURE (Final [**2139-2-3**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2139-2-2**] 6:21 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [**2139-2-5**]** Respiratory Viral Culture (Final [**2139-2-5**]): 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 [**2139-2-3**]): 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. [**2139-2-4**] 2:23 pm URINE Source: CVS. **FINAL REPORT [**2139-2-5**]** URINE CULTURE (Final [**2139-2-5**]): <10,000 organisms/ml. Brief Hospital Course: [**Hospital **] HEALTHCARE ASSOCIATED PNEUMONIA: we found an infiltrate on CXR and fever to 102 F. He had several hospitalizations for the same diagnosis and was treated during last admission with vancomycin and zosyn x 12 days. There was concern for ongoing aspiration. However on a bedside and video swallow examination there was no clear evidence of aspiration. The patient was treated with IV vancomycin and cefepime for pneumonia and PICC line placed in interventional radiology on [**2-6**]. However, despite treatment his symptoms did not improve. He remained with significant wheezing and hypoxia. The antibiotics were discontinued after we had several discussions with patient, his care giver and HCP who agreed regarding hospice care. This is because of very frequent admissions back to back during the last several months without improvement in the quality of life and the presence of several advanced diseases including recurrent bladder cancer, advanced CKD and COPD, dementia and parkinsons that limit life expectancy (see below). ACUTE ON CHRONIC KIDNEY DISEASE: His baseline creatinine is about 2.3. He had [**Last Name (un) **] on admission (up to 3.2) but improved with rehydration. His lasix was discontinued. BLADDER AND PROSTATE CANCER: Has had ongoing hematuria which cleared to dark yellow urine upon discharge. Foley was placed on admission and this was discontinued when he was transferred to the medical floor. He was followed by his urologist Dr. [**Last Name (STitle) 770**] as an outpatient. C DIFF COLITIS: He had no active diarrhea and his treatment dose of oral vancomycin was continued while on other antibiotics but should be tapered by 1 dose per day on a weekly basis (3 week taper) following his completion of vanc/cefepime on [**2-12**]. However, during this admission, he developed progressive abdominal distention and tympany. KUB showed lots og gas. A CT was not done per HCP as he requested hospice care and no more diagnostic tests. PAROXYSMAL ATRIAL FIBRILLATION: We continued amiodarone and beta blocker. Coumadin was previously discontinued because of bleeding complications (the most recent being transfusion dependent severe hematuria with resulting R kidney obstruction likely from hematoma and blood clots). HYPERTENSION, BENIGN: He was continued on his toprol but we stopped amlodipine. HYPERLIPIDEMIA: We stopped Simvastatin because of comfort measures. COPD: Standing albuterol/ipratropium nebs while inpatient. PARKINSON'S DISEASE: Continued home sinimet. DEPRESSION: Continued quetiapine and stopped mirtazapine GERD: Stopped omeprazole. BILATERAL HEEL ULCERATIONS: Wound care recs Pressure ulcer care per guidelines: Turn and reposition off back q 2 hours and prn Limit sit time to 1 hour at a time using a pressure redistribution cushion For both heels : Cleanse with wound cleanser then pat dry moisturize periwound tissue with aloe vesta For right heel : apply wound gel to Adaptic dressing then follow with dry gauze and ABD pad, wrap with Kerlix For left heel : Dry ABD pad, wrap with Kerlix change daily GOUT: stopped allopurinol. DELIRIUM/DEMENTIA: with waxing and weaning mental status HEALTH CARE PROXY/GOALS OF CARE: We had several discussions with his [**Month/Year (2) **] [**Name (NI) **] [**Name (NI) 96246**] (Phone: [**0-0-**] Cell: [**0-0-**] as he was his HCP) regarding goal of care and hospice. Initially, the patient wished to be full code. The patient's PCP was involved in his care while inpatient and discussed with the patient his medical care. The patient was not clear enough to make this decision (to change his code status to DNR/DNI) so he remained full code (initially). However, he later had some lucid times were he agreed to be DNR/DNI with comfort measures after discussion with his HCP. I discussed the goal of care and prognosis again with his his [**Year (4 digits) **] [**Name (NI) **] [**Name (NI) 96246**] and his care giver. Both strongly agreed regarding hospice care, comfort measures and no rehospitalizations. His code status was changed and most of his medications were discontinued. He was placed on oral morphine. Medications on Admission: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO MON, WED, FRI. 3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): 4x per day for 7 days then taper by 1 capsule per week until off. 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation twice a day. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 18. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 19. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Florastor 250 mg Capsule Sig: One (1) Capsule PO once a day: start after PO vancomycin is finished. Discharge Medications: 1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for continuing treatment of C.diff: take 4 times daily until [**2-12**], then taper by 1 capsule / day every week. 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 18. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 19. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours): last day [**2-12**]. 21. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours): last day [**2-12**]. 22. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a day. 23. Florastor 250 mg Capsule Sig: One (1) Capsule PO once a day: start taking after oral vancomycin is finished. Discharge Disposition: Extended Care Facility: [**Location (un) 169**] - Heathwood/ [**Location (un) 55**] Discharge Diagnosis: Primary Diagnosis: Health care associated pneumonia C diff colitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with pneumonia and treated with antibiotics. Please take your medications as prescribed and make your follow up appointments. Followup Instructions: Department: SURGICAL SPECIALTIES When: THURSDAY [**2139-3-5**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 5727**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "008.45", "599.0", "584.9", "427.32", "276.7", "707.23", "V49.86", "486", "707.07", "188.8", "491.21", "518.0", "332.0", "585.3" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

16920, 17006

8545, 12679

264, 270

17117, 17117

3255, 7182

17480, 17784

2524, 2542

14743, 16897

17027, 17027

12705, 14720

17295, 17457

2557, 3236

7217, 8522

210, 226

298, 1334

17046, 17096

17132, 17271

1356, 2280

2296, 2508

82,828

120,953

3319

Discharge summary

report

Admission Date: [**2127-8-9**] Discharge Date: [**2127-8-15**] Date of Birth: [**2064-9-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2042**] Chief Complaint: altered mental status and fall Major Surgical or Invasive Procedure: None History of Present Illness: 62 year old male with metastatic prostate cancer now presenting with delirium s/p fall. pt's wife called this am stating that last night, pt was acting "crazy, not himself" and had an unwitnessed fall. needs to come in for eval for delirium and s/p fall. Wife reports that patient was not feeling well last night and opted not to go out to dinner. This morning around 3am, came into bedroom and fell. Patient reports falling onto bottom without headstrike. + cough. No abdominal pain or dysuria. Triggered on arrival for hypoxia. Patient on coumadin for history of PE in [**Month (only) 1096**]. . In the ED, initial vitals were 99.0 120 110/64 18 84% RA. Rectal temperature was 102.8, patient was guaiac negative. CBC was significant for white blood cell count 0.4K, ANC 144, no bands, with hematocrit of 25.7 from baseline 30s, platelet count of 36K. Chem10 was significant for anion gap of 15. Lactate was 2.3. INR was 3.8 with goal INR [**2-28**], and patient was given 10 mg IV vitamin K, FFP and platelets. LFTs were unremarkable. Troponin was normal. Urinalysis showed 7 RBCs, 1 WBCs, no leuks. ECG showed sinus tachycardia to 112 bpm, nl axis, nl intervals, with <[**Street Address(2) 4793**] depressions inferolaterally. Chest X-ray showed possible left lower lobe consolidation. CTA torso showed no evidence of traumatic injury, no pulmonary emboli, but with left lung base consolidation, likely infection or aspiration. CT head showed a 9 x 5 mm hyperattenuating focus overlying the right frontal region, which may represent intracranial hemorrhage or contusion, consider dural metastasis, no fracture. CT C-spine showed no acute fracture or malalignment. Patient received vancomycin/cefepime for febrile neutropenia and likely pneumonia. Heme/Onc was consulted and stated that it was OK for patient to get platelets and reverse INR. Neurosurgery was consulted who noted a small subdural hemorrhage and recommended repeat head CT tomorrow ([**8-10**]). In the [**Name (NI) **], pt was febrile to 102.8 and on 4LNC at 88%, so he was placed on a non-rebreather and was satting 97% but hypoventilating. Pt triggered twice in the ED for BP (unclear how low) and responded to 4L total NS. On arrival to the MICU, patient's VS were T98.0 HR96 BP 108/56 R22 96% non rebreather. Pt was able to confirm limited history as above. History was primarily obtained from wife. Pt denied fevers, chills, though wife reports he has been "clammy" and with rhinorhea the last few weeks, no shortness of breath, chest pain, headaches, sore throat, diarrhea, some constipation (baseline), no BRBPR, no melena, no dysuria, no numbness/tingling, no new pain. Past Medical History: - Prostate cancer dx in [**2111**], mets to back found in [**2125**]. - hypercholesterolemia - diabetes mellitus, insulin dependent, type II - GERD - history of polio in [**2070**] - pulmonary embolism [**1-6**] - on Coumadin Social History: The patient worked for a textile company that makes lab coats and other linens. He is married. He lives with his wife in [**Name (NI) 47**]. He has two daughters (one in CT and one in CA) and one grandson. Family History: Non contributory Physical Exam: Admission Exam: General: Alert, oriented to person, place, time but occassionally drifts off, difficulty finishing sentences due to attention (not due to respiratory status), unable to give clear history HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Lungs: Clear to auscultation bilaterally Abdomen: soft, non-distended, mild tenderness to palpation, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Exam: Pertinent Results: Admission Labs: [**2127-8-9**] 10:00AM BLOOD WBC-0.4* RBC-2.86* Hgb-8.5* Hct-25.7* MCV-90 MCH-29.6 MCHC-32.9 RDW-20.5* Plt Ct-36* [**2127-8-9**] 10:00AM BLOOD Neuts-36* Bands-0 Lymphs-36 Monos-28* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2127-8-9**] 10:00AM BLOOD PT-39.0* PTT-38.4* INR(PT)-3.8* [**2127-8-9**] 10:00AM BLOOD Glucose-167* UreaN-20 Creat-1.1 Na-138 K-4.3 Cl-102 HCO3-21* AnGap-19 [**2127-8-9**] 10:00AM BLOOD ALT-17 AST-23 AlkPhos-105 TotBili-1.1 [**2127-8-9**] 10:00AM BLOOD Albumin-4.0 [**2127-8-9**] 08:53PM BLOOD Calcium-7.0* Phos-1.2* Mg-2.1 [**2127-8-9**] 07:05PM BLOOD Type-ART pO2-169* pCO2-33* pH-7.45 calTCO2-24 Base XS-0 [**2127-8-9**] 07:06PM BLOOD Type-[**Last Name (un) **] pO2-30* pCO2-53* pH-7.30* calTCO2-27 Base XS--1 [**2127-8-9**] 10:14AM BLOOD Lactate-2.3* [**2127-8-9**] 10:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2127-8-9**] 10:40AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG [**2127-8-9**] 10:40AM URINE RBC-7* WBC-1 Bacteri-FEW Yeast-NONE Epi-1 Urine Culture [**8-11**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood cultures 7/16: PENDING EKG [**8-9**]: Sinus tachycardia. Non-specific ST segment changes. Compared to the previous tracing of [**2127-1-21**] the rate has increased. CT C-spine w/out contrast [**8-9**]: IMPRESSION: No evidence of acute fracture or malalignment in c spine. Multilevel degenerative joint changes, as described above. Diffuse sclerosis of the C7 vertebral body is compatible with patient's known history of metastatic disease. Associated soft tissue mass at that level is better seen on prior MRI exam. Correlate clinically to decide on the need for further workup. CT Head w/out contrast [**8-9**]: IMPRESSION: 9 x 5 millimeter dense focus in the right frontal region is new since [**2127-1-21**] exam, and may represent a focus of intracranial hemorrhage- subdural with/without adjacent focus of contusion. Consider close followup to exclude other etiologies such as dural based lesions and if needed MRI if not CI. CXR [**8-9**]: IMPRESSION: Increased left basal opacity may reflect developing pneumonia. CTA Chest w/ and w/out contrast [**8-9**]: IMPRESSION: 1. No evidence of acute traumatic injury. No evidence of acute aortic syndrome or PE. 2. Left lung base consolidation, likely infection or aspiration in the appropriate clinical setting. 3. Multiple hepatic hypodense lesions, many of which appear stable and compatible with hemangiomas. A 1.2 x 1 cm hypodense lesion in segment VII appears new since prior exams, concerning for metastatic disease. 4. A 1.4 x 1.5 cm hypodense lesion in the left adrenal gland is new since prior exam, incompletely characterized on today's exam, highly concerning for a new metastatic focus. 5. Focal renal hypodensities, too small to characterize, likely cysts. 6. Small hiatal hernia. 7. Diffuse sclerotic lesions in the visualized axial and appendicular skeleton, compatible with the patient's known history of osseous metastatic disease, largely unchanged since [**2127-6-10**]. Few areas suggestive of early cortical breakthrough and impingment on central central canal. CXR [**8-10**]: FINDINGS: As compared to the previous radiograph, the lung volumes have decreased. As a consequence, there is crowding of the vascular and bronchial structures at both lung bases. In addition, mild areas of atelectasis have newly appeared, the atelectasis are more severe on the left than on the right. Borderline size of the cardiac silhouette without pulmonary edema. Blunting of the left costophrenic sinus, potentially caused by a minimal pleural effusion. CT Head w/out contrast [**8-10**]: IMPRESSION: 1. No interval change in tiny right subdural hematoma compared with prior exam. 2. Interval increase in concentric mucosal thickening of the left maxillary sinus, concerning for acute sinusitis. 3. Small fat containing focus anterior to Basilar A. tip- as detailed above. . [**2127-8-14**] Swallowing study: Mr. [**Known lastname 15379**] [**Last Name (Titles) 8337**] thin liquids and regular solids without concern for oral and pharyngeal dysphagia. His complaint is related to nausea that can occur without and without PO, happening this morning at 6 am without food or liquid. He is being medicated with some effect, but continues to have breakthrough symptoms. At this time, diet does not need to be modified and he can remain on a regular diet with thin liquids and can take meds whole with water. Please reconsult if there are any further concerns. . This swallowing pattern correlates to a Functional Oral Intake Scale (FOIS) rating of 7 . RECOMMENDATIONS: 1. PO diet of thin liquids and regular consistency solids 2. Meds whole with water 3. [**Hospital1 **] oral care 4. Continue trying to treat nausea as able . Brief Hospital Course: Assessment and Plan: 62 year old male with metastatic prostate cancer and h/o PE on coumadin now admitted with altered mental status, neutropenic fever and subdural hemorrhage s/p fall. Initially admitted to the [**Hospital Unit Name 153**] for sepsis, hypoxemia, and pneummonia. He was started on cefepime and vancomycin, stabalized and transferred to the floor without requiring intubation. . #Severe sepsis: At the time of admission, the patient had febrile neutropenia, altered mental status, and hypoxia. On his CT chest, a left lung base consolidation was seen that was consistent with aspiration pneumonia or pneumonia. Pt was started on cefepime and vancomycin. Fevers resolved and respiratory status resolved such that patient was on room air at time of transfer to the floors. Patient was hemodynamically stable at time of transfer. Patient's mental status had also improved significantly and he was fully oriented and able to interact and attend to conversations normally at time of transfer to the floor. . #Subdural hematoma: Patient fell at home prior to admission and was found to be supratherapeutic on his coumadin. The patient's coumadin was held and he received FFP and Vit K with a slow decrease in INR down to 1.5 at time of transfer to the floor. Neurosurgery saw the patient in the ED and recommended repeat head CT which showed stable subdural hematoma. Per outpt records, the plan was to continue lifelong anticoagulation as his previous pulmonary embolism was thought to be related to his metastatic protate cancer. After discussion with patient's primary oncologist, Dr. [**Last Name (STitle) **], his coumadin will continue to be held at the time of discharge and further anticoagulation will be addressed as an outpatient. . # LLL pneumonia noted on CTA with tachypnea: tachypnea resolved on antibiotics. Not hypoxemic. THe day prior to discharge the patient was changed from vancomycin and cefepime to cefpodoxime. He remained stable and afebrile and will complete a full course of antibiotic at home. . #Pain: From metastases. Continued home oxycodone 10mg PO q4hrs PRN pain. Initially held home fentanyl patch as absorption can be increased in febrile pts. However, this was restarted approximately 24hrs after admission (and pt remained afebrile). . #Metastatic prostate CA: New CT finding: A 1.4 x 1.5 cm hypodense lesion in the left adrenal gland is new since prior exam highly concerning for a new metastatic focus. Initially held methylphenidate, and prochlorperazine PRN, but restarted methylphenidate at discharge. Continued home prednisone. . #Depression/Anxiety: Continued home citalopram. Held home lorazepam due to altered mental status which resolved prior to transfer to the floor. . #HLD: Discontinued home pravastatin 20mg PO daily given his overall prognosis. . #Diabetes: Held home lantus and humalog. Started Humalog insulin sliding scale. . #GERD: Continued omeprazole 40mg PO daily . #Allergic rhinitis: Held home azelastine nasal spray . #febrile neutropenia with septic hemodynamics on presentation: Neutropenia resolved [**2127-8-13**]. BP now stable, altered mental status is cleared. Fevers resolved. Neutropenia resolved. Follow up blood and Urine cultures as outpatient. Changed vanc and cefepime to cefpodoxime prior to discharge. . # Metabolic Encephalopathy: due to fever and neutropenia, now back to baseline per wife and patient. Medications on Admission: 18 FRENCH RED ROBNEL CATHETER - - self catheterize as instructed once a day AZELASTINE - (Prescribed by Other Provider) - 137 mcg (0.1 %) Aerosol, Spray - 1 spray intranasally CITALOPRAM - 10 mg tablet - 1 Tablet(s) by mouth daily FENTANYL - 100 mcg/hour Patch 72 hr - apply 2 patches every 72 hours (3 days) INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 20 units at bedtime INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - [**3-2**] untis three times a day as needed for based on sliding scale LEUPROLIDE [LUPRON] - (Prescribed by Other Provider) - Dosage uncertain LORAZEPAM - 1 mg tablet - 1 Tablet(s) by mouth Q8hr as needed for anxiety, insomnia METHYLPHENIDATE - 10 mg tablet - 1/2-1 Tablet(s) by mouth twice a day as needed for for cancer related fatigue take at 8 am and noon OMEPRAZOLE - 40 mg capsule,delayed release(DR/EC) - 1 Capsule(s) by mouth DAILY (Daily) OXYCODONE - 10 mg tablet - [**1-27**] Tablet(s) by mouth every 3 hours as needed for pain PRAVASTATIN - (Prescribed by Other Provider) - 20 mg tablet - 1 Tablet(s) by mouth daily PREDNISONE - 10 mg tablet - 1 Tablet(s) by mouth daily PROCHLORPERAZINE MALEATE - 10 mg tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea WARFARIN - (Prescribed by Other Provider) - 5 mg tablet - 1.5 (One and a half) Tablet(s) by mouth once a day As directed by PCP Medications - OTC DOCUSATE SODIUM - (Prescribed by Other Provider) - 50 mg/5 mL Liquid - 1 Liquid(s) by mouth twice a day SENNOSIDES [SENNA] - (Prescribed by Other Provider) - 8.6 mg tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 100 mg 2 tablet(s) by mouth twice a day Disp #*40 Each Refills:*0 2. 18 French Red Robnel Catheter Self catheterize as instructed once a day 3. azelastine *NF* 137 mcg NU daily prn allergy symptoms 4. Citalopram 10 mg PO DAILY 5. Fentanyl Patch 200 mcg/hr TP Q72H RX *Duragesic 100 mcg/hour two patches every 72 hours Disp #*10 Each Refills:*0 6. Glargine 20 Units Bedtime 7. Lispro (Humulog) 100unit/ml cartridge [**3-2**] units three times a day as needed based on sliding scale 8. Lupron as directed (prescribed by other provider) 9. Lorazepam 1 mg PO Q8H:PRN anxiety , insomnia 10. MethylPHENIDATE (Ritalin) 5-10 mg PO 8AM AND NOON PRN cancer fatigue 11. Omeprazole 40 mg PO DAILY 12. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain RX *oxycodone 10 mg [**1-27**] tablet(s) by mouth Q3H:PRN Disp #*60 Each Refills:*0 13. PredniSONE 10 mg PO DAILY 14. Senna 1 TAB PO BID Hold for loose stools 15. Docusate Sodium 100 mg PO BID Hold for loose stools 16. Metoclopramide 10 mg PO TID BEFORE MEALS PRN nausea with meals RX *metoclopramide HCl 10 mg 1 tablet by mouth TID prn before meals Disp #*30 Each Refills:*1 17. Codeine Sulfate 15-30 mg PO HS:PRN cough You may need more senna and colace to prevent constipation RX *codeine sulfate 15 mg [**1-27**] tablet(s) by mouth QHS:PRN Disp #*30 Each Refills:*0 Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Prostate cancer with [**Last Name (un) 2043**] metastases Subdural hematoma Pneumonia diabetes mellitus, insulin dependent, type II GERD pulmonary embolism [**1-6**] - Coumadin stopped this admission due to subdural hematoma with fall 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 after a fall and required hospitalization in the intensive care unit for a subdural hematoma (blood clot under your skull), fever, neutropenia (low white blood cell count) and pneumonia. Your hematoma is very small and has been stable. Your coumadin (warfarin) blood thinner was stopped. Your low white blood count was from your recent chemotherapy and is recovering. Your pneumonia was treated with IV antibiotics and changed to antibiotics by mouth (Cefpodoxime) that you should continue to take for 10 days. Your coughing is from pneumonia. A swallowing study did NOT show that you are choking when you eat food or drink liquids. You can take codeine to decrease your cough at night. . The following changes were made to your medications: STOP Prochlorperazine (compazine) take metaclopromide (reglan) instead STOP Pravastatin STOP Warfarin (coumadin) START Metaclopromide (reglan) one before meals as needed for nausea with meals START Cefpodoxime 2 pills twice daily for 10 days START Codeine 15-30 mg at bedtime as needed for cough Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2127-8-19**] at 1 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 10784**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2127-8-19**] at 2:00 PM With: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN [**Telephone/Fax (1) 9644**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2127-9-9**] at 11:00 AM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 10784**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "V12.55", "348.31", "185", "V87.41", "288.04", "300.00", "287.5", "198.5", "V58.67", "285.9", "V12.02", "852.21", "995.92", "038.9", "493.00", "518.81", "E934.2", "V58.61", "530.81", "311", "507.0", "V45.89", "276.8", "338.3", "E884.4", "780.61", "250.00", "V49.86" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15559, 15608

9109, 12509

335, 341

15887, 15887

4166, 4166

17152, 18122

3528, 3546

14167, 15536

15629, 15866

12535, 14144

16072, 17129

3561, 4129

4147, 4147

264, 297

369, 3035

4182, 9086

15902, 16048

3057, 3285

3301, 3512

78,532

177,956

6857

Discharge summary

report

Admission Date: [**2159-5-7**] Discharge Date: [**2159-5-9**] Date of Birth: [**2117-5-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2763**] Chief Complaint: found down Major Surgical or Invasive Procedure: Left internal Jugular central line placed Right femoral dialysis catheter placed History of Present Illness: 40 yo male known to be HIV positive with unknown other medical problems, was found down 30 minutes PTA with altered mental status. It is unclear when he was last seen at baseline. EMS was called by patient's GF, who was also reportedly altered. BS in the field was 29, and EMS was unable to obtain access so patient was brought to [**Hospital1 18**]. . In the ED, patient received an amp of D50 and repeat FS was 250. Patient was started on D5 drip and mental status started to improved, and FS was 296 on first check in the ED. Initial exam was notable for dense left hemiparesis, right sided cojugate gaze, left facial droop and jaundice. Labs were notable for lactate 15.8, ph 7.03 on venous gas, AGMA 37, Cr of 5.7, BUN 43, tranaminases in the 100s, Tbili 10.8, INR 4.6, WBC 17.8, Hct 35.1, plts 232, positive UA and positive u tox for methadone and opiates. Code stroke was called for left sided weakness, and CT noncontrast showed right sided subacute infarct. Neuro advised CTA head and neck, but this was deferred given Cr of 5.7. Patient received 5L NS, vancomycin and ceftriaxone. 2 PIVs were obtained. Mental status and left sided weakness improved, and patient per nursing report was oriented and interactive. Patient was being prepared to come to the ICU when he seized GTC movements. FS during seizure was 88. Patient received ativan 5 mg and was loaded with dilantin. Patient was intubauted, and OG tube put out 650cc coffee ground emesis. Peri-intubation patient received etomidate 20 mg and Rocuronium 80 mg. He was started on a PPI drip and octreotide drip. First ABG was 6.94/40/345, for which patient recieved 1 amp of bicarb. Prior to transfer, VS were 118, 97/51, 24, 100% on TV 450 RR 24 PEEP 5 FiO2 0.1. . In the ICU, patient was intubated and sedated. Past Medical History: - HIV - Hep C - polysubstance abuse Social History: Lives at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] house. IVDU, h/o homeless. Family History: unknown Physical Exam: Vitals: T: 95.2 BP: 88/39 P: 110 R: 24 O2: 99% 450 x 24 x 5 x 50% General: Intubated, sedated HEENT: + Sclera icterus, dry MM, otherwise 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: foley with icteric urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: multiple excoriations along upper and lower extremities, Pertinent Results: [**2159-5-6**] 11:08PM URINE GRANULAR-50* HYALINE-50* [**2159-5-6**] 11:08PM URINE RBC-75* WBC-124* BACTERIA-NONE YEAST-FEW EPI-0 TRANS EPI-1 RENAL EPI-1 [**2159-5-6**] 11:08PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL BURR-1+ [**2159-5-6**] 11:08PM NEUTS-80* BANDS-10* LYMPHS-4* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-4* [**2159-5-6**] 11:08PM WBC-17.8* RBC-3.10* HGB-11.1* HCT-35.1* MCV-113* MCH-35.9* MCHC-31.7 RDW-15.8* [**2159-5-6**] 11:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-POS [**2159-5-6**] 11:08PM URINE OSMOLAL-327 [**2159-5-6**] 11:08PM OSMOLAL-330* Brief Hospital Course: 40 yo M with a past history presents after being found down for unknown duration, now with [**Last Name (un) **], Acute liver failure, AGMA and altered mental status . # AMS/Seizure: Appears to have initially mostly related to hypoglycemia, as AMS has improved with dextrose administration. Patient then had seizure in the ED, when fingerstick was within normal limits. There was initial concern for stroke given assymetric weakness, but CT head shows subacute changes, and per report weakness improved when patient was awake in the ED. This may imply that patient had recrudescence of old CVA in the setting of infection and hypoglycemia. [**Month (only) 116**] be related to cerebral edema, infection, worsening renal function, or ingestion. Received dilantin and ativan in the ED. Pt never regained baseline mental status and was unreactive at presentation. . # AGMA: Appears mostly to be secondary to lactic acidosis in the setting of renal failure and liver failure. Predicted serum osmolality 301.3, and actual serum osm 330 indicated there is a large osmolar gap of 28, indicating a high likelihood of ingestion possible with methanol or ethylente glycol. Part of Osm gap may be due to elevated lactate. Empiric fomepizole started for toxic etoh suspected ingestion given osmolar gap. Ethylene glycol and methanol levels were negative. [**2159-5-8**] continue hemodialysis started. # Acute liver failure: [**Last Name (un) **] prior liver disease, but at this time has jaundice, possible HE and coaglopathy. Concern that AGMA, hypoglycemia and ARF may be related to liver injury. U/s without evidence of PVT or CBD dilitation. Serum tylenol negative. Concern for other toxic ingestion. [**5-8**] pt started to show signs of shock liver likely secondary to hypotension. [**5-8**] Gave 3 units FFP for INR 8.2-->2.8 # [**Last Name (un) **]: Unknown baseline, but now presents with Cr above 5 with reasonably normal electrolytes. Bun:Cr ration less than 20, indicating less likely pre-renal azotemia. However, fena of 0.7 more consistent with volume depletion. Rising CKs could indicate a component of rhabdo. Given degree of hepatic dysfunction, there is some concern for HRS. Profound acidosis and stared [**5-8**] CVVH . # UGIB: Post intubation patient developed 650 cc of coffee ground emesis. Patient does not have known liver disease, and platelet count is normal making portal hypertension and varices less likely. [**Month (only) 116**] have developed spontaneous ulcer bleed in the setting of coagulopathy. He was Transfused 2 U PRBC [**5-7**] and started on PPI drip . # Shock: Patient was hemodynamically stable prior to intubation. [**Month (only) 116**] have hypotension related to UGIB as above, or could have early sepsis. No obvious sources, except for possible CNS sources as above, and maybe aspiration during seizure. Meets SIRS criteria by hypothermia, tachycardia and leukocytosis. DIC supported by elevated INR and LDH. Hemolysis appears to be limited given bilirubin is mostly direct. [**5-8**] pt required increasing pressors to maintain MAP>65,MAPs to the mid 50s, placed NICOM, stroke volume indices running low, gave fluids with improvement of MAPS in AM, gave additional fluids (6L during day) with MAPs in mid 50s-low 60s by evening of [**5-8**] pt was maxed out on dopamin, levophed, neo and vasopressin. [**5-9**] pt with lacate trending up despite maximal therapy and hypotensive. Since [**5-7**] he was broadly covered with ampicillin, acyclovir,vancomycin and ceftriaxone. stress doese steriods and insulin slidding scale started . # Respiratory failure: Intubated in the setting of seizure. ABG with good oxygenation and ventilation , but desaturates with FIO2 less than 99% 4/6pt with cardiac arrest and death pronounced. Medical examiner notified and will have autopsy performed. [**2-4**] brother [**Name (NI) **] and Social worker notified. Medications on Admission: unknown Discharge Disposition: Expired Discharge Diagnosis: septic shock, ARDS, cardiopulmonary arrest Discharge Condition: expired. Discharge Instructions: expired. Followup Instructions: expired. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2159-5-9**]

[ "518.5", "V08", "251.2", "780.39", "305.50", "276.1", "570", "584.5", "785.52", "070.71", "578.0", "584.9", "995.92", "342.90", "276.2", "038.9", "286.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.71", "38.93", "38.91", "96.04", "38.95" ]

icd9pcs

[ [ [] ] ]

7717, 7726

3769, 7659

313, 395

7812, 7822

3047, 3746

7879, 8009

2396, 2405

7747, 7791

7685, 7694

7846, 7856

2420, 3028

263, 275

423, 2202

2224, 2261

2277, 2380

19,230

102,985

22364

Discharge summary

report

Admission Date: [**2157-12-13**] Discharge Date: [**2157-12-28**] Date of Birth: [**2107-8-8**] Sex: F Service: MEDICINE Allergies: Codeine / Fentanyl / Morphine Attending:[**First Name3 (LF) 10644**] Chief Complaint: low back pain Major Surgical or Invasive Procedure: chemoembolization laminectomy History of Present Illness: 50 y/o female with RCC metastatic to lumbar spine, liver, pancreas who has been experiencing low back pain with radiation to the L leg since [**10-3**]. Her pain upon admission was [**8-7**], sharp. Pt's pain was persistent despite PO decadron and XRT which was started in [**Month (only) 359**] at outside rad-onc. Pt also reported progressive LLE weakness and urinary retention 2 days prior to admission. MRI of spine at OSH showed compression at L5 and T7. Of note, the patient did not have a BM since [**12-10**]. Sister reports that the patient has been having confusion since starting steroids on [**12-14**]. Pt was transferred to [**Hospital1 18**] where she was admitted to OMED service. Past Medical History: Onc Hx: Diagnosed in [**2155-6-29**] when she presented with a left renal mass on CT scan, undergoing nephrectomy with resection of metastatic lesions in the pancreatic tail and retroperitoneum. In [**2156-6-29**] she developed hilar lymphadenopathy and was initiated on the Avastin/Tarceva trial in [**Month (only) **] with evidence of disease progression after 24 weeks. She began SU11248 in [**2157-4-29**] with disease progression on CT scans in [**2157-8-29**] with new liver lesions and progression and lumbar vertebral mets. She received high dose IL-2; however, this was complicated by myositis and so dose was reduced. Eventually developing symptoms of cord compression from vertebral mets and undergoing XRT to spine and decadron. . Other med hx: htn anxiety d/o s/p appy s/p CCY s/p right humoral fx . Allergies: codeine and morphine (nausea), fentanyl (pruritis) Social History: quit tobacco [**2148**], no ETOH. Family History: no renal cell CA Physical Exam: Initial VS: 97.3, 126/80, p124, rr18, 93% RA ga: awake and pleasant, comfortable, NAD heent: PERRLA, anicteric, EOMI, MMM, clear OP, symmetrical smile, no carotid bruits, no cervical lad, + JVD to the ear @ 30 degrees. lungs: crackles [**1-30**] way b/l cv: tachy s1/s2, tachy, reg, no m/r/g abd: hypoactive BS, SNT/ND, no HSM ext: no edema, no calf pain, no cyanosis, full + 2 DP b/l; [**6-2**] LE distal muscles/feet; 4/5 L - [**6-2**] R Hip flexors, maybe secondary to pain; downgoing babinski; reduced proprioception on R toe; diminished fine touch over L toe; nl sensation over b/l medial and lateral maleolus; spine: tender upper and midthoracic; no step off. neuro: cn 2-12 intact . Previous motor IN ED: lower ext upper ext quad hamstr gastroc AT hip flex R [**5-3**] 4/5 [**6-2**] 5/5 [**4-2**] [**6-2**] L 4/5 [**5-3**] 5/5 [**6-2**] 3/5 [**6-2**] no ankle clonus appreciated sensation intact light touch lower ext bilat DTR - patella 2+ bilat, achilles absent Pertinent Results: . CT chest/abd/pelvis ([**11-16**]) 1. Increase in size and number of hepatic metastases. 2. Increased size of left hilar lymph node. Other prevascular and hilar lymph nodes appear stable. 3. Increased size in left adrenal nodule concerning for metastasis. New right adrenal lesion concerning for metastasis. 4. Stable pulmonary nodules. 5. Stable round lesion in the right breast. 6. Slightly worsened bone erosion in L5 vertebra. . MRI spine [**12-13**]: 1. Pathological fracture of T7 due to metastasis with moderate spinal cord stenosis and mild to moderate spinal cord compression. While most of the spinal stenosis appears to be due to bony metastatic disease, gadolinium enhanced study would help for further characterization, if clinically indicated. 2. Heterogeneous signal intensity within the T5 through T12 vertebral bodies concerning for metastatic disease in this patient with known renal cell carcinoma. 3. Focal isolated disc protrusions at C5/6, and C6/7 without spinal canal compromise. . CTA of lungs [**12-19**]: 1. No evidence of pulmonary embolism. 2. Interval development of small to moderate bilateral pleural effusions, right greater than left as well as by moderate bibasilar atelectasis. 3. Stable appearance of mediastinal and hilar lymphadenopathy. 4. Multiple areas of low attenuation in the liver consistent with metastatic disease. 5. Stable appearance of rounded right breast lesion. 6. Status post spinal fixation surgery in the lower thoracic spine with a loss of vertebral height of the seventh thoracic vertebra. . [**2157-12-13**] 08:00PM BLOOD WBC-7.8 RBC-5.09 Hgb-12.2 Hct-40.7 MCV-80*# MCH-24.1*# MCHC-30.1* RDW-24.5* Plt Ct-48*# [**2157-12-26**] 07:35AM BLOOD WBC-6.7 RBC-3.84* Hgb-11.3* Hct-33.2* MCV-87 MCH-29.3 MCHC-33.9 RDW-21.5* Plt Ct-78* [**2157-12-13**] 08:00PM BLOOD Neuts-87.1* Bands-0 Lymphs-7.9* Monos-4.3 Eos-0.4 Baso-0.3 [**2157-12-19**] 06:56PM BLOOD PT-13.9* PTT-29.2 INR(PT)-1.3 [**2157-12-13**] 08:43PM BLOOD PT-14.7* PTT-26.6 INR(PT)-1.5 [**2157-12-17**] 01:20PM BLOOD Fibrino-160 [**2157-12-15**] 05:45AM BLOOD FDP-10-40 [**2157-12-26**] 07:35AM BLOOD Glucose-112* UreaN-16 Creat-0.8 Na-134 K-3.4 Cl-100 HCO3-22 AnGap-15 [**2157-12-13**] 08:00PM BLOOD Glucose-128* UreaN-30* Creat-1.0 Na-137 K-4.7 Cl-104 HCO3-22 AnGap-16 [**2157-12-19**] 04:10PM BLOOD CK(CPK)-66 [**2157-12-17**] 04:47PM BLOOD LD(LDH)-305* [**2157-12-14**] 09:28PM BLOOD ALT-22 AST-30 AlkPhos-406* TotBili-0.5 [**2157-12-19**] 04:10PM BLOOD CK-MB-NotDone cTropnT-0.03* [**2157-12-19**] 01:35AM BLOOD CK-MB-2 cTropnT-0.03* [**2157-12-26**] 07:35AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.6 [**2157-12-14**] 09:28PM BLOOD Calcium-8.4 Phos-4.0# Mg-1.7 [**2157-12-21**] 07:25AM BLOOD TSH-8.4* [**2157-12-21**] 07:25AM BLOOD T4-4.5* [**2157-12-18**] 09:18PM BLOOD Type-ART Temp-38.0 pO2-86 pCO2-41 pH-7.40 calHCO3-26 Base XS-0 Intubat-INTUBATED [**2157-12-14**] 04:59PM BLOOD Type-ART Temp-37.2 pO2-103 pCO2-34* pH-7.38 calHCO3-21 Base XS--3 Intubat-NOT INTUBA [**2157-12-17**] 05:10PM BLOOD Glucose-156* Lactate-2.3* [**2157-12-14**] 04:59PM BLOOD Glucose-73 Lactate-1.6 Na-135 K-4.7 Cl-104 [**2157-12-18**] 09:18PM BLOOD Hgb-10.9* calcHCT-33 [**2157-12-17**] 12:31PM BLOOD Hgb-10.5* calcHCT-32 [**2157-12-18**] 09:18PM BLOOD freeCa-1.33* [**2157-12-14**] 04:59PM BLOOD freeCa-1.30 Brief Hospital Course: 50 y/o female with RCC metastatic to lumbar spine, liver, pancreas who had been experiencing low back pain with radiation to the L leg since [**10-3**]. Also symptomatic with urinary retention and worsening LLE weakness/pain. Received decadron and XRT fpr spine compression at OSH w/o significant improvement. Transferred to [**Hospital1 18**] for further evaluation and treatment. . # cord compression - bony mets with acute worsening of spinal compression as seen on MRI: T7 mild compression with retropulsion of vertebral fragments into spinal canal, moderate (50-75%) spinal canal stenosis, and soft tissue (tumor) and compression of left L5 root. She was evaluated by ortho who felt that her symptoms were stable and improving on IV steroids. Dr. [**Last Name (STitle) **] of Interventional Rads embolized L5 and T7 tumor on [**12-14**] to address increased vascularity, and then pt chose to have semi-elective laminectomy with Dr. [**Last Name (STitle) 363**] from orthopedics. This was discussed w/ the rad onc staff here to ensure that she would not have problems w/ wound healing as she had recent XRT to these areas. Her RadOnc doctor is Dr. [**Last Name (STitle) 58209**] [**Name (STitle) **] in [**Location (un) 58210**], [**State 1727**]. . Following her spine surgery, she had an uneventful recovery w/o new fevers, n/v, dysphagia, headache, cp/sob/palpitations or abdominal pain. Foley was left in place initially as she was still not able to void on her own. She had a few days during which she could urinate, but then foley had to be re-inserted prior to discharge for urinary retention. She also did not have a bowel movement for several days. In the week after her surgery, her neuro exam stabilized, and she was able to ambulate w/ some assistance. She worked w/ PT almost daily, and they felt that her progress waxes and wanes. They recommended [**Hospital 3058**] rehab for continued physical therapy. Her pain was well-controlled w/ her pre-admission dose of fentanyl patch and hydromorphone 2mg po q8prn. She was fitted for a TLSO brace and decadron was discontinued. There was no further role for XRT after surgery. She continues to have daily dressing changes at her surgical site - healing well. She will need daily PT as she has decompensated after a prolonged hospitalization. . # MS changes: the patient began to have visual hallucinations on the decadron. She does not have an underlying psych d/o. After discontinuing steroids, she noted having confusion after receiving ativan. This was temporally related to ativan dosing; she reports a history of having MS changes after ativan. Considered CT of head to r/o metastatic disease, but she was neurologically intact and remained mentally clear. Discontinued prn ativan and gave xanax instead. Also, thyroid function studies suggested that she has mild hypothyroidism; did not treat at this time as she continued to have tachycardia on small dose BB. . # Increased Temperature - Temp to 100.3 once after her surgery; afebrile since then. Likely due to atelectasis as CTA did not support PE or pna. Wound did not look infected. Urine cx negative, and blood cx w/ no growth to date; catheter tip growing coag neg staph which is likely staph epidermidis. Sweats likely related to her cancer, but not concerning at this time for new progression or mets. . # Tachycardia - Patient with ventricular bigemeny on EKG - has a history of this. No chest pain or signs of cardiac failure. CE negative x 2 more than 12 hours apart. She continued to have HR in 110s w/ low BP. Started metoprolol 25mg po bid w/o significant response in HR; BP remained stable. Did not pursue further work-up at this time as this has been a long-standing issue. . # RCC - Has received maximum chemo and XRT. Pt had foley in place until 2 days prior to admission at which point she was able to void on her own. She had some hematuria following surgery, but this was attributed to foley trauma. Pt denies any discomfort. Once stable will consider future tx with Dr. [**Last Name (STitle) **]. It appears that the family (sister is very involved) have the idea that she will be cured. emailed [**Doctor Last Name **] about this. . # hypoxia/crackles on exam - this was first noted after the chemoembolization in the PACU. Attempted some mild diuresis did not improve her hypoxia. CXR was only notable for bilateral atelectasis. In the days prior to her discharge, she was satting 94% on RA and breathing comfortably. . # low platelets/elevated INR - no schistocytes on smear, no renal failure or CNS symptoms or labs to suggest TTP, no DIC. ITP is diagnosis of exclusion. Transfused platelets to maintain >50 and gave vitamin K prior to spine surgery; platelets bumped up to 154 and then slowly drifted down. No signs of hemolysis. Last plt count was 78 and stable prior to discharge. . # Anemia - Patient with significant blood loss during surgery. Responding appropriately to transfusions and has remained stable at 30. - follow CBC . # anxiety - has history of anxiety disorder. Had been on effexor 75 qd and ativan 1mg q6 prn but she noted that she becomes confused on ativan. Switched to xanax w/ resolution of her MS changes. She continues to be anxious but responds well to assurance and prn xanax. . # Pain - controlled on fentanyl patch 100mcg q72hrs and dilaudid 2mg po q8 prn. Pt attempting to wean herself off dilaudid - not using many doses currently. . # Follow-up: Pt will call Dr. [**Last Name (STitle) **] for an appointment in the next few weeks. Medications on Admission: Lomotil 1-2 tablets q.6h. p.r.n. diarrhea Compazine 10 mg q.6h. p.r.n. nausea Ativan 1 mg q.6h. p.r.n. nausea Benadryl p.r.n. Tylenol 650 mg q.4h. p.r.n. pain oxycodone 5-10 mg q.6h. p.r.n. pain Effexor 75 mg p.o. daily Miacalcin nasal spray fent patch 100 mcg/hr q72h decadron 4mg [**Hospital1 **] 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. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for PAIN. Disp:*90 Tablet(s)* Refills:*1* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*2* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2* 7. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO QID (4 times a day) as needed for anxiety. Disp:*100 Tablet(s)* 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* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Discharge Diagnosis: renal cell carcinoma w/ metastasis to spine s/p chemoembolization s/p laminectomy hypertension anemia anxiety s/p appendectomy s/p cholecystectomy s/p R humoral fracture Discharge Condition: Stable Discharge Instructions: Please take your medications only as directed. Call your physician or go to the ED if you have fever, chills, inability to void or have BM, headache, weakness, confusion, hallucinations, fainting, uncontrolled pain, chest pain, shortness of breath or any other symptom that is concerning to you. Followup Instructions: Please follow up w/ Dr. [**Last Name (STitle) **] in the next few weeks. You will need to call for an appointment. Completed by:[**2157-12-28**]

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19070

Discharge summary

report

Admission Date: [**2144-6-12**] Discharge Date: [**2144-7-16**] Date of Birth: [**2082-7-14**] Sex: M Service: MEDICINE Allergies: Dilantin / Heparin Agents Attending:[**First Name3 (LF) 2181**] Chief Complaint: Primary: 1. Hypotension 2. Diarrhea Secondary: 1.ESRD on HD: 2. Hepatitis B 3. Alcoholic cirrhosis 4. Anemia 5.Seizure Disorder 6. Alcohol withdrawl 7. Gout 8. L knee replacement 9. HTN 10. peri-op afib many years ago 11. hypothyroidism 12. Pleural effusion status post decortication in [**9-5**] 13. h/o MRSA line infection. 14. Past Surgical Hx: Notable for abdominal trauma from a stab wound and he underwent open exploration at that time. It is unclear as to what the results of that were. Major Surgical or Invasive Procedure: [**2144-6-12**] - Placment of right femoral catheter [**2144-6-18**] - Placement of left femoral 12 french triple lumen temporary dialysis catheter [**2144-6-18**] - Removal of left tunneled IJ hemodialysis catheter [**2144-6-21**] - Thoracentesis of right pleural effusion [**2144-6-26**] - Placement of a tunneled Left IJ 14.5-French HD catheter [**2144-6-26**] - Removal of L femoral temporary HD catheter [**2144-6-26**] - Placement of Left PICC line [**2144-7-7**] - Removal of Left PICC line [**2144-7-7**] - Placement of Right PICC line [**2144-7-11**] - Removal of Right PICC line secondary to displacement [**2144-7-13**] - Attempted placement of Right IJ line, attempted placement of right femoral line [**2144-7-13**] - Placement of Left femoral central line History of Present Illness: 61 M with h/o ESRD on HD, Etoh cirrhosis, hep B and hep C, seizure d/o, gout, HTN, line infections, recently d/c'd after admit for 1 week history of diarrhea, now readmitted from HD for hypotension, continued diarrhea. Prior to last admit, pt had 1 week of yellow watery stool, non-bloody, non-black, occuring about six times/day, worse at night. At that time, he denied nausea/vomiting, fever, chills, abdominal pain, chest pain, or SOB, hematemesis, recent laxatives or antibiotics. C.diff was sent from the NH was negative. He did note progressive leg weakness over several months, and RN at the NH reported progressive mental status decline since [**10-6**], with lethargy, psychomotor retardation and confusion. During recent admit, patient had a CT of the abdomen that showed thickening of the ascending and transverse colon c/w colitis. Stool cultures including ova + parasites, and C.diff were sent which came back negative. He was transiently on Levo/Flagyl but these were discontinued after negative stool culture. By HD#4, he was forming more formed stool, and in fact his stool became too hard and so he was re-started on a stool softener colace. It was felt that he likely had a viral enterocolitis, or less likely, an ischemic colitis from possible hypotensive episode during HD session. Another possibility was a viral enteritis causing hypovolemia, then the resulting hypotension causing ischemic colitis. New acute onset of inflammatory bowel disease was thought very unlikely. Patient was not felt to warrant a colonoscopy at the time, as he improved on conservative management. . Since his discharge [**2144-6-8**], 4d PTA, the patient has had recurrence of his diarrhea, which he says only seemed to slow down somewhat but never went away. He is not clear what medicines he has been getting at [**Hospital1 11851**], including if he has gotten any laxatives or stool softeners. He has been on a BRAT diet, so presumably they have held his laxatives as well. . Patient was at HD today, with initial BP 134/74, which fell to 84/40. 300cc of NS was given, which brought up the BP to 92/60, but then it fell to 71/45. Pt had 2.5h of HD, stopped early. Received a total of 2100cc NS, and even with this and in T-[**Doctor Last Name **] SBP remained in 80s. Denied CP, SOB. When EMS arrived, BP 115/80 sitting and 96/64 lying flat. Was admitted for dehydration from continued diarrhea. BP in ED ranged 107-119/56-77, HR ranged 58-70. Past Medical History: ESRD on HD: L Hickman tunneled catheter. Hepatitis B Etoh cirrhosis Anemia Seizure Disorder Alcohol withdrawl Gout L knee replacement HTN peri-op afib many years ago hypothyroidism Pleural effusion status post decortication in [**9-5**] h/o MRSA line infection. Past Surgical Hx: Notable for abdominal trauma from a stab wound and he underwent open exploration at that time. It is unclear as to what the results of that were. Social History: Patient lives at [**Hospital3 **] home ([**Telephone/Fax (1) 25015**]). His wife died eight years ago from complications of intravenous drug abuse. He worked as a carpenter or painter and quit eleven years ago. He used to drink at least a pint of alcohol/day for many years. He denies tobacco or any other drugs currently. - Patient reports he has a son and daughter, both of whom live in [**Name (NI) 4565**]. Patient reports he is estranged from his children and adamently reports he does not want them to be part of his care, nor does he want them contact[**Name (NI) **]. Family History: Non-contributory Physical Exam: Physical Exam: Vitals: 97.2 118/60 66 18 95%onRA 76.4kg GEN: Well nourished, breathing comfortably, not in pain, NAD, slow to respond SKIN: no frank jaundice, though right arm with extensive ecchymoses and yellowing, plus one laceration over forearm HEENT: PERRL, EOMI, anicteric, dry MM, OP clear, +tongue fascic Neck: Supple, no cervical LAD, no JVD COR: RRR, nl S1, S2, [**2-9**] syst murmur at apex, no rub/gallop LUNGS: rales [**1-5**] way up bilaterally; poor air movement throughout ABD: mildly obese, nondistended, decreased bowel sounds, tender to deep palp in all four quadrants as well as with tapping of ribs over liver; no guarding/rebound RECTAL: trace guaiac positive in the ED EXT: tender bilateral knees to palpation and passive range of motion. NEURO: inattentive, oriented x 3, slow to respond, fluent, tangential, intact comprehension. CNII-XII intact. [**5-7**] strength, sensation to LT intact; +asterixis Pertinent Results: Admit labs: [**2144-6-12**] 01:15PM WBC-4.0 RBC-3.96* HGB-12.1* HCT-40.2 MCV-102* MCH-30.6 MCHC-30.1* RDW-18.7* [**2144-6-12**] 01:15PM PLT COUNT-92* [**2144-6-12**] 03:15PM GLUCOSE-98 UREA N-7 CREAT-2.6* SODIUM-143 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15 [**2144-6-12**] 01:15PM CALCIUM-6.6* PHOSPHATE-2.5* MAGNESIUM-1.6 [**2144-6-12**] 01:15PM GLUCOSE-91 UREA N-7 CREAT-2.5*# SODIUM-139 POTASSIUM-5.8* CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [**2144-6-12**] 03:15PM ALT(SGPT)-20 ALK PHOS-175* AMYLASE-27 TOT BILI-0.8 [**2144-6-12**] 03:15PM LIPASE-12 [**2144-6-12**] 03:15PM ALBUMIN-2.2* Discharge Labs: [**2144-7-15**]: WBC-13.1* Hgb-8.4* Hct-26.8* Plt-61*# s/p transfusion for platelet count of 22 59% Neutrophils, 25 bands . Coags: 14.5*1 43.6* 1.4 . Chem-7: Glu-45* BUN-33* Cr-3.6* Na-144 K-4.3 Cl-107 HCO3-24 AG-17 . [**2144-6-21**] Heparin dependent antibody - positive [**2144-6-24**] Heparin dependent antibody - Negative [**2144-6-24**] Serotonin Release Assay - Negative . [**2144-6-14**]: C. Diff toxin A - negative [**2144-6-14**]: C. Diff toxin B - negative [**2144-7-1**]: C. Diff toxin A - positive [**2144-7-1**]: C. Diff toxin B negative [**2144-7-1**] Blood cxs: No growth [**2144-7-2**] Blood cxs: No growth [**2144-7-5**] Blood cxs: No growth . ABGs: [**2144-7-13**]: 7.32 / 228* / 45 / 24 [**2144-7-13**]: 7.30 / 193* / 46* /24 [**2144-7-14**]: 7.27 / 126* / 49* /23 . Reports: [**2144-6-12**] Radiology CHEST (PORTABLE AP)AP UPRIGHT VIEW OF THE CHEST: A central line is unchanged, terminating at the aortocaval junction. The cardiac and mediastinal contours are stable. A right-sided pleural effusion with associated atelectasis is again demonstrated and not significantly changed compared to the prior study. No evidence of pneumothorax. IMPRESSION: No significant interval change compared to the radiograph of [**2144-6-3**]. . [**2144-6-12**] Radiology CT ABDOMEN PELVIS: CT OF THE ABDOMEN WITH IV CONTRAST: A right-sided pleural effusion and bilateral lower lobe multifocal patchy opacities are again demonstrated not significantly changed compared to the prior study. The liver, gallbladder, pancreas, spleen, stomach, and adrenal glands are unremarkable. The kidneys are atrophic. Enhancement of the renal parenchyma is noted. There is wall edema/thickening of the ascending colon. There is apparent wall thickening of the transverse colon as well that was also demonstrated on the prior study. The splenic flexure and descending colon is under-filled, however there also appears to be wall edema affecting these locations as well. Note is made of free fluid tracking along the pericolic gutters, increased compared to the prior study. The appendix appears less enlarged compared to the prior study. The small bowel is grossly unremarkable and of normal caliber. There are no pathologically enlarged mesenteric or retroperitoneal lymph nodes. CT OF THE ABDOMEN WITH IV CONTRAST IMPRESSION: 1. Unchanged appearance of the chest compared to the prior study with a right-sided pleural effusion and patchy multifocal opacities. 2. Wall edema/thickening of the ascending and transverse colon and possibly descending colon consistent with colitis with interval increase in free fluid tracking along the pericolic gutters. Differential diagnosis includes infectious, inflammatory, and ischemic etiologies. . [**2144-6-14**] Port Chest: 1) Persistent small curvilinear opacity at the left apex, which may reflect a small pneumothorax. 2) Stable moderate to large partially loculated right pleural effusion with adjacent opacities in the right middle and lower lobes. . [**2144-6-18**] Port Chest: Persisting moderate right-sided pleural effusion with progression of associated consolidation, which given the clinical history is likely consistent with pneumonia. No other significant interval change. . [**2144-7-6**]: Left UE US- Partially occlusive thrombus in the left internal jugular vein. Possible partially occlusive thrombus in the left basilic vein along the PICC. . [**2144-7-8**]: Portable Abdomen: 1. No free air. 2. Ill-defined nodular density at the left lung base, likely infectious or inflammatory in etiology given that it was not present on the recent prior exam. Followup recommended. [**2144-7-13**]: Port Chest: 1. Stable position of left internal jugular venous access catheter. A right- sided PICC has been removed. 2. Increase in the patchy opacities at the left base. Stable opacity at the right base. Findings could be consistent with aspiration. 3. Bilateral pleural effusions, right greater than left. . [**2144-7-14**]: pORT CHEST: IMPRESSION: No short interval change. No pneumonia or overt fluid overload. Brief Hospital Course: 1)Hypotension/Sepsis: Pt has low baseline bp, likely related to his ESLD. A day after the sigmoidoscopy, he underwent HD where he was afebrile and stable, and was transported to the GI suite for possible colonoscopy but developed severe rigor and fever. He was hypotensive to 40-90's fluctuating. Dopamine was started on the floor in addition to fluid boluses, and pt was transferred to the MICU. BCx grew E.Coli resistant to quinolones. He was initially on Ceftriaxone and Vancomycin but was tailored to Ceftriaxone. He was later transferred to the floor where his BP was stable at SBP 90-110's. He also has adrenal insufficiency from long term use of prednsione for gout. So he received stress dose steroids of fludrocortisone and hydrocortisone since the hypotensive espisode. He was treated with ceftriaxone for the E.Coli sepsis. The source was thought to be either from sigmoidiscopy or line related as he had femoral line in his right groin as well as tunneled HD line in his left IJ. After temporary HD line was placed in the left groin, both of the old lines were removed. Serial surveillance cultures have been negative. Plan at this point was to place a tunneled HD catheter by IR. Placement of this catheter was complicated by the fact that patient was having mental status change and did not have a health care proxy. After discussion with ethics, it was thought that placement of these catheters was medically necessary and both a tunneled Left HD catheter and left PICC line were placed. The left groin catheter was removed at this point. On [**2144-6-28**], the patient was noted to have a brief desaturation on the floor down to about 89% on room air, which increased to 98-99% with non-rebreather. The patient was then successfully weaned down to low-flow nasal canula. At this point, the patient had completed ceftriaxone for his previous E. Coli bactermiea, but was already receiving Flagyl for a possible previous aspiration. Blood cultures were sent. The patient was noted the day following to have a leukocytosis, which was also accompanied by abdominal pain. A [**Name (NI) 5283**] sono was negative and a port chest and KUB did not demonstrate any evidence of disease including free air. In the setting of this leukocytosis, the patient again became hypotensive and was empirically started on Vancomycin IV and Zosyn. Additionally, C. Diff toxin was sent which was positive depite having received 9+ days of Flagyl. The patient was additioanlly started on PO Vancomycin and the Flagyl was discontinued. The patient, who previously had been weaned back down to 10mg PO qd of prednisone was again brought to his stress dose steroid of 100mg hydrocortisone qd for possible adrenal insufficiency. The patient was additionally given 1 unit PRBC for low Hct. In the setting of continued GI output, the patient additionally had a rectal tube placed on [**2144-7-5**] to avoid contamination of his sacral decubitus ulcer. On [**2144-7-6**], patient's left arm was noted to be particularly swollen. A LUE US revealed partial obstruction of the left IJ and Left basilic vein. The patient's PICC was pulled and the patient was started on an IV Heparin drip. The patient was scheduled to have an additional PICC placed the following day. THat evening, the patient was noted to have some epistaxis without hemodynamic compromise and the Heparin Drip was immediatley stopped. The patient was given 1 unit of blood overnight. The patient was fairly stable on the floor with SBP 100-110 with plans of possible discharge back to nursing facility, as this was what patient repeatedly told medical team he wished to do. On the morning of [**2143-7-14**], the patient was seen in the a.m. and found to be disoriented, confused and audibly gurgling. The patient was ordered for a portable chest film, but was with satisfactory O2 sats on NC. While in HD, team was called as patient had acutely decompensated since his arrival. He was with mental deteriation and O2 sats to the high 70's and 80's. The patient was placed on a non-rebreather, an ABG and stat port film were performed and the MICU team was called to evaluate the patient. As the patient was DNR/DNI it was determined that the patient may recieve pressors if necessary in the unit, but at most could receive bi-PAP or CPAP for ventilatory support. Through the course of the day the patient was attempted to be weaned back to NC 5-6L, which failed. The patient was placed back on 100% O2 on non-rebreather, but was maintaining BP 90-110 without pressors. In the few days prior to these desaturations the patient was additionally becoming frequently hypoglycemic. The patient was not receiving insulin, and was given amps of dextrose as needed for hypoglycemic episodes as well as basal fluids with D5. Overnight, the patient was seen by the nightteam, with similar report of O2 desat and gurgling. Upon suction, frank blood was suctioned through a nasal trach tube. The patient was immediately given 1 unit of platelets for hrombocytopenia and the patient previously that evening had received i unit of FFP for an elevated INR. AM labs revealed that the patient had 25bands and was currently unweanable from 100% non-rebreather. - [**2144-7-15**] Prior conversations with the patient when he was lucid revealed that the patient was willing to continue hemodialysis, but only if he was able to go back to his retirement home for treatment. The patient reported clearly to the medical team he did not want to stay in the hospital indefinitely on hemodialysis and he did not want to die in the hospital, with his life being prolonged on hemodialysis. The patient had reported he wished to be DNR/DNI and did not want his estranged family involved in his care. At the time of the most recent events above, the medical team including all particpiating physicians, nurses, and case manager discussed the case and what they thought the patient would have wanted given his condition, his poor prognosis, and poor chance of ever going back to retirement home with a qulaity of life he would have wanted. Given the above and his recent medical decompensation, thought likely to represent sepsis and DIC, the decision was made, agreed upon by all healthcare workers involed in his care, that Mr. [**Known lastname 52065**] would not have wanted continued aggressive medical management. The decision was made to place the patient on comfort care, and all medical treatments including blood draws and HD were stopped. On [**2144-7-15**] the patient was placed on a morphine drip titrated to comfort. On the morning of [**2144-7-16**], the patient was noted to be demonstrating an agonal breathing pattern. The patient quitely passed away within a few hours without incident. 1)Colitis: The patient was recently admitted for the same symptoms. On last admission, all stool studies were negative and his diarrhea slowly resolved. He presented again with persistent diarrhea. CT of the abdomen showing wall thickening of the ascending, transverse, and descending colon. Again, all of the stool studies were negative including C.diff toxin A and B upon admission. He underwent sigmoidoscopy which showed multiple patchy erythematous and edematous area but etiology was inconclusive. The plan was to send him for colonoscopy but patient became septic with E. Coli bactermiea s/p sigmoidoscopy for which he was treated with ceftriaxone. After resolution of his septic episode, the patient continued to have diarrhea during his hospital stay, accompanied as well by abdominal pain. Despite additional treatment with Flagyl, which had been started for a likely aspiration PNA, the patient's C. diff toxin A became positive on [**2144-7-1**]. The patient was additionally started on PO Vancomycin at this time 125mg po q6h for treatment of likely C. Diff Colitis. The patient was additionally given questrum 4 gm PO QID to help solidify his bowel movements. The patient was additionally found during his stay to have frequent contamination of his sacral decubitus ulcer with feces. Because of this, a rectal tube was placed while the patient experienced diarrhea to avoid contamination of his open wound. Over the course of about a week, the patient's bowel movements became less freqient and better formed. The patient was with resolution of his diarrhea, without a rectal tube, and had his questrum dosing decreased to tid until the events as noted above. . 3)Pneumonia: CXR in MICU suggestive of possible PNA as well as worsening right side pleural effusion which was tapped. The pleural fluid was consistent with exudate by Light's criteria and is likely parapneumonic. He likely had aspiration pneumonia in the ICU while his mental status was altered. Flagyl was added in addition to Ceftriaxone to cover for anerobes for pneumonia as well as empiric coverage for GI flora. Remainder of hospital course is as noted above . 4)Thrombocytopenia: He has a baseline thrombocytopenia from chronic liver disease. However, he had a drop in plt count to the 40's. HIT antibody was sent which came back positive. Repeat HIT was negative as was Serotonin Release Assay. . 5)Mental Status: progressively declining mental status since last [**Month (only) 359**]; unclear etiology. He became more confused and disoriented after the MICU stay which was thoguht to be ICU psychosis and toxic-metabolic picture. Remainder of hospital course as above . 6)Social: Pt has no family member to contact and no health care proxy. His only contact of record is a friend/neighbor. Ethics consult was otained to define a long term care as he is clearly DNR/DNI. Also he may need a legal guardianship. Remainder of hospital course is as above. 7)Nutrition: Pt with albumin of 1.8 primarily from persistent diarrhea and decreased po intake from inumerous NPO peri-procedure and ICU stay. Paient was started and weaner from TPN during stay. remainder of hospital course as above 8)Gout: Pt with long standing use of prednisone 10 mg qd for chronic gout. This was discouraged by Rheumatology back in [**2143-10-4**] but has not been tapered. 9)Hypothyroid: His synthroid dose was just increased to 50 mcg qd on last admission. Was continued during stay. 10)CODE: DNR/DNI-well documented. [**Hospital **] hospital course as above, deceased on [**2144-7-16**] Medications on Admission: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QD (). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 7. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed. 10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): qMWF at dialysis. 12. Prednisone 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): On prednisone taper: take 9 mg qd for 1 week, then taper by 1 mg/week. 13. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Medications: None Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: 1. Hypotension 2. Diarrhea Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

[ "274.9", "427.31", "458.8", "251.2", "571.2", "784.7", "244.9", "707.03", "275.41", "507.0", "996.74", "287.4", "403.91", "453.8", "511.9", "780.39", "263.9", "008.45", "293.0", "038.42", "V45.1", "276.5", "995.92", "112.0", "285.1", "276.8", "275.3", "996.62", "070.30", "558.9", "785.52", "070.70", "286.7", "427.89", "255.5", "578.0", "E934.2", "E932.0", "286.6" ]

icd9cm

[ [ [] ] ]

[ "38.95", "99.07", "00.17", "45.24", "34.91", "39.95", "99.05", "99.15", "38.93", "99.04", "86.07" ]

icd9pcs

[ [ [] ] ]

22513, 22597

10823, 19958

781, 1553

22668, 22678

6094, 6716

22731, 22738

5101, 5119

22484, 22490

22618, 22647

21160, 22461

22702, 22708

6732, 10800

5149, 6075

247, 743

1581, 4038

19973, 21134

4060, 4489

4505, 5085

8,917

118,190

8199

Discharge summary

report

Admission Date: [**2103-10-14**] Discharge Date: [**2103-10-24**] Date of Birth: [**2047-5-25**] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old woman with a history of insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, peripheral vascular disease and current tobacco use, who was transferred from an outside hospital complaining of shortness of breath and elevated troponin. She was transferred to [**Hospital6 1760**] for cardiac catheterization which was performed on [**2103-10-15**]. Please see catheterization report for full details. In summary the catheterization showed that the patient had 100% right coronary artery lesion, 99% mid left anterior descending lesion, 70% diagonal lesion, 90% OM lesion, with LPDA of 80%. She had a TEE done also which showed an ejection fraction of 35-40%, mild mitral regurgitation, and borderline pulmonary hypertension with mild to moderate left ventricular dysfunction. She was referred to Cardiothoracic Surgery for evaluation for coronary artery bypass grafting. The patient was seen by CT Surgery and accepted for coronary artery bypass grafting. PAST MEDICAL HISTORY: Insulin-dependent diabetes mellitus. Hypertension. Hypercholesterolemia. Chronic renal insufficiency with a baseline creatinine of 2.3-2.5. History of nephrotic syndrome. PAST SURGICAL HISTORY: Status post left popliteal dorsalis pedis bypass in [**Month (only) 1096**] 199. Status post left hallux amputation after an episode of osteomyelitis. Status post right popliteal to dorsalis pedis bypass. Status post gastric bypass in the [**2069**], reversed in [**2079**]. Status post tubal ligation. Status post right hallux amputation in [**2102-9-5**]. SOCIAL HISTORY: The patient lives with her husband. Positive tobacco use, one pack per day times 37 years. She denied alcohol use. ALLERGIES: PENICILLIN CAUSES STOMACH UPSET. MEDICATIONS ON TRANSFER: Heparin drip, Iron 325 mg t.i.d., Lisinopril 20 mg q.d., Insulin NPH 40 U q.a.m., Humalog 10 U q.a.m., NPH 15 U q.p.m., with a regular Insulin sliding scale, Celexa 75 mg q.a.m., Lopressor 25 mg b.i.d., Zocor 10 mg q.d., Protonix 40 mg q.d., Multivitamin 1 tab q.d., enteric coated Aspirin 325 q.d., Mucomyst 600 mg b.i.d. PHYSICAL EXAMINATION: General: The patient was a pleasant, morbidly obese woman in no acute distress. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx clear. Neck: Supple. No jugular venous distention. No bruits. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm without murmurs, rubs, or gallops. Abdomen: Soft, obese, nontender, nondistended, with positive bowel sounds. Extremities: Without clubbing, cyanosis, or edema. Right-hand dominant. Left [**Doctor Last Name **] test satisfactory. Neurological: The patient was alert and oriented times three. Grossly intact. Pulses: Carotids 2+ bilaterally, radial 2+ bilaterally, dorsalis pedis 2+ bilaterally, posterior tibial not palpable. LABORATORY DATA: White count 6.7, hematocrit 32.2, platelet count 325; sodium 135, potassium 5.1, chloride 100, CO2 27, BUN 56, creatinine 1.6, glucose 109; PT 12.6, INR 1.1; AST 21, alkaline phosphatase 66, amylase 15, total bilirubin 0.2. The patient was initially followed by the Medical Service, and on [**10-18**], she was brought to the Operating Room at which time she underwent coronary artery bypass grafting. Please see the operative report for full details. In summary the patient had coronary artery bypass grafting times three with LIMA to the left anterior descending, saphenous vein graft to diagonal and OM sequentially. The patient's bypass time was 59 min. Cross-clamp time was 39 min. She tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had a mean arterial pressure of 61 with a CVP of 10, heart rate 84, normal sinus rhythm. She had Propofol 20 mcg/kg/min and Insulin 2 U/hr. The patient did well in the immediate postoperative periods. She remained hemodynamically stable. She did remain intubated throughout the evening of the surgical date. On postoperative day #1, she was weaned from the ventilator and successfully extubated. Additionally her Neo-Synephrine drip was weaned to off. On postoperative day #2, the patient remained hemodynamically stable. Her chest tubes were removed, and she was transferred to the floor for continued postoperative care and cardiac rehabilitation. Once on the floor, the patient had an uneventful postoperative course. With the assistance of the nursing staff and Physical Therapy, her activity level was gradually increased. It was decided on postoperative day #4, that the patient would benefit from a short-term stay in a rehabilitation setting. At that time, arrangements were begun to have her transferred to a rehabilitation facility. It is anticipated that the patient will be discharged to a rehabilitation setting on [**10-24**]. DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature 98??????, heart rate 84 in sinus rhythm, blood pressure 135/73, respirations 20, oxygen saturation 93% on room air. Weight preoperatively 131.2 kg, at transfer 140 kg. General: The patient was alert and oriented times three. The patient moves all extremities and follows commands. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular, rate and rhythm. S1 and S2. No murmur. Chest: Sternum is stable. Incision with staples, open to air, clean and dry. Abdomen: Soft and nontender with positive bowel sounds. Extremities: Warm and well perfused with 1-2+ edema. Left thigh saphenous vein graft site with Steri-Strips open to air, clean and dry. DISCHARGE LABORATORY DATA: White count 6, hematocrit 29.4, platelet count 223; sodium 135, potassium 4.3, chloride 103, CO2 23, BUN 51, creatinine 1.3, glucose 128, magnesium 2.0. DISCHARGE MEDICATIONS: Colace 100 mg b.i.d., enteric coated Aspirin 325 mg q.d., Lansoprazole 40 mg q.d., Heparin 5000 U subcue q.i.d., Epogen 5000 U 1 time per week, Metoprolol 75 mg b.i.d., Lasix 40 mg b.i.d., Potassium Chloride 20 mEq b.i.d., Celexa 75 mg q.d., Insulin NPH 30 U with 10 U regular q.a.m., NPH 11 U with 2 U regular q.p.m., additionally the patient has regular Insulin sliding scale q.i.d., Dilaudid 2-4 mg q.4 hours p.r.n. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting times three with LIMA to the left anterior descending, saphenous vein graft to diagonal and OM sequentially. 2. Insulin-dependent diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia. 5. Chronic renal insufficiency. 6. Nephrotic syndrome. 7. Left popliteal to dorsalis pedis bypass. 8. Left hallux amputation. 9. Right popliteal to dorsalis pedis bypass. 10. Status post gastric bypass, reversed in the [**2079**]. 11. Status post tubal ligation. 12. Status post right hallux amputation. DISCHARGE STATUS: The patient is to be discharged to rehabilitation. FOLLOW-UP: She is to have follow-up with Dr. [**Last Name (STitle) **] in [**2-6**] weeks. Follow-up with Dr. [**Last Name (STitle) 8521**] also in [**2-6**] weeks. Follow-up with Dr. [**Last Name (STitle) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2103-10-23**] 20:36 T: [**2103-10-23**] 20:54 JOB#: [**Job Number 29139**]

[ "401.9", "410.91", "414.01", "599.0", "250.00", "428.0", "305.1", "272.0", "593.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "37.23", "36.15", "88.56" ]

icd9pcs

[ [ [] ] ]

6046, 6466

6521, 7692

1409, 1773

5136, 6022

178, 1187

1979, 2303

1210, 1385

1790, 1953

6491, 6500

41,077

105,605

39564

Discharge summary

report

Admission Date: [**2199-8-30**] Discharge Date: [**2199-9-11**] Date of Birth: [**2121-11-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3016**] Chief Complaint: left hemiplegia Major Surgical or Invasive Procedure: MERCI procedure- (Mechanical Embolus Removal in Cerebral Ischemia) Thoracentesis x2 Nephrostomy tube replacement History of Present Illness: 77-year-old male with history gastric CA metastatic and atrial fibrillation, who developed acute onset aphasia, eye movement abnormalities and left-sided hemiplegia during an ultrasound-guided thoracentesis on [**2199-8-30**] for malignant pleural effusion. Patient had been off of coumadin for 10 days for the thoracentesis. Code stroke was called and patient was transferred to the ED. A CTA revealed a large thrombus in tip of the basilar artery, not extending into PCA's. He was taken emergently to angio, where embolectomy and intrarterial tPA injection was performed. Ischemia time was 4 hours; EBL was minimal, and he received 2U plts for plt count of 25. Patient was transferred to the SICU for postop care. Past Medical History: Stage IV gastric malignancy Atrial Fibrillation Hypertension Hyperlipidemia BPH Depression/Anxiety Osteoarthritis Obstructive Uropathy s/p right percutaneous nephrostomy Social History: His wife died in [**2193**] due to metastatic lung cancer. He previously lived alone but recently moved in with his son & daughter. [**Name (NI) **] is retired, previously working 40 years in the airline industry as a maintenance supervisor. Has family nearby who are involved in his care. Smoked 1ppd x 20 years tobacco, quitting in the [**2158**]. Social alcohol. No recreational drugs. Family History: Father died of pneumonia at 64 years old; unknown other medical issues. Mother died of pneumonia at 53 and had asthma. Physical Exam: VS: T 96.8, BP: 116/63, P:81, RR: 18, 98% on 1L GEN: Elderly male in NAD, NC in place CV: normal rate, ireg rhythm, normal s1, s2, no mr/g PULM: decreased breath sounds and dull to percussion over RLL, LLL, clear in other lung fields EXT: 2+ edema to mid-tibia, DP, PT pulses 1+ Pertinent Results: Hematology [**2199-9-11**] 06:00AM BLOOD WBC-5.7 RBC-2.86* Hgb-8.9* Hct-28.0* MCV-98 MCH-31.2 MCHC-31.8 RDW-17.1* Plt Ct-257 [**2199-9-10**] 12:43AM BLOOD WBC-6.1 RBC-2.98* Hgb-9.4* Hct-29.3* MCV-98 MCH-31.4 MCHC-31.9 RDW-16.9* Plt Ct-238 [**2199-9-9**] 05:00AM BLOOD WBC-4.6 RBC-2.92* Hgb-9.2* Hct-28.4* MCV-97 MCH-31.5 MCHC-32.3 RDW-16.8* Plt Ct-210 [**2199-8-31**] 03:05AM BLOOD WBC-5.8 RBC-2.94* Hgb-9.0* Hct-27.2* MCV-93 MCH-30.6 MCHC-33.1 RDW-14.9 Plt Ct-129* [**2199-8-30**] 10:05PM BLOOD WBC-7.0 RBC-2.89* Hgb-9.3* Hct-25.9*# MCV-90 MCH-32.1*# MCHC-35.9*# RDW-14.8 Plt Ct-121*# [**2199-8-30**] 03:30PM BLOOD WBC-9.3 RBC-3.72* Hgb-10.7* Hct-34.8* MCV-94 MCH-28.8 MCHC-30.8* RDW-14.8 Plt Ct-34*# [**2199-9-10**] 12:43AM BLOOD Neuts-70 Bands-0 Lymphs-10* Monos-19* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2199-9-9**] 05:00AM BLOOD Neuts-62 Bands-1 Lymphs-18 Monos-17* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2199-9-5**] 06:00AM BLOOD Neuts-52 Bands-2 Lymphs-29 Monos-13* Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-2* [**2199-8-30**] 10:05PM BLOOD Neuts-81.9* Lymphs-16.2* Monos-0.7* Eos-1.1 Baso-0 [**2199-9-10**] 12:43AM BLOOD PT-13.8* PTT-35.0 INR(PT)-1.2* [**2199-9-9**] 05:00AM BLOOD PT-13.9* PTT-33.5 INR(PT)-1.2* [**2199-9-7**] 05:06AM BLOOD PT-13.7* PTT-34.1 INR(PT)-1.2* [**2199-9-6**] 04:08AM BLOOD PT-13.9* PTT-53.6* INR(PT)-1.2* [**2199-9-4**] 02:29AM BLOOD PT-18.0* PTT-142.8* INR(PT)-1.6* [**2199-9-3**] 04:30PM BLOOD PT-25.2* PTT-150* INR(PT)-2.4* [**2199-9-3**] 08:30AM BLOOD PT-28.1* PTT-63.3* INR(PT)-2.8* [**2199-9-3**] 02:00AM BLOOD PT-22.8* PTT-56.0* INR(PT)-2.2* [**2199-9-2**] 10:30PM BLOOD PT-21.4* PTT-45.7* INR(PT)-2.0* [**2199-9-2**] 01:13PM BLOOD PT-23.1* PTT-53.7* INR(PT)-2.2* [**2199-9-2**] 08:24AM BLOOD PT-22.0* PTT-57.2* INR(PT)-2.1* [**2199-8-30**] 03:30PM BLOOD PT-15.5* PTT-24.6 INR(PT)-1.4* [**2199-8-30**] 01:20PM BLOOD PT-15.2* INR(PT)-1.3* [**2199-8-30**] 10:05PM BLOOD FDP-40-80* [**2199-8-30**] 05:30PM BLOOD Fibrino-213 [**2199-9-4**] 02:29AM BLOOD Ret Aut-0.5* Chemistries: [**2199-9-12**]: Creatinine is 2.0 [**2199-9-11**] 06:00AM BLOOD Glucose-97 UreaN-35* Creat-2.0* Na-140 K-4.5 Cl-105 HCO3-29 AnGap-11 [**2199-9-10**] 12:43AM BLOOD Glucose-92 UreaN-29* Creat-1.7* Na-143 K-4.6 Cl-108 HCO3-28 AnGap-12 [**2199-9-9**] 05:00AM BLOOD Glucose-86 UreaN-27* Creat-1.3* Na-141 K-4.4 Cl-106 HCO3-28 AnGap-11 [**2199-9-3**] 03:22AM BLOOD Glucose-105* UreaN-35* Creat-1.2 Na-139 K-4.0 Cl-112* HCO3-20* AnGap-11 [**2199-9-2**] 02:12PM BLOOD Glucose-109* UreaN-41* Creat-1.4* Na-136 K-4.2 Cl-106 HCO3-21* AnGap-13 [**2199-8-31**] 06:09AM BLOOD Glucose-101* UreaN-49* Creat-1.4* Na-131* K-4.6 Cl-99 HCO3-25 AnGap-12 [**2199-8-31**] 03:05AM BLOOD Glucose-102* UreaN-48* Creat-1.3* Na-133 K-4.6 Cl-100 HCO3-25 AnGap-13 [**2199-8-30**] 10:05PM BLOOD Glucose-117* UreaN-49* Creat-1.3* Na-130* K-4.7 Cl-98 HCO3-26 AnGap-11 [**2199-8-30**] 03:30PM BLOOD Glucose-116* UreaN-53* Creat-1.5* Na-133 K-5.1 Cl-97 HCO3-21* AnGap-20 [**2199-9-11**] 06:00AM BLOOD ALT-46* AST-39 LD(LDH)-251* AlkPhos-1010* TotBili-0.7 [**2199-9-10**] 12:43AM BLOOD ALT-60* AST-56* LD(LDH)-274* AlkPhos-1171* TotBili-0.9 [**2199-9-1**] 03:03AM BLOOD ALT-50* AST-42* LD(LDH)-363* AlkPhos-457* TotBili-0.8 [**2199-8-30**] 10:05PM BLOOD ALT-61* AST-45* LD(LDH)-339* CK(CPK)-81 AlkPhos-390* TotBili-0.8 [**2199-9-6**] 04:08AM BLOOD GGT-1139* [**2199-9-10**] 12:43AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.2 Mg-1.9 [**2199-9-5**] 06:00AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.5* Mg-1.9 [**2199-9-4**] 02:29AM BLOOD Albumin-3.0* Calcium-8.7 Phos-1.9* Mg-2.1 Iron-31* [**2199-8-30**] 10:05PM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.3 Mg-2.1 Cholest-153 Cardiac Enzymes: [**2199-9-6**] 04:08AM BLOOD CK-MB-3 cTropnT-0.79* [**2199-9-5**] 06:00AM BLOOD CK-MB-4 cTropnT-0.84* [**2199-9-3**] 03:22AM BLOOD CK-MB-9 cTropnT-0.59* [**2199-9-2**] 02:12PM BLOOD CK-MB-10 MB Indx-9.6* cTropnT-0.70* [**2199-8-31**] 06:09AM BLOOD CK-MB-6 cTropnT-0.40* [**2199-8-30**] 10:05PM BLOOD CK-MB-7 cTropnT-0.39* [**2199-8-30**] 03:30PM BLOOD cTropnT-0.35* Other: [**2199-9-4**] 02:29AM BLOOD calTIBC-194 Ferritn-2235* TRF-149* [**2199-8-30**] 10:05PM BLOOD %HbA1c-6.1* eAG-128* [**2199-8-30**] 10:05PM BLOOD Triglyc-186* HDL-44 CHOL/HD-3.5 LDLcalc-72 [**2199-8-30**] 10:05PM BLOOD TSH-0.98 ABG: [**2199-9-1**] 08:57AM BLOOD Type-ART pO2-167* pCO2-47* pH-7.32* calTCO2-25 Base XS--2 [**2199-8-31**] 06:05PM BLOOD Type-ART pO2-160* pCO2-42 pH-7.37 calTCO2-25 Base XS-0 [**2199-8-31**] 05:17AM BLOOD Type-ART pO2-127* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 [**2199-8-30**] 10:42PM BLOOD Type-ART pO2-202* pCO2-43 pH-7.40 calTCO2-28 Base XS-1 Chest X-ray [**2199-9-8**]: IMPRESSION: PA and lateral chest compared to [**8-9**] through [**9-3**]: Moderate left pleural effusion is reaccumulating relative to [**9-1**]. There is no pneumothorax. Right pleural effusion including a fissural component is chronic. No pulmonary edema. Heart size is top normal. Right infusion port catheter ends in the mid SVC. Presence of small pulmonary nodules would be obscured by the extensive overlying pleural abnormalities. [**2199-9-6**] Liver/ Gallbladder US: 1. Mild intrahepatic biliary dilatation, though with common bile duct within normal limits in size. MRCP could be performed to assess for relationship of hepatic metastases to intrahepatic ducts if intervention is planned. 2. Multiple known hepatic metastasis is incompletely evaluated on this study. 3. Layering sludge within the gallbladder. 4. Small amount of intra-abdominal ascites. [**2199-9-6**]: Right Femoral US: Pseudoaneurysm of the right common femoral artery. Size has slightly increased from 1.7 to 1.9 mm in the sagittal plane only. [**2199-9-2**]: CT Abdomen/Pelvis: 1. No evidence of retroperitoneal hematoma. 2. Right nephrostomy tube in stable position. Similar extent of mild left hydronephrosis and hydroureter. Retained contrast within the left kidney, likely from recent CT two days prior, is compatible with obstructive nephropathy. 3. Similar extent of bilateral pleural effusions with associated compressive atelectasis and right middle lobe collapse. 4. Metastatic gastric adenocarcinoma with unchanged omental and hepatic metastases. 5. Increased anasarca, pulmonary edema, and size of abdominal ascites, suggestive of volume overload. [**2199-8-31**]: ECHO The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No left ventricular thrombus seen. Normal global biventricular systolic function. Mild pulmonary hypertension. [**2199-8-30**] MRI HEAD: MPRESSION: Multiple small acute infarcts are identified in both parietooccipital lobes and cerebellar hemispheres without definite acute infarct within the brainstem. Small vessel disease and brain atrophy. [**2199-8-30**]: CT Head and Neck: 1. Thrombosis of the basilar artery. Possible perfusion defects concerning for infarct within the brainstem; however, CT perfusion is suboptimal for the evaluation of the posterior circulation. MRI could be performed for further evaluation. 2. Extensive focal atherosclerosis with marked narrowing of the left subclavian artery just proximal to the takeoff of the left vertebral artery. No other areas of significant stenosis or aneurysm formation are seen. Brief Hospital Course: #. Basilar stroke: Patient was transferred to [**Hospital1 18**] on [**2199-8-30**] for acute stroke. He was treated with MERCI and intra-arterial TPA: The patient's neuro status was closely monitored. He was transitioned from a heparin gtt to lovenox given recent embolic stroke and hypercoaguable state in setting of malignancy. The patient was cleared for a regular diet after a speech and swallow evaluation. #. Right common femoral artery pseudoaneurysm: Patient s/p mechanical and chemical thrombectomy via right common femoral artery puncture, and was found to have small right common femoral artery pseudoaneurysm. He had a repeat ultrasound on [**2199-9-6**] which showed the pseudoaneurysm had slightly increased in size from 1.7 to 1.9 mm in the sagittal plane only. Vascular surgery was following, and did not feel there was a need for intervention. The patient's HCT remained stable. #. Hypoxia: Likely secondary to pleural effusions (malignant). CXR on [**2199-9-3**] had shown stable reticular nodular pattern in right lung likely representing lymphatic obstruction, a stable right pleural effusion, and increased opacification in left lung likely representing increased atelectasis and increased pleural effusion. The patient's supplemental O2 was gradually weaned as tolerated. Repeat CXR on [**2199-9-8**] showed increased pleural effusion and patient had a repeat thoracentesis on [**2199-9-11**] prior to discharge. A post-procedure chest x-ray was done and there were no complications from the procedure. #. [**Last Name (un) **]: Patient has h/o bilateral hydronephrosis, likely secondary to obstructive uropathy. s/p right nephrostomy tube in 08/[**2198**]. Prior to this admission, the patient had been scheduled for bilateraly stent placement on [**2199-9-12**]. His left stent showed hematuria and had poor output in setting of creatinine increase from 1.3->1.7, his left nephrostomy tube was placed. On discharge, his creatinine was 2.0. This lab test should be repeated. #. Stage IV gastric CA: Patient recently diagnosed with gastric cancer, and gastric biopsy returned positive for poorly differentiated adenocarcinoma infiltrating through the deep mucosal layer. Cytology from the peripancreatic lymph nodes was also positive for malignant cells consistent with adenocarcinoma. Patient started first cycle of chemotherapy with epirubicin, oxaliplatin and capecitabine on [**2199-8-22**]. Given recent complications in course, chemo currently on hold. His cell counts were monitored closely in setting of recent chemo. #. Atrial Fibrillation: Patient rate-controlled with metoprolol. Coumadin had been held initially for thoracentesis, and was not restarted in setting of stroke and low platelet count. Patient was previously on argatroban gtt, but placed on heparin gtt after rise in platelets and exclusion of HIT. Patient will need long-term anticoagulation in setting of recent embolic stroke and hypercoagulable state. He was started on lovenox. #. Hypertension: BP was well-controlled after transfer to medical oncology service. The patient was continued on metoprolol for both rate control and BP control. Medications on Admission: Coumadin 5 mg daily Digoxin 0.125 mg daily Lisinopril 20 mg daily Simvastatin 40 mg daily Vicodin 1 tab Q4-6H PRN Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Tablet(s) 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 6. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 11. Outpatient Lab Work Please check CBC, Na, K, Cl, HCO3, BUN, Creatinine, Glucose on [**2199-9-13**]. Please fax results to Dr. [**Last Name (STitle) **] (Fax #[**0-0-**]). 12. Zofran 4 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for nausea. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: Primary: Cerebral Vascular Accident Secondary: Metastatic Gastric Cancer w/ obstruction of left ureter Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure being involved in your care, Mr. [**Known lastname **]. 1. Stroke: You were admitted to [**Hospital1 18**] for management of your acute stoke. You had a procedure to remove a clot from a major artery in your brain. This helped to prevent your stroke from causing more damage to your brain. You were also treated with blood thinners to prevent more clots from forming. 2. Cancer: You have been diagnosed with metastatic gastric cancer. You were not given any cancer treatments during this admission. You should follow-up with your oncologist as an outpatient as to when you should restart chemotherapy. 3. Atrial Fibrillation: You have atrial fibrillation, which is an abnormal heart rhythm. The fast rate was controlled with metoprolol, a drug that slows your heart rate down. 4. Pleural effusion: You had a thoracentesis (Draining of fluid from around the lung) on two occasions during your hospital course. 5: The following changes were made to your medications: -ADDED Lovenox 80 mg subcutaneous injection twice a day -STOPPED Lisinopril, Coumadin, Digoxin, Vicodin -ADDED Senna, Docusate, Miralax -ADDED Metoprolol 37.5 mg TID (three times per day) Followup Instructions: Please keep the following appointments: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2199-9-19**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**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: THURSDAY [**2199-9-19**] at 1 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], 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: THURSDAY [**2199-9-19**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ** please discuss your chemotherapy questions w/ your oncologist at this time*** Per urology, they would like to reschedule your stent placement for a later time, they are cancelling your appointment for tomorrow as you need to get stronger first. [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

[ "V44.6", "287.4", "197.7", "427.31", "300.4", "197.6", "E879.8", "442.3", "289.82", "V58.61", "600.00", "715.90", "285.9", "276.1", "593.4", "433.01", "511.81", "151.8", "434.11", "272.4", "799.02", "784.3", "584.9", "V15.82", "197.0", "196.2", "997.2", "E933.1", "342.92", "V87.41", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.10", "88.48", "96.71", "88.41", "96.04", "34.91", "39.74", "55.93", "00.40" ]

icd9pcs

[ [ [] ] ]

14821, 14892

10138, 13293

289, 404

15060, 15060

2199, 5849

16443, 17799

1764, 1885

13457, 14798

14913, 15039

13319, 13434

15243, 16420

1900, 2180

5866, 10115

234, 251

432, 1149

15075, 15219

1171, 1342

1358, 1748

15,510

171,412

43423

Discharge summary

report

Admission Date: [**2119-6-20**] Discharge Date: [**2119-7-7**] Service: GREEN SURGERY HISTORY OF THE PRESENT ILLNESS: The patient is an 81-year-old woman who presented with three days of abdominal pain and vomiting. The patient was in her usual state of health until three days prior to admission when she begun to experience abdominal pain which increased in severity over three days before presenting to the hospital. The CT scan of the abdomen and pelvis with contrast demonstrated prominence of the large bowel to the splenic flexure with the cecum measuring 11 cm. Numerous low-density lesions in the liver were noted, not seen on an ultrasound from [**2114**]. These findings were considered to be highly worrisome for cecal ischemia. The patient was admitted for further workup. PAST MEDICAL HISTORY: 1. Schizophrenia. 2. Depression. 3. Hypertension. ADMISSION MEDICATIONS: 1. Verapamil one pill p.o. q.d. 2. Zyprexa one pill p.o. q.h.s. 3. Furosemide one pill p.o. q.d. 4. Potassium one pill p.o. q.d. ALLERGIES: Penicillin. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile, respiratory rate 20, oxygen saturation 97% on room air, blood pressure 144/94, heart rate 112. General: the patient was an ill-appearing, obese, elderly woman. HEENT: Normocephalic, atraumatic. PERRLA. EOMI. The mucous membranes were moist. Nasopharynx clear. No JVD. No lymphadenopathy. Heart: Regular rate and rhythm. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Obese, diffusely tender, positive bowel sounds. Extremities: Warm and well perfuse. No clubbing, cyanosis or edema. Neurologic: Nonfocal. HOSPITAL COURSE: The patient underwent a subtotal colectomy with resection of tumor from left upper quadrant, Hartmann's pouch, end-ileostomy, and wedge liver biopsy. Her postoperative course was complicated by a Surgical Intensive Care Unit stay with a pressor requirement and 30 liters of IV fluid on postoperative day number one. The patient received a diagnosis of septic shock. She eventually spontaneously diuresed and was extubated. She tolerated tube feeds. Her white blood cell count was elevated. An extensive workup revealed an MRSA and Enterobacter pneumoniae. She was treated with Levaquin, Flagyl, and vancomycin. Following her transfer to the floor, the patient continued to do well. She tolerated tube feeds and then a regular diet following removal of the NG tube. She had adequate urine output and her vital signs were stable. She was deemed stable for transfer to rehabilitation. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient will be discharged to rehabilitation. DISCHARGE DIAGNOSIS: 1. Metastatic colon cancer. 2. Large bowel obstruction. 3. Hypertension. 4. Schizophrenia. 5. Depression. DISCHARGE INSTRUCTIONS: The patient was instructed to notify M.D. if she experiences fever, nausea, or vomiting, or inability to eat. She was instructed to take antibiotics as directed and to follow-up with Dr. [**Last Name (STitle) **] in two weeks. She was provided the phone number for Dr.[**Name (NI) 18535**] office. DISCHARGE MEDICATIONS: 1. Albuterol 90 micrograms one to two puffs q. two hours p.r.n. 2. Polyvinyl alcohol 1.4% drops one to two drops ophthalmic p.r.n. 3. Lanolin/mineral oil/petroleum ointment one application p.r.n. 4. Albuterol/ipratropium one to two puffs inhalations q. six hours p.r.n. 5. Epoetin alpha 8,000 units one time per week. 6. Olanzapine 5 mg p.o. q.d. 7. Heparin 5,000 units subcutaneously b.i.d. 8. Tylenol 650 mg p.o. q. four to six hours p.r.n. 9. Nystatin 5 mils p.o. q.i.d. p.r.n. 10. Miconazole powder one application t.i.d. 11. Furosemide 20 mg p.o. q.d. 12. Lansoprazole 30 mg p.o. q.d. 13. Levofloxacin 500 mg p.o. q.d. times four days. 14. Insulin sliding scale. 15. Metronidazole 500 mg IV t.i.d. 16. Vancomycin 1,500 mg IV q. 18 hours times four days. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 93434**] MEDQUIST36 D: [**2119-7-7**] 09:25 T: [**2119-7-7**] 09:39 JOB#: [**Job Number 93435**]

[ "153.7", "557.9", "295.90", "428.0", "998.0", "401.9", "560.9", "276.5", "197.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "46.21", "45.76", "50.12", "99.15", "96.6" ]

icd9pcs

[ [ [] ] ]

1079, 1118

3231, 4277

2770, 2882

1751, 2645

2907, 3208

902, 1062

1133, 1733

825, 879

2670, 2749

12,467

140,609

9357

Discharge summary

report

Admission Date: [**2191-3-18**] Discharge Date: [**2191-3-22**] Date of Birth: [**2135-1-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD with esophageal varice banding History of Present Illness: Pt is a 56 yo M w/ h/o Hep C, hepatoma, known esophageal varices, was in his USOH until 1 day prior to admission at which time he had [**1-28**] small dark stools. The following day he then had melena, described as black stool and was feeling lightheaded. He denies any recent N/V, no abd pain. No F/C. Abd girth is table. And his DOE was at baseline as well as his 1+ LE edema. In the ED 2 large bore IV were placed, NG lavage with coffee ground emesis without clearing and found to have 8 pt Hct drop. He was then transferred to the MICU for urgent EGD. Past Medical History: Hepatitis C/ cirrhosis Hepatoma- on Erbitux Esophageal varices Ascites Social History: lives with wife remote tobacco and etoh IV heroin last use 25yrs ago Family History: sister with ovarian cancer Physical Exam: T 98 BP 137/56 HR 110 RR 14 O2sats 100% RA Gen: NAD, A&O times 3 HEENT: clear OP, PERRL, mmm Neck: no JVD, no LAD Lungs: CTAB Heart: Tachy, no m/r/g Abd: Soft, obese, NT/ND + BS Ext: 1+ LE edema b/l Neuro: no asterixis Pertinent Results: [**2191-3-18**] 09:00AM WBC-8.6 RBC-2.76* HGB-9.3* HCT-27.3* MCV-99* MCH-33.8* MCHC-34.2 RDW-15.5 [**2191-3-18**] 09:00AM PLT COUNT-120* [**2191-3-18**] 09:00AM IRON-168* [**2191-3-18**] 09:00AM calTIBC-205* FERRITIN-406* TRF-158* [**2191-3-18**] 09:00AM ALT(SGPT)-32 AST(SGOT)-93* ALK PHOS-214* TOT BILI-2.1* DIR BILI-1.0* INDIR BIL-1.1 [**2191-3-18**] 11:00AM PT-15.8* PTT-30.8 INR(PT)-1.6 [**2191-3-18**] 11:00AM GLUCOSE-106* UREA N-35* CREAT-1.0 SODIUM-130* POTASSIUM-6.5* CHLORIDE-101 TOTAL CO2-23 ANION GAP-13 . ECG- sinus tachy at 114, nl axis, PR 166, QRS 84, no peaked T waves . CXR- No acute cardiopulmonary process. No intraperitoneal free air. Brief Hospital Course: 1. GIB - Pt presented with melena, lightheadedness, Hct drop, and + NG lavage for coffee emesis and has known multiple grade 3 esophageal varices concern was for bleeding varicies. They placed 2 large bore IV's, started fluid, got T&C. Pt was then sent to MICU for emergent EGD. First EGD they found showed varicies without any evidence of active bleeding, but with clots in the stomach. He received FFP and PRBCs. After EGD he continued to have melena so second EGD was performed and they found a bleeding varice in the mid esophagus that appearred to be bleeding which was banded. His diuretics were held and he was started on octreotide along with IV protonix on admission to the MICU. He was also given vitmamin K for an INR of 1.6. After the banding his melena subsided and Hct remained stable. Hcts were trended and after procedure remained stable around 33-34. His diet was advanced. He had no further melena. The octreotide was stopped and he was started on nadolol. Diuretics were resumed on discharge. . 2. HCV/Metastatic Hepatoma - He was recently started on Erbitux (study drug). Will follow up with Dr. [**First Name (STitle) **]. . 3. Cirrhosis/HCV - He was continued on lactulose and flagyl for encephalopathy. There was no evidence of encephalopathy on exam. He was temporarily started on levofloxacin for SBP prophylaxis, this was stopped prior to discharge. Pt will follow up with Dr. [**Last Name (STitle) 497**] as an outpatient. . 4. [**Name (NI) 946**] Pt came in with Na of 130. He was given NS with increase to 135. It later decreased to 131, which was monitored, did not require fluid restriction. On discharge Na was 132. . FULL CODE Medications on Admission: protonix 40mg [**Name (NI) 24018**], lactulose 30ml qid, colace, flagyl 250mg [**Hospital1 **], aldactone 200mg [**Hospital1 24018**], trazadone 25mg qhs, hydrocodone, lasix 80mg [**Last Name (LF) 24018**], [**First Name3 (LF) **] 325mg [**First Name3 (LF) 24018**], zoloft 50mg [**First Name3 (LF) 24018**] Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed. 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 3. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aldactone 100 mg Tablet Sig: Two (2) Tablet PO once a day. 8. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Esophageal varices UGIB Hepatitis C Cirrhosis Hepatoma Hyponatremia Discharge Condition: Stable, Hct stable, no melena, hematemesis Discharge Instructions: Please take all medications as instructed. You should resume all medications that you were taking prior to your admission. The one new medication you will now be taking is nadolol 20mg once a day. If you experience any nausea, vomiting, blood in your vomit, bloody stools, dark tarry stools, lightheadedness, passing out, or shortness of breath you should seek medical attention immediately. You have an appointment to meet with Dr. [**Last Name (STitle) 31961**] on [**4-12**]/o5. That day you will be having an EGD done at 9am. You should show up 1 hour before the procedure (8am). Please do not eat or drink anything after midnight the night before. Followup Instructions: Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Where: GI ROOMS Date/Time:[**2191-4-12**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2191-4-12**] 9:00 Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 5499**] Date/Time:[**2191-5-2**] 8:40

[ "285.9", "070.54", "456.20", "571.5", "537.89", "155.0", "198.5", "572.3", "456.8", "276.1", "572.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "42.33", "45.13", "99.07" ]

icd9pcs

[ [ [] ] ]

4851, 4857

2122, 3801

321, 358

4969, 5013

1428, 2099

5721, 6176

1146, 1174

4159, 4828

4878, 4948

3827, 4136

5037, 5698

1189, 1409

275, 283

386, 949

971, 1043

1059, 1130

68,140

112,268

18626

Discharge summary

report

Admission Date: [**2157-3-1**] Discharge Date: [**2157-3-1**] Date of Birth: [**2073-4-5**] Sex: M Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo male with recent complicated admission significant for: 1. Bladder CA, 7 cm mass, hematuria, with innumberable pulmonary nodules, likely metastases 2. Urosepsis, UCx + pseudomonas, h/o mutliple drug resistant UTIs, treated with 14 days of meropenem 3. Massive DVT, with IVC filter, not on anticoagulation [**1-25**] hematuria During this admission, palliative care was consulted, and significant efforts were made to address goals of care, given his poor prognosis. He was made DNR/DNI. He was discharged to a [**Hospital1 1501**] with the eventual goal of putting him under hospice care. He was then found at his [**Hospital1 1501**] unresponsive. His VS on arrival to the ED were: T 98.0, HR 160s, BP 82/50, SpO2 40% on NRB, with rhonchi on exam. He received Vancomycin 1g IV, Levofloxacin 750mg IV, and Flagyl 500mg IV. On arrival to the floor, patient was unresponsive, was agonal breathing, with an SpO2 in the 60's on a 100% FM with 6L NC. Past Medical History: 1. Pulmonary Embolism ([**2156-12-24**], IVC filter, not on anticoagulation) 2. Pancreatitis 3. Dementia 4. Type 2 Diabetes Mellitus 5. Hypertension, but not on antihypertensives 6. BPH 7. Bladder Cancer - s/p transurethral resection in [**7-31**] - completed [**3-29**] BCG treatment (missed treatment 5 [**1-25**] UTI) 8. s/p Stab Wounds 9. h/o RPR - treated in [**2119**] 10. s/p Penile Implant 11. Osteoarthritis Social History: Per previous records, patient could not complete full history with me due to his delirium and dementia. Home: lives in [**Location 4367**] [**Hospital3 400**] Facility Occupation: retired long-distance truck driver EtOH: remote history of social alcohol use; denies EtOH in > 45 years Tobacco: remote history of 1 PPD smoking history, could not tell me when he quit Drugs: denies Family History: Could not complete due to patient's dementia. Physical Exam: Vitals: BP: 52/31 P: 126 RR: 8 General: Agonal breathing, unresponsive CV: Regular Lungs: Coarse breath sounds bilaterally Ext: warm, well perfused Pertinent Results: [**2157-3-1**] 01:15AM BLOOD WBC-19.4* RBC-4.96 Hgb-11.0* Hct-40.1 MCV-81* MCH-22.2* MCHC-27.4* RDW-18.2* Plt Ct-481* [**2157-3-1**] 01:15AM BLOOD PT-18.2* PTT-34.3 INR(PT)-1.6* [**2157-3-1**] 01:15AM BLOOD Fibrino-821* [**2157-3-1**] 01:15AM BLOOD UreaN-33* Creat-1.9* [**2157-3-1**] 01:15AM BLOOD Lipase-42 [**2157-3-1**] 01:27AM BLOOD Glucose-135* Lactate-11.0* Na-166* K-4.8 Cl-115* calHCO3-23 Brief Hospital Course: 83 year old man with a h/o of metastatic bladder CA, mutliple drug resistant UTIs, & massive DVT s/p IVC filter who presented in respiratory failure likely [**1-25**] pneumonia. On admission, the patient's HCP (his wife) expressed her desire to focus on his comfort. He received supplemental oxygen, antibiotics, and was placed on a morphine gtt and he expired within 2 hours of arriving in the ICU. Medications on Admission: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:*30 Tablet(s)* Refills:*2* 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 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: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dryness. Disp:*1 bottle* Refills:*2* 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Insulin Sliding scale Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.81", "995.92", "V12.51", "276.0", "401.9", "188.9", "600.00", "486", "294.8", "038.9", "197.0", "250.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4384, 4393

2792, 3195

294, 300

4456, 4465

2370, 2769

4521, 4667

2139, 2186

4352, 4361

4414, 4435

3221, 4329

4489, 4498

2201, 2351

247, 256

328, 1284

1306, 1724

1740, 2123

17,026

101,681

51936

Discharge summary

report

Admission Date: [**2163-4-15**] Discharge Date: [**2163-4-29**] Date of Birth: [**2087-2-26**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old female with a history of aortic stenosis, coronary artery disease, congestive heart failure, diabetes, hypertension. She was seen in the Emergency Room on [**4-11**] with bronchitis and treated with Azithromycin. She saw her primary care physician [**Last Name (NamePattern4) **] [**4-13**] who treated her with meter dose inhalers and cough syrup for shortness of breath and wheezing. The patient is now here with a two to three day history of chest tightness, increased shortness of breath, wheezing, cough, no history of GI bleeding and no fevers or chills. The patient is otherwise in her usual state of health until one week ago. PAST MEDICAL HISTORY: 1. Congestive heart failure. 2. Coronary artery disease. 3. Diabetes type 2. 4. Remote history of stroke. 5. Hypertension. 6. Gangrenous left first toe. 7. Left SFA. HOME MEDICATIONS: 1. Lopressor 25 b.i.d. 2. Lipitor 10 mg q.p.m. 3. Lasix 40 mg q.a.m. 4. Relafen 750 mg b.i.d. 5. Ecotrin 325 mg po q.d. 6. K-Dur 20 milliequivalents q.a.m. 7. Colace 100 mg b.i.d. 8. NPH 22 units q.a.m., 15 units q 8 p.m. SOCIAL HISTORY: No history of tobacco or alcohol. PHYSICAL EXAMINATION: Pulse 85. Blood pressure 95/69. Respiratory rate 24. 96% oxygen saturation on 4 liters. General, the patient is an elderly female in no acute distress. Neck JVP 10 cm. HEENT mucous membranes are moist. Extraocular movements intact. Left eye lateral abduction. Cardiac sounds obscured by increased rhonchi. Pulmonary diffuse rhonchi and wheezing. Abdomen positive bowel sounds, soft. Extremities bilateral lower extremity 1+ pitting edema, 1+ bilateral dorsalis pedis pulses. LABORATORY: The patient was hyponatremic with a sodium of 127 and acute elevation of her creatinine to 1.2 from .7. Chest x-ray showed bibasilar opacities bilaterally. Pulmonary edema infiltrate, versus atelectasis. Electrocardiogram showed ST elevation in V1 through V3. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2163-4-15**] and initially treated medically by the Medicine Service. She was started on Levaquin for pneumonia. She was started on aspirin, heparin drip, beta blocker for her myocardial infarction. The patient also received Lasix for her acute congestive heart failure exacerbation. Cardiology was involved in the patient's care. An echocardiogram was performed, which showed an ejection fraction of less then 20%. Cardiac catheterization was also performed showing mitral regurgitation, left ventricular ejection fraction of 25%, global hypokinesis, 1+ mitral regurgitation, right dominant coronary angiography LMCA calcified plaque 40% proximally, left anterior descending coronary artery diffuse 70% long proximal calcified, Dig okay, left circumflex moderate distal right coronary artery 70%, osteal 95% mid lesion. The patient was taken to the Operating Room on [**2163-4-21**] where a coronary artery bypass graft times four and aortic valve replacement was performed. The patient was left with a chest tube and pacing wires in place. She required immediately postoperatively epinephrine and Propofol drips. The first postoperative day she was noted overnight to have ventricular ectopy for which she received Amiodarone. The patient received Vancomycin times four perioperatively for prophylaxis. She was started on beta blockers and Lasix at the appropriate time. At the appropriate time the patient's pacing wires and chest tubes were removed. She was stopped from her various drips when appropriate. The patient was also shown to have a wide complex tachycardia at times per cardiologist Dr. [**Last Name (STitle) **]. The patient was sent out of the Intensive Care Unit when appropriate on Lasix, Captopril and Lopressor as well as Amiodarone. Due to the patient's age and stability it was determined by her cardiologist that Coumadin probably would not be an appropriate course of therapy due to significant risks. Once the patient was on the floor when of her major issues was blood pressure control for which her blood pressure medications were progressively increased. Physical therapy saw the patient on repeated occasions and believed the patient would do well at a rehab facility. It is now [**2163-4-29**] and the patient is in stable condition. It is likely that she will be discharged today or tomorrow for rehab. The patient may shower, but should not take baths. The patient is to avoid strenuous activity. The patient should not drive while on pain medication. She is to follow up with Dr. [**Last Name (STitle) 1537**] in four weeks. She is to follow up with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 11139**] in one to two weeks and Dr. [**Last Name (STitle) **] in two to three weeks. She will be discharged on Lopressor 50 mg po b.i.d., Captopril 37.5 mg po t.i.d., Reglan 10 mg q 6, Timolol .5% one drop OD b.i.d., _____________ 2%, Timolol .5% one drop OS b.i.d., insulin sliding scale, Atorvastatin 10 mg po q.d., Amiodarone 400 mg po q.d., Benadryl 25 to 50 mg po q.h.s. prn, Milk of Magnesia 30 mg po q.h.s. prn, Percocet one to two tabs q 4 prn, Ibuprofen 400 mg po q 6 prn, Tylenol 650 mg po q 4 prn, enteric coated aspirin 325 mg po q.d., Ranitidine 150 mg po b.i.d., Colace 100 mg po b.i.d., potassium 20 milliequivalents po q 12 and Lasix 20 mg intravenous q 12. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 5919**] MEDQUIST36 D: [**2163-4-29**] 10:11 T: [**2163-4-29**] 10:31 JOB#: [**Job Number 107516**]

[ "276.1", "414.8", "486", "410.71", "414.01", "425.4", "424.1", "443.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.13", "37.23", "88.54", "39.61", "36.15", "35.21" ]

icd9pcs

[ [ [] ] ]

2124, 5820

1042, 1273

1348, 2106

160, 828

850, 1024

1290, 1325

29,264

182,651

1454

Discharge summary

report

Admission Date: [**2134-10-4**] Discharge Date: [**2134-10-11**] Date of Birth: [**2055-5-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: CHF/A fib/DOE Major Surgical or Invasive Procedure: [**2134-10-5**] MV repair (34 mm annuloplasty ring) History of Present Illness: 79 yo male recently treated for CHF ( lost 28 # with med rx). Prior to med management, he was experiencing DOE and had decreased activity tolerance. Has been followed with echos for 5 years. Most recent shows moderate to severe MR. Past Medical History: MR CAD HTN systolic CHF RHD A Fib PUD with gastric bleed [**2108**] varicosities CRI Social History: lives with wife denies tobacco use denies ETOH use retired engineer Family History: NC Physical Exam: 5'8" 114# right 104/70 left 108/72 HR 88 RR 14 NAD skin unremarkable PERRL/EOMI/NCAT neck supple, full ROM, no JVD or carotid bruits appreciated CTAB regularly irregular [**3-3**] holosystolic murmur soft, NT, ND extrems warm, well-perfused, 1+ LE edema large bilat. varicosities, right greater than left Pertinent Results: Conclusions PREBYPASS 1. The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %), in the setting of MR [**First Name (Titles) **] [**Last Name (Titles) **] may be an overestimation. 3. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 7. Moderate [2+] tricuspid regurgitation is seen. 8. Significant pulmonic regurgitation is seen. 9. There is no pericardial effusion. 10 Dr. [**Last Name (STitle) **] was notified in person of the results on 1040 at [**2134-10-5**]. POSTBYPASS 1. Patient is on epinephrine and norepinephrine infusions 2. The LV remains globally hypokinetic with an EF 20%. 3. A well seated mitral annuloplasty ring is seen in the mitral annulus. No MR is seen. 4. Aortic regurgitation remain 1+ post bypass 5. Aortic contour is smooth post decannulation. 6. Dr. [**Last Name (STitle) **] notified of findings 1457 on [**2134-10-5**] I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2134-10-7**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 8646**] Reason: eval for pneumothorax s/p chest tube removal [**Hospital 93**] MEDICAL CONDITION: 79 year old man s/p MVRepair REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal Wet Read: [**First Name9 (NamePattern2) 8647**] [**Doctor First Name **] [**2134-10-7**] 8:01 PM No ptx. CMG, b/l small effusions, retrocardiac opacity. Final Report AP CHEST, 6:39 P.M., [**10-7**] HISTORY: Mitral valve repair. Possible pneumothorax following chest tube removal. IMPRESSION: AP chest compared to [**10-4**] and 9: Lung volumes are lower following removal of the endotracheal tube, with worsened atelectasis at both lung bases, left greater than right, and increase in small bilateral pleural effusion. Increasing cardiac diameter could be due in part to lower lung volumes, and probably some mediastinal fluid collection, although there is no distention of mediastinal veins to suggest hemodynamic significance. No pneumothorax. Upper lungs clear. Right jugular sheath ends at the junction of the brachiocephalic veins. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: FRI [**2134-10-8**] 1:32 PM Imaging Lab [**2134-10-9**] 08:30AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.0* Hct-31.2* MCV-88 MCH-31.1 MCHC-35.4* RDW-14.8 Plt Ct-116* [**2134-10-4**] 07:10PM BLOOD WBC-8.3 RBC-4.40* Hgb-13.2* Hct-37.7* MCV-86 MCH-30.1 MCHC-35.0 RDW-14.2 Plt Ct-190 [**2134-10-11**] 05:30AM BLOOD PT-13.5* INR(PT)-1.2* [**2134-10-4**] 07:10PM BLOOD PT-14.1* PTT-34.1 INR(PT)-1.2* [**2134-10-10**] 07:05AM BLOOD Glucose-94 UreaN-38* Creat-1.5* Na-136 K-5.2* Cl-105 HCO3-28 AnGap-8 [**2134-10-4**] 07:10PM BLOOD Glucose-112* UreaN-39* Creat-1.5* Na-141 K-4.7 Cl-102 HCO3-30 AnGap-14 Brief Hospital Course: On [**10-5**] Mr.[**Known lastname **] [**Last Name (Titles) 8650**]t MVrepair (#34mm ring) with Dr. [**Last Name (STitle) **] . XCT=42min., CPB =68 minutes. He was transferred to the CVICU in stable condition on epinephrine, propofol and levophed drips. Extubated later that evening. POD#1 he required milrinone due to decreased cardiac output. His rhythm was intermittently SR/AFib-rate controlled. The milrinone was weaned to off with a stable cardiac output/cardiac index. All tubes and lines were discontinued when criteria was met.POD#3 he was transferred to the SDU for further telemetry and recovery. Beta-blocker optimized as BP tolerated. Mr.[**Known lastname **] was restarted on his Coumadin for his intermittent AFib. Despite discussions regarding the potential risks of stroke if not taking Coumadin, Mr.[**Known lastname **] refuses.At time of discharge Coumadin will be prescribed and he follow-up for INR/ Coumadin dosing has been arranged. the remainder of his postoperative course was essentially uneventful. He continued to progress and on POD#6 he was discharged to home with VNA. All follow-up appointments were advised. Medications on Admission: spironoloactone 12.5 mg daily MVI daily ASA 81 mg daily Vit C 500 mg daily simvastatin 20 mg daily digoxin 0.125 mg daily carvedilol 12.5 mg [**Hospital1 **] lisinopril 10 mg daily melatonin 3 mg QHS heparin IV drip Discharge Medications: 1. Carvedilol 3.125 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO BID (2 times a day). Disp:*120 [**Hospital1 8426**](s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 [**Hospital1 8426**](s)* Refills:*0* 5. Simvastatin 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily). Disp:*30 [**Hospital1 8426**](s)* Refills:*0* 6. Pantoprazole 40 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital1 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*0* 7. Digoxin 125 mcg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily). Disp:*30 [**Hospital1 8426**](s)* Refills:*0* 8. Warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily). Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*0* 9. Furosemide 20 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a day) for 7 days. Disp:*14 [**Last Name (Titles) 8426**](s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: MR s/p MV repair CAD HTN systolic CHF RHD A Fib PUD with gastric bleed [**2108**] varicosities CRI Discharge Condition: good Discharge Instructions: shower daily and pat incisions dry no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month AND until off narcotics call for fever greater than 100.5, redness or drainage Followup Instructions: see Dr. [**Last Name (STitle) 8651**] in [**1-27**] weeks see Dr. [**Last Name (STitle) 696**] in [**2-28**] weeks see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 8652**] **daily INR results to be called into Dr[**Name (NI) 8653**] office for Coumadin dosing Completed by:[**2134-10-11**]

[ "424.0", "403.90", "E878.8", "287.5", "425.4", "427.31", "585.9", "397.0", "998.0", "428.0", "428.22" ]

icd9cm

[ [ [] ] ]

[ "88.52", "88.56", "35.33", "39.61", "37.23" ]

icd9pcs

[ [ [] ] ]

8049, 8107

4911, 6055

336, 391

8250, 8257

1212, 3062

8537, 8847

861, 865

6321, 8026

3102, 3131

8128, 8229

6081, 6298

8281, 8514

880, 1193

283, 298

3163, 4888

419, 652

674, 760

776, 845

42,131

199,967

48532

Discharge summary

report

Admission Date: [**2184-7-31**] Discharge Date: [**2184-8-10**] Date of Birth: [**2102-1-3**] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Aspirin / Ace Inhibitors Attending:[**First Name3 (LF) 5018**] Chief Complaint: dysarthria and ataxia Major Surgical or Invasive Procedure: none History of Present Illness: The pt is an 82 year-old R-handed F who presents with acute onset dysarthria and ataxia. She reports that she felt fine when she went to bed around midnight last night. She awoke around 3am with a "noise" in her head, which she describes as similar to tinnitus she has had in the past but much worse. She thinks it was this noise that woke her from sleep. She got up to go to the bathroom and noticed that she felt dizzy and was having trouble walking. She thinks she was falling to both sides and had to hold on to the walls to be able to walk. She went back to sleep but got up a few more times throughout the night and continued to feel unsteady on her feet. She got up at 8:00 this morning and again found it difficult to walk so she called her son. At that point she and her son both noticed that her speech was slurred and she decided to go to the hospital. On evaluation at [**Hospital1 **] [**Location (un) 620**], she was noted to have dysarthria and ataxia on exam. Labs were wnl, and a CT head showed extensive deep white matter hypodensity extending to the subcortical regions most likely representing chronic small vessel ischemia, but no acute infarction. CTA showed occlusion of the basilar artery and she was transferred to [**Hospital1 18**] for further management. Currently she continues to experience dysarthria and gait instability. Does not think these symptoms have changed since their onset. She denies headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, or hearing difficulty. Her tinnitus has currently resolved. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Hypertension HL GERD Hx of Tuberculosis (Tx [**2118**]) Bilat TKR knee arthroplasty Social History: Divorced, lives at a senior living center, independent with all ADL's. Retired, used to be a dance instructor and also managed an art gallery and worked in real estate. Previously smoked 2ppd for most of her life, quit 20 years ago. Does not drink alcohol, no history of illicit drug use. Family History: Father was a neurologist, died of stroke at age 87. Mother died in 50's by suicide. Two children, healthy. Physical Exam: At admission Vitals: T: 97 P: 55 BP 137/55 RR 18 O2 sat 97% on 4L NC General: Awake and alert, pleasant, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is moderately dysarthric but easily understandable with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk on R, post-surgical on L. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 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 DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Romberg positive for sway. Gait wide-based and unsteady, unable to perform tandem gait. At discharge: Neurologic: -Mental Status: Drowsy, opens eyes spontaneously. No verbal production. Comprehension severely impaired. Right neglect improving. Eyes cross midline although left gaze preference. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk on R, post-surgical on L. No reaction to threat in Right visual field. Intact left visual field. confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Not tested VII: Right facial droop VIII: Not tested IX, X: Not tested [**Doctor First Name 81**]: Not tested XII: Not tested -Motor: Flaccid RUE, increased tone in RLE, normal tone in left side. No adventitious movements, such as tremor, noted. No asterixis noted. No movement of right side. Left side moves spontaneously. Difficult to test power on left side but at least antigravity. -Sensory: Withdraws to noxious on left side. Grimace to noxious on right side. Triple flexion in RLE. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was flexor on left, extensor on right. -Coordination: Not tested -Gait: Not tested Pertinent Results: Admission labs: [**2184-7-31**] 04:50PM PT-13.0 PTT-24.1 INR(PT)-1.1 [**2184-7-31**] 04:50PM WBC-8.3 RBC-4.52 HGB-13.6 HCT-39.4 MCV-87 MCH-30.1 MCHC-34.5 RDW-14.6 [**2184-7-31**] 04:50PM NEUTS-76.2* LYMPHS-17.8* MONOS-3.9 EOS-0.8 BASOS-1.3 [**2184-7-31**] 04:50PM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.1 [**2184-7-31**] 04:50PM GLUCOSE-105* UREA N-10 CREAT-0.7 SODIUM-145 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-25 ANION GAP-15 [**2184-7-31**] 07:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2184-7-31**] 07:51PM URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018 [**2184-7-31**] 07:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . INR trend: [**2184-8-3**] 11:15PM BLOOD PT-13.3 PTT-69.5* INR(PT)-1.1 [**2184-8-4**] 06:22AM BLOOD PT-13.5* PTT-24.9 INR(PT)-1.2* [**2184-8-4**] 12:45PM BLOOD PT-14.8* PTT-57.4* INR(PT)-1.3* [**2184-8-4**] 08:00PM BLOOD PT-15.6* PTT-64.0* INR(PT)-1.4* [**2184-8-5**] 05:50AM BLOOD PT-17.3* PTT-74.7* INR(PT)-1.5* [**2184-8-5**] 03:20PM BLOOD PT-19.2* PTT-71.2* INR(PT)-1.7* [**2184-8-5**] 09:20PM BLOOD PT-20.2* PTT-83.6* INR(PT)-1.8* [**2184-8-6**] 04:25AM BLOOD PT-23.3* PTT-91.3* INR(PT)-2.2* [**2184-8-6**] 01:49PM BLOOD PT-25.0* PTT-65.7* INR(PT)-2.4* [**2184-8-7**] 06:55AM BLOOD PT-25.1* PTT-30.5 INR(PT)-2.4* [**2184-8-8**] 07:00AM BLOOD PT-27.3* PTT-30.8 INR(PT)-2.6* [**2184-8-9**] 06:20AM BLOOD PT-29.7* PTT-30.6 INR(PT)-2.9* INR on [**8-10**] 2.8 . Risk factors: [**2184-8-1**] 01:16AM BLOOD ALT-11 AST-15 LD(LDH)-198 AlkPhos-68 TotBili-0.8 [**2184-8-1**] 01:16AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 Cholest-162 [**2184-8-1**] 01:16AM BLOOD Triglyc-122 HDL-43 CHOL/HD-3.8 LDLcalc-95 [**2184-8-1**] 01:16AM BLOOD %HbA1c-5.8 eAG-120 [**2184-8-1**] 01:16AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Discharge labs: . . Urine: [**2184-7-31**] 07:51PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.018 [**2184-7-31**] 07:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2184-7-31**] 07:51PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . Microbiology: [**2184-7-31**] 10:38 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2184-8-2**]** GRAM STAIN (Final [**2184-8-1**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2184-8-2**]): MODERATE GROWTH Commensal Respiratory Flora. . [**2184-8-2**] MRSA SCREEN MRSA SCREEN-NEGATIVE . . Radiology: Non-Contrast CT of Head ([**Hospital1 **] [**Location (un) 620**]): There is no evidence of hemorrhage, edema, masses, mass effect or infarction. The ventricles and sulci are prominent, compatible with the patient's age. There is extensive deep white matter hypodensity extending to the subcortical regions. This most likely reflects chronic small vessel ischemia. There is dense calcification of the cavernous carotid arteries bilaterally. The patient has undergone a scleral band of the left globe. The occular lenses have been removed bilaterally. . [**Hospital1 **] [**Location (un) 620**] CTA: Cut off of basilar artery just distal to joining of vertebral arteries. . [**Hospital1 **] [**Location (un) 620**] Brain MRI: Inferior left cerebellar infarct + a small right pontine DWI abnormality. CTA shows an abrupt cut-off in the lower midbasilar with distal reconstitution and a hypoplastic L-VA. . CT HEAD W/O CONTRAST Study Date of [**2184-7-31**] 10:01 PM IMPRESSION: No interval change from earlier study with density to the basilar artery, likely reflecting already demonstrated basilar thrombus. NOTE ADDED IN ATTENDING REVIEW: The 17 mm wedge-shaped low-attenuation focus in the periphery of the inferior left cerebellar hemisphere corresponds to the relatively acute infarct at this site, demonstrated on the MR study obtained roughly 9 hrs later. The more subacute-appearing infarct involving the right anterolateral aspect of the medulla is difficult to identify. . CHEST (PORTABLE AP) Study Date of [**2184-8-1**] 4:56 AM IMPRESSION: Evidence of prior tuberculosis and potentially asbestos exposure (pleural plaques may also be related to tuberculosis itself). No evidence of acute cardiopulmonary process. . MR HEAD W/O CONTRAST Study Date of [**2184-8-1**] 6:23 AM IMPRESSION: 1. Acute infarct involving the inferior periphery of the left cerebellar hemisphere, likely embolic, related to the proximal basilar arterial thromboembolic disease. 2. Somewhat equivocal, less marked abnormality involving the right medullary pyramid, which may represent a more subacute infarct, perhaps related to the same source. 3. Expected abnormality of the basilar arterial flow-voids, with otherwise patent intracranial vasculature. 4. Acute-on-chronic inflammatory changes involving, particularly, the maxillary sinuses and sphenoid air cells. 5. Post-surgical ocular findings. . CT HEAD W/O CONTRAST Study Date of [**2184-8-2**] 5:35 AM FINDINGS: Wedge-shaped hypodensity in the inferior aspect of the left cerebellar hemisphere (series 2, image 8) has evolved since reflecting infarction. There is no new parenchymal hypodensity to suggest interval infarction. There is no intracranial hemorrhage. Extensive periventricular white matter hypodensities reflect chronic microvascular ischemia. Ventricles and sulci are normal in size and in configuration. This noncontrast study is suboptimal for vascular assessment. A left scleral band is unchanged. Mastoid air cells are clear. Note is made of mucosal thickening as well as air-fluid levels in the paranasal sinuses, specifically involving the sphenoid and maxillary sinuses. IMPRESSION: Evolution of left cerebellar infarction and chronic microvascular disease. . CT CHEST W/CONTRAST Study Date of [**2184-8-4**] 4:45 PM IMPRESSION: Moderate-to-severe apical predominant centrilobular parenchyma. No evidence of intrathoracic malignancy. With large calcified right lung granuloma and few small calcified mediastinal lymph nodes, the ipsilateral-only, pleural calcification is more likely due to prior granumomatous infection than prior asbestos exposure. No findings of either active infection or pulmonary asbestosis. Small nodule in the right lobe of thyroid and left adrenal nodule should both be further evaluated with ultrasound, if not already performed. Moderate coronary artery calcifications. . CTA HEAD AND NECK W&W/O C & RECONS Study Date of [**2184-8-8**] 5:46 PM HEAD CT WITHOUT CONTRAST: Again confluent areas of low attenuation are redemonstrated in the subcortical and periventricular white matter, which are nonspecific and may reflect chronic microvascular ischemic disease. A more conspicuous area is noted on the left pons related with ischemia and demonstrated on the prior T2-weighted sequence MR examination dated [**2184-8-1**]. There is no evidence of acute intracranial hemorrhage or mass effect. Scleral band is redemonstrated on the left orbit, persistent mucosal thickening at the maxillary sinuses. CTA OF THE HEAD: Persistent filling defects are redemonstrated in the basilar artery, causing significant narrowing at the mid segment of the basilar artery, clearly identified in the rotational images. The V4 segment of the right vertebral artery is not clearly identified and possibly this vessel terminates on PICA versus atherosclerotic disease. Both posterior communicating arteries are patent, the distal branches of the middle, anterior and posterior cerebral arteries are not clearly identified, related with diffuse atherosclerotic disease. No aneurysms are identified. CTA OF THE NECK: Significant atherosclerotic disease and plaques are visualized at the aortic arch, the origin of the supra-aortic vessels appears patent and also demonstrates multiple atherosclerotic plaques. The right carotid cervical bifurcation appears patent with dense atherosclerotic plaques and soft plaques, the maximum caliber on the internal carotid artery in the proximal segment estimated in 6.5 mm and distally 5.3 mm. The left cervical carotid bifurcation demonstrate atherosclerotic plaques with no significant stenosis, the proximal segment measures approximately 6.2 mm and distally 4.9 mm. The right vertebral artery is nondominant and the V4 segment is thin, possibly terminating in PICA versus atherosclerotic narrowing. The left vertebral artery appears dominant with no evidence of flow or stenotic lesions. Visualized osseous structures demonstrate multilevel degenerative changes consistent with anterior and posterior spondylosis, more significant from C3 through C6 levels. The lung apices demonstrate persistent atypical centrilobular emphysema and pleural thickening. IMPRESSION: 1. Chronic microvascular ischemic disease as described above, cerebellar infarctions as well as left pontine ischemic change, previously demonstrated by MRI. There is no evidence of acute intracranial hemorrhage. 2. Significant narrowing of the basilar artery, more significant at the mid segment related with atherosclerotic disease. Diffuse atherosclerotic changes are visualized in the distal branches of the middle, anterior and posterior cerebral arteries. Bilateral atherosclerotic calcifications are visualized at the carotid cervical bifurcations with no evidence of critical stenosis. The V4 segment is not clearly identified, possibly the right vertebral artery terminates in PICA versus atherosclerotic narrowing. 3. Unchanged centrilobular emphysema and pleural thickening. 4. Multilevel degenerative changes throughout the cervical spine. . . Cardiology: Portable TTE (Complete) Done [**2184-8-2**] at 10:11:15 AM Conclusions The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Pulmonary artery hypertension. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. No definite structural cardiac source of embolism identified. Brief Hospital Course: The pt is an 82 year-old R-handed F who presented with acute onset of dysarthria and ataxia. [**Hospital1 **] [**Location (un) 620**] CTA showed an abrupt cut-off in the lower midbasilar with distal reconstitution and a hypoplastic left vertebral artery. Her deficits were remarkably mild given the location of her occlusion, she was admitted to the Neuro ICU. She was started on a heparin drip and an MRI/MRA was done that showed an inferior left cerebellar infarct and a small right pontine DWI abnormality. The patient remained stable in the NeuroICU until she noted transient episodes where she noted new RUE weakness and worsening slurred speech. Repeat head CTs showed no changes. These were initially felt to be the result of hypoperfuion and she was treated with IV fluid boluses and continuous IV fluids to help support her BP and was kept in flat bed rest. Latterly, it was discovered that she had these episodes regardless of BP or position and were anxiety related. On [**2184-8-2**] the patient was transferred to the stroke step down unit and although she was initially very anxious and having multiple of these transient episodes, these settled and she was started on citalopram for anxiety. She was encouraged to sit to chair and then undergo PT. She was transferred to rehabilitation on [**2184-8-10**] She is on Warfarin with a therapuetic INR. She will need INR checks and a goal INR of [**2-12**]. Of note the patient has been having episodes of dysarthria, and subjective tingling sensation (sometime subjective weakness in the right hand). These episodes are short lived, and will resolve in [**10-28**] minutes. She has been re-scanned during these episodes and there has not been any evidence of new lesion and she has been therapuetic on coumadin. These are likely anxiety related, and if they resolve she does not need further workup for them . # Basilar clot: Patient has risk factors of HTN and HLD, ex-smoker. She presented with acute onset dysarthria and ataxia. Neurological examination revealed dysarthria and gait instability but normal cerebellar function and no other focal neurologic signs. CT scan at [**Hospital1 **] [**Location (un) 620**] was negative for acute infarct but CTA showed an abrupt cut-off in the lower midbasilar with distal reconstitution and a hypoplastic left vertebral artery. She was outside the time window for invasive intervention. Her deficits were remarkably mild given the location of her occlusion but warrant very close monitoring and thus she was monitored on the neuro ICU. She was started on a heparin drip and an MRI/MRA was done that showed an inferior left cerebellar infarct and a small right pontine DWI abnormality. Risk factors were addressed and HbA1c was 5.8%, lipid panel showed Chol 162 TGCs 122 LDL 95. Given smoking and asbestos hx with pleural plaques requested CT-chest which showed COPD changes and pleural plaques but no mass. Patient was treated with a HISS and BP was allowed to autoregulate and initially the goal was to keep the BP elevated to prevent hypoperfusion. Echo showed mild pulmonary HTN, LVEF >55% and no cardiac source of embolism found. Currently no cause identified and we are deferring TEE. The patient remained stable in the Neuro ICU until she noted transient episodes where she noted new RUE weakness and worsening slurred speech. Repeat head CTs showed no changes. These were initially felt to be the result of hypoperfuion and she was treated with IV fluid boluses and continuous IV fluids to help support her BP and was kept in flat bed rest and salt tablets were also trialled. Latterly, it was discovered that she had these episodes regardless of BP or position and were anxiety related and these interventions were stopped. On [**2184-8-2**] the patient was transferred to the stroke step down unit and although she was initially very anxious and having multiple of these transient episodes, these settled and she was started on citalopram for anxiety. Patient was transitioned to warfarin and heparin was stopped when INR >2. We continued Atorvastatin 80mg. Repeat CTA head showed Significant narrowing of the basilar artery, more significant at the mid segment related with atherosclerotic disease in addition to diffuse atherosclerotic changes in the distal branches of the middle, anterior and posterior cerebral arteries. She was encouraged to sit to chair and then undergo PT. Patient worked with PT/OT and S&S were happy with her swallow although patient had concerns. She was transferred to rehabilitation on [**2184-8-10**] . # CVS: Patient has HTN. BP was controlled and home atenolol and amlodipine were held, using hydralazine 10 mg IV if necessary for SBP >180. Salt tablets were initially trialled and stopped. . # Pulmonary: Patient had chronic upper respiratory tract symptoms with cough productive of sputum. She had no indicators of pneumonia. She was treated with nebulisers and regular saline nebs. This may be related to the CT-chest showed no mass but identified a large, calcified right lung granuloma and a few small calcified mediastinal lymph nodes. There were no findings of either active infection or pulmonary asbestosis. # Endocrine: Patient has no hx of DM and had HbA1c 5.8%. She was initially treated with a HISS and this was stopped. Transitional issues: Radiology recommended U/S for small nodule in the right lobe of thyroid and left adrenal nodule identified on CT-chest. Medications on Admission: Medications - Prescription AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth daily ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth daily CONJ ESTROG-MEDROXYPROGEST ACE [PREMPRO] - (Prescribed by Other Provider) - 0.45 mg-1.5 mg Tablet - 1 Tablet(s) by mouth LORAZEPAM - (Prescribed by Other Provider) - Dosage uncertain OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - Dosage uncertain OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for pain TRAZODONE - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ASPIRIN [ASPIRIN LOW DOSE] - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet, Delayed Release (E.C.)(s) by mouth daily as needed CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] - (OTC) - 315 mg-200 unit Tablet - 2 Tablet(s) by mouth twice a day MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 10. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-18**] MLs PO Q6H (every 6 hours) as needed for cough. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. trazodone 50 mg Tablet Sig: 0.5 Tablet PO once a day. 14. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day. 15. multivitamin-minerals-lutein Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Cerebral embolism with infarction Basilar artery stenosis, likely secondary to atherosclerosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurology: Good power in arms and legs - mild left weakness. Dysarthria. Finger nose ataxia on left with rebound. Has episodes of worsened speech and this does not seem to be associated with her basilar thrombosis Discharge Instructions: It was a pleasure taking care of you [**Last Name (un) 22034**] your sty at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented with slurred speech and unsteadiness. You were found to have a blood clot in your basilar artery - the main blood vessel supplying the base of the brain. To prevent this from worsening, you were started on an IV blood thinner and latterly warfarin. The warfarin is now in the right range for adequate blood thinning. You had several CT scans and an MRI scan which showed and small stroke in the left cerebellum which coordinates movement in the left side of the body and accounts for your reduced coordination on that side. You also had episodes of worsened speech and generalised or right arm weakness. These were initially thought to be due to reduced blood flow to the base of the brain but latterly was felt to be less concerning and also linked to anxiety. . We REDUCED amlodipine to 5mg daily We STOPPED atenolol We INCREASED atorvastatin to 80mg daily We STOPPED PREMPRO We CHANGED prilosec to pantoprazole 40ng daily We STOPPED percocet We STOPPED aspirin We STARTED symbicort 2 puffs twice daily We STARTED warfarin 3mg daily Warfarin is a blood thinner and as such carries with it an increased risk of bleeding. If you cut yourself you may bleed for longer and if you fall and especially if you hit your head you must seek medical attention. We STARTED Guaifenasin as needed for cough We STARTED albuterol nebulisers as required We STARTED acetaminophen and laxatives Followup Instructions: Please see your PCP [**Name Initial (PRE) 176**] 1 week after discharge from rehab. . We made the following neurology follow-up for you: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 15319**] wed [**9-15**] at 1:30, in shapro [**Location (un) **] at [**Hospital1 18**] [**Hospital Ward Name **] Your other appointments: Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2185-1-17**] 11:00 Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2186-5-9**] 12:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2186-5-9**] 1:00 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

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341, 347

25689, 25689

6611, 6611

27699, 28569

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280, 303

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25704, 26055

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10,004

164,713

28035+57571+57574+57575

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2182-11-2**] Discharge Date: [**2182-11-19**] Date of Birth: [**2130-10-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: transfer from outside hospital SDH/SAH/IPH s/p fall/seizure Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Per EMS, patient was found by family seizing/unresponsive in basement. EMS intubated at scene - patient was moving all four extremities and was combative. Patient brought to OSH ([**Hospital1 **]) where CT Head showed b/l frontal SDH/diffuse SAH/diffuse IPH and skull fx - patient then tx to [**Hospital1 18**] Past Medical History: PMHx: HTN, CAD, DM, +EtOH, seizure dx Social History: PSHx: shoulder surgery b/l, lumbosacral scar Family History: unknown Physical Exam: O: T: AF BP: 125/75 HR:95 R15 O2Sats 100 - AC 600X14 PEEP 5 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**3-7**] reactive b/l; EOMs unable to assess 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: Intubated/Sedated Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 3-2 mm bilaterally. III, IV, VI: Unable to assess V, VII: Unable to assess VIII: Unable to assess IX, X: Unable to assess [**Doctor First Name 81**]: Unable to assess XII: Unable to assess Motor: Localizes pain in LUE only Toes downgoing bilaterally Pertinent Results: CT HEAD W/O Contrast IMPRESSION: 1. Diffuse extensive bilateral subarachnoid hemorrhage, bifrontal subdural hematoma, small subdural hematoma along the falx on the left, as well as multiple intraparenchymal hemorrhagic contusions as described above. Some areas of hemmorhage with fluid levels suggesting semiacute etiology. 2. Left parietal skull fracture. 3. Minimal midline shift [**2182-11-2**] 12:52PM WBC-16.6* RBC-3.62* HGB-11.8* HCT-34.0* MCV-94 MCH-32.6* MCHC-34.7 RDW-14.7 [**2182-11-2**] 12:52PM PT-12.8 PTT-23.5 INR(PT)-1.1 [**2182-11-2**] 12:52PM PLT COUNT-150 Brief Hospital Course: Pt was admitted to ICU for close monitoring. He had left arm tremors which was questionable for seizures, neurology recommended dilantin in therapeutic range. Due to his fevers he was ultimately transitioned from dilantin to keppra for seizure prophylaxis. He had glucoses in the 700s upon admisiion. He has been followed by the [**Last Name (un) **] diabetic service and is now controlled. (It is recommended that he receive D5 if tube feeds are stopped for any length of time.) He had repeat head CTs which ultimately showed continued evolution of intracranial hemorrhages. He had PEG placed [**11-8**] and trach [**11-9**]. He had fevers, was worked up and followed by ID and was diagnosed with UTI, tooth abcess and pnuemonia. He was treated with antibiotics and will still require unasyn until [**11-22**]. He was started on tube feeds and advanced to goal. He worked with PT/OT and will require extensive therapies. His neurologic exam improved slightly [**Hospital 68241**] hospital course and he was opening eyes, extending right arm, localizing left and withdrawing legs. Medications on Admission: Zetia, Tramadol, Lisinopril, Glipizide Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Hospital **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Thiamine HCl 100 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO QDAY (). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 6. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection TID (3 times a day). 8. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 10. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily). 11. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-7**] Sprays Nasal TID (3 times a day) for 3 days. 12. Oxymetazoline 0.05 % Aerosol, Spray [**Month/Day (2) **]: Two (2) Spray Nasal [**Hospital1 **] (2 times a day) for 3 days. 13. Levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day): Can increase to 1500mg in 2 days. 14. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Ampicillin-Sulbactam 3 g Recon Soln [**Hospital1 **]: One (1) Intravenous Q6H (every 6 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital Discharge Diagnosis: S/P fall with multiple areas of intracranial hemorrhages Discharge Condition: Neurologically stable vegitative state Discharge Instructions: Monitor patient for neurological changes/worsening (essentially vegitative state) at this point Monitor for fevers currently being treated for UTI and ? pneumonia Followup Instructions: Follow up with head CT with Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2182-11-15**] Name: [**Known lastname 11735**],[**Known firstname **] M Unit No: [**Numeric Identifier 11736**] Admission Date: [**2182-11-2**] Discharge Date: [**2182-11-19**] Date of Birth: [**2130-10-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3656**] Addendum: Pt was kept due to increasing fevers, antibiotics changed to Unasyn 3gms. Multiple cultures were taken all of which have been negative. A CXR on [**11-16**] showed resolving pneumonia. A Head Ct on [**11-17**] Interval worsening of bifrontal cerebral edema, with marked subfalcine herniation to the right, producing slight dilatation of the right lateral ventricle, likely from obstruction. No new foci of hemorrhage identified. A follow up head CT on [**11-19**] showed: [**Hospital1 8300**] continued to follow the patient for his blood sugars which remained in 91-165 range on 30 of Lantus [**Hospital1 **] with sliding scale. Neurologically he remained in a persistent vegitative state with occasional eye opening, extends right arm and localizes on left. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**] Completed by:[**2182-11-19**] Name: [**Known lastname 11735**],[**Known firstname **] M Unit No: [**Numeric Identifier 11736**] Admission Date: [**2182-11-2**] Discharge Date: [**2182-11-19**] Date of Birth: [**2130-10-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3656**] Addendum: pt had cbc drawn today / stable - no inc in wbc. WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 5.2 3.02* 9.6* 28.5* 94 31.8 33.7 15.3 236 pt with C-diff toxin pending - will call with results repeat CT brain [**11-6**] stable Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**] Completed by:[**2182-11-19**] Name: [**Known lastname 11735**],[**Known firstname **] M Unit No: [**Numeric Identifier 11736**] Admission Date: [**2182-11-2**] Discharge Date: [**2182-11-19**] Date of Birth: [**2130-10-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3656**] Addendum: CT scan of the brain on [**2181-11-19**] was stable with no new hemorrhage; results:Unchanged appearance of bilateral cerebral hemorrhagic contusions. 2. Interval improvement in the degree of rightward midline shift now measuring 6 mm (previously 10 mm) with less compression of the left lateral ventricle. The right lateral ventricle remains asymmetrically enlarged probably secondary to a degree of obstructive hydrocephalus from subfalcine herniation. 3. Left maxillary and right sphenoid sinus air-fluid levels consistent with acute sinusitis. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**] Completed by:[**2182-11-20**]

[ "522.5", "599.0", "461.9", "401.9", "803.25", "780.6", "250.00", "518.81", "272.0", "V11.3", "507.0", "348.4", "780.39", "E888.9", "783.7" ]

icd9cm

[ [ [] ] ]

[ "33.21", "96.72", "99.05", "43.11", "96.6", "31.1", "38.93" ]

icd9pcs

[ [ [] ] ]

8916, 9141

2178, 3267

381, 388

5313, 5354

1573, 2155

5565, 6826

877, 886

3357, 5122

5233, 5292

3293, 3334

5378, 5542

901, 1185

282, 343

416, 736

1235, 1554

1200, 1219

758, 798

814, 861

32,664

157,371

33650

Discharge summary

report

Admission Date: [**2201-6-5**] Discharge Date: [**2201-6-22**] Date of Birth: [**2178-10-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Small Bowel Obstruction Emesis Major Surgical or Invasive Procedure: 1. Exploratory laparotomy with extensive lysis of adhesions. 2. Small bowel resection with primary anastomosis. 3. Completion subtotal colectomy with end ileostomy History of Present Illness: This is a 22-year-old woman with mosaic type trisomy 13, who underwent exploratory laparotomy and sigmoid colectomy in [**2201-4-4**] for toxic megacolon limited to the sigmoid and rectum. She survived that and actually got back to near general baseline health before coming down with severe nausea and vomiting and symptoms of inability to thrive. She has had emesis since this morning, and at the same time has + ostomy output. She seems to be in pain subjectively. Past Medical History: Trisomy 13 Mosaicism Mentral Retardation - nonverbal at BL Cardiomyopathy - Unknown status. Had ECHO last at [**Hospital1 336**] (pending). PDA (congenital, closed per mother without OR) "Slow heartbeat" Aspiration PNA Neck anatomic deformity with inverted crichoid/hypoid. Pt assists herself with her fingers on the outside of her throat to pass food. . GYN HISTORY: LMP: [**2201-4-11**], regular menses with cramping OB HISTORY:G:0 . PAST SURGICAL HISTORY: Fundoplication end colostomy (hartmans pouch), R salpingoophrectomy, TAH, removal of pelvic mass [**2201-4-17**] Social History: SOCIAL HISTORY: No T/ETOH/IV drugs Family History: Breast cancer Physical Exam: VS: 96.5, 111, 89/58, 16, 92% RA Gen: appears uncomfortable, washed out. nonverbal Chest: diffuse rhonchi CV: RRR Abd: soft, NT, ND, surgical scar C/D/I, well healed, brown stool in ostomy, quaiac negative Pertinent Results: [**2201-6-5**] 04:30PM BLOOD WBC-13.7*# RBC-5.09# Hgb-14.1# Hct-42.9# MCV-84 MCH-27.7 MCHC-32.9 RDW-15.4 Plt Ct-315 [**2201-6-15**] 02:56AM BLOOD WBC-7.2 RBC-3.00* Hgb-8.4* Hct-26.0* MCV-87 MCH-28.1 MCHC-32.4 RDW-15.2 Plt Ct-218 [**2201-6-5**] 04:30PM BLOOD Glucose-209* UreaN-18 Creat-1.1 Na-134 K-5.9* Cl-90* HCO3-29 AnGap-21* [**2201-6-10**] 05:55AM BLOOD Glucose-135* UreaN-8 Creat-0.2* Na-139 K-3.9 Cl-103 HCO3-27 AnGap-13 [**2201-6-19**] 05:05AM BLOOD Glucose-125* UreaN-14 Creat-0.3* Na-138 K-4.7 Cl-103 HCO3-26 AnGap-14 [**2201-6-14**] 04:28AM BLOOD ALT-14 AST-17 LD(LDH)-169 AlkPhos-37* Amylase-134* TotBili-0.2 [**2201-6-14**] 04:28AM BLOOD Lipase-172* [**2201-6-19**] 05:05AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.8 [**2201-6-11**] 04:58AM BLOOD Triglyc-68 . CT ABDOMEN W/CONTRAST [**2201-6-5**] 8:48 PM IMPRESSION: 1. High-grade small-bowel obstruction with transition point likely in the right lower quadrant. 2. Left gonadal vein thrombus. 3. Patchy airspace opacification in the lung bases is consistent with resolving pneumonia, recurrent aspiration, or patchy bibasilar atelectasis. . CT ABDOMEN W/CONTRAST [**2201-6-8**] 12:47 PM IMPRESSION: 1. Persistently dilated loops of small bowel, decreased in overall degree of distention with oral contrast noted to pass into the colon on the current study. Persistent transition seen within the region of the right lower quadrant. 2. Increased ascites. 3. Persistent, unchanged residual pelvic lesion as noted above. 4. Findings suggestive of aspiration versus pneumonia at the lung bases as noted. 5. These findings are discussed with Dr. [**Last Name (STitle) **] at the time of dictation. . CHEST (PORTABLE AP) [**2201-6-15**] 1:54 PM IMPRESSION: Right basilar consolidation. Left retrocardiac atelectasis vs aspiration. Small right pleural effusion. . Brief Hospital Course: This is a 22 year old female with Persistent postoperative small-bowel obstruction and Megacolon. After several days of conservative management with NPO, IVF and NGT. It was clear that she was not going to open up and she was not having any stool output from her ostomy. She received a PICC and TPN for nutritional support. After discussion with the family, she went to the OR on [**2201-6-11**] for: 1. Exploratory laparotomy with extensive lysis of adhesions. 2. Small bowel resection with primary anastomosis. 3. Completion subtotal colectomy with end ileostomy. Post-operatively she went to the ICU. Pain: The nurses were administering Morphine PRN for pain control based on subjective and objective findings. she was transition to PO meds once back on a diet. Resp: She was extubated on POD 1 and placed on a face mask. She had RLL rales and rhonchi. She was receiving nebs and pulmonary hygiene. Respiratory was performing NT suctioning with good results. On POD 4, he had a CXR showing Right basilar consolidation. Left retrocardiac atelectasis vs aspiration. Small right pleural effusion. She received Lasix x 1 for diuresis and continued with Chest PT etc. GI/ABD: She was NPO with NGT in place. Her abdomen was soft with colostomy bag in intact. Her incision was C/D/I with staples in place. The NGT was removed on POD 3. Her diet was slowly advanced and she was tolerating a regular diet at time of discharge. The staples were removed and steri strips placed. The ostomy was function well at time of discharge. Post-op sinus tachycardia: Her HR was elevated to 110-125 range. She received gently hydration and continued on her home Digoxin dose. She required one time dose of Digoxin for a sub therapeutic Dig level. Activity: She was ambulating with PT and near her baseline at time of discharge. Medications on Admission: enalapril 10', digoxin 0.25', lasix 10', sertraline 50', miralax Discharge Disposition: Home With Service Facility: Partners [**Name (NI) **] [**Name2 (NI) **]-Central Intake Discharge Diagnosis: Small Bowel Obstruction Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[**11-18**] lbs) for 6 weeks. * Monitor your incision for signs of infection * You may shower and wash. No tub baths or swimming. Keep your incision clean and dry. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 3 weeks. Completed by:[**2201-6-23**]

[ "560.81", "427.89", "V16.3", "789.59", "751.3", "V85.1", "319", "758.5", "425.4", "564.89" ]

icd9cm

[ [ [] ] ]

[ "96.07", "45.62", "45.79", "99.15", "38.93", "46.23", "54.59" ]

icd9pcs

[ [ [] ] ]

5709, 5798

3776, 5593

344, 514

5866, 5873

1934, 3753

7464, 7562

1677, 1692

5819, 5845

5619, 5686

5897, 7441

1492, 1608

1707, 1915

274, 306

542, 1011

1033, 1469

1640, 1661

15,853

199,461

23001

Discharge summary

report

Admission Date: [**2174-11-21**] Discharge Date: [**2174-11-25**] Date of Birth: [**2098-2-28**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Abdominal pain, Nausea/Vomiting Major Surgical or Invasive Procedure: None. History of Present Illness: 76 year-old gentleman with known ventral hernia presents with vomiting and abdominal pain. The abdominal pain began suddenly at 6PM to the left of midline where the patient has known about a hernia for "years.". The pain was persistent and rated [**9-5**]. The EMTs came to pick the patient up and witnessed him vomit approximately 500 cc of dark emesis. Upon arrival to [**Hospital1 18**], the patient is still in pain, but pain is relieved with morphine. He is still nauseated. He denies fevers/chills. Last BM was yesterday and he is not passing flatus. Past Medical History: 1. He had a ventral hernia repair in [**2174**] that has subsequently recurred his hernia. 2. sub-pubic lipoma 3. ? back surgery in the past 4. Severe Aortic Stenosis Social History: He is a veteran of the Korean war. He worked for [**Location (un) **] township until the age of 30 when he retired due to back pain. He lives alone. He drinks 1 case of beer per week and [**1-28**] quarts of wine per week. He has a 60 pack-year smoking history, but he quit 20 years ago. Family History: His family history is only significant for hypertension. Physical Exam: On Admission VS: T 97.2, HR 89, BP 158/70, RR 20, 94%RA GEN: NAD, A&O x 3 LUNGS: Clear B/L CV: Irregularly irregular, nl S1 and S2 ABD: Soft, slightly TTP to left of midline where there is a prominent hernia, hernia is reducible when patient relaxes but reexpands immediately after, ND, no guarding, no rebound, no palpable groin hernias RECTAL: Guaiac neg EXT: 1+ edema of LE B/L At Discharge 96.6 120 110/80 20 96% RA Gen: A&Ox3, talkative and pleasant Lungs: decreased b/s at bases b/l CV: irreg irreg, tachycardic, [**5-2**] blowing systolic murmur at left sternal border Abd: soft, non-tender, easily reducable ventral hernia. Inguinal hernia firm, unchanged from admission Ext: no edema Pertinent Results: [**2174-11-20**] 10:45PM BLOOD WBC-5.7 RBC-4.44* Hgb-14.9 Hct-44.4 MCV-100* MCH-33.5* MCHC-33.6 RDW-14.4 Plt Ct-113* [**2174-11-21**] 09:05AM BLOOD WBC-2.3*# RBC-3.87* Hgb-13.5* Hct-38.9* MCV-100* MCH-34.8* MCHC-34.7 RDW-13.7 Plt Ct-91* [**2174-11-23**] 12:45PM BLOOD WBC-4.9 RBC-3.82* Hgb-12.7* Hct-38.1* MCV-100* MCH-33.4* MCHC-33.4 RDW-14.2 Plt Ct-111* [**2174-11-24**] 02:19AM BLOOD WBC-5.2 RBC-3.74* Hgb-13.0* Hct-37.5* MCV-100* MCH-34.7* MCHC-34.6 RDW-13.6 Plt Ct-96* [**2174-11-20**] 10:45PM BLOOD PT-13.8* PTT-25.7 INR(PT)-1.2* [**2174-11-20**] 10:45PM BLOOD Glucose-151* UreaN-25* Creat-1.9* Na-139 K-5.6* Cl-99 HCO3-26 AnGap-20 [**2174-11-21**] 09:05AM BLOOD Glucose-129* UreaN-25* Creat-1.8* Na-139 K-4.6 Cl-101 HCO3-27 AnGap-16 [**2174-11-23**] 12:45PM BLOOD Glucose-138* UreaN-24* Creat-1.5* Na-139 K-4.3 Cl-107 HCO3-24 AnGap-12 [**2174-11-24**] 02:19AM BLOOD Glucose-118* UreaN-28* Creat-1.4* Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 [**2174-11-21**] 12:50PM BLOOD CK(CPK)-99 [**2174-11-23**] 12:10PM BLOOD CK(CPK)-288* [**2174-11-24**] 02:19AM BLOOD CK(CPK)-245* [**2174-11-21**] 12:50PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2174-11-23**] 12:10PM BLOOD CK-MB-7 cTropnT-0.02* [**2174-11-24**] 02:19AM BLOOD CK-MB-9 [**2174-11-23**] 05:26PM BLOOD Type-ART pO2-64* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 [**2174-11-24**] 02:34AM BLOOD Type-ART pO2-62* pCO2-32* pH-7.45 calTCO2-23 Base XS-0 [**2174-11-20**] 10:54PM BLOOD Lactate-3.6* [**2174-11-24**] 02:34AM BLOOD Lactate-1.3 Brief Hospital Course: Patient was admitted to the general surgery service from the emergency room on [**11-21**] with symptoms of a small bowel obstruction secondary to a large ventral hernia. He was decompressed with an NG tube and given IV fluids for resuscitation. His large ventral hernia was tender but able to be manualy decompressed. On hospital day 2 the patient stated he was feeling better and self-d/c'd his NG tube, he refused to have another placed. He agreed to be seen by cardiology and plastic surgery for pre-operative consultation regarding his large ventral hernia, but after learning that a possible component separation would be necessary and that his cardiovascular status was significantly compromised, was adamently uninterested in any surgical intervention. Cardiology performed a TTE that revealed severe aortic valve stenosis with a valvular area of 0.6cm, and stated he would be a very high risk operative candidate, recommending a valvuloplasty prior to any elective surgery. The patient understood his condition and given that he was feeling better was adament about not undergoing further testing or intervention. He was evaluated by psychiatry and deemed competent to make such decisions on his own. On hospital day 3 he was transferred to the ICU for respiratory distress, desaturation and tachypnea. He was placed on a face mask in the ICU but was clear about his wishes to be DNR/DNI, however he did not officially sign the DNR/DNI form. His wishes were corroborated with his only out of hospital contact, [**Name (NI) 9485**] [**Name (NI) 59352**], a family friend. After rate control for his afib, he was tranferred back to the floor on hospital day 4, tolerating a regular diet and sating in the mid 90s on RA. The palliative care team, social work and case management were all [**Name (NI) 653**] regarding dispo planning for this gentleman, and a tentative plan for home hospice in the form of VNA was made. He was insistent on discharge on HD3 but agreed to stay overnight for on more day to sort out his support at home. Several friends were [**Name (NI) 653**] who agreed to check in on the patient, he refused VNA or home hospice. At the time of discharge on HD 5 he was tolerating a regular diet, his vital signs were normal and the patient, nursing and medical staff agreed on a plan for him to return home with regular visits from his several friends listed above. Medications on Admission: doxazosin, lisinopril, simvastatin Discharge Medications: 1. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: One tablet by mouth Monday-Saturday. Two tablets by mouth on Sundays. Discharge Disposition: Home Discharge Diagnosis: Severe Aortic Stenosis. Ventral hernia. Resolved small bowel obstruction. Discharge Condition: Stable. Tolerating regular diet. Not currently obstructed. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: Please call Dr [**First Name (STitle) 2819**] office to schedule an appointment [**Telephone/Fax (1) 2998**] if you would like to follow-up with him for elective surgery.

[ "V12.51", "338.29", "724.2", "427.31", "424.1", "585.9", "552.20", "600.00", "272.4", "298.9" ]

icd9cm

[ [ [] ] ]

[ "96.07", "96.27" ]

icd9pcs

[ [ [] ] ]

6729, 6735

3756, 6147

348, 356

6853, 6916

2249, 3733

8266, 8440

1460, 1518

6232, 6706

6756, 6832

6173, 6209

6940, 8243

1533, 2230

277, 310

384, 945

967, 1138

1154, 1444

26,708

119,729

10447

Discharge summary

report

Admission Date: [**2117-10-20**] Discharge Date: [**2117-10-26**] Date of Birth: [**2041-8-7**] Sex: M Service: CARDIOTHORACIC Allergies: Indocin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2117-10-19**] Cardiac catheterization [**2117-10-20**] Four vessel coronary artery bypass grafting utilizing left internal mammary to left anterior descending; vein graft to diagonal; vein graft to obtuse marginal; and vein graft to posterior descending artery. History of Present Illness: Mr. [**Known lastname 34533**] is a 76 year old male with history of coronary artery disease. He suffered an inferior myocardial infarction in [**2113**] and subsequently stenting to his RCA at that time. On the day of admission, he presented to [**Hospital1 **] [**Location (un) 620**] with chest pain. EKG was remarkable for inferior ST elevations with ST depressions in V1 and V2. His chest pain resolved with medical therapy which included Heparin, Nitro and Integrilin. He was urgently transferred to the [**Hospital1 18**] for cardiac catheterization. On admission, he remained pain free. Past Medical History: CAD - as above; [**Doctor Last Name 79**]-Parkinson-White Syndrome, Benign Kidney Tumor - s/p left nephrectomy, Chronic renal insufficiency, Gout, Neuropathy, Hypercholesterolemia, BPH, History of Pneumonia, s/p Hernia repair Social History: 25 pack year history of tobacco - quit 40 years ago. Admits to [**1-17**] alcohol drinks per day. Denies recreational drugs. He is retired from Polaroid. Family History: No premature coronary disease Physical Exam: Vitals: 139/65, 76, 24 with 98%RA General: Well developed male in no acute distress HEENT: Oropharynx benign Neck: Supple, no JVD, no carotid bruits Heart: Regular rate and rhythm, normal s1s2, no murmur Lungs: Clear bilaterally Abd: Benign Ext: Warm, no edema Pulses: 2+ distally, no femoral bruits Neuro: Nonfocal Pertinent Results: [**2117-10-25**] 10:35AM BLOOD Hct-28.4* [**2117-10-22**] 06:20AM BLOOD WBC-12.0* RBC-3.07* Hgb-10.2* Hct-29.3* MCV-95 MCH-33.2* MCHC-34.8 RDW-14.6 Plt Ct-104* [**2117-10-22**] 06:20AM BLOOD Plt Ct-104* [**2117-10-22**] CXR There has been interval removal of all tubes and catheters. There is no pneumothorax. The patient is status median sternotomy. Clips overlying the abdomen are suggestive of a left nephrectomy. There has been interval resolution of both the left upper lobe as well the retrocardiac opacity. Again seen is bilateral pleural thickening. In addition, there may be small bilateral pleural effusions. The heart is at the upper limits of normal in terms of size. Mediastinal contour is stable. [**2117-10-20**] 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. Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. [**2117-10-19**] Cardiac Catheterization 1. Coronary angiography revealed a right dominant system. The LMCA showed no significant stenoses. The LAD showed a proximal 60-70% stenosis with diffuse mild calcification and a large D1 with an 80% stenosis at its origin. The LCX showed diffuse disease with a high OM1 branch with an 80% stenosis at its origin and a large OM2 with 70% stenosis. The RCA showed a patent stent in its mid-segment with diffuse disease and 60% proximal stenosis, distal 70% stenosis. 2. Hemodynamic studies revealed normal right and left-sided filling pressures. Brief Hospital Course: Mr. [**Known lastname 34533**] was admitted and underwent urgent cardiac catheterization. Angiography showed a right dominant system with a 70% proximal LAD lesion; 80% stenosis of first diagonal; 80% ostial lesion in the first obtuse marginal; 70% stenosis in the second obtuse marginal; and a patent stent in the mid RCA with a distal 70% stenosis. Given his chronic renal insufficiency, no ventriculogram was performed. Based on his severe three vessel disease, the cardiac surgery service was consulted and further evaluation was performed. An echocardiogram revealed normal LV function and no regional wall motion abnormalities. His LVEF was estimated at 60%. Workup was otherwise unremarkable and he was cleared for surgery. In anticipation of surgery, the Integrilin was discontinued. He continued to remain pain free on medical therapy. On [**10-20**], Dr. [**Last Name (STitle) **] performed four vessel coronary artery bypass grafting. Surgery was uneventful - for further details please see operative note. After the operation, he was brought to the CSRU. Within 24 hours, he awoke neurologically and was extubated without incident. He maintained stable hemodynamics and weaned from inotropic support without difficulty. On POD#1, he transferred to the step down unit. His Sotalol and other preoperative medications were resumed. He remained fluid overloaded and required diuresis. Over several days, he made clinical improvements. He remained in a normal sinus rhythm and returned to his preoperative weight. Mr. [**Known lastname 34533**] became slightly orthostatic and his lasix was stopped. He continued to make steady progress and was discharged home on postoperative six. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Sotalol 120 [**Hospital1 **], Allopurinol 300 qd, Neurontin 300 tid, Nortriptyline 10 qhs, Cozaar 25 qd, Doxazosin 4 qd, Lovastatin 20 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: [**1-17**] Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD s/p RCA stent WPW L nephrectomy Gout Discharge Condition: Good. Discharge Instructions: Shower, wash incision with soap and water and pat dry. No lotions, creams, powders. No lifting more than 10 pounds or driving. Call with fever, redness or drainage from incisions or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) **] 2 weeks Cardiologist 2 weeks Completed by:[**2117-11-22**]

[ "411.1", "274.9", "414.01", "355.8", "426.7", "585.9" ]

icd9cm

[ [ [] ] ]

[ "99.20", "88.52", "37.23", "39.61", "36.15", "36.13", "88.56" ]

icd9pcs

[ [ [] ] ]

6781, 6830

3617, 5430

286, 553

6915, 6923

1995, 3594

7216, 7345

1613, 1644

5618, 6758

6851, 6894

5456, 5595

6947, 7193

1659, 1976

236, 248

581, 1177

1199, 1426

1442, 1597

54,056

104,798

45592+58836

Discharge summary

report+addendum

Admission Date: [**2181-2-7**] Discharge Date: [**2181-2-13**] Date of Birth: [**2111-10-20**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: pre-syncoble episode Major Surgical or Invasive Procedure: [**2181-2-8**] 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 1st diagonal coronary artery; reverse saphenous vein graft from the aorta to the distal right coronary artery. 2. Bilateral pulmonary vein isolation with the AtriCure Synergy bipolar RF device with resection of left atrial appendage. History of Present Illness: 69 year old gentleman with hypertension, AAA and SVT, was found to be in new atrial fibrillation in [**2180-7-30**] after presenting to the hospital with shortness of breath. He underwent successful left atrial PVI ablation on [**2180-10-13**]. His EF at that time was noted to be in 25-30% without clear cause. He developed recurrent atrial fibrillation on [**2180-12-6**] and underwent another electrical cardioversion. He now reports progressive exertional dyspnea along with an overall decreased level of energy. He was previously taking Furosemide on a PRN basis, and now is taking it more frequently, although not everyday. He reports a presyncopal episode approximately one week ago when he was standing in the grocery store and developed a warm sensation associated with some lightheadedness. He was able to get outside to some fresh air, he felt a little better, and he was able to drive himself home and took a 3 hour nap. He felt much better after sleeping for a bit. He continues with intermittent shortness of breath; however his greatest concern is his lack of energy and fatigue. He is now being referred to cardiac surgery for revascularization and possible MAZE. Past Medical History: Coronary artery disease Atrial fibrillation SVT Hypertension GOUT Dyslipidemia Infrarenal AAA recently diagnosed, measuring about 4cm Acute pancreatitis [**6-/2180**] Diverticulitis Hernia repair Glucose intolerance "pre diabetic" Large incision right wrist after falling thru window [**2149**] MVA with LOC, suturing of skull Tympanoplasty Depression Social History: Lives with:alone, son is involved in care Occupation:public safety as a clinician for drug and alcohol abuse for state workers Tobacco:occasional cigars ETOH:none Family History: Mother had MI at age 76 Physical Exam: Pulse:76 Resp:20 O2 sat:99/RA B/P Right:106/93 Left:116/83 Height:5'6" Weight:192 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x]; Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left:+2 DP Right: +2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit Right: none Left: +1 Pertinent Results: [**2181-2-8**] Echo: Pre Bypass The left atrium is dilated. Mild spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. The right atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 25 %). There is inferior wall and apical akinesis. The remaining left ventricular segments are hypokinetic. with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. There is mild to moderate anterior leaflet mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Post Bypass: Patient is A paced on Epinepherine 0.03 mcg/kg/min. Inferior wall function is somewhat improved as is global function. LVEF 30%. MR [**First Name (Titles) **] [**Last Name (Titles) **] moderate post bypass, but is mild after chest closure at a cardiac output of 5 lpm and sbp 110-120. Aortic contours intact. Remaing exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2181-2-12**] 06:10AM BLOOD WBC-8.8 RBC-3.42* Hgb-9.8* Hct-30.0* MCV-88 MCH-28.6 MCHC-32.7 RDW-15.3 Plt Ct-205 [**2181-2-7**] 04:10PM BLOOD WBC-6.9 RBC-4.17* Hgb-12.3* Hct-34.9* MCV-84 MCH-29.4 MCHC-35.2* RDW-15.0 Plt Ct-252 [**2181-2-8**] 05:24PM BLOOD Neuts-73.6* Lymphs-22.2 Monos-1.4* Eos-2.6 Baso-0.3 [**2181-2-13**] 04:40AM BLOOD PT-18.0* INR(PT)-1.6* [**2181-2-12**] 06:10AM BLOOD Plt Ct-205 [**2181-2-7**] 04:10PM BLOOD Plt Ct-252 [**2181-2-7**] 04:10PM BLOOD PT-14.6* PTT-26.3 INR(PT)-1.3* [**2181-2-13**] 04:40AM BLOOD Glucose-80 UreaN-37* Creat-1.2 Na-138 K-4.4 Cl-101 HCO3-28 AnGap-13 [**2181-2-12**] 06:10AM BLOOD Glucose-126* UreaN-39* Creat-1.6* Na-138 K-4.1 Cl-101 HCO3-28 AnGap-13 [**2181-2-7**] 04:10PM BLOOD Glucose-124* UreaN-27* Creat-1.1 Na-136 K-4.5 Cl-102 HCO3-25 AnGap-14 [**2181-2-7**] 04:10PM BLOOD ALT-22 AST-28 LD(LDH)-205 AlkPhos-66 Amylase-68 TotBili-0.4 [**2181-2-7**] 04:10PM BLOOD Lipase-38 [**2181-2-13**] 04:40AM BLOOD Mg-2.2 [**2181-2-7**] 04:10PM BLOOD Albumin-4.1 [**2181-2-7**] 04:10PM BLOOD %HbA1c-6.9* eAG-151* [**2181-2-8**] 12:40PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2181-2-8**] 12:40PM BLOOD HIV Ab-NEGATIVE [**2181-2-8**] 12:40PM BLOOD RedHold-HOLD CXR [**2181-2-12**] FINDINGS: Aeration of the right and left lungs is improved with residual small bilateral pleural effusions. No consolidation or pneumothorax is present. The heart and mediastinal contour are normal. Sternotomy wires are intact. IMPRESSION: Improved aeration of the lungs. Persistent small bilateral effusions. Brief Hospital Course: Mr. [**Known lastname 97236**] was a admitted one day before surgery since he was on Coumadin and required a Heparin bridge. The day of admission he also underwent usual pre-operative work-up. On [**2-8**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3 and MAZE procedure. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Amiodarone was started day of surgery for atrial fibrillation. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Beta-blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. Chest tubes and epicardial pacing wires were removed per protocol. Coumadin was initiated for his atrial fibrillation and titrated during his post-op course with a goal INR of [**1-31**].5. On post-op day three he was transferred to the step-down floor for further care. His lasix was held for increased cr to 1.6 but was down to 1.2 on discharge. He was ready for discharge to rehab at [**First Name8 (NamePattern2) **] [**Doctor First Name **] Nursing on postoperative day five. Medications on Admission: Lipitor 10 mg daily Citlapram 10 mg daily Furosemide 40 mg prn daily Latanoprost 0.005 %Drops - 1 in each eye drop in the am Lisinopril 5 mg daily Lopressor 50 mg daily Coumadin 5 mg daily (every fifth day takes 1.5 tablet-INR followed [**Hospital3 **] cardiology) Ambien 5 mdaily prn Vitamin C Aspirin 81mg daily Multivitamin daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temp/pain. 4. warfarin 5 mg Tablet Sig: goal INR 2.0-2.5 Tablets PO once a day: please check first INR [**2-14**] - and rehab physician to dose coumadin - home doses 5 mg and 7.5 mg however was not on amiodarone . 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 mg twice a day until [**2-16**] then decrease to 400 mg daily until [**2-23**] then decrease to 200 mg daily until follow with cardioversion . 10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): both eyes . 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 1 weeks: for breakthrough pain - please use tylenol first and discontinue as soon as possible - no narctotics due to confusion . 13. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please check BG ac and HS - new to oral [**Doctor Last Name 360**] . 14. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily): 75 mg daily . 15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: may need to increase dose if weight trends up . Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**] Discharge Diagnosis: Coronary artery disease s/p CABG Acute on Chronic Systolic heart failure atrial fibrillation s/p MAZE procedure Hypertension Gout Dyslipidemia Infrarenal AAA recently diagnosed, measuring about 4cm Acute pancreatitis [**6-/2180**] Diverticulitis Hernia repair Diabetes mellitus - Hgb A1C 6.9 Large incision right wrist after falling thru window [**2149**] MVA with LOC, suturing of skull Tympanoplasty Depression Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait with assistance Incisional pain managed with tylenol and ultram prn Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage, ecchymosis thigh Edema +1 bilateral lower extremity edema Discharge Instructions: Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] on [**3-6**] at 1:45pm Cardiologist: Dr. [**Last Name (STitle) **] on [**2-27**] at 12:40 Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4390**] in [**4-3**] 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 [**2-14**] Please check INR monday, wednesday, and friday for two weeks then decrease to twice a week for the first month as amiodarone dose being titrated and will affect INR - anby questions or concerns please call Please set up for coumadin management when being discharged from rehab - has been receiving 5 mg daily INR [**2-13**] (1.6) Completed by:[**2181-2-13**] Name: [**Known lastname 15497**],[**Known firstname 885**] Unit No: [**Numeric Identifier 15498**] Admission Date: [**2181-2-7**] Discharge Date: [**2181-2-13**] Date of Birth: [**2111-10-20**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1543**] Addendum: The summary of the hospital course for this patient fails to mention several significant findings which are summmarized below. He was admitted to the hospital with sytolic heart failure, by echocardiogram on [**2180-10-13**] showed "overall left ventricular systolic function is severely depressed (LVEF= 25-30 %). Right ventricular chamber size is normal. with mild global free wall hypokinesis". Post surgery this had improved slightly by echo to "inferior wall function is somewhat improved as is global function. LVEF 30%. at a cardiac output of 5 lpm and sbp 110-120". Addittionally he had post-operative anemia due to a combination of blood loss and hemodilution. His pre operative hematocrit was 34.9, initial post-op hematocrit was 22. He was transfused with 2 units of packed red blood cells and his hemaocrit responded to 29.8. he received no additional transfusions and his hematocrit continued to improve throughout his hospital course. Finally the patient had acute renal injury during this admission. His baseline creatine was mildly elevated at 1.1. Post operatively it rose to 1.6 on post-op day four, it improved from that point and was back to baseline 1.2 at discharge on post-op day five. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5670**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2181-4-4**]

[ "250.00", "780.2", "428.23", "V58.61", "285.1", "424.0", "414.01", "428.0", "401.9", "311", "427.31", "V70.7", "441.4" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "37.27", "36.15", "37.33" ]

icd9pcs

[ [ [] ] ]

13529, 13803

6013, 7207

330, 755

9987, 10283

3215, 5990

10952, 13506

2535, 2560

7590, 9391

9551, 9966

7233, 7567

10307, 10929

2575, 3196

270, 292

783, 1964

1986, 2339

2355, 2519

54,247

169,804

35561

Discharge summary

report

Admission Date: [**2121-11-27**] Discharge Date: [**2121-12-24**] Date of Birth: [**2048-1-25**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 689**] Chief Complaint: G- tube malfunction Major Surgical or Invasive Procedure: intubation transjugular liver biopsy thoracentesis paracentesis History of Present Illness: Mr. [**Known lastname 1124**] was a 73 year old gentleman with an extensive PMH, hospitalized in [**5-24**] for AVR/MVR/CABG, subsequent trach/PEG and acute renal failure then transferred to rehab, then readmitted in [**7-24**] for bleeding from tracheostomy site in the context of supratherapeutic INR, now admitted for G-tube malpositioning. . Per NE [**Hospital1 **], debate whether G tube was in the stomach or peritoneum, unable to assess whether gastrografin introduced went into peritoneum or stomach. Switched between tube feeds and NPO for high residuals, concern for ileus as patient not passing stools. Am vitals day of admission: 98.8 137/76 110 18. . In the ED, initial vitals signs were: T 100 HR 131 BP 137/72 RR 20 O2sat 99% on 50% FIO2, CPAP 14/8. Patient was given Vanc/Zosyn/Flagyl and 4L in the ED with variable blood pressures between 80-130 systolic. Femoral line was placed and pressors not initiated. Of note, the patient's R carotid artery "looked funny" per ED resident's ultrasound evaluation. . On the floor, the patient appeared comfortable and was able to speak with difficulty secondary to trach. He denied any pain and was able to mouth that he was at [**Hospital3 **]. Review of Systems was unable to be effectively obtained. Past Medical History: s/p AVR, MVR & CABG [**6-/2121**] Diabetes Mellitus Type 2 Hyperlipidemia Atrial fibrillation HIT Prostate CA s/p TURP s/p B knee replacements Depression Osteoarthritis Social History: Lives at [**Hospital1 **] trach rehab. Non-smoker Family History: No history of lung disease Physical Exam: Vitals: T: 101.3 BP: 94/63 P: 144 R: 21 O2: 99% General: Awake, alert, likely oriented, limited by speech difficulties with trach. Comfortable appearing HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP obscured by bounding carotids, no LAD Lungs: Clear to auscultation anteriorly, some wheezes CV: S1 & S2 regular but very rapid. Unable to appreciate murmurs given rate Abdomen: Distended but non-tender, bowel sounds present, G-tube in place, G-tube non-tender or erythematous. GU: foley in place with blood at meatus Ext: warm, well perfused, 2+ pulses, trace edema Pertinent Results: WBC Hb Hct Plts [**2121-12-11**] 05:25AM 12.6* 8.0* 27.1* 390 [**2121-12-10**] 07:00AM 11.9* 7.6* 24.3* 404 [**2121-12-9**] 05:45AM 12.1* 8.1* 28.7* 470* [**2121-12-8**] 03:52AM 13.0* 7.7* 25.3* 470* [**2121-12-7**] 07:20AM 15.2* 7.9* 25.4* 476* [**2121-12-6**] 03:55AM 14.5* 8.0* 27.5* 490* [**2121-12-5**] 03:14AM 15.8* 7.8* 25.0* 510* [**2121-12-4**] 03:07AM 9.9 7.1* 23.8* 401 [**2121-12-3**] 02:17AM 9.1 7.1* 23.0* 380 [**2121-12-2**] 03:33AM 12.6* 7.8* 25.7* 408 [**2121-12-1**] 03:18AM 9.1 7.2* 23.0* 364 [**2121-11-30**] 03:50AM 8.3 7.2* 23.9* 354 [**2121-11-29**] 05:51AM 13.6* 7.5* 24.2* 403 [**2121-11-28**] 03:51AM 15.2* 7.6* 23.6* 367 [**2121-11-27**] 01:03PM 18.2* 8.8* 28.4* 467 [**2121-12-5**] 03:14AM N 81.5 L 9.2 M 4.7 E 4.4 B 0.2 PT PTT INR [**2121-12-11**] 05:25AM 16.0* 27.4 1.4* [**2121-12-10**] 07:00AM 16.0* 27.8 1.4* [**2121-12-9**] 05:45AM 16.1* 30.0 1.4* [**2121-12-8**] 01:37PM 20.0* 48.8* 1.8* [**2121-12-8**] 03:52AM 30.8* 72.5* 3.1* [**2121-12-7**] 07:20AM 20.4* 41.0* 1.9* [**2121-12-7**] 02:12AM 19.4* 39.7* 1.8* [**2121-12-5**] 03:04PM 18.5* 36.1* 1.7* [**2121-12-5**] 03:14AM 17.2* 30.5 1.5* Gluc BUN Cr Na K Cl HCO3 AG [**2121-12-11**] 05:25AM 130* 36* 1.4* 143 4.8 103 34* 11 [**2121-12-10**] 07:00AM 111* 37* 1.4* 141 4.3 100 33* 12 [**2121-12-9**] 05:45AM 119* 38* 1.6* 141 4.4 101 28 16 [**2121-12-8**] 03:52AM 120* 36* 1.7* 142 4.1 102 29 15 [**2121-12-7**] 07:20AM 118* 40* 1.7* 139 4.2 100 31 12 [**2121-12-6**] 03:00PM 136* 42* 1.8* 143 4.1 105 31 11 [**2121-12-6**] 03:55AM 132* 43* 2.0* 146* 3.7 105 27 18 [**2121-12-5**] 03:09PM 161* 46* 2.0* 144 3.8 105 32 11 [**2121-12-5**] 03:14AM 109* 45* 2.1* 146* 4.1 108 29 13 [**2121-12-4**] 03:07AM 114* 43* 2.2* 147* 4.3 109* 30 12 [**2121-12-3**] 02:17AM 107* 46* 2.4* 147* 3.8 109* 27 15 [**2121-12-2**] 12:45PM 142* 46* 2.4* 146* 3.8 110* 28 12 [**2121-12-2**] 03:33AM 124* 46* 2.5* 146* 3.8 110* 27 13 [**2121-12-1**] 03:18AM 112* 52* 2.7* 147* 3.8 111* 27 13 [**2121-11-30**] 03:56PM 111* 55* 2.7* 147* 3.9 111* 25 15 [**2121-11-30**] 03:50AM 118* 58* 2.8* 147* 3.7 112* 26 13 [**2121-11-29**] 04:43PM 106* 60* 2.6* 145 4.1 110* 24 15 [**2121-11-29**] 05:51AM 88 59* 2.6* 145 4.0 110* 25 14 [**2121-11-28**] 02:52PM 112* 59* 2.5* 146* 4.3 111* 27 12 [**2121-11-28**] 03:51AM 108* 58* 2.5* 145 4.2 110* 28 11 [**2121-11-27**] 08:40PM 102 59* 2.4* 146* 4.1 108 31 11 [**2121-11-27**] 01:03PM 162* 60* 2.4* 144 4.6 103 31 15 [**2121-12-7**] 07:20AM ALT 15 AST 22 LDH 144 AP 75 Tbili 0.4 [**2121-12-5**] 03:14AM LDH 153 [**2121-12-3**] 02:17AM Amylase 29 [**2121-11-29**] 04:43PM LDH 207 [**2121-11-28**] 03:51AM CK 23 [**2121-11-27**] 08:40PM CK 18 [**2121-11-27**] 01:03PM ALT 59 ALST 82 CK 22 AP 135 Tbili 1.5 [**2121-12-3**] 02:17AM Lipase 36 [**2121-11-29**] 05:51AM CK-MB 2 TnT 0.16 [**2121-12-11**] 05:25AM Ca 9.5 Ph 3.8 Mg 2.5 [**2121-11-27**] 01:03PM Alb 3.1 Ca 9.7 Ph 2.7 Mg 2.4 [**2121-11-29**] 05:51AM TIBC 131* Ferritin 847* TRF 101* [**2121-11-27**] 08:40PM Osm 321* [**2121-11-29**] 11:13AM AUTOANTIBODIES Smooth POSITIVE TITER = 1:20 [**2121-11-29**] 11:13AM [**Doctor First Name **] POSITIVE * 1:320 PATTERN-SPECKLED [**2121-11-29**] 05:51AM PEP IgG 2070* [**2121-11-29**] 05:51AM Vanc 14.11 [**2121-12-4**] 03:07AM Digoxin 0.7 [**2121-11-29**] 05:51AM HBsAg HBsAb HBcAb HAV HCV NEGATIVE [**2121-12-7**] 07:20AM ALT 15 AST 22 LDH 144 AP 75 Tbili 0.4 [**2121-12-5**] 03:14AM LDH 153 [**2121-12-3**] 02:17AM Amylase 29 [**2121-11-29**] 04:43PM LDH 207 [**2121-11-28**] 03:51AM CK 23 [**2121-11-27**] 08:40PM CK 18 [**2121-11-27**] 01:03PM ALT 59* AST 82 CK 22* AP 135 Tbili 1.5 [**2121-12-11**] 05:25AM Ca 9.5 Ph 3.8 Mg 2.5 [**2121-12-7**] 07:20AM Alb 3.7 Ca 8.7 Ph 3.8 Mg 2.2 [**2121-12-5**] 03:14AM Tprot 7.0 Ca 8.4 Ph 3.4 Mg 2.4 Urine Analysis: [**2121-12-5**] 11:57AM Blood MOD Nitrite NEG Protein 30 Gluc NEG Ket NEG Bili NEG Urob NEG pH 5.5 Leuk LG [**2121-12-5**] 11:57AM RBC 48* WBC 67* Bact FEW [**2121-12-5**] 11:57AM CastHy 4* URINE CRYSTALS RARE OTHER URINE FINDINGS Mucous RARE [**2121-11-29**] CYTOLOGY OF PERITONIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. [**2121-12-4**] CYTOLOGY OF PLEURAL FLUID: NEGATIVE FOR MALIGNANT CELLS. [**2121-12-5**] PATHOLOGY OF PLEURAL FLUID: Negative for malignant cells. Mesothelial cells and inflammatory cells. [**2121-12-8**] LIVER BIOPSY: Liver, transjugular needle core biopsy: Markedly fragmented core biopsy of liver demonstrating: 1. Mild portal, minimal periportal, and lobular mixed inflammation comprised of lymphocytes, neutrophils, plasma cells, and eosinophils. 2. Minimal (<5% of the core biopsy) steatosis with rare balloon cell degeneration; no intracytoplasmic hyalin seen. 3. Trichrome stain shows increased portal fibrosis with septae and focal nodule formation (at least Stage 3 fibrosis, suspicious for Stage 4), see note. 4. Iron stain shows no iron deposition. [**2121-11-28**] 3:51 am SPUTUM GRAM STAIN (Final [**2121-11-28**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2121-12-7**]): SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. AZTREONAM Sensitive. GRAM NEGATIVE ROD(S). SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S [**2121-12-6**] 3:30 pm SPUTUM GRAM STAIN (Final [**2121-12-6**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2121-12-9**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF THREE COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S BLOOD CX [**12-6**], [**12-5**], [**12-3**], [**11-27**] neg C DIFF neg x 3 [**11-28**], [**12-5**], [**12-7**] [**2121-12-5**] 11:57 am URINE NO GROWTH. [**2121-12-3**] 8:20 am URINE NO GROWTH. [**2121-11-28**] 3:50 am URINE GRAM NEGATIVE ROD(S). ~[**2112**]/ML. [**2121-11-27**] 1:03 pm URINE MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. [**2121-12-4**] 6:40 pm PLEURAL FLUID GRAM STAIN (Final [**2121-12-4**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2121-12-7**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2121-12-10**]): NO GROWTH. [**2121-12-3**] 3:53 pm CATHETER TIP-IV Source: triple lumen. WOUND CULTURE (Final [**2121-12-5**]): No significant growth. [**2121-12-2**] 4:32 pm PERITONEAL FLUID GRAM STAIN (Final [**2121-12-2**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2121-12-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2121-12-8**]): NO GROWTH. [**2121-11-29**] 4:04 pm PERITONEAL FLUID GRAM STAIN (Final [**2121-11-29**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2121-12-2**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2121-12-5**]): NO GROWTH. [**2121-11-28**] 1:17 pm CATHETER TIP-IV Source: PICC. WOUND CULTURE (Final [**2121-11-30**]): No significant growth. [**2121-11-28**] 9:48 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal aspirate. Respiratory Viral Culture (Final [**2121-11-30**]): 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 [**2121-11-28**]): 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. [**2121-11-28**] 3:51 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2121-11-28**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2121-12-7**]): SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. AZTREONAM Sensitive. GRAM NEGATIVE ROD(S). SPARSE GROWTH. PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S [**2121-11-27**] KUB: IMPRESSION: Suboptimal study due to patient body habitus. Gastrostomy not identified. Prominent air distended loops of bowel not well defined, obstruction not entirely excluded. Consider CT if there remains high clinical suspicion for free air or obstruction. [**2121-11-27**] CXR: IMPRESSION: Pulmonary edema and cardiomegaly. Bilateral pleural effusions, increased on the right. [**2121-11-27**] CT ABD/PELVIS: IMPRESSION: 1. Large amount of ascites. No evidence of pneumoperitoneum. 2. Moderate bilateral pleural effusions with overlying atelectasis. 3. Separation of sternal wound, concerning for dehiscence. 4. Gastrostomy tube terminating within the stomach lumen. 5. Foley catheter positioned within the proximal urethra, with inflated balloon. Recommend repositioning to that it terminates in the bladder. 6. Shrunken liver with macro-lobular contour suggesting underlying chronic disease process such as cirrhosis. [**2121-11-28**] ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The ascending aorta is moderately dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. [**2121-11-28**] CXR: Comparison is made with prior study performed a day earlier. Mild cardiomegaly. Moderate-to-large right and small-to-moderate left pleural effusion have decreased. Pulmonary edema has improved. Right perihilar opacity and left lower lobe atelectasis have improved. Sternal wires are aligned. Tracheostomy tube is in standard position. Right PICC is in place. Left subclavian catheter tip is in the upper SVC. There is no pneumothorax. [**2121-11-28**] CAROTID DOPPLER: Impression: Right ICA with stenosis <40% . Left ICA with stenosis <40% . [**2121-11-28**] LIVER U/S WITH DOPPLERS: CONCLUSION: 1. Normal Doppler ultrasound of the liver. 2. Cirrhotic shrunken irregular liver, with no focal lesions. 3. Mild splenomegaly. 4. Moderate ascites. 5. Sludge within the gallbladder. [**2121-11-30**] BILAT LENIs: No evidence of deep venous thrombosis. [**2121-12-2**] CT CHEST: IMPRESSION: 1. Increased lucency at the sternal surgical site indicated non-healing and osteomyelitis cannot be excluded. 2. Slight progressed sternal dehiscence of the inferior sternum at the level of the inferior most sternal wire which does not bridge the surgically split sternum. 2. Large pleural effusions persist, both now loculated. Density is increased in a loculated fluid along the left mediastinum which could be due to infection/empyema less likly resolving hematoma or diluted blood. Evaluation is limited without contrast. 3. Mild pulmonary edema 4. Persistent ascites & anasarca. 5. Left subclavian IV catheter does not enter the SVC. [**2121-12-4**] RENAL U/S: CONCLUSION: Limited examination. The kidneys are of normal size, and of normal echogenicity with no hydronephrosis. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2121-12-15**] 2:33 PM FINDINGS: There is no acute hemorrhage, large areas of edema, large masses, or mass effect. There is preservation of normal [**Doctor Last Name 352**]-white matter differentiation. There is prominence of the sulci, and particularly the left Sylvian fissure, likely reflecting cortical atrophy. Slight asymmetric prominence of the extra-axial space overlying the left frontal lobe also likely reflects cortical atrophy in this region. The ventricles are normal in size and configuration, given the patient's age. Periventricular white matter hypodensities are likely due to chronic small vessel infarction. There is dense calcification of the vertebral arteries and carotid siphons, bilaterally. There is mild mucosal thickening of the left maxillary and sphenoid sinus. The mastoid air cells are clear. A focus of coarse calcification is noted within the subcutaneous fat overlying the right occiput. IMPRESSION: No acute hemorrhage, or other acute intracranial process. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2121-12-18**] 1:20 AM FINDINGS: There is no evidence of hemorrhage, edema, mass effect or infarction. The ventricles and sulci are enlarged, consistent with global parenchymal volume loss. A focus of punctate calcification is seen in the right basal ganglia. Vascular calcification is noted at the carotid siphons as well as at the V4 segment of both vertebral arteries. There is no fracture. The mastoid air cells are clear. Inspissated secretions as well as an air- fluid level and circumferential mucosal thickening are seen in the posterior ethmoidal air cells bilaterally as well as the sphenoid sinus. IMPRESSION: 1. No acute intracranial abnormality and overall no change. 2. Paranasal sinus disease. Brief Hospital Course: Mr [**Known lastname 1124**] was admitted to the medical ICU on [**11-27**] at 6pm. Patient was a 73 year old gentleman with signs of urosepsis and in supraventricular tachycardia after presenting to the ER for g-tube evaluation. He was septic then recovered, intermittently had an SVT but recovered now in NSR, treated for UTI, spontaneous bacterial peritonitis, pneumonia, noted to have acute renal failure from acute interstitial nephritis, and liver disease from possible autoimmune hepatitis. A brief description of his hospital course according to system is described below: . . #. Supraventricular Tachycardia: The patient presented to the MICU in a persistent regular rate at 140s without P waves. This appears to be a supraventricular tachycardia which, based on old EKGs, appears to be his baseline rate miscategorized as atrial fibrillation/flutter. His higher rate may be due to sympathetic drive from underlying infection. Upon reaching the floor, he received adenosine and lopressor IV and his HR decreased to the 90's and remained between 60-100 throughout the rest of his MICU course. His digoxin level was tested. He was started on Lopressor 25mg TID and his Digoxin was continued at 0.125mg PO qod. His cardiac enzymes were checked. His troponin remained elevated at 0.13-0.14 with no trend and a negative CK-MB. This was attributed to ARF or global ischemia from sepsis. Cardiology was consulted for this case and recommended Amiodarone, which could not be given to patient due to poor reaction to this medicine in the past. . #. Hypotension: When the patient arrived in the MICU, his blood pressures started to decrease from SBP of 90s to 70s. He likely had a component of distributive shock from a urosepsis or a PNA source. Additionally, his tachycardia may have been impeding his forward flow. He was started on pressors. Initially phenylephrine was started and then levophed and vasopressin. He was weaned from phenylephrine after 2 hours and from all pressors after 20 hours and his BP remained stable for the remainder of his course. . #. Trach/vent dependence: Patient has been on trach ventilation reportedly for the last 6 months. He was found to have metabolic alkalosis and current alkalemia from over ventilation. He was diuresed as need with lasix. He was switched to pressure support and was weaned to 50% trach collar at time of transfer out of MICU. He was tolerating a Passy-Muir valve that was placed by speech and able to communicate. His dependence was likely due to a combination of pneumonia, effusions, abdominal distention from ascites. . #. Pneumonia/Pleural effusion: He was found to have pleural effusions and a possible pneumonia on CXR. His sputum grew pseudomonas. He was initially treated empirically with Vancomycin and Zosyn in the ER, and then vancomycin and ciprofloxacin, and cefepime by the ICU team. The Vancomycin and Cipro were stopped when the cultures came back due to speciation and sensitivities; the pseudomonas was resistant to Cipro. He was switched from cefepime to meropenem once transferred to the floor due to concern that cefepime may have caused acute interstitial nephritis. While in the ICU, his pleural effusion appeared to have worsened and been loculated. 900 cc were successfully drained by interventional pulmonology. Analysis of the fluid showed 2+ PMN's, gram stain was negative The patient was continued on intravenous pushes of furosemide for most of hospitalization as needed to prevent further effusions and pulmonary edema. Per Hepatology, if the effusion were to become recurrent, a TIPS procedure could be considered. By the time of transfer to the floor, the patient had been weaned down to trach mask, which he tolerated well. He did have one episode where he accidentally pulled out his trach tube, unwitnessed, which resulted in a Code Blue. The patient was noted to have bradycardia into the upper 20s and was transferred back to the medical ICU. He was transferred back to the floor after a few days when stable. On the floor, he was noted to have thick secretions which may have clogged the Passe Muir valve on one occasion, dropping his O2 saturation to 91% on Trach Mask with FiO2 35%; his O2 saturation quickly returned to 96% after suctioning. Patient was saturating well on trach mask with FiO2 35% for most of his course on the floor. He was started on per oral regimen of lasix 20mg and spironolactone 75mg daily, per Hepatology recommendations, for his ascites, which would also help with associated pleural effusions. During the last week of his hospital course, the patient's secretions were thickened, and he was requiring more frequent suctioning. His oxygen requirements increased slowly to 50% FiO2 on trach mask, then to 100% FiO2. For the last one to two days of his hospitalization, he became unresponsive. He was transitioned to [**Month/Year (2) 9036**] Measures Only by family members. The patient passed on [**2121-12-24**] in the presence of his daughter, likely from respiratory failure. . #. Urosepsis: He was found to have a urinary tract infection on presentation. Vancomycin and Fluconazole had already been started in rehab for a presumed infection. His urine culture was positive for gram negative rods. He was treated with vancomycin and zosyn as above. . #. Acute on Chronic Renal failure: His ARF on presentation likely had a pre-renal component as he was not receiving as much nutrition at OSH. He was given a fluid challenge, his electrolytes were monitored and his medications were renally dosed. He had urine electrolytes and sediments and he was found to have acute intersititial nephritis; urine analysis showed persistent eosinophils with WBC casts, and eosinophilia on serum differential. There was somem concern that cefepime, which was given for treatment of pneumonia, could have caused the AIN, so the patient was switched to meropenem. Renal was consulted and requested a renal ultrasound which was normal, bladder pressure which was slightly elevated, and that we do not start steroids. His renal function continued to improve during his course; his Cr started at 2.4 and was 1.8 at time of transfer to the floor. His creatinine did come down to 1.2 at one point but then had another bump to 2.0 and trended back down to 1.7. The patient appeared to have stage III chronic kidney disease which was stable. . #Ascites/Liver disease: Patient found to have ascites on abdominal imaging. Transudative ascitic fluid suggests possible cardiac etiology of his cirrhosis which would fit into clinical picture of pulmonary hypertension in setting of dilated RV adn RV hypokinesis. Hepatology serum labs including immunoglobulins, [**Last Name (un) 15412**], ferritin, iron, TIBC suggested an autoimmune cause of his liver disease. Hepatology was consulted and agreed that was some, but not perhaps the complete cause. Had a paracentesis and 9L was removed with 87.5 g of albumin given after procedure. The peritoneal fluid was sent for culture and analysis. WBC count suggested infection, but no growth of bacteria in culture. He was continued on broad-spectrum coverage. He had a repeat paracentesis 4 days later, removing 1L of fluid and again given 87.5g after procedure. Repeat fluid analysis showed decreased PMN's (148), SAAG >1.1 with protein >2.5 suggesting cardiac etiology. Hepatology recommended spontaneous bacterial peritonitis treatment, lasix, pleural effusion drainage and liver biopsy which was done after the patient was transferred to the floor. Patient was treated with 2 week course of meropenem for SBP. It was unclear whether or not the patient's altered mental status may have been in part due to ammonia and decreased hepatic clearance, so he was started on lactulose, titrated to about [**3-19**] bowel movements per day, though his LFTs had normalized prior to discharge. Patient was [**Doctor First Name **] positive with titer of 1:320 in speckled pattern, had anti-smooth muscle antibody with titer 1:20 and elevated total IgG of 2070, which were all suggestive of autoimmunie hepatitis, but biopsy was of poor quality, so the diagnosis is not definitive. The specimen did confirm liver fibrosis and cirrhosis. Per hepatology, he does not meet criteria for steroid treatment of autoimmune hepatitis. On the floor, the patient was aggressively diuresed with intravenous lasix 40mg twice daily for volume overload. He was transitioned to a per oral regimen of 20mg lasix and 75mg spironolactone daily. It was unclear whether or not the lactulose was improving his mental status, particularly in the setting of normalized LFTs, though he was continued on lactulose titrated to about [**3-19**] bowel movements per day. #. Anemia: Patient had a stable microcytic anemia. Iron studies during this admission showed low levels of iron and also suggest anemia of chronic disease. Patient had a known GI bleed with multiple transfusions, but his hematocrit had been stable. He was guaiac negative during his course on the general medical floor. Of note, patient was on weekly Aranesp (darbepoetin alfa) prior to admission. . #. Hypernatremia: Patient was intermittently hypernatremic as high as 150. He was given free water flushes with tube feeds through his G tube and D5W as needed to correct hypernatremia. . . #. Arrhythmia: Per cardiology, patient had atrial tachycardia in the ICU, though he was in Atrial fibrillation on admission. He was given a dose of adenosine which slowed his heart rate down but did not stop his heart. He was also started on intravenous beta blocker. He was continued on his home dose of digoxin every other day. Upon transfer to the floor, he was restarted on his home dose of per oral metoprolol 25mg twice daily. The patient was monitored on telemetry throughout his hospitalization and was noted to have intermittent episodes of the atrial tachycardia. Note that the patient has had a history of HIT in the past. He was initially started on argatroban for bridging to coumadin, but the argatroban was stopped because Cardiology team determined that he would not need a bridge. His coumadin was discontinued during his second ICU stay due to history of slow GI bleed with multiple transfusions, but he was continued on his baby aspirin for CAD and pneumoboots for DVT prophylaxis. . #. Coronary Artery Disease, s/p CABG, s/p Valve Replacement: There was some concern about chronic dehiscence of sternotomy wound seen on CT. Cardiac surgery had been consulted when this finding was found on previous CT and was not concerned. His statin was stopped in the setting of elevated LFTs, which have since normalized. Patient was continued on baby aspirin. His metoprolol dose was switched to intravenous dosing initially; on the floor, he was transitioned back to his home dose of po metoprolol 25mg [**Hospital1 **]. His valve replacements were with bioprosthetic valves. . # Gtube dysfunction: Patient presented for evaluation of Gtube dysfunction. Surgery was consulted on admission. No interventions made, but G-tube functioned appropriately throughout admission. The G-tube site was nontender and did not appear to be cellulitic. . #Agitation/Hallucinations: Patient experienced some agitation and hallucination in the evenings early during his hospitalization. He was given 25mg seroquel PRN QHS, and these episodes resolved with this treatment. . # Carotid stenosis: ER thought there might be some issues with carotids based on an Ultrasound in the ER, but formal imaging showed less than 40% bilaterally. . #. Depression: Continued home Paxil . . # Fungal rash on gluteals: Patient was followed by wound care team. He was not treated with systemic antifungal treatment due to liver disease. He was treated with clotrimazole cream twice daily. . #. Diabetes Mellitus Type 2: Patient was placed on a Humalog sliding scale, and blood sugars were monitored with QID fingersticks. . #. Goals of Care On [**2121-12-19**], medical team had discussion with patient's family, including daughter who is the HCP, and determined that the patient would be DNR/DNI/Do not Hospitalize with no escalation of care. The Palliative Care team had been following with the patient for much of hospitalization. On [**2121-12-23**], the Palliative Care team had another discussion with patient's daughter, and the patient was made [**Name (NI) 9036**] Measure Only. He passed on [**2121-12-24**] in the presence of his daughter, likely secondary to mucus plugging and complications of his earlier pneumonia. # Communication: Daughter [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Known lastname 1124**] was main communication during this admission. She is the health care proxy as well: [**Telephone/Fax (1) 80948**] (home); cell: [**Telephone/Fax (1) 80949**] Medications on Admission: . Medications from [**Hospital **] Hospital: TPN Vancomycin 750mg IV q24 since [**11-25**] SSI Novolin R Lasix 20mg IV BID Fluconazole 100mg IV daily [**11-25**] x5 day course Nexium 40mg IV Daily Digoxin 0.125mg IV Every other day Aranesp 0.1mg SC Monday q5pm Ativan 0.5mg IV Q4 prn anxiety Metoprolol 5mg IV q12hr PRN Ocean Nasal Spray [**Hospital1 **] PRN Duoneb 3ml Q6 PRN dyspnea Combivent Q4 8 puffs via trach Zinc Oxide Q8 to perirectal area Simvastatin 80mg PO Daily Seroquel 25mg PO BID Vitamin D 1000 Units PO daily Paxil 40mg PO Daily Discharge Disposition: Expired Discharge Diagnosis: Hepatic Cirrhosis Pneumonia UTI Afib/SVT Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "276.3", "V42.2", "E849.7", "576.8", "V10.46", "599.0", "789.2", "428.0", "571.5", "518.83", "038.9", "E930.5", "414.00", "995.92", "536.42", "E878.2", "707.22", "482.1", "E879.8", "V43.65", "519.02", "511.9", "707.03", "567.23", "V46.11", "311", "433.30", "580.89", "997.31", "250.00", "433.10", "V44.0", "585.3", "427.89", "403.90", "584.9", "E849.8", "V45.81", "785.52" ]

icd9cm

[ [ [] ] ]

[ "50.11", "99.60", "96.72", "54.91", "34.91", "38.93" ]

icd9pcs

[ [ [] ] ]

31789, 31798

18309, 31192

296, 361

31883, 31893

2599, 18286

31946, 31954

1926, 1954

31819, 31862

31218, 31766

31917, 31923

1969, 2556

237, 258

389, 1649

1671, 1842

1858, 1910

13,464

159,360

3959

Discharge summary

report

Admission Date: [**2201-5-22**] Discharge Date: [**2201-5-28**] Date of Birth: [**2147-9-5**] Sex: M Service: SERVICE: General surgery. HISTORY: This was a 53 year-old man who entered via the Emergency Room with right upper quadrant pain. He was found to have elevated liver function tests on admission which rose to as high as 4.4 for the total bilirubin. An ultrasound demonstrated gallstones with a mildly elevated common bile duct. HOSPITAL COURSE: The patient was taken for an ERCP the day after admission, where he was found to have a stone in the common bile duct treated with sphincterotomy and stone extraction. He was treated with broad spectrum antibiotics. Following the ERCP, he then appeared to bleed from his sphincterotomy. His initial hematocrit was 40 and it then fell to 25. He received 2 units of transfusion. He was then stable after that. All of his pain resolved. Because of the events surrounding the ERCP and the patient's own work schedule, it was decided to let him go home with a planned return for an elective cholecystectomy within the next several weeks. He had no other sequela during this admission. DISPOSITION: To home. CONDITION ON DISCHARGE: Improved. DISCHARGE DIAGNOSES: 1. Common bile duct obstruction secondary to choledocholithiasis. 2. Probable acute cholecystitis. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern4) 17555**] MEDQUIST36 D: [**2201-8-31**] 18:05:01 T: [**2201-8-31**] 18:21:52 Job#: [**Job Number 17556**]

[ "998.12", "285.1", "E878.8", "300.4", "574.40", "276.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "51.64", "51.85", "45.13", "51.88" ]

icd9pcs

[ [ [] ] ]

1246, 1622

478, 1189

1214, 1225

28,455

191,845

33129

Discharge summary

report

Admission Date: [**2118-1-24**] Discharge Date: [**2118-2-14**] Date of Birth: [**2042-6-16**] Sex: F Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 10842**] Chief Complaint: ST elevations on EKG Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 75 yr old W with PMH of hypertension, hyperlipidemia, COPD, ulcerative colitis who was recently admitted [**Date range (1) 77005**] to [**Hospital 4199**] Hospital with b/l upper lobe pneumonia and COPD exacerbation. Following the pneumonia she was discharged to rehab facility on [**1-18**], but returned to [**Location 4199**] with abdominal pain, no BMs, nausea, and difficulty taking PO meds on [**1-21**] and found to have a small bowel obstruction. CT abd/pelvis [**1-22**] showed small pneumoperitoneum, SBO, ascites, pericardial effusion, and bibasilar bronchiectasis. She underwent exploratory lap and lysis of adhesions on [**1-22**]. NG tube was placed, and she was made NPO after surgery. Post op, her hematocrit dropped to 25.9 from 32, and she was transfused 2 units with a bump to 34.4. . On the morning of transfer to [**Hospital1 18**], while being transferred to chair in ICU, patient was noted to have 10mm ST elevation anterolaterally on telemetry, confirmed by 12 lead ekg (V2-V6, I, aVR). She was asymptomatic at this time, with no chest pain. She was noted to be hypertensive. Initial markers minimally elevated: CPK 79, index 7.8, trop 0.12. WBC 22.5 (down from 36) but she was on solumedrol and unasyn for PNA. She was transferred to [**Hospital1 **] for cardiac catheterization. Past Medical History: Dyslipidemia Hypertension Ulcerative colitis/Irritable bowel syndrome HTN Hyperlipidemia Hypothyroidism COPD GERD Anemia Depression/Anxiety Dermatitis/Eczema s/p back surgery for bone spur and disc Seasonal Allergies Social History: Social history is significant for hx of tobacco use, quit 3 yrs prior. There is no history of alcohol abuse. She presents from a rehab facility, but prior to that lived in a modified home, received meals-on-wheels, and had a home health aide 1 time/wk. Family History: There is no family history of premature coronary artery disease or sudden death. Mother did have coronary disease but late onset. Physical Exam: VS: T 95.4, BP 94/60, HR 105, RR 22, O2 96% on Gen: Elderly female appears agitated, tearful, older than stated age; NAD otherwise. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, unable to assess JVP as R IJ triple lumen. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased breath sounds at R base; crackles in R middle and Left lower lung field. Abd: soft, TTP in all 4 quadrants, No HSM. Voluntary guarding. Hypoactive bowel sounds, No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; Dopplerable DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; Dopplerable DP Pertinent Results: LABS: [**2118-1-24**] 05:06PM BLOOD WBC-35.7* RBC-4.14* Hgb-11.6* Hct-35.5* MCV-86 MCH-28.1 MCHC-32.8 RDW-15.3 Plt Ct-500* [**2118-2-14**] 05:41AM BLOOD WBC-10.5 RBC-3.29* Hgb-10.4* Hct-30.6* MCV-93 MCH-31.6 MCHC-34.0 RDW-17.6* Plt Ct-256 [**2118-1-24**] 05:06PM BLOOD Neuts-93.9* Bands-0 Lymphs-2.9* Monos-3.0 Eos-0.2 Baso-0.1 [**2118-2-1**] 06:12AM BLOOD Neuts-93* Bands-0 Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2118-1-24**] 05:06PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Ovalocy-OCCASIONAL [**2118-2-1**] 06:12AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL [**2118-1-24**] 05:06PM BLOOD PT-14.5* PTT-24.2 INR(PT)-1.3* [**2118-2-2**] 03:55AM BLOOD PT-12.6 PTT-26.9 INR(PT)-1.1 [**2118-1-24**] 05:06PM BLOOD Glucose-104 UreaN-19 Creat-0.5 Na-142 K-4.8 Cl-113* HCO3-22 AnGap-12 [**2118-2-14**] 05:41AM BLOOD Glucose-81 UreaN-12 Creat-0.6 Na-127* K-4.1 Cl-91* HCO3-31 AnGap-9 [**2118-1-24**] 05:06PM BLOOD ALT-12 AST-60* LD(LDH)-416* AlkPhos-53 Amylase-26 TotBili-0.3 [**2118-1-30**] 12:15AM BLOOD ALT-9 AST-13 AlkPhos-31* TotBili-0.4 DirBili-0.1 IndBili-0.3 [**2118-1-24**] 05:06PM BLOOD Lipase-27 [**2118-1-25**] 04:02AM BLOOD CK-MB-24* MB Indx-20.2* cTropnT-1.23* [**2118-1-26**] 05:02AM BLOOD CK-MB-11* MB Indx-13.3* cTropnT-0.77* [**2118-1-24**] 05:06PM BLOOD Albumin-2.6* Calcium-7.1* Phos-1.8* Mg-2.2 [**2118-2-14**] 05:41AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.8 [**2118-1-25**] 04:02AM BLOOD calTIBC-107* Ferritn-374* TRF-82* [**2118-1-30**] 12:15AM BLOOD Hapto-62 [**2118-2-9**] 06:00AM BLOOD VitB12-1517* Folate-5.6 [**2118-1-25**] 04:02AM BLOOD TSH-8.7* [**2118-1-26**] 05:02AM BLOOD Free T4-0.41* [**2118-2-3**] 09:47AM BLOOD Cortsol-14.9 [**2118-2-3**] 11:15AM BLOOD Cortsol-21.3* [**2118-2-3**] 11:15AM BLOOD Cortsol-27.2* [**2118-1-29**] 07:19PM BLOOD Vanco-47.8* [**2118-2-14**] 05:41AM BLOOD Vanco-20.2* [**2118-1-24**] 02:05PM BLOOD Glucose-113* Lactate-1.0 K-4.5 [**2118-1-25**] 04:09AM BLOOD Lactate-1.1 [**2118-1-30**] 12:20AM BLOOD Lactate-6.5* [**2118-1-30**] 04:00AM BLOOD Lactate-3.0* [**2118-2-2**] 05:15AM BLOOD Lactate-1.3 [**2118-2-3**] 06:31AM BLOOD B-GLUCAN-32 (negative) [**2118-1-24**] 08:03PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.060* [**2118-1-24**] 08:03PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-50 Bilirub-SM Urobiln-NEG pH-7.0 Leuks-NEG [**2118-1-24**] 08:03PM URINE RBC-[**3-30**]* WBC-[**3-30**] Bacteri-FEW Yeast-NONE Epi-0-2 [**2118-2-7**] 10:47AM URINE Hours-RANDOM UreaN-620 Creat-68 Na-33 Cl-32 [**2118-2-7**] 10:47AM URINE Osmolal-476 [**2118-2-3**] Flow Cytometry: INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical findings is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. . MICRO: Blood Cx: [**1-25**] x2, [**1-29**], [**2-2**], [**2-3**]: No Growth Urine Cx: [**1-25**]: No growth Urine Cx: [**1-26**]: Negative for Legionella RIJ Catheter Tip Cx: [**2-3**]: No significant growth Stool Cx: [**2-2**], [**2-4**], [**2-8**]: Negative for C. difficile Stool Cx: [**2-3**]: Negative for C. difficile toxin B Sputum Cx: [**2118-1-27**] 4:38 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2118-1-27**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2118-2-8**]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**7-/2416**]) immediately if sensitivity to clindamycin is required on this patient's isolate. YEAST. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. IDENTIFICATION AND SENSITIVITIES PER DR [**First Name (STitle) **] #[**Numeric Identifier 77006**]. PSEUDOMONAS AERUGINOSA. RARE GROWTH. 2ND STRAIN. sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | PSEUDOMONAS AERUGINOSA | | | CEFEPIME-------------- <=1 S 2 S CEFTAZIDIME----------- <=1 S <=2 S CIPROFLOXACIN--------- 1 S <=0.5 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S 2 S 2 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S 1 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S <=8 S PIPERACILLIN/TAZO----- <=4 S <=8 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S . IMAGING: EKG ([**1-25**]): Sinus rhythm at a rate of 94. Low limb lead voltage. QS pattern in leads V3-V6 consistent with anterolateral myocardial infarction. Diffuse ST segment elevations consistent with myocardial infarction or myopericarditis. . CXR ([**1-25**]): IMPRESSION: 1. New right IJ line, with tip over mid SVC. No pneumothorax detected. 2. Bilateral upper zone opacities -- this could represent aspiration, inflammatory infiltrate, or scarring. As an infiltrative process cannot be entirely excluded, further imaging to document resolution is recommended. 3. Patchy opacity left lower lobe and to a lesser extent right lower lobe consistent with collapse and/or consolidation. Small left effusion. . Abdominal Film ([**1-25**]): IMPRESSION: 1. Several top-normal diameter loops of small bowel and paucity of gas in the descending colon. Overall, this appearance is nonspecific, but could reflect the presence of an early or partial small-bowel obstruction. 2. Intraperitoneal free air, thought to be due to recent surgery. . Cardiac Catheterization ([**1-25**]): COMMENTS: 1. Coronary angiography of this right dominant system revealed a normal LMCA with a 40% mid stenosis in the LAD. The LCX had mild luminmal irregularities. The RCA had a 50% mid stenosis. 2. Resting hemodynamics revealed normal right-sided filling pressures with an RASP of 3 mm Hg, RVEDP of 6 mm Hg, PASP of 40 mm Hg and PCWP of 18 mm Hg. The LVEDP was 18 mm Hg. The cardiac output was 4.2 with an index of 2.6. 3. Left ventriculography was performed which showed severe anterolateral, apical and inferoapical akinesis with an EF of 20%. There was no mitral regurgitation. These findings were consistent with Takatsubo syndrome. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe systolic ventricular dysfunction. . TTE ([**1-25**]): The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mid to distal anteroseptum, anterior wall, and distal inferior wall hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Focal left ventricular dysfunction consistent with single vessel CAD (mid LAD). Mild mitral regurgitation. Moderate to severe tricuspid regurgitation. . ECG ([**1-25**]): Sinus rhythm at a rate of 75. Diffuse low voltage. Compared to the previous tracing there has been a decrease in overall voltage. Other abnormalities are as previously described. . CXR PA/Lateral ([**1-25**]): The heart is not enlarged. There are dense bilateral interstitial and alveolar opacities as well as patchy increased retrocardiac opacity with obscuration of the left hemidiaphragm and minimal patchy opacity at the right base. There are small bilateral effusions. Probable background COPD. There is pneumoperitoneu, with air seen beneath the right diaphragm. Osteopenia and prominent scoliosis of the spine is noted. A right IJ tube is present, tip over distal SVC. An NG tube is present, tip beneath diaphragm off film. Sideport lies in the region of the GE junction. IMPRESSION: 1. Bilateral upper zone infiltrates, left > right lower lobe infiltrates, and small effusions. Overall, findings are similar to the film from one day earlier. 2. Pneumopeirtoneum, apparently due to recent abdominal surgery. Please correlate clinically. . CT Abdomen/Pelvis ([**1-25**]): IMPRESSION: 1. Moderate bilateral pleural effusion and free intraperitoneal fluid consistent with the patient's history of resuscitation. 2. Small amount of intraperitoneal bleeding and pneumoperitoneum is noted most likely related to the patient's recent surgery. 3. Right inguinal hematoma, most likely related to the recent catheterization. 4. No retroperitoneal bleeding is visualized. 5. Bronchiectatic changes at both lung bases and diffuse centrilobular and tree-in-[**Male First Name (un) 239**] opacities are concerning for infection. . CXR Portable ([**1-26**]): IMPRESSION: 1. Bilateral upper lobe infiltrates as well as infiltrate in the right lung base and left retrocardiac region.Imaddition, a rounded lucency is seen in the mid right lung which could represent superimosed structures and less likely a true abnormailty 2. Left pleural effusion with blunting of the left costophrenic angle essentially unchanged from the previous study. 3. Persistent abdominal pneumoperitoneum with elevation of the right hemidiaphragm. Overall, the findings on today's examination have not changed when compared to the previous study. . TTE ([**1-26**]): LVEF 45%. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with distal LV and apical akinesis. The remaining segments are hyperdynamic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2118-1-24**], the degree of pulmonary hypertension detected has decreased and a small pericardial effusion is now seen. . CT Abdomen/Pelvis ([**1-29**]): IMPRESSION: 1. Slight interval increase in size of right inguinal hematoma, which tracks slightly into the anterolateral right thigh. 2. Continued evidence of recent intraperitoneal bleeding is most likely related to recent surgery. No definite evidence of new intraperitoneal bleeding. No change in quantity of intraperitoneal fluid. 3. Unchanged moderate bilateral pleural effusions, and slight increase in small pericardial effusion. 4. Decreased prominence of centrilobular nodules at the lung bases, though these are only partially imaged. . Right Femoral Vascular Ultrasound ([**1-30**]): IMPRESSION: 1. No evidence of pseudoaneurysm or fistula in the right groin. 2. Moderate to large amount of ascites seen. 3. Right groin subcutaneous hematoma, better evaluated on most recent CT. . Right Femoral Vascular Ultrasound ([**2-1**]): IMPRESSION: No pseudoaneurysm, small hematoma right groin. . CT Chest/Abdomen/Pelvis ([**2-2**]): IMPRESSION: 1) Diffuse bilateral pulmonary parenchymal opacities, most prominent in the upper lobes, are consistent with pneumonia. 2) Bilateral pleural effusions, probably slightly increased on the left. 3) Bilateral pulmonary nodules could relate to underlying infectious or inflammatory process although continued follow up to resolution after treatment is recommended. 4) Probable gastroesophageal reflux. 5) Colonic air-fluid levels, a nonspecific finding. 6) Slight decrease in right groin hematoma. . CXR Portable ([**2-3**]): IMPRESSION: Left PICC in standard position, no pneumothorax. Slight improvement in the lungs with some residual opacities at the upper lobes and the bases as well as a small left pleural effusion. . ECG ([**2-6**]): Sinus rhythm at a rate of 86. Anterolateral ST-T wave abnormalities. Cannot rule out myocardial ischemia. Low QRS voltage in the limb leads. Compared to the previous tracing of [**2118-2-2**] anterolateral ST-T wave abnormalities persist. . CXR ([**2-13**]): IMPRESSION: Subtle improvement in aeration with persistent airspace disease. Brief Hospital Course: # Takotsubo's Cardiomyopathy: At an OSH, the patient developed 10mm ST elevation anterolaterally on telemetry, confirmed by 12 lead EKG (V2-V6, I, aVR) while being transferred to a chair in the ICU. She was asymptomatic at this time, with no chest pain. Cardiac catheterization at [**Hospital1 18**] showed severe anterolateral, apical and inferoapical akinesis with an EF of 20%, consistent with Takatsubo syndrome. A repeat TTE showed mild regional LV systolic dysfunction with mid to distal anteroseptum, anterior wall, and distal inferior wall hypokinesis, and an EF 50-55%. A second repeat TTE later in the hospitalization showed mild symmetric LVH, mild to moderate regional LV systolic dysfunction with an EF 45% and with distal LV and apical akinesis, the remaining segments are hyperdynamic. She was initially placed on a heparin gtt as she had increased risk of thrombus formation at the akinetic segments; however, this was discontinued after she formed a right groin hematoma later in the hospitalization (see below). She was continued on ASA 81 daily, and started on Captopril 12.5 tid and Metoprolol 12.5 tid to help with catecholamine stress on the heart. She will be discharged on Metoprolol 25 [**Hospital1 **] and Lisinopril 5 mg daily. **She was started on Lasix 40 mg PO daily for her edema, and this should be titrated to her edema and physical exam. **Her cardiologist can consider adding back oral anticoagulation at a later date. She will likely need a repeat TTE in the future to assess apical wall motion and to evaluate for thrombus. . # Respiratory Distress: During her initial hospitalization, she would trigger for desaturations to SaO2 80% on 2 L, but she improved to 96% on 5 L. CXRs were consistent with volume overload with small bilateral pleural effusions. CXR on discharge showed persistent bilateral effusions. Her O2 requirement was weaned down to 1 L by the time of discharge. She received multiple doses of Lasix 40 IV to keep 1 L negative over the day. . # CAD: Her EKG at OSH demonstrated ST elevations in I, avL, V2-V6; Qs in II, III, aVF, V3-V6, yet the patient remained chest pain free. She was hypertensive at this time. CEs at OSH CPK 79, index 7.8, trop 0.12. At [**Hospital1 18**], Trop T 1.23-0.77, CK 119-83, CK-MB 24-11. The EKG changes were likely secondary to stress cardiomyopathy in the setting of PNA and SBO. Cardiac catheterization showed normal LMCA with a 40% mid stenosis in the LAD, the LCX had mild luminmal irregularities, the RCA had a 50% mid stenosis. She was continued on ASA 81 daily and Atorvastatin 10 mg daily. She was started on Lisinopril 5 mg daily and Metoprolol 25 mg [**Hospital1 **]. . # Hypotension: On day 2 of admission to [**Hospital1 18**], she became hypotensive in the CCU into the 60s after receiving one dose of Metoprolol 12.5. At that time her CVP was [**2-27**], so this was thought to be due to volume depletion. She received 4 L IVF bolus and Levophed x15 min. At that time, she also had a Hct drop of 35 to 26, which was likely dilutional. She received 1 U PRBCs, and a repeat Hct was 35. CT abdomen/pelvis ruled out an RP bleed. She was transferred to [**Hospital1 18**] on Methylprednisolone -> Dexamethasone, and an AM cortisol was 18.2, which is low for acute infection, but the patient was on steroids. Endocrine was curbsided, and did not think she was adrenally insufficient and recommended steroid taper. She then triggered for hypotension on [**1-29**] secondary to a right groin hematoma (see below) in the setting of supratherapeutic PTT on heparin gtt and on a steroid taper. Her heparin gtt, Coumadin, and ASA were discontinued at that time. She was transferred back to the CCU, where she was given 5 U PRBCs, 4 L NS, and briefly was on 2 pressors. She was transiently given stress dose steroids with Dexamethasone 4 mg IV Q8H while hypotensive, which was quickly changed back to her previous taper dose of Prednisone 10 mg PO x2 days. Her beta blocker and ACE-I were held during the episode of hypotension, and have since been added back. . # Right Groin Hematoma: The patient became hypotensive with SBP 68-85 on [**1-29**]. Her beta blocker and ACE-I were discontinued, and she was given 1 L NS without an increase in her blood pressure. Her heparin gtt and Coumadin were discontinued as her PTT had been >150 over the previous 2 days and her INR was 2.0->5.3 on Coumadin, and there was concern for increased ecchymosis and expanding hematoma at her right cardiac catheterization site. Her Hct dropped from 30.4 -> 25.7 -> 20.2 -> 18.0. CT abd/pelvis showed slight interval increase in size of her right inguinal hematoma which tracked slightly into the anterolateral right thigh, continued evidence of recent intraperitoneal bleeding is most likely related to recent surgery, and no definite evidence of new intraperitoneal bleeding. She was transferred back to the CCU, where she was given 5 U PRBCs, 4 U FFP, IVF NS 4 L, Phenylephrine and Norepinephrine gtt overnight, Vit K 10 SC x1, Protamine 10 IV x1, Lasix 20 IV x1 and Lasix 60 IV x1. Hct improved to 30-33. Lactate increased from 1.1 -> 6.5, and trended back down to 1.3. She received several hours of manual compression for her expanding hematoma. Right femoral vascular ultrasound showed no evidence of pseudoaneurysm or fistula in the right groin, but did show a right groin subcutaneous hematoma. Vascular surgery was consulted and thought the most likely cause of her hematoma was a ruptured pseudoaneurysm s/p catheterization in the setting of supratherapeutic INR and recent cardiac catheterization. The patient's HCP did not wish for surgical correction of the hemorrhagic source. Repeat right femoral vascular U/S showed no pseudoaneurysm and a small hematoma in right groin. . # Pneumonia: The patient was admitted [**Date range (1) 77005**] to [**Hospital 4199**] Hospital with bilateral upper lobe pneumonia and COPD exacerbation. She was treated at a rehab facility with moxifloxacin for the PNA and a steroid taper for the COPD. She received 1 dose of Levaquin in the OSH ED, and her coverage was switched to Unasyn. At the [**Hospital1 18**] CCU, her antibiotics were changed to Vancomycin and Zosyn when she became hypotensive with low grade fever, as there was initial concern for sepsis. She had an elevated WBC (35.7 on admission), but this was likely the result of steroids. A diff showed a left shift (94% neutrophils) but no bands. Initial CXR showed bilateral upper zone infiltrates, left > right lower lobe infiltrates, and small effusions. Repeat CXR showed bilateral upper lobe infiltrates as well as infiltrate in the right lung base and left retrocardiac region, concerning for a new hospital acquired pneumonia. Infectious Disease was consulted to assist with management. Urine Legionella was negative. Sputum culture showed MRSA, yeast, and GNRs. Her coverage was changed to Vanco/Meropenem as there was concern for ESBL. The GNRs speciated to pansenstive Pseudomonas; however, the patient was clinically improving (with a decreased O2 requirement) on this regimen so she remained on Vanco/Meropenem for a 2 week course from the time she started to clinically improve ([**Date range (1) 77007**]). **She will have 1 more dose of Vanco on [**2-16**], and 2 more doses of Meropenem on [**12-8**]. She does not need ID follow up as an outpatient. . # Small Bowel Obstruction: The patient is s/p ex lap and lysis of adhesions on [**1-22**] at an OSH. There was no evidence of perforation or necrosis on the ex lap. She was placed on Unasyn at the OSH. KUB at [**Hospital1 18**] showed several top-normal diameter loops of small bowel and paucity of gas in the descending colon which could reflect the presence of an early or partial small-bowel obstruction. She also had intraperitoneal free air, which was thought to be due to recent surgery. CT abd/pelvis showed small amount of intraperitoneal bleeding and pneumoperitoneum is noted most likely related to the patient's recent surgery. Her antibiotic coverage was advanced to Vanc/Zosyn when she became hypotensive, then changed to Vanc/Meropenem. Surgery was consulted at [**Hospital1 18**] for her SBO, and recommended initially continuing NPO and NG decompression until passing flatus. On [**1-26**], her diet was advanced to clears, and her NGT was removed. Her staples were removed on POD 20. Her diet has now been advanced to regular with supplements for breakfast, lunch, and dinner. She continues to complain of [**8-4**] abdominal pain, and is being treated with Oxycontin SR and Oxycodone prn. She continues to pass flatus and stool. She will follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 22020**] at [**Hospital 8**] Hospital in 2 weeks. . # Leukocytosis: The patient's WBC was persistently elevated during this hospitalization. WBC was 35.7 on admission and peaked at 42.5. She was intially on steroids, with Solumedrol->Dexamethasone->a prednisone taper; however, her WBC was still high for a week after her steroid taper was discontinued. ID was consulted. She was placed on Vanco/Meropenem for her pneumonia. Sputum culture showed MRSA, yeast, and Pseudomonas. Beta glucan was negative. CT abdomen/pelvis showed no evidence of abscess. The patient was producing some loose stools, so she was empirically started on Flagyl. However, C. diff negative x3 and C. diff toxin B negative, so Flagyl was discontinued. Her RIJ tip culture showed no significant growth. All blood cultures and urine culture showed no growth. Peripheral flow cytometry to evaluate for malignancy showed non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia/lymphoma are not seen in specimen. [**Last Name (un) **] stim test: pre: 14.9, 30 min post: 21.3, 60 min post: 27.2; indicating the patient is not adrenally insufficient. Her WBC slowly started to improve on antibiotics, and her WBC was 10.5 on discharge. . # Possible Transfusion Reaction: After the patient received the first unit of PRBCs, she developed symptoms of respiratory distress, and became pale and diaphoretic. The transfusion was discontinued. It is unclear if the patient's response was a reaction to the PRBCs vs. a normal physiologic response to her worsening anemia. . # Hypothyroidism: The patient reported taking a thyroid medication at home, but no documentation of this was in her transfer records. TSH 8.7, Free T4 0.41, but this was in the setting of acute illness. She was initially placed on Levoxyl 25 mcg daily, as we were unsure of her home dose. After speaking with her outpatient pharmacy, it was determined that she actually takes Levoxyl 88 mcg daily. Her uncontrolled hypothyroidism was likely contributing to her hyponatremia (see below). She was started back on Levothyroxine 100 mcg daily. **She will need her TFTs rechecked within the month, with consideration of changing her back to her home dose of 88 mcg daily. . # Hyponatremia/SIADH: The patient's Na had been slowly trending from 138->125 over 8 days. Urine lytes: FeNa 0.34%, FeUrea 45.6%. At the same time it was determined that the patient was being undertreated for her hypothyroidism, as it was unclear initially what her outpatient dose was. Once her Levoxyl was increased from 25 to 100 mcg daily, her Na started to trend up. **Na was 127 at the time of discharge, and should continue to be monitored as an outpatient. . # Hyperlipidemia: Continued Atorvastain 10 mg daily. . # COPD: The patient was discharged from an OSH with PNA and COPD on a steroid taper. She was placed on Solumedrol and Dexamethasone initially in the CCU for concern for adrenal insufficiency in the setting of hypotension. Once she improved, she was transitioned to a short prednisone taper. She was continued on tiotropium 1 cap IH dialy, albuterol IH q6hr prn, and Advair 500-50 1 puff [**Hospital1 **]. . # Anemia: Hct 35.5 on admission. Fe studies showed Fe 39, TIBC 107, Ferritin 374, TRF 82. Stools were guaiac positive. She also had a Hct drop during her groin hematoma (see above). Her home dose of FeSO4 tid was intially held because we didn't want to cause constipation in the setting of her SBO. **She can have iron studies rechecked as an outpatient, with consideration of uptitrating her dose to her previous regimen. . # Ulcerative Colitis: Continued Asacol 400 mg PO bid. . # GERD: Continued Protonix daily. . # Depression/Anxiety: The patient became increasingly depressed during the hospitalization, which was likely confounded be her hyponatremia and hypothyroidism. She was very lonely while hospitalized, and did much better when her family was around. Geriatrics was consulted and recommended checking Vit B12 which was high, and folate which was normal. Psychiatry was consulted and recommended continuing her Bupropion 150 [**Hospital1 **]. They recommended increasing her Fluoxetine to 40 mg daily, and decreasing her Ativan to 0.5 mg [**Hospital1 **] (with consideration of tapering off). Her amitryptilline was held during this hospitalization, as it was unclear what the indication was for this medication. . # Skin blisters and erythema: Patient complains of severe back pain from ulcers. Wound care was consulted and left recommendations. . # Access: PICC . # Code: DNR/DNI . # Communication: patient; HCP is daughter, [**Name (NI) **] [**Name (NI) 77008**] [**Telephone/Fax (1) 77009**] (h), [**Telephone/Fax (1) 77010**] (c). Medications on Admission: TRANSFER MEDS (FROM OSH) 4 baby asa via ng tube Lopressor 5mg x3 doses [**2118-1-24**] Morphine 4 mg IV PRN abdominal pain, last dose at 730am, will get a dose at 1230 prior to transfer on [**1-25**] Lovenox 40mg SQ daily, last dose 12/30 at 2pm Solumedrol 70mg q12hours, last dose 12/31 at 0200 Protonix 40mg IV, last dose 12/30 at 10pm Unasyn 1.5mg IV q8hours, due at 12noon and has not received a dose as of yet, last dose 4am IV Fluid/Drips: D5 1/2 NS at 100cc/hr . HOME MEDS (Per OSH d/c summ): Ferrous sulfate 325mg PO tid Advair 500/50 1 puff [**Hospital1 **] Lipitor 10mg PO daily Asacol 400 mg PO bid Lisinopril 40 daily Lovenox 40 SQ daily Avelox 400 PO daily Prednisone taper Tylenol w codeine 1 tab PO bid Albuterol MDI Amitriptyline 25mg PO qHS ASA 81 PO daily Ativan 1mg PO bid Omeprazole 20mg PO daily Spireva 18mcg INH daily Wellbutrin SR 150mg PO bid Prozac 30mg PO daily Dulcolax 10mg PO daily PRN constipation . Allergies: Iodine/IV DYE Discharge Medications: 1. Medication Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation 1 puff [**Hospital1 **] (). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 13. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 14. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 21. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous once for 1 doses: Give on [**2118-2-16**]. 22. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 days. 23. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 25. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: PRIMARY: Takotsubo's Cardiomyopathy Coronary Artery Disease Hypotension Community and Hospital Acquired Pneumonia Right Groin Hematoma Anemia Small Bowel Obstruction Leukocytosis Possible Transfusion Reaction Hyponatremia/SIADH Hypothyroidism Skin Breakdown and Blisters on Back . SECONDARY: Hyperlipidemia COPD Ulcerative Colitis/IBS GERD Depression/Anxiety Discharge Condition: Stable Discharge Instructions: 1. If you develop shortness of breath, chest pain, fever >101.5, worsened symptoms of cough or more productive of sputum, palpitations, weakness or numbness, difficulty speaking or swallowing, lightheadedness or dizziness, or any other symptoms that concern you, call your primary care physician or return to the ED. 2. Take all medications as prescribed. 3. Attend all follow up appointments. Followup Instructions: You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1147**] in Cardiology ([**Telephone/Fax (1) 8468**]) [**2118-3-24**] at 3:30 at [**Street Address(2) 16386**]. [**Location (un) 4628**], MA. . You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 22020**] in Surgery ([**Telephone/Fax (1) 77011**]) on [**2118-2-28**] at 10:15 am at [**Hospital 4199**] Hospital.

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Discharge summary

report

Admission Date: [**2193-2-22**] Discharge Date: [**2193-3-21**] Service: MEDICINE Allergies: Demerol / Aspirin / Dilaudid Attending:[**First Name3 (LF) 1973**] Chief Complaint: Lung mass. Major Surgical or Invasive Procedure: Lung biopsy on [**2193-2-28**]. Vertebroplasty History of Present Illness: 88 year old male with a history of prostate cancer, CVA, DM2, CEA and [**Hospital 2182**] transferred to the medicine service for further evaluation of a lung mass. The patient was in his usual state of health until one month prior to admission when he developed upper extremity weakness, right more than left as well as bilateral shoulder pain and a cough. He was admitted to an OSH and was found to have a LLL infiltrate and was treated for pneumonia and COPD flare. He also had a spine MRI which demonstrated a T1 compression fracture. The patient was transitioned to rehabilitation. At the rehab facility he continued to have upper extremity weakness and bilateral shoulder pain refractory to conservative measures. MRI of his brain showing no significant change from his post-stroke MRI per report. His R hand weakness progressed and he was sent from rehab back to the OSH where he again had a MRI of his C-spine which showed interval progression of the compression fracture with retropulsion of the posterior fragment into the upper thoracic cord. Additionally, a soft tissue mass anterior to the vertebral body brought up the possibility of metastatic disease. His PSA remained flat at this time and a CT chest showed 2 LLL masses along with renal and thyroid cysts. He was started on steroids and sent to [**Hospital1 18**] for further managment. Incidentally, he was restarted on CTX/gentamycin at the OSH per family report because he developed fevers but they denied any other infectious symptoms at this time including SOB, cough, dysuria, or abdominal pain. He did have mild diarrhea. . At [**Hospital1 18**], his films were reviewed by neurosurgery and no cord compression was noted. His thoracic vertebral fracture was thought to be stable and he was fitted for a brace. IP was consulted to perform a percutaneous biopsy of the mass and CT of the chest, abdomen and pelvis were performed. A bone scan and CT head were ordered along with a MRI of C5-T4. The patient was transfered to medicine for further work-up of his lung mass once acute neurosurgical issues were excluded. . On interview today, the patient feels generally well. He denies any CP, SOB, abdominal pain, nausea, vomiting or headache. He does have some LE paresthesias and notes weakness in his R hand that is worse than baseline. His family notes chronically loose bowels but states this has been worse of late and feels that his cognition has slipped over the past month. Past Medical History: 1. HTN 2. Prostate CA s/p XRT and since treated w/ lupron and zoladex 3. CVA '[**92**] w/ residual R sided weakness 4. DM2 5. s/p Nephrectomy ~'[**82**] 6. GIB 7. carotid endarterectomy 8. COPD 9. Shoulder OA 10. Glaucoma Social History: Lives with sons but most recently in rehab. Social EtOH. Quit smoking ~20yrs ago (30-45pk/yrs prior). No drug use. Worked for [**Company 2676**] but also spent time in a [**Doctor Last Name **] quarry. No work in construction, demolition, or shipyard. No exposure to chemicals. Family History: Noncontributory. Physical Exam: (on admission) 99.3, 126/69, 88, 20, 98%RA Gen: WNWD Elderly [**Male First Name (un) 4746**] sitting up in chair w/ neck brace in place HEENT: MMM, O/P clear, EOMI, PERRLA CV: RRR, 3/6 SEM at the apex Lungs: Decreased breath sounds on the L Abd: S/NT/ND, +BS, -HSM Ext: No peripheral edema Neuro: Decreased strength on R side w/ worst strength in grip, intact sensation to light touch bilaterally, AAO to person and year but not date or location, 0/3 recall immediately and w/ prompting, thought 5 quarters in $1.75, intact heel-to-shin on L but impaired on R, able to name watch/pen and describe what they are used for Skin: No rashes (on discharge) 99.1, 130/70, 74, 18, 95% on 2L NC Gen: chronically ill appearing male in soft neck collar in place HEENT: OP clear, EOMI, MMM CV: RRR, 3/6 SEM apex radiating to axilla, heard across precordium Resp: sporadic ronchi, decreased breath sounds left Abd: soft, nontender, nondistended, normal bowel sounds Ext: No edema, able to move UE/LE bilaterally Pertinent Results: At the time of callout from the MICU ([**2193-3-2**]): . Labs: Remarkable for WBC 18.3 trending downward, Hct 27.9 baseline 32, INR 1.3. . MR thoracic and cervical spine without contrast ([**2193-2-25**]): 1. Again seen is compression deformity involving the T1 vertebral body. There is no evidence of cord signal abnormality. Degenerative changes within the cervical spine result in areas of spinal canal stenosis, as described above. 2. There is left pleural effusion and ill-defined mass in left lower lobe, which is better evaluated on prior CT scans. . Bone Scan ([**2193-2-26**]): No evidence of osseous metastatic disease. Focal uptake in the lower neck likely correlates with T1 compression fracture on CT scan. . CT chest/abd/pelvis ([**2193-2-24**]): 1. Multiple heterogeneously enhancing soft tissue masses within the posterior left lung likely centering within the pleura extending into the lateral chest wall and causing mild bony erosion. A small linear calcification is noted adjacent to the pleura within the dominant mass suggesting possible mesothelioma. Additional diagnoses within the differential include primary lung cancer or metastatic lesion from thyroid or renal cell carcinoma. The lesion appears to be amenable to percutaneous biopsy. 2. Heterogeneously enhancing middle mediastinal left thyroid lesion. This likely represents a simple goiter but can be further evaluated with ultrasound if clinically indicated. 3. Cholelithiasis without evidence of acute cholecystitis. 4. Multiple right renal hypoattenuating lesions, some of which are clearly cystic and others which are too small to characterize. 5. Diffuse atherosclerotic calcifications. 6. T1 compression fracture with multilevel degenerative changes throughout the spine, including grade 1 anterolisthesis of L5 on S1 and mild posterior disc protrusion of L3-4 intervertebral disc. . Bronchial brushings and washings ([**2193-2-28**]): Negative for malignant cells. . Lymph node biopsy ([**2193-2-28**]): Non-diagnostic, lymph node not sampled, likely reactive lymphocytes. . Echo ([**2193-3-1**]): The left atrium is elongated. The left ventricular cavity size is normal. Left ventricular systolic function is grossly preserved although views are technically suboptimal (EF probably >45%). Regional wall motion could not be fully assessed. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) 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.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR ([**2193-3-1**]): Large lower lobe consolidation. This may be due to aspiration, hemorrhage, or pneumonia. . CXR ([**2193-3-2**]): Increased airspace opacity involving both lungs is new when compared to the previous chest radiograph and CT. The finding represents mild pulmonary edema. Previously identified bilateral lower lobe opacities are much less conspicuous on the current exam. Deviation of the trachea from the midline to the right attributable to the previously seen enlarged thyroid. . CTA ([**2193-3-1**]): 1. No pulmonary embolism. 2. New bilateral pleural effusions, moderate on the left and small on the right. 3. Consolidation of the majority of the right lower lobe. Increased consolidation surrounding the left lower lobe masses. This may be infectious or due to aspiration. 4. No short interval change in the left lower lobe masses previously detailed on the study from five days ago. . TTE [**2193-3-3**]: The left atrium is elongated. The left ventricular cavity size is normal. Left ventricular systolic function is grossly preserved although views are technically suboptimal (EF probably >45%). Regional wall motion could not be fully assessed. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) 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.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Thyroid Ultrasound: 1) Very limited study due to overlying brace and patient immobility. Thyroid parenchyma not visualized. 2) 4.1-cm mass centered in the expected position of the upper lobe of the left thyroid/supraclavicular region. It is impossible to tell on the current study whether this lesion is exophytic from the left lobe thyroid or represents supraclavicular adenopathy, though the former appears more likely in correlation with the recent CTA chest. . Noncontrast CT Chest: 1. No change in large soft tissue mass in the left lower lobe with extension/invasion into adjacent chest wall, pleural effusion, and infrahilar and mediastinal lymphadenopathy. 2. Decreased right pleural effusion and improved right basilar atelectasis/consolidation. . CT Head ([**3-13**]) for mental status changes: 1. No hemorrhage or mass effect. 2. Old bilateral basal ganglia and left cerebellar infarcts. . Brief Hospital Course: 1. T1 compression fracture: the patient was initially evaulated by neurosurgery who did not feel that the patient had new weakness or evidence of spinal cord compression. He was fitted for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] brace which he wore at all times. In an effort to free the patient from the brace and improve his pain, he underwent interventional radiology-vertebroplasty. After that, the patient was able to be changed to a small soft collar, but had very little palliation from the procedure. His mobility is significantly limited and requires significant assistance to get out of bed. At discharge, he could move all extremities at his baseline. Radiation oncology was involved and radiated his T1 lesion in a single fraction, with little palliation. Tissue biopsy at the time of vertebroplasty was unrevealing. . 2. LLL mass: likely primary lung cancer, however, no definitive tissue pathology was obtained despite several attempts including transbronchial biopsy. DDx included thyroid and renal cell cancers, and the patient does have a large thyroid nodule which was unable to be biopsied secondary to his neck fracture constraints. Oncology consulted who thought patient was not a chemotherapy candidate given his solitary kidney and poor performance status. Radiation oncology consulted, as above. He was not a candidate for radiation to the lung mass. . 3. Post obstructive pneumonia: The patient was intermittently febrile throughout the hospitalization and was found to have a postobstructive pneumonia. He was treated with broad spectrum antibiotics for a prolonged course given his inability to clear secretions effectively. Chest PT was not able to be done given the constraints of his neck fracture. On the day of discharge, he was febrile to 102 after a long period of being afebrile with a resolving leukocytosis. He was continued on antibiotics at discharge. . 4. Atrial fibrillation: the patient developed new onset atrial fibrillation during the hospitalization around the time of his transbronchial biopsy. He was diltiazem refractory and ultimately responded to IV Metoprolol. He was maintained on Metoprolol orally during the hospitalization. He received a course of Amiodarone and coverted to sinus rhythm. He was discharged on 200 mg Amiodarone daily in NSR. . 5. Hypoxia: the patient was intermittently hypoxic during the initial period of his hospitalization from the large LLL mass, post obstructive pneumonia/mucus plugging, paroxysmal atrial fibrillation and intermittent volume overload. He would have a tendency to desaturate overnight, but would respond to increased oxygen and diuresis if overloaded. At discharge, the patient had a much improved requirement of 2 liters by nasal cannula. . 6. Left Lobe Thyroid Nodule. Incidentally found on chest CT on [**2193-2-23**]. Normal thyroid function. Thyroid ultrasound completed, but limited by the patient's large neck brace and T1 fracture. The decision was made not to pursue further characterization of the thyroid nodule. . 7. Anemia of chronic inflammation: stable at his baseline hematocrit of 28-30. . 8. Prostate cancer: prior history, on Zoladex as outpatient. Not continued as inpatient. PSA flat despite evidence of metastatic disease. Stable as inpatient. . 9. Diabetes: home regimen of metformin and glipizide held in the hospital, placed on sliding scale. Uncontrolled sugars in the setting of steroids for pain control. Titrating Lantus based on sliding scale requirement. . 10. Pain and Palliation: Palliative care consulted given that the patient's pain was difficult to control. He was refractory to Tylenol but very sensitive to narcotics. He was on several regimens during the hospitalization, but was ultimately discharged on Methadone 0.5 mg q8 am and q2 pm. He was also maintained on Ritalin for improved mood and energy during the day. He was also pulsed with Decadron with improvement in his mood, but not pain. Decadron was tapered to 4 mg daily with the plan to taper off as tolerated. . 11. Glaucoma: continued home Latanoprost . 12. Gout: continued home allopurinol. No acute issues. . 13. Hypertension: well controlled initially on home regimen, but became difficult to control in the setting of steroids. At discharge, he was stable in 130s/70s on Lisinopril and Metoprolol. . 14. Disposition: the patient had a long and complicated hospital course, ultimately resulting in vertebroplasy for his T1 compression fracture. He was deconditioned and depressed at the time of discharge to hospice. Palliative care followed closely in the management of this patient and helped the family cope with the new diagnosis and complications. Ultimately it was decided not to pursue aggressive diagnostic and therapeutic measures and the patient was discharged to hospice care. . Medications on Admission: (on transfer): HSQ ISS Allopurinol 300mg Latanoprost 1 drop qhs CTX 1g Gentamycin 80mg [**Hospital1 **] Protonix 40mg Iron 325mg [**Hospital1 **] Propoxyphene-APAP prn FA Glipizide 5mg . Meds (at rehab): Lisinopril 20mg Glipizide 5mg Allopurinol 300mg Lasix 40mg ASA 325mg Metformin 500mg Lactulose prn Xalatan eye drop qhs Naprosyn prn Zantac 150mg [**Hospital1 **] FA 1mg Lidocaine patch to back Darvocet prn Prednisone taper Zoladex 10.8mg q3mo (due this mo) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for 12 hours, off for 12 hours. 8. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): At 10 am daily. 9. Oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q3H (every 3 hours) as needed. 10. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days: Please take 4 mg for five days, then 2 mg for five days, then stop. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 13. Methadone 10 mg/5 mL Solution Sig: 0.5 mg PO PLEASE GIVE AT 8AM, 2PM () as needed for PRN pain. 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 17. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. 18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 19. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: 0-12 units Subcutaneous four times a day: per sliding scale. 20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. 21. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day. 22. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day. 23. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: community hospice Discharge Diagnosis: T1 compression fracture Lung mass, likely NSCLC Shoulder Pain Hypertension Diabetes mellitus Prostate Cancer CVA with residual R weakness s/p Nephrectomy GIB Carotid endarterectomy COPD Shoulder OA Glaucoma Discharge Condition: Stable. On 3L O2, to Hospice Discharge Instructions: Discharge to Hospice. Please return to the ED as needed. Followup Instructions: As needed.

[ "162.8", "274.9", "707.14", "416.8", "285.29", "198.5", "241.0", "733.13", "428.20", "584.9", "496", "799.02", "486", "427.31", "428.0", "V10.46", "250.92", "365.9" ]

icd9cm

[ [ [] ] ]

[ "33.27", "38.93", "40.11", "33.24", "88.72" ]

icd9pcs

[ [ [] ] ]

17839, 17883

10322, 15161

247, 296

18134, 18165

4414, 10299

18270, 18284

3360, 3378

15674, 17816

17904, 18113

15187, 15651

18189, 18247

3393, 4395

197, 209

324, 2797

2819, 3043

3059, 3344

61,538

188,323

13366

Discharge summary

report

Admission Date: [**2128-5-6**] Discharge Date: [**2128-5-9**] Date of Birth: [**2066-2-24**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2901**] Chief Complaint: dissection of LAD and diagonal branch Major Surgical or Invasive Procedure: cardiac catheterization and placement of 3 stents in LAD History of Present Illness: Mr. [**Known lastname 15018**] is a 62M w/ CAD, hx MR, HTN, hyperlipidemia who had chest pressure and palpitations on Sunday AM [**4-2**]. He presented to his community physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5310**]. He During denies SOB at rest or on exertion, lightheadedness orsyncope. He denied PND, orthopnea, or peripheral edema. Per documentation, his most recent stress testing was performed in [**2127-2-11**] and demonstrated an EF of 65%. Patient's previous PCI interventions are summarized below. Patient referred to [**Hospital1 18**] for LH catheterization. During the LH cath procedure today, there was evidence of a moderate lesion in the LAD, with flow distal to the wire at 0.72 ration, so it was decided to intervene on the lesion, which was located near diag take off. Catheterization was complicated by dissection occurring at diag and LAD. Three stents were then placed in LAD, no stents to diag, with some flow through diag branch. The patient had persistent chest pain after the procedure. He has 2/10 chest pain at last report. Approach was R radial. The patient was transferred to the CCU for observation s/p complication. On arrival to the floor, patient had 2/10 chest pain, was otherwise comfortable but slightly sedated. Patient was afebrile, 60, 113/68, 19, 94%RA. REVIEW OF SYSTEMS On review of systems, he denies recent fevers, chills or rigors. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. The patient has some sub-sternal chest pain, [**1-23**]. Past Medical History: CAD CARDIAC RISK FACTORS: CAD, Dyslipidemia, Hypertension CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: s/p stenting OM3 (80%) in [**3-15**]. Angiography demonstrated a right dominant coronary circulation. The left main was free of significant obstruction. The LASD had 50-60% bifurcation stenosis involving origin of D1. The LCX had 80% hazy stenosis of a large OM3. The RCA had 50% stenosis of the distal RCA involving the orign of PDA and PL branches. -s/p PTCA of OM3 (for in stent restenosis) with stent to distal LCx and R-PDA [**8-15**] - Mitral regurgitation OTHER PAST MEDICAL HISTORY: Knee replacement, left Back surgery Shoulder surgery Social History: Lives with wife and son, age 25. Retired marine engineer. Tobacco: Quit [**2117**] ETOH: None Contact upon discharge: [**Name (NI) **] [**Name (NI) 15018**], wife. C: will provide Home Care Services: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: ADMISSION EXAM: VS: afebrile, 60, 113/68, 19, 94%RA. GENERAL: Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. R radial wrist guard on. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ DISCHARGE EXAM: Vitals: Tc 98.7 Tm 100.1 BP 97-119/57-76 HR 66-82 RR 18 O2 98 RA GENERAL: Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. R radial wrist guard on. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2128-5-7**] 05:50AM BLOOD WBC-15.7* RBC-4.40* Hgb-13.2* Hct-39.6* MCV-90 MCH-29.9 MCHC-33.2 RDW-13.6 Plt Ct-222 [**2128-5-7**] 05:50AM BLOOD PT-10.7 PTT-29.4 INR(PT)-1.0 [**2128-5-7**] 05:50AM BLOOD Glucose-151* UreaN-13 Creat-0.9 Na-137 K-3.9 Cl-103 HCO3-23 AnGap-15 [**2128-5-7**] 06:30PM BLOOD CK(CPK)-620* [**2128-5-6**] 05:38PM BLOOD CK-MB-32* [**2128-5-7**] 05:50AM BLOOD CK-MB-104* [**2128-5-7**] 11:14AM BLOOD CK-MB-83* cTropnT-1.23* [**2128-5-7**] 06:30PM BLOOD CK-MB-49* MB Indx-7.9* cTropnT-1.08* [**2128-5-6**] 05:38PM BLOOD Mg-1.6 [**2128-5-7**] 05:50AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.6 RELEVANT LABS: [**2128-5-6**] 05:38PM BLOOD CK-MB-32* [**2128-5-7**] 05:50AM BLOOD CK-MB-104* [**2128-5-7**] 11:14AM BLOOD CK-MB-83* cTropnT-1.23* [**2128-5-7**] 06:30PM BLOOD CK-MB-49* MB Indx-7.9* cTropnT-1.08* [**2128-5-6**] C. CATH: 1. Severe single vessel coronary artery disease. 2. Normal systemic arterial blood pressure. 3. Successful PCI of the LAD with BMS complicated by diagonal branch dissection (see PTCA comments). 4. Continue aspirin indefinitely. 5. Continue prasugrel 10 mg daily for minimum 1 month, with 3 months better and 12 months optimal. 6. Monitor closely in CCU. 7. Follow renal function and cycle cardiac enzymes. [**2128-5-7**] ECHO: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to apical hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. DISCHARGE LABS: [**2128-5-9**] 06:58AM BLOOD WBC-11.0 RBC-4.29* Hgb-12.6* Hct-39.0* MCV-91 MCH-29.5 MCHC-32.4 RDW-13.7 Plt Ct-232 [**2128-5-9**] 06:58AM BLOOD PT-11.4 PTT-27.5 INR(PT)-1.1 [**2128-5-9**] 06:58AM BLOOD Glucose-120* UreaN-18 Creat-1.1 Na-141 K-4.4 Cl-106 HCO3-26 AnGap-13 [**2128-5-9**] 06:58AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 Brief Hospital Course: 62M w/ CAD, hx MR, HTN, hyperlipidemia who presented w/ chest pressure and palpitations on Sunday AM [**4-2**]. He had an elective coronary catheterization today that demonstrated a lesion in the LAD, complicated by dissection of LAD. Three stents were placed in the LAD. The patient was transferred to the CCU for observation. # CAD / LAD dissection- Moderate lesion in CAD on this coronary catheterization, with flow ratio of 0.7. Lesion near the first diagonal. During intervention, dissection was appreciated. Three stents were placed in the LAD. Radial approach. Pt was loaded w/ prasugrel 60mg in the cath lab. Patient was transferred to CCU after cath for monitoring where he continued to have chest pain overnight and into the next morning requiring nitro gtt to resolve pain. He had some slight lateral ST-depressions, which may demonstrate some ischemia of the diagonal branch near the lesion. This was thought to be iatrogenic [**1-15**] stenting and possible jailing of the diagonal, so he was started on heparin drip and treated for STEMI. His CE were trended. CK-MB peaked at 104 and trop at 1.23, then trended down. An echo was obtained which showed elongated left atrium, mild RA dilation, mild symmetric LVH with LVEF 50%, and LV apical hypokinesis. RV normal. 1+ MR. [**Name13 (STitle) **] was treated with prasugrel 10mg [**Last Name (LF) **], [**First Name3 (LF) **] 325, and switched from home simvastatin to high dose atorvastatin for treatment of acute STEMI. His metoprolol was restarted and uptitrated to 75mg XL qd. # HTN: Patient normotensive on arrival to CCU. Held beta blocker on arrival since he received XL the previous night and HR was in 50s, then restarted and uptitrated to 75mg qd. # HLD: placed pt on high dose atrovastatin rather than home simvastatin due to STEMI. TRANSITIONS OF CARE: - will f/u with PCP and cardiologist as outpt - will take Aspirin 325mg x1 month and then back to 81mg qd Medications on Admission: CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - one Tablet(s) by mouth at bedtime METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - one Tablet(s) by mouth at bedtime NITROGLYCERIN - (Prescribed by Other Provider) - Dosage uncertain PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - one Tablet(s) by mouth once a day in am SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - one Tablet(s) by mouth at bedtime Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - one Tablet(s) by mouth at bedtime NIACIN - (Prescribed by Other Provider) - 250 mg Capsule, Extended Release - one Capsule(s) by mouth at bedtime OMEGA-3 FATTY ACIDS-FISH OIL [OMEGA 3 FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. nitroglycerin Sublingual 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 3. niacin 250 mg Tablet Sig: One (1) Tablet PO once a day. 4. omega-3 fatty acids-fish oil Oral 5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily): take for 1 month, then go back to taking aspirin 81mg daily. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2* 8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: dissection of LAD s/p stent placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 15018**], You came into the hospital for a cardiac catheterization. The procedure was complicated by injury to one of the coronary arteries. Thus, you were transferred to the cardiac intensive care unit for monitoring over night and did very well and were then transferred to the floor. You did have some chest pain which resolved. The following changes were made to your medications: -STOP taking Plavix -STOP taking Simvastatin -INCREASE Metoprolol XL to 75mg daily -INCREASE Aspirin to 325mg daily for 1 month, then you can resume taking 81mg daily -START taking Prasugrel 10mg daily; DO NOT STOP TAKING THIS MEDICATION WITHOUT FIRST SPEAKING DIRECTLY TO YOUR CARDIOLOGIST -START Atorvastatin 80mg daily (instead of Simvastatin) -START Lisinopril 10mg daily On discharge, please follow up with your cardiologist and primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] below. It was a pleasure taking care of you, we wish you all the best. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Z. Address: [**Street Address(2) 40623**], [**Location (un) **],[**Numeric Identifier 40624**] Phone: [**Telephone/Fax (1) 13254**] Appt: [**5-11**] at 3:15pm Name: [**Last Name (LF) 5310**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: [**Doctor Last Name 37166**],LOWER LEVEL, [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 5315**] Appt: [**5-19**] at 11:20am [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2128-5-9**]

[ "401.9", "272.4", "414.01", "V45.82", "414.12", "424.0" ]

icd9cm

[ [ [] ] ]

[ "00.40", "36.06", "88.56", "00.47", "00.66" ]

icd9pcs

[ [ [] ] ]

10578, 10584

6753, 8562

340, 399

10666, 10666

4460, 4460

11842, 12505

3001, 3115

9597, 10555

10605, 10645

8716, 9574

10817, 11819

6401, 6730

3130, 3770

3786, 4441

263, 302

2896, 2985

427, 2081

4476, 6385

10681, 10793

8583, 8690

2708, 2762

2778, 2880

76,930

164,055

34114+34115

Discharge summary

report+report

Admission Date: [**2108-5-2**] Discharge Date: [**2108-5-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: Bradycardia, Hypotension Major Surgical or Invasive Procedure: Cordis placement History of Present Illness: Mr. [**Known lastname 19371**] is a [**Age over 90 **] yo man with DM2, h/o aortic valve replacement (St. [**Male First Name (un) 923**]), PAD s/p bypass surgery and recurrent LE ulcers who recently was admitted to the [**Hospital1 **] in [**2108-1-29**] following a cardiac arrest at home. The patient was resuscitated within 5 minutes of arresting after being found to be pulseless and apneic by the EMS team. Upon arrival to [**Hospital1 18**], he was cooled per protocol following his cardiac arrest. The patient developed seizure activity in the setting of anoxic brain injury, and neurologically was felt to have a very grim pronosis. Despite this, the patient eventually underwent trach and peg as his family wished to keep him full code and he was eventually weaned off the ventilator. He was then discharged to a long term care facility on XXX following a prolonged hospitalization with minimal responsiveness at baseline. This evening the patient was transferred to [**Hospital1 18**] from his nursing home after being found to be hypotensive to 86/44 and bradycardic to the 40's. There are notes stating the patient had last recieved a dose of carvediolol and lasix approx 12 hours prior to arrival in the ED, and a CXR obtained on [**2108-4-30**] at [**Hospital3 **] showed bilateral large pleural effusions and a possible LUL infiltrate. . In the ED, the patient's V/S were: Tm: 102 (rectal) HR 40, BP 90/40 RR 20 O2 100% on Vent. The patient's BP was noted to drop down to 75/18 in ED. He received: Vancomycin, Zosyn, 1mg Atropine, 60grams of Kayexalate, 1 gram of Calcium gluconate, Insulin/D50, and 2.0L of IVF. A central venous line was placed. HR improved to 60's and SBP improved to 126/42 after receiving treatment for his hyperkalemia. . ROS: Full ROS unable to obtain due to poor mental status. Per ED staff, pt with hematuria in foley catheter Past Medical History: Anoxic brain injury with poor mental status Seizure disorder Atrial Fibrilation Type II Diabetes with neuropathy CKD (Baseline Cr 1.9 - 2.8) Peripheral arterial disease s/p unsuccessful right fem-[**Doctor Last Name **] bypass ([**6-6**]) Coronary artery disease Aortic valve disease, s/p [**Month/Year (2) 1291**] St. [**Male First Name (un) 923**] Chronic systolic CHF (EF 20-30%) Chronic bilateral foot ulcers Anemia MRSA Social History: Widowed; previously lived at home. Currently has been living at [**Hospital1 **]; daughter very active in patient's care ([**Doctor First Name **] [**Telephone/Fax (1) 78656**]); denies tobacco or ETOH use Family History: Father died at 84yrs Mother died at 64 [**1-2**] complications of DM and CAD Physical Exam: Admission Exam: VS: T-97.2 BP 92/43, P -58, R - 20, O2 98% Vent settings: 450/20/10/60% GENERAL: Elderly man, eyes closed not responding to commands, not sedated HEENT: NCAT. Sclera anicteric. No scleral edema. Dolls eyes normal without fixed gaze. NECK: JVP of 8 cm. RIJ Cordis in place. Tracheostomy collar in place. Site appears clean without erythema or drainage. CARDIAC: II/VI systolic murmur heard best at RUSB, otherwise distant heart sounds LUNGS: mechanical breath sounds bilaterally, no wheeze or rales anteriorly ABDOMEN: Soft, non-distended, hypoactive bowel sounds. Guaiac negative per report. EXTREMITIES: No c/c/e. R groin TLC in place with some oozing from the site. LLE with 2+ pitting edema to knee, RLE with 1+ pre-tibial edema to the knee. SKIN: Heel ulcer with clean dressing in place over R and L feet. stage II decubitus ulcer NEURO: R pupil 3 mm and sluggish but reactive PULSES: Right: DP dopplerable Left: DP dopplerable ========================= Discharge Exam: Tmax: 36.5 ??????C (97.7 ??????F)Tcurrent: 36 ??????C (96.8 ??????F)HR: 63 (59 - 70) bpm BP: 113/39(58) {101/32(49) - 122/44(65)} mmHg RR: 19 (6 - 20) insp/min SpO2: 97% I/O: +1.3L GENERAL: Elderly man, eyes open not responding to commands, not sedated HEENT: NCAT. Sclera anicteric. No scleral edema. Dolls eyes normal without fixed gaze. NECK: Tracheostomy collar in place. Site appears clean without erythema or drainage. CARDIAC: II/VI systolic murmur heard best at RUSB, otherwise distant heart sounds LUNGS: mechanical breath sounds bilaterally, no wheezes or rales ABDOMEN: Soft, non-distended, hypoactive bowel sounds. EXTREMITIES: No c/c/e. Bilateral [**1-3**]+ LE edema SKIN: Heel ulcer with dressing in place, slightly bloody but no e/o active bleeding. stage II decubitus ulcer . Macular papular lesions on face PULSES: Right: DP dopplerable Left: DP dopplerable Pertinent Results: ADMISSION LABS: [**2108-5-1**] 11:30PM BLOOD WBC-8.6 RBC-2.83* Hgb-7.9* Hct-25.8* MCV-91# MCH-28.0# MCHC-30.7* RDW-20.1* Plt Ct-167 [**2108-5-1**] 11:30PM BLOOD Neuts-80.9* Lymphs-13.6* Monos-5.1 Eos-0.2 Baso-0.2 [**2108-5-1**] 11:30PM BLOOD PT-49.5* PTT-65.5* INR(PT)-5.6* [**2108-5-1**] 11:30PM BLOOD Glucose-177* UreaN-160* Creat-2.3* Na-144 K-5.9* Cl-104 HCO3-27 AnGap-19 [**2108-5-2**] 09:25AM BLOOD ALT-169* AST-266* LD(LDH)-295* AlkPhos-[**2083**]* TotBili-2.6* [**2108-5-1**] 11:30PM BLOOD CK-MB-3 cTropnT-0.15* [**2108-5-2**] 09:25AM BLOOD CK-MB-4 cTropnT-0.16* [**2108-5-2**] 08:08PM BLOOD CK-MB-NotDone cTropnT-0.16* [**2108-5-1**] 11:30PM BLOOD Calcium-7.8* Phos-4.6* Mg-2.8* ========================== DISCHARGE LABS: [**2108-5-15**] 04:44AM BLOOD WBC-15.6* RBC-2.56* Hgb-7.6* Hct-22.5* MCV-88 MCH-29.6 MCHC-33.7 RDW-17.3* Plt Ct-189 [**2108-5-15**] 04:44AM BLOOD PT-16.4* PTT-43.4* INR(PT)-1.5* [**2108-5-15**] 04:44AM BLOOD Glucose-135* UreaN-276* Creat-5.0* Na-128* K-5.0 Cl-89* HCO3-15* AnGap-29* [**2108-5-14**] 04:01AM BLOOD ALT-34 AST-32 LD(LDH)-237 AlkPhos-706* TotBili-1.0 [**2108-5-15**] 04:44AM BLOOD Calcium-6.8* Phos-9.8* Mg-3.1* ========================== MICROBIOLOGY: Blood Cx [**2108-5-2**]: Proteus mirabilis Blood Cx [**2108-5-3**]: Enterococcus faecium Blood Cx [**5-4**], [**5-6**], [**5-8**]: Negative Growth Blood Cx [**5-10**]: Pending at discharge [**2108-5-2**] 12:50 am BLOOD CULTURE 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------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R ----- _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R Urine Cx [**2108-5-2**]: Proteus Mirabilis Urine cx [**2108-5-4**]: Negative growth URINE CULTURE (Final [**2108-5-5**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. 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------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R Right Foot Wound Cx [**2108-5-10**]: Staph Aureus Coag +, Proteus Mirabilis, Pseudomonas. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PROTEUS MIRABILIS | | PSEUDOMONAS AERUGINOSA | | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S 8 S CEFTAZIDIME----------- <=1 S 2 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R 2 I CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S 8 I 4 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S <=0.25 S OXACILLIN------------- =>4 R PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ 2 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R VANCOMYCIN------------ <=1 S ===================================================== Renal U/S [**5-3**] IMPRESSION: No evidence of hydronephrosis. RUQ U/S [**5-3**] IMPRESSION: 1. Gallbladder filled with gallstones, without evidence of biliary ductal dilatation. 2. Bilateral pleural effusions. RUQ U/S [**5-6**] IMPRESSION: 1. Persistent cholelithiasis without evidence of biliary ductal dilatation. Complete evaluation for gallbladder wall integrity limited by shadowing from stone burden. 2. Stable moderate right pleural effusion. Right Foot Xray [**2108-5-8**]: Findings are concerning for osteomyelitis involving the base of the fifth metatarsal head and cuboid. Further evaluation with MRI is recommended. ECHO [**2108-5-10**]: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %) secondary to extensive anteroseptal and apical hypokinesis/akinesis. There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2108-2-28**], the left ventricular ejection fraction is increased CXR [**2108-5-12**]: There is interval increase in the right pleural effusion, currently moderate to large. A left pleural effusion is also present. There is mild vascular engorgement. Bibasilar opacities are present and might represent a combination of atelectasis with infection. The tracheostomy tip is 7.5 cm above the carina. The right internal jugular line tip is at the level of superior SVC. Brief Hospital Course: [**Age over 90 **] yo man with DM2, PAD, anoxic brain injury after asystolic cardiac arrest, currently ventilator dependent, presents from [**Hospital3 **] with bradycardia, hypotension and hyperkalemia. # Septicemia: Patient presented with hypotension and was also found to be febrile to 102 degrees. His admission WBC count was 8.6 on admission. There was concern for possible pneumonia seen on initial CXR. Hypotension was fluid responsive.He was covered broadly with Vancomycin and Zosyn. A repeat CXR the following morning showed clearance of the questionable opacity and most likely represented atelectasis. The patient was found to have a postive UA that grew proteus, resistant to bactrim and cipro. Blood cultures were subsequently also positive for proteus implying urosepsis. Additionally, LFTs on admission were consistent with an obstructive picture suggestive of possible cholangitis, however, a RUQ U/S was performed that showed stones, but no obstruction so more likely this LFT elevation represented shock liver. Furthermore, blood cultures from [**2108-5-3**] grew GPCs which speciated out to VRE. Vancomycin was then switched to linezolid. Serial cultures up to the time of discharge remain no growth. A transthoracic echocardiogram on [**5-10**] was negative for vegetations. The patient has been intermittently hypothermic requiring a bear hugger at times. He was not required bear hugger for over 72 hours. In addition, blood pressure has remained stable with systolics in the mid 90's to low 100's. He was switched from Zosyn to Ceftriaxone and completed a total 14 day course today, [**2108-5-15**]. He is due to complete a 14 day course of Linezolid on [**2108-5-18**]. On [**2108-5-19**] he should begin a suppressive course of doxycycline 100mg [**Hospital1 **] indefinitely (proteus found to be sensitive to tetracycline). Patient followed by the ID consult service who agreed with this plan of management. # Bradycardia: Patient noted to be bradycardic to the 40's on arrival that appeared to be either slow afib vs junctional rhythm. Bradycardia improved with improvement of hyperkalemia, which was also present on admission. We felt that bradycardia likely related to a combination of metabolic derangements, underlying conduction system disease and active infection. A temporary pacer was considered on admission but deferred given concern of active infection. Heart rate has remained stable in the 50's-60's throughout the duration of his admission. His carvedilol has been held since admission given bradycardia and borderline blood pressure. # Hyperkalemia: On admission potassium 5.9 in the setting of elevated BUN/Cr. He was given calcium gluconate and kayexalate in the ED. Potassium has remained stable without any further intervention but would anticipate this could rise as renal function continues to deteriorate. # Decubitis ulcer/ Heel Ulcer: Patient with chronic ulcers on admission. The ulceration on the foot show exposed tendon and muscle. Xray of the right foot concerning for osteomyelitis involving the base of the fifth metatarsal head and cuboid. A swab of one of the multiple foot eschar's grew out proteus resistant to bactrim and cipro. As noted above, he completed a 14 day course of zosyn/ceftriaxone and will begin a suppressive course of doxycycline since proteus found to be tetracycline sensitive. Patient seen by podiatry who did not feel that the patient is a surgical candidate. Podiatry has recommended silvadene and adaptic dressing dry dressing changes every other day. #Acute on Chronic Kidney Disease: The patient on admission had a creatinine of 2.3. It trended up daily with decreasing urine output. The renal failure was consistent with ATN secondary to hypotension and subsequent ischemia. A renal u/s did not show signs of hydronephrosis. Patient became oliguric shortly after admission. The renal team was consulted and felt that given the patient's very poor prognosis that he was not a candidate for renal replacement therapy. Large bolusus of lasix as well as lasix drip were initiated in order to manage volume overload, however, patient remained resistant and all lasix has been stopped. Given rising hyperphosphatemia he was started on aluminum hydroxide and lanthunum. At time of discharge the patient is nearly anuric. # Elevated LFTs: On admission the patient had elevated LFTs with elevated AP and bilirubin. See above for septicemia management. We felt that this either represented a transient cholangitis versus shock liver. A liver U/S on [**5-3**] and on [**5-6**] showed stones, but no signs of obstruction. As noted above, we covered him empirically with vancomycin and zosyn before culture results available. No Notably, LFTs have trended down and AST,ALT,LDH and Bili are in a normal range at time of discharge. Alk phos remains elevated at 706 though GGT on admission was 644 so this residual elevation could be from bone rather than a GI source. # Supratherapeutic INR: The patient was on anti-coagulation for St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**]. On admission his INR was 5.6 and coumadin was held. He continued to ooze from his trach site, head lesion, and stools. INR initially trended down with coumadin held, but then began to increase likely secondary to poor nutritional status,liver failure and antibiotics. He did receive 2mg Vit K. Coumadin was restarted on [**5-8**] and then again stopped on [**5-10**] due to brisk bleeding from a biopsy site on his foot. Coumadin was restarted on day of discharge given no further bleeding. # Anemia: The patient had an elevated ferritin indicative of anemia of chronic inflammation. Hemolysis labs were checked and unremarkable. Additionally, his stools were light brown, but guaiac positive. He has been transfused a total of 4 units of PRBCs on this admission given hematocrits trending down to the 21 range. He was started briefly on epogen for one week which was stopped given no appreciable effect. Patient was on aranesp prior to admission which it may be reasonable to restart at time of discharge. Likely his continued anemia is related to a combination of his chronic renal failure and a dilutional effect from significant volume overload. Hct has remained relatively stable ar 22-24 since [**5-12**]. # Hematuria: Patient with recurrent hematuria with blood clots intermittently requiring CBI. Likely this was related to traumatic foley placement in the setting of elevated INR. Urology was consulted and agreed with CBI as needed but did not feel further work up of hematuria warranted given his many medical comorbidities. # Maculopapular lesions: Maculopapular lesions on face noted on [**2108-5-14**]. This is felt to be a drug reaction possibly secondary to ceftriaxone which was begun two days earlier and stopped today. Patient started on fexofenadine. Could also consider topical steroids. # Resp Failure/Ventilator Dependency: Patient has been vent dependent since prior to admission. Patient has a tracheostomy in place and has remained comfortable on CIMV. No changes were made to his ventilator settings. Multiple chest xrays, the most recent being [**2108-5-12**], have confirmed proper placement of the tracheostomy tip. # Coronary Artery Disease: Patient is status post cardiac arrest in [**2-6**] and despite cooling protocol was determined to have sustained anoxic brain injury. On this admission, troponin was elevated at 0.15 with CK 30. There were no ECG changes to suggest ischemia. # Seizure Disorder: Patient previously on Keppra but no longer on anti-epileptic medication while at [**Hospital1 **]. No evidence of further seizure activity on this admission. # DM2: Blood sugars remained stable on this admission. He was continued on his outpatient regimen of Lantus and Lispro insulin sliding scale. # Goals of care: Goals of care were addressed on multiple occasions with family. Ethics service consulted for assistance. While family was aware of his poor prognosis they have remained in favor of keeping him full code and exploring all possible medical options for his care. Patient was a FULL code during this admission. Medications on Admission: Glargine 28 Units SQ QHS Lispro sliding scale Vancomycin 1gm IV daily ([**Date range (1) 4859**]) for MRSA + sputum FWF 180 cc q4 Lasix 40 mg po q12 Darbepoetin 100mcg SQ q week Carvedilol 6.25mg q12 MVI po daily Ascorbic acid 500mg po daily Protonix 40 mg po daily Senna 1 tab po q12 Polyvinyl Alcohol-Povidone 1.4-0.6 % 1-2 Drops Ophthalmic PRN (as needed). White Petrolatum-Mineral Oil 42.5-56.8 % Ointment One Appl Ophthalmic PRN (as needed). Warfarin 2.5 mg PO Once Daily - on hold Discharge Medications: 1. Linezolid 600 mg Tablet [**Date range (1) **]: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 2. Doxycycline Hyclate 100 mg Capsule [**Date range (1) **]: One (1) Capsule PO twice a day. 3. Insulin Glargine 100 unit/mL Solution [**Date range (1) **]: Twenty Eight (28) units Subcutaneous at bedtime. 4. Insulin Lispro 100 unit/mL Solution [**Date range (1) **]: see below Subcutaneous once a day: per previous sliding scale. 5. Hydration Please continue Free Water Flushes 180cc q4h per PEG 6. Darbepoetin Alfa In Polysorbat 100 mcg/0.5 mL Pen Injector [**Date range (1) **]: One Hundred (100) mcg Subcutaneous once a week. 7. Ascorbic Acid 90 mg/mL Drops [**Date range (1) **]: One (1) PO DAILY (Daily). 8. Therapeutic Multivitamin Liquid [**Date range (1) **]: One (1) Tablet PO DAILY (Daily). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Drops [**Last Name (STitle) **]: [**12-2**] Ophthalmic once a day as needed for dry eyes. 12. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Month/Day (2) **]: [**12-2**] Ophthalmic once a day as needed. 13. Warfarin 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 14. Lanthanum 500 mg Tablet, Chewable [**Month/Day (2) **]: Three (3) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Aluminum Hydroxide Gel 600 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30) ML PO Q6 (). 16. Fexofenadine 60 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily) as needed for rash. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: - UTI- proteus - Bacteremia- VRE (and proteus) - Chronic osteomyeletis - Acute on Chronic Renal Insufficeny - Shock Liver - resolved Secondary Diagnosis: - Anoxic brain injury - Seizure disorder - Atrial fibrillation - Diabetes - Coronary Artery disease - St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] - CHF, EF 20-30% Discharge Condition: septicemia resolved, hemodynamically stable, afebrile for days Discharge Instructions: You had a slow heart rate and low blood pressure and were hypothermic when you came in. This was due to sepsis, and the bacteria came from a bad urinary infection. This was treated with a 14 day course of antibiotics. You also have chronic osteomyelitis that was not an acute infection, nor was there anything that could be surgically intervened upon. You will be taking chronic suppresive therapy for this chronic osteomyeletis. Your liver function has improved. The kidney function is worsening, but from consultation with the kidney specialist there is no medication indication for dialysis and no forseable improvement. Medication changes: - Take Linezolid for 3 more days - Then start Doxycycline 100mg twice a day - Lasix was discontinued as it was not having any effect on urine output from the status of his kidney disease - Carvedilol was discontinued as he was normotensive for days without it - Protonix was changed to Lansoprazole for easier administration - The Kepppra was discontinued at [**Hospital1 **] prior to admission and it was not restarted while in the hospital. - Lanthanum three times a day was started for hyperphosphetemia - Aluminum hydroxide was added for hyperphosphetemia every 6 hours If there are acute medical issues that arise the physicians at the rehab will decide when it is appropriate to transfer to more acute care. Followup Instructions: The physicians at [**Hospital1 **] will follow as needed. The primary care physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 26735**]. Her number if needed is [**Telephone/Fax (1) 26736**] Completed by:[**2108-5-16**] Admission Date: [**2108-5-15**] Discharge Date: [**2108-5-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: Bradycardia, Hypotension Major Surgical or Invasive Procedure: RIJ Placement/Removal PICC Line Placement History of Present Illness: Mr. [**Known lastname 19371**] is a [**Age over 90 **] yo man with DM2, h/o aortic valve replacement (St. [**Male First Name (un) 923**]), PAD s/p bypass surgery and recurrent LE ulcers who recently was admitted to the [**Hospital1 **] in [**2108-1-29**] following a cardiac arrest at home. The patient was resuscitated within 5 minutes of arresting after being found to be pulseless and apneic by the EMS team. Upon arrival to [**Hospital1 18**], he was cooled per protocol following his cardiac arrest. The patient developed seizure activity in the setting of anoxic brain injury, and neurologically was felt to have a very grim pronosis. Despite this, the patient eventually underwent trach and peg as his family wished to keep him full code and he was eventually weaned off the ventilator. He was then discharged to a long term care facility on XXX following a prolonged hospitalization with minimal responsiveness at baseline. This evening the patient was transferred to [**Hospital1 18**] from his nursing home after being found to be hypotensive to 86/44 and bradycardic to the 40's. There are notes stating the patient had last recieved a dose of carvediolol and lasix approx 12 hours prior to arrival in the ED, and a CXR obtained on [**2108-4-30**] at [**Hospital3 **] showed bilateral large pleural effusions and a possible LUL infiltrate. . In the ED, the patient's V/S were: Tm: 102 (rectal) HR 40, BP 90/40 RR 20 O2 100% on Vent. The patient's BP was noted to drop down to 75/18 in ED. He received: Vancomycin, Zosyn, 1mg Atropine, 60grams of Kayexalate, 1 gram of Calcium gluconate, Insulin/D50, and 2.0L of IVF. A central venous line was placed. HR improved to 60's and SBP improved to 126/42 after receiving treatment for his hyperkalemia. . ROS: Full ROS unable to obtain due to poor mental status. Per ED staff, pt with hematuria in foley catheter Past Medical History: Anoxic brain injury with poor mental status Seizure disorder Atrial Fibrilation Type II Diabetes with neuropathy CKD (Baseline Cr 1.9 - 2.8) Peripheral arterial disease s/p unsuccessful right fem-[**Doctor Last Name **] bypass ([**6-6**]) Coronary artery disease Aortic valve disease, s/p [**Month/Year (2) 1291**] St. [**Male First Name (un) 923**] Chronic systolic CHF (EF 20-30%) Chronic bilateral foot ulcers Anemia MRSA Social History: Widowed; previously lived at home. Currently has been living at [**Hospital1 **]; daughter very active in patient's care ([**Doctor First Name **] [**Telephone/Fax (1) 78656**]); denies tobacco or ETOH use Family History: Father died at 84yrs Mother died at 64 [**1-2**] complications of DM and CAD Physical Exam: Admission: VS: T-97.2 BP 92/43, P -58, R - 20, O2 98% Vent settings: 450/20/10/60% GENERAL: Elderly man, eyes closed not responding to commands, not sedated HEENT: NCAT. Sclera anicteric. No scleral edema. Dolls eyes normal without fixed gaze. NECK: JVP of 8 cm. RIJ Cordis in place. Tracheostomy collar in place. Site appears clean without erythema or drainage. CARDIAC: II/VI systolic murmur heard best at RUSB, otherwise distant heart sounds LUNGS: mechanical breath sounds bilaterally, no wheeze or rales anteriorly ABDOMEN: Soft, non-distended, hypoactive bowel sounds. Guaiac negative per report. EXTREMITIES: No c/c/e. R groin TLC in place with some oozing from the site. LLE with 2+ pitting edema to knee, RLE with 1+ pre-tibial edema to the knee. SKIN: Heel ulcer with clean dressing in place over R and L feet. stage II decubitus ulcer NEURO: R pupil 3 mm and sluggish but reactive PULSES: Right: DP dopplerable Left: DP dopplerable Pertinent Results: ADMISSION LABS: [**2108-5-1**] 11:30PM BLOOD WBC-8.6 RBC-2.83* Hgb-7.9* Hct-25.8* MCV-91# MCH-28.0# MCHC-30.7* RDW-20.1* Plt Ct-167 [**2108-5-1**] 11:30PM BLOOD Neuts-80.9* Lymphs-13.6* Monos-5.1 Eos-0.2 Baso-0.2 [**2108-5-1**] 11:30PM BLOOD PT-49.5* PTT-65.5* INR(PT)-5.6* [**2108-5-1**] 11:30PM BLOOD Glucose-177* UreaN-160* Creat-2.3* Na-144 K-5.9* Cl-104 HCO3-27 AnGap-19 [**2108-5-2**] 09:25AM BLOOD ALT-169* AST-266* LD(LDH)-295* AlkPhos-[**2083**]* TotBili-2.6* [**2108-5-1**] 11:30PM BLOOD CK-MB-3 cTropnT-0.15* [**2108-5-2**] 09:25AM BLOOD CK-MB-4 cTropnT-0.16* [**2108-5-2**] 08:08PM BLOOD CK-MB-NotDone cTropnT-0.16* [**2108-5-1**] 11:30PM BLOOD Calcium-7.8* Phos-4.6* Mg-2.8* MICROBIOLOGY: Blood Cx [**2108-5-2**]: Proteus mirabilis Blood Cx [**2108-5-3**]: Enterococcus faecium Blood Cx [**5-4**], [**5-6**], [**5-8**]: Negative Growth [**2108-5-2**] 12:50 am BLOOD CULTURE 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------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R ----- _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R Urine Cx [**2108-5-2**]: Proteus Mirabilis Urine cx [**2108-5-4**]: Negative growth URINE CULTURE (Final [**2108-5-5**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. 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------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R Right Foot Wound Cx [**2108-5-10**]: Staph Aureus Coag +, Proteus Mirabilis, Pseudomonas. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PROTEUS MIRABILIS | | PSEUDOMONAS AERUGINOSA | | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S 8 S CEFTAZIDIME----------- <=1 S 2 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R 2 I CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S 8 I 4 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S <=0.25 S OXACILLIN------------- =>4 R PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ 2 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R VANCOMYCIN------------ <=1 S ===================================================== Renal U/S [**5-3**] IMPRESSION: No evidence of hydronephrosis. RUQ U/S [**5-3**] IMPRESSION: 1. Gallbladder filled with gallstones, without evidence of biliary ductal dilatation. 2. Bilateral pleural effusions. RUQ U/S [**5-6**] IMPRESSION: 1. Persistent cholelithiasis without evidence of biliary ductal dilatation. Complete evaluation for gallbladder wall integrity limited by shadowing from stone burden. 2. Stable moderate right pleural effusion. Right Foot Xray [**2108-5-8**]: Findings are concerning for osteomyelitis involving the base of the fifth metatarsal head and cuboid. Further evaluation with MRI is recommended. ECHO [**2108-5-10**]: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %) secondary to extensive anteroseptal and apical hypokinesis/akinesis. There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2108-2-28**], the left ventricular ejection fraction is increased CXR [**2108-5-12**]: There is interval increase in the right pleural effusion, currently moderate to large. A left pleural effusion is also present. There is mild vascular engorgement. Bibasilar opacities are present and might represent a combination of atelectasis with infection. The tracheostomy tip is 7.5 cm above the carina. The right internal jugular line tip is at the level of superior SVC. Brief Hospital Course: [**Age over 90 **] yo man with DM2, PAD, anoxic brain injury after asystolic cardiac arrest, currently ventilator dependent, presents from [**Hospital3 **] with bradycardia, hypotension and hyperkalemia. # Septicemia: Patient presented with hypotension and was also found to be febrile to 102 degrees. His admission WBC count was 8.6 on admission. There was concern for possible pneumonia seen on initial CXR. Hypotension was fluid responsive.He was covered broadly with Vancomycin and Zosyn. A repeat CXR the following morning showed clearance of the questionable opacity and most likely represented atelectasis. The patient was found to have a postive UA that grew proteus, resistant to bactrim and cipro. Blood cultures were subsequently also positive for proteus implying urosepsis. Additionally, LFTs on admission were consistent with an obstructive picture suggestive of possible cholangitis, however, a RUQ U/S was performed that showed stones, but no obstruction so more likely this LFT elevation represented shock liver. Furthermore, blood cultures from [**2108-5-3**] grew GPCs which speciated out to VRE. Vancomycin was then switched to linezolid. Serial cultures up to the time of discharge remain no growth. A transthoracic echocardiogram on [**5-10**] was negative for vegetations. The patient has been intermittently hypothermic requiring a bear hugger at times. He was not required bear hugger for over 72 hours. In addition, blood pressure has remained stable with systolics in the mid 90's to low 100's. He was switched from Zosyn to Ceftriaxone and completed a total 14 day course on [**2108-5-15**]. He completed his 14 day course of Linezolid on [**2108-5-18**] and began a suppressive course of doxycycline 100mg [**Hospital1 **] indefinitely (proteus found to be sensitive to tetracycline). Patient followed by the ID consult service who agreed with this plan of management. # Bradycardia: Patient noted to be bradycardic to the 40's on arrival that appeared to be either slow afib vs junctional rhythm. Bradycardia improved with improvement of hyperkalemia, which was also present on admission. We felt that bradycardia likely related to a combination of metabolic derangements, underlying conduction system disease and active infection. A temporary pacer was considered on admission but deferred given concern of active infection. Heart rate has remained stable in the 50's-60's throughout the duration of his admission. His carvedilol has been held since admission given bradycardia and borderline blood pressure. # Hyperkalemia: On admission potassium 5.9 in the setting of elevated BUN/Cr. He was given calcium gluconate and kayexalate in the ED. Potassium began to rise as renal function continued to deteriorate. Renal agreed that dialysis was not medically indicated. # Decubitis ulcer/ Heel Ulcer: Patient with chronic ulcers on admission. The ulceration on the foot show exposed tendon and muscle. Xray of the right foot concerning for osteomyelitis involving the base of the fifth metatarsal head and cuboid. A swab of one of the multiple foot eschar's grew out proteus resistant to bactrim and cipro. As noted above, he completed a 14 day course of zosyn/ceftriaxone and will begin a suppressive course of doxycycline since proteus found to be tetracycline sensitive. Patient seen by podiatry who did not feel that the patient is a surgical candidate. Podiatry has recommended silvadene and adaptic dressing dry dressing changes every other day. #Acute on Chronic Kidney Disease: The patient on admission had a creatinine of 2.3. It trended up daily with decreasing urine output. The renal failure was consistent with ATN secondary to hypotension and subsequent ischemia. A renal u/s did not show signs of hydronephrosis. Patient became oliguric shortly after admission. The renal team was consulted and felt that given the patient's very poor prognosis that he was not a candidate for renal replacement therapy. Large boluses of lasix as well as lasix drip were initiated in order to manage volume overload, however, patient remained resistant and all lasix has been stopped. Given rising hyperphosphatemia he was started on aluminum hydroxide and lanthunum. At time of discharge the patient is nearly anuric. # Elevated LFTs: On admission the patient had elevated LFTs with elevated AP and bilirubin. See above for septicemia management. We felt that this either represented a transient cholangitis versus shock liver. A liver U/S on [**5-3**] and on [**5-6**] showed stones, but no signs of obstruction. As noted above, we covered him empirically with vancomycin and zosyn before culture results available. No Notably, LFTs have trended down and AST,ALT,LDH and Bili are in a normal range at time of discharge. Alk phos remains elevated at 706 though GGT on admission was 644 so this residual elevation could be from bone rather than a GI source. # Supratherapeutic INR: The patient was on anti-coagulation for St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**]. On admission his INR was 5.6 and coumadin was held. He continued to ooze from his trach site, head lesion, and stools. INR initially trended down with coumadin held, but then began to increase likely secondary to poor nutritional status,liver failure and antibiotics. He did receive 2mg Vit K. Coumadin was restarted on [**5-8**] and then again stopped on [**5-10**] due to brisk bleeding from a biopsy site on his foot. Coumadin was restarted. # Anemia: The patient had an elevated ferritin indicative of anemia of chronic inflammation. Hemolysis labs were checked and unremarkable. Additionally, his stools were light brown, but guaiac positive. He has been transfused a total of 4 units of PRBCs on this admission given hematocrits trending down to the 21 range. He was started briefly on epogen for one week which was stopped given no appreciable effect. Patient was on aranesp prior to admission which it may be reasonable to restart at time of discharge. Likely his continued anemia is related to a combination of his chronic renal failure, blood loss from bleeding and a dilutional effect from significant volume overload. # Hematuria: Patient with recurrent hematuria with blood clots intermittently requiring CBI. Likely this was related to traumatic foley placement in the setting of elevated INR. Urology was consulted and agreed with CBI as needed but did not feel further work up of hematuria warranted given his many medical comorbidities. # Maculopapular lesions: Maculopapular lesions on face noted on [**2108-5-14**]. This is felt to be a drug reaction possibly secondary to ceftriaxone which was begun two days earlier and stopped today. Patient started on fexofenadine. Could also consider topical steroids. # Resp Failure/Ventilator Dependency: Patient has been vent dependent since prior to admission. Patient has a tracheostomy in place and has remained comfortable on CIMV. No changes were made to his ventilator settings. Multiple chest xrays, the most recent being [**2108-5-12**], have confirmed proper placement of the tracheostomy tip. # Coronary Artery Disease: Patient is status post cardiac arrest in [**2-6**] and despite cooling protocol was determined to have sustained anoxic brain injury. On this admission, troponin was elevated at 0.15 with CK 30. There were no ECG changes to suggest ischemia. # Seizure Disorder: Patient previously on Keppra but no longer on anti-epileptic medication while at [**Hospital1 **]. Keppra was restarted although patient had no seizure activity, only myoclonic jerks likely related to anoxic brain injury and concommitant uremia. # DM2: Blood sugars remained stable on this admission. He was continued on his outpatient regimen of Lantus and Lispro insulin sliding scale. # Goals of care: Goals of care were addressed on multiple occasions with family. Ethics service consulted for assistance. While family was aware of his poor prognosis they remained in favor of keeping him full code and exploring all possible medical options for his care. Discussion on [**5-21**] eventually led to their agreement to a CPR not indicated order, and morphine for comfort. The patient passed away on [**5-22**]. Patient was a FULL code during this admission then DNR/DNI-CPR not indicated- as of [**2108-5-21**]. The patient passed away on [**2108-5-22**]. Medications on Admission: Glargine 28 Units SQ QHS Lispro sliding scale Vancomycin 1gm IV daily ([**Date range (1) 4859**]) for MRSA + sputum FWF 180 cc q4 Lasix 40 mg po q12 Darbepoetin 100mcg SQ q week Carvedilol 6.25mg q12 MVI po daily Ascorbic acid 500mg po daily Protonix 40 mg po daily Senna 1 tab po q12 Polyvinyl Alcohol-Povidone 1.4-0.6 % 1-2 Drops Ophthalmic PRN (as needed). White Petrolatum-Mineral Oil 42.5-56.8 % Ointment One Appl Ophthalmic PRN (as needed). Warfarin 2.5 mg PO Once Daily - on hold Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Primary diagnosis: - UTI- proteus - Bacteremia- VRE (and proteus) - Chronic osteomyeletis - Acute on Chronic Renal Insufficeny - Shock Liver - resolved Secondary Diagnosis: - Anoxic brain injury - Seizure disorder - Atrial fibrillation - Diabetes - Coronary Artery disease - St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] - CHF, EF 20-30% Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2108-5-30**]

[ "707.14", "V12.04", "038.49", "414.01", "867.0", "V09.80", "599.0", "E930.5", "V46.11", "357.2", "E934.2", "707.19", "412", "585.9", "272.4", "348.1", "518.0", "345.90", "707.06", "730.17", "V43.3", "428.22", "427.89", "780.65", "570", "707.22", "998.11", "995.92", "250.60", "285.1", "038.0", "V44.0", "518.83", "428.0", "427.31", "693.0", "403.90", "707.03", "584.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "96.6", "86.11", "00.14" ]

icd9pcs

[ [ [] ] ]

42981, 42990

34024, 42415

24353, 24396

43402, 43412

28047, 28047

43464, 43498

26988, 27067

42953, 42958

43011, 43011

42441, 42930

43436, 43441

5605, 11362

27082, 28028

3976, 4855

23046, 23763

24288, 24315

24424, 26300

43185, 43381

28063, 34001

43030, 43164

26322, 26749

26765, 26972

29,142

183,208

18497

Discharge summary

report

Admission Date: [**2113-12-15**] Discharge Date: [**2114-1-4**] Date of Birth: [**2071-4-30**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 338**] Chief Complaint: Alcoholic pancreatitis Major Surgical or Invasive Procedure: [**12-14**] Intubation [**12-16**] IVC filter placement [**12-16**] right IJ dialysis catheter placement [**12-19**] right radial arterial line placement [**12-21**] right femoral dialysis catheter re-placement [**12-21**] right IJ central venous line [**1-1**] Percutaneous tracheostomy History of Present Illness: 42 year old male with history of asthma, hypertension, macrocytic anemia, DVT/PE in [**2108**] and erosive gastritis who was admitted to [**Hospital6 33**] with alcoholic pancreatitis and transferred to [**Hospital1 18**] for acute respiratory failure and shock. Briefly, the patient increased alcohol consumption recently to [**12-4**]+ pints daily in the setting of becoming unemployed ([**Month (only) 956**] [**2112**]). Reportedly he had consumed no alcohol for ~ four days prior to admission to OSH [**2113-12-13**] for abdominal pain. The abdominal pain occurred ~9:30am on [**2113-12-13**] after he had a light breakfast (half a bagel). He described the pain as epigastric and tight band-like, with associated nausea, no vomiting. +chills, no fevers or sweats. He received 8 liters of volume resuscitation on the medicine floor but became hypotensive to SBP60s on [**2113-12-14**] and was transferred to the ICU where he was resuscitatied with 10-12 more liters but required norepinephrine to maintain his blood pressures. His creatinine rose to 2.9 (from 1.0), his calcium dropped to 4s, his magnesium also dropped to 1.2. CT abdomen/pelvis (without contrast) showed severe pancreatitis but no evidence of other complications. Because of his history of prior DVT/PE and his hemodynamic instability, LENIs were performed showing a DVT in his right popliteal fossa and the patient was started on heparin gtt (at 1500 units). As his abdomen became more distended, the patient developed respiratory distress and was intubated ~ midnight [**2113-12-15**], sedated with fentanyl (150mcg) and propofol (70mcg) and his norepi was increased (0.9mcg). He was started on bicarb gtt for metabolic acidosis and renal failure. Overnight [**2113-12-15**] from midnight to 7am, the patient was oliguric (130cc) and CXR showed low lung volumes, atelectasis. His labs were notable for Na 121, K 5.9, Cr 5.0, calcium 3.2, magnesium 1.8, CK 8565 and albumin 1.6. He was treated for his hyperkalemia with IV bicarb gtt (100cc/hr), 10 grams IV calcium gluconate, insulin gtt (12 units, for blood sugars 300s). Left IJ and arterial line placed prior to transfer. The patient was started on Vasopressin en route (0.4) and Vent settings were AC18, PS 22, PEEP 10, FiO2 60%. On arrival to the ICU, inital vitals were, T: 97.2 BP: 68/39 P: 113 R: 12 O2: 100% on AC (PMV). The patient's norepi and vasopressin were increased and phenylephrine was started, in addition to fluid boluses. Bladder pressure was 25. Review of systems: Unable to obtain, pt intubated Past Medical History: -Extensive ETOH abuse, drinks 1.5 pints Vodka per day may be 3 pints since the age of 18, admits to black outs and tremors and history of severe DTs - Alcoholic pancreatitis [**6-/2109**]: Requiring intubation X 30 days and tracheostomy; failed extubation twice, difficult to wean [**1-4**] agitation. ?initially intubated for alcohol withdrawal (requiring ativan gtt). Course complicated by coag neg staph bacteremia, PE, erosive esophagitis bleed - ?Neuroleptic malignant syndrome during [**2108**] admission (fevers, elevated CKs, no rigidity, was on haldol) -Erosive gastritis -Asthma -GERD/PUD -HTN -Chronic diarrhea -Macrocytic anemia -s/p MVA [**2095**] with R leg/foot skin grafts -Anxiety/agitation -h/o physical abuse by father -Pulmonary emboli [**2108**] Social History: -Married w/ 4 children (26 year old from first marriage, 10 year old with current wife; wife has 23 year old and 17 year old from own first marriage), worked in construction/truck driving until laid off 2 years ago, +TOB 1ppmonth previously now occasional (<1 pack per week) -Extensive alcohol abuse as noted above, no h/o DTs or hospitalizations for ETOH w/drawal or abuse -per wife, denies any other form of drug abuse Family History: Mother is living and in the [**Name (NI) 86**] area. Father died six years ago in MVA resulting in significant guilt for patient. Obesity, diabetes, CAD. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.2 BP: 68/39 P: 113 R: 12 O2: 100% on AC (PMV) RR12, PEEP 10, TV 450, FiO2 40%, PSV 12 General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD, large neck Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi although diminished breath sounds on right CV: Regular rhythm, tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Distended, firm, ?bowel sounds present (hypoactive), no organomegaly (difficult to assess) GU: Foley in place, scrotal edema Ext: Cold, + DP/PT pulses, no clubbing, cyanosis or edema DISCHARGE: Patient passed away with no evidence of spontaneous breathing, heart sounds, and pupils are non-reactive. Pertinent Results: LABS: On admission: [**2113-12-15**] 05:40PM BLOOD WBC-8.6# RBC-2.20*# Hgb-7.1* Hct-21.5* MCV-97# MCH-31.9 MCHC-33.0 RDW-13.7 Plt Ct-114* [**2113-12-15**] 05:40PM BLOOD Neuts-61 Bands-17* Lymphs-18 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1* [**2113-12-15**] 05:40PM BLOOD PT-11.1 PTT-50.1* INR(PT)-1.0 [**2113-12-15**] 05:40PM BLOOD Fibrino-532* [**2113-12-15**] 05:40PM BLOOD Ret Aut-3.3* [**2113-12-15**] 05:40PM BLOOD Glucose-139* UreaN-48* Creat-5.3*# Na-129* K-4.5 Cl-104 HCO3-17* AnGap-13 [**2113-12-15**] 05:40PM BLOOD ALT-90* AST-300* LD(LDH)-1611* CK(CPK)-8784* AlkPhos-48 TotBili-2.4* [**2113-12-15**] 05:40PM BLOOD Lipase-662* [**2113-12-15**] 05:40PM BLOOD CK-MB-115* MB Indx-1.3 cTropnT-<0.01 [**2113-12-15**] 05:40PM BLOOD Albumin-1.9* Calcium-4.6* Phos-6.6* Mg-1.7 [**2113-12-15**] 05:40PM BLOOD Ferritn-2403* [**2113-12-15**] 05:40PM BLOOD Triglyc-2143* [**2113-12-15**] 05:46PM BLOOD Lactate-3.0* Discharge: None remarkable, patient passed away. Brief Hospital Course: 42 yo M w/ PMH of asthma, HTN, macrocytic anemia, PE/DVT, erosive gastritis, alcoholism, and prior bouts of alcohol-induced pancreatitis requiring ICU stay in [**2108**], transferred from OSH for shock, likely secondary to severe pancreatitis. ACTIVE ISSUES BY PROBLEM: # Shock: Distributive and hypovolemic shock in the setting of severe pancreatitis, resulting in respiratory failure, renal failure, and pressor-dependence. Had questioned possible cardiogenic component, given possibility of PE with known DVT, however echo did not show signs of right heart strain and EF normal. On admission, started on triple pressors with norepinephrine, vasopressin, and neosynephrine, but he was quickly weaned off the neosynephrine. He was aggressively volume resuscitated, getting almost 20L of fluid within the first day of arrival. Lactates normalized. Able to intermittently wean down pressors as he appeared to stabilize after 3-4 days. His pressures improved with fluid removal w/ CVVH. Pt remained on low-dose norepi w/ CVVH until decision was made to move towards comfort measures due after discussion with family. # Acute respiratory failure: Due to combination of shock with aggressive volume resuscitation, ARDS, and extra-thoracic pressure from abdominal distension. PE thought to be unlikely given normal echo, but could not obtain CTA given renal failure. Questioned possible pneumonia on admission-- sputum at OSH grew moraxella and haemophilus at OSH and had positive gram stains here at [**Hospital1 **], however never cultured any organisms from sputum since his arrival at [**Hospital1 **]. Pt completed empiric 8 day treatment for HAP/HCAP with Vancomycin/Zosyn/levofloxacin (finished [**12-20**]). Started on ARDSnet protocol, paralyzed initially for more effective ventilation. Put on APRV for further recruitment and increased oxygenation. Weaned off paralytics. Had numerous episodes of spontaneous desaturations with movements from mucous plugging, bronched on [**12-21**] with removal of thick mucous plugs. Then able to start weaning down APRV settings, down to CMV. Pt had a repeat bronchoscopy to try to remove excess mucus on [**12-29**]. Given his continued illness, Pt had a tracheostomy placed on [**1-1**] by interventional pulmonology. # Acute renal failure: Developed at the OSH, Cr 4.5 on transfer. Etiology likely ATN in the setting of shock and severe hypovolemia. Renal consulted, felt that CVVH would be preferable to HD, given his severe acidosis on admission and his hemodynamic instability. Dialysis catheter placed [**12-16**] and intiated CRRT that day. Unfortunately experienced numerous complications with his CRRT, including malfunctioning catheter (requiring replacement [**12-20**]) and multiple episodes of clotting in the filters. # Fever, leukocytosis: Course complicated by repeated fevers and leukocytosis. Most likely due to continuing pancreatitic inflammation, perhaps formation of abscess/necrosis. Pt had a very thorough workup for possible infectious etiology of his fevers including multiple blood cultures, urine cultures, stool cultures and C diff antigens, and sputum cultures. Pt was treated for HAP/HCAP with Vancomycin/Zosyn/levofloxacin for 8 days. His chest x-ray continued to improve. He never grew any signficant organisms from his urine culture, and he had several c diff stool toxin tests which were all negative. Infectious disease was consulted, which showed # Pancreatitis: Likely [**1-4**] alcoholism. OSH CT abdomen showed no pseudocysts or necrotizing tissue but was limited by having no IV contrast, impressive stranding seen however which may organize in the next several days. RUQ US did not show CBD dilatation or stone. Not continued on heparin despite DVT to avoid causing pancreatic hemorrhage. Triglycerides and lipase trended down. Repeat CT abdomen obtained on [**12-21**] due to rising fevers and WBC count, showed increasing pancreatic inflammation but no evidence of pseudocyst or drainable collection. # Metabolic acidosis: pH 7.03 initially on presentation, likely from elevated lactate, sepsis, renal failure. pH improved with initiation of dialysis and increased ventilation of vent. # Anemia: Likely multifactorial ?????? normocytic with low reticulocyte index suggests ongoing alcohol abuse, chronic illness. Also hemedilution with volume resuscitation. Low grade GI bleed likely given guaiac positive from NG and flexiseal. Heme looked at smear, no evidence of hemolysis. # Thrombocytopenia: Likely splenic sequestration from alcoholic liver disease and hemodilution. Initially had concern for HIT, however timing is not quite right. HIT antibody sent anyway, came back negative. Heme evaluated, thought vanc/zosyn may cause thrombocytopenia, no DIC, few spherocytes but no schistos on smear. Lots of bands w/ toxic granulation consistent w/ sepsis. # Increased bladder pressure: Stable, in mid 20s, 29 right now. KUB suggests ascites; the patient likely third spacing fluid into his abdomen and also likely has liver cirrhosis, malnutrition (low albumin). Concerning for developing abdominal compartment syndrome. Bladder pressure constant at 24. UOP 5 over the last day. # Hyponatremia: Most likely hypovolemic hyponatremia. Given aggressive volume resuscitation, IVF boluses with normal saline as respiratory status tolerates. Trend electrolytes q4 hours # Alcohol abuse: Per the patient, had not had alcohol X 4 days prior to admission. Does have history of DTs and difficult to manage last admission for pancreatitis at [**Hospital1 18**] (in [**2108**]) # Transaminitis: Stable, trending down # Right lower extremity DVT: Seen on LENIs at OSH. IVC filter placed, back on heparin SC. #Afib w/ RVR: started night of [**12-18**], seemed to be in response to respiratory distress. Now back in normal sinus. # Asthma: Stable; significant issues with wheezing last admission in [**2108**] # Depression: Stable, likely self-medicating with alcohol # Hypertension: Currently hypotensive on pressors # Patient passed away [**2114-1-4**] at 0616 with family at bedside following a discussion regarding goals of care. Medications on Admission: Medications on transfer: Acetaminophen 650 q6 hours PRN Albuterol inhaler 2 puffs q4 hours PRN Albuterol nebs q4 hours PRN Maalox 30 mL tweice daily PRN Librium 75mg every 6 hours PRN Dilaudid 2mg q3 hours PRN Ipratropium nebs q4 hours PRN Zofran 4mg q6 hours PRN Celexa 40mg daily Advair 250/50mcg twice daily Folate 1mg daily Fentanyl gtt Heparin gtt Insulin gtt Multivitamin daily Norepi gtt Pantoprazole 40mg IV daily Propofol gtt Sodium bicarb gtt Thiamine 100mg daily Trazodone 100mg daily Vasopressin gtt . Medications at home: * Celexa 40mg daily * Trazodone 100mg qHS * Advair 250/50 1 puff twice daily * Albuterol inhaler PRN shortness of breath Discharge Medications: Patient passed away Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure, renal failure, necrotizing pancreatitis. Discharge Condition: Patient passed away Discharge Instructions: Patient passed away Followup Instructions: Patient passed away

[ "275.41", "530.81", "276.1", "995.94", "276.7", "303.91", "487.0", "789.59", "V12.55", "305.1", "453.41", "585.6", "276.2", "571.2", "693.0", "934.9", "E930.8", "584.5", "E912", "577.0", "287.5", "263.9", "518.81", "535.40", "427.31", "999.32", "571.1", "728.88", "493.90", "E879.8", "403.91", "V12.51", "482.83", "785.59", "285.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "39.95", "38.95", "38.97", "96.72", "38.7", "31.1" ]

icd9pcs

[ [ [] ] ]

13251, 13260

6343, 12501

291, 580

13365, 13386

5342, 5349

13454, 13476

4403, 4559

13207, 13228

13281, 13344

12527, 12527

13410, 13431

13062, 13184

4599, 5323

3124, 3157

229, 253

608, 3104

5363, 6320

12552, 13041

3179, 3948

3964, 4387

13,503

138,078

4699

Discharge summary

report

Admission Date: [**2195-10-27**] Discharge Date: [**2195-11-4**] Service: MEDICINE Allergies: Ciprofloxacin / Sulfonamides Attending:[**First Name3 (LF) 1148**] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: None. History of Present Illness: 88 year old man with a history of asthma, aspiration, CRI, MIBI perfusion defect in [**2191**], Afib, HTN, and recent admission for pneumonia in [**2195-6-1**] who presents with cough productive of bright yellow sputum, that was poorly responsive to albuterol at home, over the two days prior to admission on [**10-27**]. He denied any vomiting, or cough productive of blood-tinged sputum, but endorsed nausea. On the morning of [**10-27**], patient developed increased dyspnea, but denied chest pain, or syncopal episodes. Patient denied any jaw pain or shoulder pain. . At baseline, patient can walk one to two blocks and climb stairs with assistance, per son. During the several days prior to admission, he lost his appetite and felt quite weak. Of note, patient relates that he returned from a 10-day cruise with his son, who had had a cough during the trip. . Patient was brought to the ED by ambulance and had an SaO2 of 77% on room air, that increased to 94% on NRB. He was alert and oriented throughout time in the ED. Chest Xray revealed a new right lower lobe pneumonia, and he was started on ceftriaxone & azithromycin, but later switched to cefepime, flagyl, and azithromycin, as there was concern to cover aspirated flora. In the ED, he also received two courses of combivent nebulized breathing treatments and improved markedly, with SaO2 increasing to the mid 90s on 2L NC. In the ED, he also received ASA, 10mg IV lopressor, and IVF (1.5 L of NS). Elevated troponins to 0.36 (.32-->.36-->.30) and EKG demonstrated changes from before, with t-wave inversions in V2-V6. Cardiology consulted on [**10-28**], patient was loaded with plavix, started on heparin gtt, aspirin, statin, and telemetry. Transferred to the floor on [**10-28**]. Past Medical History: Chronic renal insufficiency Cr [**3-6**] Asthma Atrial fibrillation Hypertension Gout Prostate surgery Kidney tumor bilaterally dx 30yrs ago, s/p partial resection Left Lower Lobe pneumonia Dementia BPH Social History: Patient never smoked, drinks no alcohol and never used drugs. Widowed. He is very functional, performing all ADL's. Family History: Has 2 living brothers and 5 deceased brothers and sisters. [**Name (NI) **] has 5 children and 3 grandchildren, one of his sons has CAD s/p bypass. Physical Exam: Vitals upon admission to MICU ([**2195-10-27**]): Tm:98.9, Tc:96.3, P:67 (64-120), BP:103/35 (120-130s)/(40-90s), RR:23, O2sat: 93% on 35% humidified air . On transfer to Medical Service ([**2195-10-28**]): VS: Tc 95.8, HR: 70, BP: 114/60, RR:20, 94% on 4L O2 Gen: Patient resting comfortably in bed. Pleasant. NAD. Alert and oriented to person, place, date. HEENT: Slightly dry mucous membranes. No scleral icterus. Lungs: Crackles in lower lung fields, with right greater than left. Upper lung fields demonstrate mild rhonchi, bilaterally. CV: Irregularly irregular pulse. Normal S1 and S2. Did not auscultate any murmurs, rubs, or gallops. Abd: Active bowel sounds throughout. No tenderness to palpation. Soft and slightly distended. Rectal: guiac negative brown stool in ICU. Ext: WWP. 2+ bilateral DP and radial pulses, bilaterally. No edema. No cyanosis. Pertinent Results: EKG ([**10-28**]): AF @60, nl axis, Q waves in V1-2, 1mm STE in V2-3, 1mm STD in V4-5 with TWI, low voltage . ECHO ([**10-29**]): The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with septal hypokinesis. Overall left ventricular systolic function is mildly depressed. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2195-6-9**], septal hypokinesis is new. . CXRAY([**11-2**]): Right upper lobe pneumonia has largely cleared. There is new collapse of the left lower lobe, accounting for leftward mediastinal shift. Generalized hyperinflation suggests COPD. Heart size top normal, unchanged. . Video Oropharyngeal Swallowing ([**10-28**]): An oropharyngeal swallowing video fluoroscopy study was performed in collaboration with the speech and swallow department. Varying consistencies of barium were administered under constant fluoroscopic guidance. Patient demonstrated mild-to-moderate penetration with nectar thick and thin liquids. Silent, mild aspiration of thin liquids was seen secondary to spillover of penetration and/or residue in the valleculae and piriform sinuses. . Urine Culture ([**10-27**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML. . Sputum Culture ([**10-28**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. SPARSE GROWTH. . [**2195-11-4**] 06:40AM BLOOD WBC-9.2 RBC-3.75* Hgb-11.1* Hct-32.6* MCV-87 MCH-29.5 MCHC-34.0 RDW-13.5 Plt Ct-389 [**2195-11-3**] 05:10AM BLOOD WBC-10.2 RBC-3.72* Hgb-10.9* Hct-32.0* MCV-86 MCH-29.2 MCHC-34.0 RDW-13.4 Plt Ct-330 [**2195-10-27**] 12:00PM BLOOD WBC-25.2*# RBC-4.06* Hgb-12.2* Hct-35.7* MCV-88 MCH-29.9 MCHC-34.1 RDW-13.4 Plt Ct-208 [**2195-11-3**] 05:10AM BLOOD PT-16.2* PTT-32.0 INR(PT)-1.5* [**2195-10-27**] 12:00PM BLOOD PT-14.9* PTT-31.7 INR(PT)-1.3* [**2195-11-3**] 05:10AM BLOOD Glucose-86 UreaN-25* Creat-1.9* Na-133 K-4.1 Cl-98 HCO3-24 AnGap-15 [**2195-10-27**] 12:00PM BLOOD Glucose-146* UreaN-38* Creat-2.3* Na-138 K-4.6 Cl-101 HCO3-20* AnGap-22* [**2195-11-3**] 05:10AM BLOOD CK-MB-3 cTropnT-0.30* [**2195-11-2**] 05:10AM BLOOD CK-MB-NotDone cTropnT-0.56* [**2195-11-1**] 09:05PM BLOOD CK-MB-NotDone cTropnT-0.62* [**2195-11-1**] 03:00PM BLOOD CK-MB-3 cTropnT-0.68* [**2195-10-27**] 04:45PM BLOOD cTropnT-0.26* [**2195-11-3**] 05:10AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.9 [**2195-10-28**] 02:10AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9 [**2195-10-29**] 08:35AM BLOOD Triglyc-45 HDL-52 CHOL/HD-1.9 LDLcalc-40 Brief Hospital Course: Assessment and Plan: 88 year old man with previous coronary artery disease, CRI, asthma, aspiration, AF, HTN, and previous admissions for pneumonia who presents with acute onset of dyspnea and productive cough over the past two days. Radiographic evidence of new right lower lobe pneumonia and laboratory evidence (troponins) and EKG changes of acute coronary syndrome. . 1) Hypoxia: Patient presented on [**2195-10-27**] in acute respiratory distress, with oxygen saturations to 77% on room air. Chest xray revealed new evidence of pneumonia in right lower lobe. Began ten-day course of azithromycin and flagyl, as sputum culture ([**10-28**]) speciation revealed staph aureus. Azithromycin course will be completed on [**11-5**]. Discontinued flagyl on [**11-2**], as no evdience of anaerobes. Repeat chest Xray on [**11-2**] revealed resolving right sided pneumonia, but slight new collapse in left lower lobe. Will encourage patient to continue respiratory exercises. Patient's oxygen saturations on room air in the mid-90's. On physical examination, slight crackles in lower right lung fields remain, but marked improvement from admission. Cough productive of yellow/white sputum, but developed slight hemoptysis for one day. Believed result of previous heparin administration. By discharge, no evidence of hemoptysis for several days. During hospitalization, continued nebulizers for asthma. . 2) Potential ACS: Despite denying chest pain, nausea, shortness of breath, on admission evidence of lateral ischemia (T-wave inversions in lateral leads, V1-V4, in patient with LAD disease, documented in [**2191**]), consistent with NSTEMI. New septal hypokinesis detected on cardiac echo on [**10-29**]. Discussed possible cardiac catheterization on [**10-30**], but patient and team decided that renal insufficiency and underlying comorbidities obviated benefit of procedure. Started on 48 hours of heparin gtt and clopidogrel. Troponins found to be 0.45 on [**10-29**] and slowly trended up to 0.68 on [**11-1**], but decreased to 0.19 on evening of [**11-2**]. During admission, cardiology team consulted. On [**11-1**], in the setting of elevated troponins, recommended starting low dose beta blocker, with HR goal in the 60's. Restarted plavix, metoprolol 12.5, and began isosorbide 30mg on [**11-1**]. Of note, episode of asymptomatic bradycardia on [**10-30**], when low dose beta blocker was administered, so cardiac parameters followed. In the setting of new, confirmed coronary artery disease, discontinued diltiazem and amlodipine, and initiated beta blocker. Titrated beta blocker for goal heart rate in the 60's. No evidence of any worsened asthma. On [**11-1**], patient developed NSVT, lasting for 6 beats. Electrolytes repleted to ensure K>4.0 and Mg>2.0. Continued patient's aspirin and initiated atorvastatin 40mg PO qd. . 3) UTI: During [**2195-6-1**] hospitalization, patient's urine positive for pseudomonas. Urine culture on admission revealed pseudomonas. Initially treated with cefepime during current admission, but switched to ciprofloxacin when sensitivities determined. Will continue ten day course of antibiotic until [**2195-11-8**]. . 4) Chronic renal failure: Patient's baseline creatinine is near 2.0. On admission, creatinine 2.3, but returned to baseline of 1.9 on discharge. Initially increased, most likely due to decreased intravascular volume status. Improved with IV hydration during stay. . 5) Atrial Fibrillation: Patient remained in atrial fibrillation during hospitalization. Monitored on telemetry. Rate controlled with metoprolol 12.5mg [**Hospital1 **]. Thrombosis risk reduction with aspirin and clopidogrel. Ideal heart rate in the 60's for patient's with coronary artery disease. Previous notes document fall risk. In reviewing the medical record, risk for anticoagulation is previous GI bleed. Need to consider anticoagulation in this patient on out-patient basis. . 6) BPH: Continue flomax and finasteride. Medications on Admission: -Amlodipine 10 mg qd -Diltiazem HCl 180mg qd -Fluticasone 110 mcg 2 puffs [**Hospital1 **] -Atovent 2 puffs qid -Aspirin 325 mg qd -Finasteride 5 mg qd -Flomax 0.4mg qhs -Prevacid 30mg qd -Centrum 1 tab qd -B12 1000mcg qd -Folic acid 800mg qd -Probenecid 500mg qd Discharge Medications: 1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 2 days. Disp:*2 Capsule(s)* Refills:*0* 2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Probenecid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Aspiration Pneumonia Non ST-elevation myocardial infarction . Secondary: Chronic renal insufficiency asthma atrial fibrillation hypertension gout benign prostate hypertrophy Discharge Condition: Stable. Discharge Instructions: **You were hospitalized for a pneumonia that was most likely caused by aspiration. You received antibiotics that you will need to continue for the next several days. In addition, you were treated for a urinary tract infection, that was also treated with an antibiotic. ** A video swallowing test demonstrated that you can only tolerate THINH FLUIDS AND SOFT SOLIDS. You should continue this regimen to prevent further risk of aspiration pneumonia. **You have a history of heart disease and you sustained some damage to your heart, as demonstrated by cardiac ECHO. You were treated to prevent further damage and are being discharged home some new medications, while some of your other medications were discontinued. You will be started on atorvastatin, plavix (clopidogrel), metoprolol, and isosorbide, all medications that are cardio-protective. YOU ARE DISCONTINUING DILTIAZEM and AMLODIPINE. **You will need to call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19819**], to schedule an appointment in the next week. In addition, you need to arrange an appointment with a cardiologist. ** You also need to see a dermatologist for the lesion on your back. **You will be given prescriptions for 2 medications to take for your pneumonia and UTI: ciprofloxacin (started on [**2195-10-31**] and you will complete 10 day course on [**2195-11-8**]), azithromycin (started on [**10-28**] and you will complete 10 day course on [**2195-11-5**]). **If you develop chest pain, shortness of breath, or any other concerning symptoms, please call your doctor immediately or go to the ED. Followup Instructions: **You need to schedule an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19819**] ([**Telephone/Fax (1) 19820**]), in the next week. ** You will need to arrange an appointment with a cardiologist in the next week. You can discuss this issue with Dr. [**First Name (STitle) 19819**].

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icd9cm

[ [ [] ] ]

[]

icd9pcs

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12285, 12343

6328, 10345

246, 253

12570, 12580

3476, 6305

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44139

Discharge summary

report

Admission Date: [**2180-9-13**] Discharge Date: [**2180-9-23**] Service: MEDICINE Allergies: Codeine / Demerol Attending:[**First Name3 (LF) 99**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation, central venous cathaterization History of Present Illness: [**Age over 90 **]F female with complicated medical hx including dementia, GERD, spinal stenosis/ chronic pain, HTN, OA, h/o DVT, recurrent UTIs with recent visits for UTI and possible pna, C. Difficile colitis s/p treatment, presenting with altered mental status. The patient was difficulty to arouse this morning per her daughter. . Over last few days, has not been herself. Had heart rates in 120s. This AM, pt was not responsing. Dtr initially waited thinking she was sleeping then called PCP who suggested that she come to ED. Dtr then called EMS. . Per daughter, patient has not had cough, URI symtpoms, chest pain, fever, chills, abdominal pain, vomiting, or diarrhea. Endorsed shortness of breath. Daughter also states that pt has been weak and unable to walk for last week. . In the ED, initial VS were: 96.6 74 154/74 12 95% ra. Exam was uncooperative with exam. Lab significant for lactate of 2.2, WBC 11, negative CEs and BNP of 2230. EKG NSR at83, LAD, TWF laterally. CXR showed ? LLL consolidation. Head CT was negative. UA was negative. . Received: - Today 17:12 CeftriaXONE 1g - Today 19:25 Azithromycin 500mg - Today 19:41 Acetaminophen 1300mg PR . Initially had bed on general medicine floors however then became hypotensive to 80s. Conversative with fluids initially then bolused with 3L with 100s. Became hypoxic to 90s on 2L then went to NRB then back down to 2L NC. Also was initially altered however was more conversant after receiving fluid. Also becamwse febrile to 103 and cultures were taken. . On arrival to the MICU, pt was moaning and yelling. Upon translation via daughter, pt denied pain however stated that the nasal canula was uncomfortable. She also complained of headache without photophobia, neck stiffness, or nausea. Past Medical History: - Recurrent UTIs - GERD (gastroesophageal reflux disease) - Ventral hernia - Dementia - Recurrent urinary tract infection - Pulmonary Nodules/Lesions, Multiple - Diverticulosis - Fatty Liver - Inguinal Hernia Unilateral - Lumbar Spinal Stenosis - Chronic Pain - CARDIOVASC DISEASE, UNSPEC - SPINAL STENOSIS - CERVICAL - OSTEOARTHRITIS, LOCALIZED SECONDARY - SHOULDER - OSTEOARTHRITIS, LOCALIZED PRIMARY - KNEE - THROMBOPHLEBITIS - DEEP, LOWER EXTREM - ANEMIA - VITAMIN B12 DEFIC - ANEMIA - IRON DEFIC, UNSPEC - HYPERTENSION - ESSENTIAL, UNSPEC - GOITER - NONTOXIC MULTINODULAR Social History: Lives with daughter. Dependent on most ADLs Family History: unknown. Physical Exam: General: uncooperative with exam, moaning and yelling HEENT: Would not open eyes or mouth Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: on right lateral cubitus positioning, decreased breath sounds on left base, crackles throughout right lung fields Abdomen: soft, non-tender, obese, bowel sounds present, no organomegaly GU: foley in place Ext: cool 2+ pulses, no clubbing, cyanosis; trace to 1+ pitting edema to mid shins, feet skin appeared slightly mottled. Neuro: uncooperative with exam Pertinent Results: [**2180-9-13**] 01:50PM BLOOD WBC-11.1*# RBC-3.71* Hgb-12.3 Hct-39.2 MCV-106* MCH-33.2* MCHC-31.4 RDW-14.7 Plt Ct-380 [**2180-9-13**] 01:50PM BLOOD Neuts-83.9* Lymphs-11.9* Monos-3.8 Eos-0.2 Baso-0.2 [**2180-9-14**] 04:17AM BLOOD WBC-17.6*# RBC-3.83* Hgb-12.6 Hct-41.2 MCV-108* MCH-32.9* MCHC-30.5* RDW-14.6 Plt Ct-390 [**2180-9-15**] 12:27AM BLOOD WBC-23.5* RBC-3.56* Hgb-11.8* Hct-37.0 MCV-104* MCH-33.0* MCHC-31.8 RDW-14.6 Plt Ct-419 [**2180-9-17**] 04:22AM BLOOD WBC-6.7 RBC-3.52* Hgb-11.1* Hct-36.3 MCV-103* MCH-31.7 MCHC-30.7* RDW-14.7 Plt Ct-310 [**2180-9-13**] 01:50PM BLOOD Glucose-135* UreaN-26* Creat-0.7 Na-139 K-5.5* Cl-101 HCO3-33* AnGap-11 [**2180-9-14**] 04:17AM BLOOD Glucose-122* UreaN-24* Creat-0.7 Na-143 K-4.9 Cl-107 HCO3-28 AnGap-13 [**2180-9-17**] 04:22AM BLOOD Glucose-92 UreaN-18 Creat-0.7 Na-145 K-3.7 Cl-109* HCO3-25 AnGap-15 [**2180-9-15**] 05:45AM BLOOD ALT-21 AST-31 LD(LDH)-336* AlkPhos-102 TotBili-0.2 [**2180-9-13**] 01:50PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2230* [**2180-9-14**] 04:17AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.4 [**2180-9-14**] 09:46PM BLOOD Calcium-8.6 Phos-3.7 Mg-2.4 [**2180-9-14**] 04:17AM BLOOD Digoxin-<0.2* [**2180-9-14**] 04:17AM BLOOD Phenoba-<1.2* [**2180-9-13**] 01:50PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2180-9-14**] 08:09PM BLOOD Type-ART pO2-93 pCO2-77* pH-7.27* calTCO2-37* Base XS-4 [**2180-9-14**] 09:56PM BLOOD Type-ART pO2-134* pCO2-95* pH-7.17* calTCO2-37* Base XS-3 [**2180-9-15**] 12:38AM BLOOD Type-ART pO2-373* pCO2-29* pH-7.58* calTCO2-28 Base XS-6 [**2180-9-16**] 06:33PM BLOOD Type-ART Temp-35.7 pO2-62* pCO2-24* pH-7.42 calTCO2-16* Base XS--6 Intubat-INTUBATED [**2180-9-13**] 10:50PM URINE bnzodzp-NEG barbitr-POS opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [**2180-9-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL {CLOSTRIDIUM DIFFICILE} Brief Hospital Course: [**Age over 90 **]yoF with history of vascular dementia, GERD, recurrent UTIs, recently PNA and C. diff infection who presented with altered mental status and hypotension and transferred to the MICU due to respiratory distress. MICU Course: In the MICU, the pt was treated with broad spectrum antibiotics for PNA, however when CTA failed to demonstrate e/o infiltrate, antibiotics were discontinued. Leukocytosis worsened and c.diff toxin returned positive on [**9-15**]. Patient was started flagyl with plan to treat for 14 days from end of broad spectrum antibiotics (end date [**2180-9-29**]). On [**9-14**], the patient developed hypercarbic respiratory failure requiring intubation. Just prior to the event, the patient was given small amount of IV ativan for agitation and for concern of barbituate withdrawal as a source for her tachycardia. The patient had urine tox positive for barbituates; the family noted that patient was taking many sedating Russian medications with phenobarbital, digitalis and belladonna. Her respiratory failure was believed to be secondary to sedating medications. She was extubated on on [**9-16**] without issue. . The patient was transferred to the floor on [**9-16**] after stabilization. Several hours after reaching the floor, the patient developed respiratory distress while being shifted in bed. She was placed on a NRB, and sats dipped to low 70s. She was given lasix IV 20 mg X 1. A respiratory code was called and she was transferred to the MICU after intubation. On arrival to the MICU she was hypotensive to SBP mid-70s and was given fluid boluses and started on pressors. She was restarted on vancomycin/zosyn due to concern for possible aspiration event. On [**9-21**] she passed SBT and was extubated. However she continued to be somnolent despite discontinuing all sedative meds, not following commands and opening eyes only to sternal rub. She had O2 desaturations to the high 70s and was placed on NRB with improvement in oxygenation. Her BP decreased to 70s-80s and she was started on phenylephrine. Over the following 2 days her CXR continued to show increased pulmonary edema and she had decreased urine output. Her mental status continued to decline and she lost corneal reflexes. Repeat CXR on [**9-23**] showed left lung collapse. Family expressed that they did not want her to be re-intubated and her code status was changed to DNR/DNI, and then ultimately changed goals of care to CMO. Pressors were discontinued. She passed away on [**2180-9-23**] with family present. Family declined autopsy. Medications on Admission: Hydrochlorothiazide 12.5 mg Oral Capsule Take 1 capsule daily - Gabapentin 300 mg Oral Capsule take 3 daily - Desoximetasone 0.05 % Topical Cream apply twice daily to groin rash. stop medication as soon as possible after rash clears. - Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) 1 capsule twice daily - Ketoconazole (NIZORAL) 2 % Topical Cream Apply to affected area twice daily until infection resolves - Tramadol 50 mg Oral Tablet take 1-2 tablets 3 times daily as needed for pain - Diclofenac Sodium (SOLARAZE) 3 % Topical Gel apply three times daily - Miconazole Nitrate (ZEASORB AF) 2 % Topical Powder twice a day - Cyanocobalamin, Vitamin B-12, (VITAMIN B-12) 1,000 mcg/mL Injection Solution Inject 1000mcg IM monthly - Metoprolol Succinate 50 mg Oral Tablet Extended Release 24 hr Take 2 tablets daily - Amlodipine 2.5 mg Oral Tablet Take 1 tablet daily - RIBOSE, BULK, MISC Ribose (d-ribose) dose unknown-powder three times daily - Prochlorperazine Maleate (COMPAZINE) 5 mg Oral Tablet take 1 tablet up to every 8 hours as needed for nausea - VITAMIN D 1,000 UNIT TAB (CHOLECALCIFEROL) take 1 tablet daily - CALCIUM ORAL take 2 tablet daily - L-CARNITINE ORAL (LEVOCARNITINE) take three times daily - COENZYME Q10 200 MG CAP (UBIDECARENONE) take three times daily - VITAMIN B-12 ORAL (CYANOCOBALAMIN) None Entered - FERGON 240 MG (27 MG IRON) TAB (FERROUS GLUCONATE) take 1 tablet qd 1. Sedalgin (for pain): codeine 10, caffeine 50, phenacetin 200, ASA 200, phenobarbitol sodium 25 2. Pumpan (for palpitations): crataegus, arnica, kalium carbonleum, convallaria, digitalis 3. Persen: (valetiana, menthol 4. Melatonin 5. Valocordin: phenobarbitoal, ethylbromizovalerianate, peppermint oil 6. [**Location (un) 94725**] 7. Just started 3 days ago: Insomnia (for insomnia): hyoscyamus [**Country 11730**], ignatia [**Last Name (LF) **], [**First Name3 (LF) **] phos Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

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9751, 9760

5246, 7816

245, 289

9823, 9832

3363, 5223

9884, 9890

2753, 2763

9781, 9802

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9856, 9861

2778, 3344

184, 207

317, 2075

2097, 2676

2692, 2737

68

108,329

9139+56002+56004

Discharge summary

report+addendum+addendum

Admission Date: [**2174-1-4**] Discharge Date: [**2174-1-19**] Date of Birth: [**2132-2-29**] Sex: F Service: MEDICINE Allergies: Nevirapine / Abacavir / Ampicillin / Tylenol / Zidovudine Attending:[**First Name3 (LF) 2145**] Chief Complaint: increased lower extremity swelling. Concern about ability to care for self at home. Major Surgical or Invasive Procedure: L femoral central line, R internal jugular central line, CVVH History of Present Illness: 41F with advanced HIV/AIDS (last CD4 5 in [**8-23**], unknown viral load) and cardiomyopathy (EF 20%) who was recently hospitalized at [**Hospital1 18**] [**Hospital Ward Name **] for bibasilar pneumonia for which she completed a full 2 week course of levo and flagyl. She is a poor historian. She notes having leg swelling at that time and was discharged to home 2 days ago with [**Male First Name (un) **] stockings. She says she has been wearing her [**Male First Name (un) **] stockings since leaving the hospital. She returned to the ED last night with complaints of continued leg swelling and feeling week for the last two weeks. She denies SOB, DOE, orthopnea, PND. She denies eating fast food or salty foods, but then states she has been eating chicken noodle soup from a can. She denies fever/chills. Denies cough but has been spitting up clear fluid that looks like saliva. Denies dysphagia. She has only got half of her prescriptions since discharge from hospital, and says she has taken Bactrim, immodium, digoxin, and pain medication. She does not know the name, number, or type of HAART drugs that she takes, and only identifies Bactrim as her "HIV medicine." . In the ER the patient received 10IV lasix, and a femoral line was placed (she has VERY difficult access and last picc just d/ced two days ago). . She denies feeling unsafe at home (although by report last night this is her reason for admission). States she has her daughter and [**Name (NI) 269**] to help her. She has occasional abdominal pain across the top of her abdomen nad occasional associated nausea, but none right now. No other complaints. Past Medical History: HIV/AIDS - h/o PCP x 2, MAC, cervical dysplasia, HSV anal ulcers. CD4 ct 5 in [**2173-8-19**], viral load unknown cardiomyopathy - EF 20% [**2173-12-28**] new renal insufficiency since [**2173-11-18**] with baseline cr mid 2s depression asthma Social History: Divorced. Lives in apartment with 13 yo daughter. [**Name (NI) **] [**Name2 (NI) 269**] at home. Pt reports feeling safe at home. Ambulates with walker. Denies tobacco, alcohol, or other drug use. Family History: CAD: mother died age 57 MI Physical Exam: VS 97.7 112/68 18 on room air (O2 sat not yet checked) Gen: sitting up in bed, very quiet speaking, NAD, pleasant HEENT: NCAT Neck: no LAD, no JVD Cor: s1s2, +s3, no r/g/m, tachy Pulm: CTA, decreased BS at B bases L>R, very mild crackle at R base Abd: soft, NTND, +bs, no hsm Ext: [**Male First Name (un) **] stockings on, 2+PT pulses, 1+ pitting edema through, R femoral line line in place, sanguinous drainage on dressing, stockings to knees Skin: no rashes GU: foley catheter wtih yellow urine in bag Pertinent Results: -BNP 64,499. Digoxin 0.8. Creatinine 2.1 (lower than new baseline since [**Month (only) **]). Hct 27.5 ( above baseline). Albumin 2.2. -CXR: persistant bibasilar pna with persistant bilateral effusions. -Echo LVEF 20%, small-mod pericardial effusion with no tamponade, global hypokinesis on [**2173-12-28**] Brief Hospital Course: Ms. [**Known lastname 31473**] is a 41 yo woman with end stage AIDS, HIV cardiomyopathy with last EF [**12-24**] <20%, and HIV nephropathy with very low UOP and nephrotic range proteinuria who was hospitalized in [**Month (only) 1096**] for 3 weeks with bibasilar pneumonia for which she was given a 2 week course of levo/flagyl. She was discharged with stable LE edema and on an HIV salvage regimen consisting of 5 HAART meds. She returned to the hospital one day after discharge complaining of possible increased LE edema, which was found to be unchanged from prior on exam. She seemed to feel "unsafe" at home but was unable to elaborate on that. Cultures from previous hospitalization returned at that time with [**Doctor First Name **] in sputum and stool and she was started on treatment. . Five days after admission, the patient was prepared for discharge to a [**Hospital1 1501**] with HIV specialty floor, when she complained of new onset SOB, RR 30s-40s x hours, and eventual hypoxia. ABG revealed lactic acidosis with lactate of 16 and ph of 7.19. FS at that time was 24. This was all believed to be lactic acidosis caused by HIV meds (zidovudine) interfering with mitochrondrial function. She recieved 1 amp NaHCO3, 1 amp D50 and 500 cc NS bolus. . She was transferred to the ICU, where she required CVVH for lactic acidosis and D10 for hypoglycemia. She developed multi-system organ failure, including liver failure, increased oliguria, pancreatitis, and hemolysis. She responded well to CVVH and after family meeting CVVH was discontinued and decision was made not to restart dialysis of any sort even if her lactic acidosis were to recur. She was treated with aztreonam and vanco by levels for bilateral pneumonia. The patient expressed an interest in going to hospice. A palliative care consult was ordered and pt was transferred to floor. . The patient's 13 year old daughter is not aware of her mother's HIV status and the patient has not been forthcoming about her current prognosis. A family meeting with the patient, Drs. [**Last Name (STitle) 31478**] and [**Name5 (PTitle) 31479**] social worker [**Name (NI) 30513**], the patient's daughter [**Name (NI) 31480**], her daughter's cousin, and Ms. [**Known lastname 31476**] sister-in-law. At this meeting the family was updated on the patient's generally poor prognosis. The pt decided that she would like to go to hospice, and understood the goals of hospice. The pt was seen by Palliative care and she was placed in a hospice of her choice. The pt stated she would like to complete the course of PO antibiotics which were started in the MICU. Her central line was pulled, uneventfully, on the day of discharge. The patient was discharged on cefpodoxime and azithromycin for 4 days to complete her course of antibiotics for pneumonia. The pt will be continued on her digoxin for heart failure, ipratropium nebulizer for shortness of breath, Bactrim for PCP prophylaxis, [**Name9 (PRE) 31481**] for hyperphosphatemia secondary to renal failure and lasix for shortness of breath and painful lower extremity edema. . The pt reported that she will inform her family of the tranfer to the hospice facility. Her brother was present for this conversation. Medications on Admission: (unclear which meds pt was taking for the 2 days between discharge from hospital and this admission but she reports not missing any Bactrim doses) (HAART meds are "salvage Tx") bactrim megace 40 qday ritonavir 200 [**Hospital1 **] lamivudine 100 qday zidovudine 300 [**Hospital1 **] tipranavir 500 [**Hospital1 **] tenofovir 300qwed, sat loperamide 2mg qid prn diarrhea digoxin 125mcg qOd azithromycin 600mg qwed bactrim ss qday oxycodone [**4-27**] q6h prn pain protonix 40qday Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO qday prn as needed for shortness of breath or painful edema. 7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 4 days. 8. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital6 2542**] - [**Hospital1 1474**] Discharge Diagnosis: HIV/AIDS Cardiomyopathy (EF 20%) [**2173-12-28**] New renal insufficiency (baseline Cr 2s) GERD Asthma Depression Discharge Condition: Stable Discharge Instructions: You are being transferred, at your request, to a hospice. Goals of care are to continue meds by mouth that will help you feel better or prevent further infections, but no IV's, labs, or fingersticks will done. Followup Instructions: none [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2174-1-18**] Name: [**Known lastname 5477**],[**Known firstname **] Unit No: [**Numeric Identifier 5478**] Admission Date: [**2174-1-4**] Discharge Date: [**2174-1-19**] Date of Birth: [**2132-2-29**] Sex: F Service: MEDICINE Allergies: Nevirapine / Abacavir / Ampicillin / Tylenol / Zidovudine Attending:[**First Name3 (LF) 839**] Addendum: The patient was discharged with 600mg Azithromycin (admission medication) for MAC prophylaxis. Discharge Disposition: Extended Care Facility: [**Hospital6 5479**] - [**Hospital1 328**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 841**] Completed by:[**2174-1-18**] Name: [**Known lastname 5477**],[**Known firstname **] Unit No: [**Numeric Identifier 5478**] Admission Date: [**2174-1-4**] Discharge Date: [**2174-1-19**] Date of Birth: [**2132-2-29**] Sex: F Service: MEDICINE Allergies: Nevirapine / Abacavir / Ampicillin / Tylenol / Zidovudine Attending:[**First Name3 (LF) 3930**] Addendum: After discussion with Dr. [**Last Name (STitle) 1629**], it was decided that the patient will not be discharged on MAC prophylaxis (Azithromycin) and Digoxin. This was to prevent digoxin toxicity in light of declining renal function (pt will not have any lab testing done at hospice). Also, the pt did not have any evidence of MAC on discharge and will continue her 4 day course of antibiotics for pneumonia. Her goals of care are comfort measures only Discharge Disposition: Extended Care Facility: [**Hospital6 5479**] - [**Hospital1 328**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3931**] Completed by:[**2174-1-19**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.15" ]

icd9pcs

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40244

Discharge summary

report

Admission Date: [**2183-12-16**] Discharge Date: [**2184-1-9**] Date of Birth: [**2104-2-9**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4891**] Chief Complaint: Acute stroke, Aspiration PNA, Rhabdomyolysis Major Surgical or Invasive Procedure: Mechanical Intubation PEG tube placement PICC line placement History of Present Illness: Ms [**Known lastname **] is a 79 year-old female with history of schizoaffective disorder, history of stroke, and hypothyroidism who was admitted to the cardiology service on [**12-16**] with an NSTEMI and an acute stroke after a fall on the night of [**12-15**]. Per the admit note she tried to go to the bathroom around 1 am, tripped and fell and wasn't able to get up. She was found in a prone position by an aide. Upon arrival in the ED she was reportedly dysarthric and neurology was consulted due to concern for stroke. She was also noted to have [**3-2**] upper extremity strength. CT head and spine were initially negative for any acute process. EKG showed no ischmic changes, however trop returned 0.68 with a CK of 3362. She was admitted to [**Hospital1 **] for NSTEMI on a heparin gtt. . On the floor she continued to have dysarthric speech. MRI of her brain was ordered which did show bilateral subacute ischemic changes in both basal ganglia and body of the caudate nucleus on the right with no hemorrhagic changes. CK's trended upwards, concerning for rhabdo and her Cr on admission was elevated, but has since trended downwards with IVF. Cardiology felt that her troponin leak was likely due to demand ischemia. Her heparin gtt was stopped shortly after admission. Neurology consult team has been following. . Ortho spine had also been consulted due to the fall and she has had CT of her C-spine which [**Last Name (un) **] significant canal stenosis which could predispose to cord trauma even after minor injury so a MRI of c-spine was done to rule out acute cord injury which was limited due to motion artifact. Ortho spine did subsequently clear her cervical spine in the am of [**12-17**] and her collar was removed. . She was noted to have paradoxical breathing which initially improved after her cervical collar was removed, which subsequently worsened. With a respiratory rate is in the mid 30's and 95% oxygen saturation on a face mask, she was found to have a WBC 20K and repeat CXR showed right-sided opacity concerning for possible aspiration PNA. She was started on vanc, cefepime, and flagyl prior to transfer to the medical ICU. . On arrival to the MICU she continued to have paradoxical breathing and was very lethargic. She was subsequently stabilized, and transferred back to the medical floor for continued management. Past Medical History: # Hypothyroidism # Schizoaffective disorder # Multipel lacunar infarcts # Left Cataract # Mamogram: [**2183-11-18**]: Possible developing density of the R breast laterally on C view. Increasing prominence of axillary tail lymph nodes. Social History: She lives in an [**Hospital3 **] facility. Participates in adult daycare. Has son in the area, and sister-in-law is HCP in [**Name2 (NI) **] state. Family History: Brother with MI in 50's or 60's. Physical Exam: Admission Exam to [**Hospital1 1516**] VS: T=95.8 BP=136/55 HR=84 RR=20 94O2 sat= 2L GENERAL: Obsese female with red face, peri-orbital edema HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, with mild pallor, no cyanosis of the oral mucosa. No xanthalesma. NECK: JVP was unassessed due cervical collar. CARDIAC: Faint S1 and S2, no S3 or S4, no murmurs appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Patient had an end expiratory wheeze, with wheezes appreciated anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. DP 2+ SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: L/R carotid could not be assessed due to cervical collar. . Admission to MICU GEN: Elderly female lying in bed with paradoxical breathing. HEENT: Pupils small, but reactive and equal, anicteric, face mask present. Abrasions over her face. RESP: Tachypneic with respiratory muscle use. Coarse breath sounds anteriorly bilaterally. CV: RRR, no MRG ABD: +BS, soft, obese, NTND. No HSM. EXT: no c/c/e, 2+ DP NEURO: Lethargic, does not open eyes to command. Will very slightly move fingers and toes to a combination of verbal and tactile stimulus. hyperreflexic biceps and brachioradialis reflexes b/l. Down-going Babinskis bilaterally. . Discharge Exam Vitals: 97.9 (m98.3) 125/79 (121-129/50-79) 63 (60-72) 20 98% RA Gen: no acute distress; speech appears to be improving HEENT: EOMI Neck: Supple CV: RRR, +S1, S2, no m/r/g Resp: CTA bilaterally on anterior exam Abd: Moderate tenderness to palpation in LLQ. No rigidity or rebound. Ext: W/WP, 1+ DP pulses, no edema Neuro: Speech improving. Pertinent Results: Admission Labs: [**2183-12-16**] 11:22AM GLUCOSE-125* LACTATE-3.2* NA+-147 K+-3.8 CL--108 TCO2-23 [**2183-12-16**] 11:16AM CK-MB-39* MB INDX-1.2 [**2183-12-16**] 11:16AM CK(CPK)-3362* [**2183-12-16**] 11:16AM LIPASE-47 [**2183-12-16**] 11:16AM cTropnT-0.68* [**2183-12-16**] 11:16AM WBC-18.0* RBC-5.37 HGB-15.3 HCT-46.3 MCV-86 MCH-28.5 MCHC-33.1 RDW-13.7 [**2183-12-16**] 11:16AM PLT COUNT-206 [**2183-12-16**] 11:16AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR [**2183-12-16**] 11:16AM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 Labs on transfer to MICU: Na 149 K 3.8 Cl 113 Bicarb 25 BUN 18 Cr 1.1 Glu 117 Ca 9.7 Mg 1.8 Phos 2.8 . TSH 0.93 Lithium 0.3 CK 9174 <- 9641 <- 3362 MB 62 <- 84 <- 39 MBI 0.7 <- 0.9 <- 1.2 Trop 0.56 . WBC 20.0 Hct 41.1 Plt 230 . PTT 40.4 . ABG 7.38 pCO2 42 pO2 60 Lactate 1.3 9am ABG 7.32 pCO2 52 pO2 80 Lactate 1.5 7 pm . UA 0-2 WBC, 21-50 RBC, neg leu, neg nitr . Discharge Labs: WBC 9.1, HCT 35.7, INR 1.1\ 137/4.1/101/32/30/1.1 . EKG: normal sinus rhythm, nl axis, nl intervals, no STE or STD . Imaging: TTE [**12-18**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. . CT head [**12-18**]: Bilateral basal ganglial infarcts ( acute - subacute and a few chronic alcunar infarcts) without evidence of hemorrhagic transformation or hydrocephalus or significant mass effect. Pl. see prior MR for additional details. . CXR [**12-17**]: Bilateral enlargement of the hila is redemonstrated. There is also upper zone redistribution. These findings may represent a combination of pulmonary arteriovenous hypertension but no pulmonary edema is seen. The left lower lobe opacity appears to be unchanged since the prior study and might represent a combination of atelectasis, aspiration or infection. Upper lungs are clear. . CT head without contrast [**12-16**]: IMPRESSION: No evidence for acute intracranial process. . CXR [**12-16**]: IMPRESSION: No evidence for acute cardiopulmonary process. Left upper lung opacity versus bony sclerotic focus could be further evaluated with non-urgent chest CT. . CT C-spine [**12-16**]: IMPRESSION: No fracture or malalignment noted. There is significant canal stenosis at C5-C6 due to an eccentric disc osteophyte complex which predisposes to cord injury even from minor trauma. Given apparent neurologic deficit, consider MRI for further evaluation to assess for cord injury, not assessed by CT. . MRI Cervical spine [**12-16**]: Limited examination due to motion artifact. Multilevel degenerative changes with most significant change at C5-6 level. Apparent signal abnormality within the cord may be real or artifactual. Repeat examination is advised once the patient is able to tolerate the exam or with conscious sedation. The change from wet read and findings/recommendations were communicated to Dr. [**Last Name (STitle) **] by Dr. [**Last Name (STitle) **] at 9:30 a.m. on [**2183-12-17**]. . MRI head [**12-16**]: Bilateral subacute ischemic changes involving the basal ganglia bilaterally with extension into the body of the caudate nucleus on the right with no evidence of hemorrhagic transformation. There is no evidence of mass effect or hydrocephalus. . CXR [**12-17**]: The NG tube tip is in the stomach. The ET tube tip is most likely 5 cm above the carina. There is worsening of the left lower lobe atelectasis. The enlargement of both pulmonary arteries is unchanged. The upper lungs are essentially clear. . ECHO [**2183-12-18**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. . CT Head [**2183-12-18**]: IMPRESSION: Bilateral basal ganglial infarcts ( acute - subacute and a few chronic alcunar infarcts) without evidence of hemorrhagic transformation or hydrocephalus or significant mass effect. Pl. see prior MR for additional details. Brief Hospital Course: 79 year-old female with schizoaffective disorder, history of stroke, and hypothyroidism who was admitted on [**12-16**] with an NSTEMI and an acute stroke s/p hypercarbic respiratory failure secondary to aspiration PNA, who improved but had subsequent difficulties swallowing and PEG tube placement. During the subsequent hospital course, the patient underwent speech therapy and continued to improve to the point of tolerating increasing PO trials prior to discharge to rehab. . # Stroke: The patient was found to have subacute strokes in her basal ganglia and caudate and had weakness and dsyarthria present on admission, which corresponded to her neurologic deficits. She was initially unable to cooperative fully with a neuro exam, but did have hyperreflexic reflexes on exam here. Neurology was consulted and recommended aspirin and plavix, which was held briefly around the time of her PEG placement. An NG tube was attempted to be placed, but patient did not tolerate exam. She failed speech and swallow multiple times. A PEG tube was placed for tube feeding after serial discussions with the patient and family. Later in her hospital course, prior to discharge, a video swallow study was conducted, showing that she had regained some swallowing function and so pureed solids were started in addition to tube feeds. The patient will need serial speech and swallow evaluations at her rehab center to monitor her improvement and determine when, if at all, the PEG tube can be removed. . # Hypercarbic respiratory failure: Thought to be secondary to aspiration pneumonia. She finished a full 8 day course of vancomycin/cefepime/flagyl. Respiratory status was stable once extubated. . # Spinal Stenosis: Patient had trauma CT on admission remarkable for severe spinal stenosis with some cord compression. Spine surgery was consulted and felt no acute need for surgery or steroids however when her condition improves will likely need surgery. Initially had a hard collar in place, but after discussion with Ortho Spine, felt that collar could be removed. Patient will need follow-up with Dr. [**Last Name (STitle) 363**] in Ortho Spine in 2 weeks. . # Trop leak/Demand ischemia: The patient was initially admitted to cardiology and felt to have demand ischemia in the setting of recent fall and stroke. She was inititally treated with a heparin gtt which was stopped shortly after admissison as the cardiologists felt it was demand ischemia in setting of infection. Her enzymes trended down and no ECG changes were noted. TTE on [**12-18**] showed normal systolic function with no wall motion abnormalities. . # Acute kidney injury: Elevated Cr on presentation, but trended down with IVF. Likely secondary to prerenal intravascular depleption. . # Urinary Retention: The patient was found to have urinary retention after extubation. She failed several voiding trials and so a foley was placed. The patient should have serial voiding trials at rehab to determine when the foley can be removed. . # Nutrition: As noted, the patient underwent PEG placement. She was maintained on TPN pre-procedurally, while the patient and family considered placement of a PEG tube and while the patient deferred a dobhoff feeding tube. The day prior to discharge, the patient was able to start PO trials after her video swallow study, and the goal was to gradually increase PO intake by transitioning to night-time feedings at rehab. Comm: sister-in-law [**Name (NI) 88344**] [**Telephone/Fax (1) 88345**]/3339 Code: Full code Medications on Admission: Synthroid 50 mcg daily Lithium 600 mg PO daily ASA 81 mg PO daily Colace 100 mg PO daily Crestor 10 mg daily Vit D 400 units PO daily. Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 3. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 8. lithium citrate 8 mEq/5 mL Solution Sig: Six Hundred (600) mg PO once a day. 9. Tube Feeds Tubefeeding: Fibersource HN Full strength; Starting rate:10 ml/hr; Advance rate by 10 ml q6h Goal rate:50 ml/hr Cycle?: Yes Cycle start:[**2172**] Cycle end:800 Residual Check:q4h Hold feeding for residual >= :200 ml Flush w/ 350 water q4h 10. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] hospital Discharge Diagnosis: Primary: stroke, Demand ischemia, cervical spinal stenosis, dysphagia Secondary: schizoaffective disorder Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during your hospitalization. You were admitted after being found down at home. After further work-up, it was determined that you had a stroke. A CT scan of your neck also showed cervical spinal stenosis, or a narrowing of the spinal canal in your neck. It was also thought that you were having a heart attack, however this ultimately was not felt to be true. Unfortunately, you had an aspiration event and were sent to the ICU where you were intubated. You completed a course of antibiotics for an aspiration pneumonia and were able to be extubated without difficulty. You failed several speech and swallow exams and needed a PEG tube placed to be able to use your GI tract. This was placed by IR. You started slowly re-developing the ability to swallow and take some food by mouth. We hope that you will continue to improve your swallowing to the point that we be able to remove the PEG tube. . You also developed urinary retention here in the hospital, and are being discharged with a foley. Your rehab center should continue to do voiding trials. We hope you will improve and we will be able to remove the foley. . We made the following changes to your medications: STARTED Plavix STARTED Senna . Please go to all of the appointments scheduled below. Followup Instructions: Name: [**Last Name (LF) **], [**Name8 (MD) **] MD (Neurology) Location: [**Hospital1 **] Phone: [**Telephone/Fax (1) 88346**] Appointment: Tuesday [**2184-1-20**] at 10 AM Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Orthopedics) Location: [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 551**] Phone: [**Telephone/Fax (1) 3573**] Appointment: Thursday [**2184-1-22**] 2:30pm

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icd9cm

[ [ [] ] ]

[ "96.71", "43.11", "38.93", "96.6", "99.15", "96.04" ]

icd9pcs

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29332

Discharge summary

report

Admission Date: [**2124-12-24**] Discharge Date: [**2125-1-6**] Date of Birth: [**2044-12-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Dizziness, SOB Major Surgical or Invasive Procedure: None History of Present Illness: 79 yo M [**Country 3587**] speaking only w/HTN, DM, Hyperlipidemia, T-Ao aneurysm w/moderate AR, p/w productive cough and SOB. Per pt, however he denies any CP/Palpitations or SOB. He was brought to ED by family for dizziness. Pt states he's had dizziness for several years, worse w/position changes and getting up. Pt denies falling. Pt denies cough, no f/c/sweats. As per family, palpitations x several years. One week of productive cough of white sputum, no fever, chills, or chest pain. No increase in palpitations. 2 days prior family noted increasing labored breathing, improved within the afternoon. last night 9 pm family noted patient looked short of breath, increased work of breathing and patient commented he felt dizzy and unwell. To ED. No episodes of SOB, or CHF in the past. . ED Course: VS-101.2 BP161/88 HR 72 RR 37 92%Hypoxic in ED 86% RA -->97%NRB, then bedside BiPAP +Nitro gtt. Pt off BiPAP and Nitro gtt, O2 sats 96% 3L NC. Received Tylenol, Levoflox 500mg IV, Vanco 1gm IV x1, ASA 325mg x1. Pt admitted for CHF exacerbation, ROMI. Past Medical History: 1. Insulin-dependent diabetes mellitus. 2. Hypertension. 3. Thoracic aortc aneurysm with Moderate aortic regurgitation [aneurysm is approaching the point (5.0 cm) at which surgical therapy is indicated] 4. Hyperlipidemia. 5. Paroxysmal supraventricular tachycardia Social History: Emigrated from [**Country 3587**] 11/[**2123**]. Non english speaking. The patient denies alcohol. He has approximately a 50-year history of pipe smoking of which he quit five years ago; he does not drink caffeine. Hx of medication non compliance, but since emigration family reports he is taking all medications and seeing cardiologist and PCP [**Name Initial (PRE) 30449**]. Family History: He denies a family history of nephrolithiasis or of prostate cancer or of any other GU malignancy Physical Exam: VS: 95.1 BP 154/92 HR 79 RR22 94%RA FS 314 WT 72.8KG GEN: NAD, calm, lying comfortably in bed HEENT: Dry MM, adentulous, PERRL RESP: Bibasilar crackles 1/3 up, no wheezing CV: Reg +PVCs, Nml S1, Split S2, 2/6 SEM at RUSB, displaced PMI ABD: soft ND/NT +BS, No rebound, no guarding EXT: no peripheral edema, warm, 2+DP pulses b/l NEURO: A&Ox1-however language barrier makes it difficult to understand, no focal neuro deficits Pertinent Results: [**2124-12-24**] 12:30AM PT-13.4* PTT-23.3 INR(PT)-1.2* [**2124-12-24**] 12:30AM NEUTS-81.2* LYMPHS-13.3* MONOS-3.5 EOS-1.7 BASOS-0.2 [**2124-12-24**] 12:30AM WBC-13.6* RBC-4.06* HGB-13.6* HCT-36.1* MCV-89 MCH-33.5* MCHC-37.6* RDW-14.1 [**2124-12-24**] 12:30AM TSH-1.6 [**2124-12-24**] 12:30AM CALCIUM-9.1 PHOSPHATE-3.1 MAGNESIUM-1.7 [**2124-12-24**] 12:30AM CK-MB-NotDone [**2124-12-24**] 12:30AM cTropnT-<0.01 proBNP-1466* [**2124-12-24**] 12:30AM CK(CPK)-98 [**2124-12-24**] 12:30AM estGFR-Using this [**2124-12-24**] 12:30AM GLUCOSE-331* UREA N-19 CREAT-0.9 SODIUM-125* POTASSIUM-4.9 CHLORIDE-90* TOTAL CO2-23 ANION GAP-17 [**2124-12-24**] 12:37AM LACTATE-2.3* [**2124-12-24**] 02:05AM URINE RBC-1 WBC-1 BACTERIA-RARE YEAST-NONE EPI-1 TRANS EPI-0-2 [**2124-12-24**] 02:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2124-12-24**] 02:05AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2124-12-24**] 02:15AM URINE HOURS-RANDOM CREAT-73 SODIUM-25 [**2124-12-24**] 10:28AM WBC-9.8 RBC-4.02* HGB-13.1* HCT-35.7* MCV-89 MCH-32.5* MCHC-36.7* RDW-14.2 . EKG- [**12-24**] NSR, HR 71 LBBB(old), IVCD, significant LVH, TWI I,aVL,V6; wandering pacer vs. MAT . CHEST (PORTABLE AP) [**2124-12-24**] 12:27 AM Comparison is made to [**2124-10-30**]. There are new airspace opacities involving both lungs with predominance at the lower lungs with air bronchograms, consistent with multifocal pneumonia. Less likely this may represent edema as there is also increased perihilar vasculature. . CHEST XR on [**2125-1-6**] The endotracheal tube in the left-sided central venous catheter are unchanged in position. There is again seen marked prominence of the pulmonary interstitial markings without focal areas of consolidation. Overall the findings are stable. . . [**2125-1-1**] ECHO: Compared with the prior study (images reviewed) of [**2124-12-25**], the right ventricle is now dilated and hypokinetic. Left ventricular systolic function appears similar to prior. . [**2125-1-1**] CTA IMPRESSION: 1. No evidence of pulmonary embolism. 2. Evidence of severe diffuse interstitial pneumonitis, greater in the lower than upper lobes. The appearance is most suggestive of acute interstitial pneumonitis or drug-related pneumonitis, and already shows fibrotic change. 3. Stable dilatation of the aortic root to 48 mm. 4. Mediastinal and hilar lymphadenopathy. 5. Questionable sludge within the gallbladder. . MICRO: All Blood and urine cultures: NGTD . [**2124-12-27**] Sputum: MRSA and GNR [**2125-1-2**] SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2125-1-2**]): <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2125-1-4**]): OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. FUNGAL CULTURE (Final [**2125-1-15**]): YEAST. ACID FAST SMEAR (Final [**2125-1-3**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . . . [**2124-12-31**] Rapid Respiratory Viral Screen & Culture Rapid Respiratory Viral Antigen Test-FINAL; VIRAL CULTURE-FINAL INPATIENT . . [**2124-12-31**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; POTASSIUM HYDROXIDE PREPARATION-FINAL; IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII-FINAL; FUNGAL CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE-FINAL; NOCARDIA CULTURE-FINAL Brief Hospital Course: 79 yo M [**Country 3587**] speaking only w/HTN, DM, Hyperlipidemia, T-Ao aneurysm w/moderate AR, p/w productive cough and SOB, likely pneumonia and CHF exacerbation, with question SVT with abberancy. His hospital course by problem is as follows: . Hypoxia: Family reports one week of cough, without fever chills, productive of white sputum. In ED, febrile with CXR consistent with multifocal pneumonia. Presumed infection leading at least in part to SOB. Initially started on Levofloxacin in house for likely community aquired pneumonia. Then during hospital course, pt became acutely more hypoxic, a trigger was called for sats in 83-87% on 5L NC, and patient was transferred to ICU for closer monitoring. At that time Abx coverage was broadned to Vanc/Zosyn. In the ICU, he was not intubated immediately and for the first day seemed to be tolerating face mask; however, he was RR 30's and unable to wean off oxygen. Then after 2 days in MICU, pt had decline of resp status, increased RR to 30's, not oxygenating well despite non-invasive ventilation 7.53/35/61, and he was intubated. CXR at the time showed worsening bilateral interstitial dx concerning for ARDS. CTA negative for PE. Over the remainder of his hosp course, his resp status continued to decline. BAL grew nothing. Sputum grew MRSA and GNR, and he continued broad spectrum abx. . Hypotension: During the ICU course pt became increasingly hypotensive, all BP meds were discontinued, and he was started on neosynephrine. Initially there was concern for overdiuresis; however, BP did not return after fluids. CVP remained between [**7-8**]. His pressures were noted to be very PEEP dependent. Ultimately, he was felt to have septic physiology. He continued broad spectrum Abx, neosynephrine, fluids as needed and CVP stayed within [**7-8**], [**Last Name (un) 104**] stim was appropriate and no steroids given. ECHO with signs of worsening RV hypokinesis, but EF remained >55%. His BP did not improve and he ultimately required addition of Levophed and vasopressin to even maintain BP in 90's. Despite maximimal pressors and daily adjustment of Vent settings to help BP, he still became increasingly hypotensive. . Acidosis: Towards the end of his hospital course, patient became increasing acidotic felt [**12-29**] sepsis. Bicarb was given as needed for pCO2<7.15. . ARF: Pt dveloped ARF over ICU course. Renal consulted and felt that this was likely ATN secondary to hypotension, sepsis. CVVH initiated but then stopped given hypotension. . CHF: Shortness of breath, cough and patchy infiltrates which could represent CHF. Elevated BNP. Considered infection precipitating bouts of tach, likely SVT, with decompensation given aortic insuffiency. He was diuresed on the floor prior to transfer to ICU for concern of concomitant CHF exacerbation in addition to pneumonia. . AVNRT: History of SVT with abberancy in previous admission [**Date range (1) 25710**]. Followed by cardiology. Episode on floor, resolved with 5 mg IV lopressor. Cardiology consulted. Consider CHF as possible result of tachycardia, with inability to compensate. Pt reports episodes of palpitations x several years while in [**Country **], not associated with shortness of breath, or chest pain. Cardiology seen as outpatient two days prior to admssion. In MICU, he continued to have episodes of AVNRT that was very responsive to carotid amnipulation. . DM II- Poor control as outpatient with Hemoglobin A1C to 14.6. Seen by [**Last Name (un) **]. Sliding scale while in house. Infection likely leading to increased levels. Glargine twelve units in AM. . . GOALS of CARE: During the MICU course, patient's family was closely involved and informed at all stages of his care. His son-in-law [**Name (NI) **] was the main family spokesperson. Ultimately, in light the pts multi-organ failure (ARF, liver failure) septic shock, severe acidosis (pH 7.13) and hypotension on maximal pressors, the family decided not to escalate care further. On [**1-6**] at 2:45PM, the family decided to make him comfort measures only. Patient passed on [**2125-1-6**] at 3:45PM. Medications on Admission: 1. Cardura 4 mg q.h.s. 2. Aspirin 325mg daily 3. Hydrochlorothiazide 25mg daily 4. Lisinopril 40mg daily 5. Lipitor 20 mg daily 6. Metoprolol 50mg [**Hospital1 **] 7. Insulin 8U glargine daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired

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icd9cm

[ [ [] ] ]

[ "93.90", "33.24", "96.6", "39.95", "96.04", "96.72", "38.95", "38.93" ]

icd9pcs

[ [ [] ] ]

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332, 338

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10627

Discharge summary

report

Admission Date: [**2148-5-29**] Discharge Date: [**2148-6-14**] Date of Birth: [**2071-7-26**] Sex: M Service: CARDIOTHORACIC Allergies: Antihistamines Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2148-5-29**] - CABGx1 (Vein to Circumflex), Catheterization procedure of Circumflex pseudoaneurysm Embolization [**2148-6-7**] Sternal re-wiring for dehiscence History of Present Illness: 76 y/o gentleman with known coronary artery disease who was recently admitted to MWMC for palpitations and chest pain. A cardiac catheterization was performed where stenting of the circumflex artery resulted in an aneurysm. He is now referred for surgical revascularization. Past Medical History: Hyperlipidemia, Hypertension, Paroxysmal Atrial Fibrillation, Benign Prostatic Hypertrophy, PTCA/Stenting, Peripheral Vascular Disease s/p Aorto-Bifem AAA Stent, Cerebrovascular Accident 10 yrs ago, Bell's palsy, s/p RIH repair x 2, s/p L breast mass removal, s/p B cataract extract., s/p TURP x 2 Social History: Lives with wife. Retired. [**Name2 (NI) 4084**] smoked and does not drink. Family History: Father with MI @ 76 Physical Exam: VS: 55 183/93 5'9" 150# GEN: WDWN in NAD HEENT: EOMI, PERRL, OP benign Neck: Supple, -JVD, -carotid bruits Lungs: CTAB -w/r/r Heart: RRR, Nl S1-S2, -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, +BLE spider veins Neuro: Nonfocal, MAE, A&O x 3 Pertinent Results: [**2148-6-4**] 06:04AM BLOOD WBC-8.8 RBC-3.03* Hgb-9.9* Hct-29.4* MCV-97 MCH-32.6* MCHC-33.7 RDW-14.2 Plt Ct-180 [**2148-6-5**] 06:33AM BLOOD PT-31.0* INR(PT)-3.3* [**2148-6-5**] 06:33AM BLOOD K-3.7 [**2148-6-4**] 06:04AM BLOOD Glucose-110* UreaN-23* Creat-0.9 Na-135 K-4.2 Cl-97 HCO3-28 AnGap-14 [**2148-6-5**] CXR Small bilateral pleural effusions with associated atelectasis. Unremarkable appearance of sternal wires. [**2148-5-29**] Catheterization 1. Selective angiography of the left coronary showed a 30% LMCA stenosis, mild diffuse LAD disease with a muscle bridge and a large pseudoaneurysm of the proximal LCX with ligation of the distal vessel. 2. Resting hemodynamics showed normal central aortic pressures. 3. Successful coil embolization of the LCX aneurysm with minimal flow into the aneurysm at the completion of the procedure. Brief Hospital Course: Mr. [**Known lastname 34907**] was admitted to the [**Hospital1 18**] on [**2148-5-29**] for surgical management of his coronary artery disease and aneurysm. He was taken directly to the operating room where he underwent coronary artery bypass grafting to the circumflex artery followed by coil embolization of the proximal circumflex artery. Please see operative report for surgical details. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He had several episodes of atrial fibrillation requiring cardioversion. On postoperative day one, Mr. [**Known lastname 34907**] [**Last Name (Titles) **]e neurologically intact and was extubated. Amiodarone was started for atrial fibrillation and he again required cardioversion. He was gently diuresed towards his preoperative weight. Coumadin and heparin were started for anticoagulation given his persistent atrial fibrillation. The EP service was consulted who assisted with his medication management. On postoperative day five, he was transferred to the cardiac step down floor for further recovery. Heparin was stopped once his INR was within a therapeutic range. The physical therapy service was consulted for assistance with his postoperative strength and mobility. On post-op day 7 there was a notable sternal click without drainage. The following day his click was still present and sternum was unstable. He was given Vitamin K to lower INR in preparation for sternal re-wiring. He was brought back to the operating room on post-op day 9 ([**6-7**]) secondary to sternal dehiscence for sternal re-wiring. Following surgery he was transferred to the CSRU on Vancomycin and Levaquin pending cultures from OR. And Gentamycin chest irrigation. Later on this day pt was weaned from sedation, awoke neurologically intact and was extubated. Medications prior to sternal re-wiring were re-started. Including Coumadin and Amiodarone for Afib. He remained in the CSRU for several more days and was transferred to the cardiac surgery step-down floor on post-op day #12&3. Cultures revealed COAG negative staph, resistant to Levaquin, but sensitive to Vancomycin. Therefore Levaquin was stopped and Vancomycin continued. Infectious disease was consulted as well, who agreed to continue Vancomycin for several weeks and will follow Mr. [**Known lastname 34907**] as outpatient. Post-op day #15 PICC line was placed. Labs, physical exam, and vital signs were relatively stable over next couple of days and he was discharged to rehab on [**2148-6-14**] with the appropriate follow-up appointments. Medications on Admission: Lopressor Lipitor Aspirin Norvasc Discharge Disposition: Extended Care Facility: [**Hospital3 15644**] Long Term Health - [**Location (un) 47**] Discharge Diagnosis: Coronary Artery Disease w/ Pseudoaneursym of Circumflex Artery s/p Coronary Artery Bypass Graft x 1 and Coil Embolization of Pseudoaneurysm of circumfelx Sternal Dehiscence s/p Sternal Re-wiring PMH: Hyperlipidemia, Hypertension, Paroxysmal Atrial Fibrillation, Benign Prostatic Hypertrophy, PTCA/Stenting, Peripheral Vascular Disease s/p Aorto-Bifem AAA Stent, Cerebrovascular Accident 10 yrs ago, Bell's palsy, s/p RIH repair x 2, s/p L breast mass removal, s/p B cataract extract., s/p TURP x 2 Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of greater then 2 pounds in 24 hours or 5 pounds in one week. 4) Wear [**Doctor Last Name **] of hearts monitor as instructed. [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] in 1 month Follow-up with Dr. [**First Name (STitle) **] in [**1-29**] weeks. Follow-up with Dr. [**First Name (STitle) 1075**] in [**3-1**] weeks. Follow-up with Dr. [**Last Name (STitle) 2716**] as instructed. Call all providers for appointments. Completed by:[**2148-6-14**]

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icd9cm

[ [ [] ] ]

[ "37.0", "89.60", "39.79", "34.79", "36.11", "38.93", "88.55", "39.61" ]

icd9pcs

[ [ [] ] ]

5036, 5126

2375, 4952

292, 456

5667, 5673

1498, 2352

1189, 1210

5147, 5646

4978, 5013

5697, 5984

6035, 6361

1225, 1479

242, 254

484, 760

782, 1081

1097, 1173

11,043

139,662

1719

Discharge summary

report

Admission Date: [**2160-7-29**] Discharge Date: [**2160-8-22**] Date of Birth: [**2091-4-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Chief Complaint: Hyponatremia, weakness Reason for MICU transfer: Hyponatremia Reason for CCU transfer: Hypotension and Hyponatremia Major Surgical or Invasive Procedure: PICC Line palcement [**2160-8-11**] Paracentesis [**2160-8-11**] Liver Bx [**2160-8-21**] History of Present Illness: Mr. [**Known lastname 9723**] is a 69 yo M with h/o chronic systolic CHF (EF 20%) [**3-13**] ischemic cardiomyopathy (severe 3VD), severe pulm HTN (on sildenafil and milrinone gtt), severe TR, and recurrent ascites [**3-13**] CHF requiring paracentesis q2 weeks who presents with weakness and muscle cramping x5-6 days. He is poor historian, most details of history come from ED report. Patient's symptoms started 5-6 days ago after his most recent paracentesis. Yesterday he accidentally took three times his usual dose of sildenafil (took 60mg). This morning he complained of orthostatic dizziness and nosebleed after getting up from a nap; otherwise in usual state of health. Wife checked his BP when he felt dizzy, was normal (118/50). Per his family, he has become slower to respond to questions, but has not seemed confused or disoriented. No increased/decreased fluid intake or changes in urine/stool output. He has also been having leg cramps (chronic, but worse than baseline). He has baseline nonproductive cough which has not worsened, no increased shortness of breath or leg swelling. His weight is currently down to 115 lbs (baseline 122, sinusoidal, varies by ~5kg based on volume removal with paracentesis); per wife he has gained 2.5 lbs over past day or so. . Per recent cardiology notes, patient has had progressively worsening hyponatremia over the past two weeks weeks in setting of his worsening end-stage CHF. On [**7-16**] sodium was 125, and on [**7-23**] sodium was 124. On [**7-23**] he had a 5L paracentesis. His wife has recently increased his Torsemide to 100mg daily (feels 80mg daily is "not enough"). . In the ED, initial vitals were: 97.4 109/63 74 18 100% RA. Pt [**Name (NI) 9830**]3 though slow to respond to questions. Exam notable for loud systolic murmur, JVD to mandible, ascites, no LE edema. Labs notable for Na 120, creatinine 2.4 (baseline 1.72-2.6 over past several weeks), glucose 255, Posm 289, BNP 3621 (has been as high as 3972 in past). CXR showed low lung volumes, head CT showed no acute intraparenchymal changes. Unable to obtain urine sample in ED. Patient was admitted to MICU for workup of hyponatremia. Vitals prior to transfer: . On arrival to MICU, vitals are: 98.0 103/75 86 18 100% RA. Patient AAOx3, slow to respond to questions (native language is Pakistani). He endorses hunger and thirst, also complains of BL leg pain. Repeat labs on arrival to MICU show Na 122, Posm 289, Uosm 279. . His sodium initially improved from 120->122->124 with fluid restriction alone, so in ICU he was restarted on home meds (Torsemide, Spironolactone, Milrinone) and home 1.5L fluid restriction and low-salt diet. After he was restarted on home regimen, his sodium again fell again, suggesting overdiuresis on home regimen and hypovolmeic hyponatremia. His toresmide dose was decreased from 100 to 80mg daily. . Patient was also noted to have 4/4 bottles growing GPCs thought to be due to his PICC line through which milrinone was administered and this was pulled. Patient had been receiving Vancomycin for treatment of line-associated bacteremia. . The patient denied shortness of breath, chest pain, and muscle cramping. He was called out to the [**Hospital1 1516**] service given relative resolution of his hyponatremia. . On [**8-3**] at 1600 hours, CCU contact[**Name (NI) **] by [**Name (NI) 1516**] resident as patient was hypotensive to the 60's mmHg systolic. Throughout the day SBP's had been in the 100-120mmHg range. About 1500 hours, patient's milirnone gtt was stopped due to vancomycin administration. Also given 2.5 mg lisinopril at that time. An hour later noted to have hypotension in the 60's mmHg systolic. Bolused 250 cc NS. Peripheral dopamine started and uptitrated to 15 mcg/kg/hr. Family meeting at bedside reinforced DNR/DNI status with pt's wife [**Name (NI) 382**] as well as his two sons. ICD turned off by cardiology fellow at the bedside given DNR/DNI status. Family requested pressor support, necessitating ICU transport for central line and arterial line. BP prior to transport was 86/50. . In the CCU, patient is mentating well communicating in his language (Pakistani) with his family. Tachycardic to 120's on dopamine gtt, SBP 90's/50's on NIBP. Past Medical History: 1. sCHF (EF 20% [**2160-6-26**]) [**3-13**] ischemic cardiomyopathy (severe 3VD), s/p ICD 2. CAD, status post CABG with percutaneous coronary intervention. 3. Severe tricuspid regurg 4. Severe pulmHTN on milrinone infusion + sildenafil 5. Recurrent ascites [**3-13**] refractory end-stage CHF, requires paracentesis q2 weeks 6. Type II NIDDM 7. Nephropathy related to diabetes. 8. Anemia of chronic disease. 9. Lichen simplex chronicus. 10. Left subclavian vein occlusion. 11. Hernia repair. 9. Left-sided pleurodesis with past Pleurx catheter placed in [**2157**]. 10. Recent pancreatitis with a laparoscopic cholecystectomy and ERCP. 11. Gout. Social History: Lives with wife and daughters. Ambulatory at baseline. Has five children and two grandchildren. Born in [**Country 9819**] - has lived in USA for 15 years. Previous leather goods importer/exporter. Never smoked cigs, drank ETOH or used recreational drugs. Family History: Several first degree family members with positive PPD. Brother had MI at 48. Mother had DM, CHF and MI at unknown age. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.0 103/75 86 18 100% RA General: thin M in NAD, AAOx3, responding slowly but appropriately HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, EJ elevated to 6cm above clavicle (non-pulsatile), unable to visualize IJ CV: Regular rate and rhythm, 3/5 SEM heard throughout precordium, no rubs/gallops Lungs: faint crackles at bases. No wheezes/rhonchi. Abdomen: +ascites with fluid wave. Mildly TTP in RLQ, no peritoneal signs. +BS. Unable to palpate liver/spleen. GU: has condom cath Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge Physical Exam: GENERAL: A and O x 3. NAD. Mood, affect appropriate. HEENT: NCAT. EOMI grossly. CARDIAC: RR, normal S1, S2. [**4-15**] Holosystolic murmur heard best at the left scapular border at the 5th intercostal space LUNGS: CTA b/l, no w/r/r ABDOMEN: Soft, nondistended. No HSM or tenderness. Some bruising on the abdomen. Pleurx catheter over RUQ with no surroundng erythema, draining well EXTREMITIES: 2+ dp b/l, without edema Pertinent Results: ADMISSION [**2160-7-29**] 02:30PM BLOOD WBC-5.7 RBC-3.61* Hgb-10.9* Hct-33.0* MCV-91 MCH-30.2 MCHC-33.1 RDW-15.3 Plt Ct-281 [**2160-7-29**] 02:30PM BLOOD Neuts-79.6* Lymphs-10.0* Monos-7.3 Eos-2.4 Baso-0.6 [**2160-7-29**] 02:30PM BLOOD Glucose-255* UreaN-83* Creat-2.4* Na-120* K-4.2 Cl-85* HCO3-25 AnGap-14 [**2160-7-29**] 07:20PM BLOOD Calcium-8.2* Phos-3.9 Mg-2.6 [**2160-7-29**] 02:30PM BLOOD Osmolal-289 . PERTINENT [**2160-7-29**] 02:30PM BLOOD cTropnT-0.06* proBNP-3621* [**2160-7-29**] 07:20PM BLOOD TSH-3.1 [**2160-7-30**] 01:41AM BLOOD Cortsol-PND [**2160-7-29**] 5:20 pm BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. Aerobic Bottle Gram Stain (Final [**2160-7-30**]): Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2160-7-30**] @ 8:01 AM. GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2160-7-30**]): GRAM POSITIVE COCCI IN CLUSTERS. . CT HEAD W/O CONTRAST Study Date of [**2160-7-29**] 3:00 PM There is no evidence of acute hemorrhage, edema, mass, mass effect, or acute territorial infarction. There is overall increased size in the ventricles and sulci out of proportion to patient's age. There is opacification of the left maxillary sinus and mucus seen in the right maxillary sinus along with cortical thickening indicating likely chronic problem. There is also some opacification of the ethmoid air cells on the left as well as the left sphenoid sinus with some aerosolization. The orbits appear unremarkable. The right mastoid is not well pneumatized. No fracture is identified. There is mild periventricular white matter hypodensities likely the sequelae of small vessel ischemic disease. IMPRESSION: 1. No acute intracranial process. 2. Atrophy out of proportion to patient's age. 3. Sinus disease. . CHEST (PA & LAT) Study Date of [**2160-7-29**] 3:28 PM FINDINGS: PA and lateral views of the chest. There are low lung volumes which exaggerate the prominence of the vascular structures as well as heart size. Given the low lung volumes, edema or consolidation cannot be ruled out. Pacemaker leads are in stable position. There are aortic knob calcifications. There is no pleural effusion identified. There is no pneumothorax. PICC line ends in the upper SVC. IMPRESSION: Low lung volumes obscure the study and edema or pneumonia cannot be entirely ruled out. The left lung is slightly obscured from overlying hardware. Discharge Labs [**2160-8-22**] 10:05AM BLOOD WBC-3.5* RBC-2.44* Hgb-7.3* Hct-22.5* MCV-92 MCH-30.0 MCHC-32.6 RDW-16.1* Plt Ct-265 [**2160-7-29**] 02:30PM BLOOD Neuts-79.6* Lymphs-10.0* Monos-7.3 Eos-2.4 Baso-0.6 [**2160-8-22**] 10:05AM BLOOD Plt Ct-265 [**2160-8-22**] 10:05AM BLOOD Glucose-174* UreaN-41* Creat-1.4* Na-125* K-4.6 Cl-95* HCO3-23 AnGap-12 [**2160-8-14**] 11:15AM BLOOD ALT-13 AST-21 AlkPhos-102 TotBili-0.2 [**2160-8-22**] 10:05AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.8 Brief Hospital Course: Assessment and Plan: 69 yo M with h/o chronic systolic CHF (EF 20%) [**3-13**] ischemic cardiomyopathy (severe 3VD), severe pulm HTN (on sildenafil and milrinone gtt), severe TR, and recurrent ascites [**3-13**] CHF requiring paracentesis q2 weeks who presents with weakness and muscle cramping x5-6 days, found to have hyponatremia. #Goals of Care/CHRONIC END STAGE SYSTOLIC CHF: Pt has end-stage systolic CHF (EF 20%) [**3-13**] iCMP with severe 3VD. Has ICD. Has severe PAH requiring milrinone and sildenafil, response to these has been worsening lately. Requires frequent paracenteses due to right heart failure causing systemic volume overload. His home ASA, Torsemide, Spironolactone, Sildenafil and Metoprolol were continued in ICU initially. Daily weights were stable. The patient was determined to be end-stage and for palliative care in the ICU. Palliative care was consulted and DNR/DNI status was confirmed. However, the patient's family desired pressor support and treatment of hyponatremia. Given hypotension, his metoprolol, sildenafil, spironolactone, and torsemide were held once transferred to the CCU. He was continued on milrinone as above. Ultimately, IV morphine was started to minimize pain and oxygen hunger. When goals of care changed, patient became a candidate for LVAD placement. The goals of care were changed because when medical care was witheld from patient, his clinical impression changed dramatically. He began more responsive and alert, his hyponatremia improved from 118 to 125, and his pressure was maintained on milrinone without his other BP meds. The workup began for a potential LVAD. During this time we transferred him back to the ICU from the floor due to BPs in the 80s systolic. He did not need any other pressor support to maintain BPs. He went for a liver biopsy that ruled out cirrhosis. Patient was then transferred to [**Hospital 3278**] Medical Center for right heart cath and subsequent LVAD placement # CHRONIC HYPONATREMIA: Patient initially presented to hospital with hypovolemic hyponatremia secondary to increase in home torsemide dose. Sodium ran as low as 120 and was refractory to tolvaptam therapy. This was d/c'ed after a goals of care discussion with the family. After goals of care changed and patient became a candidate for LVAD, sodiums levels were low to normal and no further work-up was performed. #Hypotension: Patient??????s etiology likely is a combination of endstage heartfailure/cardiogenic shock as well as iatrogenic causes from multiple blood pressure lowering medications including sildenafil, metolazone, recent use of lisinopril, metoprolol, spironolactone, and torsemide, which were restarted once patient arrived on floor. While patient had gram positive bacteremia with MRSE, he did not appear septic and received appropriate antibiotic coverage with vancomycin. He was started on peripheral dopamine for BP support on the floor. On arrival to the CCU, his BP medications and diuretics were held. A CVC was placed and he was started on levophed, dopa and continued on milrinone. Patient was eventually weaned off dopa and levophed after patient was made CMO. After goals of care changed, paitent was continued on milrinone and did not require additional pressors both on the floor and upon return to CCU. . # POSITIVE BLOOD CULTURES: Blood cultures obtained in ED on [**7-28**] grew 4/4 bottles GPCs in clusters, with the likely culprit being chronic PICC for milrinone infusion. Pt was empirically started on Vancomycin (course completed in house.) Surveillance BCx were obtained. His home PICC line was discontinued. Repeat cultures were negative. Another PICC line was placed to continue milrinone infusion. # Acute Kidney Injury - His baseline Cre appears to be around 1.8 but this rose to 2.8 over the course of his admission, likely [**3-13**] to failing pump function +/- a component of overdiuresis at various times. UOP was maintained around 20-50cc/hr over the course of his time in the CCU with levophed and milrinone. He put out adequate urine on the floor as well upon transfer back to the CCU. His discharge creatinine is 1.4 which is the lowest since admission. #Pulmonary Hypertension Has been continued on Sildenafil. Transitional #Hypertension: Patient was on many hypertensive medications upon admission to [**Hospital1 18**] including Metoprolol and spironolactone. These are currently being held and will continue to be held upon discharge. Please note these medications for when he is discharged from [**Hospital **] medical center. Medications on Admission: -Allopurinol 100mg PO daily -Glimepiride 2mg PO daily -Metoprolol succinate 25mg PO daily -Milrinone 1mg/mL sol'n: 4.2 mL/hr (0.25mcg/kg/min based on wt 56kg) -Potassium chloride 20mg PO QOD -Sildenafil 20mg PO TID -Simvastatin 40mg PO daily -Spironolactone 12.5mg PO daily -Torsemide 100mg PO daily -ASA 81mg PO daily -Multivitamin Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 2. Docusate Sodium (Liquid) 100 mg PO BID 3. Milrinone 0.25 mcg/kg/min IV INFUSION Use dosing weight of 56 kg RX *milrinone 1 mg/mL continuous Disp #*1 Bag Refills:*0 RX *milrinone 1 mg/mL 0.25mcg/kg/min infusion continuous Disp #*1 Bag Refills:*0 4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 5. Senna 1 TAB PO BID:PRN Constipation 6. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q2H:PRN SOB, pain RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth q 2-4 hrs Disp #*30 Milligram Refills:*3 7. Lorazepam 1 mg PO Q4H:PRN anxiety 8. Aspirin 81 mg PO DAILY 9. Allopurinol 100 mg PO DAILY 10. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 11. Heparin 5000 UNIT SC TID 12. Acetaminophen 650 mg PO Q6H:PRN pain please do not exceed 2 grams daily 13. Benzonatate 100 mg PO BID:PRN cough 14. Guaifenesin [**6-19**] mL PO Q6H:PRN cough 15. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 16. Sarna Lotion 1 Appl TP QID:PRN pruritis 17. Sildenafil 20 mg PO TID Hold for systolic BP <80, please [**Name8 (MD) 138**] MD if holding dose 18. Simvastatin 40 mg PO DAILY Discharge Disposition: Home with Service Discharge Diagnosis: Primary diagnosis: Chronic systolic heart failure 3V coronary artery disease Secondary diagnosis: Hypertension Hyperlipidemia Gout Type 2 diabetes mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [**Known lastname 9723**], You were hospitalized with weakness and muscle cramps. The sodium level in your blood was low. You were also noted to have bacteria growing in your blood thought to be due to the PICC line that you had in place. The old PICC line was discontinued. You had a new PICC placed during this admission. You also underwent a paracentesis to remove the fluid that accumulated in your abdomen. We have placed a permanent catheter in your abdomen to continuosly drain the fluid. The decision was made by your family to transition your care to focus on comfort. We moved you down to the floor ([**Hospital Ward Name 121**] 3) and you became better from a clinical standpoint. Dr. [**First Name (STitle) 437**], your attending cardiologist, decided given your clinical turn, you may benefit from an LVAD (Left ventricular assist device). Because of this change, we restarted your medications and monitored your sodium more closely. You were then transferred back to the floor because we needed to more closely watch your blood pressures. We started your workup for an LVAD with a liver biopsy to rule out a condition called cirrhosis. Fortunately, the biopsy came back negative and you are now being trasferred to [**Hospital 3278**] Medical Center for first a right heart cath, and then LVAD placement. It was a pleasure taking care of you, Mr [**Known lastname 9723**]. Followup Instructions: Is being transferred to [**Hospital 3278**] Medical center for LVAD placement PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Hospital6 733**] ([**Telephone/Fax (1) 9831**]) Cardiologist: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] ([**Telephone/Fax (1) 9832**])

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Discharge summary

report

Admission Date: [**2196-3-27**] Discharge Date: [**2196-4-6**] Date of Birth: [**2130-10-1**] Sex: F Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors / Reglan / Pravastatin Attending:[**First Name3 (LF) 2265**] Chief Complaint: SOB, weight gain, abdominal distension Major Surgical or Invasive Procedure: Right IJ CVL History of Present Illness: 65 F with history of DMII, HTN, HL, CHF, CKD (baseline creat 1.1-1.5) presents with worsening SOB and DOE x 5 days that started after her colonoscopy for which she took Golytely. Reports 10 lb weight gain and sensation of abdominal distension since then. Had transient substernal chest pain since this morning, started while at rest, worse with moving. Denies any fevers, chills, n/v, cough, diarrhea, dysuria. Had some chills at home but when took temperature, did not have a fever. Her cardiologist had asked her to increase torsemide from 10 mg daily to 20 mg daily recently in the setting of increase weight gain. Daughter states her systolic bp earlier today was in the 70's-80's, baseline is usually 110-120s. . In the ED, her initial vitals were: 100.8 97 106/54 18 93% RA. EKG showed concern for lateral ST depressions. Found to have a systolic blood pressure in the 70s, CVL was placed, levophed started with stabilization of BP in low 100s. CXR shows pulmonary edema. BNP notably elevated at 7436, JVP elevated, she was given lasix 20 mg IV x1, and lasix 40 mg IV x1. Repeat rectal temperature was 102.0F, was given ceftriaxone and azithromycin for concern of pneumonia. Her chest pain improved following 2mg of IV morphine. Guaiac negative, was given ASA and started on heparin drip. Labs notable for troponin of 0.91, creatinine elevated at 2.4 from her baseline of 1.1-1.5, lactate of 2.9. . On transfer to CCU her most recent vitals were: 107/60, 80, 98%1L . Notably, was admitted here for CHF flare in 11/[**2195**]. At the time had enterococcus bacteremia. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for chest pain, dyspnea on exertion, SOB, orthopnea, weight gain. Denies palpitations, syncope or presyncope. Past Medical History: DMII HTN HL CHF Chronic Kidney Disease CAD / LCX angioplasty without stent [**2178**] Diabetic gastroparesis Social History: No tobacco, alcohol, illicits. Lives with daughter Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: Admission physical exam: GENERAL: NAD, AAOx3 HEENT: PERRL, EOMI, OP clear, MMM, +JVD to jaw CARDIAC: faint heart sounds, S1S2, RRR, no m/r/g LUNGS: bibasilar crackles, respiration unlabored ABDOMEN: soft, distended, nontender, +BS EXTREMITIES: light 1+ edema bilatearlly, 2+ peripheral pulses NEURO: AAOx3, CNII-XII intact, 5/5 strength throughout Discharge physical exam: Vitals: 98.2 126/77 75 98% RA Fs 190 I/O: [**Telephone/Fax (1) 100115**] (-700cc) x24 hrs GENERAL: NAD, Sitting up in bed speaking in full sentences HEENT: MMM, JVP difficult to assess [**2-4**] body habitus. CHEST: Few bibasilar crackles CV: RRR, no excess sounds appreciated ABD: regular bowel sounds, soft, non tender, no rebound/guarding. EXT: wwp, no edema. Pertinent Results: [**2196-3-27**] 02:24PM BLOOD WBC-9.4 RBC-3.19* Hgb-9.6* Hct-27.9* MCV-87 MCH-30.2 MCHC-34.5 RDW-14.0 Plt Ct-216 [**2196-3-31**] 07:30AM BLOOD WBC-12.8* RBC-2.92* Hgb-8.4* Hct-26.2* MCV-90 MCH-28.6 MCHC-31.9 RDW-14.2 Plt Ct-374 [**2196-4-2**] 02:57AM BLOOD WBC-17.2* RBC-2.64* Hgb-7.9* Hct-23.9* MCV-91 MCH-30.1 MCHC-33.1 RDW-14.4 Plt Ct-460* [**2196-4-1**] 07:45PM BLOOD Neuts-87.5* Lymphs-10.5* Monos-1.7* Eos-0.1 Baso-0.1 [**2196-3-30**] 06:16AM BLOOD PT-12.1 PTT-27.0 INR(PT)-1.1 [**2196-3-27**] 02:24PM BLOOD Glucose-263* UreaN-54* Creat-2.4*# Na-138 K-4.5 Cl-103 HCO3-21* AnGap-19 [**2196-4-1**] 10:55AM BLOOD Glucose-403* UreaN-57* Creat-2.2* Na-135 K-4.8 Cl-92* HCO3-25 AnGap-23* [**2196-3-30**] 06:16AM BLOOD Glucose-267* UreaN-37* Creat-1.5* Na-137 K-4.4 Cl-99 HCO3-27 AnGap-15 [**2196-4-2**] 03:31PM BLOOD Glucose-220* UreaN-66* Creat-3.0* Na-142 K-4.4 Cl-103 HCO3-25 AnGap-18 [**2196-4-1**] 07:20AM BLOOD ALT-46* AST-28 LD(LDH)-298* CK(CPK)-73 AlkPhos-94 TotBili-0.7 . Imaging: CXR [**3-27**] FINDINGS: Compared to prior exam, there is increased pulmonary edema, which is now moderate-to-severe. Subtle consolidation may be obscured by this edema. There is likely a left pleural effusion; retrocardiac opacity may be related to adjacent atelectasis but is incompletely evaluated on this single view. No pneumothorax is detected. Cardiomegaly persists. IMPRESSION: Increased moderate-to-severe pulmonary edema TTE [**3-29**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with basal to mid inferior and lateral akinesis to hypokinesis. Estimated LVEF ?35-40 percent but views are subotpimal for assement of ventricular wall motion. Right ventricular chamber size is normal with borderline normal free wall function (regional motion could not be adequately assessed). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a trivial pericardial effusion. . CXR [**3-31**]: FINDINGS: There is significant improvement in bibasilar opacities compared to [**3-29**]. Cardiomegaly and moderate bilateral pleural effusions are essentially unchanged. There is no definite focal consolidation; however, underlying pneumonia cannot be excluded. There is no pneumothorax. The right internal jugular catheter has been removed. IMPRESSION: Improved pulmonary edema. . CXR [**4-2**]: FINDINGS: In comparison with the earlier study of this date, there is now a nasogastric tube in place. It extends well into the stomach, then coils back on itself so that the tip lies in the upper stomach, both below the esophagogastric junction. There is still significant pulmonary edema, though improved since the earlier study. . [**4-3**] CT abdomen and pelvis 1. No acute abdominal pathology, especially no evidence of colitis or bowel obstruction is seen. 2. Extensive vascular calcifications of the abdominal aorta and major visceral branches. 3. Bilateral moderate-sized simple pleural effusion, with compressive atelectasis of the lung bases. 4. Small subcutaneous bleed in the the left lower abdomen, likely related to subcutaneous injection. . Troponin trend: [**2196-3-27**] 02:24PM BLOOD cTropnT-0.91* [**2196-3-28**] 04:21AM BLOOD CK-MB-5 cTropnT-1.11* [**2196-3-28**] 05:31PM BLOOD CK-MB-5 cTropnT-1.08* [**2196-4-1**] 07:20AM BLOOD CK-MB-2 cTropnT-0.38* . Discharge labs: [**2196-4-6**] 06:55AM BLOOD WBC-12.2* RBC-2.94* Hgb-8.6* Hct-27.1* MCV-92 MCH-29.1 MCHC-31.6 RDW-16.7* Plt Ct-451* [**2196-4-6**] 06:55AM BLOOD Plt Ct-451* [**2196-4-6**] 06:55AM BLOOD Glucose-56* UreaN-35* Creat-1.5* Na-143 K-3.6 Cl-102 HCO3-30 AnGap-15 [**2196-4-1**] 07:20AM BLOOD ALT-46* AST-28 LD(LDH)-298* CK(CPK)-73 AlkPhos-94 TotBili-0.7 [**2196-4-5**] 07:40AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.3 [**2196-4-2**] 05:34PM BLOOD Lactate-0.8 Brief Hospital Course: SUMMARY: 65F with history of DMII, HTN, HL, CHF, CKD admitted for acute on chronic systolic heart failure exacerbation briefly requiring pressors. Also required transfer to MICU for short period for insulin gtt during hyperglycemia and evolving acidosis . #. Acute on Chronic Diastolic CHF - Patient was diuresed in the CCU on a lasix gtt while requring pressor support for hypotension. She was then transitioned to an IV bolus regimen of 40mg lasix. She was discharged at her estimated dry weight of ~66-67kg. She was restarted on daily torsemide upon discharge, with instructions to follow-up with her PCP and outpatient cardiologist. . # Hypotension - She was thought be hypotensive due to heart failure on admission. She initially had a fever and leukocytosis, however work-up was unrevealing and empiric antibiotics were stopped shortly after admission. She was quickly weaned of pressors within 24 hours. . # Demand Ischemia - Troponin elevated at 0.91 on admission. EKG with some subtle ST changes in lateral leads. This was felt most likely related to demand ischemia in the setting of heart failure and hypotension. Initially started on heparin drip on admission, but this was stopped for low suspicion of ACS. . # Acute on chronic renal failure - Baseline creat 1.1-1.5, but presented with creat 2.4. Initially this improved with diuresis, however worsened in the setting of severe N/V and hyperglycemia. After further diuresis, her Cr was improving at the time of discharge. Most likely etiology was poor forward flow in setting of heart failure and hypotension given improvement with diuresis. Lisinopril was held . # Hyperglycemia Last A1c dated [**2196-3-1**] was 8.6. Her PO intake was inconsistent during her stay due to significant nausea and vomiting. Her insulin doses were decreased due to multiple episodes of hypoglycemia to the 40s. On [**4-1**], she had blood sugars in the 400s and an evolving anion gap. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was called and recommended an insulin drip. She was transferred to the MICU team for this drip. She was weaned off the gtt and transferred back to the floor. Her sugars began to stabilize and she was transitioned to a subcutaneous insulin regimen with the help of the [**Last Name (un) **] team. Her outpatient endocrinologist was contact[**Name (NI) **], and the patient was instructed to contact her diabetes specialist within 24 hours after discharge and to carefully record her blood sugars. She was to use the [**Last Name (un) **] recommended regimen until discussing with her outpatient team. . # CAD: See discussion above regarding CHF. Metoprolol was continued as blood pressures stabilized. ASA was continued. . # N/V: Most likely related to severe gastroparesis. Improved with NPO and IV anti-emetics. A KUB did not reveal obstruction, and an NG tube did not improve her symptoms. Her omeprazole was decreased to [**Hospital1 **] dosing from TID. . # Leukocytosis: Unclear etiology. Work-up was unrevealing. Was trending down at discharge, and should be followed closely with her PCP. . # HTN: Lisinopril held in setting of hypotension and [**Last Name (un) **]. Should be followed at PCP [**Name9 (PRE) 702**] visit. . # HL: In setting of statin allergy, ezetimibe was continued. . =============== -Consider restarting ACE-I at follow-up visit if creatinine and blood pressures tolerate -Follow resolving leukocytosis and acute kidney injury at follow-up visit with PCP [**Name10 (NameIs) 100116**] regimen to be titrated by outpatient endocrinologist -[**Month (only) 116**] need colonoscopy rescheduling per PCP [**Name10 (NameIs) **] on 20mg daily torsemide at discharge Medications on Admission: Lisinopril 5 mg daily Prilosec 20 mg TID before meals Docusate Sodium 2 tablets qAM, 1 tablet qPM Torsemide 20 mg daily Ferrous Sulfate 325 mg daily Insulin Glargine 28 units [**Hospital1 **] Insulin Aspart sliding scale Metoprolol Succinate 12.5 mg daily Aspirin 81 mg daily Calcium Carbonate-Vitamin D3 500 mg(1,250mg)-400 unit, 2 tablets [**Hospital1 **] Cod Liver Oil 2 tablets daily Multivitamin 1 tablet daily Sennosides 1 tablet prn constipation Colestipol 1 gram daily (4 hours away from all other meds) Erythromycin 250 mg TID Omega-3 Fatty Acids-Vitamin E 1,000 mg 2 capsuls daily Ezetimibe 10 mg daily Trazodone 50 mg qhs Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. Calcium with Vitamin D Oral 8. cod liver oil Capsule Sig: Two (2) Capsule PO once a day. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 12. omega-3 fatty acids-vitamin E 1,000 mg Capsule Sig: Two (2) Capsule PO once a day. 13. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 15. Insulin According to the attached directions, please call to discuss with your primary endocrinologist after discharge Discharge Disposition: Home Discharge Diagnosis: Acute systolic congestive heart failure Acute on chronic renal insufficiency Hyperglycemia and type 2 diabetes diabetic gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted and treated for an exacerbation of your heart failure which caused shortness of breath. We treated you with water pills to get rid of the excess fluid. You should continue to follow a strict diet limiting your salt and fluid intake. . You also had some problems with your blood sugars. Attached you will find the insulin regimen recommended by our diabetes doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] were in the hospital. As we discussed, you should use this scale until you call your regular outpatient endocrinologist and carefully record your blood sugars when you return home. . Please also note the following medication changes: -Please STOP taking lisinopril until you see your primary doctor next week -Please DECREASE omeprazole to twice daily dosing -Please TAKE your home dose of torsemide this evening, and then continue taking torsemide 20mg daily until you see your primary doctor -Please take your other medications as previously prescribed Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please call your endocrinologist when you return home to discuss your insulin regimen and to schedule an appointment Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA (works with Dr. [**Last Name (STitle) **] Location: [**Location (un) 2274**]-[**Location (un) **], Internal Medicine Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 17465**] Appt: [**4-11**] at 11am Name: Come, [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) 2274**] [**Location (un) **], Cardiology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] ***The office is working on an appt for you in the next [**2-5**] weeks and will call you at home with the appt. IF you dont hear from them by Thursday, please call the office directly to book. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**] Completed by:[**2196-4-7**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

13375, 13381

7717, 11423

358, 372

13559, 13559

3540, 7230

14813, 15910

2653, 2768

12106, 13352

13402, 13538

11449, 12083

13710, 14358

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14378, 14790

280, 320

400, 2436

13574, 13686

2458, 2568

2584, 2637

3157, 3521

10,635

119,604

50063

Discharge summary

report

Admission Date: [**2122-4-6**] Discharge Date: [**2122-4-11**] Date of Birth: [**2068-11-10**] Sex: F Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female with a complicated history of asthma and demyelinating syndrome presenting with shortness of breath and worsening cough. The patient was in her usual state of health until [**2122-4-2**] when she developed a cough and upper production. She noted that either Thursday or Friday, she also has a fever to 101.6. She denied nausea, vomiting currently, but had an episode of emesis on Friday, which was approximately three days prior to admission. She denied any abdominal pain, chest pain. She had shortness of breath. The patient denies any recent animal contacts, but does note that she went to [**University/College **], [**Location (un) 3844**] with her daughter denies any diarrhea or constipation. She had a mild headache. She denied any photophobia or neck pain. In the Emergency Department, the patient was put on continuos albuterol nebulizers and treated with levofloxacin, hydrocortisone and Solu-Medrol as per med sheet. She was transferred to the Medical Intensive Care Unit for management and further observation. PAST MEDICAL HISTORY: 1. Asthma. Unresponsive to steroids and heliox in the past. The patient has been intubated times two . She is on BiPAP 15 x 5 at home. She has a pCO2 which runs in the 40-60 range. Most recent PFTs from [**2115**] show an FVC of 1.07, which is 34% of predicted, FEV1 of 0.88, which is 37% predicted and an FEV1 to FVC ratio of 108% and a normal corrected DLCO. 2. Demyelinating syndrome with autonomic instability. 4. Labile hypertension. 5. Depression/anxiety 6. Right IJ deep vein thrombosis. 7. Muscle spasms. 8. History of IgG deficiency. 9. Cholecystectomy. 10. Odynophagia with percutaneous endoscopic gastrostomy placement. 11. Hypercholesterolemia. 12. Breast papilloma. 13. Anemia. 14. Status post appendectomy. 15. Status post mastoidectomy. 16. Hypothyroidism. ALLERGIES: The patient has an allergy to the propellent in Azmacort. She states she is allergic to versed, clindamycin and Fentanyl. MEDICATIONS ON ADMISSION: 1. Levoxyl 15 mcg po q.d. 2. Baclofen 20 mg po t.i.d. 3. Florinef 0.1 mg po q.d. 4. Klonopin 2 mg po t.i.d. . 6. BuSpar 10 mg po t.i.d. 7. [**Year (4 digits) 102130**] 8 mg po q.i.d. 8. Serax prn. 9. Lipitor 10 mg po q.d. 10. Ultram 100 mg po q. 6 hours prn. 11. Ativan prn. 12. Albuterol nebulizers. 13. Tube feeds (Nutren [**12-21**] cans q.d.). SOCIAL HISTORY: The patient has a 25 pack year tobacco history. She quit years ago. She denies any alcohol use. She lives at home with her husband. FAMILY HISTORY: Patient has a family history of colon cancer, breast cancer and brain cancer. PHYSICAL EXAMINATION: Vital signs: Temperature 97.6. Pulse of 100. Blood pressure 96/56. Respiratory rate of 16, saturating 96% on 100% face mask and nasal cannula. In general chronically ill appearing, the patient is a pleasant female in moderate respiratory distress, speaking in short sentences. Head, eyes, ears, nose and throat shows dry mucous membranes. Pupils equal, round and reactive to light. Extraocular movements are intact. The neck is supple. There is no lymphadenopathy. The heart is regular rate and rhythm. There are no murmurs, rubs or gallops. The lungs show diffuse rhonchi. There are no wheezes. The abdomen is soft, nontender, nondistended. There are normal active bowel sounds. The extremities are without cyanosis, clubbing or edema. There was 1+ edema bilaterally. The pulses are intact distally. The neurological exam shows her to be alert and oriented times three. She has left-sided upper and lower extremity weakness 4/5. The right side has 5/5 strength. Sensation is intact throughout. The reflexes are somewhat spastic on the left when compared to the right. LABORATORIES ON ADMISSION: White blood cell count of 6.7, hematocrit of 42.6, platelets of 358,000 with an MCV of 96. Sedimentation rate is 4, that was on [**3-24**]. Sodium was 143, potassium 3.3, chloride was 105, bicarbonate 29, BUN 9, creatinine 0.6, glucose of 104, calcium of 9.5, phosphorus of 3.3, magnesium of 2.2, free T4 is 1.1. Arterial blood gases done in the Emergency Department showed 7.28, pCO2 of 65 and PO2 of 88. IMAGING: A chest x-ray done on admission showed no acute changes compared with old. It was clear. HOSPITAL COURSE: The patient was initially admitted to the Medical Intensive Care Unit for further observation and management. Once she was admitted to the Medical Intensive Care Unit, they noted an increase respiratory rate and the patient became increasingly hypoxic. The team wanted to intubate her at that time, but the patient declined. She wanted to continue to try to manage her own airway. In addition, she had coffee grounds, which were suctioned from her G tube. She was started on levofloxacin and Flagyl for a question of bronchitis and possible aspiration. She was started on Protonix b.i.d. given the evidence of acute gastrointestinal bleed. On the first hospital night, the patient had multiple episodes of elevated respiratory rate, which were all responsive to reassurance and Ativan. The patient was getting cool mist nebulizers continuously with good effect. Her arterial blood gases in the afternoon of [**4-6**], showed an improvement to 7.31 with a pCO2 down to 49 and a PO2 up to 184 on cool mist nebulizers. The patient was transferred to the General Medical Floor on [**2122-4-7**]. On arrival to the floor, the patient was saturating around 90% on nasal cannula. She was started on a cool mist face mask and her saturation increased to 99%. She also was complaining left-sided rib pain, which hurt with inspiration and movement. She denied any other pain. She stated her breathing felt slightly "labored." On exam at that time, significant findings included intense pain laterally over the inferior costal margin on the left. The rest of this dictation will be continued in system format. 1. Pulmonary: Given the patient's shortness of breath and sputum production, she was felt to have a likely asthma exacerbation with possible bronchitis. In addition, an allergic reaction was felt to be a possible instigating factor. This seemed possible especially given her recent trip to [**Location (un) 3844**]. She has a history of allergies in the past. She was started on [**Doctor First Name **] 60 mg po b.i.d. as well as beconase nasal spray b.i.d. She was continued on Atrovent and albuterol standing four times a day, as well as albuterol and Atrovent nebulizers as needed. Her hydrocortisone was changed to prednisone 60 mg a day. Her antibiotics were discontinued as there was no evidence of active infection. It was felt to watch her clinically and follow her cultures. If she were to spike a fever, then antibiotics would be re-instituted. Each day, she continued to improve from a pulmonary standpoint. When she initially came to the floor, she appeared somewhat lethargic and was likely retaining CO2 given her history of this in the past. Her oxygen was titrated down to maintain saturations around 93% and she eventually became more alert and by the time of discharge, she was saturating 93% on room air. 2. Musculoskeletal: Given her left-sided chest pain, a set of plain films were obtained of her ribs which showed rib fractures of the tenth and eleventh ribs laterally on the left. She was started on Percocet for pain relief with good effect. She did not have increasingly somnolence from the Percocet, but was able to take deeper breaths given her pain relief. She was started on calcium and Vitamin D for likely osteoporosis, given her long-term history of steroid use, as well as immobility. She may need to be started on Fosamax as an outpatient. She was due for a bone density test during this admission, which was scheduled for an outpatient, however, she was not able to make this appointment. She will reschedule as an outpatient. 3. Gastrointestinal: The patient had an episode of coffee grounds noted suctioned from her percutaneous endoscopic gastrostomy tube while in the Medical Intensive Care Unit. Her hematocrit went from 42.6 at admission down to 35.6 on the second hospital day. However, after that, it remained stable in the 34 range. She had no further episodes of blood noted. She had a guaiac negative stool the day prior to discharge. She was continued on Protonix throughout her hospital course. She was able to tolerate soft po in addition to her supplemental tube feedings. 4. Endocrine: The patient was continued on her levothyroxine for her hypothyroidism. Her blood pressure was watched carefully given her history of steroid use, but no evidence of adrenal insufficiency occurred. She was continued on her Florinef q.d. 5. Psychiatry: The patient has a history of anxiety and depression, as well as the question of paroxysmal vocal cord dysfunction, which is increased with anxiety. It is noted that her respiratory distress does get worse when she is anxious although it is equally likely that she gets more anxious as a result of being short of breath. She was continued on her antianxiety medications while in the hospital with good effect. CONDITION AT DISCHARGE: Good. The patient was much more awake and alert, moving around the room, up in her wheelchair, functioning well. As already stated, her saturation was 93% on room air. MEDICATIONS ON DISCHARGE: 1. Albuterol MDI 2 puffs q.i.d. 2. Albuterol nebulizers 1 nebulizer q. 4-6 hours prn. 3. [**Doctor First Name **] 60 mg po b.i.d. 4. Ativan 1 mg po q.d. prn. 5. Baclofen 20 mg po t.i.d. 6. Beclomethasone 2 sprays each nostril b.i.d. 7. BuSpar 10 mg po t.i.d. 8. [**Doctor First Name 102130**] 4 mg po q. 6 hours. 9. Tums 500 mg po t.i.d. with meals. 10. Klonopin 2 mg po t.i.d. 11. Colace 100 mg po t.i.d. 12. Flovent 2 puffs b.i.d. 13. Florinef 0.1 mg po q.d. 14. Atrovent 2 puffs q.i.d. 15. Levoxyl 50 mcg po q.d. 16. Lipitor 10 mg po q.d. 17. Prednisone taper over the next ten days. 18. Protonix 40 mg po q.d. times two months. 19. Roxicet 5-10 cc po q. 4-6 hours prn. 20. Ultram 50 mg 1-2 tablets po q. 6 hours prn. 21. Vitamin D 400 units po q.d. 22. Nutren fiber tube feeds 1 can t.i.d. prn. It should be noted that the pharmacy called me the night of discharge as Roxicet was not available. The patient was given a change in prescription to Percocet 1-2 tablets po q. 4-6 hours prn. DISCHARGE FOLLOW-UP: The patient was to make an appointment with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1446**] [**Last Name (NamePattern1) **], within one week following discharge. In addition, she was to have repeat pulmonary function tests performed when her rib fractures were healed. She would be followed by her usual physical therapist, [**Doctor First Name 4051**], at phone number [**Telephone/Fax (1) 104528**]. DISCHARGE DIAGNOSES: 1. Asthma exacerbation. 2. Upper gastrointestinal bleed. 3. Constipation. 4. Rib fractures (left tenth and eleventh). 5. Demyelinating syndrome. Add- We also suggested that pt would benefit from outpatient pulmonary f/u including PFTs once at her baseline and possible pulmonary rehab. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**] Dictated By:[**First Name3 (LF) 104533**] MEDQUIST36 D: [**2122-4-13**] 12:00 T: [**2122-4-13**] 12:00 JOB#: [**Job Number **]

[ "300.00", "255.4", "341.9", "493.02", "276.8", "733.19", "578.9", "458.9", "276.5" ]

icd9cm

[ [ [] ] ]

[ "96.36", "96.6" ]

icd9pcs

[ [ [] ] ]

2749, 2828

11075, 11636

9573, 11054

2223, 2580

4498, 9361

2851, 3955

9376, 9547

184, 1254

3970, 4480

1276, 2197

2597, 2732

14,037

185,837

13666+56477

Discharge summary

report+addendum

Admission Date: [**2196-8-15**] Discharge Date: [**2196-8-24**] Date of Birth: [**2146-12-16**] Sex: M Service: Oncology Medicine HISTORY OF PRESENT ILLNESS: This is a 49-year-old man with a history of systemic and CNS lymphoma, who was transferred from [**Hospital1 41211**] Hospital after he experienced a prolonged seizure tonic-clonic lasting approximately one hour. According to his family, patient was doing well at home until yesterday despite a recent Clostridium difficile and Port-A-Cath infection. One day prior to admission, he had seemed more tired than usual, although he had no specific complaints. His wife heard him moan the evening before admission, which he typically does at the onset of seizure. She went to check on him. He was shaking all 4 extremities. His head was deviated to the right. This lasted about 3 minutes and then stopped. She asked some questions but he was unable to respond. She asked him to raise his arm if he understood, and he was able to do that. She says this seizure was typical with seizures. They start with eyes and head turning to the right followed by generalized tonic-clonic activity. His last seizure prior to this was in [**2196-4-24**]. About one minute after his seizure stopped, his seizure recurred. His eyes again deviated to the right. He was shaking all 4 extremities. After this continued for approximately 4 minutes, she called EMS. The next hour during the ambulance ride and arrival at the outside hospital, the patient continued to have seizure on and off. In the ambulance, he was given 4 mg of IV Ativan and received another 4 mg at the outside hospital and his seizures ceased. He did not require intubation. He is normally on Depakote and Keppra. His family denies any recent doses or any change in his doses. His valproic acid level was 95. Unknown if this was a trough and he was given another 500 mg of Depakote IV. PAST MEDICAL HISTORY: 1. EBV positive B-cell lymphoma. 2. CNS lymphoma status post XRT and intrathecal chemotherapy complicated by meningitis requiring shunt removal. 3. Seizure disorder status post left frontal craniotomy with residual left frontal lymphoma. 4. Hypertension. 5. Clostridium difficile infection. 6. Recent Port-A-Cath infection. MEDICATIONS: 1. Decadron 2 mg p.o. q.d. 2. Keppra 1,000 mg p.o. b.i.d. 3. Depakote 750 mg p.o. q.i.d. 4. Protonix 40 mg p.o. q.d. 5. Actonel 30 mg p.o. q week. 6. KCl 20 mEq p.o. q.d. 7. Flagyl 500 mg p.o. t.i.d. 8. Thiamine 100 mg p.o. q.d. 9. Rituxan. ALLERGIES: 1. ACE inhibitors. 2. Bactrim. 3. Question Dilantin caused transaminitis. SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **] alcohol or tobacco. Worked in finance prior to his medical problems. PHYSICAL EXAM: Temperature was 96.4 F. Pulse was 58. Blood pressure was 120/60. Respiration was 18. Saturation was at 98% on room air. Generally, he was not responding to voice. But he opened his eyes to sternal rub. He moved his left arm and leg spontaneously, but no verbal output. He had moist mucous membranes. His head was normocephalic, atraumatic. Oropharynx was clear. Neck was supple without carotid bruits. Lungs were clear. Heart was regular, rate, and rhythm. Abdomen was benign. Extremities were without edema. NEUROLOGICAL EXAMINATION: He opened his eyes to sternal rub, BUT not following commands at all. He did not have verbal output at all. Cranial nerves II through XII: Discs were not well visualized, with difficulty dolling eyes to the left. He had pendular nystagmus and a right facial droop. He would not protrude his tongue. Motor: When his left arm was lifted, he was able to hold it up by himself for at least 5 seconds. Spontaneously raises his left arm, right arm with decreased tone, falls right to the bed when released, withdrew with both legs to nail bed pressure and winced. His right leg was externally rotated, withdrew less to plantar stimulation with right leg compared to the left. He withdrew from pain sensation at all 4 extremities and winces. Deep tendon reflexes were decreased throughout and flexor plantar responses bilaterally. Coordination was not able to assess and gait was deferred. LABORATORIES FROM THE OUTSIDE HOSPITAL: White count of 2.8, 65 neutrophils, 7 bands, 2 lymphocytes, 5 atypical lymphocytes, 2 metamyelocytes, and 9 eosinophils. Hematocrit 29.5, platelets 70. Sodium 139, potassium 4.3, chloride 100, bicarb 29, BUN 19, creatinine 1.3, glucose 86, calcium 8, magnesium 1.4, albumin 2.9, AST 29, ALT 28, alkaline phosphatase 55, and total bilirubin less than 0.5. Valproic acid was 94.5 at midnight on [**2196-8-14**]. Blood cultures x 2 were negative growth to date. A head CT showed small areas of hyperintensity in the left frontal lobe, which is likely consistent with residual lymphoma. No evidence of a new hemorrhage or mass effect. Patient was admitted and his hospital course was significant for the following issues: Patient was admitted initially to the Neuro ICU. (1) Seizures: A Neurology consult was obtained in the Emergency Department. An EEG was obtained, which showed nearly persistent polymorphic theta frequency slowing seen over the left frontal and temporal lobes. The entire record was of low amplitude. There was no epileptiform features and no electrocardiographic seizures are recorded, thought to be consistent with a post-ictal state after prolonged seizure. A repeat EEG was obtained the following day. It was consistent with encephalopathy. Multifocal isolated sharp waves seen on the right parasagittal, central, and posterior regions. A MRI of the head was obtained, which was abnormal on FLAIR. There was extensive white matter disease in the left frontal greater than the right frontal, but study showed no evidence of a brain abscess and abnormalities did not change significantly since the prior examination. Lumbar puncture was obtained. CSF was remarkable for a white count of 1, no red blood cells, protein of 91, glucose of 41, and LDH of 30. CSF cytology was pending at the time of dictation as was beta-2 microglobulin. Gram stain was negative. The patient's Keppra level was increased to 1500 mg b.i.d. and was continued on the valproic acid 750 mg q 6 hours. Sepsis workup was undertaken with the LP negative for acute infectious process. The Flagyl, which the patient had been started on for Clostridium difficile was changed to vancomycin given the concern for a decrease seizure threshold with the metronidazole. On the next day, the patient's mental status improved but had residual right sided weakness. A swallowing study was obtained. The patient had a video swallow study. Recommendations were initiated p.o. diet consistency of thin liquids and soft solids, crushing pills in puree. Maintaining aspiration precautions with one-to-one supervision at meals to provide q's, to make sure that the patient cleared his throat and swallowed after every [**2-27**] bites or sips. Patient remained alert and oriented to name, occasionally to place. He continued to experience difficulty with word finding. No further seizure activity was observed, and he was transferred to the Oncology Medicine floor on [**2196-8-18**]. At that time, the patient seemed comfortable with no signs of seizure activity. He was continued on Keppra and Depakote. Over the next few days, the patient continued to improve. On the [**2196-8-21**], the patient was noted to have some global seizure activity in the right upper extremity and left upper extremity. On that day, he was started on Lamictal 25 mg b.i.d. and received that dose for one day afterwards the dose was reduced to 12.5 mg p.o. q.d. given the concern for increased half-life of the drug with concurrent valproic acid. He remained seizure free throughout the rest of the hospital course, and his mental status continued to improve. His right sided weakness also resolved. Patient was discharged on valproic acid, Keppra, and Lamictal with plans to titrate up the Lamictal within the next several weeks. Patient had a tremor, which was thought to be secondary to high levels of valproic acid. Tremor was not present at the time of discharge. (2) Metastatic CNS lymphoma: Due to the MRI and CSF profile provided evidence for disease progression, a staging CT of the torso was done, which showed the patient had a right sided pulmonary embolism. (3) Pulmonary embolism: Patient had a pulmonary embolism diagnosed on [**8-19**] on a staging CT. He was started on a heparin drip without a bolus. PTT was maintained in the 80 to 100 range. He also started on Coumadin. A Pulmonary consult was obtained given the concern that this might be tumor invasion. However, this was thought to be a pulmonary embolism and the patient was recommended to be on life-long anticoagulation. He was discharged on Coumadin. Heparin drip was discontinued 24 hours prior to discharge after the patient's INR was therapeutic. (4) Hyponatremia: Patient experienced hyponatremia in the Neuro ICU, question of whether this was related to fluid depletion versus CNS hyponatremia. However, the patient seemed to resolve over the next few days with IV fluids. A sodium was stable for several days prior to discharge. (5) Oncology/systemic lymphoma: CT of the torso did not show significant progression of the disease. Patient was on filgrastim for several days during the hospital course, but it was discontinued on [**2196-7-20**]. His white count decreased over the next few days. This will be monitored as an outpatient. The patient has cutaneous manifestations of his lymphoma with red blotchy areas on his back, right pelvis, and arm, which seem to come and go. The rash was watched closely given the concern for Lamictal toxicity. The patient showed no signs of this toxicity while in the hospital. (6) Infectious Disease/C. difficile Diarrhea: Patient was continued on p.o. vancomycin and discharged on p.o. vancomycin for a 14 day course. (7) FEN: The patient's electrolytes were monitored and repleted as necessary. The patient was maintained on H2 blocker and pneumoboots for DVT prophylaxis. Communication with his wife was maintained throughout the hospital course. Patient was also seen by Physical Therapy, who deemed that the patient was initially not safe to go home by himself. However, a discussion with the family was undertaken and the decision was made that the patient would go home with home physical therapy and 24 hour care. Nutrition consult was also obtained. Patient improved throughout his hospital course and was eating and drinking with supervision, diet of soft solids and thin liquids with one-to-one supervision prior to discharge. DISPOSITION: The patient was sent home with VNA services and physical therapy, and will be maintained on his seizure medications which will be titrated as an outpatient as well as Coumadin for anticoagulation. CONDITION ON DISCHARGE: The patient was discharged in good condition to home. DISCHARGE DIAGNOSES: 1. Pulmonary embolism. 2. Seizure 3. Central nervous system and systemic lymphoma. DISCHARGE MEDICATIONS: 1. Keppra 1500 mg p.o. b.i.d. 2. Lamotrigine 12.5 mg p.o. q.d. 3. Dexamethasone 2 mg p.o. q.d. 4. Famotidine 20 mg p.o. b.i.d. 5. Vancomycin 125 mg q 6 hours x 8 days. 6. Thiamine 100 mg p.o. q.d. 7. Coumadin: The dose was still to be determined at the time of this dictation pending INR. FOLLOW-UP PLANS: Patient will follow up with Dr. [**Last Name (STitle) 724**] as an outpatient. [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**MD Number(1) 748**] Dictated By:[**Last Name (NamePattern1) 10195**] MEDQUIST36 D: [**2196-8-24**] 10:34 T: [**2196-8-26**] 11:52 JOB#: [**Job Number 41212**] Name: [**Known lastname 7430**], [**Known firstname **] Unit No: [**Numeric Identifier 7431**] Admission Date: [**2196-8-15**] Discharge Date: [**2196-8-24**] Date of Birth: [**2146-12-16**] Sex: M Service: Oncology Medicine ADDENDUM: 1. Anticoagulation: Patient's INR on the day of discharge was 4.3. The patient was discharged with instructions to hold the Coumadin for the day of discharge and the following day, and to restart 0.5 mg starting on Friday x3. Patient has nursing for INR checks at home, which will be reported to Dr. [**Last Name (STitle) 25**]. [**Doctor Last Name **] [**Doctor First Name 58**] [**Name8 (MD) **], M.D. [**MD Number(1) 59**] Dictated By:[**Last Name (NamePattern1) 2685**] MEDQUIST36 D: [**2196-8-24**] 13:53 T: [**2196-8-26**] 06:02 JOB#: [**Job Number 7432**]

[ "782.1", "276.1", "202.80", "780.39", "401.9", "415.19", "008.45" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

11062, 11146

11169, 11460

2778, 10961

11478, 12717

176, 1929

1951, 2617

2634, 2762

10986, 11041

21,405

175,729

53726

Discharge summary

report

Admission Date: [**2182-11-6**] Discharge Date: [**2182-12-6**] Service: HISTORY OF PRESENT ILLNESS: Patient is an 84-year-old male with past medical history of diverticulosis, anemia, silent MI with ejection fraction of 25%, prostate cancer, gastrointestinal bleed, polymazic rheumatica and infrarenal abdominal aortic aneurysm of 7.3 cm. Patient had an elective abdominal aortic aneurysm repair on the [**8-30**]. It was an endovascular repair for a 7.5 infrarenal abdominal aortic aneurysm. The procedure was complicated by a type I endoleak. The patient returned for an open repair on the [**9-5**] then admitted to the SICU. With difficulty weaning the patient postoperatively, he remained on a ventilator until [**11-13**]. The patient required diuresis in order to be weaned from the ventilator. He also was treated with Kefzol for 11 days due to bilateral drainage from groin incisions. He also had received Ceftriaxone to cover for a possible pneumonia. The patient had episodes of paroxysmal atrial fibrillation postoperatively with a heart rate in the 150s and drop in his blood pressure. EP was consulted. The patient was treated initially with beta blocker and Amiodarone with anticoagulation. The patient converted back into normal sinus rhythm, though he did have episodes of bradyarrhythmia down to the 30s. EP felt the patient had Tachy-Brady syndrome and recommended against continuing further beta blocker. It was felt that the patient had infiltrates and pneumonia possibly secondary to aspiration that was contributing to his paroxysmal atrial fibrillation. The pneumonia was treated for 14 days of Ceftriaxone. The patient went into normal sinus rhythm and remained there for the rest of his hospital stay. After extubation on the 30th, the patient remained having some respiratory difficulty requiring Bi-PAP for CO2 retention. He had problems with thick tenacious secretions with waxing mental status. He was eventually weaned from the Bi-PAP to nasal cannula and transferred to the floor on the [**10-22**]. He was saturating in the 90s on nasal cannula. On the [**10-26**], the patient had a swallowing study which showed aspiration. The patient became tachypneic and had an ABG of 7.22, 63, 111. He was transferred back to the MICU secondary to hypercarbia, respiratory distress and change in mental status. He was stabilized on Bi-PAP. He remained stable until the [**10-28**] where he had decreased mental status and an ABG showing 7.12, 94, 163 on Bi-PAP. The patient was having thick tenacious tan secretions which altered his respiratory status. He was transferred from the MICU on the 14th for stabilization and management of his respiratory failure. PAST MEDICAL HISTORY: 1. Myocardial infarction. He had a V-fib arrest on a tennis court approximately 30 years ago. Ejection fraction is approximately 25% on echo in [**2182-10-15**]. He had a Persantin thallium test on [**2182-10-23**] which showed a fixed inferior defect with an ejection fraction, once again, of 25%. 2. The patient has prostate cancer thought possibly to be metastatic. He is currently taking Lupron injections. His last injection was 22.5 mg IM on the [**11-4**]. Infrarenal abdominal aortic aneurysm of 7.3 cm. 4. Also a 5.6 cm ascending aortic aneurysm. 5. Anemia with a ferratin greater than detectable levels indicating chronic disease. 6. PMR on chronic Prednisone 5 mg q.d. 7. Vertebral compression fractures. 8. GI bleed. He required transfusion two years. Colonoscopy showed diverticulosis as the most likely etiology. 9. Hernia repair approximately 40 years ago. ALLERGIES: 1. Norvasc. 2. Celebrex. OUTPATIENT MEDICATIONS: 1. Prednisone 5 mg q.d. 2. Losartan 50 mg q.d. 3. Toprol 75 mg q.d. SOCIAL HISTORY: Patient is married. His sons and wife are also involved in his care. He smoked for approximately 10 years and quit about 35 years ago. Prior to admission the patient used a walker for ambulation. PHYSICAL EXAMINATION: Vitals, 98.8 F temperature, pulse 83, blood pressure 153/66, respiratory rate 17, SVO2 100% on AC of 550 with tidal volume 410 to 720, respiratory rate of 12 to 19 with PEEP of 5 and fio2 of 100%. Patient was a thin elderly man intubated. Pupils were constricted. Sclerae nonicteric. Dry blood in creases of mouth with dry mucous membranes. No jugular venous distention. Coarse breath sounds. Bilateral diffuse rales. Regular rate and rhythm, S1, S2. There is a II/VI systolic ejection murmur right sternal border greater than left. Midline abdominal scar with staples. Soft with normoactive bowel sounds. No tenderness, no rebound, no distention. Extremities: No cyanosis, clubbing or edema. The patient does have a slightly bulging area from his right groin. Neuro: He was non-responsive when he was admitted due to sedation and intubation. LABORATORIES ON ADMISSION TO MICU: Sodium 143, potassium 4.3, chloride 107, bicarbonate 27, BUN 46, creatinine 0.6. CKs were flat at 28, 32, 20. White count 12.9, hematocrit 33.2, platelets 235 at the time of admission. Last ABG at the time of admission to the MICU of 7.36, 69, 94% and free calcium 7.24. MICU COURSE: Patient is an 84-year-old male status post abdominal aortic aneurysm repair complicated by endoleak, hypotension converted to open repair, prolonged weaning from vent most likely secondary to volume overload with extended intubation followed by possible probable aspiration in context of a swallowing study and respiratory distress secondary to that aspiration and mucous plugging. 1. RESPIRATORY FAILURE: Patient was initially AC intubated. He eventually underwent trach placement on the [**10-29**]. The patient also had chest VT and frequent suctioning to help with mucous plugging. The patient initially had difficulty weaning off AC on the trach tube. We tried to wean him to pressor support and then to trach mask. The patient had stridorous noises coming from the trach tube without a leak, pain as well as respiratory distress every time he was taken off of the ventilator onto the trach mask. The patient was rebronched on the 19th. It was discovered that his trach tube was too large and the posterior aspect of the trach tube was being occluded by the posterior wall of the trachea as well as resulting in a small ulceration in the posterior wall of the trachea. The trach tube was changed to an appropriate sized trach tube with the help of Interventional Pulmonology. After being changed, the patient was able to be weaned from AC to pressor support and then to a trach mask, 50% trach mask on the day of discharge, the [**11-5**]. His last ABG on 50% trach mask on the 21st was 7.36, pO2 of 123 and CO2 of 49. The patient has not had any problems with mucous plugging over 36 hours. He definitely requires significant pulmonary toilet and having the patient out of bed in a chair will in addition improve his mucous plugging pulmonary status as well as hydration and intact via his J tube. 2. CARDIAC: Patient for blood pressure control was continued on Losartan and was started on a low dose of Hydrochlorothiazide 12.5 mg. His beta blocker was held secondary to problems with bradyarrhythmia. The patient was continued on his aspirin. The patient has had systolic blood pressures in the 130s except when he becomes agitated. His blood pressure does rise into the 190s region. Usually treating the source of the agitation, for example pain, with Morphine results in decrease of the patient's blood pressure and pulse. The patient also has received at times 2.5 IV Lopressor very slowly times one with results of decreasing of his blood pressure and his heart rate. 3. RHYTHM: Patient had paroxysmal atrial fibrillation thought to be secondary to pneumonia that developed during his hospital to the floor perioperatively. The patient remained in normal sinus rhythm throughout his stay in the MICU becoming tachycardic and hypertensive secondary to agitation. This resolved by treating the source of the agitation as well as with p.r.n. once every other day or so 2.5 mg of Lopressor IV. The patient was seen by Electrophysiology and felt to have Tachy-Brady syndrome secondary to his bradying down following beta blocker, significant doses of Toprol like 75 mg q. day. The patient brady down to the 30s. He had initially been treated as per early stay with Amiodarone for his atrial fibrillation. The patient remains in normal sinus rhythm. The patient's family declined permanent pacemaker placement. It is possible that the patient may benefit from a low dose of a beta blocker like 12.5 Toprol as his respiratory status and functionality continues to improve. 4. NEUROLOGY: Agitation. The patient has had some agitation, usually 10 PM on the last three to five days prior to discharge from the MICU. Often this was relieved with pain control. The patient is able to communicate pain or hunger despite being trached. His agitation, though, has gotten better with the removal of tubes like his NG tube and we will remove his A-line today which should further help him. He had initially been managed with benzodiazepine, but this is felt that it may have worsened his mental status. The patient was started on a form of Zyprexa. He was started at 5 and titrated up to 10 mg q. day as well as Trazodone 25 mg q.h.s. It is felt to be best given at approximately 8 PM as the patient tends to sundown at about 10 PM. On the night before discharge, the patient did not require any additional medications for agitation except for the Zyprexa and Trazodone. He did receive 0.5 mg of subcutaneous Morphine for relief of pain secondary to his J tube placement and this satisfied his agitation resolving his pain. We recommended trying to avoid treating the patient with benzodiazepine where possible. 5. HEMATOCRIT: Patient had chronic anemia seeming to be secondary to chronic disease. He has received transfusions through his hospital course. His hematocrit was 29.5 the day prior to discharge and 27.9 on the day of discharge, but his hemoglobin only went down from 9.9 to 9.2. It is felt that if the hematocrit was to drop any further, we would recommend transfusing the patient one unit with an approximate goal of 28 to 30 with his hematocrit as well as maybe possibly following the patient's B12 and folate and possibly starting supplementation if necessary. 6. NUTRITION: The patient received a J tube which was placed on the [**11-3**] without complication via Interventional Radiology. The patient began tube feeds with Ultracal 10 cc per hour on the [**11-4**]. This was titrated up 10 cc an hour per six hours. He currently, at the time of this dictation, was tolerating 40 cc per hour while finishing without complications without changes in abdominal pain, or any signs of not tolerating the tube feeds. He also was receiving his last bag of TPN. When the patient reaches his goal of 60 cc per hour, his TPN bag will be stopped and he will receive approximately 250 cc b.i.d. of free water boluses to meet his water necessity in addition to his 60 cc an hour of the tube feeds of the Ultracal. 7. ENDOCRINE: Patient was initially switched from his Prednisone to Hydrocortisone 10 q. 12 hours status post placement of the NG tube. When the patient was taking p.o. This was switched over back to is 5 mg q.d. The patient was covered on a sliding scale regular insulin with fingersticks. Steroids is his most likely etiology of his hypercholesterolemia. Tight control was the goal for his blood sugars with sliding scales being instituted over 150. The patient generally had good control of blood sugar with a max of 148 on the 22nd, max of 133 on the 21st, max of 132 on the 20th, max of 152 on the 19th. The patient's requirement may go down as he is being switched back from the Hydrocortisone to the Prednisone. 8. PROPHYLAXIS: Patient was placed initially on IV Protonix 40 mg q.d. which changed to Lansoprazole 30 mg elixir per J tube. He is also placed on subcutaneous heparin 500 q. b.i.d. and pneumo-boots as the patient was sitting up in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3788**] chair the day before discharge and as he becomes more functional and able to ambulate, this requirement may not be necessary. Nutrition as previously stated, patient is on Ultracal with a goal of 60 cc per hour. He is currently at 40 cc per hour tolerating with no problems. [**Name (NI) **] may be finishing his last back of TPN. The patient also will be receiving three water boluses 250 b.i.d. 9. CODE STATUS: Patient is full code as per family. 10. COMMUNICATION: [**Name (NI) **] wife and sons were involved in the patient's care and were consulted regarding any major issues and this should be continued. The patient's oncologist, Dr. [**Last Name (STitle) **] was also contact[**Name (NI) **] and secondary to his instructions, an injection of Lupron 20 2.5 mg was injected for his prostate cancer. The patient's further Lupron injections, Dr. [**Last Name (STitle) **] should be consulted regarding these approximately every three to four weeks. DISPOSITION: Patient has improved with showing signs of decreased agitation, decreased evidence of respiratory failure, stability with his heart rate and cardiac rhythm, tolerating tube feeds. It is felt as the patient's gains strength with nutrition and Physical Therapy, his pulmonary toilet issues will improve as well. CONTACT INFORMATION: His wife, [**Name (NI) **] at phone # [**Telephone/Fax (1) 110288**]. The patient is to be transferred to a long-term care facility on the [**11-5**] as per attending, case management and family. [**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 1659**] MEDQUIST36 D: [**2182-12-6**] 12:12 T: [**2182-12-6**] 12:12 JOB#: [**Job Number **]

[ "458.2", "518.5", "428.0", "996.1", "507.0", "441.4", "733.13", "998.11", "427.31" ]

icd9cm

[ [ [] ] ]

[ "31.1", "46.32", "96.6", "99.15", "88.42", "96.04", "39.49", "38.44", "97.23", "33.22", "96.72" ]

icd9pcs

[ [ [] ] ]

3697, 3769

4009, 13947

113, 2724

2746, 3673

3786, 3986

1,186

104,140

46018

Discharge summary

report

Admission Date: [**2145-1-13**] Discharge Date: [**2145-2-10**] Date of Birth: [**2068-9-1**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3984**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: endotracheal intubation tracheostomy PEG placement History of Present Illness: 76 yo male with a history of end-stage pulmonary sarcoidosis who presents with increased shortness of breath over last 24hrs, tachycardia, general fatigue x 1 week. Similar prior presentations, felt to be related to sarcoidosis. Denies any increase in cough or sputum production, fevers, chills or sweats. No abdominal pain, nausea, vomting or diarrhea. Past Medical History: 1. Pulmonary sarcoidosis with pumonary fibrosis, dx [**2128**], s/p lung bx 2. BPH 3. Hypercholesterolemia 4. Orthostatic hypotension 5. L eye ptosis since birth 6. Glucose intolerance 7. Chronic Encephalomalacia secondary to head trauma while playing ice hockey in [**2106**] 8. h/o "tummy tuck" remotely Social History: Retired from import/export business in plumbing. Ran his own business. Only out of country travel was to Bermuda years ago. Smoking hx 1-1/2 ppd x 15 yrs, quit [**2117**]. No etoh or drugs. Lives alone. Brother and his familiy live in [**Name (NI) 3146**]. Family History: mother died at [**Age over 90 **] y.o. hx [**Name (NI) 11964**], Father died at 75 yo, stroke/cerebral hemorrhage. Patient has 2 brothers, healthy. [**Name2 (NI) 4084**] married, no children Physical Exam: PE on admission: GEN: tachypnic appearing male HEENT: [**Name (NI) 2994**], ptosis on left, anicteric, dry mucous membranes, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: rhonchorous diffusely, poor air movement, using accessory muscles of neck and abdomen to assist with ventilation CV: tachycardic, no murmurs ABD: nd, +b/s, soft though muscles contracted EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. . Exam on Discharge Gen: awake and alert w/trach in place, sitting up in bed, thin frail-appearing man HEENT: PERRLA. EOMI. CV: rrr, no m/g/r Lungs: diffuse coarse inspiratory and expiratory sounds. Expiratory wheezing more prominent on right lung fields. [**Last Name (un) **]: soft nondistended and nontender Ext: no edema, + peripheral pulses bilaterally Neuro: grossly intact, writing notes to communicate Pertinent Results: Admission Labs [**2145-1-13**] 11:30AM BLOOD WBC-13.6*# RBC-4.83# Hgb-15.2# Hct-45.7# MCV-95 MCH-31.5 MCHC-33.3 RDW-13.0 Plt Ct-247 [**2145-1-13**] 11:30AM BLOOD Neuts-91.1* Lymphs-5.6* Monos-2.7 Eos-0.3 Baso-0.4 [**2145-1-13**] 11:30AM BLOOD Glucose-107* UreaN-15 Creat-0.8 Na-143 K-3.8 Cl-101 HCO3-31 AnGap-15 [**2145-1-13**] 11:30AM BLOOD cTropnT-<0.01 [**2145-1-13**] 07:56PM BLOOD CK-MB-3 cTropnT-<0.01 [**2145-1-14**] 06:19AM BLOOD CK-MB-3 [**2145-1-13**] 07:56PM BLOOD Calcium-7.1* Phos-2.6* Mg-1.4* [**2145-1-13**] 07:56PM BLOOD Cortsol-29.8* [**2145-1-13**] 11:33AM BLOOD Lactate-2.1* K-3.7 . Pertinent Labs [**2145-1-17**] 04:42AM BLOOD WBC-7.0 RBC-3.36* Hgb-10.5* Hct-31.6* MCV-94 MCH-31.2 MCHC-33.2 RDW-13.1 Plt Ct-196 [**2145-1-22**] 03:02AM BLOOD WBC-9.1 RBC-3.56* Hgb-10.8* Hct-32.5* MCV-91 MCH-30.4 MCHC-33.3 RDW-12.7 Plt Ct-341 [**2145-1-26**] 02:44AM BLOOD WBC-9.3 RBC-3.08* Hgb-9.5* Hct-28.4* MCV-92 MCH-30.9 MCHC-33.5 RDW-13.3 Plt Ct-399 [**2145-2-7**] 04:20AM BLOOD WBC-9.5 RBC-3.81* Hgb-11.9* Hct-35.9* MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-449* [**2145-1-21**] 04:06AM BLOOD Plt Ct-323 [**2145-1-26**] 02:44AM BLOOD Plt Ct-399 [**2145-2-6**] 06:07AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [**2145-2-7**] 04:20AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [**2145-1-22**] 04:23PM BLOOD Glucose-86 UreaN-18 Creat-0.4* Na-139 K-3.5 Cl-94* HCO3-39* AnGap-10 [**2145-1-25**] 03:01AM BLOOD Glucose-87 UreaN-21* Creat-0.4* Na-146* K-3.7 Cl-106 HCO3-38* AnGap-6* [**2145-2-4**] 04:07AM BLOOD Glucose-78 UreaN-19 Creat-0.4* Na-145 K-3.8 Cl-98 HCO3-40* AnGap-11 [**2145-2-7**] 04:20AM BLOOD Glucose-101* UreaN-16 Creat-0.5 Na-148* K-3.9 Cl-100 HCO3-43* AnGap-9 [**2145-1-25**] 03:01AM BLOOD ALT-33 AST-24 LD(LDH)-162 AlkPhos-98 TotBili-0.2 [**2145-1-15**] 03:44AM BLOOD Type-ART Temp-36.8 Rates-/25 PEEP-5 FiO2-40 pO2-163* pCO2-59* pH-7.33* calTCO2-33* Base XS-3 Intubat-INTUBATED Vent-SPONTANEOU [**2145-1-22**] 04:34PM BLOOD Type-[**Last Name (un) **] Temp-37.5 Rates-/12 Tidal V-320 PEEP-5 FiO2-30 pO2-48* pCO2-66* pH-7.43 calTCO2-45* Base XS-15 Intubat-INTUBATED Vent-SPONTANEOU [**2145-1-27**] 03:36AM BLOOD Type-[**Last Name (un) **] Temp-38.2 Rates-/28 Tidal V-400 PEEP-5 FiO2-30 pO2-32* pCO2-59* pH-7.41 calTCO2-39* Base XS-8 Intubat-INTUBATED Vent-SPONTANEOU [**2145-2-4**] 12:07AM BLOOD Type-ART pO2-127* pCO2-73* pH-7.39 calTCO2-46* Base XS-15 Intubat-INTUBATED . Microbiology [**2145-1-13**] 12:00PM URINE Blood-MOD Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2145-1-18**] 03:34PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2145-2-6**] 02:12PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM . Blood cultures ([**2145-1-13**]): No growth Urine culture ([**2145-1-13**]): No growth Sputum ([**2145-1-13**]): GRAM STAIN (Final [**2145-1-13**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2145-1-15**]): SPARSE GROWTH Commensal Respiratory Flora. DIRECT INFLUENZA A ANTIGEN TEST (Final [**2145-1-14**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2145-1-14**]): Negative for Influenza B. Blood cultures ([**2145-1-15**]): No growth Blood cultures ([**2145-1-18**]): No growth Blood cultures ([**2145-1-27**]): No growth CXR ([**2145-1-13**]): Aside from slightly lower lung volumes, there is no significant interval change in the appearance of the end-stage sarcoidosis as previously documented. . CXR ([**2145-1-24**]): Comparison with the previous study done [**2145-1-20**]. There are extensive parenchymal and pleural changes consistent with end-stage sarcoidosis as before. An endotracheal tube and nasogastric tube remain in place. Allowing for differences in technique, there is no significant change. No significant interval change. . CXR ([**2145-2-3**]): Previously questioned retrocardiac nodular infection has cleared, presumably representing secretions resolved from a region of cystic lung. In all other respects the radiographic appearance of these severely scarred and bronchiectatic lungs, as well as bilateral pleural abnormalities are unchanged over the long-term. There are no findings to suggest acute pneumonia or pulmonary edema. Brief Hospital Course: 76 yo male with end stage sarcoidosis presenting with dyspnea. . # HYPERCARBIC RESPIRATORY FAILURE: Pt presented to the ER with increased shortness of breath over 24hrs, tachycardia, and generalized fatigue. Similar prior presentations were felt to be related to sarcoid flares. CXR showed end stage pulmonary fibrosis but no other abnormalities. It was felt his sx likely represented pneumonia in setting of severe underlying fibrotic lung disease. Pt was unable to sustain high minute ventilatory rate, evidenced by a rising pCO2 and thus required emergent intubation shortly after arrival to ICU. The patient was treated for presumed pneumonia with levofloxacin and meropenem given leukocytosis and dyspnea. Infectious work-up including multiple blood cultures and viral cultures were negative. The patient was not given steroids since it was felt that his sx were related to an infectious process rather than a flair of his sarcoid lung disease. The patient was made DNR after talking with the son. IP consult was sought for trach placement given the patient's inability to wean off the ventilator with subsequent placement of tracheostomy and PEG on [**1-26**] and [**1-27**] respectively. Pt tolerated trach mask well. He was transferred to the floor on [**2-3**]. Later that afternoon he was noted to desat into the 50's with increased work of breathing and was requiring high levels of nursing care. He was transferred back to the MICU where he again experienced agitation and increased work of breathing. He was placed back on the vent on PS overnight and tolerated this well and eventually was able to transition to trach mask throughtout the day and night. Clinical decompensation attributed to mucus plugging. # CHRONIC ORTHOSTATIC HYPOTENSION: Pt normotensive on admission to ICU. His home medications of midodrine and fludricortisone were continued while admitted. # Agitation: The patient had issues with agitation especially at night. Geriatrics was consulted and a regimen of Seroquel was initiated as well as efforts to limit lines and to orient him frequently. His mental status waxed and waned and he fell out of bed twice but sustained no injuries. By [**2-1**] his delirium had improved on a regimen of seroquel to 12.5 mg [**Hospital1 **], seroquel 25 mg QHS and Seroquel 25mg prn. Upon readmission to the MICU, however, he again became significantly agitated and required IV haldol in addition to his scheduled seroquel. EKG the following morning did not show any eveidence of prolonged QT. Per geriatric recommendations the pt's seroquel was increased to 50mg qhs and his sundowning improved. QTc was noted to 419 on discharge dose of seroquel. . The patient was on SubQ heparin for DVT prophylaxis and PPI for stress ulcer prophylaxis. Communication was with the patient and his [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 2013**] ([**Name (NI) 802**]) [**Telephone/Fax (1) 97950**]. Code status was DNR/DNI, confirmed with HCP. . # Malnutrition: He failed swallowing test twice with concern for aspiration. PEG tube was placed and his tube feeds were advanced to goal rate of 35 cc/hr. Medium chain trigylcerides were added for coloric help. . Follow up at Rehab 1. Sundowning: [**Month (only) 116**] increase his schedule dose of seroquel [**Hospital1 **] and qhs. His QTc on current dose is only 419. Please check EKG after increasing his dose to ensure there is no significant QTc prolongation. Medications on Admission: 1. Fludrocortisone 0.1 mg DAILY 2. Tamsulosin 0.4 mg HS 3. Docusate Sodium 100 mg [**Hospital1 **] as needed for constipation 4. Midodrine 1.25 mg PO BID 5. Acetaminophen 1000 mg PO Q6H as needed for pain Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 2. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 3. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. midodrine 2.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day). 6. beclomethasone dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Inhalation [**Hospital1 **] (2 times a day). 7. fludrocortisone 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 11. nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed for thrush. 12. acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: One (1) ML Miscellaneous Q4H (every 4 hours). 13. oxycodone-acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 15. quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 16. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H (every 8 hours). 17. medium chain triglycerides 7.7 kcal/mL Oil [**Last Name (STitle) **]: One (1) ML PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary Diagnosis 1. Hypercarbic respiratory failure 2. Pneumonia 3. Sarcoidosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted because you had shortness of breath which was thought to be due to a pneumonia in setting of your underlying sarcoidosis. You were treated with antibiotics called MEROPENEM and VANCOMCYIN. You needed help with mechanical ventilation to breathe. A tracheostomy was performed as you required prolong ventilatory support. You were removed off of mechanical ventilation and were breathing on trach collar mask prior to transfer to [**Hospital **] rehab. . Followup Instructions: Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2145-3-10**] at 3:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2145-3-10**] at 4:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: WEDNESDAY [**2145-3-10**] at 4:00 PM [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "307.9", "600.00", "743.61", "515", "292.81", "E929.8", "790.29", "348.89", "276.4", "262", "486", "135", "272.0", "518.84", "787.22", "E939.4", "E884.4", "458.0", "V49.86", "517.8", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "96.72", "31.1", "96.6", "43.11" ]

icd9pcs

[ [ [] ] ]

12621, 12721

7001, 10446

279, 331

12846, 12846

2580, 6978

13522, 14260

1336, 1528

10701, 12598

12742, 12825

10472, 10678

13024, 13499

1543, 1546

232, 241

359, 715

1560, 2561

12861, 13000

737, 1044

1060, 1320

18,673

105,474

26380

Discharge summary

report

Admission Date: [**2129-1-7**] Discharge Date: [**2129-1-14**] Date of Birth: [**2058-10-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: History: From Daughter, served as interpreter PCP: [**Name Initial (NameIs) 65249**] 70 y.o. female with COPD on 4L home O2 and BiPAP, CHF (s/p ICD), CAD s/p CABG, HTN, presents with dyspnea and hypercarbic respiratory distress. She was in her USOH (sleeping in a reclining chair, with DOE at 10 feet) until 1 week ago when she stopped wearing her BiPAP. Her daughter notes that she became gradually fatigued over the past week. Three days prior to admission her daughter noted that she was more short of breath and called her in the middle of the night complaining of dyspnea on each of the nights prior to admission. On the morning of admission the patient was even more dyspneic and called her daughter, who was out of the house. The patient then pressed her life alert button and activated EMS. In the ER she was found to be hypercarbic with 7.27/93/76. SBP:140s, HR:70s. CXR with pulmonary Edema. She was given 80 mg IV lasix, neb treatment, Solumedrol 125 x 1 and Levofloxacin 500 mg IV x 1. She was admitted to the MICU with hypercarbic respiratory failure and CHF. ROS: POSITIVE: non-compliant with low Na diet, +PND over the last 3 days, DOE with walking 10 feet, mild wheezing. NEGATIVE: fevers, wt change, CP, Palp, Edema, ABD pain, weakness, numbness, change in urination, dysuria. Past Medical History: 1) CAD s/p 4-vessel CABG in [**2119**] 2) CHF with EF 40% by echo at [**Hospital3 **] on [**2128-8-25**] with mild TR, mild Pulm HTN (38mm Hg) 3) DM Type 2 4) HTN 5) COPD on home O2, BIPAP with multiple past admissions for non-compliance with BiPAP and pCO2 in the 70-80 range 6) Schizophrenia 7) L3 fracture in [**2127**] 8) Runs of symptomatic VT s/p ICD in [**1-2**] Social History: Do not Intubate. Lives in an [**Hospital3 **] facility. Persian-speaking only. Former home maker. 70 pack year history, quit in [**2098**]. No EtOH. Uses a walker or cane to ambulate. Can only take 10 steps prior to having severe dyspnea. Her daughter cooks her meals for her. Family History: Mother with CHF Physical Exam: Temp:98.0 BP: 127/43 HR: 80 RR:10 O2: 95% Gen: Fatigued, some accessory muscle use. CPAP mask on without leak. Pt opens eyes to voice. A/O x 3. GCS 15. HEENT: PEARLA. EOMI. No JVD. Dry mm CV: RR. Non-displaced PMI. No murmurs Pulm: Rales at bases b/l ABD: Soft NT/ND. Mild hepatic pulsatility Ext: Trace edema b/l Neuro: Motor [**6-3**] at all flex/ex. [**Last Name (un) **]: GI to LT. CN II-XII GI. Pertinent Results: Imaging: [**2129-1-7**] CXR - Congestive heart failure with perihilar and interstitial edema as well as small pleural effusions [**2129-1-9**] CXR - Again seen is an ICD with lead terminating in the right ventricle. There continues to be a hazy bilateral vasculature with pulmonary vascular redistribution consistent with fluid overload/CHF. Compared to the film from the prior day, there has been no significant change [**2129-1-10**] ECHO - The left atrium is moderately dilated. The left ventricular cavity size is top normal/borderline dilated. There is mild regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include mid to distal anteroseptal and apical hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. [**2129-1-11**] CXR - Improved opacity within the right lung base, likely due to resolving atelectasis. Otherwise unchanged since [**2129-1-9**] Cultures: [**2129-1-7**] Urine - no growth [**2129-1-7**] Blood - pending Labs: [**2129-1-7**] 11:40AM BLOOD WBC-9.9 RBC-3.51* Hgb-9.9* Hct-30.8* MCV-88 MCH-28.1 MCHC-32.1 RDW-15.5 Plt Ct-192 [**2129-1-8**] 04:57AM BLOOD WBC-7.9 RBC-2.95* Hgb-8.2* Hct-25.6* MCV-87 MCH-27.7 MCHC-31.9 RDW-15.8* Plt Ct-198 [**2129-1-8**] 06:35AM BLOOD Hct-25.6* [**2129-1-12**] 04:16AM BLOOD WBC-7.4 RBC-3.38* Hgb-9.4* Hct-30.1* MCV-89 MCH-27.9 MCHC-31.4 RDW-15.2 Plt Ct-182 [**2129-1-13**] 05:27AM BLOOD WBC-8.3 RBC-3.58* Hgb-10.1* Hct-31.2* MCV-87 MCH-28.3 MCHC-32.5 RDW-15.2 Plt Ct-166 [**2129-1-7**] 11:40AM BLOOD PT-12.4 PTT-21.7* INR(PT)-1.0 [**2129-1-7**] 11:40AM BLOOD Plt Smr-NORMAL Plt Ct-192 [**2129-1-8**] 04:57AM BLOOD PT-13.3 PTT-21.8* INR(PT)-1.2 [**2129-1-8**] 04:57AM BLOOD Plt Ct-198 [**2129-1-13**] 05:27AM BLOOD PT-12.7 PTT-21.2* INR(PT)-1.1 [**2129-1-13**] 05:27AM BLOOD Plt Ct-166 [**2129-1-7**] 11:40AM BLOOD Glucose-146* UreaN-30* Creat-0.9 Na-141 K-5.1 Cl-97 HCO3-38* AnGap-11 [**2129-1-7**] 07:46PM BLOOD Glucose-151* UreaN-33* Creat-0.8 Na-143 K-4.6 Cl-96 HCO3-39* AnGap-13 [**2129-1-11**] 02:28AM BLOOD Glucose-295* UreaN-48* Creat-1.0 Na-142 K-4.9 Cl-99 HCO3-37* AnGap-11 [**2129-1-12**] 04:16AM BLOOD Glucose-170* UreaN-47* Creat-0.9 Na-145 K-4.5 Cl-101 HCO3-40* AnGap-9 [**2129-1-13**] 05:27AM BLOOD Glucose-163* UreaN-31* Creat-0.9 Na-141 K-4.2 Cl-96 HCO3-38* AnGap-11 [**2129-1-7**] 11:40AM BLOOD ALT-11 AST-16 CK(CPK)-44 [**2129-1-7**] 07:46PM BLOOD CK(CPK)-23* [**2129-1-8**] 04:57AM BLOOD CK(CPK)-24* [**2129-1-7**] 11:40AM BLOOD CK-MB-NotDone [**2129-1-7**] 11:40AM BLOOD cTropnT-<0.01 proBNP-2233* [**2129-1-8**] 04:57AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2129-1-7**] 11:40AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.1 [**2129-1-7**] 07:46PM BLOOD Calcium-9.1 Phos-5.2* Mg-1.7 [**2129-1-12**] 04:16AM BLOOD Calcium-9.0 Phos-3.6# Mg-2.7* [**2129-1-13**] 05:27AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0 [**2129-1-8**] 04:57AM BLOOD calTIBC-384 Ferritn-33 TRF-295 [**2129-1-7**] 11:40AM BLOOD Digoxin-0.6* [**2129-1-11**] 08:00AM BLOOD Digoxin-0.7* [**2129-1-13**] 05:27AM BLOOD Digoxin-0.4* [**2129-1-7**] 11:40AM BLOOD Valproa-14* [**2129-1-11**] 01:00PM BLOOD Valproa-10* [**2129-1-7**] BLOOD Type-ART pO2-76* pCO2-93* pH-7.27* calHCO3-45* Base XS-11 [**2129-1-8**] BLOOD Type-ART pO2-76* pCO2-80* pH-7.33* calHCO3-44* Base XS-11 [**2129-1-8**] BLOOD Type-ART pO2-108* pCO2-94* pH-7.30* calHCO3-48* Base XS-15 [**2129-1-8**] BLOOD Type-ART pO2-63* pCO2-77* pH-7.36 calHCO3-45* Base XS-13 [**2129-1-8**] BLOOD Type-ART pO2-76* pCO2-75* pH-7.35 calHCO3-43* Base XS-11 [**2129-1-9**] BLOOD Type-ART pO2-74* pCO2-73* pH-7.36 calHCO3-43* Base XS-11 [**2129-1-9**] BLOOD Type-ART pO2-60* pCO2-72* pH-7.39 calHCO3-45* Base XS-14 [**2129-1-9**] BLOOD Type-ART pO2-66* pCO2-78* pH-7.36 calHCO3-46* Base XS-13 [**2129-1-9**] BLOOD Type-ART pO2-74* pCO2-76* pH-7.36 calHCO3-45* Base XS-12 [**2129-1-10**] BLOOD Type-ART pO2-64* pCO2-62* pH-7.36 calHCO3-36* Base XS-6 [**2129-1-10**] BLOOD Type-ART pO2-65* pCO2-69* pH-7.39 calHCO3-43* Base XS-12 [**2129-1-10**] BLOOD Type-ART pO2-75* pCO2-84* pH-7.35 calHCO3-48* Base XS-16 [**2129-1-10**] BLOOD Type-ART pO2-68* pCO2-74* pH-7.36 calHCO3-44* Base XS-11 [**2129-1-10**] BLOOD Type-ART pO2-83* pCO2-78* pH-7.34* calHCO3-44* Base XS-11 [**2129-1-10**] BLOOD Type-ART pO2-80* pCO2-84* pH-7.34* calHCO3-47* Base XS-15 Intubat-NOT INTUBA [**2129-1-11**] BLOOD Type-ART pO2-81* pCO2-82* pH-7.26* calHCO3-39* Base XS-6 [**2129-1-11**] BLOOD Type-ART pO2-88 pCO2-84* pH-7.29* calHCO3-42* Base XS-10 [**2129-1-11**] BLOOD Type-ART pO2-104 pCO2-84* pH-7.30* calHCO3-43* Base XS-11 [**2129-1-12**] BLOOD Type-ART pO2-92 pCO2-72* pH-7.35 calHCO3-41* Base XS-10 [**2129-1-7**] BLOOD Lactate-1.0 Brief Hospital Course: 70 y.o. female with OSA/COPD (on home O2 with BIPAP at night), schizophrenia, CAD s/p CABG, CHF with EF 40% presents with dyspnea and hypercarbic respiratory distress > CHF flare. 1) Hypercarbic Respiratory Distress: She has severe COPD and sleep apnea on 3L home O2 and 14/8 nasal BIPAP. According to her primary physician and her daughter, she has been extremely non-compliant with BIPAP and home medications. Baseline CO2 elevated (~70s-80s) per records from [**Hospital3 **]. On admission here her ABG was 7.27, PCO2 93, PO2: 105. According to her daughter, she had not worn her BiPAP for 1 week prior to admission likely accounting for her hypercarbia. He bicarbonate level of 38 suggests that she had been compensating for a chronic respiratory acidosis for some time. She was initially placed on a CPAP mask with bimodal settings in the ER, but upon arrival to the MICU she was unresponsive to deep sternal rub and as she was Do-not-intubate code status, she was placed on AC setting through the CPAP full face mask. After ~4-6 hours she became more responsive and pH rose above 7.3. She was able to wean to nasal cannula after ~14 hours with pCO2 in the high 70s. On the 3 night of hospitalization she was somewhat agitated and was given 15 mg temazepam (7.5 x 2) which she takes at home to sleep. Subsequently she became more lethargic and an ABG was 7.11/132/134. She was then placed on Pressure Control Ventilation (PCV) mode through the CPAP mask with pressures of 18 and had tidal volumes of ~450 with a rate set at 22. She gradually improved with subsequent ABG of 7.26/82/81. Over the next 2 days she was able to be weaned to BiPAP at night only (using her home nasal BIPAP mask) and it was decided that we would not check blood gases unless she had a change in mental status and would not prematurely start BiPAP (prior to the evening) unless her pH was <7.3. She was transferred to the floor with nighttime Bipap settings of 14/8 and did well. She continued to oxygenate well on the floor with NC 4L and nightly BIPAP. 2) COPD Flare. She was initially given duonebs q1 hour, then q2 hours, then weaned to q4 hours. She was also empirically treated with 125 solumedrol x 2 days, then prednisone taper. She was also treated empirically with levaquin 500 x 7 days. 3) CHF with EF 40%. She was diuresed 2 liters per day for a length of stay (-) 6 L with IV lasix boluses. As she was initially hypertensive, she was started on a Nitro drip with good blood pressure control. This was weaned off on HD #2. Toprol 50, digoxin, ACE-I were restarted but limited at times by bradycardia. Strict I/O, 1 liter fluid restriction, daily weights, Low Na diet were maintained. Positive pressure to reduce afterload was used at night (as above). 4) H/O VT with ICD. 1 7-beat run of NSVT on hospital day 5, asymptomatic. We maintained K>4, Mg>2 5) CAD s/p CABG. No evidence of ischemia by signs or symptoms. ECG unchanged. ASA , BB, ACE-I, statin continued. 6) DM: Glucose well controlled on ISS, then glyburide and metformin. Creatinine was 0.9-1.1 throughout admission. Her blood sugars became more elevated after initiation of the steroid taper. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was called and the patients glyburide was increased to [**Hospital1 **]. The patient and family agreed to placement in rehab. She was discharged to rehab on [**2129-1-14**]. Medications on Admission: Metformin 1000 [**Hospital1 **] Lasix 60 daily Digoxin 0.25 daily Glyburide 5 daily Lisinopril 5 daily Toprol 50 daily ASA 81 daily L-thyrox 125 daily Medroxyprogesterone 10 qAM Lipitor 10 daily Zoloft 75 qAM Abilify 20 QHS Risperdal 2 QHS Depakote 125 daily Duo Neb qid Flovent 4 puffs [**Hospital1 **] Flonase 2 puffs Nasal [**Hospital1 **] Restoril 7.5 QHS Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 9. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4 (). 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 13. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: do not give more than 4 g in 24 hours. 15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 21. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-1**] Sprays Nasal QID (4 times a day) as needed. 22. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 24. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 25. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 26. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 27. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 28. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days: from [**2129-1-16**] to [**2129-1-18**]. 29. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: thru [**2129-1-15**]. 30. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 31. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 32. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 33. GlyBURIDE 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)): can stop after patient off steroids. 34. Insulin Regular Human 100 unit/mL Solution Sig: 1-20 units Injection four times a day: per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: COPD CHF Discharge Condition: Fair; oxygenating in the mid 90's on 4L NC, getting BIPAP at night. Mentating AAOx3. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet --Please continue to take all medications as prescribed --Return to hospital for any change in breathing, SOB, coughing, fevers, chills, chest pain. Followup Instructions: --Please make an appointment with your primary care doctor (Dr. [**Last Name (STitle) 4922**] in the next 1-2 weeks.

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icd9pcs

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864

Discharge summary

report

Admission Date: [**2117-1-16**] Discharge Date: [**2117-1-25**] Date of Birth: [**2072-1-20**] Sex: M Service: [**Year (4 digits) 662**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 562**] Chief Complaint: DOE/AMS Major Surgical or Invasive Procedure: PD BAL Intubation CVVHD Central Line placement History of Present Illness: 44 yo male with history of HIV (CD4 202, VL 27,200 in [**5-3**]), ESRD [**12-31**] HIV nephropathy, CHF (EF 25%) who presents with dyspnea on exertion. Pt was very lethargic when I interviewed him due to recent ativan dose. States he has been having shortness of breath on and off for the last week. Denies any chest pain, palpitation, increasing LE edema, orthopnea, PND. States he has been doing his PD 5 times a day as directed last done at 3pm and diasylate still in peritoneal cavity. Admits to recent crack cocaine use but could not give details. Also admits to drinking [**11-30**] pint- 1 pint liquor per day. Last drink within past 24 hours. States he has had recent fevers. Denies any nausea, vomiting. Positive non-bloody diarrhea for several days. Was arrousable only to pain by the time MICU resident evaluated him - he had been given 4 mg ativan IV as he was confused, agitated, hypertensive and tachycardic in the ED - this concerning for ETOH W/D. As such, MICU was called to evaluate him and he was accepted on MICU service. Past Medical History: - HIV >10 yrs [**5-3**] CD4 202, VL 27,200 - End-stage renal disease secondary to HIV nephropathy- on PD - CHF EF 25% - Anemia on Aranesp. - Hyperparathyroidism. - Hyperphosphatemia. - Sickle cell trait. - Polysubstance abuse. Social History: -Crack cocaine use, see HPI -h/o EtOH abuse - see hpi -smokes ~1 PPD -lives in own apt in public housing Family History: Significant for ethanol abuse in the mother as well as diabetes and multiple myeloma. Physical Exam: MICU admit PE T 99.1 BP 161/131 HR 130 RR 16 O2sats 96% on RA Gen: Very lethargic, falling asleep throughout exam and not complying with my requests, periodically apneic with snoring (OSA) HEENT: PERRL, mmm, anicteric Neck: unable to assess JVD as patient would not sit up Lungs: CTAB but very poor effort Heart: RRR no m/r/g Abd: Distended but soft, + fluid wave, NT, hypoactive bowel sounds Ext: no edema Neuro: To lethargic to due exam, no asterixis Pertinent Results: ECG [**2117-1-16**]- Sinus tachycardia, LAD, LVH nl intervals, no ST/T wave changes . CTA chest [**2117-1-16**]- No PE. Mild pulmonary edema. Fluid in upper abdomen from peritoneal dialysis. . CXR [**2117-1-16**]- Probable mild asymmetric pulmonary edema, given the prior appearance of the same on earlier radiograph. . Stress Test [**9-2**]- Nonspecific T wave changes in the absence of anginal symptoms. Blunted [**Month/Year (2) **] pressure response to exercise. MIBI- Normal myocardial perfusion at the level of stress achieved. Enlarged left ventricle with global hypokinesis. Calculated LVEF 23%. . ECHO [**2117-1-18**]: - EF 20-25% The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal with severe global. Systolic function of apical segments is relatively preserved suggestive of a non-ischemic cardiomyopathy. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2116-8-14**], the findings are similar. Given the normal ascending aortic and left atrial size, the absence of a history of systemic hypertension, the prominent symmetric hypertrophy suggests an infiltrative process (e.g., amyloid). Brief Hospital Course: 44 yo M with history of HIV, ESRD, CHF initially presented with worsening DOE and altered mentation after ativan, 4 mg IV given for agitation in ED and ? ETOH W/D, in setting of recent crack cocaine use. . MICU: . # AMS - - Initially, it was felt that this was likely due to ativan given for agitation. In addition, it was questionable how adherent patient was to his home peritoneal dialysis. . An ABG on admission to the MICU revealed that the patient was in hypoxic respiratory failure. Hence, he was intubated and oxygenated. . In addition, the differential on admission included: - head bleed: Head CT negative for bleed or mass lesions - delirium tremens: he was monitored for evidence of worsening tachycardia/tremulousness,hypertension and placed on a CIWA scale. he did not require any benzodiazepines. - Infection - [**Year (4 digits) **] cx and peritoneal diasylated cultures were negative. -Metabolic disturbance - TSH, Ca, Lytes were wnl . [**2117-1-20**]: Extubated, initially sedated because of administration of haldol - by [**1-22**], patient more alert and answering questions. . # DOE - our intial diagnoses included CHF(known EF of 25%), PE, volume overload due to failure to due PD, ACS, PNA (community acquired vs atypical vs PCP). Also could be secondary to crack cocaine use leading to myocardial ischemia and worsening CHF. . - [**1-17**] : intubated for hypoxia along with general restlessness of patient which made dialysis and other management very difficult -> he was found to have picture of acute pulmonary edema. He was dialyzed over the course of his MICU stay. From time of intubation ([**1-16**]) to day of extubation, patient oxygenated and ventilated well. . -Tele monitored over MICU course. No significant events noted. -Cardiac enzymes found to be elevated, but this was ascribed to his baseline renal failure. No significant EKG changes. -Induced sputum was negative for PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] was placed on a treatment dose of IV bactrim, but this was discontinued when he was found to be PCP [**Name Initial (PRE) 5963**]. . # CHF - - patient with known EF of ~ 25% from old ECHO. - repeat ECHO on [**2117-1-18**] reveal symmetric LVH with EF ~ 25% . Likely multifactorial from cocaine use, ETOH use. No history of CAD and normal perfusion stress test in [**9-2**], however patient at risk for accelerrated development of CAD due to HIV and HAART regimen(if he is taking), tobacco use and crack cocaine use. . # [**Name (NI) 5964**] Pt does self PD at home; however probably is poorly compliant. - patient received PD per renal service while in MICU with negative fluid balance - electrolytes were corrected as necessary - started on Epogen for anemia and Fe for iron deficiency anemia. . # [**Name (NI) **] Unclear if he has been taking HAART regimen and Bactrim. -started for a short period on HAART, then discontinued. - CD4 was 319 on [**2117-1-17**]; last VL [**Numeric Identifier **] [**5-2**]. . # Anemia- Baseline varies from 29-35. Currently 31. No signs of active bleeding. -started on Iron and EPO . # Sinus tachycardia- Multiple causes possible including cocaine use, ETOH use, withdrawals, fever, hypovolemia. - intitially came in with HR to 140s-150s - on [**1-22**], on discharge to floor, HR in 100s-110s. . # HTN- Likely secondary to non-med compliance, ETOH and cocaine use. - initial HTN on admission was due likely to fluid overload and cocaine use. - AntiHTN home regimen: lisinopril and diltiazem - Toxicology consult in ED recommended not to use BB because of his cocaine use; would be cautious on discharging on a BB because he likely will continue to use cocaine at home. - [**Month/Year (2) **] pressure was controlled with nitrate in MICU; then discontinued as his [**Month/Year (2) **] pressure stabilized. . # ETOH abuse/Cocaine abuse- Pt with recent crack cocaine use and chronic ETOH use, drinbk [**11-30**] pint- 1pint liquor qday. . # Diarrhea- Given HIV status could be any potential infectious [**Doctor Last Name 360**]. Appears to be fairly acute over past few days. - stool cultures, cdiff, O&P all negative - had some diarrheal BM on discharge . # FEN- Renal, Low Na, cardiac diet. . # PPx- Heparin SC, bowel regimen . # Code- FULL . # Communication: Partner. # is in OMR. . Completed by Dr. [**First Name (STitle) 4154**] - Signed by Dr. [**First Name (STitle) **] Medications on Admission: Patient only takes meds sporadically. Brought list with dosages-diltiazem, bactrim, retrovir, renal caps, norvir, epivir, lexiva, lisinopril, viread, protonix, fosrenol. This list coincides with his discharge meds from [**9-2**]. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TIDAC (3 times a day (before meals)). 3. Lamivudine 100 mg Tablet Sig: [**11-30**] Tablet PO DAILY (Daily). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 7. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO 1X/WEEK ([**Doctor First Name **]). 9. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 11. Zidovudine 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a day. 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Renal Failure CHF Hypertension Secondary: ESRD Anemia HIV Hyperparathyroidism Discharge Condition: Stable Discharge Instructions: 1. Please report to the nearest emergency department if you have fever, chills, abdominal pain, abdominal distension (worsening pain), nausea or vomiting or shortness of breath. 2. Please continue to take medications as directed. Please continue to take HARRT medication as you were at home. 3. Please follow up with Dr. [**Last Name (STitle) **] as he has directs. 4. STOP taking your diltiazem and your lisinopril. You should not take these medications until you see Dr. [**Last Name (STitle) **] in clinic and have your bloodwork checked. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] as he has directed you to. Please call at [**Telephone/Fax (1) 2393**]

[ "291.81", "292.81", "518.81", "305.61", "425.4", "V15.81", "303.91", "428.0", "282.5", "787.91", "403.91", "583.9", "585.6", "042", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "54.98", "38.93", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

9969, 9975

4110, 8494

339, 388

10107, 10116

2424, 4087

10713, 10839

1848, 1936

8775, 9946

9996, 10086

8520, 8752

10140, 10690

1951, 2405

292, 301

416, 1460

1482, 1710

1726, 1832

13,570

198,374

3428

Discharge summary

report

Admission Date: [**2103-6-10**] Discharge Date: [**2103-6-16**] Date of Birth: [**2044-11-29**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old female with diabetes, coronary artery disease, peripheral vascular disease, and hypertension who presented to an outside hospital with severe substernal chest pain, dyspnea, and ruled in for MI by enzymes. The patient was transferred to the [**Hospital3 **] Medical Center for cardiac catheterization. The patient's presentation began at approximately 2:00 a.m. with shortness of breath and [**10-12**] substernal chest pain and was taken to the Emergency Department at the outside hospital by the patient's daughter. The patient's saturation at the time was 78% on room air. The patient was noted to have EKG changes with acute ST depressions in leads V3 through V6, aVF and V3. The patient was also noted to be in CHF at this time. The patient was given sublingual nitroglycerin as well as Lasix and aspirin with corresponding resolution of pain. The patient was also initiated on a heparin drip prior to arriving to [**Hospital6 1760**]. Cardiac catheterization on [**2103-6-11**] revealed LMCA 80%, LAD subtotal mid, severe diffuse mid and distal disease, approximately 80% D1, LCX 70% origin, diffuse up to 70% mid, RCA 80% proximal and mid, 80% PLV, other 70% RAMUS diseased vessels were determined. Given these findings, CT surgical evaluation was sought by the Medicine Service. PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus type 2. 2. Cardiac catheterization times 2. 3. Peripheral vascular disease. 4. Unstable angina. 5. Hypertension. 6. Hypercholesterolemia. 7 Status post toe amputation. ALLERGIES: Aspirin induces GI bleed, erythromycin causes nausea and vomiting. ADMISSION MEDICATIONS: 1. Glucophage 1,000 XR one tablet p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Cardizem 240 mg p.o. q.d. 4. Isordil. 5. Trental 400 mg p.o. t.i.d. 6. Hydrochlorothiazide 37.5 mg p.o. q.d. 7. Tri-Cor 160 mg p.o. q.d. 8. Zantac 150 mg p.o. b.i.d. 9. Paxil 30 mg p.o. q.d. 10. Pravachol 20 mg p.o. q.d. SOCIAL HISTORY: The patient quit tobacco smoking approximately 15 years prior. The patient is currently divorced with four children. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.1, pulse 80, sinus, blood pressure 123/70, respirations 18, 98% on room air. General: The patient was a well-developed, well-nourished female, mildly obese, in no apparent distress. HEENT: Sclerae anicteric. Mucous membranes moist. No evidence of oral ulcers. Cranial nerves: II through XII intact. No evidence of cervical lymphadenopathy noted. Chest: Clear to auscultation bilaterally. Sternotomy incision site without evidence of erythema. No serosanguinous drainage. No evidence of click on palpation. Cardiac: Regular rhythm and rate. No evidence of murmurs, click, or rub. Abdomen: Positive bowel sounds, soft, nondistended, nontender, with no evidence of hepatosplenomegaly, nor inguinal lymphadenopathy. Lower extremities: Minimal edema. No evidence of rash. LABORATORY/RADIOLOGIC DATA: On [**2103-6-15**], white blood cell count 9.1, hematocrit 24.6, platelet 183,000. Sodium 136, potassium 4.3, chloride 99, bicarbonate 28, BUN 26, creatinine 0.9, glucose 163, magnesium 1.8, calcium 8.5, phosphorus 3.1. HOSPITAL COURSE: The patient is a 58-year-old female with a known history of coronary artery disease, unstable angina, insulin-dependent diabetes mellitus, hypertension, peripheral vascular disease, who underwent an uncomplicated CABG times four, LIMA to DIAG, SVG to PDA, SVG to left PL, LAD sequential on [**2103-6-12**]. Postoperatively, the patient was taken to the CSRU for close monitoring, where upon the patient was promptly extubated, maintaining good saturation on 4 liters nasal cannula in normal sinus rhythm. By postoperative day number one, the patient's Lopressor was initiated at 25 mg p.o. b.i.d. and Swan discontinued. At this time, the chest tube was also removed and the patient was transferred to the floor. By postoperative day number two, the patient's metoprolol was titrated to 50 mg p.o. b.i.d. At this time, the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was removed along with the remainder of the lateral chest tubes. As the patient's physical recovery was remarkably rapid, Physical Therapy evaluation was sought, at which time the patient achieved level V goal cardiac discharge criteria by postoperative day number three. At that time, the patient's sternal wires were removed and the decision was made to discharge the patient in good condition. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Status post CABG times four (LIMA to DIAG, SVG to PDA, SVG to left PL, LAD sequential). DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Zestril 10 mg p.o. q.d. 3. Lasix 20 mg p.o. b.i.d. times seven days. 4. Potassium 20 mEq p.o. b.i.d. times seven days. 5. Glucophage XR 1,000 mg p.o. q.d. 6. Paroxetine 30 mg p.o. q.d. 7. Regular insulin sliding scale as per prior to surgery. 8. Iron supplements and vitamin supplements. FOLLOW-UP: The patient was instructed to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in four weeks. The patient was additionally instructed to follow-up with her cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. The patient's Lasix should be titrated by Dr. [**Last Name (STitle) **] within seven days of discharge. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 11079**] MEDQUIST36 D: [**2103-6-16**] 03:25 T: [**2103-6-16**] 06:25 JOB#: [**Job Number 15841**] cc:[**Last Name (NamePattern4) 15842**]

[ "272.0", "414.01", "401.9", "410.71", "428.0", "250.00", "443.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "99.20", "39.61", "36.15", "88.53", "36.13" ]

icd9pcs

[ [ [] ] ]

4918, 5941

4806, 4895

3395, 4723

1830, 2136

2308, 3377

1511, 1807

2153, 2293

4748, 4784

13,265

162,736

48395

Discharge summary

report

Admission Date: [**2143-1-4**] Discharge Date: [**2143-1-8**] Date of Birth: [**2079-5-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: transfer s/p episode of pulseless VT Major Surgical or Invasive Procedure: none History of Present Illness: This is a 63 yo female with h/o CAD s/p NSTEMI and previous vfib arrest, severe AS, amyloidosis, smoldering myeloma, and ESRD on HD who was transferred to the MICU s/p VT arrest in the dialysis unit. The patient came to dialysis as an outpatient and completed her dialysis with 1 kg fluid taken off. She had a 2K bath b/c she had recently had potassiums in the 5 range and diarrhea. Post dialsysis labs showed hypokalemia. After dialysis she began to c/o some diarrhea and then became unresponsive. A code was called and the patient was found to be apneic and in pulseless VT. She was bagged and chest compressions were initiated. She was shocked once at 200 joules with return of pulse and breathing, as well as return of consciouness. At that point pt's PCP entered the room and anounced that patient was DNR/DNI and would not want to be rescusitated. She had already regained a stable narrow complex rhythm and a pulse. She was transferred to the MICU for further management. . The patient denied pain or SOB. Of note pt had severe constipation at hospice after taking a lot of oxycodone. Disimpacted this weekend and started on lactulose, now having diarrhea. Past Medical History: CAD (s/p NSTEMI-> OM1 stent in [**10-1**]) CHF Primary Amyloidosis diagnosed [**8-31**] Smoldering Myeloma Schizotypal Disorder Major depressive d/o Basal cell carcinoma Hypothyroidism Hypercholesterolemia ESRD on HD Hypertension Aortic stenosis bicuspid aortic valve Recent admit with vfib arrest s/p HD cardiac arrest [**10-1**], [**1-2**] Social History: Divorced with two sons. Currently lives in [**Location 86**] with one of her sons. Formerly worked as a teacher but currently lives off SS assistance. Former smoker but quit 20yr ago. Prior EtOH abuse, denies current. Denies illicits. Recently discharged home with hospice and was DNR/DNI Family History: Mother w/ CVA, brother w/ CAD, and another brother w/ IVDU. Physical Exam: Temp 96.3 BP 90/58 HR 62 O2 sat 95% RR 12 Gen: chronically ill appearing, thin female, groggy, A& HEENT: anicteric sclera, dry MM Neck: supple, JVP 7 cm Pulm: CTA b/l Cardio: RRR, nl S1 s2 4/6 systolic ejection murmur heard throughout Abd: soft, NT, ND , + BS Ext: no edema, 2+ DP pulses Neuro: A&Ox2, groggy but conversing appropriately moving all extremities pupils equal and round Pertinent Results: [**2143-1-4**] 03:45PM PLT COUNT-251 [**2143-1-4**] 03:45PM WBC-5.0 RBC-3.96* HGB-12.0 HCT-36.7 MCV-93 MCH-30.2 MCHC-32.6 RDW-17.3* [**2143-1-4**] 03:45PM ALBUMIN-3.0* CALCIUM-7.5* PHOSPHATE-1.6*# MAGNESIUM-1.5* [**2143-1-4**] 03:45PM CK-MB-NotDone cTropnT-0.16* [**2143-1-4**] 03:45PM ALT(SGPT)-20 AST(SGOT)-48* CK(CPK)-34 ALK PHOS-97 TOT BILI-0.3 [**2143-1-4**] 03:45PM GLUCOSE-124* UREA N-5* CREAT-2.3*# SODIUM-142 POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-30 ANION GAP-14 [**2143-1-4**] 05:21PM PT-35.7* PTT-150* INR(PT)-3.9* [**2143-1-4**] 05:21PM PLT COUNT-234 [**2143-1-4**] 05:21PM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-1+ [**2143-1-4**] 05:21PM NEUTS-52.9 LYMPHS-35.0 MONOS-8.5 EOS-3.2 BASOS-0.5 [**2143-1-4**] 05:21PM WBC-3.5* RBC-4.10* HGB-12.5 HCT-37.9 MCV-93 MCH-30.4 MCHC-32.9 RDW-17.6* [**2143-1-4**] 05:21PM CALCIUM-7.9* PHOSPHATE-1.8* MAGNESIUM-1.4* [**2143-1-4**] 05:21PM CK-MB-NotDone cTropnT-0.17* [**2143-1-4**] 05:21PM CK(CPK)-37 [**2143-1-4**] 05:21PM GLUCOSE-107* UREA N-5* CREAT-2.7* SODIUM-143 POTASSIUM-2.5* CHLORIDE-100 TOTAL CO2-30 ANION GAP-16 [**2143-1-4**] 07:55PM TYPE-ART PO2-78* PCO2-45 PH-7.42 TOTAL CO2-30 BASE XS-3 [**2143-1-4**] 11:50PM CALCIUM-7.6* PHOSPHATE-2.7 MAGNESIUM-2.5 [**2143-1-4**] 11:50PM CK-MB-NotDone cTropnT-0.27* [**2143-1-4**] 11:50PM CK(CPK)-28 [**2143-1-4**] 11:50PM GLUCOSE-70 UREA N-6 CREAT-3.6* SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16 [**2143-1-8**] 05:10AM BLOOD WBC-5.6 RBC-3.35* Hgb-10.5* Hct-31.5* MCV-94 MCH-31.4 MCHC-33.4 RDW-19.3* Plt Ct-200 [**2143-1-8**] 05:10AM BLOOD Glucose-77 UreaN-18 Creat-4.5*# Na-133 K-4.7 Cl-98 HCO3-27 AnGap-13 [**2143-1-4**] 05:21PM BLOOD CK(CPK)-37 [**2143-1-4**] 11:50PM BLOOD CK(CPK)-28 [**2143-1-5**] 05:53AM BLOOD CK(CPK)-32 [**2143-1-4**] 05:21PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2143-1-4**] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.27* [**2143-1-5**] 05:53AM BLOOD CK-MB-NotDone cTropnT-0.27* Brief Hospital Course: This is a 63 yo female with h/o CAD s/p NSTEMI and previous vfib arrest, severe AS, amyloidosis, smoldering myeloma, ESRD on HD who was transferred to the MICU s/p cardiac arrest and [**Hospital 101916**] transferred to the floor. . 1. S/p cardiac arrest: The patient was had a pulseless VT arrest after on HD [**2143-1-4**] which was likely attributed to hypokalemia and insufficient preload in the setting of severe AS. This is her second arrest post dialysis. Stent thrombosis was initially a concern given the patient had a coronary stent placed ~3months ago and she has been non-compliant w/ her meds. However, an EKG did not show ST elevations and CE were negative. She was monitored overnight in the MICU without further cardiac events. The following morning, she was transferred to the medicine floor and had no further events during her hospitalization. . 2. Diarrhea: The patient's diarrhea was thought to be due to recent aggressive bowel regimen. Her diarrhea resolved during her hospitalizatio w/o intervention. . 3. Severe AS: The patient is likely pre-load dependent with valve area 0.7. She was bolused 1L in the MICU and maintained euvolemic during the rest of her hospitalization. . 4. CHF: The patient has systolic dysfunction with an EF 40-45% which is likely secondary to ischemic cardiomyopathy, amyloidosis, and severe AS. Her lisinopril and metoprolol were initially held in the setting of recent cardiac arrest. However, metoprolol was added back after her BP stabilized. . 5. CAD s/p NSTEMI and stent placement: Initially, EKG showed lateral ST depressions s/p cardiac arrest. She was continued on [**Month/Day/Year **], plavix, and lipitor. Her metoprolol was added back after BP stabilized. Cardiac enzymes checked, w/ a slightly elevated troponin, but normal CKs. . 6. ESRD on HD: Renal service followed throughout her admission. She recieved on more HD session prior to discharge w/o event. . 7. Amyloidosis: No treatment. . 8. Code status: FULL CODE- The patient was initially DNR/DNI. But after admission to MICU, teh patient informed the MICU team that she wanted to be full code. A Palliative care consult was obtained and the issue of code status was discussed multiple times by various staff members. The patient clearly stated on many occasions that she wishes to be full code. The patient remained full code upon discharge. Medications on Admission: Aspirin 325 mg qd Clopidogrel 75 mg qd Levothyroxine 75 mcg qd Amiodarone 200 mg po BID Fluoxetine 20 mg qd Metoprolol Tartrate 25 mg, 0.5 Tablet PO BID? Acetaminophen 1000 mg TID Midodrine 5 mg Tablet 3x per week on HD day Oxycodone 5 mg Tablet 2 Tabs PO Q4-6H Calcium Carbonate 500 mg Tablet PO TID W/MEALS Docusate Sodium 100 mg PO BID Lidocaine 5 %(700 mg/patch) Adhesive Patch Diazepam 5 mg Tablet Sig: 0.5 Tablet PO BID Lactulose Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2188**] Discharge Diagnosis: primary: VT cardiac arrest . Secondary: amyloidosis CAD CHF Schizotypal Disorder Major depressive d/o Hypothyroidism Hypercholesterolemia ESRD on HD Hypertension Aortic stenosis Discharge Condition: Good. Discharge Instructions: Please return to the hospital if you experience lightheadedness, loss of consciousnesss, chest pain, or any other symptoms that concern you. . please continue to take all of your medications as previously prescribed. Please keep your appointment with Dr. [**Last Name (STitle) **] on [**2-12**], [**2142**]. Please resume your outpatient HD schedule. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2143-2-12**] 2:00 Provider: [**Name10 (NameIs) 19240**],[**Doctor Last Name **] PSYCHIATRY OPD Date/Time:[**2143-1-29**] 3:30 Completed by:[**2143-1-10**]

[ "V45.82", "427.1", "277.39", "424.1", "276.51", "403.91", "244.9", "583.81", "428.0", "276.8", "295.72", "427.5", "414.01", "428.22", "272.0", "585.6" ]

icd9cm

[ [ [] ] ]

[ "99.62", "39.95", "99.60" ]

icd9pcs

[ [ [] ] ]

8478, 8528

4709, 7083

350, 357

8752, 8760

2731, 4686

9159, 9443

2246, 2308

7570, 8455

8549, 8731

7109, 7547

8784, 9136

2323, 2712

274, 312

385, 1554

1576, 1920

1936, 2230

46,287

137,331

36086

Discharge summary

report

Admission Date: [**2196-5-5**] Discharge Date: [**2196-5-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **] yo female with history of severe COPD on home oxygen(4L), diastolic heart failure, and kyphoscoliosis who presented to the [**Hospital 4199**] Hospital with increasing shortness of breath the evening prior to admission. She was being treated at her [**Hospital3 **] for heart failure exacerbation, however she had an aspiration event in the dining room at dinner, desatted to low 80s on 4liters, tachycardic prompting transfer to the ED. There she was febrile to 102 and felt to have active acute on chronic diastolic heart failure, copd flare, and pneumonia. She also complained of chest pain, but details are unclear. She received vanco/solumedrol/lasix and ntg paste at OSH prior to ED to [**Hospital **] transfer to [**Hospital1 18**] for further management at the request of the family. On arrival at [**Hospital1 18**], her room air sat was in the 80s and she was tachypnic to 40s. She was started on bipap and received cefepime and gentamycin and blood cultures were sent. . In the ED, initial vs were: T 102.2 HR 96afib BP 136/74 RR 26 POx 87. Prior to transfer to the floor HR 98 BP 135/71. Her IV infiltrated and was removed. She was given 1gm Vanc, 125mg solumedrol, and nitropaste at [**Last Name (un) 4199**] for SOB and ? chest pain. At [**Hospital1 18**] ED On the floor, she is comfortable on BiPAP, satting 92% on FiO2 30%, but does not remember what happened at dinner the previous night. Review of systems: (+) Per HPI (-) Denies any current pain, but unable to obtain further information given pt on BiPAP mask. Past Medical History: Diastolic Heart Failure Atrial Fibrillation on coumadin Remote h/o TIAs COPD on home O2 (3-4L at baseline) Scoliosis Osteoarthritis L hip/R pelvis fx managed nonoperatively Recent LLE cellulitis Anxiety Chronic Anemia (baseline hct 32) Social History: From chart, limited [**12-28**] BIPAP Lives at nursing home. Ambulates with a walker at baseline. Alert and oriented x 3 at baseline. On home oxygen 3-4L. Past smoker but quit 30 years ago. No ethanol or illict drugs. Son and daughter live nearby and are involved. Family History: Positive for hypertension and type II diabets. Given age non-contributory to current illness. Physical Exam: Vitals: T: 96.2 BP: 152/71 P: 94 R: 27 O2: 93% on BiPAP 30% FiO2, 14/8 General: Easily arousible, follows commands, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, diminished breath sounds at Right base. CV: Irregularly irreg, 2/6 SEM at LUSB without rubs, gallops Abdomen: soft, non-tender, minimally distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+ edema at ankles. Neuro: responds to verbal stimuli, unable to understand her while on BiPAP, moving all 4 extremities equally. Pertinent Results: [**2196-5-5**] 04:41AM TYPE-ART PO2-74* PCO2-76* PH-7.42 TOTAL CO2-51* BASE XS-19 [**2196-5-5**] 04:41AM LACTATE-1.7 [**2196-5-4**] 11:57PM LACTATE-2.1* [**2196-5-4**] 11:45PM GLUCOSE-191* UREA N-29* CREAT-1.1 SODIUM-142 POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-42* ANION GAP-14 [**2196-5-4**] 11:45PM CK(CPK)-61 [**2196-5-4**] 11:45PM cTropnT-0.04* [**2196-5-4**] 11:45PM CK-MB-NotDone proBNP-2595* [**2196-5-4**] 11:45PM WBC-8.2 RBC-3.94* HGB-11.7* HCT-36.2 MCV-92 MCH-29.7 MCHC-32.3 RDW-17.2* [**2196-5-4**] 11:45PM NEUTS-94.9* LYMPHS-3.6* MONOS-1.3* EOS-0.1 BASOS-0.1 [**2196-5-4**] 11:45PM PLT COUNT-232 [**2196-5-4**] 11:45PM PT-18.9* PTT-22.7 INR(PT)-1.7* [**2196-5-4**] 11:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2196-5-4**] 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: This is a [**Age over 90 **] yo F with severe COPD, diastolic heart failure, kyphoscoliosis who presents with acute on chronic diastolic heart failure and aspiration pneumonia. # Hypoxia - Presented with aspiration pneumonitis/pneumonia and component of acute on chronic diastolic heart failure. Underlying COPD, kyphoscoliosis contributing. ABG with baseline hypercarbia of PCO2 76. Presented with lactate of 2.1, but down to 1.7 after 1 L NS resuscitation. She was maintained at first on Bipap with sats >92% so was then weaned to NC with sats in the low 90s for most of the first hospital day. When she fell asleep she did require CPAP with PS using full face mask set at IPAP of 15 and EPAP of 5 with 2-4L oxygen to maintain oxygen sats of 88-92%. She was started on vanc/zosyn on [**2196-5-5**] for HCAP given that she lives in a [**Hospital3 **] and has had multiple recent hospital admission and her CXR had evidence of RLL infiltrate. She will complete an 10 day course on [**2196-5-15**]. She was maintained on her home dose of lasix which was increased the day of admission (she takes 80mg PO at home and got 40mg IV here) for goal fluid balance net negative 500mL daily. # ECG changes: [**First Name8 (NamePattern2) **] [**Hospital 4199**] hospital ED, patient was complaining of chest pain and given nitro paste. Cardiac biomarkers were flat (0.04->0.02), EKG in am was unchanged. She was started on asa while awaiting results of ROMI. She had no further episodes of chest pain and her cardiac enzymes were negative. Aspirin was continued in place of coumadin for her atrial fibrillation. # COPD on home O2 (3-4L at baseline): On admission bicarb was at her baseline and her hypercarbia was at baseline with PCO2 of 76. Also was on prednisone for recent exacerbation and was given 125mg solumedrol at [**Hospital 4199**] hospital. Kept O2 sats 89-92. Received scheduled Nebs and PRN for SOB. Continued prednisone 20mg which should be tapered as she continues to improve. ABx as above. # A fib on coumadin: She had a sub therapeutic INR of 1.7 on admission with good rate control with Cardizem and metoprolol. She was switched to short acting dilt while hospitalized with HRs in low 60s and switched back at the time of discharge. She was continued on metoprolol for rate control. Given the risk/benefit of coumadin in this patient, decision was made to treat with aspirin alone. # Acute on chronic Diastolic heart failure: ECHO from [**10/2195**] showed EF of 70-80% with Mild PAH and significant pulmonic regurg. On admission appeared euvolemic. She was given 1 L NS in ED for lactate of 2.1 which improved to 1.7 after fluids. BNP was mildly elevated at level it had been on past admissions. Her CXR did not appear grossly fluid overloaded so lasix was initially held but as above over the day she had some increasing O2 requirements and she was given her recently increased home dose of lasix. We recommend continuing with daily weights, maitain goal I/O at negative 500cc /day, titrating lasix and monitoring electrolytes as necessary. # Chronic Aspiration - Patient should be maintain on aspiration precautions and dysphagia diet of pureed solids and nectar thickened liquids. The risk of future aspiration events discussed with patient's family. It is their wish to continue with feeding. # Goals of Care - Family very interested in initiating palliative care/home hospice when the time comes for her to transition home and would like more information on this. # hyperglycemia - In setting of steroids patient was noted to have elevated blood sugars. A humalog sliding scale was started. # Prophylaxis: Subcutaneous heparin and H2 blocker # Access: peripherals # Code: DNR/DNI per family and nursing home records # Communication: [**Name (NI) **] (son/power of attorney) [**Telephone/Fax (5) 81861**]. [**Doctor First Name **] (daughter) [**Telephone/Fax (3) 81862**], [**Doctor First Name 1494**] (daughter): [**Telephone/Fax (1) 81863**]. Medications on Admission: prednisone 20 mg 1 tab(s) qd Atrovent 0.02% 3 mL QID Cardizem CD 180 mg/24 hours 1 cap(s) once a day Lasix 80 mg 1 q am Lasix 40 mg/60 mg 1 tab(s) q o 12 noon Lanoxin 0.0625 mg 1 tab qod Coumadin 2 mg as directed q pm BuSpar 10 mg 1 tab(s) TID Celexa 20 mg 1 tab(s) once a day ferrous gluconate 1 qd Prilosec 20 mg 1 cap(s) once a day senna 8.6 mg 2 tab(s) once a day (at bedtime) Bisac-Evac 5 mg 2 tab(s) once a day Lopressor 12.5mg as directed Q12H Vitamin C 500 mg 1 tab(s) once a day Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO Q4PM (). 17. Vancomycin 1000 mg IV Q48H First dose [**2196-5-4**] 18. Piperacillin-Tazobactam 2.25 g IV Q6H First dose [**2196-5-4**] 19. Ondansetron 4 mg IV Q8H:PRN nausea 20. Cardizem CD 180 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 21. Insulin Lispro 100 unit/mL Solution Sig: as directed units Subcutaneous QACHS: sliding scale, w/ meals start at BS 160 - 2units, go up by 2 units for every increase in 40 of BS. At HS, start at BS 200 same scale. 22. 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. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary - Pneumonia Secondary - Acute on chronic diastolic heart failure - Chronic obstructive pulmonary disease - Atrial fibrillation Discharge Condition: Hemodynamically stable, O2 sats 88-92% on nasal cannula. Discharge Instructions: You were admitted with shortness of breath. This was thought to be due a pneumonia with possible exacerbation of your congestive heart failure. You were started on antibiotics with improvement. You were continued on your pureed diet and thickened liquids as was consistent with your goals of care. You also were started on CPAP w/ IPAP of 15/EPAP of 5 ccH2O while you sleep with great improvement in your respiratory status. You will be discharged to Rehab for further care. The following changes were made to your medications: Your coumadin was discontinued and replaced with aspirin You were started on vancomycin/zosyn for treatment of your pneumonia with plan for total of 10 day course from [**2196-5-5**] . Please take all medications as prescribed. Call your doctor or 911 if you develop chest pain, difficulty breathing, fevers > 101, dizziness, change in mental status, bleeding, or any other concerning symptoms. Followup Instructions: Please follow up with your PCP, [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**], within 1-2 weeks of discharge. Her office number is [**Telephone/Fax (1) 608**].

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icd9cm

[ [ [] ] ]

[ "93.90", "99.21", "38.93" ]

icd9pcs

[ [ [] ] ]

10664, 10743

4160, 8138

280, 286

10922, 10981

3235, 4137

11954, 12144

2443, 2539

8676, 10641

10764, 10901

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11005, 11931

2554, 3216

1771, 1879

221, 242

314, 1752

1901, 2139

2155, 2427

69,144

153,453

37028

Discharge summary

report

Admission Date: [**2178-6-20**] Discharge Date: [**2178-6-23**] Date of Birth: [**2122-6-12**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headache Major Surgical or Invasive Procedure: [**6-21**]: Left craniotomy for SDH evacuation History of Present Illness: 56yo man p/w headache for 1 month. Recalls banging head on cabinet one month ago. Denies nausea, vomiting, double vision, numbnes, weakness. Does have some dizziness with standing. Also c/o "flashing lights" in vision lasting 15 minutes. Takes ASA for a fib. Also noted some hearing loss with headaches. Past Medical History: afib, chronic low back pain, anxiety Social History: Married, resides at home with wife. [**Name (NI) 1403**] in a local school district in computer maintanence. Reports [**2-11**] alcoholic beverages per night/5dys per week Family History: Non-contributory Physical Exam: On Admission: O: T:98.5 BP:119 /63 HR:66 R18 O2Sats 99 Gen: WD/WN, comfortable, NAD. HEENT: Pupils:ERRLA EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-10**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4to3 left,3 to 2 mm on right. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-12**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Exam on Discharge: Alert and oriented x 3. PERRL, EOMS intact. Face symmetric, tongue midline. No pronator drift. Full strength and sensation throughout. Incision is clean, dry, and intact. Pertinent Results: Labs on Admission: [**2178-6-19**] 10:30PM BLOOD WBC-7.1 RBC-4.71 Hgb-14.3 Hct-40.4 MCV-86 MCH-30.3 MCHC-35.3* RDW-14.0 Plt Ct-228 [**2178-6-19**] 10:30PM BLOOD Neuts-62.5 Lymphs-25.8 Monos-6.9 Eos-3.7 Baso-1.0 [**2178-6-19**] 10:30PM BLOOD PT-12.7 PTT-27.6 INR(PT)-1.1 [**2178-6-19**] 10:30PM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-140 K-4.0 Cl-103 HCO3-26 AnGap-15 [**2178-6-20**] 06:55AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.3 [**2178-6-19**] 10:30PM BLOOD ASA-NEG Ethanol-25* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs on Discharge: WBC RBC Hgb Hct Plt Ct [**2178-6-23**] 06:15AM 11.5* 4.58* 13.5* 39.9* 280 Glu BUN Creat Na K Cl [**2178-6-23**] 06:15AM 92 11 138 4.3 102 29 Dilantin 8.5 - patient received bolus afterwards IMAGING: CT Head [**6-19**]: TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. Multiplanar reformatted images were generated. FINDINGS: Overlying the anterior left cerebral convexity is a collection of mixed attenuation material, consistent with subdural hematoma. Heterogeneous attenuation likely represents a combination of relatively early and late subacute bleeding. The lower attenuation material is not CSF density, suggesting the hematoma is not chronic. There is approximately 6 mm of associated rightward, subfalcine herniation of the midline. The underlying sulci demonstrate hemispheric effacement. The left lateral ventricle demonstrates mass effect. There are no other foci of intracranial hemorrhage. The basilar cisterns are symmetric. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is no fracture. The mastoid air cells and paranasal sinuses are well aerated. Soft tissues are unremarkable. IMPRESSION: Mixture of early and delayed subacute subdural hematoma overlying the left anterior convexity, resulting in 6 mm of rightward subfalcine herniation and midline shift, with sulcal effacement and mass effect on the left lateral ventricle. This appears stable compared to the recent MR. MRI Brain [**6-20**]: TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired. FINDINGS: There is an acute/subacute subdural hematoma seen on the left extending from frontal to the occipital region. The maximum width of the hematoma is seen in the frontal region measuring approximately 18 mm and it is measuring approximately 14 mm in the parietal region. The hematoma contains a high T1 and high T2 signal indicating subacute hemorrhage. Additionally, low T2 signal collection is also seen which indicates acute hemorrhage. There is mass effect on the left cerebral hemisphere with obliteration of sulci. Mild shift of the midline is seen to the right side with deformity of the left lateral ventricle. The hematoma slightly extends to the interhemispheric fissure posteriorly. There is no acute infarct seen. There is no hydrocephalus. Few scattered foci of hyperintensity in the white matter of nonspecific nature are seen which could indicate early changes of small vessel disease. Note is made of increased signal in the right sigmoid sinus and proximal jugular vein on FLAIR and T2-weighted images. Increased signal is also seen in this region on T1 sagittal images. Although this could be secondary to artifact it is unusual to have this much hyperintensity on T1-weighted images. Thrombosis of the sinus is suspected. To further evaluate MRV of the head or CTA venography of the head and neck are recommended. CT venography of the head and neck may provide further information . IMPRESSION: 1. Left-sided acute/subacute subdural hematoma extending from frontal to the occipital region with maximum width of 1.8 cm. Tiny right frontal subdural is also seen. 2. Abnormal signal in the right sigmoid sinus and proximal jugular vein suspicious for thrombosis. Further evaluation with CT venography of the head and neck recommended. 3. Mild changes of small vessel disease. 4. Mild midline shift to the right. CTA/V of Head/Neck [**6-20**]: TECHNIQUE: Axial acquired images were obtained through the brain without contrast followed by post-contrast images through the brain and neck per CTB protocol. Coronal and sagittal reformations were evaluated. CT OF THE HEAD WITHOUT AND WITH INTRAVENOUS CONTRAST: Evolving mixed acute and chronic left subdural hematoma displays no significant interval change in size from prior exam. The degree of mass effect on the adjacent sulci as well as subfalcine herniation measuring approximately 6-7 mm is also stable. No new parenchymal abnormalities are identified. Mass effect on the left occipital and temporal horns is stable. Globes and soft tissues are unremarkable. Mild right sphenoid sinus mucosal thickening is noted with remaining paranasal sinuses and mastoid air cells appearing unremarkable. Small mucous retention cysts are also present within the right and left maxillary sinuses. Post contrast administration, there is no thrombosis of the venous sinuses with appropriate filling of the sigmoid sinuses bilaterally. The posterior circulation appears codominant. The right PCA displays a fetal-type configuration. Anterior circulation is unremarkable with no aneurysmal dilatation noted. A somewhat prominent left cortical vein is noted, likely appearing more prominent, related to the adjacent subdural hematoma. No AV malformation is present. CT OF THE NECK WITH INTRAVENOUS CONTRAST: Jugular veins are patent. Included portions of the aortic arch and great vessel origins are normal. There is no flow-limiting stenoses involving the origins of the vertebral arteries or internal carotid arteries. Soft tissue structures within the neck are unremarkable. No pathologically enlarged lymph nodes are present. Mild-to-moderate bilateral periodontal disease is noted. The septum is noted to be rightward deviated with mild spur formation causing mass effect on the right inferior turbinate. IMPRESSION: 1. No significant interval change to acute on chronic evolving left subdural hematoma with stable rightward subfalcine herniation. 2. Patent jugular veins bilaterally. Patent venous sinuses. The abnormality seen on MRI was likely due to flow artifact. Head CT [**2178-6-21**]: FINDINGS: There has been interval left frontal craniotomy, with evacuation of a left subdural hematoma. There is a postoperative changes within the left subdural space, residual left subdural collection, consisting of air, and residual blood products, measuring approximately 13 mm in maximal dimensions. Local mass effect on adjacent sulci, with mild sulcal effacement is unchanged. There is a rightward subfalcine herniation of approximately 4 mm, which is improved from prior study (previously 7 mm). No additional foci of hemorrhage are identified. The caliber of the ventricular system is stable, without evidence of new hydrocephalus. No infarct is identified. Visualized paranasal sinuses and mastoid air cells are normally aerated. IMPRESSION: 1. Status post evacuation of the left subdural hematoma, with postoperative pneumocephalus, and residual blood products within the left subdural space, measuring approximately 13 mm in maximal dimensions. 2. Improvement in rightward subfalcine herniation, with herniation of approximately 4 mm. Brief Hospital Course: 56M admitted to the Neurosurgery service after complaining of a history of recurrent headache and word finding difficutly. CT of the head was done revealing a left sided acute on chronic SDH. MRI was also performed at the OSH prior to transfer. Radiology [**Location (un) 1131**] at [**Hospital1 18**] had a question of sinus flow-signal [**Last Name (LF) 83486**], [**First Name3 (LF) **] a CTA/V of the head and neck to rule out jugular thrombosis. This study ultimately proved to be negative. He was admitted to the neurosurgery floor with plans to take him to the operating room on the subsequent day for left sided crani for evacuation of blood components. On [**6-21**], he was taken to the OR and recovered in the ICU overnight. The patient was kept flat for 24 hours and was placed on a non-rebreather mask at 100% for 24 hours for pneumocephalus. He was transferred to the neurosurgical floor on [**6-22**]. The patient ambulated with nursing assistance and did very well. Overnight the patient hit his head on the side rail. He did not lose consciousness and his neuro exam was unchanged. Therefore a head CT was not performed. The following day he was ambulating on his own with no difficulty. His wound looked clean, dry, and intact. There did not appear to be any disruption from striking his head overnight. Neurologically he had no deficits and was deemed ready for discharge. His dilantin level was slightly low on the day of discharge so the patient received a bolus and his dose was increased. He went home with his wife on [**2178-6-23**]. Medications on Admission: atenolol, asa 325, seroquel,xanax Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*30 Capsule(s)* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: No driving while on this medication. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left sided acute on chronic SDH Discharge Condition: Neurologically Stable Discharge Instructions: ??????Have a friend/family member check your incision daily for signs of infection. ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????You may wash your hair only after sutures have been removed. ??????You may shower before this time using a shower cap to cover your head. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ??????You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ??????Clearance to drive and return to work will be addressed at your post-operative office visit. ??????Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ??????New onset of tremors or seizures. ??????Any confusion or change in mental status. ??????Any numbness, tingling, weakness in your extremities. ??????Pain or headache that is continually increasing, or not relieved by pain medication. ??????Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ??????Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please return to the office in [**7-17**] days(from your date of surgery) for removal 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**]. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. ??????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**]. Completed by:[**2178-6-23**]

[ "300.00", "278.00", "427.31", "852.21", "E917.9" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

12100, 12106

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328, 377

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2508, 2513

13916, 14665

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11526, 12077

12127, 12161

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405, 713

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2317, 2489

2527, 3032

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790, 963

62,183

159,875

34735

Discharge summary

report

Admission Date: [**2149-8-11**] Discharge Date: [**2149-8-20**] Date of Birth: [**2083-8-6**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Mental Status Changes Major Surgical or Invasive Procedure: L occipital crani for mass resection History of Present Illness: HPI: This is a 66 year old male known to the OMed service at [**Hospital1 18**], as he is s/p resection of a neuroendocrine small cell CA to his L axilla lymph node in [**2146**], who now presents to the ED with a [**2-6**] week history of mental status changes. Per his family's report, the patient has had a whole host of symptoms over the past several weeks, including abdominal pain, nausea/vomiting, a UTI, and L epididymitis. His wife has noticed that he has been "speaking nonsense" for several weeks, and this has increased in severity. They decided to come to the ED tonight, where a Head CT demonstrated a new L parietal occipital mass with edema Past Medical History: Neuroendocrine tumor resection Social History: Married. Works as a dentist. No smoking history Family History: N/C Physical Exam: PHYSICAL EXAM: O: T: 98.5 BP: 137/83 HR: 94 R:16 O2Sats: 95% Gen: WD/WN, comfortable, NAD. HEENT: NC, AT Pupils: aniscoric, R>L EOMs full Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person only, confused to location ("school") and thinks it is winter Language: Expressive aphasia. Receptive intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5 to 4 R, 4 to 3 L bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-9**] throughout. No pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: ADMISSION LABS: [**2149-8-11**] 03:50PM PT-11.7 PTT-22.6 INR(PT)-1.0 [**2149-8-11**] 03:50PM WBC-8.1 RBC-5.17 HGB-15.8 HCT-46.0 MCV-89 MCH-30.5 MCHC-34.2 RDW-15.0 [**2149-8-11**] 03:50PM ALT(SGPT)-22 AST(SGOT)-35 ALK PHOS-72 TOT BILI-0.4 [**2149-8-11**] 03:50PM GLUCOSE-113* UREA N-17 CREAT-1.0 SODIUM-139 POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-18 DISCHARGE LABS: [**2149-8-19**] 08:50AM BLOOD WBC-6.7 RBC-4.93 Hgb-15.1 Hct-43.6 MCV-88 MCH-30.6 MCHC-34.6 RDW-14.9 Plt Ct-221 [**2149-8-13**] 07:40AM BLOOD Neuts-92.1* Lymphs-4.5* Monos-3.2 Eos-0.1 Baso-0.1 [**2149-8-18**] 03:35PM BLOOD PT-11.2 PTT-23.1 INR(PT)-0.9 [**2149-8-19**] 08:50AM BLOOD Glucose-125* UreaN-18 Creat-1.0 Na-140 K-4.0 Cl-99 HCO3-31 AnGap-14 IMAGING: CT Head [**8-11**]: Large left cerebral mass or possible conglomerate of smaller masses with surrounding vasogenic edema and causing compression of the left lateral ventricle with dilation of the left temporal [**Doctor Last Name 534**] and fourth ventricle. 5 mm rightward midline shift. Differential diagnosis includes primary brain lesion vs metastasis. MRI is recommended for further evaluation. CT C/A/P [**8-12**]: MPRESSION: 1. No CT evidence of acute intrathoracic or intraabdominal abnormality. 2. Stable appearance of radiation changes in the left upper lobe. 3. Possible left-sided hydrocele partially imaged on this examination. CTA Head [**8-12**]: A hypervascular left parieto-occipital mass. Predominant arterial vascular supply is via the PCA. Predominant venous drainage is into the straight sinus. MRI Head [**8-13**]: MPRESSION: 1. Large heterogeneous mass in the posterior aspect of the left cerebral hemisphere, extending into the splenium of the corpus callosum, with evidenceof subependymal spread along the left lateral ventricle, and with slowdiffusion. Diagnostic considerations include lymphoma, particularly if the patient is immunocompromised, neuroendocrine tumor metastasis, and glioblastoma multiforme. 2. Dilatation of the temporal [**Doctor Last Name 534**] of the left lateral ventricle is suggestive of trapping, given compression of the atrium of the left lateral ventricle. 3. Mild left uncal herniation. MRI Head [**8-14**]: IMPRESSION: 1. Irregular enhancing lesion in the left temporo-occipital region with subependymal spread and trapping of the left temporal [**Doctor Last Name 534**], most consistent with a glioma. 2. Enhancement of the right cochlea which could be secondary to labrynthitis or other inflammatory changes, and clinical correlation recommended. CT Head [**8-15**]: IMPRESSION: 1. Interval development of left occipital hypodensity corresponding to known occipital infarct seen on MR imaging. 2. Progression of post-surgical change after mass resection with interval decrease in subcutaneous emphysema, pneumocephalus and surgical site hemorrhage with persistent vasogenic edema. No evidence of new hemorrhage or hydrocephalus. Brief Hospital Course: The patient was admitted to the OMed service for further work up of this newfound brain mass, which entailed MRI imaging and neuro-oncology consults. MRI revealed a large L-sided occipital mass with edema and entrapment of the lateral ventricle. A thorough pre operative work up did not reveal any primary mass or lesion. He was transferred to the NSurg service where he was placed on decadron and keppra. On [**8-14**] he underwent a Left parietal-occipital crani for mass resection. The preliminary pathology report was consistent with a neuroendocrine tumor. He tolerated the procedure well and went immediately to CT Scan, where no post operative hemorrhage was revealed. On [**8-15**], patient has some expressive aphasia, but is otherwise intact. His decadron was weaned and PT/OT consults were ordered. Rehab was recommended. MRI showed some evidence of residual tumor, but was otherwise intact. On [**8-17**], patient's aphasia was slightly improving, his exam stable and he was transferred to SDU. On [**8-18**], patient had one episode of VT noticed on telemetry. EKG was done and showed no changes from previous EKG. Patient was asymptomatic, but cardiac enzymes were ordered. His enzymes and ECG were both normal, and no further cardiac events persisted. On [**8-20**] - the patient was accepted at [**Hospital3 **]. He went with his Decadron tapered to 2mg [**Hospital1 **] and his Keppra to 500mg [**Hospital1 **]. His expressive aphasia was improved since surgery, but consistent with his preoperative status. Medications on Admission: No medications Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 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 for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: L occipital Mass - Prelim Neuroendocrine Metastasis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-14**] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. 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) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. ?????? You are scheduled for a Brain Tumor Appoitment on [**8-22**] at 2:30 pm with Dr. [**Last Name (STitle) 6570**] on [**Hospital Ward Name **] 8. Please call [**Telephone/Fax (1) 1844**] with any questions. Completed by:[**2149-8-20**]

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Discharge summary

report

Admission Date: [**2161-11-9**] Discharge Date: [**2161-11-27**] Date of Birth: [**2099-7-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: Dyspnea, nausea, vomiting Major Surgical or Invasive Procedure: received WBRT x 10 cycles History of Present Illness: Mr. [**Known lastname 42603**] is a 62 year old male with history of metastatic large cell lung cancer to bone and recurrent malignant pleural effusion requiring PleurX catheter placement, HIV (CD4 535 in [**Month (only) 116**]) previously on HAART, who presented to the ED with N/V and SOB and tachypnea (RR of 55) that has not resolved since previous admission [**Date range (1) 42607**] where he was briefly in the MICU. He was admitted for dyspnea/tachypnea/epigastric pain, and found to have a Coag negative Staph in his pleural fluid and Urine and treated with levofloxacin. Also found to have tachypnea at that time that was thought to be [**3-9**] anxiety where morphine and ativan relieved his symptoms. . Patient states he has vomited every time he eats. It is non-bloody, non-bilous. He is also complaining of right sided upper flank/RUQ pain since yesterday ([**11-8**]) that is crampy, [**11-14**], and worsens with movement. Nothing appears to make it better, although now he states it is a [**2162-7-12**] on its own, although he received morphine and ativan in ED. He has also taken nausea pills that have helped some but have not fully relieved his symptoms. Of note, in his prior admission, an EGD was performed that showed gastritis. Yesterday, he also felt short of breath where he felt he could not catch his breath and was breathing fast while he was taking a shower. He stated it lasted most of the day. He states oxygen appears to make the breathing better. . In the ED initial vitals were HR 120, RR: 40, SBP in 140s, O2 sats: 95% on RA. He received 2 L NS, Vancomycin 1 gram, Zosyn 4.5 grams, morphine 4 mg, ativan 1 mg. Reportedly placed on a [**Last Name (LF) 597**], [**First Name3 (LF) **] signout but no documentation in chart. Noted to have a wbc of 12.2. CT Torso was done that showed a stable pleural effusion that was not drained. Concern for PE, but patient not a canidate for CTA because of creatinine of 1.5, V/Q wouldn't work due to malignancy. Not a good candidate for anticoagulation given his gastritis and mets. Upon leaving the ED, VS: 101 131/93, RR:28, 100% on 3LNC. RR rate fluctates between 20 and 30 that responded to morphine and ativan. Upon arrival to the ICU, patient was saturating 100 % on 2 L O2. breathing at a RR in the 20s with BP [**12/2117**] of and HR in the low 100s. Abdominal/rt flank pain had decreased to a [**2162-7-12**] and was complaining of thirst. Drank [**MD Number(4) 42608**] with good effect. Past Medical History: [**7-/2159**]: Diagnosed with non small cell lung cancer by CT guided biopsy [**2159-9-20**]: PET scan with low-attenuation lesion in the left lobe of the thyroid gland measuring 25 x 7 mm in addition to markedly FDG avid left upper lobe mass consistent with known cancer and FDG avid prominent bilateral axillary lymphadenopathy suspicious for metastatic disease, but no pathologically enlarged infraclavicular lymph nodes. He also had retroperitoneal internal and external iliac chain FDG avid lymphadenopathy considered unusual for lung carcinoma. [**2159-10-29**]: FNA of the thyroid, which was negative. [**2159-10-31**]: Left axillary lymph node dissection. With pathology revealing florid reactive follicular hyperplasia consistent with HIV associated lymphadenopathy. Further staging and treatment were deferred until the patient was stabilized on HAART therapy. He was initially seen by infectious disease doctors [**Last Name (NamePattern4) **] [**2160-1-10**] and was started on HAART therapy in 01/[**2160**]. [**3-/2160**]: He was hospitalized for influenza. After the hospitalization, he was lost to follow up until [**Month (only) **]. Other than the visit with his infectious disease on [**2160-5-5**], he then lost to follow up until [**7-13**]. [**2160-7-24**]: CT demonstrated left upper lobe mass minimally increased in size from [**3-/2160**] with a sub 5 mm left upper lobe pulmonary nodule with additional stable bilateral nodules, new left-sided pleural effusion. [**2160-8-6**]: Bronchoscopy, mediastinoscopy, and pleural drainage and talc pleurodesis by Dr. [**Last Name (STitle) **]. Pathology revealed 4R lymph nodes with no malignancy but frozen sections showed metastatic large cell carcinoma and 4L lymph nodes that showed metastatic large cell carcinoma. A level 7 lymph node showed metastatic large cell carcinoma and a parietal pleural biopsy also showed metastatic large cell carcinoma involving the pleura. He was started on carboplatin and gemcitabine on [**2160-8-28**] he has completed 4 cycles. [**2160-12-5**]: MR [**Name13 (STitle) **] with L1 lesion . MEDICAL HISTORY: - Peripheral vestibulopathy - HIV: Diagnosed in the [**2142**], he had been previously cared for by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 42604**] at [**Hospital6 **]. [**2160-10-30**] -> CD4 425, VL undetectable - Positive PPD-negative AFB [**1-11**]-s/p 6 months Rifampin in [**2148**]. - Hypertension. - History of appendicitis status post appendectomy in [**2126**]. Social History: He is originally of Haitian origin. His wife and children live in [**Country 2045**]. He is an employee in the food service industry here at [**Hospital1 18**]. He reports a prior history of tobacco, having stopped in [**2148**]. He is sexually active only with women. He denies any intravenous drug use. He received transfusions potentially around the time of his appendectomy in [**2126**]. His wife has not been able to immigrate to the U.S., and he currently lives with his five children in [**Location (un) 2268**]. Family History: No premature CAD or cancer. Physical Exam: Vitals - T: afebrile BP: 120s/70s HR: 80s RR: 16 02 sat: 97% RA GENERAL: NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD CARDIAC: RRR, S1/S2, no mrg LUNG: CTA, diminished breath sounds on left base ABDOMEN: nondistended, +BS, mildly tender in RUQ, LLQ, no rebound/guarding, no HSM, no [**Doctor Last Name **] sign M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, blunted affect, A and O x 3 Exam on discharge: T 98 109/83 RR 18 97% RA HR 85 GENERAL: NAD, A and O x 3 SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMi, PERRLa, anicteric sclera, pink conjunctiva, patent nares, MMM, nontender supple neck, no LAD CARDIAC: RRR, S1/S2, no mrg LUNG: diminished breath sounds over left base, o/w CTA ABDOMEN: nondistended, +BS, mild tenderness in LUQ to deep palpation, no rebound/guarding, no HSM M/S: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact with unchanged sluggish left-sided EOM, improved affect, A and O x 3, DTRs 2+ bilaterally, no cerebellar signs; strength 5/5 in LUE, LLE, 4+/5 in RUE, RLE; sensation intact, normal gait. exam unchanged Pertinent Results: Admission Labs: [**2161-11-9**] 09:25PM GLUCOSE-157* UREA N-10 CREAT-1.7* SODIUM-144 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-24 ANION GAP-14 [**2161-11-9**] 09:25PM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-2.3 [**2161-11-9**] 09:25PM WBC-9.4 RBC-3.17* HGB-8.7* HCT-27.1* MCV-86 MCH-27.5 MCHC-32.1 RDW-17.5* [**2161-11-9**] 09:25PM NEUTS-63.0 LYMPHS-28.4 MONOS-7.4 EOS-0.8 BASOS-0.4 [**2161-11-9**] 09:25PM PLT COUNT-506* [**2161-11-9**] 09:25PM PT-13.4 PTT-27.4 INR(PT)-1.1 [**2161-11-9**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2161-11-9**] 03:23PM LACTATE-2.0 K+-3.9 [**2161-11-9**] 03:15PM ALT(SGPT)-20 AST(SGOT)-31 CK(CPK)-54 ALK PHOS-286* TOT BILI-0.3 [**2161-11-9**] 03:15PM LIPASE-53 [**2161-11-9**] 03:15PM cTropnT-<0.01 [**2161-11-9**] 03:15PM ALBUMIN-2.9* Results: CT chest/abdomen/pelvis: 1. Largely stable moderate left pleural effusion, containing pleural catheter located along the periphery of the effusion, unchanged from prior. 2. Slight increase in atelectasis/consolidation of the left lower lobe. No significant change in left upper lobe mass. 3. Unchanged innumerable pulmonary metastatic lesions. 4. Innumerable bony metastatic lesions, without evidence of pathological fracture at this time. 5. No superimposed acute abnormalities in the chest, abdomen or pelvis, given non-contrast examination.. . MR head: 1. Interval development of numerous supratentorial, infratentorial, and brainstem enhancing lesions, some of them which are in the periphery [**Doctor Last Name 352**]-white matter junction and others which appear to invade/arise from the leptomeningeal space consistent with new intracranial metastatic disease. . 2. Questionable focus of enhancement within the right posterolateral aspect of the cervical spinal cord at the level of C1/C2 measuring 3.3 mm seen on the coronal images (series 1000, image 76). MRI of the cervical spine might be helpful to further assess. . 3. Stable sellar mass, likely representing a macroadenoma . MR spine: 1. Extensive osseous metastatic lesions in the cervical, thoracic and lumbar spine as well as in the iliac bones and sacrum. Extension into the neural foramina is difficult to assess, given the limitations of the study due to motion. Within these limitations no gross epidural mass noted. No abnormal enhancement noted in the cord. 2. Multilevel degenerative changes in the cervical, thoracic and lumbar spine, with moderate spinal canal stenosis and possible deformity of the ventral cord, as seen on the sagittal sequences do not convincingly conformed on the axial sequences; moderate spinal canal stenosis at L4-5 and L5-S1 levels from disc, facet and ligamentum changes resulting in compression on the roots of the cauda equina better seen on the sagittal than on the axial. CXR: Slight decrease in left pleural effusion compared to the prior study. Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 16.9* 3.43* 10.0* 28.9* 84 29.3 34.8 17.3* 369 Glucose UreaN Creat Na K Cl HCO3 AnGap 163* 26* 1.4* 130* 4.1 90* 33* 11 ALT AST LD AlkPhos TotBili 28 32 342* 0.3 Calcium Phos Mg 9.2 3.5 1.9 Brief Hospital Course: 62 year old man with HIV (CD4 483 in [**Month (only) **]) and a history of metastatic large cell lung cancer to the bone, and recurrent malignant pleural effusion with indwelling pleurx catheter, admitted for dyspnea and intractable nausea and vomiting. . # Nausea/vomiting RUQ Pain: Patient had a significant workup in prior admissions with EGD showing gastritis and a RUQ ultrasound was negative. He was H. pylori negative. He is also s/p cholecystectomy and appendectomy. CT abdomen also negative for acute process. Since he has not been taking his HAART medication for some time, it was felt he can be safely transitioned to high dose proton pump inhibitors until he re-starts his HAART medication. He was also given zofran and compazine as needed for nausea. An MRI head showed metastatic disease of his large cell lung cancer, and this was thought to be the etiology of his nausea and vomiting. The patient was started on decadron with good response. He also received 9 of 10 cycles of palliative whole brain radiation therapy. He should receive his tenth and last cycle on [**2161-11-30**]. His neuro exam was monitored daily for any new neurologic deficits- there were no changes in his exam, see above. He will follow up with his oncologist, Dr. [**Last Name (STitle) 3274**], in the next few weeks. . # Dyspnea: Initially patient's RR was in the 40s, with oxygen saturations in the high 90s. Patient never had low saturations and was placed on nasal cannula at 3 liters/min of oxygen mainly for comfort. He was monitored overnight in the intensive care unit and his respiratory rate decreased to the teens and 20s. It was felt that his tachypnea was due to the significant back/right upper quadrant pain, his persistent vomiting which may have strained some of his muscles, and a large degree of anxiety. He was started on a fentanyl patch and given morphine and ativan as needed. There was a low suspicion for thromboembolic disease. He continued to recevie three times weekly drainage of his indwelling pleurx catheter during his hospital course. He should continue to receive thrice weekly drainage of 300 cc from his left-sided pleurx to manage his recurrent malignant pleural effusion. . # HIV: Last CD4 in [**Month (only) **] was 483. HAART stopped for renal/liver failure during last admission. He was told to re-start after seeing his infectious disease. He has not seen his doctor prior to this admission. HAART was held throughout his hospital course per his primary infectious disease physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7443**], because of the patient's borderline renal insufficiency and his PPI therapy. . # Renal insufficiency: creatinine remained stable and at his baseline of 1.3-1.5 throughout his hospital course. Of note, the patient was started on metformin for management of his steroid-induced hyperglycemia, and tolerated metformin well. . # Steroid-induced hyperglycemia: This progressed as the patient continued receiving decadron. He was initially managed with a basal/bolus regimen of insulin, but was transitioned to metformin with sliding scale insulin in an effort to limit his insulin requirements. He should continue this regimen following discharge. . # ANXIETY: Stable. Was given ativan as needed. . # Hypertension: Normotensive. Amlodipine, HCTZ, and imdur managed BP well. #Social Situation: Many discussions held w/ pt by attending,Nurse [**Doctor Last Name **] who has followed him in [**Hospital **] clinic speaking Creole,social worker etc about end of life issues /terminal nature of illness.His home situation(lack of spouse,5 children recently from [**Country 2045**],language barrier,etc)preclude d home w/ hospice presently.Discussion about return to [**Country 2045**] where his wife lives also held but medically not feasible. # CODE: Full code but changed to DNR later in stay Medications on Admission: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 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). 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. 9. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 10. Lactulose 10 gram Packet Sig: One (1) PO once a day. Disp:*30 packets* Refills:*2* Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 6. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 9. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. 12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days: please start on [**2161-12-2**]. 13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: please start on [**2161-12-7**]. 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED). 17. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 18. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 19. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QTUTHSA (TU,TH,SA). 20. Ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary Diagnosis: metastatic large cell lung carcinoma Secondary Diagnoses: - Peripheral vestibulopathy - HIV: Diagnosed in the [**2142**], he had been previously cared for by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 42604**] at [**Hospital6 **]. [**2160-10-30**] -> CD4 425, VL undetectable - Positive PPD-negative AFB [**1-11**]-s/p 6 months Rifampin in [**2148**]. - Hypertension. - History of appendicitis status post appendectomy in [**2126**]. Discharge Condition: stable and improved, nausea resolved Discharge Instructions: You were admitted to the hospital with shortness of breath and persistent nausea and vomiting. Your shortness of breath was thought to be due to anxiety and improved with medications. You had an MRI of your head that showed your lung cancer had likely spread to your brain, and this was likely causing the nausea and vomiting. After talking to your regular oncologist, Dr. [**Last Name (STitle) 3274**], you agreed to undergo whole brain radiation therapy. You were scheduled to receive 10 sessions of radiation along with a course of steroids. Your nausea and vomiting improved with the radiation and steroids. You required insulin to control elevated blood sugars which were most likely due to the steroids. You tolerated the radiation well, and you were discharged on [**2161-11-27**] in improved and stable condition. Please see below for your follow up appointments. See below for changes to your medications. Please call your physician [**Last Name (NamePattern4) **] 911 if you develop fevers/chills, worsening nausea/vomiting or abdominal pain, shortness of breath, lightheadednes or dizziness, chest pain, or any other concerning medical symptoms. Followup Instructions: Please call Dr.[**Name (NI) 3279**] office to schedule your next appointment with him. He would like to see you in early to mid [**Month (only) **]. His number ([**Telephone/Fax (1) 3280**]. . If you have questions in the meantime, please call Dr. [**Name (NI) 42609**] office. You can speak with [**Doctor First Name 42610**] Pail at that time. ([**Telephone/Fax (1) 5562**] is the number. you have your last radiation session on Monday, [**11-30**]. Please come to [**Hospital Ward Name 332**] Basement at 10:15 on Monday at [**Hospital1 18**] [**Hospital Ward Name **]. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

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icd9cm

[ [ [] ] ]

[ "92.29" ]

icd9pcs

[ [ [] ] ]

17393, 17434

10707, 14592

341, 368

17958, 17997

7455, 7455

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5977, 6006

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5431, 5961

43,084

169,551

27204

Discharge summary

report

Admission Date: [**2119-10-12**] Discharge Date: [**2119-10-14**] Date of Birth: [**2040-9-21**] Sex: F Service: NEUROLOGY Allergies: Aspirin Attending:[**First Name3 (LF) 618**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: intubation [**10-12**] History of Present Illness: This is a 78yo W with a history of CKD, COPD, 55 pack year smoking history, Alzheimer's dementia, atrial fibrillation (not anticoagulated), hypertension, history of right ICA occlusion and previous SAH who is transferred from an OSH for an intracranial hemorrhage. At baseline, we know that Ms. [**Known lastname 66736**] is described to be quite "weak", and has been sleeping more lately. She enjoys watching TV, is able to maintain some conversation and her language function is mostly normal. She does have difficulty with short term memory. She is mostly functional with her ADLs, lives at home with her husband, and depends on her husband for her medications. Lately, she has been missing some of her medications, and her son describes that she has been more "sleepy" lately. At approximately 5pm this evening, the patient was riding in her husband's car to [**Holiday **] dinner and acutely started to moan incoherently for a few seconds, and then started to blankly stare. She started to froth from her mouth. Her husband thought initially that her oxygen tank wasn't working properly, but it was working just fine. He called EMS, and the patient was taken to an outside hospital where she was noted to be "aphasic and not moving her right side". She had one episode of vomitting, and out of concern for airway protection, she was electively intubated. She had a head CT that showed evidence of a 7cm IPH with midline shift and concern for an underlying mass. There is a significant SAH component, and she was transferred to the [**Hospital1 18**] for a higher level of care. She was med flighted here, and was noted to be initially hypertensive to the 170s systolic on arrival, and then started on propofol which brought her pressures down to the 140s. Propofol was held for my examination. Past Medical History: - Chronic kidney disease with baseline Cr 1.2 - Atrial fibrillation (not on anticoagulation), rate controlled - Hypertension complicated by hypertensive encephalopathy - History of SAH (see d/c summary from [**2113**]) - Right ICA occlusion thought to be chronic - Alzheimer's dementia - COPD on home oxygen Social History: 55 pack year smoking history, baseline functioning as above. No EtOH or illicit drugs. Family History: Mother died from aneurysmal rupture in 50s, father died of prostate cancer in 70s. Physical Exam: ADMISSION PHYSICAL EXAM: Physical Exam: Vitals: HR 61, BP 140s systolic, AF, RR 16, 100% Intubated on CMV 16/400/40%/5, breathing 16 times/minutue General: Intubated, very limited spontaneous movements. HEENT: NC/AT, no conjunctival icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no masses or lymphadenopathy Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted, C-section scar well healed Extremities:warm and well perfused Skin: no rashes or lesions noted. Neurologic Examination (off propofol x 10 minutes): - There are some spontaneous movements of the left arm - She does not follow commands, track objects. - Her eyes are open spontaneously, but with a prominent left ptosis - Pupils are reactive and equal bilaterally (5-3mm) - Corneal and VOR reflex are absent - Good gag/cough, and facial grimace is grossly symmetric - She does not overbreathe the vent. - LUE localizes to pain, LLE triple flexes to pain - RUE just twitches to painful stimuli, RLE does flex slightly to pain - Toes are up bilaterally, reflexes are symmetric and present throughout PHYSICAL EXAM AT TIME OF DEATH at 9:00am on [**10-14**] GEN: elderly woman lying in bed, pale skin, not moving HEENT: pupils fixed and dilated CV: no hearbeat auscultated or palpated PULM: no respirations auscultated or palpated EXT: cool, not moving Pertinent Results: ADMISSION LABS: [**2119-10-12**] 07:30PM BLOOD WBC-7.5 RBC-4.34 Hgb-12.5 Hct-37.5 MCV-86 MCH-28.7 MCHC-33.2 RDW-12.8 Plt Ct-215 [**2119-10-12**] 07:30PM BLOOD PT-11.2 PTT-20.7* INR(PT)-0.9 [**2119-10-12**] 07:30PM BLOOD Fibrino-461* [**2119-10-13**] 02:20AM BLOOD Glucose-147* UreaN-25* Creat-1.1 Na-138 K-4.0 Cl-99 HCO3-28 AnGap-15 [**2119-10-13**] 02:20AM BLOOD ALT-9 AST-31 CK(CPK)-128 AlkPhos-42 TotBili-0.3 [**2119-10-12**] 07:30PM BLOOD cTropnT-0.07* [**2119-10-13**] 02:20AM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.40* [**2119-10-13**] 08:09AM BLOOD CK-MB-9 cTropnT-0.44* [**2119-10-12**] 07:30PM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 [**2119-10-12**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2119-10-12**] 07:31PM BLOOD Type-ART pO2-235* pCO2-41 pH-7.43 calTCO2-28 Base XS-3 Comment-GREENTOP [**2119-10-12**] 07:31PM BLOOD Glucose-133* Lactate-0.8 Na-145 K-3.7 Cl-105 calHCO3-27 [**2119-10-12**] 07:31PM BLOOD freeCa-1.08* DISCHARGE LABS: Did not obtain as pt [**Name (NI) 3225**] at time of death IMAGING: CT HEAD [**2119-10-12**]: IMPRESSION: 1. Extensive subarachnoid hemorrhage, left frontal, parietal and temporal intraparenchymal hemorrhage, and bilateral intraventricular hemorrhage with effacement of the left ventricle and rightward shift of normally midline structures. 2. Right temporal [**Doctor Last Name 534**] dilation is concerning for early ventricular entrapment and obstructive hydrocephalus. 3. Early tonsillar herniation appears to be present. CTA [**2119-10-13**]: IMPRESSION: 1. Massive left frontoparietal intraparenchymal hemorrhage with extensive vasogenic edema and approximately 7 mm of rightward shift of midline structures. 2. Subarachnoid hemorrhage in the suprasellar cistern, interpeduncular fossa, sylvian fissures, and perimesencephalic cisterns. Intraventricular blood products in the occipital horns of the lateral ventricles. 3. No evidence of aneurysm or other vascular anomaly. 4. Chronically occluded proximal right internal carotid artery with a small amount of reconstituted flow manifest as a string sign, unchanged from [**2114-3-5**]. Brief Hospital Course: This is a 78yo W with a history of CKD, COPD, 55 pack year smoking history, Alzheimer's dementia, atrial fibrillation (not anticoagulated), hypertension, history of right ICA occlusion and previous SAH who ws transferred from an OSH for an intracranial hemorrhage. Her NCHCT done here showed worsening of her IPH, and extension to 9x8cm over 19 slices with a significant subarachnoid component and intraventricular component that raiseed the possibility of an aneurysmal bleed, particularly given that there is a family history of catastrophic aneurysmal rupture and death, although most likely etiology was amyloid angiopathy. Her prognosis was poor given the extent of her hemorrhage. CTA was done that showed no vessel abnormalities that led to the bleed, and pt was made [**Year (4 digits) 3225**] on [**10-13**]. Palliative care was consulted, and they recommended morphine, ativan, zofran, zyprexa and hyoscyamine PRN discomfort, all of which were started. Pt died peacefully on [**10-14**] at 9am. Medications on Admission: - CaCO3 500mg [**Hospital1 **] - Celexa 20mg daily - Lasix 20mg daily - Potassium Chloride 20mEq daily - MVI daily - Atrovent/Albuterol nebs - Diltiazem 300mg CD daily - Aricept 10mg daily - Fluticasone 250ug daily - NTG SL PRN daily - Remeron 7.5mg daily Discharge Medications: N/A pt expired. Discharge Disposition: Expired Discharge Diagnosis: Large intraparenchymal hemorrhage Discharge Condition: N/A, pt expired on [**10-14**] Discharge Instructions: N/A pt expired on [**10-14**] Followup Instructions: Not applicable, pt expired on [**10-14**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

7647, 7656

6289, 7300

287, 311

7733, 7765

4132, 4132

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2595, 2680

7607, 7624

7677, 7712

7326, 7584

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5120, 6266

2735, 4113

231, 249

339, 2143

4149, 5103

2165, 2475

2491, 2579

1,470

146,882

24373

Discharge summary

report

Admission Date: [**2111-11-28**] Discharge Date: [**2111-12-29**] Date of Birth: [**2072-8-15**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 297**] Chief Complaint: hemetemesis Major Surgical or Invasive Procedure: s/p TIPs [**2110-11-29**] History of Present Illness: HPI: 39yoM w/ h/o EtOH abuse, esophageal variceal bleed [**2108**] s/p banding, Hep C initially presented to [**Hospital6 33**] [**2110-11-28**] with hemetemesis. He reported 5 days of weakness and generalized malaise prior to presentation. The day prior to presentation he began vomiting BRB with clots, multiple times an hours (unable to quantify), progressively worsening, associated with lightheadedness, prompting him to present to [**Hospital3 **]. There, bp 143/72, HR 118, resp 12, O2 98% 2L NC. HCT 24, INR 2. EGD showed 4 chains of grade 3 esophageal varices, and multiple large proximal gastric varices with large clots. The clots were cleared, and several read wheals were noted. 6 bands were placed in the distal esophagus; 1 L of BRB suctioned. However, the source of bleeding could not be clearly identified, and was believed to be gastric in origin. He was transfused 4 u PRBC, 2u FFP, received vit K 10 mg SC X 1, and was started on protonix gtt and octreotide gtt prior to transfer to [**Hospital1 18**] for possible TIPS. Currently, he notes mild epigastric pain, continued nausea (vomited ~ 50 cc of BRB with clots following arrival), and chills without fever. He had an episode of melena in the ambulance on the way to [**Hospital1 18**], but denies BRBPR/melena/diarrhea prior to admission. He denies recent EtOH use (reports last drink ~1 month ago) although serum EtOH at OSH 68. . ROS: (+) LH with sitting up. No chest pain, shortness of breath, confusion, dysuria, hematuria. (+) 30 lb wt loss over the last 3 months Past Medical History: PMHx: 1) EtOH abuse: - 18 beers a day X 20 yrs 2) UGI bleed: h/o UGI bleeding with esophageal variceal banding in [**2108**] 3) Asthma 4) HTN 5) PTSD 6) Depression: h/o suicide attempt [**11-26**] 7) Iron deficiency anemia Social History: SHx: Divorced, three children, lives alone. EtOH abuse X 20 yrs. Occasional marijuana, no other drug use. No tobacco use. Family History: FHx: Father had multiple MIs, first in his early 50s. Mother has COPD (smoker). Brother has "metastatic cancer." No family history of liver disease Physical Exam: Tc 99, bp 150/70, HR 117, resp 17, 98% 2L NC Gen: pleasant, cooperative male, A&OX3, appears mildly uncomfortable HEENT: mild icterus, PERRL, (+) lateral nystagmus bilaterally, OMM dry with dried blood in mouth, neck supple, no LAD, no JVD Cardiac: tachycardic, regular, II/VI SM heard throughout the precordium, loudest at the apex. Pulm: CTA bilaterally Abd: moderately distended, easily reducible umbilical hernia, NABS, soft, no HSM appreciated Ext: No edema, warm with 2+ DP/radial/PT bilaterally, (+) clubbing. No cyanosis noted. Skin: (+) spider angiomata over upper chest. Neuro: CN II-XII grossly intact and symmetric bilaterally, [**3-25**] strength throughout, 2+ DTR bilaterally throughout, sensation intact to light touch proximally and distally in upper and lower extremities bilaterally. (-) asterixis Pertinent Results: LABS ON ADMISSION: [**2111-11-28**] 08:51PM BLOOD WBC-2.1* RBC-1.62*# Hgb-4.5*# Hct-13.0*# MCV-80*# MCH-27.6 MCHC-34.4 RDW-19.1* Plt Ct-38* [**2111-11-28**] 08:51PM BLOOD Neuts-75.1* Lymphs-20.7 Monos-3.3 Eos-0.7 Baso-0.3 [**2111-11-28**] 08:51PM BLOOD PT-24.4* PTT-65.8* INR(PT)-4.4 [**2111-11-28**] 11:02PM BLOOD Fibrino-143* D-Dimer-1257* [**2111-12-7**] 04:00AM BLOOD Ret Aut-2.5 [**2111-11-28**] 08:51PM BLOOD Glucose-118* UreaN-15 Creat-0.5 Na-140 K-4.2 Cl-108 HCO3-20* AnGap-16 [**2111-11-28**] 08:51PM BLOOD ALT-39 AST-113* LD(LDH)-376* AlkPhos-86 Amylase-69 TotBili-5.3* [**2111-11-28**] 08:51PM BLOOD Lipase-89* [**2111-11-28**] 08:51PM BLOOD Albumin-3.0* Calcium-6.5* Phos-2.4*# Mg-1.3* Iron-214* [**2111-11-29**] 04:10AM BLOOD Hapto-<20* [**2111-11-28**] 08:51PM BLOOD calTIBC-230* VitB12-569 Folate-11.8 Ferritn-34 TRF-177* [**2111-12-8**] 03:45AM BLOOD Triglyc-92 [**2111-11-28**] 08:51PM BLOOD TSH-0.39 [**2111-12-4**] 03:25AM BLOOD Cortsol-6.6 [**2111-12-2**] 12:03PM BLOOD Glucose-102 [**2111-12-2**] 05:03PM BLOOD Glucose-114* K-3.7 [**2111-12-3**] 01:48AM BLOOD Lactate-2.9* Labs Trends by [**12-18**]: [**2111-12-18**] 03:04AM BLOOD PT-25.1* PTT-47.7* INR(PT)-2.5* [**2111-12-18**] 03:04AM BLOOD Glucose-113* UreaN-78* Creat-4.0* Na-143 K-4.8 Cl-107 HCO3-25 AnGap-16 [**2111-12-18**] 03:04AM BLOOD TotBili-31.2* [**2111-12-15**] 04:03AM BLOOD Lipase-267* [**2111-12-18**] 03:04AM BLOOD Calcium-7.9* Phos-5.8* [**2111-12-17**] 07:57AM BLOOD Cortsol-11.7 [**2111-12-17**] 07:57AM BLOOD Cortsol-16.7 [**2111-12-17**] 09:30AM BLOOD Cortsol-18.7 [**2111-12-16**] 06:04PM BLOOD Lactate-1.7 MICRO: All bcx negative BAL negative x 2 ([**12-16**] and [**12-3**]) SC cath tip with [**Month/Year (2) **] neg [**Month/Year (2) **] [**12-16**] Sputum with MRSA [**12-3**] Sputum with GNR - not speciated [**12-9**] Sputum repeatedly with yeast IMAGING: ABD US [**11-28**]: IMPRESSION: Thrombosis of the main portal vein, not entirely occlusive. Hepatofugal flow in the main portal vein and its major branches. TIPS [**11-29**]: IMPRESSION: 1. Transjugular intrahepatic portosystemic shunt placement between right hepatic vein and right portal vein with pressure gradient at 6 mmHg at the end of the procedure. 2. Successful embolization of four locations of gastric variceal veins. CT [**11-29**]: IMPRESSION: 1. Findings consistent with cirrhosis and significant portal hypertension with splenomegaly and multiple large gastric, esophageal and splenic varices. 2. There is probably a nonocclusive thrombus within the right portal vein. The main portal vein is patent. The hepatic veins and the hepatic artery are patent. 3. No significant amount of ascites. Tiny amount of free fluid in the pelvis. 4. Fluid within the mesentery and retromesentery and retroperitoneum around the tail of the pancreas. Clinical correlation is recommended. Possibility of pancreatitis involving the tail of the pancreas should be considered and correlation should made with amylase and lipase. Alternatively, this could be secondary to the portal hypertension. 5. Cholelithiasis. US doppler of TIPS [**11-30**]: IMPRESSION: Patent TIPS with relatively elevated flow velocities that may reflect the patient's baseline high portal venous flow rate. Given these findings and the question of thrombus within the portal venous system on a CT from [**2111-11-29**], a short- term interval followup is recommended (within several days). US abd [**12-2**]: IMPRESSION: Patent TIPS with relatively elevated flow velocities that are unchanged compared to [**2111-11-30**]. No thrombus seen in the visualized portal venous system. CT abd [**12-3**]: IMPRESSION: 1. Worsening multilobar consolidations, suspicious for pneumonia and/or ARDS. 2. Mediastinal lymphadenopathy. 3. Hepatic cirrhosis and fatty replacement. 4. Status post TIPS. 5. Interval reduction in peripancreatic fluid. 6. Small amount of ascites. LENI [**12-4**]: IMPRESSION: No evidence of DVT in the right lower extremity. US abd [**12-5**]: IMPRESSION: 1. Patent TIPS. 2. A small amount of fluid within the right and left lower quadrants. This was not deemed to be adequate for marking for paracentesis by clinical staff. This was conveyed to the clinical staff at the time this study was performed. Renal US [**12-6**]: IMPRESSION: 1. No evidence of hydronephrosis or stones. CXR [**12-8**]: IMPRESSION: Persistent multifocal opacities, likely failure/ARDS with superimposed pneumonia. US abd [**12-9**]: IMPRESSION: 1. Patent TIPS with unchanged flow velocities. No thrombus seen. 2. Moderate amount of intra-abdominal ascites. CT ABD [**12-12**]: IMPRESSION: 1. Small, bilateral pleural effusions with reactive atelectasis. Interval resolution of airspace opacities seen at the lung bases previously. 2. Findings of cirrhosis, TIPS, varices and metallic coils are stable. The pancreas is unremarkable without CT evidence of pancreatitis. 3. Anasarca, ascites and small amount of free fluid within the pelvis. CT Head [**12-16**]: IMPRESSION: No evidence of intracranial hemorrhage or edema. Pan sinus and ethmoid air cell fluid/opacification. US abd [**12-16**]: IMPRESSION: 1. Patent TIPS with elevated flow velocities compared to [**2111-12-9**]. Close interval followup is suggested. 2. Small amount of ascites in the right and left lower quadrants of the abdomen in a quantity insufficient to be marked for safe paracentesis. 3. Gallbladder wall edema, a finding consistent with underlying liver dysfunction and ascites that is unchanged compared to [**2111-12-9**]. 4. Cirrhotic liver with splenomegaly. CXR [**12-17**]: IMPRESSION: 1) New patchy opacity in the right lower lobe may represent aspiration/pneumonia. 2) Slightly improving CHF. 3) Lines and tubes in good position. TTE: [**2111-12-21**]: Left Atrium - Long Axis Dimension: *6.7 cm (nl <= 4.0 cm) Right Atrium - Four Chamber Length: *6.5 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: *5.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.60 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 1.10 Mitral Valve - E Wave Deceleration Time: 221 msec TR Gradient (+ RA = PASP): *34 to 35 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV systolic function. AORTA: Normal aortic root diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left atrium is elongated. The right atrium is moderately dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Mild (1+) to mild to moderate mitral regurgitation is seen. 6.There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2111-11-30**], there is an increase in the severity of the mitral regurgitation seen. No masses or vegetations seen on the aortic or mitral valve leaflets. [**2111-12-22**] Renal US: Comparison is made to renal ultrasound performed [**2111-12-19**]. The right kidney measures 14.6 cm, and the left kidney measures 14.7 cm. There is no hydronephrosis, stone, or mass in either kidney. Cortical echogenicity is normal bilaterally. Small amount of ascites is seen around the liver. IMPRESSION: Unremarkable renal ultrasound, unchanged from the prior study. ABD US: [**2111-12-23**]: Limited four quadrant ultrasound showed larges quantity of ascites, the skin over the right lower quadrant was marked for paracentesis to be performed by the clinical staff. CXR: [**2111-12-24**] Pulmonary edema has improved minimally since [**12-23**] at 11 p.m. after worsening during the preceding day. A focal region of particularly dense consolidation in the right lower lobe could be pneumonia or hemorrahge. Mild cardiomegaly, mediastinal vascular engorgement and small-to-moderate left pleural effusion are stable. Small right pleural effusion has decreased. Endotracheal tube tip at the thoracic inlet, left jugular line tip projecting over the upper SVC and right jugular dual channel catheter projecting over the lower SVC and superior cavoatrial junction are in standard placements. A feeding tube passes below the diaphragm and out of view. Vascular occlusion coils project over the left upper abdominal quadrant. No pneumothorax. ----- Please see OMR and pt's chart for pertinent labs and studies during long ICU course. Brief Hospital Course: A: 39 yoM w/ h/o EtOH cirrhosis, prior esophageal variceal bleed s/p banding, Hep C presented with hemetemesis likely secondary to gastric variceal bleed. Pt had protracted ICU course with diagnosis/development of liver failure, hepatorenal syndrome, ARDS, shock, fungemia, anemia/thrombocytopenia/autoanticoagulation, pancreatitis, and aflutter/ventricular bigeminy. . P: . # Fevers/leukocytosis - Concern initially for bacteremia c/w + MR [**First Name (Titles) **] [**Last Name (Titles) **] - on L IJ tip. Patient initially with MRSA + sputum but repeat BAL negative for MRSA. Patient was treated empirically with Vancomycin, Ceftaz and Flagyl. After persistant fevers, the ABX coverage was changed to Linezolid and Cefepime. Repeat CXR were consitent with multilobular infiltrates. No source was identified on repeat US, abdominal CT. Patient was found to have diffuse sinusitis on [**12-12**] CT of the head. ENT was consulted and did not find a drainable abscess but recommended continuation of antibiotics and nasal washes. Linezolid [**12-16**], Cefipime [**12-18**] continued(to cover pseudomonas adequately) -- renally doses. When pt developed candidemia, ambisome was started. Cipro prphylaxis for SBP was also begun this hospitalization. . # Shock- Initially, patient was requiring Levophed intermittently. DDx included volume loss with bleeding vs adrenal insufficiency (on steroids) vs evolving sepsis (on extensive ABX therapy) vs worsening pancreatitis. Pt was off Levophed since [**12-17**] 8 am, with MAPs >65. [**Last Name (un) **] stim test showed inadequate bump in cortisol -- started stress dose steroids - [**12-18**]. Pentoxyphyline started as per liver recs to increase perfusion and for anti-TNF effects to modulate possible sepsis . # Adrenal insuficiency - [**12-4**] Am cortisol was 6.6-> on hydrocortisone/fludrocortisone [**12-5**] -> d/c fludrocort [**12-9**] upon resolution of hypotension. Patient again was initiated on stress dose steroids after his hypotension returned on [**12-18**]. . # PNA/ARDS/Hypoxia: Likely progressed to sepsis physiology with continually low MAPs. CT showed worsening multi-lobar PNA, likely with ARDS. Patient was maintained on lung protective (hypercarbic) ventilation. He also receiveded extensive ABX coverage. Repeat bronchoscopy did not reveal new obstruction except for some local plugs and also showed negative cultures. Patient was also diuresed with diuretics and subsequent CVVH. . **ARDS** -- hypercarbic ventilation, back on AC with low TV -- Surgery evaluated patient on multiple occassions for trach, but given high risk and poor prognosis for weaning and long-term outcome, plans were put on hold. . ***PNA*** - BAL results negative - MRSA on [**12-3**] sputum with rare yeast on [**12-2**] - Vanco [**12-3**]; Ceftaz [**12-3**]; Flagyl [**12-2**] - end [**12-16**] - Linezolid started on [**12-16**] for better lung penetration for 10 day course. . # ARF - FeNa 0.2%, UNa 19 with resulting FeNa of 14. Patient was subsequently started on midodrone and octreotide. The renal function continued to worse. Renal service was consulted and agreed with the hepatorenal diagnosis. Patient had a nl renal US. Of note, patient did experience severe penile bleeding episode mid [**Month (only) 404**] complicated by his underlying coagulopathy. Patient's bleeding was controlled by inserting a larger [**Last Name (un) 21655**] acting as a tamponade. The 3 way [**Last Name (un) 21655**] always remained patent. Renal service subsequently agreed to initiate CVVH as patient was becoming grossly edematous with worsening renal failure. Edema was also complicating his pulmonary status. Patient underwent tunneled dialysis line placement on [**12-21**] and received dialysis 4x/week. . # Pancreatitis - patient initially with peaked lipase of 600s, and also pancreatic fluid around the tail on [**11-29**] CT. Most likely etiology: etoh vs cholelithiasis, however lab were not consitent with obstruction. Subsequent CT scan showed resolution of pancreatic fluid. However, repeat lipase remained in 150-200 range. Patient's sedation was subsequently changed from propafol to versed and fentanyl. NGT was changed to post-pyloric TF and trophic feeds were initiated without complication. However, later in hosp course, pt developed lipases >1500 and TF were held, then changed to elemental and restarted at trophic levels. . #UGI bleed/Hep C- EtOH cirrhosis: secondary to gastric variceal bleed, although no active bleeding noted on EGD [**11-29**]. Pt is s/p TIPS on [**11-29**]. Increase flow within TIPS on [**11-30**] c/w increased portal HTN. Initially ([**11-29**]) Abd CT showing a nonocclusive thrombus within the right portal vein, is not seen on [**11-30**] US. With worsening liver failure (AST>ALT suggests EtOH hepatitis), increasing TBili and trending up INR, intermitent hypoglycemia. Liver service followed pt throughout stay. He was not a transplant cand. given recent EtOH. C-diff B toxin was neg. Protonix by gtt or IV BID throughout stay. . # EtOH/hep C cirrhosis: Currently AST>ALT suggests EtOH hepatitis. Patient was followed by liver service. He is not currently a transplant candidate given recent EtOH use. His coagulopathy continued to worsen with increasing INR despite vitamin K and worsening bilirubin. His malnutrition was addressed via TF. . # EtOH abuse: denied EtOH use X 1 month, however EtOH 68 at OSH. Patient was continued on MV1 QD, thiamine, folate. . # Anemia: Persistant drifting hematocrit with guiac positive stools in light of coagulopathy with liver failure. Patient also had elevated LDH and low haptoglobin that could be present in liver failure patient's as well. He was managed with blood products as needed. . # Asthma: continue albuterol MDI and atrovent MDI Q4hrs - on steroids . #Communication: Patient; HCP sister [**Name (NI) 501**] [**Name (NI) 3265**] [**Telephone/Fax (1) 61734**]. Team communicated with family on daily basis. In final days, team repeatedly shared prognosis with family, and relayed options to them regarding levels and goals of care. Family decided CMO on [**12-28**], but team rec'd awaiting for imp pt cognizance on [**12-29**]; family agreed. When mental status did not return, despite diminished sedation, family confirmed desire for CMO. Social work and priest notified. Medications on Admission: Meds (home) albuterol prn . Meds (on transfer) 1) Protonix 8 mg/hr gtt 2) Octreotide 50 mcg/hr gtt Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Hematamesis Discharge Condition: Expired

[ "571.2", "427.1", "428.0", "570", "291.81", "572.3", "518.81", "303.01", "571.1", "427.31", "117.9", "482.41", "572.4", "578.1", "286.7", "070.70", "038.9", "584.5", "285.1", "452", "456.20", "599.7", "577.0", "995.92", "578.0", "V09.0", "456.8", "473.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.07", "99.15", "44.43", "96.6", "45.13", "96.04", "22.19", "96.72", "54.91", "33.24", "38.95", "99.05", "39.1", "00.14", "99.04", "00.17" ]

icd9pcs

[ [ [] ] ]

19230, 19239

12698, 19050

282, 309

19294, 19304

3285, 3290

2282, 2432

19200, 19207

19260, 19273

19076, 19177

2447, 3266

231, 244

337, 1881

3305, 12675

1903, 2127

2143, 2266

22,080

124,978

24264

Discharge summary

report

Admission Date: [**2190-5-24**] Discharge Date: [**2190-6-15**] Date of Birth: [**2115-12-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Cardiac arrest at home Major Surgical or Invasive Procedure: Coronray Artery Disease s/p Coronary Artery Bypass Graft x 3 on [**2190-6-8**] History of Present Illness: 74M with PMHx of HTN who pw s/p cardiac arrest at home. He was doing yardwork for 2 hours with his son, with out cp, sob,doe. After he was eating a snack family member noted patient with head back, snoring?, son went to evaluate - patient with eye rolled back, vomitting, gasping for breath. Son tried to clear airway, performed cpr. EMS arrived (s/p about 5 minutes)and found patient to be in vfib and shocked pt out of rhythm. Patient arrived in the ed and was found to to be in afib. After stablization of pt in the ED (airway management, multiple gtts) he was worked up and found to have a pulmonary embolism and aspiration pneunia. Also post-admission pt went into polymorphic VT multiple times and each time was shocked back into NSR. Past Medical History: Hypertension Polio (Left lef involvement) s/p R. Hip Replacement Social History: Married with son [**Name (NI) 1139**] x 20 yrs, quit 15 yrs ago Family History: Non-Contributory Physical Exam: SR@60 116/56 CVP14 SPO295 at 5:30 PM AC 500 x 34, Fio2 .5, peep 15 intubated and sedated perrla, anicteric supple neck, rt ij, left subclavian cordis rrr, s1/s2, no m/r/g ronchorous bs, no crackles obese, soft distended abdomen no clubbing, le cyanosis DP,femoral wnl non purposeful movement, responds to noxious stimuli Pertinent Results: Cath [**6-7**]: 1. Two vessel coronary artery disease (LMCA 80%) 2. Mild mitral regurgitation. 3. Moderate diastolic ventricular dysfunction. 4. Mild systolic ventricular dysfunction. 5. Right femoral IABP. Chest CT [**5-25**]: 1. Moderately large pulmonary embolism extending into the superior segment of the right pulmonary artery, into the distal branches. 2. Bilateral dense, posterior consolidations consistent with aspiration pneumonia. 3. Dense coronary artery calcifications. 4. Prominent bilateral axillary and a single enlarged subcarinal lymph node. 5. Generalized edema within the subcutaneous soft tissues. CXR [**6-14**]: No evidence of pneumothorax. Bilateral moderate-sized pleural effusions. CXR [**6-6**]: There is continued mild congestive heart failure with cardiomegaly and bilateral small pleural effusions. There is continued bibasilar patchy atelectasis. The left subclavian IV catheter remains in place. [**5-24**]: 1)Endotracheal tube 6.2 cm above the carina. 2) Bilateral pulmonary opacities, likely representing pulmonary edema and possibly aspiration. [**2190-5-24**] 02:37PM BLOOD WBC-13.9* RBC-5.61 Hgb-17.6 Hct-51.4 MCV-92 MCH-31.3 MCHC-34.2 RDW-12.9 Plt Ct-234 [**2190-5-26**] 03:52AM BLOOD WBC-15.6* RBC-3.88* Hgb-11.9* Hct-35.0* MCV-90 MCH-30.7 MCHC-34.1 RDW-13.3 Plt Ct-122* [**2190-5-28**] 04:30PM BLOOD WBC-12.1* RBC-3.25* Hgb-9.9* Hct-29.3* MCV-90 MCH-30.3 MCHC-33.7 RDW-13.5 Plt Ct-119* [**2190-6-3**] 02:35PM BLOOD WBC-14.7* RBC-3.67* Hgb-11.2* Hct-33.7* MCV-92 MCH-30.6 MCHC-33.3 RDW-13.9 Plt Ct-287 [**2190-6-9**] 04:03AM BLOOD WBC-18.4* RBC-3.30* Hgb-10.2* Hct-29.9* MCV-91 MCH-30.8 MCHC-34.0 RDW-14.2 Plt Ct-318 [**2190-6-14**] 05:42AM BLOOD WBC-10.6 RBC-3.16* Hgb-9.6* Hct-29.0* MCV-92 MCH-30.2 MCHC-33.0 RDW-14.0 Plt Ct-332 [**2190-5-24**] 02:37PM BLOOD PT-12.6 PTT-22.4 INR(PT)-1.0 [**2190-5-26**] 03:52AM BLOOD PT-19.0* PTT-150* INR(PT)-2.4 [**2190-5-27**] 03:51AM BLOOD PT-13.9* PTT-54.0* INR(PT)-1.3 [**2190-5-31**] 04:15AM BLOOD PT-13.0 PTT-46.9* INR(PT)-1.1 [**2190-6-7**] 12:30PM BLOOD PT-13.9* PTT-30.0 INR(PT)-1.3 [**2190-6-15**] 08:40AM BLOOD PT-13.7* PTT-49.1* INR(PT)-1.3 [**2190-5-24**] 02:37PM BLOOD Glucose-276* UreaN-22* Creat-1.0 Na-143 K-3.4 Cl-104 HCO3-19* AnGap-23* [**2190-5-25**] 03:32PM BLOOD Glucose-156* UreaN-19 Creat-0.9 Na-144 K-4.0 Cl-113* HCO3-20* AnGap-15 [**2190-6-7**] 12:30PM BLOOD Glucose-115* UreaN-17 Creat-0.7 Na-141 K-4.2 Cl-109* HCO3-23 AnGap-13 [**2190-6-14**] 05:42AM BLOOD Glucose-109* UreaN-13 Creat-0.8 Na-138 K-4.1 Cl-107 HCO3-22 AnGap-13 [**2190-5-25**] 04:30AM BLOOD ALT-80* AST-62* LD(LDH)-241 CK(CPK)-227* AlkPhos-55 TotBili-0.9 [**2190-6-7**] 12:30PM BLOOD ALT-24 AST-19 AlkPhos-57 TotBili-0.6 [**2190-5-24**] 05:50PM BLOOD Calcium-7.6* Phos-5.2* Mg-1.9 [**2190-6-14**] 05:42AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.9 [**2190-6-7**] 12:30PM BLOOD Triglyc-126 HDL-36 CHOL/HD-4.8 LDLcalc-113 [**2190-5-24**] 03:04PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.022 [**2190-5-31**] 08:13PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.009 [**2190-5-24**] 03:04PM URINE Blood-MOD Nitrite-NEG Protein-500 Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2190-5-31**] 08:13PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2190-5-24**] 03:04PM URINE RBC-21-50* WBC-[**2-27**] Bacteri-MANY Yeast-NONE Epi-[**6-4**] [**2190-5-31**] 08:13PM URINE RBC->50 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [**2190-5-24**] 03:04PM URINE CastGr-0-2 COARSE GRANULAR CASTS Brief Hospital Course: As mentioned in the HPI, this is a 74 yr old with relatively unremarkable past medical history who went into V.Fib arresst at home and was shocked out of rhythm by EMS in field. After stabilzation of pt. in the [**Name (NI) **], pt. found to have pumonary embolism and ?pneumonia/increased WBC. He was started on Heparin for the PE and abx for increased WBC. PNA. Pt. remained intubated until [**6-5**] when he was successfully extubated. During this time ([**Date range (1) 56879**]) pt was followed by medicine, cardiology, nutrition, etc. and had numerous studies performed (CXRs,CTs,Cultures-blood,urine,sputum,Echos,etc.). Finally on [**2190-6-7**] pt underwent a cardiac cath which revealed severe LMCA and mult. vessel disease. An IABP was placed and pt was scheduled for a CABG the next day. On [**6-8**] pt was brought to the OR and underwent a CABG x 3. Pt. tolerated the procedure well with a total bypass time of 65 minutes and cross-clamp time of 54 minutes. Please see op note for full surgical details. Pt was transferred to CSRU in stable condition with a MAP of 85, CVP 16, PAD 16, [**Doctor First Name 1052**] 23, and HR 88 A-paced. He was being titrated on Neo and propofol. Later on op day pt was weaned from mechanical ventilation and propofol and was succesfully extubated. He was awake, alert, mae, and following commands. POD #1 pt's IABP was removed. Neo was weaned and diuretics and b-blockers were started per protocol. He was started back on Heparin and Coumadin. On POD #2 his chest tubes, epicardial pacing wires, and foley catheter were all removed per protocol. POD #[**1-28**] pt with ?aspiration. Speech study performed showed thin liquid aspiration. Remained in the CSRU until POD#4 when he was transferred to telemetry floor. Cont. to have course bs bilat. Pt. encouraged to get OOB and ambulate. POD #[**4-30**] pt cont. to progress slow d/t ambulation limitationa from polio. He was cont. on Heparin and Coumadin for PE/A.Fib and Vanco for asp. PNA. POD #7 pt was doing well, but needed transfer to Rehab before going home. He was transferred there on heparin, coumadin, and vanco. His physical exam was much improved with 1+ edema and irregular rate and heart rhythm. Appropriate follow-up appointments were made. Medications on Admission: 1. Hctz 2. Altace Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 4 days. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). 12. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO once a day: Adjust for Goal INR of [**1-27**].5. 13. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1700 (1700) units/hr Intravenous as directed: Titrate for a PTT goal 40-60. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Coronray Artery Disease s/p Coronary Artery Bypass Graft x 3 Aspiration Pneumonia (MRSA) V.Fib Arrest Pulmonary Embolism Hypertension Polio (Left lef involvement) s/p R. Hip Replacement Discharge Condition: Good Discharge Instructions: Wash incisions with water and gentle soap. Gently pat dry. Do not take bath or swim. Do not apply lotions, creams, or ointments to incisions. Do not drive for 1 month. Do not lift more than 10 lbs for 2 months. Take all medications. Make/Keep all follow-up appointments. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks Follow-up with Dr. [**Last Name (STitle) **] in [**1-28**] weeks Follow-up with Dr. [**Last Name (STitle) **] (EP) in 4 weeks Follow-up with Dr. [**Last Name (STitle) 61560**] ([**Street Address(1) 61561**]., [**Location (un) **], [**Numeric Identifier 61562**], Phone # [**Telephone/Fax (1) 61563**]) Completed by:[**2190-6-15**]

[ "711.55", "518.81", "599.0", "410.71", "401.9", "998.12", "414.01", "138", "V43.64", "482.41", "785.51", "427.31", "424.0", "507.0", "428.0", "415.19" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.56", "99.62", "39.61", "00.17", "37.23", "38.93", "99.10", "36.12", "38.91", "99.60", "88.72", "96.72", "36.15", "37.61", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

8906, 8985

5320, 7574

345, 425

9214, 9220

1756, 5297

9539, 9927

1380, 1398

7642, 8883

9006, 9193

7600, 7619

9244, 9516

1413, 1737

283, 307

453, 1195

1217, 1283

1299, 1364

78,076

160,515

10769

Discharge summary

report

Admission Date: [**2114-2-11**] Discharge Date: [**2114-2-16**] Date of Birth: [**2043-3-24**] Sex: M Service: SURGERY Allergies: Aspirin / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2836**] Chief Complaint: LLQ abdominal pain, diarrhea Major Surgical or Invasive Procedure: [**2114-2-13**]: Percutaneous G-J Tube replacement History of Present Illness: Patient is a 70M who is well-known to the West 2 surgical service. He has a complex medical history of gallstone pancreatitits, with necrotizing pancreatitis and abdominal compartment syndrome requiring decompressive laparotomy. At the subsequent reattempt at abdominal closure, the patient again developed abdominal compartment syndrome. His course was significant for respiratory and renal failure ultimately requiring tracheostomy/PEG tube placement. He also had infectious complications from his [**Hospital 9914**] hospital course. He recovered well from this initial insult. The patient required three laparoscopic necrosectomies. However, the patient developed a pancreatico-[**Last Name (un) **]-cutaneous fistula that has healed well in the interim. He was recently admitted to [**Hospital1 18**] and dishcarged in [**Month (only) 1096**]. Since then, he has been at rehab where he has been tolerating Passy-Muir valve and walking with assistance. Two days ago, he began to develop left lower quadrant abdominal pain with 2 episodes of diarrhea 2 days ago and 5 episodes yesterday. He was told that he had a diagnosis of C difficile colitis at the rehabilitation facility, which was later confirmed. He is now transferred to [**Hospital1 18**] for further care given increasing LLQ tenderness and pain. Past Medical History: PMHx: asthma, HTN, basal cell carcinoma, DM, gallstone pancreatitis c/b respiratory and renal failure, abdominal compartment syndrome, necrotizing pancreatitis PShx: rib frx plating approx 5 years ago. On last admission [**2113-7-13**] closure, GJ tube [**2113-7-8**] partial abd closure, drsg [**Name5 (PTitle) **] [**2113-7-4**] Open abdomen dressing revision [**2113-7-3**] Decompressive laparotomy, open abd [**2113-7-8**] partial closure abdominal wound [**2113-7-13**] formal closure GJ tube [**2113-7-19**] Decompressive laparotomy, open abd [**2113-7-24**] tracheostomy [**2113-7-29**] abdominal closure with mesh [**2113-8-13**] and [**2113-8-18**] -I&D of pancreatic fluid collection and subsequent upsizing of drain by IR [**2113-8-22**], [**2113-8-28**], [**2113-9-4**] -Laparoscopic pancreatic necrosectomy Social History: Married for 45+ years. Three daughters, one son. Retired six years ago, owned upholstery business. Never smoker, one glass of wine per evening with dinner. No illicits. Family History: Sister died from breast cancer, another sister (deceased) with CRF on HD Physical Exam: On Admission: VS: 96.9 107 105/70 20 99%RA General: awake and alert CV: RRR Lungs: CTA bilaterally Abdomen: soft, (+) LLQ tenderness, + rebound on palpation of LLQ, no other rebound/guarding, hypoactive BS Rectal: heme (-), loose yellow stool noted Ext: warm, no edema . At Discharge: VS: 97.7 PO, 110, 118/78, 20, 98% RA GEN: Deconditioned in NAD. HEENT: Sclerae anicteric. O-P clear. Neck: Supple. Prior tracheostomy site (now decannulated) clean/intact with DSD cover. LUNGS: CTA(B) COR: Episodic tachycardia, otherwise RRR. ABD: Graft clean, healing well. G-J tube patent/intact. Site benign. BSX4. Soft/NT/ND. EXTREM: WWP; no c/c/e NEURO: A+Ox3. Pleasant. Deconditioned. Pertinent Results: On Admission: [**2114-2-11**] 09:24PM URINE BLOOD-SM NITRITE-POS PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2114-2-11**] 09:15PM GLUCOSE-115* UREA N-23* CREAT-1.3* SODIUM-137 POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-12 [**2114-2-11**] 09:15PM CALCIUM-8.5 PHOSPHATE-2.9# MAGNESIUM-1.7 [**2114-2-11**] 02:11PM LACTATE-2.1* [**2114-2-11**] 02:00PM GLUCOSE-149* UREA N-25* CREAT-1.5* SODIUM-136 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-14 [**2114-2-11**] 02:00PM ALT(SGPT)-7 AST(SGOT)-19 ALK PHOS-75 TOT BILI-0.5 [**2114-2-11**] 02:00PM LIPASE-30 [**2114-2-11**] 02:00PM WBC-11.9* RBC-3.38* HGB-9.9* HCT-30.3* MCV-90 MCH-29.3 MCHC-32.7 RDW-15.5 [**2114-2-11**] 02:00PM NEUTS-83.1* LYMPHS-11.7* MONOS-4.4 EOS-0.7 BASOS-0.1 [**2114-2-11**] 02:00PM PLT COUNT-283 [**2114-2-11**] 02:00PM PT-15.9* PTT-24.4 INR(PT)-1.4* . IMAGING: [**2114-2-11**] ABD/PELVIC CT W/CONTRAST: 1. Wall thickening of the rectum, sigmoid, descending and transverse colon with surrounding fat stranding compatible with colitis. The etiology are most likely infectious or inflammatory in nature. C. diff. colitis may explain these findings. ISchemic etiology is felt less likely, although not entirely excluded. 2. Slightly smaller fluid and air collection in the mid pancreas, extending inferiorly, compared to prior study from [**2113-10-23**]. Clinical correlation for possible acute process is recommended. 3. Right lower lobe consolidation with heterogeneous enhancement and calcification and soft tissue in a lower lobe bronchus may represent post-obstructive pneumonia. While this can be secondary to mucous secretions, given that it persists since prior exams, underlying endobronchial lesion can not be excluded. Suggest pulmonary consultation for possible bronchoscopy. 4. Multiple liver hypodensities are grossly stable. 5. Severe coronary artery calcifications. . [**2114-2-11**] AP CXR: Single AP upright portable view of the chest was obtained. Right basilar opacity persists which may represent consolidation, partial right lower lobe collapse and/or effusion. Chest CT is pending. Minimal blunting of the left costophrenic angle may be due to a trace effusion versus pleural thickening, without significant interval change. Tracheostomy tube is again seen. There is no significant interval change in the mediastinal or cardiac silhouettes. No overt pulmonary edema is seen. . [**2114-2-13**] CXR: Stable chest findings, no new pulmonary abnormalities since the next preceding study. . MICROBIOLOGY: [**2114-2-14**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL: FECAL CULTURE (Final [**2114-2-14**]): NO APPROPRIATE SPECIMEN RECEIVED FOR THE REQUESTED TEST, SPECIMEN ON TRANSPORT MEDIA RECEIVED. TEST NOT PERFORMED. PATIENT CREDITED. CAMPYLOBACTER CULTURE (Final [**2114-2-14**]): TEST NOT PERFORMED NO APPROPRIATE SPECIMEN RECEIVED FOR THE REQUESTED TEST, SPECIMEN ON TRANSPORT MEDIA RECEIVED. PATIENT CREDITED. OVA + PARASITES (Final [**2114-2-14**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. . FEW POLYMORPHONUCLEAR LEUKOCYTES. CHARCOT-[**Location (un) **] CRYSTALS PRESENT. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2114-2-14**]): TEST NOT PERFORMED NO APPROPRIATE SPECIMEN FOR THE REQUESTED TEST, SPECIMEN ON TRANSPORT MEDIA RECEIVED. PATIENT CREDITED. . [**2114-2-13**] BLOOD CULTURE: NO GROWTH TO DATE - PRELIM. [**2114-2-13**] BLOOD CULTURE: NO GROWTH TO DATE - PRELIM. [**2114-2-13**] URINE URINE CULTURE-PRELIMINARY {ESCHERICHIA COLI}: ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML [**2114-2-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL {CLOSTRIDIUM DIFFICILE): POSITIVE. [**2114-2-12**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL: **FINAL REPORT [**2114-2-14**]** FECAL CULTURE (Final [**2114-2-14**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2114-2-14**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2114-2-13**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2114-2-12**] MRSA SCREEN: NEGATIVE. [**2114-2-11**] MRSA SCREEN: NEGATIVE. [**2114-2-11**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}: **FINAL REPORT [**2114-2-14**]** URINE CULTURE (Final [**2114-2-14**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [**2114-2-11**] BLOOD CULTURE: NO GROWTH TO DATE. Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment of abdominal apin and diarrhea. Admission abdominal/pelvic CT revealed wall thickening of the rectum, sigmoid, descending and transverse colon with surrounding fat stranding compatible with colitis. The etiology are most likely infectious or inflammatory in nature. C. diff. colitis consistent with these findings. Blood, urine , and stool cultures were sent. The patient was made NPO, started on IV fluid rescusitation, a foley catheter was placed, and the patient started on IV Flagyl and oral and rectal Vancomycin. The patient was hemodynamically stable. . Neuro: The patient did not experience any significant pain, and did not require pain medications other than acetaminophen PRN. He remained neurologically intact. He required Physical Therapy due to his deconditioned status. Discharge to rehabiliation facility was recommended. . CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. He was continued on Metoprolol IV Q6hours while admitted. . Pulmonary: The patient underwent tracheostomy during a prior, prolonged admission for respiratory failure. The patient had been tolerating Passy-Muir valve. His tracheostomy was capped for 2 days during this admission with no complications or phonation difficulties. On [**2114-2-15**], the patient was decannulated without problem, and a DSD dressing applied. The patient remained stable from a pulmonary standpoint. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. . GI/GU/FEN: Upon admission, the patient was made NPO with IV fluids. After the GJ-Tube was replaced as the formed one was cracked on [**2114-2-13**], tubefeeds via the J-port of the GJ-Tube were restarted, and advanced back to goal with good tolerability. Foley catheter was discontinued on [**2-13**]; the patient subsequently voided without problem. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. . ID/INTEG: Upon admission, the patient was pan-cultured, including stool cultures and c. diff, and the patient started on IV Flagyl, and PO and rectal Vancomycin. After admission, confirmation from [**Hospital **] Rehab Hospital of a positive C. diff screen was received. Ciprofloxacin was added on [**2-12**] for E. Coli UTI. The Infectious Disease Service was consulted; their recommendations appreciated and followed. Cipro was discontinued on [**2-14**] as the urine C&S revealed Cipro to be resistant. Repeat Urine culture confirmed multi-antibiotic resistant E. Coli. IV Unasyn was started. Rectal Vancomycin was also discontinued. The patient was discharged on Flagyl and PO Vancomycin to complete a two week course. Wound care: The abdomninal skin graft remained clean, intact, and was healing nicely. Xerofoam was placed on the graft with a DSD cover. The GJ-Tube site remained benign. . Endocrine: The patient's blood sugar was monitored throughout his stay; sliding scale insulin was administered when indicated. . Hematology: The patient's complete blood count was examined routinely; no transfusions were required. . Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating continuous tubefeeds via the J-port of the GJ-tube at goal, ambulating with assistance, voiding without assistance, and was not experiencing any significant pain. He was discharged back to a rehabilitation facility, where he will complete a two week course of antibiotic therapy for Clostridium difficile colitis. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) mL Injection Q8H (every 8 hours) as needed for nausea. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain / fever. 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO DAILY (Daily). 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscellaneous Q6H (every 6 hours) as needed for secretion. 9. Nutrition Please continue enteral feeds: Replete with fiber Full strength 40 mL/hr with 30 mL water flush q6h. Medium chain triglycerides 25 mL QID. 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-6**] Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for Anxiety. 7. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. 8. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 9. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every six (6) hours as needed for GI gassiness, bloating. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 13. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO once a day. 14. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One Hundred (100) mL (500mg) Intravenous every eight (8) hours: Completion Date: [**2114-2-26**]. 15. Metoprolol Tartrate 5 mg/5 mL Solution Sig: 0.5 mL (2.5mg) Intravenous every six (6) hours: Hold for HR<60 or SBP<100 . 16. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours: Completion Date: [**2114-2-26**]. 17. Ampicillin-Sulbactam 3 gram Recon Soln Sig: One (1) recon soln Injection every six (6) hours for 5 days. 18. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous QID (4 times a day) for 11 days: Completion date [**2114-2-26**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: 1. Clostridium difficile colitis 2. Resistant ESCHERICHIA COLI UTI Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: Please call your doctor or return to the hospital if you experience: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-14**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . GJ-Tube Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. * Flush G and J-ports of GJ-Tube with 30mL water Q4Hours. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2114-2-28**] 1:15. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].

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icd9cm

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16168, 16240

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330, 383

16351, 16351

3560, 3560

18743, 18970

2773, 2848

14178, 16145

16261, 16330

13138, 14155

16523, 17495

2863, 2863

3148, 3541

17528, 18720

262, 292

11986, 13112

411, 1725

3575, 9093

16365, 16499

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5,061

153,155

26639

Discharge summary

report

Admission Date: [**2194-2-14**] Discharge Date: [**2194-2-24**] Date of Birth: [**2134-5-28**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 1666**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: 1) Broncoscopy [**2-16**] 2) Embolization of RUL bronchial arteries [**2-17**] & [**2-19**] History of Present Illness: 59yM w/ hemoptysis since [**2-8**] presented to OSH. Bronchoscopy x3, EGD, nasopharyngeal endoscopy without evidence of source. Transfered to [**Hospital1 18**] [**2-14**] for further evaluation. On admission, denied significant hemoptysis for ~36 hours, denied CP, SOB, N/V, h/o hemoptysis, weight loss. Reported chronic cough occasionally productive of normal sputum for years. Reported DOE since construction accident and leg injury many years ago. Denied melena, hematochezia. Past Medical History: 1) COPD 2) HTN 3) DM, type 2 4) chronic pancreatitis (EtOH) with known splenic vein thrombosis and h/o UGIB from gastric varices 5) crush injury of R leg Social History: 1ppd x48y, h/o EtOH use ("cut back" 30y ago, now [**12-2**] drinks/week), lives alone, no family except cousin [**Name (NI) **] [**Name (NI) 10168**] Family History: father died of lung cancer, mother died of "female" cancer Physical Exam: Admission Exam 96.3 66SR 158/73 18 96%RA wt 77.7kg NAD, anicteric, no JVD/LAD coarse B/L, regular ND, soft, NT no edema Pertinent Results: [**2194-2-24**] 06:10AM BLOOD WBC-5.5 RBC-3.54* Hgb-10.8* Hct-32.9* MCV-93 MCH-30.5 MCHC-32.9 RDW-13.5 Plt Ct-277 [**2194-2-23**] 04:15AM BLOOD WBC-4.0 RBC-3.02* Hgb-9.5* Hct-27.6* MCV-92 MCH-31.5 MCHC-34.4 RDW-13.6 Plt Ct-209 [**2194-2-15**] 04:45AM BLOOD Hct-28.5* [**2194-2-14**] 11:52PM BLOOD WBC-5.0 RBC-3.14* Hgb-10.3* Hct-29.6* MCV-94 MCH-33.0* MCHC-35.0 RDW-13.1 Plt Ct-172 [**2194-2-24**] 06:10AM BLOOD Plt Ct-277 [**2194-2-23**] 04:15AM BLOOD Plt Ct-209 [**2194-2-17**] 07:55AM BLOOD PT-12.6 PTT-24.4 INR(PT)-1.1 [**2194-2-14**] 11:52PM BLOOD Plt Ct-172 [**2194-2-24**] 06:10AM BLOOD Glucose-148* UreaN-9 Creat-0.7 Na-138 K-4.3 Cl-101 HCO3-26 AnGap-15 [**2194-2-23**] 04:15AM BLOOD Glucose-153* UreaN-11 Creat-0.6 Na-134 K-4.6 Cl-101 HCO3-24 AnGap-14 [**2194-2-15**] 04:45AM BLOOD Glucose-184* UreaN-9 Creat-0.7 Na-133 K-4.2 Cl-103 HCO3-24 AnGap-10 [**2194-2-14**] 11:52PM BLOOD Glucose-43* UreaN-11 Creat-0.8 Na-137 K-3.9 Cl-105 HCO3-26 AnGap-10 [**2194-2-15**] 04:45AM BLOOD ALT-19 AST-26 LD(LDH)-113 AlkPhos-61 TotBili-0.4 [**2194-2-24**] 06:10AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.8 [**2194-2-23**] 04:15AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.5* [**2194-2-15**] 04:45AM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.6 Mg-2.2 [**2194-2-14**] 11:52PM BLOOD Calcium-8.7 Phos-3.3 Mg-1.4* CT CHEST W/O CONTRAST [**2194-2-15**] 12:29 PM CT CHEST W/O CONTRAST Reason: Please perform High Resolution cutshemoptysis, localization Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: 59 yo male with hx of onset of persistent hemoptyis, 3 bronchocopies non-diagnostic. outside CT? RUL ground glassCXR ?generalzied hazy ground glass REASON FOR THIS EXAMINATION: Please perform High Resolution cutshemoptysis, localization and r/o bronchiectasis, CONTRAINDICATIONS for IV CONTRAST: None. REASON FOR EXAMINATION: Persistent hemoptysis. TECHNIQUE: MDCT contiguous images of the chest from the thoracic inlet through the level of the adrenals were obtained without injecting of the IV contrast media. The 5 and 1.25-mm slices were reconstructed for evaluation. The heart is normal. Multiple coronary calcifications are seen. No pericardial effusion is present. Multiple small mediastinal lymph nodes are seen which do not meet the criteria for pathological lymph node enlargement. The aorta and pulmonary trunk are normal within the limits of this unenhanced chest CT. Multiple apical pleural bullae are seen bilaterally, more prominent on the right. No pneumothorax is seen. A widespread centrilobular emphysema is seen mostly within the upper lobe, but the lower lobes are involved as well. Some amount of subpleural emphysema is also present bilaterally. Small blebs are seen within the lower lungs. Prominent thickening of the bronchial wall is seen mostly on the right, especially within the right middle lobe. Ground-glass opacity is seen within the right middle lobe with areas of air cavities within it which may represent blebs surrowneded by consolidation. Some element of volume loss within the right middle lobe is also present. Widespread areas of patchy ground-glass opacity are seen within the right lower lobe, right middle lobe, and of small amount in the right upper lobe. A 1-cm pulmonary nodule with indistinct spiculated borders is seen within the right middle lobe, series 102, images 143-148. In addition, multiple small tiny nodules are seen scattered bilaterally, but most prominent on the right. The images of the upper abdomen reveal multiple small calcifications within the pancreas mostly within the body and tail which represent most probably chronic pancreatitis. IMPRESSION: 1. Bilateral centrilobular and subpleural emphysema most prominent in the upper lung lobes. 2. Ground-glass opacities most prominent in the right middle and right lower lobe and may represent infectious, inflammatory noninfectious process as well as hemorrhage. 3. An ill-defined 1-cm nodule in the right middle lobe is seen. Further followup with chest CT is recommended in three months. 4. Multiple tiny nodules are spread over the right lung which may be related to the diffuse above-described process. 5. Thickening of the bronchial wall and small bronchiectasis more prominent in the right perihilar region and right middle lobe. 6. Chronic pancreatitis. TRANCATHETER EMBOLIZATION [**2194-2-18**] IMPRESSION: 1. Selective arteriography of 2 additional right bronchial arteries (not visualised on the study of [**2-18**]) supplying the right upper lobe demonstrated abnormal tortuous distal vessels associated with contrast blushing. No active extravasation was demonstrated in this distribution and no spinal artery was visualized. Given the current active hemoptysis, embolization of these 2 additional bronchial arteries with 300-500 micron particles was performed. Hemostasis was achieved in the superior vessel and significant reduction of blood flow was achieved in the inferior vessel. 2. Selective arteriography of the main right bronchial artery confirmed complete stasis of blood flow in this distribution consistent with right bronchial artery embolization on [**2194-2-17**]. 3. Selective arteriography of the left bronchial artery demonstrated normal- appearing vessels. 4. At procedures end, there was cessation of active hemoptysis and no neurologic deficits appreciated. CT CHEST W/O CONTRAST [**2194-2-20**] 5:16 PM CT CHEST W/O CONTRAST Reason: please perform high res CT scan of chest Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: 59 year old man s/p empolization of vessels of RUL REASON FOR THIS EXAMINATION: please perform high res CT scan of chest CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 59-year-old man with embolization of right upper lobe vessel. TECHNIQUE: Contiguous axial CT images of the chest are obtained without the administration of IV contrast [**Doctor Last Name 360**]. COMPARISON: Chest CT dated [**2194-2-15**]. FINDINGS: The evaluation of pulmonary and mediastinal vasculature is somewhat limited due to lack of intravenous contrast. Small mediastinal nodes are seen, however, there is no significant mediastinal or hilar lymphadenopathy. Coronary artery is calcified. The heart is normal in size, and there is no evidence of pericardial or pleural effusion. In the lung window, again note is made of centrilobular emphysematous change. Note is made of peribronchial thickening in right middle lobe, with patchy opacities, slightly improved compared to the prior study. Again note is made of 8 mm somewhat spiculated nodule in the right middle lobe, which needs followup in three months. Note is made of small cyst in the left lower lobe. The central airways are patent. In the visualized portion of the upper abdomen, calcified pancreas is seen. There is no suspicious lytic or blastic lesion in skeletal structures. IMPRESSION: 1. Overall unchanged appearance of the chest with emphysematous changes, peribronchial thickening in right middle lobe. 2. 8 mm nodule in the right middle lobe, which needs followup in three months. Alternatively comparison with prior outside studies would determine the chronicity of this finding. 3. Please note the evaluation of pulmonary and mediastinal vasculature is somewhat limited due to lack of intravenous contrast. UNILAT LOWER EXT VEINS RIGHT [**2194-2-21**] 8:14 PM UNILAT LOWER EXT VEINS RIGHT Reason: RT LEG SWELLING, EVAL FOR DVT [**Hospital 93**] MEDICAL CONDITION: 59 year old man s/p angiography with Right leg weakness and swelling REASON FOR THIS EXAMINATION: eval for DVT INDICATION: 59-year-old male with right leg weakness and swelling. TECHNIQUE: Grayscale and Doppler ultrasound of the right lower extremity. No comparison. FINDINGS: Normal flow, augmentation, compressibility are seen, in superficial femoral veins as well as in popliteal veins. No evidence of DVT. IMPRESSION: No evidence of DVT. MR THORACIC SPINE [**2194-2-21**] 10:21 AM MR THORACIC SPINE Reason: Assess for spinal infarction [**Hospital 93**] MEDICAL CONDITION: 59 year old man with hx of COPD, DMII, DJD of spine unknown level p/w hemoptysis now with RLE paralysis after pulm embolization REASON FOR THIS EXAMINATION: Assess for spinal infarction INDICATION: Patient with COPD and diabetes type 2 and degenerative disease of the spine. Patient presented with hemoptysis and now with right lower extremity paralysis post-pulmonary embolization. Evaluate for infarction. No prior studies are available for comparison. TECHNIQUE: Sagittal T1, T2 and STIR images of the thoracic spine were obtained, with axial T2-weighted images from approximately the T6/7 through L2/3 levels. Additional sagittal T2-weighted images from C2 through the upper thoracic spine were obtained, with axial T2-weighted images of the upper thoracic spine. FINDINGS: Vertebral body heights in the cervical, thoracic and lumbar spine are maintained. The spinal canal is patent. On small field of view thoracic spine sagittal T2 images, there are multiple small foci of elevated T2 signal within the spinal cord. The multiple foci are scattered over at least six levels. The axial images demonstrate the elevated T2 signal to be located within the central [**Doctor Last Name 352**] matter of the spinal cord. There is bulging of the T12-L1 disk, with mild encroachment on the spinal cord. The intervertebral disc spaces are normal, were well visualized in the central portion of the thoracic spine. No other paraspinal pathology is identified. Conclusion: Multiple foci of elevated T2 signal within the [**Doctor Last Name 352**] matter of the spinal cord most likely representing foci of infarction. Brief Hospital Course: Pt is a 59 yo man w/ PMH of COPD, DM, HTN admitted to OSH [**2-8**] with hemoptysis ~100-200cc/da. At OSH recieved 3 negative bronch, EGD and nasopharyngeal EGD. Pt was transfered to [**Hospital1 18**] for further management on the Thoracics service [**2-14**]. On workup of hemoptysis pt was noted to have spiculated 9mm RML lesion and 1.5mm infrahilar node on CT. 2 days ago Interventional pulmonology performed a bronch which showed No endobronchial lesions but active bleeding in posterior segment of RUL. Embolization was then performed by IR on [**2194-2-17**] to R bronchointercostal trunk. He continued to have hemoptysis and underwent repeat embolization by IR. Pt was transfered out of the MICU as his hemoptysis had seemed to decrease over the last day s/p embolization. On the floor the patient was discovered to have new RLE weakness, a MRI was performed which showed spinal cord infacrt the patient was seen by neuro who recommend PT, Physical Therapy saw pt in hospital and cleared pt for home with home PT. Pts Hematocrits remained stable after transfer to the floor and hemoptysis resolved. Pt was discharged on his home regimen of medications plus a bowel regimen. Medications on Admission: NPH 13BID protonix 40qd fentanyl patch 50q48 colace 100bid pancrease 4 caps TID enalapril 5bid restroil 30qhs ativan 0.5q8 prn augmentin 500bid 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Transdermal every seventy-two (72) hours. 4. Axid 150 mg Capsule Sig: One (1) Capsule PO twice a day. 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). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed. 9. Enalapril Maleate 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 13 units Subcutaneous at bedtime. 11. Humalog 100 unit/mL Solution Sig: as per sliding scale Subcutaneous with finger stick glucose checks. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary: Hemoptysis, status post embolization Right spinal cord infarct Secondary: Diabetes Hypertension COPD Chronic Pancreatits History of right lower extremity crush injury Discharge Condition: Stable Discharge Instructions: You have been diagnosed with bleeding from your right upper lung, your bleeding is now stable status post embolization by Interventional Radiology. On workup for your bleeding a mass was found in your right middle lung. This will need follow up with a high resolution CT scan 1 month from discharge, you primary care doctor has been contact[**Name (NI) **] and will help you arrange this close to where you live. Also while you were in the hospital your spinal cord loss some blood flow leading to right leg weakness. Continue to use a walker to ambulate and do not drive until cleared by a physical therapist. Physical Therapy has been arranged to work with you at home. Continue to take medications as prescribed. Return to the Emergency Room or call your doctor if you develop increasing cough, increasing blood in your sputum, shortness of breath, chest pain, abdominal pain, episodes of fainting, new weakness or sensory changes or any other concerns. Be sure to follow up as directed. Followup Instructions: Follow up with your primary care doctor, you have an appointment on [**2-28**] at 3:45PM with Dr. [**Last Name (STitle) 26056**], call ([**Telephone/Fax (1) 65700**] with questions or concerns. You will need follow up with a Pulmonologist and a Neurologist, speak with your primary care doctor about arranging follow up appointments with physicians near your home. You will need a follow up CAT scan of your chest in 1 month to monitor your lung nodule. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

[ "401.9", "780.6", "786.3", "E929.1", "250.00", "793.1", "997.09", "577.1", "722.6", "V58.67", "496", "906.4", "336.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.79", "88.43", "96.56" ]

icd9pcs

[ [ [] ] ]

13561, 13617

11058, 12245

279, 372

13837, 13846

1461, 2902

14892, 15480

1246, 1306

12439, 13538

9422, 9550

13638, 13816

12271, 12416

13870, 14869

1321, 1442

229, 241

9579, 11035

400, 886

908, 1063

1079, 1230

53,308

104,682

42337

Discharge summary

report

Admission Date: [**2193-9-14**] Discharge Date: [**2193-10-2**] Date of Birth: [**2131-3-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 7835**] Chief Complaint: Found down [**2193-9-12**] Major Surgical or Invasive Procedure: LP History of Present Illness: 62 yo M h/o hep C (stable in remission), depression/psych dz on Effexor, Risperdal, Wellbutrin, Sertraline, Remeron, and methylphenidate, DM on insulin found unconscious on the ground at 10am of [**2193-9-12**]. Paramedics noted GTC seizure activity and intubated him in the field for airway protection. Mother spoke to him night before, said he sounded normal, but unknown how long he had been lying on the floor. Admission VS included low grade temp, pulse 109, BP 127/73. Potassium 5.8, Bicarb 16, BUN 49, Cr 4, glucose 324, latate 5, WBC 17. ABG: 7.33/36/312/18. U/A showed 1000 glucose, 10 ketones, 35 red cells, 10 white, hyaline casts, 100 prot. Head CT with no acute process. CXR showed LLL atelectasis/infiltrate. . The pt was admitted to [**First Name4 (NamePattern1) 487**] [**Hospital3 91711**] ICU and was given IVF, Zozyn, and Vanc. Neurology c/s noted that hyperglycemic acidosis, metabolic derangements, & mult psych meds could have precipitated seizure/obtundation. Also, couldn't r/o stroke. Started on phenytoin, asa, EEG unhelpful, MRI when stable. Patient started to improve and was extubated but never recovered basline mental status. CXR's no acute process/infiltrate. Renal fxn improved, Cr 3.2 from 4, CK down from 58,000 to 31,000. Renal US showed no hydro/stones. liver with fatty infiltration. . 26 hours later around noon [**2193-9-13**], patient spiked fever to 103, persisting, ID worried about encephalitis/meningitis, started empirically on acyclovir/ctx/vanc, with new bld cx. previous blc/urine cx ngtd. LP not performed. . Today [**9-14**], fevers persist and pt noted to be stiff throughout, increased ms [**Last Name (Titles) **], diaphretic/tachy to low 100s, hypertensive w SBP 150-160s, tachypneic in 20s, satting at 95% on 60%mask. CPK began to rise again to 47,000, ? neuroleptic malignant syn --> started on baclofen. LFTs with high AST>>ALT c/w rhabdo. Uric acid 16.1 --> 10.9. Last lactate 2.6. Prior to transfer to [**Hospital1 18**], pt 102.6(was on cooling blanket), 146/55, 77, 17, 95% FM @ 60%. Sustained good UOP. CXR clear today but limited study. . On arrival to the [**Hospital Unit Name 153**], patient remains somnelent/obtunded, opens eyes initially to his name but unable to stay open, unable to follow any commands. VS detailed below. Past Medical History: HTN Hep C (in remission) depresion GERD ?suicidality degenerative disk dz s/p L shoulder [**Doctor First Name **] s/p card cath at least 5 years ago, negative according to sister. Social History: Air Force veteran, lives w mom, sister helps to take care of him, takes him out shopping, hx of tobacco abuse but quit. h/o alcohol abuse per sister. Family History: non contributory Physical Exam: On Admission Vitals: 101.4, 86 152/81 24 94% on 4LNC General: somnelent, obtunded HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: no JVD, LAD, stiff neck but unclear if generalized Lungs: CTAB CV: RRR, no murmurs Abdomen: soft, obese GU: draining clear brownish urine. Ext: no edema, very stiff Neuro: opens eyes briefly to name, retracts to pain, unable to follow instructions, moving all extrem spontaneously, very stiff extremities, lower > upper. Pertinent Results: On Admission: [**2193-9-14**] 01:59PM WBC-17.6* RBC-4.37* HGB-12.6* HCT-36.0* MCV-82 MCH-28.9 MCHC-35.0 RDW-16.2* [**2193-9-14**] 01:59PM NEUTS-65.9 LYMPHS-24.2 MONOS-8.9 EOS-0.3 BASOS-0.7 [**2193-9-14**] 01:59PM PT-17.6* PTT-24.9 INR(PT)-1.6* [**2193-9-14**] 01:59PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2193-9-14**] 01:59PM VANCO-<1.7* [**2193-9-14**] 01:59PM TSH-0.36 [**2193-9-14**] 01:59PM CALCIUM-7.2* PHOSPHATE-4.2 MAGNESIUM-1.4* URIC ACID-10.6* [**2193-9-14**] 01:59PM CK-MB-12* MB INDX-0.0 cTropnT-0.11* [**2193-9-14**] 01:59PM ALT(SGPT)-203* AST(SGOT)-912* LD(LDH)-1725* CK(CPK)-[**Numeric Identifier **]* ALK PHOS-74 TOT BILI-0.9 [**2193-9-14**] 01:59PM GLUCOSE-110* UREA N-54* CREAT-3.0* SODIUM-150* POTASSIUM-3.0* CHLORIDE-108 TOTAL CO2-27 ANION GAP-18 [**2193-9-14**] 02:51PM freeCa-0.87* [**2193-9-14**] 02:51PM LACTATE-2.9* K+-3.0* [**2193-9-14**] 02:51PM TYPE-ART TEMP-38.3 O2-94 O2 FLOW-4 PO2-74* PCO2-31* PH-7.59* TOTAL CO2-31* BASE XS-8 AADO2-569 REQ O2-93 INTUBATED-NOT INTUBA [**2193-9-14**] 02:52PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2193-9-14**] 02:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2193-9-14**] 02:52PM URINE RBC-165* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [**2193-9-14**] 03:09PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2193-9-14**] 09:33PM freeCa-0.85* [**2193-9-14**] 09:33PM GLUCOSE-194* LACTATE-2.5* NA+-147* K+-3.1* CL--106 TCO2-27 [**2193-9-14**] 10:45PM CEREBROSPINAL FLUID (CSF) PROTEIN-41 GLUCOSE-106 [**2193-9-14**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-2385* POLYS-66 LYMPHS-26 MONOS-6 EOS-1 BASOS-1 [**2193-9-14**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-1360* POLYS-30 LYMPHS-55 MONOS-15 [**2193-9-14**] 09:33PM TYPE-ART PO2-116* PCO2-27* PH-7.61* TOTAL CO2-28 BASE XS-6 BLOOD [**2193-9-15**] 04:26AM BLOOD WBC-12.2* RBC-4.04* Hgb-11.4* Hct-33.6* MCV-83 MCH-28.2 MCHC-33.9 RDW-16.0* Plt Ct-136* [**2193-9-18**] 03:41AM BLOOD WBC-10.5 RBC-3.70* Hgb-10.7* Hct-31.8* MCV-86 MCH-28.8 MCHC-33.6 RDW-15.4 Plt Ct-86* [**2193-9-23**] 03:33AM BLOOD WBC-10.9 RBC-3.32* Hgb-9.8* Hct-30.2* MCV-91 MCH-29.6 MCHC-32.5 RDW-19.0* Plt Ct-138* [**2193-9-26**] 05:11AM BLOOD WBC-6.8 RBC-2.93* Hgb-8.8* Hct-27.1* MCV-93 MCH-30.0 MCHC-32.4 RDW-19.6* Plt Ct-116* [**2193-9-20**] 05:00AM BLOOD Neuts-55 Bands-2 Lymphs-31 Monos-7 Eos-2 Baso-1 Atyps-0 Metas-2* Myelos-0 NRBC-1* [**2193-9-22**] 04:49AM BLOOD Neuts-60.4 Lymphs-26.3 Monos-7.5 Eos-4.9* Baso-0.8 [**2193-9-26**] 05:11AM BLOOD Neuts-62.1 Lymphs-28.8 Monos-4.7 Eos-3.7 Baso-0.7 [**2193-9-14**] 01:59PM BLOOD PT-17.6* PTT-24.9 INR(PT)-1.6* [**2193-9-16**] 03:44AM BLOOD PT-16.4* PTT-28.5 INR(PT)-1.4* [**2193-9-20**] 05:00AM BLOOD PT-18.2* PTT-24.7 INR(PT)-1.6* [**2193-9-22**] 04:49AM BLOOD PT-14.4* PTT-24.4 INR(PT)-1.2* [**2193-9-15**] 03:25PM BLOOD Glucose-272* UreaN-50* Creat-2.0* Na-147* K-3.6 Cl-111* HCO3-25 AnGap-15 [**2193-9-19**] 06:00AM BLOOD Glucose-244* UreaN-38* Creat-1.2 Na-144 K-4.2 Cl-111* HCO3-26 AnGap-11 [**2193-9-21**] 05:15PM BLOOD Glucose-238* UreaN-47* Creat-1.3* Na-151* K-3.6 Cl-119* HCO3-25 AnGap-11 [**2193-9-23**] 03:33AM BLOOD Glucose-86 UreaN-36* Creat-1.2 Na-147* K-3.6 Cl-116* HCO3-25 AnGap-10 [**2193-9-26**] 05:11AM BLOOD Glucose-151* UreaN-27* Creat-0.8 Na-141 K-3.8 Cl-112* HCO3-24 AnGap-9 [**2193-9-14**] 01:59PM BLOOD ALT-203* AST-912* LD(LDH)-1725* CK(CPK)-[**Numeric Identifier **]* AlkPhos-74 TotBili-0.9 [**2193-9-15**] 04:26AM BLOOD ALT-176* AST-794* LD(LDH)-1668* CK(CPK)-[**Numeric Identifier 91712**]* AlkPhos-63 TotBili-0.7 [**2193-9-16**] 03:04PM BLOOD CK(CPK)-[**Numeric Identifier 91713**]* [**2193-9-17**] 03:59AM BLOOD CK(CPK)-[**Numeric Identifier 7244**]* [**2193-9-20**] 05:00AM BLOOD ALT-90* AST-189* CK(CPK)-1652* AlkPhos-71 TotBili-0.5 [**2193-9-23**] 03:33AM BLOOD ALT-64* AST-121* LD(LDH)-429* CK(CPK)-734* AlkPhos-59 TotBili-0.6 [**2193-9-26**] 05:11AM BLOOD ALT-67* AST-128* LD(LDH)-390* CK(CPK)-771* AlkPhos-64 TotBili-0.4 [**2193-9-14**] 01:59PM BLOOD CK-MB-12* MB Indx-0.0 cTropnT-0.11* [**2193-9-18**] 03:41AM BLOOD cTropnT-0.03* [**2193-9-15**] 03:25PM BLOOD Calcium-7.3* Phos-3.1 Mg-2.3 [**2193-9-21**] 05:15PM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1 [**2193-9-26**] 05:11AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0 [**2193-9-20**] 02:49PM BLOOD Ammonia-97* [**2193-9-20**] 02:49PM BLOOD Osmolal-330* [**2193-9-14**] 01:59PM BLOOD TSH-0.36 [**2193-9-23**] 01:20PM BLOOD Type-ART pO2-86 pCO2-30* pH-7.51* calTCO2-25 Base XS-1 [**2193-9-19**] 08:58AM BLOOD Lactate-2.1* ARBOVIRUS ANTIBODY IGM AND IGG Results Pending [**2193-9-24**] Radiology CHEST PORT. LINE [**First Name9 (NamePattern2) **] [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-23**] Radiology CT CHEST W/CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-23**] Radiology CT ABD & PELVIS WITH CO [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-20**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-20**] Radiology LIVER OR GALLBLADDER US [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-19**] Radiology MR HEAD W & W/O CONTRAS [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-19**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-19**] Radiology CT HEAD W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-18**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] R. Approved [**2193-9-18**] Neurophysiology EEG [**2193-9-18**] [**Last Name (LF) **],[**First Name3 (LF) **] L. [**2193-9-17**] Neurophysiology EEG [**2193-9-17**] [**Last Name (LF) **],[**First Name3 (LF) **] L. [**2193-9-16**] Neurophysiology EEG [**2193-9-16**] [**Last Name (LF) **],[**First Name3 (LF) **] L. [**2193-9-15**] Radiology CHEST PORT. LINE [**First Name9 (NamePattern2) **] [**Last Name (LF) 2437**],[**First Name3 (LF) **] Approved [**2193-9-15**] Radiology -76 BY SAME PHYSICIAN [**Name9 (PRE) 2437**],[**Name9 (PRE) **] Approved [**2193-9-15**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 2437**],[**First Name3 (LF) **] Approved [**2193-9-15**] Neurophysiology EEG [**2193-9-15**] [**Last Name (LF) 20564**],[**First Name3 (LF) **] C. [**2193-9-14**] Radiology MR HEAD W/O CONTRAST [**Last Name (LF) 2437**],[**First Name3 (LF) **] Approved [**2193-9-14**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 2437**],[**First Name3 (LF) **] Approved [**2193-9-14**] Cardiology ECG [**2193-9-17**] [**Last Name (LF) **],[**First Name3 (LF) **] R. Brief Hospital Course: 62 M h/o Hep C, HTN, depression on mult psych meds p/w altered mental status/obtunded, rhabdo, fevers, and increased stiffness after found down at home, transferred to us from [**Hospital1 487**] for worsened fever, rigidity, CK. Had indications of rhabdo. His mental status waxed and waned. Most likely was [**1-23**] NMS. Was having continuous fevers and worsened obtundation. After gradual improvement in mental status, he was transferred to the floor. . # Altered MS: Initially on admission he had an LP which showed alot of RBC's. Differential was aseptic vs. blood tap vs. subarachnoid blood from encephalitis / necrosis. He was placed on CTX, Vanc, Amp, and acyclovir ([**9-14**]) and started cooling. Neuro was following while he was in the ICU who believed this is most likely due to NMS which might take about 14 days to improve. He was treated with bromocriptine. EEE, West Nile virus, lyme serology were sent. Lyme and RPR negative. MRI brain showed mild to moderate cortical atrophy. His Parasite smear and OSH cultures were negative. PICC line placed [**9-15**]. CSF HSV PCR was negative and acyclovir subsequently was discontinued ([**9-18**]) along with the other antibiotics ([**9-17**]) given the low suspicion of bacterial cause. EEG initially showed high epileptiform activity and valium was started. Subsequent EEG monitoring showed no seizure activity with gradual taper of valium and discontinuation on [**9-18**]. On [**9-19**] he was more obtunded with increased oxygen requirement. Therefore, CT and MRI head were done which showed no acute changes. Vanc anc cefepime were started on the same day to cover for presumed HAP given increased oxygen requirement. CXR didn't show new infiltrates. Abx dc'ed [**9-25**]. IV acyclovir was restarted [**9-20**] but dc'ed Lactulose was initiated given concern of hepatic encephalopathy in setting of HCV and elevated liver enzymes. RUQ ultrasound showed cirrhosis with trace ascites. His mental status improved. He received tube feeds starting from [**9-15**] and discontinued after NG tube was self-removed by him on [**9-26**]. satting 92-93% on RA while attempting to place an NG tube which eventually failed and not pursued further. Tolerating apple sauce. His mental status continued to improve. Recommendation by Neurology is to continue bromocriptine until [**2193-10-5**] and continue Keppra for now. Pt was started on Lactulose and should continue on this titrating to 3BMs per day to avoid any component of hepatic encephalopathy. . # Hypoxia Continued oxygen requirement during his stay, but was satting in 90's on RA even during NG tube insertion multiple attempts on his transfer day. stable. Cultures were have been unremarkable. Large amounts of mucus were removed [**9-19**] with poor gag reflex. Suspect due to secretions and AMS with poor cough. He was treated empirically for PNA. This improved with improvement in mental status and has been off oxygen prior to discharge. . # Transaminitis: Persistently elevated AST and ALT. Evidence of cirrhosis on RUQ US and CT. History of HepC. Continued laculose empirically for hepatic encephalopathy. . # Hypernatremia Resolved, likely due to poor access to free water. . # ARF/rhabdo: Initially Cr 3.0 on admission, ARF due to rhabdomyolysis, CPK [**Numeric Identifier 24869**]. He received aggressive IVF hydration with improvement in CPK and normalization of Cr to 0.7. . # HTN: Controlled on Labetalol 200 mg [**Hospital1 **]; . # DM on insulin: -on lantus and ISS . # Elevated Troponins: Was not concerning for ACS. Was in setting of ARF, elevated CK w rhabdo, tachycardia. EKG sinus, normal int/axis, no st changes. . Rehab Issues: . #Speech and Swallow recommendations: 1. PO diet: Thin liquids, pureed solids. 2. 1:1 supervision with POs. 3. One sip of liquid at a time. 4. Pills crushed with applesauce. 5. TID oral care. 6. Keppra to be cut and given with applesauce. . #Psych recommendations: -Would utilize behavioral means to reduce delirium (ie. maintain light/dark cycles, frequent redirection). -Would not initiate psychiatric medications at this time (antipsychotics or antidepressants). At least two weeks should be allowed to elapse after recovery from NMS before rechallenge with a low-potency antipsychotic. -In case of behavioral agitation, would refrain from use of antipsychotic and instead utilize benzodiazepines (ie. Ativan) or mechanical restraints (ie. posey, wrist restraints). -Pt. should be followed by rehab psychiatrist, with followup with outpatient treaters arranged. Medications on Admission: Home meds: Omeprazole 20 [**Hospital1 **] effexor 125 TID Risperdal 6 qhs Wellbutrin 100 [**Hospital1 **] Sertraline 100 [**Hospital1 **] Remeron 30 daily methylphenidate 10 daily ibuprofen 600 QID Spironolactone 25 codeine 30 [**Hospital1 **] Flexeril 10mg TID Insulin, unknown dose/type Transfer Medications: Tylenol Acyclovir 575mg IV q8h DuoNeb q6h ASA 81 Baclofen 10mg [**Hospital1 **] Ceftriaxone 2g IV BID Lasix 80 [**Hospital1 **] Metop 25 [**Hospital1 **] Zofran prn Protonix 40 IV daily Phenytoin 100 IV TID senna prn ISS Lantus 30 u SQ daily Lactulose 20mg QID Heparin sq Colace prn Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): titrate to [**1-24**] BMs a day. 9. bromocriptine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): until [**2193-10-5**]. 10. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing, SOB. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 15. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for fever, pain. 16. insulin glargine 100 unit/mL Solution Sig: Forty Five (45) units Subcutaneous at bedtime. 17. Keppra 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: please cut in 2 and give with applesauce. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Neuroleptic malignant syndrome Cirrhosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted from another hospital after being found unconscious at home. You had a syndrome called "neuroleptic malignant syndrome", which was most likely related to your large amounts of risperidone which you were taking for your schizoaffective disorder. You were managed in the intensive care unit and your psychiatric medications were held. You were started on a medication called bromocriptine which you should take until [**10-5**]. You were also found to have cirrhosis of your liver and this should be followed your PCP or [**Name Initial (PRE) **] Gastroenterologist. Followup Instructions: Please follow up with your PCP and Psychiatrist (NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 91714**] [**Hospital1 189**] VA [**Telephone/Fax (1) 91715**]) after discharged from rehab.

[ "E939.3", "293.0", "333.92", "571.5", "728.88", "E912", "345.90", "584.9", "530.81", "295.70", "789.59", "933.1", "250.00", "V62.84", "V58.67", "722.6", "311", "070.71", "276.69", "401.9", "276.0", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.97", "03.31" ]

icd9pcs

[ [ [] ] ]

17312, 17355

10418, 14958

329, 333

17440, 17440

3563, 3563

18226, 18435

3046, 3065

15604, 17289

17376, 17419

14984, 15274

17618, 18203

3080, 3544

263, 291

15296, 15581

361, 2658

3578, 10395

17455, 17594

2680, 2862

2878, 3030

68,457

109,940

51457

Discharge summary

report

Admission Date: [**2131-11-12**] Discharge Date: [**2131-11-30**] Date of Birth: [**2062-6-28**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Aspirin / Compazine / spironolactone Attending:[**First Name3 (LF) 2782**] Chief Complaint: Right knee pain Major Surgical or Invasive Procedure: Right total knee arthroplasty initiation of hemodialysis placement of tunneled hemodialysis catheter History of Present Illness: From orthopedics: Mr. [**Known lastname **] returns. Her orthopedic history is well documented. The shots that I give her improve her symptoms significantly, so that she can walk around without pain. Unfortunately, the pain returns. It is the pain in her right knee that is keeping her from ambulating as pain in the right knee that is keeping her from doing all her activities of daily living and it is the pain that keeps her intermittently in a wheelchair. She also has chronic lower back issues, which hurt as well. [**Hospital Unit Name 92800**]: 69 yo F with CKD stage 4, CAD with CABG, morbid obesity, who was admitted for right TKR, s/p TKR on [**2131-11-12**], transferred to the [**Year (4 digits) **] floor given [**Last Name (un) **] on CKD and volume overload. Per report, patient had a right TKR on [**2131-11-12**]. Per orthopedics, patient would need to be on Lovenox for DVT/PE prophylaxis in the setting of recent TKR. They were concerned about patient's cardiac function and underlying CAD. Med Consult was consulted POD2 given hypoxia, decreased uop, and acute on chronic renal disease. Patient was noted to require 3L of O2 from a baseline of only intermittent 1-2 L NC. Patient was feeling very fatigued. Patient was noted to be 6.7 L net positive on [**2131-11-14**]. She was ultimately transferred to the [**Year (4 digits) **] Hospitalist Service for further management. It was thought that patient was volume overloaded. Nephrology was consulted on [**2131-11-15**] for acute on chronic kidney disease and thought that patient should continue with diuresis. MICU consult was called on [**2131-11-16**] given altered mental status. Patient was noted to be lethargic on [**2131-11-15**] in the setting of getting diuresis, pain medications, and home gabapentin. Her pain medications were stopped. She was found to be sobbing in the morning of [**2131-11-15**] from pain at the surgical site. Patient was given 2.5 mg po oxycodone and 160 mg IV lasix and metolazone. She was then found to be somnolent and difficult to arouse from the sternal rub. When evaluated patient's vitals were 97.8, 107/50, 69, 20, 96% on 2L NC (although the oxygen was not turned on upon my entering to the room). Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG ([**2129-7-27**]): LIMA-LAD, SVG-OM1, SVG-OM2 c/b non-healing sternal incision wound - MI in [**2128**] and [**2129**] - Diastolic heart failure (EF >55%) - PERCUTANEOUS CORONARY INTERVENTIONS: None in [**Hospital1 18**] records - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -Cerebrovascular accident with L residual hemiparesis ([**10-30**]) -T2DM on insulin (last A1c=6.4%) -Chronic kidney disease with microalbuminuria (stage III) -Hyperlipidemia -Hypertension -Asthma - intubated "many years ago." Per patient last exacerbation requiring hospitalization was 2-3 years ago. -Morbid obesity -UGIB [**7-31**] suspected d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear Social History: The patient lives in [**Hospital3 4634**] and is very limited in terms of her physical mobility. Has severe right knee pain, is winded & tires very easily. No ETOH, smoking or illicit drug use. Has children, originally from Barbados, has home services. Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: Diabetes, unsure of cause of death, no reported CAD - Father: Died in 30s from trauma after falling off a horse Physical Exam: Orthopedics Admission exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples, no erythema * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm [**Hospital Unit Name 153**] admission exam: Vitals: 98.3, 66, 127/55, 18, 99% 2L. General: Alert, oriented x 2 (knows in [**Hospital1 18**], knows president [**Last Name (un) 2753**], but thought it is [**2124**] [**Month (only) 404**]), sobbing HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP difficult to assess due to body habitus but EJ is prominent, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diminished breath sounds in the basis, difficult exam due to pain and inspiratory effort, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: + Foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis, trace edema Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, limited exam in the RLE given pain, grossly normal sensation, gait deferred Discharge Exam: General: alert, oriented x3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL CV: RRR, 3/6 systolic murmur LUSB; pt with R tunneled HD catheter C/D/I Lungs: diminished breath sounds at bases, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis, trace ankle edema. Right knee with staples in place, no erythema, or warmth Neuro: CNII-XII intact, gait deferred, moving all extremities Pertinent Results: Admission labs: [**2131-11-12**] 05:37PM BLOOD WBC-6.9 RBC-3.06* Hgb-9.8* Hct-29.2* MCV-96 MCH-32.1* MCHC-33.5 RDW-13.9 Plt Ct-254 [**2131-11-12**] 05:37PM BLOOD Glucose-119* UreaN-72* Creat-2.4* Na-140 K-4.3 Cl-106 HCO3-22 AnGap-16 [**2131-11-16**] 07:55AM BLOOD ALT-5 AST-33 AlkPhos-100 TotBili-0.2 [**2131-11-12**] 05:37PM BLOOD Calcium-8.9 Phos-4.3 Mg-1.7 [**2131-11-17**] 04:04AM BLOOD CRP-200.3* [**2131-11-16**] 01:40PM BLOOD Type-ART pO2-78* pCO2-35 pH-7.37 calTCO2-21 Base XS--3 [**2131-11-16**] 01:40PM BLOOD Lactate-0.6 Discharge labs: [**2131-11-30**] 05:41AM BLOOD WBC-10.1 RBC-2.59* Hgb-8.0* Hct-25.4* MCV-98 MCH-30.8 MCHC-31.5 RDW-16.8* Plt Ct-135* [**2131-11-30**] 05:41AM BLOOD Glucose-101* UreaN-34* Creat-3.1* Na-138 K-4.1 Cl-101 HCO3-25 AnGap-16 [**2131-11-30**] 05:41AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1 RELEVANT LABS: [**2131-11-22**] 03:18AM BLOOD calTIBC-241* Ferritn-454* TRF-185* [**2131-11-27**] 05:13AM BLOOD PTH-383* [**2131-11-20**] 02:19AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2131-11-27**] 05:13AM BLOOD 25VitD-LESS THAN Micro: [**2131-11-16**] 10:30 pm BLOOD CULTURE Source: Line-PICC. **FINAL REPORT [**2131-11-22**]** Blood Culture, Routine (Final [**2131-11-22**]): NO GROWTH. [**2131-11-16**] 5:27 pm URINE Source: Catheter. **FINAL REPORT [**2131-11-17**]** URINE CULTURE (Final [**2131-11-17**]): NO GROWTH. [**2131-11-23**] PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 8 I MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S [**2131-11-26**] 1:54 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2131-11-27**]** C. difficile DNA amplification assay (Final [**2131-11-27**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Imaging: [**11-12**] R KNEE TISSUE PATH: Bone, right knee, right total knee replacement (A-B): Trabecular bone and overlying articular cartilage with degenerative changes. Dense fibroadipose tissue with focal chronic inflammation, fat necrosis, and dystrophic calcification. [**11-12**] R KNEE XR 1. Status post right knee total arthroplasty. Surgical hardware intact with no evidence for hardware failure. 2. Expected post-operative changes. [**11-13**] CXR Bilateral hazy opacifications likely represent a component of pulmonary edema. Heart size is unchanged since prior study. No large pleural effusion or pneumothorax. [**11-15**] ECHO The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Elevated LVEDP and mild pulmonary hypertension. [**11-15**] RENAL US No evidence for urinary obstruction. [**11-16**] CXR In comparison with study of [**11-13**], there is continued enlargement of the cardiac silhouette with pulmonary vascular congestion. In the appropriate clinical setting, supervening pneumonia would be difficult to exclude. [**11-17**] B/L LE Venous Extremely limited examination in the postoperative setting due to patient body habitus and discomfort. Diminished respiratory variation on the left greater than the right may be related to body habitus; however, upstream venous occlusion cannot be entirely excluded. [**11-19**] CXR As compared to the previous radiograph, the patient shows unchanged alignment of sternal wires. A right PICC line is in correct position. Moderate cardiomegaly with signs of mild-to-moderate pulmonary edema, but without evidence of pleural effusions or pneumonia. Mild tortuosity of the thoracic aorta. Venous mapping [**2131-11-23**]: FINDINGS: Some asymmetric decreased phasicity in the right subclavian vein is noted, which could imply some impaired flow centrally however this may simply be secondary to the right internal jugular large-caliber dialysis catheter currently in place. RIGHT SIDE: The right cephalic vein caliber ranges from 1.5 mm proximally to 0.8 mm distally. At the antecubital fossa, it is not well seen secondary to an intravenous catheter. The right basilic vein caliber ranges from 2.7 mm proximally to 1.9 mm distally. The right brachial artery appears duplicated. The smaller caliber vessel measures 1.9 mm and large caliber vessel measures 2.9 mm and has some calcification which appears mild. The right radial artery measures 1.1 mm in caliber and has mural calcification. LEFT SIDE: The left cephalic vein in the upper arm has a caliber ranging from 1.7 mm to 1.9 mm. In the antecubital fossa, it measures 2.8 mm. In the forearm, the caliber ranges from 1.5 mm proximally to 1.2 mm distally. The caliber of the left basilic vein ranges from 1.7 mm proximally to 1.5 mm distally. The left brachial artery appears duplicated with a smaller vessel measuring 2.5 mm in caliber and the larger vessel measuring 3.5 mm in caliber. The left radial artery measures 1.9 mm in caliber. No significant calcification of left-sided arteries. CONCLUSION: Bilateral vein mapping as above with patent cephalic and basilic veins as described. Asymmetric decreased phasicity in the right subclavian vein may in part relate to an indwelling right internal jugular vein large bore IV catheter. Right Tunneled line placement [**2131-11-27**]: CONCLUSION: Uncomplicated placement of a tunneled hemodialysis catheter, 23 cm tip-to-cuff, with tip in the right atrium. Brief Hospital Course: Brief Course: 69 yo F diastolic heart failure with pulmonary hypertension, CAD with CABG, morbid obesity, CKD, who was admitted for TKR, s/p TKR on [**2131-11-12**], transferred to the [**Year (4 digits) **] floor given [**Last Name (un) **] on CKD and volume overload, then transferred to [**Hospital Unit Name 153**] for altered mental status. She underwent dialysis and mental status improved and transferred to the floors. A tunneled line was placed and transplant surgery was consulted for possible AV graft after discharge. Pt was discharged to rehab. ACTIVE ISSUES: # Delirium: Likely multifactorial given recent surgery, hospitalization, pain medications, and possibly uremia. Pain medications were adjusted in respect to renal clearance and oversedation, and pt's somnolence improved. Per PCP, [**Name10 (NameIs) **] was having trouble with self-care at baseline and it is possible she has some baseline cognitive deficits. A UA on [**2131-11-23**] was concerning for a UTI and the patient was started on ceftriaxone. The urine culture grew pseudomonas aeruginos sensitive to cipro and pt was switched to complete 7 day course of cipro, last day on [**2131-12-2**]. On discharge, her MS was improved and she was oriented to person, place, month and year but had difficulties with the date, though she could recall the date as [**2131-11-30**] on the day of discharge. Pt also with anxiety and concern for mental status throughout course. Would suggest neurocognitive evaluation on discharge from rehabilitation. # Acute on chronic renal failure: Baseline Crt 2.5-2.9. Her Cr had been trending up since surgery. Obstructive etiologies ruled out with renal U/S. Nephrology was consulted, who felt that granular casts, hyaline casts, and tubular epithelial cells seen on sediment could be the result of fluctuating BPs or mild ATN. It is thought that perhaps the amount of fluid she received led to acute exacerbation of dCHF, leading to poor forward flow. She was initially started on IV lasix for diuresis per renal recs, and her Cr began to improve. On [**11-18**], the patient's UOP dropped despite furosemide gtt and 80 torsemide PO. This also proved refractory to another 80 torsemide and 25 chlorthalidone. A temporary dialysis catheter was placed on [**11-20**] and she was started on CVVH for volume overload. Patient was called out of the [**Hospital Unit Name 153**] and was started on hemodialysis. She was evaluated by renal transplant and the left arm was preserved. The patient was continued on HD and a tunneled HD line was placed on [**2131-11-27**] without complication. Transplant surgery recommended left AV graft. Her plavix was held on discharge in anticipation of surgery on Wednesday [**2131-12-5**]. She will continue on HD TuThSat. She was started on Sevalmer, iron with HD, and high-dose Vitamin D repletion. PPD placed in house was negative. # Acute on chronic diastolic CHF: Pt was grossly fluid overloaded in the [**Hospital Unit Name 153**]. Echo showed normal EF without wall motion abnormality. Previous chest imaging showed cardiomegaly. Likely a diastolic component of CHF. CXR was consistent with pulmonary vascular congestion as well and pt was initially hypoxic in the ICU. Pt was diuresed with IV lasix until HD was started. The patient underwent HD with good effect and improved respiratory status. She was placed on Metoprolol (held on HD days given low BP). Pt's weight on discharge was 119.2kg. # S/p right total knee replacement & persistent knee pain: Elective surgery on [**11-12**]. Patient continued to have significant pain despite pain medication. Patient received SQH TID for prophylaxis. Persistent knee pain was concerning for possible development of hematoma, hemorrhagic effusion (given also dropping Hct), or post-op infection (giving rising WBC). A repeat knee XRay revealed small suprapatellar effusion but no evidence of acute complication. Her pain was managed with tylenol TID and morphine prn. LENIs were performed to r/o DVT, which were inconclusive because they were limited by body habitus. Pain persisted during her hospital course. Her pain control improved with standing tylenol and low dose oxycodone prn. She will follow-up with orthopedics as an outpatient on [**2131-12-4**]. # Anemia, normocytic: Chronic in nature. Baseline Hct usually in the 28-30. Most likely has some degree of anemia from chronic kidney disease which is now worsened by acute on chronic KD and recent acute blood loss from TKR. Her Hct was monitored with a transfusion threshold of 21. Her stools (x3) were hemoccult negative. On [**11-20**], patient received 1u pRBC during CVVH. She was given an additional unit of blood on [**2131-11-23**]. She was started on iron with HD. # Coronary artery disease with CABG surgery in [**2129**] complicated by nonhealing sternal incision wound, MI in [**2128**] and [**2129**]. Pt had rise in troponin during ICU stay, most likely due to renal failure and decreased clearance. Plavix was held pre-IR guided tunneled line, and continued to hold on discharge in anticipation of AV graft procedure as discussed above. She was continued on metoprolol, rosuvastatin, and isosorbide. Her Plavix should be restarted after the AVG placed on [**2131-12-5**]. # Thrombocytopenia: Mild drop to 130s, low concern for HIT given not consistent with time course, and no evidence of thrombosis. 4T score calculated at 2. Her platelets remained stable and were 135 on discharge with no signs or symptoms of bleednig. # Hypertension: BP well-controlled in house. She had mild drop in BP with dialysis after UF. She also had brief period of hypertension [**2-22**] anxiety associated with procedure. Her BP on discharge was in systolic 120s. INACTIVE ISSUES: # CVA in [**2128**]. # Insulin-dependent diabetes: Difficult to dose insulin appropriately given flux in renal function and desire to avoid hypoglycemic episode in vasculopathic cardiac pt. ISS adjusted in house. # Hyperlipidemia: Continued on rosuvastatin. TRANSITIONAL ISSUES: # CODE: FULL # CONTACT: Name of health care proxy: [**Name (NI) 1670**] [**Known lastname **] Relationship: daugther Phone number: [**Telephone/Fax (1) 106689**] Cell phone: [**Telephone/Fax (1) 106688**] # Follow-up: - Orthopedics [**2131-12-4**] - PCP after discharge from rehab - Transplant surgery - planned AV graft placement on Weds [**2131-12-5**] # Medications: - Restart Plavix after AVG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol 100 mg PO DAILY 2. Amlodipine 5 mg PO DAILY hold for SBP < 110 3. Carvedilol 6.25 mg PO BID hold for SBP < 110 4. Clopidogrel 75 mg PO DAILY 5. Famotidine 20 mg PO Frequency is Unknown 6. Gabapentin 100 mg PO BID 7. HydrALAzine 50 mg PO BID hold for SBP < 110 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY Start: In am hold for SBP < 110 9. Lidocaine 5% Patch 1 PTCH TD DAILY Discharge Medications: 1. Allopurinol 100 mg PO EVERY OTHER DAY 2. Gabapentin 100 mg PO BID HOLD if sedated or confused 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY hold for SBP < 110 4. Lidocaine 5% Patch 1 PTCH TD DAILY 5. Acetaminophen 1000 mg PO Q6H 6. Rosuvastatin Calcium 10 mg PO DAILY 7. Heparin 5000 UNIT SC TID 8. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) Duration: 1 Months 9. sevelamer CARBONATE 1600 mg PO TID W/MEALS 10. OxycoDONE Liquid 2.5 mg PO Q6H:PRN pain 11. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR 12. Metoprolol Tartrate 12.5 mg PO BID HOLD for SBP<100, HR<60 13. Senna 2 TAB PO HS:PRN constipation 14. Docusate Sodium 100 mg PO BID 15. Glargine 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 16. Ciprofloxacin HCl 250 mg PO Q24H Duration: 2 Days to be completed on [**2131-12-2**] 17. Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: Primary: Total knee arthroplasty Acute on chronic renal failure Complicated cystitis Acute on chronic diastolic heart failure Secondary: Coronary artery disease Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during this admission. You were admitted for knee replacement which was done with the surgeons. The surgery went well, however, you weren't breathing well and required transfer to the intensive care unit. Your kidney function was worse and you were started on dialysis. You were intermittently confused but this improved with dialysis. The transplant surgeons saw you and recommend a graft in the future for continued dialysis. Please see the attached medication list. Followup Instructions: Please keep the following appointments: - TRANSPLANT surgery [**2131-12-5**]. The transplant surgery coordinator will call the rehabilitation center to give the time for transport. ***PLEASE ENSURE PT IS NPO FOR PROCEDURE ON [**2131-12-5**]. Department: ORTHOPEDICS When: TUESDAY [**2131-12-4**] at 2:40 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PA [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PODIATRY When: MONDAY [**2132-1-7**] at 2:15 PM With: [**Hospital 1947**] CLINIC (SB) [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2131-12-2**]

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Discharge summary

report

Admission Date: [**2197-1-19**] Discharge Date: [**2197-1-27**] Date of Birth: [**2170-7-26**] Sex: M Service: NICU/Neurology DIAGNOSIS: 1. Generalized tonic-clonic seizure 2. Small intracerebral hemorrhages on right frontotemporal and 3. Thalassemic trait 4. Aortic graft infection Procedures: 1. PICC line placement HISTORY OF PRESENT ILLNESS: Mr [**Known lastname 732**] is a 26 year old right-handed man who was recently hospitalized at [**Hospital6 256**] from [**Month (only) **] through [**Month (only) 1096**] for multiple injuries sustained after a motor vehicle accident. For the details please refer to previous discharge summary. In summary, on [**10-20**], the patient sustained an unrestrained 28 feet ejection. He sustained a severe head injury with a reported [**Location (un) 2611**] Coma Scale of 14 at the scene. The patient developed a retrograde amnesia of the events preeceding the accident of about one hour and post traumatic amnesia for about two months. He also developed traumatic aortic dissection, liver laceration, severe pulmonary contusion. He was intubated for two and a half months due to recurrent pneumonias. Other Injuries included bilateral orbital fractures, pelvic fracture, left radial fracture, pneumo and hemothorax. After a prolonged hospital stay, the patient underwent rehabilitation at [**Hospital 1319**] Hospital. On [**1-19**] while at [**Hospital **] Hospital, he had a generalized tonic-clonic seizure. At that time, it was decided to transfer him to [**Hospital1 18**] for further management. He had a second seizure en- route and a third in [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Room. In the [**Hospital1 18**] ER he was treated with a total of 8 mg of Ativan, 1 gm of Dilantin. His magnesioum level was 1.1 mg/dl. He was intubated in the Emergency Room and treated with 20 mg/kg/dose of Phenobarbital. His head CT was normal. A CSF sample obtained by lumbar puncture showed three white blood cells, 1500 red blood cells. A second tube was clear and colorless. Blood cultures from [**1-19**] showed coagulase negative Staphylococcus as well as coagulase negative Staphylococcus which was resistant to Cephalin. He was extubated on [**1-22**] and tranferred to the Neurology Service for further management. PAST MEDICAL HISTORY: None. MEDICATIONS ON TRANSFER TO FLOOR: 1. Vancomycin 1 gm q. 12 2. Labetalol 200 mg q. 8, hold for systolic blood pressure of less than 110 3. Dilantin 100/100/150 4. Lovenox 13 mg subcutaneously b.i.d. 5. Protonix 40 mg q. day 6. Clonidine patch 0.1 mg q.d. 7. Fentanyl patch 25 mcg q.d. 8. Tube feeds at 50 cc/hr ALLERGIES: Penicillin PHYSICAL EXAMINATION: Physical examination on admission on [**1-19**], general examination revealed temperature 101.2, his temperature reached maximum of 104.1. Blood pressure was 130/64, heart rate 131, respirations 18. The patient appeared agitated and restless, moving all extremities. Lungs with coarse breathsounds bilaterally. Cardiac examination was notable for regular rate and rhythm, tachycardiac to auscultation. Abdomen was soft, no tenderness to palpation. No cyanosis or edema of extremities. Neurological examination: On mental status examination the patient was drowsy, but arousable, moved eyes to name, grunting, could not tell the examiner where he was, his name or the date. He did not follow any commands. On cranial nerves examination, discs were normal, pupils were 8 mm and reactive. Extraocular movements intact. Visual fields were full grossly to threat. Face was symmetric with palatal elevation of tongue. Motor, moving all extremities, withdraws to pain times four. Motor examination persistent. Reflexes, reflexes were 2+ bilaterally at biceps, triceps and brachioradialis, patella, ankle and toes downgoing on both sides. LABORATORY DATA: Laboratory values showed an INR of 1.5, chest x-ray showed a questionable left lower lobe atelectasis or infiltrate. Computerized tomography scan did not show any obvious infarct or hemorrhage. HOSPITAL COURSE: The patient was initially managed in the Neurological Intensive Care Unit where he remained intubated until [**1-22**], the morning of which he was extubated as his condition improved and he was transferred to the floor for further management. 1. Generalized tonic clonic seizure assessment and management: -The patient was initially treated with 350 mg/die of Dilantin however, his PTN levels were repeatedly below the expected range. On [**1-25**], he had a PTN level of 4.9 ug/dl and therfore he received an additional 600 mg bolus. His daily Dilantin dose was also increased to 250 mg [**Hospital1 **]. Due to his history of liver damage, there was concern that the amount of free PTN would be higher as expected by the total serum PTN level. Therefore, a free PTN level was obtained and it is pending at the time of the present dictation. During the present hospital course the patient did not have any other seizures. A MRI scan showed very small hemorrhages in the right frontotemporal and left parietal lobes consistent with his history of head injury. 2. Aortic graft/repair -Because of the central lines infection with coagulase negative Staphylococcus and his initial fevers, the patient was started on Vancomycin and the Infectious Disease service was consulted. On [**1-24**], his Vancomycin peak was elevated. The dose of Vancomycin was then decreased from 1 gm q. 12 to 7 and 15 mg q. 12. He needs to complete a 10 day course of Vancomycin for prophylactic reasons until [**1-30**]. As per Infectious Disease recommendation, he needs to get three independent sets of blood cultures after he finishes his course of Vancomycin and will need close follow-ups because of the possibility of the aortic graft being infected is real and is of concern. The patient is to continue to meet a target systolic blood pressure of less than 150 systolic. He is to follow up with Dr. [**Last Name (STitle) **], from the cardiothoracic surgery service. He will also remain on sternal precautions of lifting no more than 5 pounds until [**2-21**]. 3. Infectious disease -As mentioned above, the patient will need to complete a course of Vancomycin 150 mg q. 12 until [**1-30**]. Until then, the dose of Vancomycin will be adjusted according to his blood levels. The patient did very well after extubation. On neurological examination, he was alert and appropriate. His motor exam showed Deltoids 4- on the left, 4 on the right; biceps 4 bilaterally; triceps 4 bilaterally; wrist extensors 4 bilaterally; finger extensors were 4 bilaterally; iliopsoas was 4+ bilaterally; hamstring 4 bilaterally; quadriceps 4 bilaterally; anterior tibialis was 3+ on left, none on the right; gastrocnemius was 4- on the left, none on the right; EM could not be elicited bilaterally. Laboratory data at time of dictation: His magnesium was 1.8. All of his blood cultures subsequent to the intial positive ones are pending at this time. His PT was 13.2, PTT was 39.0, INR was 1.2. Magnesium was 1.6. TIBC was 222. Reticulocyte count 0.2, haptoglobin 266, ferritin was pending, transferrin was 171, LDH was 201, total bilirubin 0.3, iron 49. Vancomycin peak was 57. Trough was still pending at time of dictation. Blood cultures were pending. The Hematology Team concluded that he may have a thalassemic trait that is clinically irrelevant at the present time. They do no reccomend further workup at the present time. He will continue on subcutaneous Heparin until he can ambulate on his own. DISCHARGE MEDICATIONS: 1. Vancomycin 750 mg q. 12, this may have to be adjusted depending on the peak and trough level after third dose tomorrow evening 2. Labetalol 200 mg q. 8, hold for systolic blood pressure less than 110 3. Dilantin 250 mg q. day, this may have to be adjusted after tomorrows value 4. Heparin subcutaneous 5000 units b.i.d. 5. Protonix 14 mg q. day 6. Clonidine 0.1 mg q. week, patch 7. Fentanyl 25 mcg q. 72 hours 8. Tube feed at 50 cc/hr goal 9. Captopril 12.5 mg t.i.d. prn to keep blood pressure less than 150 systolic FOLLOW UP: 1. The patient is to follow up with Dr. [**Last Name (STitle) **] in Cardiothoracic Surgery as mentioned above. 2. He is to be on strict blood pressure control regimen, or systolic less than 150 as mentioned above. 3. He should get three sets of independent blood draws after Vancomycin is stopped to make sure that he doesn't have any nidus infectious that could potentially seed aortic graft. 4. He is to continue receiving subcutaneous Heparin until he is fully ambulatory. 5. He is to follow up with his primary care provider as soon as he leaves the rehabilitation facility. 6. He is to arrange visit with a neurologist as needed. [**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**] Dictated By:[**Name8 (MD) 11440**] MEDQUIST36 D: [**2197-1-25**] 18:04 T: [**2197-1-25**] 18:12 JOB#: [**Job Number 35708**]

[ "996.62", "518.81", "038.11", "780.31" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.71", "96.04", "03.31", "96.6" ]

icd9pcs

[ [ [] ] ]

7627, 8159

4119, 7604

8170, 9049

2743, 4101

373, 2347

2370, 2720

58,643

109,931

43645

Discharge summary

report

Admission Date: [**2160-9-8**] Discharge Date: [**2160-9-20**] Service: CARDIOTHORACIC Allergies: Atenolol Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2160-9-16**] Coronary Artery Bypass graft x 3 (left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the first marginal branch and the terminal circumflex coronary artery) History of Present Illness: 87 yo male with a history of coronary artery disease status post multiple stents and endarterectomy more than 10 years ago at [**Hospital1 18**], Hypertension, dyslipidemia, prostate cancer treated with XRT, COPD/chronic bronchitis with bronchoreactive airway disease, chronic pain issues treated with steroids-seen by pain clinic presents to OSH with substernal chest pain and EKG changes. Cardiac cath performed shows significant critical multivessel coronary artery disease. Pt was transferred on Integrilin and Nitroglycerin drips to [**Hospital1 18**] for surgical revascularization with Dr.[**Last Name (STitle) **]. Past Medical History: Coronary Artery Disease status post multiple stents, Hypertension, Dyslipidemia, Prostate cancer treated with XRT, Chronic obstructive pulmonary disease/chronic bronchitis with bronchoreactive airway disease, Chronic pain issues chronic pain issues treated with steroids, Hematuria Social History: Lives with:wife Occupation:full time employee in motor coach industry with Celtics and [**Company **] Tobacco:distant HX of cigar use. Denies cigareete use ETOH:denies Family History: Noncontributory Physical Exam: Skin: Dry [] intact []: (L)thigh cellulitis/indurated/warm/erythemarous area HEENT: PERRLA [] EOMI [x] Neck: Supple [] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: Left: Carotid Bruit Right: Left: Pertinent Results: [**2160-9-9**] Carotid Ultrasound: Right ICA stenosis <40%. Left ICA stenosis <40%. [**2160-9-9**] PFT's: SPIROMETRY 2:21 PM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 2.71 3.95 69 2.93 74 +8 FEV1 1.53 2.39 64 1.68 70 +10 MMF 0.54 1.89 28 0.55 29 +2 FEV1/FVC 56 61 93 57 95 +2 DLCO 2:21 PM Actual Pred %Pred DSB 17.05 22.03 77 VA(sb) 4.65 6.78 69 HB 11.80 DSB(HB) 18.71 22.03 85 DL/VA 4.03 3.25 124 [**2160-9-15**] Echo: Prebypass: No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. There is mild regional left ventricular systolic dysfunction with LVEF of 45%. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). There is hypokinesia of the apex, apical and mid portions of the anterior wall and anterior septum. Right ventricular chamber size and free wall motion are normal. with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2160-9-15**] at 815am. Post bypass: Patient is a paced and receiving an infusion of phenylephrine and epinephrine. LV sytolic function is slightly improved. RV systolic function is unchanged. Mild mitral regurgitation persists. Aorta is intact post decannulation. [**2160-9-20**] 05:21AM BLOOD WBC-12.4* RBC-3.09* Hgb-9.3* Hct-27.9* MCV-90 MCH-30.0 MCHC-33.2 RDW-14.4 Plt Ct-418 [**2160-9-15**] 11:16AM BLOOD PT-13.1 PTT-36.1* INR(PT)-1.1 [**2160-9-20**] 05:21AM BLOOD Glucose-100 UreaN-22* Creat-1.1 Na-139 K-4.2 Cl-100 HCO3-29 AnGap-14 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 93843**] was transferred on Integrilin and Nitroglycerin drips to [**Hospital1 18**] for surgical revascularization. Her underwent appropriate surgical work-up which included carotid U/S, pulmonary function tests and echo. He was medically managed which included Nitroglycerin and Heparin gtt, along with antibiotics for cellulitis on left thigh. Surgery also was delayed for a work-up of GI bleed. On [**9-15**] he was cleared for surgery by GI and brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He was disoriented to place post-operatively, but his exam was non-focal. He also experienced paroxysmal atrial fibrillation which resolved. He was transferred to the floor to begin increasing his activity level. Beta blockade titrated and he was gently diuresed toward his preop weight. Chest tubes and pacing wires removed per protocol. He was cleared for discharge by Dr. [**Last Name (STitle) 914**] to rehab on post-operative day five. Medications on Admission: ASA 325mg qd, Simvistatin 80mg qd, Lopressor 12.5mg [**Hospital1 **], Cozaar 50mg qd, Allopurinol 100mg qd, Spiriva [**Hospital1 **], Vicodin 1mg [**Hospital1 **] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 8. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection [**Hospital1 **] (2 times a day) for 10 days. Disp:*400 mg* Refills:*0* 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. Disp:*qs * Refills:*0* 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. Disp:*40 Tablet(s)* Refills:*0* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 13. 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: Extended Care Facility: tba Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass graft x 3 PMH: status post multiple stents, Hypertension, Dyslipidemia, Prostate cancer treated with XRT, Chronic obstructive pulmonary disease/chronic bronchitis with bronchoreactive airway disease, Chronic pain issues chronic pain issues treated with steroids, hematuria,radiation colitis, GI bleed Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 1295**] in [**1-29**] weeks. Please follow-up with Dr. [**Last Name (STitle) 1270**] in 2 weeks. [**0-0-**] Scheduled appointments: Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2161-3-25**] 9:30 Completed by:[**2160-9-20**]

[ "E934.2", "414.01", "599.71", "272.4", "569.49", "410.91", "790.92", "682.6", "595.82", "V10.46", "427.31", "493.20", "578.1", "909.2", "402.90", "429.9", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "36.12", "45.24" ]

icd9pcs

[ [ [] ] ]

7473, 7503

4246, 5504

232, 450

7898, 7904

2207, 4223

8702, 9162

1608, 1625

5717, 7450

7524, 7877

5530, 5694

7928, 8679

1640, 2188

182, 194

478, 1102

1124, 1407

1423, 1592

24,955

154,989

1582

Discharge summary

report

Admission Date: [**2142-9-21**] Discharge Date: [**2142-10-8**] Date of Birth: [**2080-10-27**] Sex: M Service: SURGERY Allergies: Tetracycline / Percocet Attending:[**First Name3 (LF) 668**] Chief Complaint: anuric s/p cadaver renal transplant with elevated creatinine. Readmitted from rehab (Northeast in [**Location (un) 701**]. Major Surgical or Invasive Procedure: renal transplant biopsy [**2142-10-3**] cline placement History of Present Illness: 62 y.o. male s/p cadaver renal transplant [**2142-9-10**] with repair of left inguinal hernia after failed renal transplant in [**2135-7-21**] [**1-17**] DM/HTN. Recent renal transplant c/b delayed graft function and worsening of CHF. He was discharged to rehab with a foley in place for bladder retention. He was sent to rehab on flomax on [**9-18**]. The foley was to remain in place for 2 weeks. During his stay at rehab, the foley was removed. Creatinine increased to 7.5 with 2-3+ bilateral leg edema, low blood pressure and urine output was low. Patient had no specific complaints. Past Medical History: 1) Coronary artery disease, status post CABG in the year [**2136**], s/p multiple PCI's 2) End-stage renal disease secondary to polycystic kidney disease and is on hemodialysis. 3) Status post failed renal transplant. 4) GERD. 5) Peptic ulcer disease 6) Mitral regurgitation. 7) Diabetes mellitus type 2. 8) Hypertension. 9) Hyperlipidemia. 10) Peripheral vascular disease. 11) Gout. 12) Status post appendectomy. 13) Depression and anxiety. Social History: Lives at home with his wife and one of his children. Family History: Notable for CAD, diabetes mellitus, hypertension, and a sister with kidney disease. Physical Exam: 98.3-83-20, 86/68 O2 98% NAD, A&O MMM, Lungs: course breath sounds B. Tessio Left upper chest. Cor: II/VI sys murmur, Crackles 1/3 up bilat. ABD: staples in place on tx incision. Dry Ext: [**1-18**]+ edema Pertinent Results: [**2142-9-20**] 10:34PM URINE AMORPH-MOD [**2142-9-20**] 10:34PM URINE GRANULAR-[**5-25**]* [**2142-9-20**] 10:34PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2142-9-20**] 10:34PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2142-9-20**] 10:34PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016 [**2142-9-20**] 10:40PM PT-14.0* PTT-27.4 INR(PT)-1.3 [**2142-9-20**] 10:40PM PLT COUNT-238 [**2142-9-20**] 10:40PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ [**2142-9-20**] 10:40PM NEUTS-84.8* LYMPHS-9.1* MONOS-4.3 EOS-1.7 BASOS-0.1 [**2142-9-20**] 10:40PM WBC-7.4 RBC-3.23* HGB-10.3* HCT-30.2* MCV-94 MCH-31.9 MCHC-34.1 RDW-16.1* [**2142-9-20**] 10:40PM ALBUMIN-3.7 [**2142-9-20**] 10:40PM CK-MB-NotDone [**2142-9-20**] 10:40PM cTropnT-0.34* [**2142-9-20**] 10:40PM LIPASE-29 [**2142-9-20**] 10:40PM ALT(SGPT)-7 AST(SGOT)-14 LD(LDH)-216 CK(CPK)-48 ALK PHOS-83 TOT BILI-0.5 [**2142-9-20**] 10:40PM GLUCOSE-134* UREA N-80* CREAT-6.4*# SODIUM-133 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-20* ANION GAP-20 Brief Hospital Course: Admitted via ED where a foley was placed. A renal duplex u/s demonstrated the transplanted kidney in the left lower quadrant measuring 11.7 cm. There were no stones, masses, or hydronephrosis. Resistive indices ranged from 0.68-0.87. Normal venous flow was demonstrated. He was started on Levaquin for a urinalysis that revealed >50 wbc, and >rbc without bacteria. Creatinine was 6.4. Nephrology was consulted and followed the patient throughout this hospital course. A renal biopsy was deferred initally to allow for relief of bladder retention by replacement of foley and treatment of UTI. Lasix was started for fluid overload. Midodrine was also started in an attempt to increase his BP. BP ran low (80/50). Tamsulosin and lopressor were stopped. BP continued to be low. Midodrine was increased without improvement. The creatinine improved to 5.6 with the foley in place. Hct was 27.1. Epogen was started. Iron was 35, tibc 156, and ferritin 845. He was transused with a unit of PRBC. On HD 3, he started to complain of severe penile burning/pain and low back pain. A small amount of urine drained from his foley. Pyridium was started without improvement of penile pain. Lasix was given [**Hospital1 **]. A repeat u/a demonstrated wbc, 21-50* rbc [**11-4**]* bacteria FEW yeast NONE and epi 0-2. Urology was consulted. Paraphymosis (reddened)and edema was noted. DRE revealed exquisitely tender swollen gland. Prostatis was suspected. Recommendations included continuation of Levaquin for 2 weeks. Morphine was administered with decreased pain. Triple antibiotic at the meatus and elevation were recommended as well as hemodialysis to decrease swelling. Dialysis was deferred. Impaired arterial flow to the renal transplant [**1-17**] low bp was felt to compound the delayed graft function. Cardiology was consulted assist in management of CHF and low BP. A TTE demonstrated an EF of 40-45%. The left atrium was moderately dilated. There was moderate symmetric left ventricular hypertrophy. The left ventricular cavity size was normal. Overall left ventricular systolic function [**Last Name (un) **] mildly depressed. Inferior akinesis was present. The aortic valve leaflets were moderately thickened. The mitral valve leaflets were moderately thickened. Severe (4+) mitral regurgitation was seen. Moderate [2+] tricuspid regurgitation was seen. There was moderate pulmonary artery systolic hypertension. Compared with the findings of the prior study of [**2142-9-11**], there had been no significant change. Cardiology recommended stopping the midodrine and digoxin, resuming low dose lopressor po and lasix IV 80mg tid. At this point, given his severe penile pain, volume overload and hypotension, he was transferred to the SICU for intubation for respiratory distress, management of hypotension and pain control. IV Dobutamine, levaophed and pitressin were initiated to keep sbp >100. CVVHD was done. PRBC were transfused for hct of 27. Urine output improved to 1.5 liters per day. Pitressin, levophed and dobutamine were weaned. He was extubated and transfered back to the medical surgical unit. Lopressor 12.5mg [**Hospital1 **] was started to lower heart rate to allow for increased filling time to improve cardiac output. BPs averaged 80s/49-119/68 with a heart rate in 80-90s. Lasix was started with small response. The creatinine remained in the range of 2.7-2.9. Urine output averaged 600cc/day. Due to some GI complaints and elevated creatinine, cellcept was decreased. Rapamune was started in an attempt to wean off prograf which can be nephrotoxic. This plan was reversed when a renal transplant biopsy on [**10-3**] revealed rejection demonstrated by endotheleitis. Three solumedrol pulses of 500mg qd x3 days were given with a decrease in creatinine to 2.6. Rapamune was stopped and prograf was uptitrated given the diagnosis of rejection. Target prograf levels are [**9-26**]. Cellcept should continue at 1gram [**Hospital1 **]. Cardiology was reconsulted. Low dose nesereitide was recommended. On [**10-4**], asymetrical swelling in RUE was noted. An u/s revealed a thrombus in the right subclavian extending to the axillary vein. He was started on IV heparin and coumadin. Heparin was stopped on [**10-8**] when the INR increased to 3.5 on coumadin 5mg qd. Coumadin will be held [**10-8**] and resumed at 2.5mg on [**2142-10-9**]. Left subclavian line was removed prior to discharge. A Tessio catheter was left in place for future lab drawing and possible hemodialysis if graft failure. Physical therapy followed and recommended rehab for deconditioning, impaired balance, decreased ADL independence and decreased strength. Nutrition was consulted for poor po intake. Boost supplements were started. [**Last Name (un) **] followed and adjusted his glargine and humalog. Hyperglycemia improved off solumedrol pulse doses. Given prolonged bedrest and decreased mobility he developed decubitus. A wound care nurse consult was obtained with the following recommendations. Stage 1 sacral decubitus required duoderm gel followed by Allevyn changed every 3 days. His right heel developed a large blister requiring daily dsd and multipodis boots in addition to a 1st step mattress. The right inner tibial area developed a stage 2 ulcer treated with daily saline cleansing, followed by aquacel then dsd. He will be discharged to [**Hospital1 **] for PT, medication, wound care and fluid/electrolyte monitoring and coumadin management. PT/INR should be done daily until INR is at goal (2-2.5). Transplant labs should be drawn every Monday and Thursday for cbc, chem 7, calcium, phosphorus, ast, tbili, albumin, urinalysis and trough prograf level. Results should be fax's to [**Hospital1 18**] Transplant office [**Telephone/Fax (1) 697**]. Foley catheter should remain in for a total of 2 weeks given bladder retention/BPH issues. Follow is scheduled in the Transplant office as an outpatient to determine when to remove foley. weight 71 kg Labs upon discharge were as follows: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2142-10-8**] 06:15AM 4.8 3.71* 11.5* 35.8* 97 31.0 32.1 15.8* 273 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2142-10-8**] 06:15AM 273 [**2142-10-8**] 06:15AM 22.1* 80.9* 3.5 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2142-10-8**] 06:15AM 156* 45* 2.6* 138 4.61 103 232 17 SLIGHTLY HENOLYZED 1 HEMOLYSIS FALSELY ELEVATES K 2 NOTE UPDATED REFERENCE RANGE AS OF [**2142-6-15**] CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2142-10-8**] 06:15AM 3.5 7.7* 2.7 1.4* SLIGHTLY HENOLYZED TOXICOLOGY, SERUM AND OTHER DRUGS FK506 [**2142-10-8**] 06:15AM PND Medications on Admission: Bactrim ss qd, valcyte 450mg qod, protonix 40qd, colace 100bid, tylenol 650mg prn, benadryl prn, nystatin 5ml qid, heparin 5000 units [**Hospital1 **] sc, digoxin 0.125mg q mon/wed/fri, glargine 6 units qd, insulin sliding scale prn qid, dulcolax 5mg-10mg prn qd, ambien 5mg qhs prn, metoprolol 12.5mg [**Hospital1 **] , calcium carbonate 500mg tid, protonix 40mg [**Hospital1 **], prograf 4mg [**Hospital1 **], plavix 75mg qd, asa 325mg qd, levofloxacin 250mg qod, cellcept 500mg [**Hospital1 **] Discharge Medications: . 24. Outpatient Lab Work Labs [**10-9**] for PT/INR qd for INR goal of [**1-17**].5. Labs every Monday & Thursday for cbc, chem 7, calcium, phosphorus, ast, t.bili, albumin, PT/INR, urinalysis and trough prograf level. Fax results to [**Hospital1 18**] Transplant office [**Telephone/Fax (1) 697**] 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD (). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 6. Mycophenolate Mofetil 500 mg Tablet Sig: One (2) Tablet PO BID (2 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Topical Q6H (every 6 hours) as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) Injection QMOWEFR (Monday -Wednesday-Friday). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold if sbp <100 or if hr <60. 14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: monitor plain tylenol usage. Not to exceed 4 grams of tylenol in a day. 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 16. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 17. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 18. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 19. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 20. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for nausea. 21. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 22. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day: Insulin SC Fixed Dose Orders Breakfast Glargine 12 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 2 Units 2 Units 0 Units 141-160 mg/dL 3 Units 3 Units 3 Units 0 Units 161-180 mg/dL 4 Units 4 Units 4 Units 2 Units 181-200 mg/dL 5 Units 5 Units 5 Units 2 Units 201-220 mg/dL 6 Units 6 Units 6 Units 2 Units 221-240 mg/dL 7 Units 7 Units 7 Units 3 Units 241-260 mg/dL 8 Units 8 Units 8 Units 4 Units 261-280 mg/dL 9 Units 9 Units 9 Units 5 Units 281-300 mg/dL 10 Units 10 Units 10 Units 6 Units 301-320 mg/dL 11 Units 11 Units 11 Units 7 Units 321-340 mg/dL 12 Units 12 Units 12 Units 8 Units 341-360 mg/dL 13 Units 13 Units 13 Units 9 Units 361-380 mg/dL 14 Units 14 Units 14 Units 10 Units 381-400 mg/dL 15 Units 15 Units 15 Units 11 Units Ordered by [**Last Name (LF) 9203**],[**Name8 (MD) 9204**], MD Beeper#: [**Numeric Identifier 9205**] on [**10-6**] @ 1009 Acknowledged by RN on [**10-6**] @ 1040 by EGAL,[**Name8 (MD) 9206**], RN Processed by pharmacy on [**10-6**] @ 1010 by [**Last Name (LF) 9207**],[**First Name3 (LF) 2801**] Order #:[**Telephone/Fax (2) 9208**] . 23. Outpatient Lab Work Labs [**10-9**] for PT/INR then every Monday & Thursday for cbc, chem 7, calcium, phosphorus, ast, t.bili, albumin, PT/INR, urinalysis and trough prograf level. Fax results to [**Hospital1 18**] Transplant office [**Telephone/Fax (1) 697**] 24. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: start [**10-9**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: acute rejection s/p cadaver renal transplant [**2142-9-11**] exacerbation of CHF CAD s/p CABG Mitral regurgitation h/o gout depression R subclavian thrombus extending to R axillary vein sacral/R heel/R tibial pressure ulcer Urinary retention prostatitis depression BPH Discharge Condition: stable Discharge Instructions: call if fevers, chill, nausea, vomiting, inability to take medication, increased shortness of breath, decreased urine output, 3 lbs weight gain in a day, increased leg edema, or any bleeding/excessive bruising. Labs Tuesday [**10-9**] then every MOnday & Thursday for cbc, chem 7, calcium, phosphorus, ast, t.bili, albumin,PT/INR and trough prograf level. Fax results to [**Hospital1 18**] as soon as available [**Telephone/Fax (1) 697**]. No heavy lifting Followup Instructions: Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-10-9**] 1:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-10-15**] 9:20 Provider: [**Name10 (NameIs) 454**],ELEVEN DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2142-10-15**] 11:00 Completed by:[**2142-10-8**]

[ "707.03", "578.0", "250.40", "601.9", "403.91", "518.82", "443.9", "276.2", "V45.82", "600.01", "458.9", "285.9", "997.5", "276.8", "530.81", "788.20", "412", "276.1", "753.12", "428.0", "428.30", "584.5", "424.0", "996.81", "V45.81", "585.6", "707.07", "599.0", "311", "274.9", "E878.0", "414.00", "707.06", "453.8", "428.20" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.04", "89.64", "38.93", "96.04", "57.94", "39.95", "55.23" ]

icd9pcs

[ [ [] ] ]

14738, 14810

3109, 9839

406, 464

15123, 15132

1961, 3086

15638, 16067

1634, 1719

10387, 14715

14831, 15102

9865, 10364

15156, 15615

1734, 1942

244, 368

492, 1081

1103, 1547

1563, 1618

13,542

115,692

42661

Discharge summary

report

Admission Date: [**2106-2-24**] Discharge Date: [**2106-3-12**] Service: MEDICINE Allergies: Penicillins / Quinine / Sulfonamides Attending:[**First Name3 (LF) 317**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right hip replacement [**2106-2-24**] intubation hemodialysis cardiac catheterization History of Present Illness: The patient is an 84 year-old female with a history of CHF (EF 20-25% in [**11-28**]), CAD (s/p CABG '[**81**]( SVG->LAD) with multiple stents most recent NSTEMI in [**11-28**]), HOCM and severe MR who was originally admitted to the orthopedic service on [**2106-2-24**] for removal of a sliding screw and plate, removal of the femoral head and neck and reconstructive bipolar hemiarthroplasty on [**2106-2-24**]. In short, the patient had bilateral hip fractures in [**2103**] and is s/p repair complicated by CHF exacerbation. She has since had persistent right hip pain, and was walker- dependent. The patient received 2900 cc IVF intraoperatively and lost 750 cc of blood and was transfused 1 unit PRBC. She received 2 mg morphine x 5 in PACU for hip pain. She developed an episode of shortness of breath in the PACU where her O2 saturation dropped to 80% and was placed on 3 liters of O2, then saturating 97%. Her CXR showed no evidence of CHF or infiltrate. Hours later, her systolic blood pressure dropped to 75/40 and she was started on neosynephrine which was subsequently switched to levophed. The patient then received one 250 cc bolus of NS and then another 250 cc 1/2 NS with an increase in her SBP to 90s-100. She was given another bolus of 250 cc NS and her SBP was stable at 101 on levophed which was subsequently weaned off. Her hypotension as felt to be secondary to dehydration given her volume loss. She lost an additional 350 cc blood in her hemovac. She was transferred to the CCU from the PACU for further care. In the CCU, the pt. was observed overnight and her cardiac enzymes were cycled. On transfer, the patient offered no complaints. She is concerned over her low blood pressure. She also complained of residual "numbness" over her right hip. She denied fever, chills, cough, N/V/D, chest pain, shortness of breath. She r/o for MI. 24 hrs later she was transfered to MICU for hypotension on the medical floor. During transfer she had a respiratory arrest requiring intubation. She suffered a inferiolateral NSTEMI and underwent cath [**2-27**] with LCX taxus stent to LCX instent restenosis. She was re-admitted to the CCU post cath. The EKG showed LBBB. The echocardiogram showed new akinesis of in the posterolateral wall. Past Medical History: 1. CAD - s/p CABG '[**81**], multiple stents total of 9 (SVG-LAD [**10/2096**], [**Doctor First Name 10788**] [**8-/2099**], [**2105-9-18**] 2 stents, [**11-28**] 1 stent) 2. HOCM 3. CRF (creatinine 3.0) s/p fistula placement rt. arm 4. HTN 5. CHF/ischemic cardiomyopathy - EF 20-25% in [**11-28**] 6. HTN 7. Gout 8. LLL lung resection for carcinoid 9. s/p cholecystectomy [**10**]. s/p abdominal hysterectomy 11. s/p rt ant tib surgery [**12**]. rt. hip fracture [**10-28**], now with artificial hip and reconstruction as discussed in HPI Social History: Pt is a nonsmoker, does not use alcohol, is retired and lives with her husband. Family History: Remarkable for an extensive history of CAD. Physical Exam: Vitals: T: 98.3F P: 80 R: 18 BP: 120/48 SaO2: 99% on 2L via NC General: Awake, alert, NAD. HEENT: NC/AT, [**Month/Year (2) 2994**], EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP, NC in place Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, III/VI blowing HSM at mitral area radiating to apex Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Dressing in place over R hip, hemovac in place draining serosanguinous fluid Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout with exception of RLE which was not tested [**1-27**] to recent surgery. Pt noted to be somewhat tremulous. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and ankle jerks bilaterally with exception of RLE which was not tested. Plantar response was flexor bilaterally. Pertinent Results: Labs on admission: [**2106-2-24**] 05:45PM BLOOD WBC-13.4*# RBC-4.37 Hgb-13.1 Hct-40.1 MCV-92 MCH-30.0 MCHC-32.7 RDW-15.7* Plt Ct-177 [**2106-2-24**] 05:45PM BLOOD Neuts-82.6* Lymphs-13.0* Monos-4.0 Eos-0.2 Baso-0.2 [**2106-2-24**] 05:45PM BLOOD Glucose-118* UreaN-36* Creat-4.4* Na-139 K-4.9 Cl-104 HCO3-23 AnGap-17 [**2106-2-24**] 05:45PM BLOOD Calcium-9.7 Phos-5.4* Mg-1.5* [**2106-2-24**] 05:45PM BLOOD CK(CPK)-356* [**2106-2-24**] 05:45PM BLOOD CK-MB-6 cTropnT-0.2* [**2106-2-24**] 11:54PM BLOOD CK(CPK)-393* [**2106-2-24**] 11:54PM BLOOD CK-MB-5 cTropnT-0.25* Labs on transfer: [**2106-2-25**] 12:15PM BLOOD Glucose-97 UreaN-45* Creat-5.7*# Na-136 K-5.2* Cl-102 HCO3-24 AnGap-15 [**2106-2-25**] 12:15PM BLOOD ALT-70* AST-147* AlkPhos-165* TotBili-0.8 [**2106-2-25**] 12:15PM BLOOD Albumin-3.1* Calcium-9.4 Phos-6.3* Mg-1.4* EKG: NSR at 84bpm, LBBB (old) PA and lateral radiographs of the chest. The previously identified congestive heart failure has been slightly improving. This continued mild congestive heart failure with cardiomegaly and bilateral pleural effusions. There is continued bibasilar patchy atelectasis. Echo: Left Ventricle - Ejection Fraction: 20% to 25% (nl >=55%) Conclusions: 1. The left atrium is moderately dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed with EF 20-25%. Resting regional wall motion abnormalities include mid and apical septal, anterior, lateral and inferolateral akinesis. The remaining left ventricular segments are hypokinetic. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally mildly thickened with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. 6.There is no pericardial effusion. 7. The aorta was not well seen. Compared to the previous study of [**2105-9-30**], the mid and basal portion of the inferolateral wall which had been previously normal is now akinetic in the mid portion and hypokinetic at the base. Cardiac catheterization results: 1. Selective coronary angiography revealed a right dominant system and two vessel CAD. The LMCA was diffusely diseased without flow limiting stenoses. The LAD was proximally occluded and filled retrogradely via the SVG-LAD. The LCX was proximally diffusely diseased. There was a 90% stenosis just proximally to the recent stent as well as a 60% in-stent stenosis. The RCA was diffusely diseased without flow limiting stenoses angiographically. 2. Selective vein graft angiography showed a patent SCG-LAD with a 30% in-stent stenosis. 3. Limited resting hemodynamics showed a normal cardiac output and index (CO 4.3 l/min, CI 3.1 l/min/m2) obtained on Dopamine. 4. Successful PTCA and stenting of the LCX with a 3.0 x 28 mm Taxus DES. Final angiography revealed no residual stenosis, no apparent dissection, and normal flow (see PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. LCX in-stent restenosis treated with placement of a drug-eluting stent. Brief Hospital Course: The patient is an 84 year old female with an extensive cardiac history who developed hypotension post-operatively (S/P right hip hemiarthroplasty) likely related to a combination of hypovolemia and sedation with narcotic analgesics. Ms. [**Known lastname 23**] was hypotensive, requiring pressor support and this was initially thought to be secondary to blood loss vs. peri-op sedation. The increased troponin was likely demand related. Her cardiac markers were cycled and her BB and ACEI were held. Her cultures were negative, suggesting that her hypotension was not secondary to sepsis. Her markers increased and EKG was consistent with NSTEMI so she was taken to the catheterization lab, where she was restented. For her CAD, Ms. [**Known lastname 23**] was continued on [**Known lastname **], aspirin, and Lipitor. Her beta-blocker and ACE I were initially held but restarted once she stabilized. Ms. [**Known lastname 23**] did develop evidence of pulmonary edema, and her TTE revealed a grossly reduced EF of 20%. Of note, she had an akinetic ventricle and so she was started on both digoxin and warfarin. These levels were in the therapeutic range at discharge. Ms. [**Known lastname 23**] has chronic renal insufficiency on hemodialysis. The renal team followed her and determined that her sevelamer should be discontinued as her phosphate was low enough. Her creatinine stablized around 4.4. Her dry weight appears to be 52 kilograms. Ms. [**Known lastname 23**] developed an ulcer on her coccyx that was likely secondary to prolonged bed rest during intubation and poor nutrition. She was followed by the skin care team and started on nepro supplements in addition to vitamin C and zinc. The ulcer improved as soon as she mobilized. The patient was s/p right hip hemiarthroplasty. The Ortho service intially followed her and once she stabilized, she worked with the physical therapy to improve her mobilization. Her staples were removed the day prior to discharge. During her course, Ms. [**Known lastname 23**] was given empiric broad spectrum antibiotics for fevers while she was intubated. Cultures were negative. She eventually developed c.diff colitis and was started on flagyl. Her diarrhea resolved prior to discharge. On the day of discharge, the patient was transfused one unit of PRBC for a Hct of 28 (her baseline is 30) and she received dialysis shortly thereafter to remove excess fluid. Medications on Admission: 1. Aspirin 325 mg PO DAILY 2. Clopidogrel Bisulfate 75 mg PO DAILY 3. Atorvastatin Calcium 40 mg PO DAILY 4. Pantoprazole Sodium 40 mg PO Q24H 5. Sevelamer HCl 1600 mg TID 6. Gabapentin 100 mg PO HS 7. Metoprolol Tartrate 12.5mg po bid 8. Digoxin 125 mcg Tablet 0.5 Tablet PO DAILY 9. Lisinopril 2.5 mg Tablet PO DAILY 10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Witch [**Female First Name (un) **]-Glycerin (Hamamel) Pads, Medicated Sig: One (1) Pads, Medicated Topical QD PRN (). 14. Starch 51 % Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] PRN (). 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 16. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 18. Warfarin Sodium 1 mg Tablet Sig: 0.5 Tablet PO QOD (). 19. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 20. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO Q3 DAYS (). 21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 36730**] [**Hospital 4094**] Hospital - [**Hospital1 **] Discharge Diagnosis: Non ST segment MI Clostridium difficile colitis CAD s/p CABG in [**2081**] and in [**2095**], 98, 99, [**2104**] PTCA stents respiratory arrest, requiring intubation HOCM hypertension CHF hyperparathryroidism Gout ischemic cardiomyopathy Chronic renal insufficiency Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 Call your doctor for increased chest pain, leg swelling, shortness of breath, dizziness, nausea or vomitting. You will continue hemodialysis 3 days per week. Followup Instructions: Please call Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C [**Telephone/Fax (1) 44354**] for an appointment in the next 2 weeks.

[ "785.50", "584.9", "458.29", "263.9", "410.71", "276.5", "V45.82", "733.82", "412", "V45.81", "274.9", "252.00", "424.0", "799.1", "707.03", "996.72", "403.91", "428.0", "285.1", "425.1", "008.45" ]

icd9cm

[ [ [] ] ]

[ "36.07", "96.04", "96.07", "88.56", "78.65", "81.52", "99.04", "38.93", "96.72", "89.64", "37.22", "36.01", "39.95" ]

icd9pcs

[ [ [] ] ]

12818, 12913

8041, 10462

255, 343

13223, 13229

4767, 4772

13560, 13701

3323, 3368

10880, 12795

12934, 13202

10488, 10857

7903, 8018

13253, 13537

4237, 4748

3383, 4140

204, 217

371, 2635

4787, 7886

4155, 4220

2657, 3210

3226, 3307

711

168,530

44890

Discharge summary

report

Admission Date: [**2184-10-16**] Discharge Date: [**2184-11-5**] Service: MEDICINE Allergies: Bactrim / Remeron Attending:[**First Name3 (LF) 330**] Chief Complaint: dyspnea, tachypnea Major Surgical or Invasive Procedure: PEG placement History of Present Illness: Mr. [**Known lastname 11455**] is an 84 y/o man with PMH notable for CAD s/p MI ([**2174**]), type 2 DM, hypertension, PVD, and chronic atrial fibrillation on [**Year (4 digits) **] who presents to the ED from [**Hospital 100**] Rehab after being discharged from [**Hospital1 18**] less than 24hr prior to representation. On [**10-3**] he was admitted with hypotension (BP80s/50s) attributed to a combination of dehydration, urosepsis, and partial SBO. He was initially treated broadly with vancomycin and zosyn. This was tapered to Bactrim to which he developed a drug rash and was finally changed to Cipro for UTI (to be completed on [**10-18**]). In terms of his SBO, he was seen by surgery who recommended medical treatment with NGT and NPO as diet. His bowel was decompressed and he began to have BMs prior to d/c. Stool was positive for C. diff and he was sent home on flagyl to be continued until after completion of other antibiotics. He presents today with a chief complaint of worsening dyspnea. At rehab he was noted to have increased WOB, RR 22-24 with O2 sat 70%. He was initially taken to OSH where he reportedly complained of chest pain and shortness of breath. He was given Lasix 10mg PO. He was then transferred to [**Hospital1 18**] for further care. En route was hypoxic to 74% on RA to 80s on NRB. EMS gave 40mg IV lasix and SL NTG. After nitro BP dropped to 80s systolic. At [**Hospital1 18**] ED, VS were T100, HR 99, BP 80/49, R31, O2sat 95% NRB. BP improved to 92/57, HR 99. He was started on CPAP and given Levofloxacin/Flagyl for possible UTI/PNA. He was also given an aspirin. Past Medical History: Peripheral arterial disease s/p right SFA to AT bypass in [**5-8**] Prior NSTEMI in setting of rapid afib (admission [**5-8**]) Chronic atrial fibrillation on [**Month/Year (2) **] DM2 Hypercholesterolemia Hypothyroidism Post-polio weakness/contractures Social History: Prior to hospitalization in [**Month (only) 547**], patient was living at home with wife. [**Name (NI) **] recently at [**Hospital 100**] Rehab. Prior smoker. Drinks 1 glass wine/nightly prior to recent hospitalization and rehab stay. Has two sons. Previously worked at Dept. of Public Health. Family History: Non-contributory Physical Exam: T:95.3 BP: 135/73 HR: 98/[**Hospital **] RR: 23/[**Hospital **] O2 100% on NRB Gen: Elderly male in NAD. Using accessory muscles. HEENT: No conjunctival pallor. PERRL. EOMI. Tongue dry. NECK: Supple, JVD 10 cm. No thyromegaly or palpable lymphadenopathy. CV: irregularly irregular with nl S1, S2. No m/r/g. LUNGS: Rales bilaterally, R>>L. ABD: Slightly distended, nontender to palpation. EXT: 2+ edema in b/l LE as well as UE. DP pulses 2+ bilaterally. Bandage covering R great toe. SKIN: erythematous rash over LLE NEURO: A&Ox3. CN 2-12 grossly intact. Gait not assessed. Pertinent Results: Labs: [**2184-10-15**] 05:55AM BLOOD WBC-12.2* RBC-3.52* Hgb-10.6* Hct-30.8* MCV-87 MCH-30.2 MCHC-34.5 RDW-16.4* Plt Ct-356 [**2184-10-16**] 02:45PM BLOOD Neuts-89* Bands-2 Lymphs-5* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2184-10-15**] 05:55AM BLOOD PT-25.1* PTT-35.2* INR(PT)-2.5* [**2184-10-15**] 05:55AM BLOOD Plt Ct-356 [**2184-10-15**] 05:55AM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-134 K-4.1 Cl-104 HCO3-22 AnGap-12 [**2184-10-16**] 06:04AM BLOOD CK(CPK)-70 [**2184-10-25**] 02:54AM BLOOD Lipase-19 [**2184-10-16**] 06:04AM BLOOD CK-MB-NotDone proBNP-5528* [**2184-10-15**] 05:55AM BLOOD Albumin-2.3* Calcium-7.6* Phos-3.3 Mg-1.8 [**2184-10-18**] 04:41AM BLOOD calTIBC-134* VitB12-1077* Folate-11.9 Ferritn-370 TRF-103* [**2184-10-19**] 02:15PM BLOOD Type-ART Temp-37.0 FiO2-95 O2 Flow-15 pO2-113* pCO2-34* pH-7.58* calTCO2-33* Base XS-10 AADO2-556 REQ O2-89 Intubat-NOT INTUBA [**2184-10-16**] 06:12AM BLOOD Lactate-2.1* [**2184-10-25**] 08:46PM BLOOD O2 Sat-89 [**2184-10-20**] 04:18PM BLOOD freeCa-1.11* [**2184-10-16**] Sputum Cx - MRSA [**2184-10-28**] Blood Cx - Coag negative staph [**2184-10-28**] Blood Cx - Coag negative staph Brief Hospital Course: Mr. [**Known lastname 11455**] is an 84 y/o man with history of CAD s/p MI, HTN, hypercholesterolemia and recent admission for UTI, hypotension, partial SBO admitted with shortness of breath likely due to pulmonary edema +/- pneumonia in setting of IVF overload. Course complicated by difficulty weaning oxygen. CT chest showed collapsed L lobe with large bilateral effusions. # Hypoxemia/Respiratory distress: Likely due to pulmonary edema +/- pneumonia (possibly aspiration) in the setting of neuromuscular weakness from multiple recent hospitalizations, nutritional deficiency, and post-polio. Last echocardiogram done in [**5-/2184**] with normal EF 60%, no evidence of diastolic dysfunction, repeat done on [**10-18**] showed new moderate pulmonary hypertension and [**2-3**]+TR, otherwise unchanged. Negative 6-7L since admission. CT chest showed large regions of atelectasis within the lower lobes [**3-5**] mucus within the segmental and subsegmental airways and bilateral pleural effusions. Patient underwent IR guided thoracentesis on [**10-24**], removal of 2L. He was electively intubated on [**10-25**] for PEG procedure and bronchoscopy was done with copious removal of mucus. He was extubated the following day and was maintained on intermittent CPAP. He completed a 10 day course of IV vnacomycin for MRSA PNA. Hypoxia initially improved although patient had recurrent mucus plugging and frequent desaturations during his ICU course secondary to LLL collapse. Eventually, when his BP tolerated, he was diuresed successfully with IV lasix drip. One day prior to discharge, patient was transitioned from lasix drip to IV lasix boluses of 40mg IV lasix [**Hospital1 **] with goal of 500cc-1L negative daily. He was followed daily with [**Hospital1 **] electrolytes in the setting of aggressive diuresis. Upon discharge, patient's respiratory status improved significantly and was requiring between 2-4L oxygen by nasal canula. # Cardiac: The patient has a h/o NSTEMI attributed to AF with RVR. He was maintained on aspirin. His [**Hospital1 **] was held given his acute illness and the planned PEG placement on [**2184-10-25**]. He was started on a heparin drip for anticoagulation but was eventually stopped because of bloody secretions, a 7 point hematocrit drop, and guiac positive stools. Regarding future anticoagulation, patient should have a repeat colonoscopy as an outpatient and readdress anticoagulation as an outpatient. Given his guiac positive stools and discussion with PCP, [**Name10 (NameIs) **] was discontinued. Regarding his heart rate control, he was maintained on metoprolol when his BP tolerated. For much of his ICU course this was held but was restarted as his BP tolerated. He was restarted on metoprolol 12.5mg PO bid several days prior to discharge. This may be titrated up as his blood pressure tolerates. # Anemia: Over the course of his admission, pt's hematocrit slowly trended downward to a nadir of 21.4. He was transfused one unit of pRBCs with a 1 point increase in his hematocrit. Patient is recommended to have a repeat colonoscopy as an outpatient. He should have CBC's checked every other day for the next week and transfused for hct <24. If transfusion needed, it should be given with a dose of IV lasix. # C. diff: Loose stool on admission. Presented with elevated WBC count to 25, now down to 13. Had been treated for C. diff last admission, positive on culture from [**10-7**]. C. diff negative x2. No diarrhea currently. The patient was continued on PO vancomycin (concern for resistant C. diff), PO flagyl. The plan was for both PO flagyl and PO vanco to be continued 1 week after other antibiotics are stopped. C diff toxin B was positive and patient was recommended to continue PO vancomycin and flagyl through [**2184-11-18**], 2 weeks after completing his antibiotic course. He was also started on cholestyramine for symptom relief. # UTI: Positive UA on admission. History of UTI sensitive to Cipro. It was felt that hypotension last admission was related to urosepsis. He initially completed a course of levofloxacin. Subsequently, a UA was again positive on [**2184-10-28**] and the patient was started on a 7 day course of ceftriaxone. Cultures were negative. # DM: BG have been well controlled. He was maintained on an insulin sliding scale. # Hypothyroidism - The patient was continued on synthroid. Medications on Admission: Levothyroxine 25mcg tablet daily Metoprolol tartrate 25mg tablet [**Hospital1 **] Clopidigrel 37.5mg daily Lisinopril 20mg daily Flagyl 500mg TID Zolpidem 5mg hs RISS Protonix 40mg [**Hospital1 **] Tylenol PRN Ciprofloxacin 250mg q12H (for 3 days) Warfarin 1mg daily Simvastatin 5mg qMWF Lactobacillus 2 capsules PO TID x 7 days Discharge Medications: 1. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 2. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Simvastatin 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO QMWF (). 4. Clopidogrel 75 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 5. Levothyroxine 25 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 7. Lidocaine HCl 2 % Solution [**Hospital1 **]: One (1) ML Mucous membrane TID (3 times a day) as needed. 8. Zinc Oxide-Cod Liver Oil 40 % Ointment [**Hospital1 **]: One (1) Appl Topical PRN (as needed). 9. Sucralfate 1 g Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day) as needed. 11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed. 13. Cholestyramine-Sucrose 4 g Packet [**Hospital1 **]: One (1) Packet PO BID (2 times a day). 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 15. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day) for 13 days: last day should be [**2184-11-18**]. 16. Vancomycin 250 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO q6H () for 13 days: last day should be [**2184-11-18**]. 17. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2 times a day). 18. Furosemide 10 mg/mL Solution [**Month/Day/Year **]: One (1) Injection [**Hospital1 **] (2 times a day). 19. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: 1-20 units Injection ASDIR (AS DIRECTED): please follow provided insulin sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Pulmonary Edema 2. Pneumonia 3. Atrial Fibrillation 4. Clostridium Difficile 5. Type 2 Diabetes Mellitus SECONDARY DIAGNOSES: 1. Peripheral arterial disease s/p right SFA to AT bypass in [**5-8**] 2. Prior NSTEMI in setting of rapid afib (admission [**5-8**]) 3. Chronic atrial fibrillation on [**Month/Year (2) **] 4. DM2 5. Hypercholesterolemia 6. Hypothyroidism 7. Post-polio weakness/contractures Discharge Condition: Stable - Patient is tolerating Discharge Instructions: While you were in the hospital, you were diagnosed with significant shortness of breath and respiratory distress. This was thought most likely secondary to fluid in your lungs, pneumonia, and significant neuromuscular weakness. We treated your pneumonia with antibiotics, we removed significant amounts of fluid from your lungs with lasix, and we tried to improve your strength with physical therapy and nutrition. Upon leaving the hospital, you were requiring just 2-4 liters of oxygen by nasal canula alone. When you leave the hospital, it will be very important for you to continue your water medications to remove more fluid from your lungs. It will also be important for you to participate in physical therapy and rehabilitation to improve your strength. If you have persistent or worsening shortness of breath, please seek medical attention. Followup Instructions: Please follow-up with your appointments with the [**Month/Year (2) 1106**] lab on [**2184-12-28**] 2:30 and your [**Date Range 1106**] surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2184-12-28**] 3:15. If you need to cancel or reschedule, please call Dr.[**Name (NI) 1720**] office at [**Telephone/Fax (1) 1237**]. When you go to rehab, you will still require diuresis to remove fluid from your lungs. You are currently on 40mg IV lasix [**Hospital1 **]. Please continue this regimen for at least 2-3 days upon rehab with daily electrolytes. After this, you may re-assess your fluid status to decide about a further regimen. Please also follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] upon your discharge from rehab. His phone number is [**Telephone/Fax (1) 3603**].

[ "263.9", "440.20", "V09.0", "244.9", "428.0", "584.9", "008.45", "599.0", "250.00", "428.33", "272.0", "999.31", "276.0", "482.41", "427.31", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.05", "96.71", "38.93", "43.11", "96.6", "34.91" ]

icd9pcs

[ [ [] ] ]

11104, 11170

4304, 8712

244, 259

11638, 11671

3128, 4281

12568, 13473

2501, 2519

9092, 11081

11191, 11191

8738, 9069

11695, 12545

2534, 3109

11340, 11617

186, 206

287, 1895

11210, 11319

1917, 2173

2189, 2485

4,987

177,411

9793

Discharge summary

report

Admission Date: [**2165-4-29**] Discharge Date: [**2165-5-14**] Date of Birth: [**2117-4-3**] Sex: M Service: PRESENT ILLNESS: Upper GI bleeding. HISTORY OF PRESENT ILLNESS: This is the first admission to [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Known firstname **] [**Known lastname 32978**] who is a 48-year-old male, who works as an interior design contractor, who has a past medical history significant for AIDS. The patient states that he was feeling well and was in his usual state of health until 3 weeks prior to admission when he developed what he thought was the flu which was manifested by chills, myalgias, and night sweats. During this time the patient denied nausea, vomiting, or abdominal pain but did note a decreased appetite. The patient took occasional ibuprofen for relief and noted improvement in his symptoms until 2 days prior to admission when he began to notice bright red blood per rectum. The patient states he first noticed normal stool streaked with blood early in the morning on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**]. Over the course of the day the patient noted increasingly bloodier bowel movements approximately every 2 hours that eventually developed into bright red blood per rectum. On the following day the patient noted continued blood per rectum. In addition, the patient noted increased shortness of breath and dyspnea with walking across the room which prompted the patient to call 911, and he was brought to the [**Hospital1 346**] for evaluation and treatment of his bleeding. PAST MEDICAL HISTORY: The patient has a past medical history significant for AIDS with a recent CD4 count of 53 and a viral load of 84,000; anal condyloma; hypothyroidism; depression; and chronic back pain. The patient notes a hospitalization in [**2159**] for anemia, during which time an upper endoscopy demonstrated 2 bleeding esophageal ulcers and a gastric mass with an indeterminate biopsy that was presumed to Kaposi sarcoma. PAST SURGICAL HISTORY: The patient's past surgical history is significant only for fulguration of anal condyloma. MEDICATIONS AT HOME: Medications include Dapsone, Kaletra, Videx, Viread, Diflucan, Synthroid, AndroGel, and Wellbutrin. Of note, the patient has been poorly compliant with his antiretroviral regimen secondary to his recent illness. SOCIAL HISTORY: Social history includes a 18-pack-year history of smoking; 9 years x 2 packs per day. The patient states that he quit smoking 7 weeks ago. He also states that he engages in social drinking on the weekends, though he admits to a remote history of alcohol dependency. The patient states that he is a homosexual but denies recent anal intercourse. FAMILY HISTORY: Insignificant for bleeding disorders, GI cancers, or vascular malformations. PHYSICAL EXAMINATION: On initial examination his temperature was 103.2, with a pulse of 130, the blood pressure was 114/60, a respiratory rate of 16, oxygen saturation of 97% on 2 liters. His mucous membranes were dry. Cardiovascular exam revealed tachycardia with a normal S1 and S2 without murmurs. Mild crackles were noted on auscultation of the lungs at the left base without dullness to percussion and normal tactile fremitus. LABORATORY DATA: His initial laboratory studies showed a white blood cell count of 9.1, a hematocrit of 25.3, and a platelet count of 182. Coag's were a PT of 13.1, a PTT of 23.5, INR of 1.1. Electrolytes showed a sodium of 155, potassium of 3.4, chloride of 103, bicarbonate of 22, BUN and creatinine were 26/1.0. BRIEF HOSPITAL COURSE: A nasogastric tube was placed, and lavage revealed only bilious return without evidence of occult blood. A chest x-ray on admission showed left lower lobe pneumonia. A CT scan was obtained but showed no pathology. The patient was admitted to the internal medicine service and transfused 2 units of packed red blood cells. On hospital day 1, the patient was transfused a total of 4 units of blood. His hematocrit's remained between 18 and 25. A bleeding scan on hospital day 2 showed bleeding in the left upper quadrant, and a flexible sigmoidoscopy showed blood clots without any source of bleeding. An EGD showed a fibrous bridge which was noted at 35 mm from the incisors, indicative of an esophageal ulcer now healed. A small punctate erosion in the stomach body was cauterized, and erythema was noted in the stomach body/antrum and patchy areas of the fundus consistent with gastritis. However, these findings did not account for the patient's large gastrointestinal bleed. The patient was kept on supportive therapy by the medical service during this time. Angiography showed no extravasation of contrast, and as such a source was not found. On hospital day 3 the patient's hematocrit dipped to 16.3, and the patient was transfused with an additional 6 units of packed red blood cells. The patient underwent a push endoscopy which showed erosion in the stomach body, blood in the 4th part of the duodenum and jejunum, and angioectasia's in the 4th part of the duodenum. These were treated with thermal therapy. An angiography on hospital day 3 showed active extravasation involving the proximal jejunum and just beyond the ligament of Treitz, and the patient continued to bleed. He continued to have melanotic stools on the following - hospital day 4 - and required several units of blood products, bringing the total of 21 units of packed red blood cells on hospital day 4. On hospital day 4 the patient was seen by the surgical service, and at the time the decision was made to take the patient to surgery for definitive surgical treatment of his upper GI bleeding. The patient underwent an exploratory laparotomy and excision of the proximal jejunum as well as retroperitoneal exploration. Please see the operative note for details of this procedure. The patient tolerated the procedure well and was transferred to the floor in stable condition. The postoperative course was remarkable only for a prolonged postoperative ileus and postoperative oliguria. It was noted that after surgery the patient remained massively edematous and required continuous fluid boluses to maintain urine output. This continued up until postoperative day 6, when the patient required transfer to the intensive care unit for intense monitoring. A central venous line was placed, and the central venous pressure was monitored during this time. The patient remained in the ICU only for a brief amount of time, during which his hematocrit's were noted to be stable and his urine output continued to improve as he began to diurese third-space fluid that he accumulated after receiving many units of blood products preoperatively and crystalloid solution intraoperatively and postoperatively. The patient was able to pass flatus after some time postoperatively, and he diet was advanced as tolerated. The patient's central line was removed as was his Foley catheter and was noted to be stable and able to ambulate well. His antiretroviral regimen was restarted prior to his discharge. DISCHARGE DISPOSITION: The patient was discharged home on postoperative day 12. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: The patient was discharged on his preadmission regimen of antiretroviral therapy as well as prophylaxis therapy. DISCHARGE INSTRUCTIONS: Specific instructions to follow up with Dr. [**Last Name (STitle) **] in 2 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**] Dictated By:[**Doctor Last Name 32979**] MEDQUIST36 D: [**2165-8-6**] 13:59:17 T: [**2165-8-6**] 14:57:13 Job#: [**Job Number 32980**]

[ "V10.89", "276.2", "311", "584.5", "285.1", "276.5", "042", "244.9", "486", "999.2", "537.83", "532.40", "789.5", "451.84" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.15", "45.24", "96.07", "88.47", "44.43", "45.62", "45.11", "44.44", "45.23", "38.93" ]

icd9pcs

[ [ [] ] ]

7101, 7159

3608, 7077

2755, 2833

7220, 7334

7359, 7704

2162, 2375

2048, 2140

2856, 3584

197, 1589

1612, 2024

2392, 2738

7184, 7193

10,241

193,822

2646

Discharge summary

report

Admission Date: [**2153-10-24**] Discharge Date: [**2153-11-2**] Date of Birth: [**2081-10-28**] Sex: M Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: This is a 72 year-old gentleman with a history of a large anterior wall myocardial infarction in [**2146-6-25**] who has been experiencing shortness of breath and substernal chest tightness over the last month. An echocardiogram performed on [**9-27**] revealed an ejection fraction of 20 to 25% with severe hypokinesis of the anterolateral walls, trace aortic regurgitation and 1+ mitral regurgitation. The patient was referred for cardiac catheterization on [**10-18**], which showed an ejection fraction of 35%, a 30% left main osteal lesion, 90% mid vessel left anterior descending coronary artery lesion involving a large diagonal, a 60% osteal circumflex lesion and a 50% osteal right coronary artery lesion. The patient was referred to Dr. [**Last Name (STitle) 70**] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Status post myocardial infarction [**2146**] with a history of a stent to left anterior descending coronary artery. 3. History of atrial fibrillation on Coumadin. 4. Status post left hip replacement in [**2152**]. 5. Status post back surgery in [**2140**]. 6. Status post bilateral cataract surgery in [**2153**]. SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **] has a ten pack year smoking history, but he quit twenty years ago and has one to two alcoholic drinks per week. ALLERGIES: Penicillin, which causes anaphylaxis and Procainamide, which causes fevers and shakes. PREOPERATIVE MEDICATIONS: 1. Amiodarone 200 mg po q day. 2. Vasotec 15 mg po b.i.d. 3. Lipitor 20 mg po q day. 4. Lasix 20 mg po q.o.d. 5. Aspirin 81 mg po q day. 6. Multivitamin q day. 7. Coumadin 5 mg po q day and 7.5 mg po q Friday. 8. Eye drops b.i.d. 9. Omega 3 fish oil q day. 10. Q-10 enzymes q day. 11. Vitamin E. 12. Chondroitin and Glucosamine q day. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**10-24**] for a coronary artery bypass graft times two off pump with Dr. [**Last Name (STitle) 70**]. The patient had left internal mammary coronary artery to left anterior descending coronary artery, and saphenous vein graft to D1. The patient was transferred to the Intensive Care Unit in stable condition. Please see operative note for further details. The patient was extubated from mechanical ventilation on the evening of postoperative day zero. The patient required neo-synephrine and fusion into postoperative day number one to maintain blood pressure. The patient had excellent hemodynamic parameters with cardiac index greater then 3. The patient's pulmonary artery catheter was removed on postoperative day number one. The neo-synephrine was weaned to off. On postoperative day number two the patient went into atrial fibrillation with variable ventricular response. The patient was bolused and restarted on Amiodarone. The Electrophisiology Service was consulted. The patient was preoperatively recommended to have an ICD implanted due to his low ejection fraction. The patient was started on heparin for anticoagulation for his atrial fibrillation and had been started on Plavix per the off pump coronary artery bypass graft protocol. On postoperative day number three the patient experienced some mild confusion and was given some low dose Haldol, subsequently confusion resolved. Postoperative day three the patient was ambulating with physical therapy and had an episode of orthostasis. His Lasix was discontinued at this time as the patient was below his preoperative weight. The patient was transferred from the Intensive Care Unit to the regular floor on postoperative day number five. The patient was beginning to ambulate with physical therapy. On the evening of postoperative day number five the patient converted from atrial fibrillation to sinus rhythm. On postoperative day number six the patient was taken to the Electrophisiology Laboratory for implantation of his AICD. He tolerated this procedure well and was transferred back to the floor in stable condition. Chest x-ray the following day showed no effusion and no pneumothorax. Testing of the device the following day showed that it was functioning adequately. On postoperative day number seven after the patient had been on bed rest for 24 hours for his implantation of his AICD the patient attempted ambulation with physical therapy. At that time the patient was noted to be significantly orthostatic and was not able to ambulate. No intervention was taken, however, when the patient stood up a few hours later he was not orthostatic. On postoperative day number eight the patient was able to ambulate with physical therapy at about 200 feet without problems. On postoperative day number nine the patient was able to complete a level five with physical therapy, which is walking 500 feet and climbing one flight of stairs without any difficulty without requiring oxygen and while remaining hemodynamically stable. The patient's INR on Coumadin had risen to 1.5. It was decided that the patient could be cleared for discharge to home with Lovenox therapy until his INR became therapeutic. CONDITION ON DISCHARGE: Temperature max 98.6. Pulse 80. A paced, blood pressure 102/60. Respiratory rate 16. Room air oxygen saturation 96%. Significant laboratory data, hematocrit 25, potassium 4.7, BUN 20, creatinine 1.3. Neurological the patient is awake, alert and oriented times three, very anxious to go home. Heart regular rate and rhythm without murmur or rub. Breath sounds are equal bilaterally with rhonchi at the bases, which clear with deep inspiration. Abdomen has hypoactive bowel sounds, soft, nontender, nondistended. The patient is tolerating a regular diet and having normal bowel movements. Extremities are warm and well perfuse without edema. Sternal incision Steri-Strips are intact. No erythema. No drainage. Sternum is stable. The left pacer pocket has slight swelling, which is of no clinical significance. There is no ecchymosis and the incision is dry and intact without any erythema. The left leg vein harvest site the calf has a small hematoma, which is mildly tender to palpation. There is no erythema and there is no drainage. DISCHARGE MEDICATIONS: 1. Lopresor 50 mg po b.i.d. 2. Colace 100 mg po b.i.d. 3. Enteric coated aspirin 325 mg po q day. 4. Percocet 5/325 one to two tablets po q 4 to 6 hours prn. 5. Plavix 75 mg po q day times three months. 6. Prednisolone acetate 1% eye drops one drop each eye b.i.d. 7. Protonix 40 mg po q day. 8. Amiodarone 400 mg po q day times two weeks and then 200 mg po q day. 9. Lovenox 60 mg syringes, 60 mg subcutaneously b.i.d. until INR is greater then 2. 10. Lipitor 20 mg po q day. 11. Coumadin 5 mg po q day on [**10-14**] and [**11-4**]. The patient should contact Dr.[**Name2 (NI) 13265**] office for INR on [**11-5**] and further Coumadin dosing. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post off pump coronary artery bypass graft times two. 3. Postoperative atrial fibrillation. 4. Status post AICD insertion. DISCHARGE CONDITION: The patient is discharged to home in stable condition. The patient is to have an INR drawn by the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 766**] [**11-5**]. The results should be called to Dr.[**Name (NI) 13265**] office at [**Telephone/Fax (1) 13266**] and the patient should contact Dr.[**Name (NI) 13265**] office for results and further Coumadin dosing. Coumadin should be titrated for an INR of 2 to 2.0. The patient is to follow up with Dr. [**Last Name (STitle) **] in two to three weeks. The patient has an appointment with the Device Clinic for check of his AICD on [**11-9**] at 11:00 a.m. in the [**Hospital Ward Name 23**] Center Cardiac Services Department. The patient should follow up with Dr. [**Last Name (STitle) **] in one to two weeks in the office. The patient should see Dr. [**Last Name (STitle) 70**] in five to six weeks in the office. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2153-11-2**] 12:47 T: [**2153-11-2**] 13:19 JOB#: [**Job Number 13267**]

[ "272.0", "V45.82", "293.9", "412", "427.31", "414.01", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "36.15", "37.94", "36.11", "37.26" ]

icd9pcs

[ [ [] ] ]

7269, 8468

7081, 7247

6401, 7060

2047, 5300

1681, 2029

179, 995

1017, 1366

1383, 1655

5325, 6378

22,917

113,215

2967

Discharge summary

report

Admission Date: [**2140-4-5**] Discharge Date: [**2140-4-8**] Service: [**Last Name (un) 7081**] HISTORY OF PRESENT ILLNESS: Briefly, this is an 82 year old nonsmoker, active female who had undergone a right upper lobe resection for T1 N0 adenocarcinoma in [**2139-12-20**], who presented with right upper lobe mass found on routine computerized tomography scan for follow up. It was discussed with Dr. [**Last Name (STitle) 175**] and his plan was to do a resection at this time. PAST MEDICAL HISTORY: Past medical history is significant for high cholesterol, osteoarthritis, and thrombocytosis. She is status post appendectomy. MEDICATIONS ON ADMISSION: Avapro, Lipitor, Hydrochlorothiazide, Vioxx, Nexium, Os Cal, aspirin, multivitamins, _______ eyedrops and Hydroxyurea. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is a nondrinker, nonsmoker. FAMILY HISTORY: Significant for lung cancer in her brother, pancreatic cancer in another brother, colon cancer in a sister. PHYSICAL EXAMINATION: Physical examination shows her afebrile with stable vital signs. Her lungs were clear. Heart was regular. Abdomen was soft, nontender, nondistended. Bowel sounds were present. Extremities were warm and well perfused. LABORATORY DATA: Laboratory studies were all within normal limits. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2140-4-5**], for a video-assisted thoracoscopic wedge resection of the right upper lobe mass, please see the operative report for further details. The patient was transferred to the floor postoperatively. She had an epidural for pain. Her chest tubes were put in in the Operating Room and these were kept to suction. The patient continued to do well postoperatively. On postoperative day #1, it was noted that her sodium had dropped from a normal preoperative level in [**Month (only) 404**], to 123. Therefore, she was followed for serial sodiums to monitor for changes. Her sodium dropped to as low as 117. At this point in time, she had mental status changes and it is decided the patient would be transferred to the Intensive Care Unit. She was started on a 3 percent sodium chloride drip for slow correction of her sodium. She slowly improved from this and her sodium improved. By postoperative day #2, the sodium had climbed up to 123. Renal was consulted for evaluation for syndrome of inappropriate antidiuretic hormone. They felt that the management was correct and when her sodium was corrected up to a level of mid 20s that she could be started on a fluid restriction and salt tablets. Her sodium slowly corrected over the next couple of days and she was put on fluid restriction as well as a high sodium diet. Her sodium was followed closely and on the day of discharge it had climbed back up to 127. It was felt that this drop in sodium was linked either to the long surgery itself or to the possibility of the mass causing trouble and it was also felt that this could be treated with sodium tablets and fluid restriction. Physical therapy was consulted for evaluation of her ambulation and her strength and it is found that she was doing quite well and could be discharged home when medically stable. She did well over the next couple of days and her chest tubes were removed. On postoperative day #3, she was doing well, tolerating a regular diet and her sodium returned to a level of 127 prior to discharge. Therefore it was decided that the patient could be discharged home. The patient was discharged home in stable condition. She was instructed to follow up with her primary care physician for [**Name Initial (PRE) **] recheck of her sodium as well as follow up with Dr. [**Last Name (STitle) 175**] in two to three weeks for evaluation of her wounds. She was discharged on all of her home medications as well as ________for pain, Colace, stool softener and sodium chloride tablets, 2 gm p.o. t.i.d. The patient is discharged in stable condition. DISCHARGE DIAGNOSIS: 1. Right upper lobe mass, status post video-assisted thoracoscopic wedge resection of the right upper lobe. 2. Severe acute hyponatremia, status post correction with 3 percent normal saline drip as well as sodium chloride tablet. 3. Right upper lobe adenocarcinoma, status post right upper lobe wedge resection. 4. High cholesterol. 5. Osteoarthritis. 6. Thrombocytosis. 7. Status post appendectomy. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 7082**] Dictated By:[**Doctor Last Name 11225**] MEDQUIST36 D: [**2140-4-8**] 19:21:26 T: [**2140-4-8**] 21:12:38 Job#: [**Job Number 14202**]

[ "197.0", "289.9", "276.1", "162.3", "272.0" ]

icd9cm

[ [ [] ] ]

[ "40.11", "89.61", "38.93", "33.28", "34.22" ]

icd9pcs

[ [ [] ] ]

900, 1009

4004, 4418

674, 833

1341, 3983

1032, 1323

138, 496

519, 647

850, 883

4443, 4710

29,815

177,575

8345

Discharge summary

report

Admission Date: [**2128-6-11**] Discharge Date: [**2128-6-17**] Date of Birth: [**2057-2-24**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Fall from roof Major Surgical or Invasive Procedure: 1. Irrigation and debridement of open tibia fracture with an inclusive of level of bone. 2. Open reduction and fixation right tibia proximal fracture with 55 mm locking plate. 3. Open reduction internal fixation of left distal radius fracture with locking plate. 4. Closed treatment of radius fracture without manipulation. 5. Inferior vena cava filter placement History of Present Illness: 71 year old man who fell 25 feet off a roof. Was brought to [**Hospital1 18**] from the scene of the accident. Says he was cleaning out gutters and the ladder fell out from under him. No loss of consciousness. Past Medical History: PMHx: Multiple admissions for falls from roofs, severe kyphoscoliosis Surgical History: Fixation left pelvic fracture [**2119**], bilateral sinus, right nasal/ethmoid fractures [**2125**] Social History: Worked as a construction worker. Married. Family History: Non-contributory Physical Exam: Afebrile, HR 90, BP 99/50, RR 12, O2 sat 100% via 2L NC Gen: Awake, alert, oriented, recalls accident CV: RRR No M/R/G Resp: Clear to ausculation bilaterally Abd: Soft/NT/ND HEENT: Obvious left facial trauma Ext: Deformity of left wrist, left leg Pertinent Results: [**2128-6-11**] 09:56AM PT-12.7 PTT-24.8 INR(PT)-1.1 [**2128-6-11**] 09:56AM PLT COUNT-250 [**2128-6-11**] 09:56AM WBC-11.5* RBC-4.20* HGB-13.3* HCT-38.0* MCV-91 MCH-31.8 MCHC-35.1* RDW-13.7 [**2128-6-11**] 09:56AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2128-6-11**] 10:05AM GLUCOSE-121* LACTATE-2.8* NA+-141 K+-4.1 CL--104 TCO2-22 [**2128-6-11**] 11:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2128-6-11**] 11:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2128-6-11**] 05:47PM WBC-13.1* RBC-2.99*# HGB-9.6*# HCT-27.6*# MCV-92 MCH-32.2* MCHC-34.8 RDW-13.3 [**2128-6-11**] 05:47PM CALCIUM-7.7* PHOSPHATE-4.1 MAGNESIUM-1.5* [**2128-6-11**] 05:47PM GLUCOSE-160* UREA N-16 CREAT-0.8 SODIUM-139 POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11 [**2128-6-11**] 06:31PM TYPE-ART TEMP-35.9 RATES-[**10-19**] TIDAL VOL-600 O2-50 PO2-217* PCO2-44 PH-7.34* TOTAL CO2-25 BASE XS--2 INTUBATED-INTUBATED VENT-IMV EKG [**6-11**]: Sinus rhythm CT Head [**6-11**]: IMPRESSION: 1. No acute intracranial hemorrhage. 2. Extensive fractures of the right facial bones with evidence of old injury s/p hardware fixation. Please refer to dedicated facial bone CT for furtherdetail. CT C-spine [**6-11**]: IMPRESSION: 1. Exaggerated cervical lordosis with levoscoliosis. No fracture or malalignment. 2. Extensive fractures involving the right maxilla with premaxillary hematoma. Please refer to dedicated CT of the facial bones for further detail. 3. Cervical spine degenerative changes with multilevel neural foraminal stenosis. CT Torso [**6-11**]: IMPRESSION: 1. No acute sequelae of trauma in the chest, abdomen, or pelvis. 2. Bilateral renal hypodensities, likely cysts. 3. Right lower lobe nodular opacity, stable from [**2119**], likely rounded atelectasis. 4. Chronic right rib cage deformity, right scapular deformity, left acetabular hardware with advanced arthritis at the left hip joint. No evidence of acute fractures. 5. Moderate sized hiatal hernia is present. CT Facial Bones [**6-11**]: IMPRESSION: 1. Acute fractures involving the right maxilla as described with extensive premaxillary soft tissue swelling. 2. Acute fracture through the medial and lateral right orbital wall with extraconal hematoma along the medial orbit and blood noted within the ethmoid air cells. 3. Right nasal bone fracture. Possible fracture of the nasal septum. 4. Possible right zygomatic arch fracture. 5. Chronic injury to the frontal bone with hardware in place. 6. Fractured upper incisor. Periapical lucency along the right canine tooth - correlate clinically. Left leg xrays [**6-11**]: 1. Markedly comminuted fracture of the left tibial plateau with associated lipohemarthrosis. CT is recommended to further evaluate prior to surgical repair. 2. Post-surgical changes at the left acetabulum with advanced degenerative disease at the left hip joint. Right wrist XR [**6-11**]: IMPRESSION: 1. Right distal radius intraarticular and impacted acute fracture. 2. Acute fracture of the right third metacarpal shaft. 3. Limited views of the left wrist with acute fracture (probably intra- articular) of the left distal radius. 4. Possible foreign bodies in the soft tissues of the mid forearm. CT left lower extremity [**6-11**]: IMPRESSION: 1. Markedly comminuted, depressed, intra-articular fracture of the tibial plateau, with separation of the articular fragments from the proximal tibia, consistent with a Schatzker type VI fracture. 2. Displacement of intercondylar eminence fragment with possible associated ACL injury. 3. Comminuted fracture of fibular head and neck, and associated injury to the "posterolateral corner" structures should be considered. 4. Rotated, displaced fracture fragment, in close proximity to the popliteal artery. Although fat plane exists, possible injury to the popliteal artery should be entertained. Right upper extermity [**6-11**]: IMPRESSION: 1. Right distal radius intraarticular and impacted acute fracture. 2. Acute fracture of the right third metacarpal shaft. 3. Limited views of the left wrist with acute fracture (probably intra- articular) of the left distal radius. 4. Possible foreign bodies in the soft tissues of the mid forearm. Chest XR [**6-13**]: Cardiomegaly, CHF, probable small bilateral effusions and underlying collapse and/or consolidation. Brief Hospital Course: Traumatic fall: Pt brought to ED after 25 foot fall from roof without loss of consciousness. Primary and secondary surveys were performed and multiple x-rays and CT scans were performed to determine extent of injuries. Trauma surgery, plastic surgery, orthopedic surgery, and ophthalmology evaluated the patient. Injuries were identified: non-operative distal right radius fracture, operative left distal radius fracture, left tibial fracture, left facial bone fractures. Ophthalmology evaluated the patient because of his periorbital facial trauma and determined that his vision was within normal limits and that no further evaluation or intervention was required from them. Plastic surgery evaluated the patient and felt that there was no functional need to operate on his facial fractures, but that comesis would be improved through surgery. He decided not to pursue plastic surgery for his facial bone fractures, so plastic surgery signed off. Orthopedic surgery evaluated him and took him to the OR on [**6-12**] with the following preoperative diagnoses: 1. Open left proximal shaft tibia fracture. 2. Left distal radius multi-part fracture. 3. Right distal radius fracture. They performed the following procedures: 1. Irrigation and debridement of open tibia fracture with an inclusive of level of bone. 2. Open reduction and fixation right tibia proximal fracture with 55 mm locking plate. 3. Open reduction internal fixation of left distal radius fracture with locking plate. 4. Closed treatment of radius fracture without manipulation. Post-operatively, the patient was tranferred to the [**Month/Year (2) 13042**] while still intubated. He had been a difficult intubation and there was some concern that if reintubation was required, it would be challenging. After several hours of good urine output and stable vitals in the [**Last Name (LF) 13042**], [**First Name3 (LF) **] attempt at extubation was made. Pt quickly became agitated and tachypneic so the decision was made to keep him sedated and intubated. He was admitted to the trauma ICU for further treatment. In the TSICU, hematocrits were checked and had fallen significantly from pre-operative levels, so 2 units PRBCs were transfused and additional fluid resuscitation was provided. Subsequent hematocrits were stable. On [**6-13**], patient was successfully extubated and continued to be observed. On [**6-14**], he was tranferred to the floor. He received an IVC filter from interventional radiology in an effort to prevent pulmonary embolisms. His diet was slowly advanced to soft regular, his foley catheter was replaced with a condom catheter because of his severely limited bilateral upper extremity mobility. He was given a bowel regiment and had a bowel movement. His IV fluids were discontinued when he was taking good PO. Pain was controlled on oral medications. He received physical and occupational therapy evaluation and treatment. He was deemed ready for discharge to a rehabilitation facility on [**6-17**]. Medications on Admission: None 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 BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Traumatic fall from ladders with multiple face fractures, open left tibial fracture, left radius fracture Discharge Condition: Stable, meets discharge criteria to rehab facility, eating soft diet, voiding via condom catheter, pain well controlled on oral medications. Discharge Instructions: Take your medications as prescribed. You will be discharged to a recharge facility where physical and occupational therapists will continue to work with you to improve your strength and mobility. Return to the Emergency Department or see your own doctor right away if any problems develop, including the following: * Swelling, pain or redness getting worse. * Fingers or toes become pale (whiter) or become dark or blue. * Numbness, tingling or coldness of your fingers or toes. * Loss of movement. * Rubbing sensation, burning or soreness of your skin, especially under a cast. * Chest pain, shortness of breath or trouble breathing. * Fever or shaking chills. * Headache, confusion or any change in alertness. * Anything else that worries you. The Emergency Department is open 24 hours a day for any problems. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 22750**] to schedule an appointment. Follow up with the orthopedic trauma clinic in 1 week to have your staples removed. Call ([**Telephone/Fax (1) 2007**] to schedule an appointment. Follow up with your Follow up with the plastic surgery clinic if you decide you want to pursue reconstructive surgery for your facial bone fractures, call Dr.[**Name (NI) 29526**] office at ([**Telephone/Fax (1) 29527**] to schedule an appointment.

[ "823.30", "802.0", "V15.88", "E849.3", "873.63", "815.03", "372.72", "E891.8", "737.10", "553.3", "802.8", "780.6", "285.9", "813.42", "801.01", "802.4" ]

icd9cm

[ [ [] ] ]

[ "79.36", "79.02", "38.7", "96.71", "79.66", "79.32", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9453, 9519

6013, 9031

329, 710

9669, 9812

1535, 5990

10722, 11242

1235, 1253

9086, 9430

9540, 9648

9057, 9063

9836, 10699

1268, 1516

275, 291

738, 949

971, 1160

1176, 1219

54,489

153,459

30568

Discharge summary

report

Admission Date: [**2183-12-16**] Discharge Date: [**2183-12-24**] Date of Birth: [**2133-12-19**] Sex: M Service: SURGERY Allergies: Shellfish Derived Attending:[**First Name3 (LF) 6346**] Chief Complaint: Right Upper Quadrant Abdominal Pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy [**2183-12-16**] Laparoscopic converted to open cholecystectomy [**2183-12-18**] History of Present Illness: The patient is a 49 year old male with history of long standing alcohol abuse with resultant alcoholic cirrhosis who presented initially to [**Hospital3 4107**] on [**2183-12-15**] with symptoms of 2 days of epigastric and right upper quadrant pain. The patient reports his ain is sharp, stabbing, [**10-10**] at it's worst, and radiates to his back. He reports associated symptoms of nausea and vomiting of non-bloody, non-bilious fluid with associated chills. The patient denies hematemsis, BRBPR, melena, chest pain. He does report some shortness of breath which he attributes to difficulty taking deep breaths because of his abdominal pain. At [**Hospital3 4107**] the patient had labs pertinent for Cr 1.4, Alb 3,9, Tb 4.1, Db 1.2, Alk Phos 102, ALT 68 and AST 77, WBC 15.2 (2% Bands), HCt 44.2, and platelet 129. Per D/C summary, the patient had an abdominal ultrasound which revealed gallstones and CBD of 6mm, no ascites. A CT Abd/Pelvis was subsequently performed which is reported to have revealed cholelithiases with a 7mm stone in the distal CBD as well as gallstones in the neck of the gallbladder (CT report not accompanying). No intrahepatic lesions of dilated intrahepatic ducts were noted. The liver was with irregular contour suggestive of cirrhosis. Given report of stone present in the CBD, the patient is now being transferred to [**Hospital1 18**] with plan for ERCP. In anticipation of the need for eventual cholecystectomy, a surgical consult is requested by the hospitalist today. On arrival to the medical floor patient confirms history as above. The patient reports he has history of relapsiing alcoholism, however, he reports his alst drink was now 3 weeks ago. He reports history of tremors and has undergone detox, denies history of seizures or DTs. The patient reports ongoing abdominal pain. On review of systems he reports some difficulty taking deep breaths secondary to his abdominal pain, mild sensation of associated air hunger. Remainder of ROS negative. Past Medical History: #. History of Alcohol abuse - history of tremors and blackouts. Has been in detox - no DTs, no seizures #. Alcholic Cirrhosis - denies history of variceal bleed although history of GI bleed NOS previously - denies history of ascites - history of encephalopathy documented #. Thrombocytopenia #. History of GI Bleeding #. Gastritis/Duodenitis #. Cholelithiasis #. Pancreatitis #. Hypothyroidism Social History: The patient lives in [**Hospital1 **] with his sister. [**Name (NI) **] was previously employed insecurity at a hotel, now going to start new job as security in a hotel. ETOH: No use x 3 weeks, previous 18 beers daily or 2 pints of vodka daily Tobacco: None Illicits: None Family History: Noncontributory Physical Exam: Vitals on admission: 100.4, 112/80, 118, 16, 95% RA General: Patient is a middle aged male, appears to be in pain, no acute distress. Appropriate, oriented x 3. No asterixis HEENT: NCAT, EOMI, sclera mildly icteric, conjunctiva WNL OP: MMM, no lesions Neck: Supple, no LAD, no JVD Chest: Generally clear anterior. Small crackles at both bases, poor air movement in general, + splinting. + spider angioma Cor: Tachycardic, regular, no M/R/G Abdomen: Mildly distended, hypoactive BS. Mod tenderness throughout, severe tenderness in RUQ and epigastrium with voluntary guarding, no rebound. Rectal: empty rectal vault, guaiac negative fluid Ext: No edema Skin/Nails: + spider angioma Neuro: Oriented x3, no asterixis, appropriate Vitals on discharge: 100.2, 99.8, 98, 110/80, 20, 96RA Gen: NADS, AAO x 3 Lungs: CTA Cardio: Tachy, normal sinus rhythm Abd: soft, distended, non-tender, act bowel sounds Wound: staples to subcostal area, mildly erythematous. Areas packed with wtd to midline and right lateral edge. No purulent drainage Ext: No C,C,E Pertinent Results: . CXR [**2183-12-16**]: Bibasilar atelectasis, small R pleural effusion, low lung volumes . ERCP [**2183-12-17**]: 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: Normal major papilla Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome. Contrast medium was injected resulting in complete opacification. A 0.035in in diameter and 260cm in length straight tip glidewire was placed. The existing guidewire was replaced with a jagwire. . Biliary Tree: A mild diffuse dilation was seen at the main duct with the CBD measuring 9mm. There were filling defects that appeared like sludge in 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. Post sphincterotomy, pus could be seen coming out from the major papilla. Some sludge was extracted successfully using a 8 mm balloon. Impression: A mild diffuse dilation was seen at the main duct with the CBD measuring 9mm. There were filling defects that appeared like sludge in the lower third of the common bile duct. Successful sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Post sphincterotomy, pus could be seen coming out from the major papilla. Successful extraction of sludge using a 8 mm balloon. [**2183-12-22**] Cholangiogram: No evidence of biliary leak. [**2183-12-18**] 05:30PM BLOOD WBC-8.1 RBC-2.85* Hgb-9.6* Hct-27.5* MCV-97 MCH-33.9* MCHC-35.0 RDW-14.6 Plt Ct-118* [**2183-12-18**] 07:21PM BLOOD WBC-8.4 RBC-2.93* Hgb-9.9* Hct-28.5* MCV-97 MCH-33.8* MCHC-34.8 RDW-14.8 Plt Ct-99* [**2183-12-19**] 02:48AM BLOOD WBC-6.4 RBC-2.90* Hgb-9.8* Hct-27.4* MCV-95 MCH-34.0* MCHC-35.9* RDW-15.8* Plt Ct-97* [**2183-12-20**] 06:35AM BLOOD WBC-8.9 RBC-3.13* Hgb-10.3* Hct-29.8* MCV-95 MCH-33.0* MCHC-34.6 RDW-15.2 Plt Ct-126* [**2183-12-21**] 03:15AM BLOOD WBC-8.3 RBC-2.91* Hgb-9.7* Hct-27.9* MCV-96 MCH-33.2* MCHC-34.7 RDW-15.1 Plt Ct-139* [**2183-12-22**] 06:00AM BLOOD WBC-6.7 RBC-2.69* Hgb-8.9* Hct-24.9* MCV-93 MCH-32.9* MCHC-35.5* RDW-14.8 Plt Ct-124* [**2183-12-16**] 01:30AM BLOOD Glucose-107* UreaN-22* Creat-1.6* Na-128* K-4.5 Cl-93* HCO3-25 AnGap-15 [**2183-12-16**] 07:05AM BLOOD Glucose-97 UreaN-21* Creat-1.5* Na-131* K-3.3 Cl-96 HCO3-27 AnGap-11 [**2183-12-17**] 07:10AM BLOOD Glucose-88 UreaN-14 Creat-1.2 Na-135 K-3.5 Cl-100 HCO3-25 AnGap-14 [**2183-12-19**] 02:48AM BLOOD Glucose-119* UreaN-11 Creat-0.9 Na-140 K-4.1 Cl-109* HCO3-24 AnGap-11 [**2183-12-16**] 01:30AM BLOOD ALT-55* AST-74* LD(LDH)-480* AlkPhos-74 Amylase-34 TotBili-4.7* DirBili-1.8* IndBili-2.9 [**2183-12-17**] 07:10AM BLOOD ALT-38 AST-35 AlkPhos-121* TotBili-5.0* [**2183-12-18**] 07:30AM BLOOD ALT-27 AST-25 AlkPhos-106 TotBili-3.2* [**2183-12-21**] 03:15AM BLOOD ALT-22 AST-44* AlkPhos-78 TotBili-2.3* DirBili-1.3* IndBili-1.0 [**2183-12-22**] 06:00AM BLOOD ALT-16 AST-34 AlkPhos-69 TotBili-1.5 DirBili-0.9* IndBili-0.6 Brief Hospital Course: The patient is a 49 year old male with medical history of alcoholic cirrhosis who presented with epigastric and RUQ pain with concern for impacted stone on CT seen at OSH. He was transferred from [**Hospital3 **]. He was found to have cholangitis. #. Biliary Obstruction/Cholangitis/Fever/Cholecystitis: At [**Hospital3 4107**] the patient had labs pertinent for Cr 1.4, Tb 4.1, Db 1.2, Alk Phos 102, ALT 68 and AST 77, WBC 15.2 (2% Bands). At the outside hospital, the patient had an abdominal ultrasound which revealed gallstones and CBD of 6mm, no ascites. A CT Abd/Pelvis was subsequently performed which is reported to have revealed cholelithiases with a 7mm stone in the distal CBD as well as gallstones in the neck of the gallbladder (CT report not accompanying). No intrahepatic lesions of dilated intrahepatic ducts were noted. The liver was with irregular contour suggestive of cirrhosis. Given report of stone present in the CBD, the patient was transferred to [**Hospital1 18**] with plan for ERCP. The patient here was treated with IVF, dilaudid for pain, and IV Levo/flagyl given his bandemia at the OSH. He was febrile here to 102 prior to his ERCP. He underwent ERCP on [**12-17**] which showed a mild diffuse dilation at the main duct with the CBD measuring 9mm. There were filling defects that appeared like sludge in the lower third of the common bile duct. Successful sphincterotomy was performed. Post sphincterotomy, pus could be seen coming out from the major papilla. Successful extraction of sludge using a 8 mm balloon. He was treated with IV Levo/flagyl for 2 additional days.Surgery was consulted for consideration of cholecystectomy. Patient was then admitted to general surgical service and was taken to the operating room on [**2183-12-18**] for a laparoscopic cholecystectomy. With low platelets of 71,000, platelets were placed on call to the operating room. During procedure, there was extensive bleeding and because of the difficult dissection, surgery converted to open cholecystectomy. Overall fluid balances were - received 3400ml crystalloid, 3 units pRBC, 2 units FFP, 1 six-pack platelets for EBL 1600cc, UOP 250cc. Patient was kept intubated and transferred to SICU for O/N observation. He maintained hemodynamically stable and postoperative Hct of 28.5. On POD1-2, patient was weaned from ventilation and extubated. He was kept on IV levaquin and flagyl. His NGT, arterial line and foley were removed. Patient was transferred to the general surgical floor for further post-operative recovery. He remained tachycardic but completely asymptomatic. Patient's diet was advanced from sips to clears. On POD3-4, patient developed a fever of 102.3. He was pan-cultured. Bile cultures returned to have sparse enterococcus. He was started on augmentin in which he will be kept on for 2 weeks. Medial aspect of his abdominal staple incision was opened and swabbed. Gram stain result showed gram positive coccus and sensitivities are still pending on day of discharge. Incisional areas were packed wet to dry and will be changed twice a day. There appeared to be a darker colored output from the JP drain from a serosanguinous color. On POD5, HIDA scan was ordered to assess for any intra-biliary leaks. Results from imaging showed patent ducts with no extravasation of material. He was discharged home on POD6 with a two week course of augmentin and VNA to teach patient to pack wound with wet to dry dressings twice a day. He is tolerating a regular diet, ambulating and voiding without difficulty. He is to call Dr. [**First Name (STitle) 2819**] to schedule an appointment for follow up clinic visit. #. Acute Renal Failure: Patient's baseline unknown (1.2 in [**2181**]), Cr was 1.4 at outside hospital the day prior to admission, and was 1.6 on admission here. Differential was pre-renal vs. contrast-nephropathy from his CT scan. FeNa was 0.2%, and creatinine trended down with IVF, consistent with pre-renal/dehydration. After IVF, his Creatinine was back down to 1.2. . #. Anemia: Hct at OSH 44, repeat on arrival here 35.0 Patient guaiac negative on exam, prior baseline in [**2181**] appears to be near 36. Elevated Hct at OSH likely reflective of hemoconcentration -trend . #. Hyponatremia: Sodium was 128 on admission, and patient appeared hypovolemic with urine chemistries consistent with prerenal etiology of ARF. He was hydrated with IVF with resolution of his hyponatremia. . #. Dyspnea: Symptoms seemed related to splinting and hypoventilation from pain. CXR showed bibasilar atelectasis and small r pleural effusion. BNP only 400s. He was treated with pain control and incentive spirometry. . #. Coagulopathy: Likely related to underlying cirrhosis, no active evidence of bleeding. Vit K 10mg once on admission as well as 2 units of FFP prior to ERCP. . #. Alcoholic Cirrhosis: Currently without bleeding, appears to be without encephalopathy. Abdominal exam limited by pain, no obvious ascites (none on US at OSH per report) -eval for varices on ERCP; would likely benefit from nadolol given varices seen on CT at OSH -would obviously benefit from long term alcohol abstinence -outpatient management for ongoing cirrhosis management: HCC screening, variceal bleed ppx, etc Medications on Admission: Levothyroxine - dose unknown Iron tab daily Potassium Chloride daily Prilosec 20mg daily Discharge Medications: 1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days. Disp:*36 Tablet(s)* Refills:*0* 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not operate heavy machinery or consume alcohol. [**Month (only) 116**] cause drowsiness. Disp:*40 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while using narcotics for pain control to help prevent constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Cholelithiasis and choledocholithiasis Gangrenous Cholecystitis Alcoholic Cirrhosis Acute Blood Loss Anemia Wound Infection Gastritis Hypothyroidism Thrombocytopenia Discharge Condition: Tolerating regular diet Ambulating and voiding without difficulty Incisional area with staples, 2 areas packed with gauze Normal bowel movements Discharge Instructions: General: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Please pack wound with wet to dry dressings twice a day. Followup Instructions: Follow up with Dr. [**First Name (STitle) 2819**] in [**1-1**] weeks; please call ([**Telephone/Fax (1) 8105**] to schedule an appointment Follow up with PCP [**Last Name (NamePattern4) **] 1 week

[ "276.1", "584.9", "576.1", "E878.6", "303.92", "285.1", "998.59", "571.2", "041.04", "V64.41", "287.5", "572.3", "244.9", "535.50", "998.11", "574.31" ]

icd9cm

[ [ [] ] ]

[ "99.05", "51.85", "51.22", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

13290, 13347

7360, 12597

317, 424

13556, 13703

4278, 7337

14962, 15162

3180, 3197

12737, 13267

13368, 13535

12623, 12714

13727, 14939

3212, 3219

3960, 4259

241, 279

452, 2455

3233, 3946

2477, 2873

2889, 3164

31,837

100,594

34460

Discharge summary

report

Admission Date: [**2117-8-4**] Discharge Date: [**2117-8-9**] Date of Birth: [**2048-6-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 492**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: [**2117-8-5**] Flexible bronchoscopy with narrow-band imaging and therapeutic aspiration. [**2117-8-6**] Flexible bronchoscopy with therapeutic aspiration. [**2117-8-6**]: Bronchial angiogram History of Present Illness: 69 yo transferred from [**Hospital2 **] [**Hospital3 6783**] hospital with a course of hemoptyis the began on the [**7-24**] for which he was admitted. At that time, he underwent bronchoscopy, and received bronchial artery embolization after a CT exam showed an increased density and bronchiectasis. Following this procedure and discharge, he continue to have a single episode of hemoptysis (teaspoon full). He was subsequently readmitted on [**8-1**] [**Hospital3 6783**] after a second episode of hemoptysis, [**2-16**] of a cup. Upper endoscopy showed a gastric ulcer in the fundus, 80% healed. During this hospitalization, he developed massive hemoptysis on [**8-3**], which was bright red blood with tissue, about 600 cc. He was unresponsive and was intubated. He was transfused 1 unit. Bronchoscopy was performed and showed no clots in the bronchus. Repeated upper endoscopy showed no change in the gastric ulcer. the patient subsequently self extubated himself on [**8-4**]. He was transferred to [**Hospital1 18**] for further work-up on [**8-4**] Past Medical History: Hypertension Dyslipidemia PVD, s/p fem-fem bypass Essential tremor Bladder Ca, s/p radical prostatetectomy and cystectomy w/ileal loop conduit [**2115**] Gastric ulcer w/negative biopsy and negative h.pylori AAA repair [**2105**] Bronchiectasis TIA w/left sided weakness Bilateral internal carotid stenosis Pulmonary AVM with coil embolization [**2105**] Hemoptysis Social History: Ex-smoker, stopped in [**2102**] Family History: No history of AVM Physical Exam: VS: Tm98.4 Tc97.4 HR62 BP124/60 RR20 94%RA Gen: No acute distress, AAO Card: RRR Lungs: CTA B/L Abd: +BS Pertinent Results: [**2117-8-4**] 11:54PM BLOOD WBC-8.8 RBC-3.36* Hgb-10.1* Hct-29.8* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.6* Plt Ct-278 [**2117-8-7**] 03:23AM BLOOD WBC-5.5 RBC-3.10* Hgb-9.5* Hct-27.2* MCV-88 MCH-30.6 MCHC-34.8 RDW-15.0 Plt Ct-238 [**2117-8-8**] 07:00AM BLOOD WBC-6.0 RBC-3.36* Hgb-10.5* Hct-29.1* MCV-86 MCH-31.3 MCHC-36.3* RDW-14.7 Plt Ct-292 [**2117-8-4**] 11:54PM BLOOD PT-13.2 PTT-23.8 INR(PT)-1.1 [**2117-8-4**] 11:54PM BLOOD Plt Ct-278 [**2117-8-8**] 07:00AM BLOOD Plt Ct-292 [**2117-8-4**] 11:54PM BLOOD Glucose-101 UreaN-18 Creat-1.1 Na-145 K-3.8 Cl-110* HCO3-27 AnGap-12 [**2117-8-7**] 03:23AM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-140 K-4.0 Cl-105 HCO3-32 AnGap-7* [**2117-8-8**] 07:00AM BLOOD Glucose-106* UreaN-18 Creat-0.9 Na-140 K-3.8 Cl-103 HCO3-29 AnGap-12 [**2117-8-4**] 11:54PM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8 [**2117-8-7**] 03:23AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0 [**2117-8-8**] 07:00AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 Brief Hospital Course: The patient was admitted on [**2117-8-4**] by the thoracic surgery service to the SICU for treatment and evaluation of massive hemoptysis. ENT evaluated the patient for bleeding sources: Fiberoptic exam revealed no source of blood from the nose, nasopharynx, oropharynx, oral cavity, hypopharynx or larynx; there were no supraglottic lesions. CTA on [**8-5**] showed a Left superior segment coiled AVM with an adjacent ground glass opacity. It was thought that this finding could represent intraparenchymal hemorrhage or it could represent aspiration, given the dependent consolidation seen in both lower lobes and the secretion seen in the right main bronchus. Imaging also revealed a question of a completely thrombosed aorta just distal to the origin of the renal arteries with extensive collaterals in the abdominal wall musculature. Due to this finding, ultrasound of the aorta was performed. While a suboptimal study due to bowel gas, arterial flow and normal waveforms was noted is seen in the right and left distal most external iliac arteries and common femoral arteries bilaterally consistent with a prior femoral-femoral bypass. On [**8-5**], flexible bronchoscopy with narrow-band imaging and therapeutic aspiration was performed. A fresh blood clot was identified in the right lower lobe lateral segment which was therapeutically aspirated. A clot was also identified left main-stem and this was emanating from the left lower lobe. There was evidence of possible pulmonary AVMs in the left main-stem medial segment; however, this was compounded somewhat by the traumatic appearance of the airways. Under white-light imaging, these areas appeared erythematous. No other definitive AVMs were noted under narrow-band imaging. On [**8-6**], a repeat flexible bronchoscopy was performed to isolate a source of bleeding.There was a small clot on the right main stem, however, there were no clots or active bleeding in the right upper lobe, right middle lobe, right lower lobe. The left main stem again had a questionable area of erythema, possible arteriovenous malformation in the medial aspect of the left main stem. The left upper lobe and lingula were free from clots or blood. There was an old blood clot emanating from left lower lobe, which was therapeutically aspirated. Upon examination, the anteromedial segment of the left lower lobe demonstrated a fresh clot with active oozing of blood, which was confirmed with a bronchial wash. The posterior and lateral segment of the left lower lobe were both washed and there was no active oozing. The final impression was that the Left lower lobe anteromedial segment is likely source of hemoptysis. The patient was taken to the angio suite on [**8-6**] for possible embolization. A preliminary report revealed: 1. Aortogram demonstrating no visualized bronchial artery branches. 2. Selective angiograms of intercostal arteries demonstrating no irregularity. 3. Subclavian arteriogram demonstrating no abnormality of the left internal mammary artery. No intervention was performed. The patient was transferred to the floor on [**8-7**], and kept for observation. The patient had several more episodes of hemoptysis on [**8-8**] - 2 tsp of bright red blood without clots - which resolved without intervention. On the evening of [**2034-8-7**], the patient had no episodes of hemopysis. The Interventional Pulmonology team, staff and patient agreed that is was appropriate to discharge the patient to home on [**8-9**] with follow as needed. The patient is being discharge stable, in good condition. Medications on Admission: zertec 10mg QD pletal 50mg [**Hospital1 **] Guaifenesin-Codeine 5-10mL PO q6h prn simvastatin 10mg po qhs lisinopril 10mg po qdaily nasonex 50mcg qam atenolol 50mg po qdaily qvar 80mcg 1-2 puffs Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: [**12-16**] puffs Inhalation 1-2 puffs [**Hospital1 **] (). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 10. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: HTN, Dyslipidemia, PVD, s/p fem-fem bypass, Essential tremor Bladder Ca, s/p radical prostatetectomy and cystectomy w/ileal loop conduit [**2115**], Gastric ulcer w/negative biopsy and negative h.pylori AAA repair [**2105**], Bronchiectasis, TIA w/left sided weakness, Bilateral internal carotid stenosis, Pulmonary AVM with coil embolization [**2105**] Hemoptysis Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 79205**] if you develop chest pain, shortness of breath, increased bloody sputum or any other symptoms that concern you. Followup Instructions: Call Dr.[**Doctor Last Name **] office [**Telephone/Fax (1) 10084**] for a follow up appointment. Follow up with your primary care doctor. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**] Completed by:[**2117-8-10**]

[ "V10.51", "440.4", "786.3", "747.3", "729.89", "333.1", "V45.74", "V44.6", "438.89", "401.9", "433.30", "V44.2", "272.4", "440.20", "433.10" ]

icd9cm

[ [ [] ] ]

[ "88.42", "88.44", "33.22", "96.05" ]

icd9pcs

[ [ [] ] ]

7960, 7966

3205, 6775

328, 523

8375, 8382

2238, 3182

8608, 8890

2071, 2091

7020, 7937

7987, 8354

6801, 6997

8406, 8585

2106, 2219

278, 290

551, 1614

1636, 2004

2020, 2055

15,892

109,678

24280+57394

Discharge summary

report+addendum

Admission Date: [**2127-6-17**] Discharge Date: [**2127-7-11**] Date of Birth: [**2090-12-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p motorbike injury LLE diarticulation Major Surgical or Invasive Procedure: [**6-17**]: L leg amputation, diagnostic peritoneal lavage, exploratory laparotomy, L arm operative debridement [**6-19**]: ORIF L SI joint & acetabular fracture [**6-25**]: LUE STSG x2, closure of LLE amputation with skin flap History of Present Illness: 36F s/p unhelmeted MVC motorbike vs car collision, with obvious L leg fracture at site of accident. She presented to [**Hospital 8641**] Hospital in hypovolemic shock, received 6 units of PRBC and was transferred to [**Hospital1 18**] for further care. Past Medical History: unknown Social History: HCP: [**Name (NI) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 61578**], work [**Telephone/Fax (1) 61579**] Family History: unknown Physical Exam: Temp 96, pulse 110, BP 80/40 Intubated, sedated Tachy, CTA B Soft NT, negative DPL LUE with multiple abrasions, palp pulses LLE grossly deformed with large laceration near amputation at hip. No distal cap refill Pertinent Results: Please refer to carevue for specific lab data. On discharge: [**2127-7-8**] 03:00AM BLOOD WBC-8.1 RBC-2.94* Hgb-8.1* Hct-25.9* MCV-88 MCH-27.7 MCHC-31.5 RDW-15.1 Plt Ct-909* [**2127-7-6**] 03:17AM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1 [**2127-7-8**] 03:00AM BLOOD Glucose-91 UreaN-7 Creat-0.3* Na-137 K-4.7 Cl-103 HCO3-28 AnGap-11 [**2127-7-7**] 01:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2127-7-7**] 01:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-8.0 Leuks-MOD [**2127-7-7**] 01:35PM URINE RBC-0-2 WBC-21-50* Bacteri-MOD Yeast-MOD Epi-0 [**7-7**] CXR: 1) Lines and tubes in stable position. 2) No significant interval change in patchy opacities within the medial aspect of the right upper and left lower lung fields, findings that likely relate to atelectasis. No definite evidence of pneumonia. [**7-3**] ANGIO: Successful placement of a retrievable Bard Recovery nitinol IVC filter with the tip in an infrarenal position. [**6-29**] MR spine: No evidence of abnormal vertebral body or ligamentous signal seen in the cervical region. Small disc herniation at C5-6 level slightly indenting the thecal sac. No evidence of extrinsic spinal cord compression or intrinsic spinal cord signal abnormalities. [**6-29**] MR [**First Name (Titles) **] [**Last Name (Titles) **] evidence of acute infarct. Brief Hospital Course: Admitted from [**Hospital 8641**] Hospital. Taken emergently to OR by trauma surgery/ortho/vascular. Please refer to previously dictated op notes, which state that L lower extremity was not viable and was disarticulated at the hip . Negative ex lap & debridement of arm wounds. Admitted to SICU following OR. Please refer to medical record for specifics of ICU course & interventions, but brief synopsis of her current status follows. NEURO: significant postop pain. treated with methadone & prn oxycodone. IV meds DC'd once she was able to take meds via dobhoff. CARDS: stable RESP: failed to wean off vent. Percutaneous tracheostomy placed on [**7-3**]. FEN: Tubefeedings via dobhoff tolerated well. Refer to page 1 for details. HEME: hematocrit relatively stable following initial operation. ID: treating with kefzol for prophylaxis while JPs in place, levaquin for UTI, fluconazole for fungal UTI. PROPH: prevacid, SQ heparin, s/p IVC filter placement MSK: s/p LLE amputation. wound infection vs dehiscence followed by plastics. JP management per plastics team. treat with wet to dry dressing packings. Plastics will follow in clinic in 1 week: call to schedule an appointment. Medications on Admission: unknown Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: [**1-12**] units Injection ASDIR (AS DIRECTED): follow attached sliding scale. Disp:*100 units* Refills:*2* 2. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: crush all meds. Disp:*4 Tablet(s)* Refills:*0* 3. Keflex 250 mg/5 mL Suspension for Reconstitution Sig: Two (2) teaspoons PO four times a day: while JP drains are in place. Disp:*250 ML* Refills:*2* 4. Fluconazole 40 mg/mL Suspension for Reconstitution Sig: One (1) teaspoon PO once a day for 1 weeks. Disp:*100 ML* Refills:*2* 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). Disp:*90 ML* Refills:*2* 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO DAILY (Daily). Disp:*30 dose* Refills:*2* 7. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): give separately from levaquin. Disp:*30 Tablet(s)* Refills:*2* 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: crush all pills. Disp:*30 Tablet(s)* Refills:*2* 9. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: or liquid alternative. Disp:*30 Tablet, Chewable(s)* Refills:*2* 10. Methadone 10 mg/5 mL Solution Sig: One (1) teaspoons PO twice a day. Disp:*300 ml* Refills:*2* 11. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons PO BID (2 times a day) as needed. Disp:*30 teaspoons* Refills:*0* 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*1 container* Refills:*0* 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*0* 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal twice a day as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 15. Outpatient Lab Work CBC, Chem-10 twice weekly Discharge Disposition: Extended Care Facility: northeast specialties [**Hospital1 **] Discharge Diagnosis: s/p motorbike accident L femur disarticulation circulatory arrest requiring CPR T10-T11 spinous process fractures R 4th rib fracture lung contusion comminuted L acetabular & pubic ramus fracture large LUE abrasion s/p debridement wound infection urinary tract infection postop atelectasis hypokalemia Discharge Condition: improved Discharge Instructions: Tube feedings as tolerated. Meds via dobhoff tube. Wet to dry dressing changes as directed. Contact your MD if you develop any fevers > 101, increasing pain or if there are any questions. Followup Instructions: Follow up at [**Hospital 3595**] clinic next Tuesday [**Telephone/Fax (1) 274**]. Follow up at Trauma clinic next Tuesday [**Telephone/Fax (1) 2359**]. Completed by:[**2127-7-8**] Name: [**Known lastname 11132**],[**Known firstname 4377**] Unit No: [**Numeric Identifier 11133**] Admission Date: [**2127-6-17**] Discharge Date: [**2127-7-11**] Date of Birth: [**2090-12-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3524**] Addendum: Since her last discharge summary, Ms. [**Known lastname **] has completed her antibiotic course for her urinary tract infection and completely defervesced. She has been waiting for rehab placement. Her LLE stump wound was re-evaluated by Plastic Surgery, who removed her JP drains. Finally, a Passy-Muir valve was inserted on [**7-10**]. Chief Complaint: s/p motorbike accident, with LLE amputation Major Surgical or Invasive Procedure: [**6-17**]: L leg amputation, diagnostic peritoneal lavage, exploratory laparotomy, L arm operative debridement [**6-19**]: ORIF L SI joint & acetabular fracture [**6-25**]: LUE STSG x2, closure of LLE amputation with skin flap [**7-3**]: placement of IVC filter [**7-11**]: final placement of postpyloric feeding tube History of Present Illness: see prior DC summary Past Medical History: unknown Social History: HCP: [**Name (NI) **] [**Name (NI) 11134**] (mother) [**Telephone/Fax (1) 11135**], work [**Telephone/Fax (1) 11136**] Family History: unknown Physical Exam: at discharge: AVSS Alert, nonverbal communication follows commands & moves all extremities s/p trach RRR CTA B soft NT LLE stump: +erythema surrounding wound. JP removed Pertinent Results: [**2127-7-8**] 03:00AM BLOOD WBC-8.1 RBC-2.94* Hgb-8.1* Hct-25.9* MCV-88 MCH-27.7 MCHC-31.5 RDW-15.1 Plt Ct-909* Brief Hospital Course: see prior DC summ Medications on Admission: unknown Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: [**1-12**] units Injection ASDIR (AS DIRECTED): follow attached sliding scale. Disp:*100 units* Refills:*2* 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). Disp:*90 ML* Refills:*2* 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO DAILY (Daily). Disp:*30 dose* Refills:*2* 4. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): give separately from levaquin. Disp:*30 Tablet(s)* Refills:*2* 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: crush all pills. Disp:*30 Tablet(s)* Refills:*2* 6. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: or liquid alternative. Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. Methadone 10 mg/5 mL Solution Sig: One (1) teaspoons PO twice a day. Disp:*300 ml* Refills:*2* 8. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons PO BID (2 times a day) as needed. Disp:*30 teaspoons* Refills:*0* 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*1 container* Refills:*0* 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*0* 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal twice a day as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 12. Outpatient Lab Work CBC, Chem-10 twice weekly 13. Lorazepam 2 mg/mL Solution Sig: 1-2 mg Injection every eight (8) hours as needed for agitation. Disp:*30 ML* Refills:*2* Discharge Disposition: Extended Care Facility: northeast specialties [**Hospital1 **] Discharge Diagnosis: s/p motorbike accident L femur disarticulation circulatory arrest requiring CPR T10-T11 spinous process fractures R 4th rib fracture lung contusion comminuted L acetabular & pubic ramus fracture large LUE abrasion s/p debridement wound infection urinary tract infection postop atelectasis hypokalemia Discharge Condition: improved Discharge Instructions: Tube feedings as tolerated. Meds via dobhoff tube. Wet to dry dressing changes as directed. Contact your MD if you develop any fevers > 101, increasing pain or if there are any questions. Followup Instructions: Follow up at [**Hospital 6655**] clinic Tuesday [**7-22**] ([**Telephone/Fax (1) 5721**]) Follow up at Trauma clinic Tuesday [**7-22**] ([**Telephone/Fax (1) 3594**]) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**] Completed by:[**2127-7-11**]

[ "285.1", "808.53", "823.32", "E812.2", "807.01", "861.21", "958.4", "997.62", "682.2", "518.5", "599.0", "904.7", "805.2", "821.11", "276.8", "348.1", "881.10", "839.05", "427.5" ]

icd9cm

[ [ [] ] ]

[ "38.7", "79.39", "84.18", "54.11", "99.60", "86.69", "54.25", "96.72", "86.22", "86.74", "96.6", "83.45", "79.69", "80.15", "31.1" ]

icd9pcs

[ [ [] ] ]

10182, 10247

8471, 8490

7559, 7884

10592, 10602

8334, 8448

10841, 11167

8118, 8127

8548, 10159

10268, 10571

8516, 8525

10626, 10818

8142, 8142

8157, 8315

1368, 2689

7476, 7521

7912, 7934

7956, 7965

7981, 8102

12,927

128,786

48990

Discharge summary

report

Admission Date: [**2189-12-4**] Discharge Date: [**2189-12-14**] Date of Birth: [**2136-6-5**] Sex: F Service: MEDICINE Allergies: Bactrim Ds / Terbutaline Attending:[**First Name3 (LF) 21990**] Chief Complaint: Hypercalcemia Major Surgical or Invasive Procedure: Intubation Blood transfusion Bronchoscopy History of Present Illness: 53 yo [**Hospital **] transferred to [**Hospital1 18**] on [**2189-12-4**] from NH for symptomatic hypercalcemia and acute renal failure. Upon admission, patient reported [**2-12**] day period of weakness with loss appetite. Night sweats X9 months. No pain/fever/pruritus/abd pain/constipation/diarrhea. In the ED, Ca was 14.9, with Phos 5.5 and creat 3.3. Received NS with Lasix and calcitonin in the ED. Patient with improvement of serum calcium with fluids and lasix, and decrease in in Cr to 2.1 over first 2 days in the the hospital. Patient then spiked fever to 103, assoicated with cough. CXR without clear infiltrate. Patient subsequently started on azithromycin for presumed bronchitis. On [**12-5**] patient received small dose of ativan for anxiety. That evening, she became lethargic with increased respiratory rate and decreased O2 sats to the 80s. CT head at this time was negative for acute process and ABG showed marked acute respiratory acidosis (7.24/104/58). Nasal BiPap was attempted without improvement, and patient was transferred to the [**Hospital Unit Name 153**] for full mask PPV, but was subsequently intubated given persistent decreased mental status. Patient was continued on azithomycin and was started on solumedrol . CXR without evidence of new infiltrate. After improvement of mental status, patient was successfully extubated on [**12-9**], and transferred to the floor this evening. She was transitioned from Solumedrol to prednisone taper. Hospital course also notable for: 1)Improved hypercalcemia with fluids and lasix; SPEP/UPEP negative. PTH wnl; Phos elevated. ACE Pending. Awaiting diagnostic procedure. 2)Continued renal insufficiency without evidence of nephrolithiasis or hydronephrosis on ultrasound, random urine negative for eosinophils and FeNa >1%. Urine calcium not measured over 24 hours. SPEP and UPEP negative. 3)Anemia with Fe/TIBC <15%, with stable hematocrit. Upon transfer to floor, patient reports feeling at her baseline respiratory status. She denies any fevers, chills, chest pain, abdnominal pain or skin lesions. She reports that she has had dry and red eyes ever since she began not feeling well. She denies any vision changes. Past Medical History: 1. Asthma, s/p multiple hospitalizations and intubations. Now on home O2 3. Diastolic congestive heart failure with mild (+1)mitral regurgitation ([**9-11**]). 4. History of paroxysmal supraventricular tachycardia (MAT) 5. Diabetes mellitus. 6. Obstructive sleep apnea on Bipap 7. Hypertension. 8. History of tuberculosis, status post isoniazid treatment. 9. Her last exercise stress test was [**12-14**]; She exericsed for 4 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and was stopped for fatigue. Very limited functional capacity. At peak exercise the patient reported a [**8-21**] SSCP (resolved with rest by minute 6 in recovery while sitting). No significant ST segment changes were noted. Social History: Former smoker. Lives in [**Hospital3 1186**]. No tobacco or ETOH Family History: Non-contributory Physical Exam: Vs 98.2, 72, 164/75, 20, 94 %2lt Gen: [**Last Name (un) **] obese AAF,slightly tachypneic, though able to speak in [**4-16**] word sentences HEENT: Ophtalmologic exam not performed; PEERL; mild conjunctival injection; OP-clear; no accessory muscle use NEck: JVP difficult to assess [**1-13**] habitus; supple; no adenopathy Lungs: severely diminished breath sounds throughout; rales at R mid lobe; no wheezes; prolonged expiratory phase CVS: S1 S2 RRR no m/r/g Abd: Obese/S/NT/ no palpable splenomegaly; no inguinal LAD Extr: Trace bilat [**Location (un) **]; no lesions appreciated Pertinent Results: [**2189-12-3**] 10:10PM BLOOD WBC-5.3 RBC-3.07* Hgb-8.6* Hct-26.1* MCV-85 MCH-27.9 MCHC-32.9 RDW-14.2 Plt Ct-243 [**2189-12-3**] 10:10PM BLOOD Neuts-77.2* Lymphs-10.6* Monos-7.5 Eos-4.4* Baso-0.3 [**2189-12-3**] 10:10PM BLOOD PT-12.6 PTT-22.3 INR(PT)-1.0 [**2189-12-3**] 10:10PM BLOOD Glucose-175* UreaN-70* Creat-3.3*# Na-140 K-4.5 Cl-88* HCO3-41* AnGap-16 [**2189-12-4**] 05:35AM BLOOD ALT-21 AST-21 LD(LDH)-210 AlkPhos-115 TotBili-0.2 [**2189-12-3**] 10:10PM BLOOD Albumin-3.7 Calcium-14.9* Phos-5.5*# Mg-1.8 [**2189-12-3**] 10:10PM BLOOD TSH-1.1 [**2189-12-4**] 05:35AM BLOOD PTH-451 [**2189-12-4**] 05:35AM ALT(SGPT)-21 AST(SGOT)-21 LD(LDH)-210 ALK PHOS-115 TOT BILI-0.2 [**2189-12-4**] 05:35AM PEP-NO SPECIFI [**2189-12-4**] 05:35AM BLOOD calTIBC-337 Ferritn-68 TRF-259 Fe 35 [**2189-12-4**] 05:06AM URINE U-PEP-NO PROTEIN [**2189-12-4**] 05:06AM URINE HOURS-RANDOM UREA N-272 CREAT-34 SODIUM-97 TOT PROT-<6 CALCIUM-8.9 [**2189-12-4**] 05:06AM URINE EOS-NEGATIVE [**2189-12-4**] 06:09PM BLOOD VITAMIN D [**1-5**] DIHYDROXY-PND [**2189-12-7**] 04:44AM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-PND [**2189-12-9**] 04:32AM BLOOD WBC-6.1 RBC-3.25* Hgb-9.3* Hct-28.0* MCV-86 MCH-28.7 MCHC-33.2 RDW-14.3 Plt Ct-200 [**2189-12-9**] 04:32AM BLOOD Plt Ct-200 [**2189-12-9**] 04:32AM BLOOD PT-12.7 PTT-20.5* INR(PT)-1.0 [**2189-12-9**] 05:36PM BLOOD Glucose-145* UreaN-78* Creat-1.8* Na-146* K-3.8 Cl-101 HCO3-35* AnGap-14 [**2189-12-9**] 05:36PM BLOOD Calcium-10.4* Phos-6.2* Mg-2.2 Micro: Direct Influenza A&B: negative [**12-6**] urine Culture- negative [**12-5**] Blood Cx- NGTD [**2189-12-4**] 9:15 pm SPUTUM GRAM STAIN (Final [**2189-12-5**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2189-12-6**]): MODERATE GROWTH OROPHARYNGEAL FLORA. ACID FAST SMEAR (Final [**2189-12-7**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): Radiology: [**12-4**] CT CHEST W/O CONTRAST FINDINGS: Bilateral axillary lymphadenopathy is noted, with the largest node located on the left measuring 1.6 cm in greatest short axis dimension. Mediastinal and bilateral bulky hilar lymphadenopathy is also appreciated. Patchy pleural thickening is noted bilaterally. There are wedge-shaped areas of consolidation in two separate locations within the right lung, the features of which likely represent either scarring or atelectasis. Given their distribution, infection is less likely. Small cystic air spaces are present at the lung apices. No discrete nodules are seen. Limited imaging of the upper abdomen demonstrates a large, lamellated calcified gallstone which may be within the gallbladder neck. A small retrocrural and periportal lymph nodes are also present. BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions. IMPRESSION 1. Axillary, hilar, and mediastinal bilateral lymphadenopathy. The distribution is more suggestive of a systemic process such as sarcoid or atypical infection, with lung cancer being much less likely. 2. Cholelithiasis. [**12-7**] CXR: b/l perihilar haziness with upper zone redistribution with upper zone predominence; b/l hilar enlargement; b/l pleural effusions [**12-9**] Renal U/S: IMPRESSION: Intrinsic renal disease. No nephrolithiasis or hydronephrosis. Brief Hospital Course: This 53 yo AAF with h/o severe asthma, OSA, diastolic dysfunction, TB s/p INH therapy, admitted with hypercalcemia, hyperphosphatemia, ARF, anemia, and hilar, medicastinal and axillary LAD with hospital course c/b acute hypercarbic respiratory failure s/p extubation at baseline respiratory status, with improved Ca, persistent renal insufficiency and anemia. This is a brief hospital course by problem: 1)Hypercalcemia with normal PTH: diff Dx includes malignancy, granulomatous diseases, namely sarcoid, intake of Vit D and calcium, although less likely. ACE slightly elevated at 74. Vit D levels and a repeat PTH were pending at discharge. Bronchoscopy was not able to be tolerated secondary to desaturations. A formal eye exam was done showing only enlarged lacrimal glands which also can be associated with sarcoid and outpatient eye follow up was arranged. Her calcium and phospate levels decreased with hydration, lasix and renagel as needed. 2)Adenopathy: hilar, mediastinal and axillary LAD-possible secondary to sarcoidosis vs. malignancy (LDH nl). Surgery was consulted and felt that an axillary biopsy would not be helpful. They recommended for mediastinoscopy. Interventional pulmonary attempted transbronchial biopsy but this was aborted as she desaturated with introduction of the bronchoscope into the pharynx. Nephrology did not feel that a renal biopsy would be helpful in determining if she has sarcoid. As she stabilized the issue of what and when to biopsy was deferred to outpatient management. 3) Elevated creatinine: Resolving, but creatinine still elevated from baseline (0.9), with elevated BUN. This patient has chronic intrinsic renal disease, with acute worsening of renal function. She had no hydronerphosis on renal ultrasound and her initial FeNA >1% and thus indicating a intrinsic process. Her urine was negative for eosinophhils. Her SPEP and UPEP were negative. A renal consult was obtained and the conclusion was that her renal dysfunction was secondary to chronic kidney disease from HTN and microvascular disease, for which she needs outpt followup, that was exacerbated by hypercalcemia from calcium supplements and furosemide. It was felt that she did not require a renal biopsy to help elucidate the diagnosis of sarcoid, as the sarcoid findings on biopsy are nonspecific. She was given IV fluids and diuretics as needed through her admission and her creatinine improved to 1.7 at discharge. 4)Anemia: The patient has progressive anemia over last 6 months normal reticulocyte count but low index. It is likely that there is a component of mild iron deficiency (fe/tibc<15%, but clearly with muliple other possible etiologies (ie- renal insufficiency; ?reticuloendothial disease ?splenomegaly). She received 2 units PRBCs this admission. Currently with stable HCt. 5)Respiratory Failure: Hypercarbic Resp failure requiring intubation. ddx: benzodiazepine intolerance vs asthma exac. Currently at baseline s/p extubation on a prednisone taper. We avoided benzos and all sedating agents while she was on the floor. 6)Asthma: She was put on a prednisone taper and continued on monoleukast, fluticasone, tiotropium, albuterol INH. She responded well to the prednisone and is currently back at ther baseline functioning 7)HTN: We continued here outpatient regimen except for the lisinoril. This was restarted on the day of discharge as her creatinine continued to improve and this has been shown to have long term benefits in diabetics. 8)diastolic CHF: we maintained her blood pressure on a Beta Blocker, hydralazine, and Calcium Channel Blocker. She received lasix as needed for diuresis and management of hypercalcemia. 9)OSA: continued on nightly outpatient BiPap settings of 18/12 10) DM: we held her outpatient po medications (hold metformin and glipizide given renal failure; hold Avandia given need for fluids and risk of heart failure) and maintained her on glargine and RISS with qid FS. Her sugars were elevated while she was on the prednisone taper. This will continue to need close monitoring as an outpatient. 11)Hyperphosphatemia: this appeared to worsen during the admission. She was put on sevelamer with good resolution. 12)OSA: continued nightly BiPap 14/10 on 3L O2. She tolerated this very well. 13) Fever: She developed a fever but her cultures were sterile. She completed a course of azithromycin on [**12-10**]. She had no further episodes of elevated temperatures. 14)PSych: continued on fluoxentine and buspar Medications on Admission: Prednisone 10 mg p.o. q. day. Singulair. Aldactone 25 qd. Zyrtec Lisinopril. Metformin. ASA 81 qd Prozac 10 qd Lasix 120 qod - 80 qod Metolazone Kcl 40 mEq qd Lipitor 20 qd Colace 100 [**Hospital1 **] Oyster CalD 500 [**Hospital1 **] Pulmicort 200 tid Buspirone 5 tid Diltiazem ER 480 qd Glipizide Avandia 4 qd . Medications at transfer to floor: Fluoxetine HCl 10 mg PO DAILY Aspirin 81 mg PO DAILY Heparin 5000 UNIT SC TID Montelukast Sodium 10 mg PO DAILY BusPIRone 5 mg PO TID Diltiazem 60 mg PO QID hold for sbp <110, HR <50 Atorvastatin 20 mg PO DAILY Senna 1 TAB PO BID:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN Fluticasone Propionate 110mcg 6 PUFF IH [**Hospital1 **] Tiotropium Bromide 1 CAP IH DAILY Pantoprazole 40 mg IV Q24H Docusate Sodium (Liquid) 100 mg PO BID Albuterol [**12-13**] PUFF IH Q6H:PRN Metoprolol 50 mg PO TID Hold for SBP<110, HR<55 Hydralazine HCl 50 mg PO Q6H Hold for SBP <110 Azitromycin 250mg prednisone taper Discharge Medications: 1. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO qd () for 1 doses. 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 2 doses. 3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 4 doses. 4. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. 8. Buspirone HCl 15 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Pulmicort Inhalation 10. Diltiazem HCl 240 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO once a day. 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 4 doses. 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Zyrtec Oral 14. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO once a day. 15. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day. 16. Metformin HCl 1,000 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1) Tab,Sust Rel Osmotic Push 24HR PO once a day. 17. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a week. 18. Insulin Regular Human 300 unit/3 mL Syringe Sig: qs Subcutaneous four times a day as needed for elevated fingerstick blood sugar: use sliding scale as attached. 19. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 21. Lisinopril 40 mg Tablet Sig: 1.5 Tablets PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Hypercalcemia Hyperphosphatemia Hypercarbic Respiratory failure requiring intubation Acute on chronic renal failure Hypertension Severe Asthma Obstructive sleep apnea requiring BiPAP Diabetes Mellitus Diastolic congestive heart failure Anemia requiring transfusion Low grade fever, resolved Discharge Condition: Stable and improved, ambulating with oxygen at her baseline. Discharge Instructions: Follow up with your doctor immediately if you experience fever greater than 100.5, shaking chills, chest pain, palpitations, worsening shortness of breath from your baseline, severe nausea or vomiting, abdominal pain, difficulty or decreased urination, muscle cramps, weakness, numbness or tingling. Check your fingerstick blood sugars four times daily. You are being sent home on a prednisone taper. You may resume all your former outpatient medications EXCEPT FOR the following changes: 1. DO NOT TAKE Oyster Cal D or any calcium or vitamin D supplements unless told otherwise by a physician. 2. Take Lasix 80 mg daily. 3. You may need potassium supplements, but this should be determined by your physician after checking your labwork in two days. Please take your medications as instructed. You will need to continue outpatient follow up for your symptoms and for your enlarged lymph nodes. Please follow up as an outpatient as below. Please use your BiPAP machine at night. Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2190-1-5**] 11:00 2. Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2190-1-12**] 3:15 3. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] REHAB SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2190-1-12**] 3:30 4. Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], for further workup of your symptoms and enlarged lymph nodes. Call [**Telephone/Fax (1) 608**] to make an appointment. 5. Please call the renal clinic at [**Telephone/Fax (1) 60**] to arrange followup for your kidney disease. 6. Please have your Chem 10 panel checked in two days. 7. Test for consideration post-discharge: Vitamin D 25 Hydroxy, HbA1C

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icd9cm

[ [ [] ] ]

[ "96.04", "99.04", "96.71" ]

icd9pcs

[ [ [] ] ]

14627, 14700

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300, 344

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25075

Discharge summary

report

Admission Date: [**2144-11-19**] Discharge Date: [**2144-11-25**] Date of Birth: [**2071-12-20**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Low Back Pain, ? Discitis txfr from OSH Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 72F who is a prior laminectomy patient of Dr. [**Last Name (STitle) **] 4yrs ago, who was transferred from OSH for concerns of discitis versus post-surgical changes of the lumbar region. Past Medical History: -HTN -hypercholesterolemia -OA/gout -s/p cholecystectomy -colon polyp, s/p partial colectomy -s/p Lami L3-4 4yrs ago Social History: -no tobacco; no alcohol Family History: -non contributory Physical Exam: On Discharge: AOx3, following commands. Full strength and sensation in upper extremities. Lower extremities in full strength and sensation with exception of right quadraceps which is 5-. Pertinent Results: Labs on Admission: [**2144-11-20**] 02:22AM BLOOD WBC-10.7 RBC-3.46* Hgb-10.2* Hct-30.1* MCV-87 MCH-29.4 MCHC-33.9 RDW-12.7 Plt Ct-527* [**2144-11-20**] 02:22AM BLOOD PT-14.6* PTT-32.1 INR(PT)-1.3* [**2144-11-20**] 02:22AM BLOOD Glucose-117* UreaN-19 Creat-1.4* Na-134 K-3.6 Cl-93* HCO3-35* AnGap-10 [**2144-11-20**] 02:22AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.5 [**2144-11-23**] 11:55AM BLOOD %HbA1c-6.0* Labs on Discharge: [**2144-11-24**] 05:35AM BLOOD WBC-10.7 RBC-4.16* Hgb-12.2 Hct-35.8* MCV-86 MCH-29.3 MCHC-34.0 RDW-12.7 Plt Ct-497* [**2144-11-24**] 05:35AM BLOOD PT-15.4* PTT-32.2 INR(PT)-1.4* [**2144-11-24**] 05:35AM BLOOD Glucose-118* UreaN-10 Creat-1.1 Na-139 K-3.7 Cl-101 HCO3-29 AnGap-13 [**2144-11-24**] 05:35AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.0 Imaging: MRI [**11-21**] T&L Spine: THORACIC SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images were obtained before gadolinium. T1 sagittal and axial images were obtained following gadolinium. FINDINGS: There is no evidence of discitis or osteomyelitis in the thoracic region. Mild multilevel degenerative change is seen. No evidence of epidural abscess or spinal cord compression seen. No paraspinal fluid collection seen. Partially visualized medial right sternoclavicular joint fluid is identified. IMPRESSION: No evidence of discitis or osteomyelitis or epidural abscess in the thoracic region. Fluid within the right sternoclavicular joint. LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were obtained before gadolinium. T1 sagittal and axial images of the lumbar spine were acquired following gadolinium. FINDINGS: At L4-5 level, there is increased signal seen within the disc with decreased T1 and increased inversion recovery signal in the adjacent L4 and L5 vertebral bodies. Mild spondylolisthesis of L4 over L5 is seen. Following gadolinium, enhancement of the endplates are identified. There are laminectomies at L3 and L4 level. Soft tissue changes are seen at the laminectomy site and also within the spinal canal at this level indicative of epidural inflammatory phlegmon. The inflammatory phlegmon changes extend through right L4-5 neural foramen to the paraspinal region. There is no fluid collection seen to indicate underlying abscess. There are extensive soft tissue changes with increased signal seen at the laminectomy site in the posterior soft tissues. There is scoliosis of lumbar spine convex to the left side in the lower lumbar region. From L1-2 to L3-4, degenerative disc disease and bulging are identified. At L3-4, there is a right foraminal stenosis identified secondary to degenerative change and scoliosis. At L5-S1 level mild degenerative changes are seen. The distal spinal cord shows normal signal intensities. IMPRESSION: Laminectomies at L3 and L4 level. Findings are indicative of discitis and osteomyelitis at L4-5 level with epidural phlegmon and right paraspinal phlegmon extending through the right L4-5 neural foramen. No epidural abscess identified. Degenerative changes at other levels as above. No evidence of paraspinal abscess. Brief Hospital Course: Patient was transferred from OSH on [**11-19**] after concerns of discitis of the lumbar spine. Prior to admission, patient reports that she had been working with a heavy [**Location (un) **] feeder, and was concerned that she "threw her back out" as the next day, had difficulty raising from her chair. Imaging was performed here at [**Hospital1 18**] to reveal ?discitis with no clearly defined abscess. In the setting of being afebrile, no point tenderness, absent leukocytosis or neutrophilia and attending surgeon review of imaging; discitis determined to not be a valid diagnosis. This MRI changes are normal post operative changes consistent with lumbar laminectomy in the remote past. To address her low back pain, she was evaluated by physical therapy, and thought to benefit from [**Hospital 3058**] rehabilitation. She was discharged to an appropriate facility on [**11-25**] with instructions to follow up in 4 weeks with Dr. [**Last Name (STitle) **]. Medications on Admission: Terazosin 2 mg qhs, Lasix 20 mg [**Hospital1 **], Citalopram 20 mg q day, Clozanepam 0.5 mg [**Hospital1 **], Nortriptyline 75 mg qhs. Discharge Medications: 1. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. 15. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for Diarrhea. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Chronic Back Pain Urinary Tract Infection Discharge Condition: Neurologically Stable Discharge Instructions: ?????? Do not smoke. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? 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. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in 4 weeks. ??????You will not need x-rays/CT-scan prior to your appointment. Completed by:[**2144-11-25**]

[ "715.90", "274.9", "401.9", "V12.72", "272.4", "338.29", "724.2", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6600, 6697

4187, 5154

362, 369

6782, 6806

1037, 1042

7992, 8258

796, 815

5340, 6577

6718, 6761

5180, 5317

6830, 7969

830, 830

844, 1018

283, 324

1459, 4164

397, 598

1056, 1440

620, 738

754, 780

7,023

150,952

30016

Discharge summary

report

Admission Date: [**2160-1-9**] Discharge Date: [**2160-1-17**] Date of Birth: [**2094-4-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Status epilepticus Major Surgical or Invasive Procedure: IVC filter placement IR guided LP History of Present Illness: 65yo F w/ stage III ovarian CA treated w/ carboplatin+taxol, hypthyroidism, HL, HTN, CAD, DVT, rt Bell's palsy, & SAH [**9-30**] here after an episode of decreased responsiveness on [**1-9**]. The pt's presentation has been documented in the chart; briefly she Per husband, pt took her dose of dexamethasone in preparation for her chemo cycle morning of admission. Her husband called EMS, by the time they arrived she was unresponsive. En route to [**Hospital1 498**] she had a tonic-clonic seizure that resolved after 5mg IV valium. She was intubated and started on propofol gtt. OSH head CT was negative for ICH. She was given 1 gm dilantin load, EEG confirmed status epi. She was given an additional 400 mg IV dilantin, repeat EEG then showed pt to be out of status. Dilantin level checked at that time was 16, so patient was given another 200 mg IV. She was also given CTX per OSH records. She was transferred to [**Hospital1 18**] MICU for further evaluation and continuous EEG monitoring. . Of note, similar episode occured in [**9-30**] when pt was found to be unresponsive. She was taken to [**Hospital1 498**] and found to have a left parieto-occipital SAH by MRI. At that time she was also diagnosed with ovarian CA - found to have 2 ovarian masses. In addition, she was found to have multiple DVTs in [**Last Name (LF) **], [**First Name3 (LF) **] IVC filter was attempted but due to the clot burden, this was not possible. She was then started on lovenox [**Hospital1 **]. A repeat MRI 2 months later demonstrated resolution of SAH. She has been taking keppra for sz ppx since [**9-30**] and has not missed a dose (husband administers medications). She had never had another sz. prior to the one prompting this admission. She normally walks with a walker, as she does not fill steady standing up. . In the MICU MRI w/ contrast showed revealed no evidence of metastases. EEG showed slow waves w/ ? rt occipital focus of eliptogenicity and ? encephalitis. LENI demonstrated large RLE DVT--IVC filter was placed on [**1-11**]. TTE demonstrated no PFO. There was no significant stenosis of the lt or rt carotids on U/S. Image guided LP appeared benign but cytology is pending. The pt's mental status improved and she was extubated on [**1-10**] and she was transfered to the floor on [**1-12**]. Past Medical History: 1. Ovarian CA - stage III, on taxol and carboplatin (4th cycle)- oncologist is Dr. [**First Name (STitle) **] at [**Hospital1 **] 2. Hypothyroidism 3. HL 4. h/o left parieto-occipital SAH [**9-30**], repeat MRI 2 months later showed resolution 5. HTN 6. LBBB 7. h/o right pelvic vein DVT 8. Anxiety, longstanding predating diagnosis of CA 9. h/o right Bell's palsy, since 1.5 yrs ago Social History: Married, lives with her husband. Quit smoking 20 yrs ago, no EtOH, no illicits. Formerly worked at [**Doctor Last Name **] factory soldering electronics. Family History: No hx of seizures. Physical Exam: VS: Tc 98.1, BP 118/64, HR 76, RR 12, SaO2 100% on 2L General: NAD, lying in bed, teary HEENT: NC/AT, PERRL, EOMI, neck supple, left and right beatin nystagmus, no JVD Chest: CTAB CV: RRR, s1 s2 normal, no m/g/r Abd: soft, NT/ND, no HSM Ext: left groin has dry intact dressing. No edema, 2+ DP pulses bilaterally. Neuro: Alert rt facial droop. Visual fields grossly intact on this exam though pt has recent hx lt neglect. Otherwise CNII-XII intact. Strength 5/5 in all extremities. Thinks year is [**2128**] and that she was born in [**2098**]. Says she is at [**Hospital1 18**] and that day is Wednesay the 14th. Knows [**Last Name (un) 2450**] is president. Pertinent Results: REPORTS: BILAT LOWER EXT VEINS PORT [**2160-1-10**] 10:59 AM Substantial non-occlusive thrombus extending from the right popliteal vein to the junction of greater saphenous and common femoral veins. CT may be obtained, if further evaluation of proximal extent is needed. . MR HEAD W & W/O CONTRAST [**2160-1-10**] 5:15 AM Normal MRI of the brain. . TTE: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60-70%). Regional left ventricular wall motion is normal. 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. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. . CAROTID SERIES COMPLETE [**2160-1-11**] 12:49 PM Minimal bilateral ICA plaque, no appreciable associated stenosis, however (graded as less than 40% bilaterally). . CT HEAD W/O CONTRAST [**2160-1-12**] 8:44 AM No acute intracranial hemorrhage or mass effect. . EEG: Abnormal routine EEG in the waking and sleeping states due to the diffuse right hemiphere slowing suggestive of subcortical dysfunction, which at times spread to the left temporal region. Rare right occipitotemporal dicharges were seen, consistent with a focal area of potential epileptogenesis. However, the frequency of the discharges has significantly reduced and this is much improved compared to her previous study on [**2160-1-10**]. Focal slowing seen in the left temporal region suggest subcortical dysfunction in that region. . CSF: NEGATIVE FOR MALIGNANT CELLS. Predominantly blood. . LABS: . [**2160-1-17**] 06:20AM BLOOD WBC-4.7 RBC-3.26* Hgb-10.4* Hct-29.7* MCV-91 MCH-31.8 MCHC-34.9 RDW-19.4* Plt Ct-259 [**2160-1-16**] 06:25AM BLOOD WBC-4.4# RBC-3.14* Hgb-10.2* Hct-28.2* MCV-90 MCH-32.4* MCHC-36.1* RDW-19.2* Plt Ct-252 [**2160-1-15**] 04:30AM BLOOD WBC-11.2* RBC-3.36* Hgb-10.8* Hct-29.7* MCV-88 MCH-32.3* MCHC-36.5* RDW-19.0* Plt Ct-282 [**2160-1-14**] 04:35AM BLOOD WBC-12.9*# RBC-3.74* Hgb-11.9* Hct-34.5* MCV-92 MCH-31.9 MCHC-34.6 RDW-19.4* Plt Ct-263 [**2160-1-13**] 06:20AM BLOOD WBC-6.3 RBC-3.41* Hgb-10.9* Hct-31.3* MCV-92 MCH-31.9 MCHC-34.8 RDW-19.0* Plt Ct-240 [**2160-1-12**] 07:10AM BLOOD WBC-6.1 RBC-3.27* Hgb-10.4* Hct-30.1* MCV-92 MCH-31.9 MCHC-34.6 RDW-19.3* Plt Ct-214 [**2160-1-11**] 03:55AM BLOOD WBC-6.2 RBC-3.22* Hgb-10.2* Hct-29.8* MCV-93 MCH-31.7 MCHC-34.3 RDW-19.7* Plt Ct-218 [**2160-1-10**] 04:28AM BLOOD WBC-11.2* RBC-3.49* Hgb-10.9* Hct-31.7* MCV-91 MCH-31.4 MCHC-34.5 RDW-20.0* Plt Ct-264 [**2160-1-9**] 08:30PM BLOOD WBC-11.4* RBC-3.52* Hgb-11.6* Hct-31.1* MCV-88 MCH-32.9* MCHC-37.2* RDW-19.8* Plt Ct-256 [**2160-1-17**] 06:20AM BLOOD Plt Ct-259 [**2160-1-17**] 06:20AM BLOOD PT-11.4 PTT-27.8 INR(PT)-1.0 [**2160-1-16**] 06:25AM BLOOD Plt Ct-252 [**2160-1-16**] 06:25AM BLOOD PT-11.9 PTT-27.2 INR(PT)-1.0 [**2160-1-15**] 04:30AM BLOOD Plt Ct-282 [**2160-1-15**] 04:30AM BLOOD PT-13.5* PTT-30.4 INR(PT)-1.2* [**2160-1-14**] 04:35AM BLOOD Plt Ct-263 [**2160-1-13**] 06:20AM BLOOD Plt Ct-240 [**2160-1-12**] 07:10AM BLOOD Plt Ct-214 [**2160-1-11**] 03:55AM BLOOD Plt Ct-218 [**2160-1-9**] 08:30PM BLOOD PT-12.0 PTT-31.2 INR(PT)-1.0 [**2160-1-17**] 04:10PM BLOOD K-4.2 [**2160-1-16**] 06:25AM BLOOD Glucose-109* UreaN-4* Creat-0.5 Na-137 K-3.2* Cl-102 HCO3-25 AnGap-13 [**2160-1-13**] 06:20AM BLOOD Glucose-100 UreaN-6 Creat-0.5 Na-136 K-3.6 Cl-99 HCO3-25 AnGap-16 [**2160-1-10**] 04:28AM BLOOD Glucose-123* UreaN-7 Creat-0.6 Na-140 K-3.9 Cl-107 HCO3-22 AnGap-15 [**2160-1-9**] 08:30PM BLOOD Glucose-135* UreaN-7 Creat-0.7 Na-143 K-3.5 Cl-104 HCO3-23 AnGap-20 [**2160-1-9**] 08:30PM BLOOD ALT-30 AST-22 LD(LDH)-221 AlkPhos-61 Amylase-46 TotBili-0.2 [**2160-1-9**] 08:30PM BLOOD Lipase-15 [**2160-1-17**] 04:10PM BLOOD Mg-2.4 [**2160-1-17**] 06:20AM BLOOD Albumin-3.2* Calcium-8.2* Phos-2.2* Mg-1.4* [**2160-1-14**] 04:35AM BLOOD Albumin-3.5 Calcium-8.4 Phos-1.9* Mg-1.6 [**2160-1-10**] 04:28AM BLOOD Calcium-7.9* Phos-3.6 Mg-2.5 [**2160-1-9**] 08:30PM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.1 Mg-0.7* [**2160-1-9**] 08:30PM BLOOD TSH-3.9 [**2160-1-17**] 06:15AM BLOOD PTH-86* [**2160-1-17**] 06:20AM BLOOD Phenyto-6.2* [**2160-1-16**] 06:25AM BLOOD Phenyto-8.7* [**2160-1-12**] 05:55PM BLOOD Phenyto-18.3 [**2160-1-11**] 03:55AM BLOOD Phenyto-23.1* [**2160-1-9**] 08:30PM BLOOD Phenyto-15.3 [**2160-1-9**] 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2160-1-10**] 05:26PM BLOOD Lactate-1.5 [**2160-1-9**] 08:59PM BLOOD Lactate-1.6 . MICRO: . Blood cx's: pending Urine cx: negative CSF cx: NGTD Stool cx: positive for C.diff Brief Hospital Course: # Status epilepticus - Head CT x 2 and MRA negative for bleed or metastases. EEG showed ? encephalitic picture w/ ? rt occipital focus of eliptogenicity. No significant stenosis of carotids on U/S. She has a large chronic LE DVT, though TTE demonstrated no PFO. IR LP had negative gram stain. She was treated with Dilantin and Keppra and had no further clinical seizures. The pt's mental status improved and by [**1-10**] she was extubated and transferred from the MICU to the floor on [**1-12**]. . Upon arrival on the floor she complained of dizziness when sitting or standing that resolved immediately upon lying down. Physical exam demonstrated horizontal nystagmus, negative [**Location (un) **] Hallpike maneuver. Phenytoin level was 23. Likely Dilantin toxicity given temporal association with the drug. BPV was also a possibility. Dilantin was held for 24 hours, with resolution of nystagmus and improvement of dizziness. Dilantin was restarted at a reduced dose of 100mg [**Hospital1 **] IV. Given coverage with keppra, she was later had a 5 day taper of dilantin 100mg qhs po. She had no clinically evident seizures aside from the presenting event during this admission. . As for the source of seizure, there was no clear cause found on this admission despite imaging and CSF workup. Differential includes metastases, leptomeningeal carcinomatosis, hemorrhage, tumor, infection, hypertensive episode, or toxic/metabolic. Her EEG showed a question of epileptiform source in the rt occipital region. She had previously had SAH in [**9-30**] in the left parieto-occipital region. No blood or masses were found on CT x2 and MRI. There was blood on her LP, though serial imaging was not consistent with SAH and this was thought to be due to a traumatic tap. CSF fluid did not suggest infection and HSV PCR was negative. There were no malignant cells on CSF cytology, though there were predominantly RBCs. After discussion w/ neuro and medicine attending, second tap was deferred as the probability of leptomeningeal carcinomatosis was low. . # ID: At the beginning of her admission she was started on ciprofloxacin for UTI. Near the end of the course of this drug, her temp spiked to 102, she had a WBC bump to 12 and diarrhea. She was treated empirically w/ flagyl for c diff--c diff toxin was positive. Diarrhea, fever, and WBC count resolved on flagyl. She will complete her 10 day course of flagyl as an outpatient. . # DVT - Pt has history dvt in [**9-30**] but now w/large RLE clot seen on U/S. No clinical sx's to suggest PE. IVC filter placed by IR and treated with lovenox. . # Ovarian CA - The patient was scheduled to receive chemo the day after admission. She usually sees Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 699**] at [**Hospital1 498**], who has been notified. She will follow up with him within the week. . # Anxiety - the patient suffered from anxiety during this admission, which is a longstanding issue for her. She had an episode of "seeing spots" and an episode of "heaviness" along her chin bilaterally associated with teariness, anxiety. MD was called and present for all of these episodes; vitals were stable and neurological exam was unchanged. Sx resolved completely in ~20min to ~1hr after administration of 1mg ativan. Pt will be discharged on paxil 20mg qd. Pt will also receive ativan 0.5mg po bid + up to 2 x 0.5mg tabs prn per day for anxiety. . # For hypothyroidism, hyperlipidemia, htn, anxiety she was treated with her outpatient medications. . # FEN/GI - She had a regular diet throughout this admission. Of note, Mg was 0.7 on admission. Electrolyte abnormalities were carefully followed and repleted. She was discharged on her home electrolye regimen including klorcon and calcitriol. Oral magnesium and phosphate repletion was also added. Covering providers for her oncologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 699**]) and PCP (Dr. [**Last Name (STitle) 71629**] [**Numeric Identifier 71630**]) were contact[**Name (NI) **]. [**Name2 (NI) **] the oncology clinic her Ca, Phos, Mg had been low (~6.9, ~2.0, ~1.4) throughout her last admission in [**Month (only) **]. Apparently electrolye abnormalities are longstanding--they may potentially be related to her cancer or chemotherapy. Her PTH during this admission was elevated at 86. The patient has been instructed to make appointments with her primary care doctor early next week to monitor her electrolyes and discuss her medications. . # MISC - On CXR there there is a note of an incidentally noted T5 or T6 compression fracture - ? etiology given isolated nature, and high level in thoracic spine. We recommend further follw-up. . # Code - full Medications on Admission: 1. Lovenox 90 mg [**Hospital1 **] 2. Levothyroxine 0.05 mg qd 3. Keppra 500 mg [**Hospital1 **] 4. Simvastatin 40 mg qhs 5. Calcitriol 0.25 mcg qd 6. Protonix 40 mg [**Hospital1 **] 7. Propranolol 40 mg tid 8. Zofran prn 9. Prochorperazine prn 10. Ambien prn 11. kclor 11. Lorazepam 0.5 mg qd prn 12. Hydrocodone 1 mg qd prn 13. Dexamethasone 20 mg [**Hospital1 **] prn Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous Q12H (every 12 hours). [**Hospital1 **]:*90 30* Refills:*2* 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 5. Propranolol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Zofran 8 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 7. Hydrocodone-Acetaminophen 5-500 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for pain. 8. Dilantin 100 mg Capsule Sig: One (1) Capsule PO at bedtime for 4 days. [**Hospital1 **]:*4 Capsule(s)* Refills:*0* 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. [**Hospital1 **]:*18 Tablet(s)* Refills:*0* 11. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO twice a day. [**Hospital1 **]:*150 Tablet(s)* Refills:*2* 12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. Klor-Con M20 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. [**Hospital1 **]:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 15. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) PO once a day for 2 weeks. [**Telephone/Fax (3) **]:*14 14* Refills:*2* 16. Magnesium Chloride 64 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. [**Telephone/Fax (3) **]:*28 Tablet Sustained Release(s)* Refills:*2* 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety: Please take 0.5mg twice a day, make take an additional tablet as needed. Please discuss this with your PCP. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 18. Outpatient Lab Work Please get your electrolytes including calcium, phosphate, and magnesium measured at your pcp's office on monday or tuesday of the week of [**1-21**]. Discharge Disposition: Home Discharge Diagnosis: Primary: 1) Status epilepticus - etiology unclear 2) Phenytoin toxicity 3) DVT while on chronic anticoagulation, s/p IVC filter placement 4) there is a note of "an incidentally noted T5 or T6 compression fracture - query etiology given isolated nature, and high level in thoracic spine" in the record communicated to us. However no record of this finding was found on any of the imaging studies performed at this hospital; it may have been found at the outside hospital. Would suggest imaging confirmation of this finding. 5) hypokalemia, hypophosphatemia, hypomagnesemia 6) C dificile colitis Secondary: 1) Ovarian CA - stage III 2) h/o SAH 3) Hypothyroidism 4) Hyperlipidemia 5) HTN 6) LBBB 7) Anxiety 8) Bell's palsy Discharge Condition: Fair. Has had no seizures since inciting event. Improving C dif diarrhea. Discharged home on keppra. Finishing a dilantin taper and 10 day Flagyl course. Discharge Instructions: You were diagnosed with a seizure (status epilepticus). You received two drugs, Dilantin and Keppra, to prevent new seizures. You also received a intravenous filter to prevent extension of your DVT (deep venous thrombosis) into your heart and lungs. . Please call your physician or return to the hospital if you develop headache, loss of consciousness, change in mental status, sedation, seizure, dizziness, chest or abdominal pain, or shortness of breath. . You had an diarrheal infection (c. dificile) which was treated with flagyl (an antibiotic). . Please make appointments to see your oncologist and primary physician. [**Name10 (NameIs) **] should see you primary physician early next week. You should have your electrolyte levels (including potassium, calcium, magnesium and phosphate) measured at this time. We also suggest you take your lorazepam 0.5mg twice a day, and then take up to an additional 0.5mg as needed for anxiety. You were also started on Paxil (paroxetine) 20mg each day for anxiety. Please review your anxiety medications with you physician early next week. . Please take all medications as directed. Please discuss these medication changes with your physician. [**Name10 (NameIs) 357**] keep all of your follow up appointments. Followup Instructions: 1) Please call your oncologists office ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 699**]) to set up an appointment with him next week. 2) Please call your primary care doctor's office (Postnitz) to set up an appointment to check your electrolytes early next week. 3) You have an appointment with Dr. [**First Name (STitle) 951**] (neurology) on [**3-21**]. 4) There is a note of an 'incidentally noted T5 or T6 compression fracture - query etiology given isolated nature, and high level in thoracic spine' in the records communicated to us. However no record of this finding was found on any of the imaging studies performed at this hospital; it may have been found at the outside hospital. Please discuss this finding with your PCP--[**Name10 (NameIs) **] suggest imaging confirmation. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2160-3-21**] 2:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2160-1-18**]

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Discharge summary

report

Admission Date: [**2132-7-3**] Discharge Date: [**2132-7-5**] Date of Birth: [**2071-6-8**] Sex: M Service: MEDICINE Allergies: Codeine / Compazine Attending:[**First Name3 (LF) 10370**] Chief Complaint: Alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 99662**] presented to the ED the morning of admission at 10 AM, appearing disheveled and smelling of urine per triage note. He told the nurses and doctors in the [**Name5 (PTitle) **] that he felt like he was "going to have a seizure" and reported a history of alcohol withdrawal seizures. He reports to us that he has recently been drinking a large bottle of vodka each day, indicating with his hands a bottle of a height suggestive of a liter's volume. He did not remember this admission when he's had his last seizure although he is sure that he has had them in the past; a past note includes his statement that he last had one in [**2132-3-16**]. Of note he has been admitted to the [**Hospital1 18**] several times in the past few months, including a recent admission on [**5-16**]/09 in which he complained of hematemesis, and an EGD was unrevealing; and an alcohol withdrawal admission in [**Month (only) 956**] of this year. He left AMA for the latter admission. He has had periods of sobriety and claimed in his prior admission that he had only recently started drinking five days prior to that admission. He endorses tremulousness and some anxiety and agitation. He denies chest pain or shortness of breath. He denies recent GI bleeding or hematemesis. He does report some pain in his right groin which he evidently initially reported as right lower quadrant abdominal pain. In the emergency department his initial vitals were t 98.1, bp 137/95, hr 98, rr 18, O2 99% on room air. He received 3L NS; a banana bag of thiamine, folate, MVI; valium 10, 20, 20, 10, with a "may repeat" order for another 20, suggesting a total dosing of 60. He was in the observation unit of the ED and there were some gaps in him receiving timely valium doses. He got an abdominal CT because of concern about his RLQ pain; this did not show any acute process. A head CT showed stably large ventricles. Past Medical History: * recent admission for hematemesis, thought likely to be [**Doctor First Name **]-[**Doctor Last Name **] tear, endoscopy was unremarkable * hypertension * past chronic hepatitis C, genotype 2; (followed by Dr. [**Last Name (STitle) **]; since [**2126**] has had undetectable viral loads after successful treatment w interferon and ribavarin; last VL in system from [**7-/2131**]) * ?hepatitis B exposure in the past * alcoholism * prior IDU with prior methadone maintenance * depression/anxiety * panic disorder with agoraphobia * GERD s/p [**5-19**] Enteryx procedure * s/p CCY * chronic LBP, inactive * tobacco use * prior patellofemoral syndrome R knee * s/p medial meniscectomy [**10-19**] R knee * persistent nasal congestion * s/p inguinal hernia repair [**2132-6-3**] . Social History: Patient reports started drinking at age 13 with chronic use since that time. He reported on a past admission that his longest period of sobriety 4.5 years, although on this admission, claimed 19 years. History of blackouts, numerous prior detox programs. Remote cocaine, heroin, barbituates, +IVDU last active illicit use in [**2113**]. Per last admission, started drinking and smoking again 5 days prior to prior admission (presumably ~[**2132-6-19**]). Lives in [**Location **] on [**Location **]. In contact with mother ([**Age over 90 **] yo) and daughter ([**Name (NI) 12000**]). Family History: Father died at age 33 from malignant hypertension, mother with depression but otherwise healthy at [**Age over 90 **] yo, Daughter died of ovarian cancer, multiple other family members with etoh abuse on both sides of family (cousin, sister, uncle, aunt, father). Physical Exam: On presentation to the MICU: Flowsheet Data as of [**2132-7-4**] 02:19 AM Vital Signs Tmax: 36.4 ??????C (97.6 ??????F) Tcurrent: 35.9 ??????C (96.6 ??????F) HR: 90 (89 - 92) bpm BP: 152/95(105) {133/77(90) - 152/95(108)} mmHg RR: 14 (13 - 16) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) Height: 69 Inch O2 Delivery Device: Nasal cannula SpO2: 97% Physical Examination General Appearance: Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , No(t) Wheezes : ) Abdominal: Soft, Bowel sounds present, Tender: Extremities: Right: Trace, Left: Trace Skin: Warm, No(t) Rash: no stigmata of liver disease, No(t) Jaundice Neurologic: Attentive, Follows simple commands, interactive w conversation, somnolent when initially examined/interviewed; Movement: purposeful; no focal deficits . Pertinent Results: [**2132-7-3**] 10:00AM WBC-6.7 RBC-5.11 HGB-17.2 HCT-46.5 MCV-91 MCH-33.7* MCHC-37.0* RDW-14.8 [**2132-7-3**] 10:00AM NEUTS-47.6* LYMPHS-40.5 MONOS-5.9 EOS-4.5* BASOS-1.5 [**2132-7-3**] 10:00AM PLT COUNT-205 . [**2132-7-3**] 10:00AM GLUCOSE-82 UREA N-9 CREAT-0.9 SODIUM-144 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-27 ANION GAP-23* . [**2132-7-3**] 10:00AM ALT(SGPT)-42* AST(SGOT)-60* LD(LDH)-218 ALK PHOS-96 TOT BILI-1.5 [**2132-7-3**] 10:00AM LIPASE-33 [**2132-7-3**] 10:00AM CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-1.7 . CT ABD/PELV: IMPRESSION: 1. No evidence of appendicitis. 2. Fatty infiltration of the liver. 3. Diverticulosis without evidence of diverticulitis. 4. Scattered simple renal cysts. . CT HEAD: IMPRESSION: No acute intracranial process Brief Hospital Course: 61yo M with EtOH abuse admitted for withdrawal. #. Alcohol Withdrawal: Mr. [**Known lastname 99662**] on arrival showed signs of intoxication but also signs of withdrawal including tremulousness, tachycardia, and hypertension as well as agitation. He states a history of prior seizures during withdrawal. MCV of 91 and no appearance of malnourishment supports possibility that relapse into serious alcohol abuse is relatively recent, and he may have had even recent periods of genuine sobriety. Pt does affirm a past devotion to 12 step groups and has had 2 different sponsors in the past. He was intially requiring Q1H IV valium due to CIWA of 20-27, but his requirement has decreased and he was ordered for PO valium with CIWA of 14 on morning after admission. Patient was trasnferred to the floor and no longer required any additional Valium as per his CIWA scale. Patient decided to leave AMA. Explained to patient the risks of continued binge drinking as well as his liver disease. # HTN: Holding BP meds as he was normotesnive on presentation and we were better able to assess withdrawal symptoms. Patient instructed to resume his outpatient medications on discharge. # Anxiety: C/O agoraphobia however not anxious when full medical team in room. Patient states he is extremely nervous and anxious and needs to leave the hospital. Social work was consulted and note in the chart. Patient left AMA so was not able to furthur address this issue. # Hep C: Due for RUQ u/s as does not get followed as o/p for this disease. Would rather set him up with liver service here and then they can further evaluate him. Patient left AMA prior to scheduling outpatient appointments. Patient advised that he needs outpatient liver ultrasound and outpatient liver follow up. Patient advised that needs to stop drinking. Medications on Admission: As of last admission [**2132-6-24**], but these were not discharge meds given that he left AMA while still on a CIWA scale: 1. Thiamine HCl 100 mg PO DAILY 2. Folic Acid 1 mg PO DAILY 3. Omeprazole 20 mg daily 4. Lisinopril 10 mg PO DAILY 5. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: NA Discharge Disposition: Home Discharge Diagnosis: Primary: alcohol withdrawal . SEcondary: * recent admission for hematemesis, thought likely to be [**Doctor First Name **]-[**Doctor Last Name **] tear, endoscopy was unremarkable * hypertension * past chronic hepatitis C, genotype 2; (followed by Dr. [**Last Name (STitle) **]; since [**2126**] has had undetectable viral loads after successful treatment w interferon and ribavarin; last VL in system from [**7-/2131**]) * ?hepatitis B exposure in the past * alcoholism * prior IDU with prior methadone maintenance * depression/anxiety * panic disorder with agoraphobia * GERD s/p [**5-19**] Enteryx procedure * s/p CCY * chronic LBP, inactive * tobacco use * prior patellofemoral syndrome R knee * s/p medial meniscectomy [**10-19**] R knee * persistent nasal congestion * s/p inguinal hernia repair [**2132-6-3**] Discharge Condition: afebrile, HR 74, BP 150/100, R 18 95% on RA Discharge Instructions: NA Followup Instructions: Patient left AMA Completed by:[**2132-7-5**]

[ "070.32", "562.10", "303.01", "593.2", "305.1", "291.81", "401.9", "530.81", "300.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8088, 8094

5913, 7732

297, 303

8954, 8999

5126, 5838

9050, 9096

3669, 3934

8061, 8065

8115, 8933

7758, 8038

9023, 9027

3949, 5107

239, 259

331, 2249

5847, 5890

2271, 3051

3067, 3653

24,528

168,104

9362+56027

Discharge summary

report+addendum

[**Numeric Identifier 31993**] Admission Date: [**2140-10-27**] Discharge Date: [**2140-11-14**] Date of Birth: Sex: M Service: HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is an 80 year old white male who had the acute onset of heavy, [**6-26**], substernal chest pain from his jaw to his mid-sternum which radiated to his left shoulder and arm. He had tingling of his left arm, right eye blurriness and denied back pain. He was visiting his wife who was having surgery at [**Hospital1 **] [**Name (NI) **] and presented to the emergency room where his pain had decreased to [**12-28**]. He had a CT which revealed a type A dissection including the arch vessels. Dr. [**Last Name (Prefixes) **] was consulted and the patient was transferred immediately to the operating room. PAST MEDICAL HISTORY: History of hypertension. History of bradycardia status post pacemaker. Status post bilateral inguinal hernia repairs. History of chronic venous stasis ulcers bilaterally. Stable abdominal aortic aneurysm which has been followed. MEDICATIONS ON ADMISSION: Norvasc, hydrochlorothiazide. ALLERGIES: No known allergies. SOCIAL HISTORY: The patient does not smoke cigarettes, does not drink alcohol. He is married. FAMILY HISTORY: Father died of abdominal aortic aneurysm. Brother had ruptured abdominal aortic aneurysm. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: The patient was an elderly white male in no apparent distress. Vital signs were temperature 96.1, heart rate 57, blood pressure 94/50, respiratory rate 16, O2 sat 95 percent. HEENT exam normocephalic, atraumatic, extraocular movements intact, oropharynx benign. Neck was supple, full range of motion, no lymphadenopathy or thyromegaly, carotids 2+ and equal bilaterally. Lungs were clear to auscultation and percussion. Cardiovascular exam regular rate and rhythm, normal S1, S2 with no rubs, murmurs or gallops. Abdomen was soft, nontender with positive bowel sounds, no masses or hepatosplenomegaly. Extremities had 2+ femoral pulses bilaterally. HOSPITAL COURSE: The patient was transferred to the operating room where he had replacement of the ascending aorta and transverse arch with valve resuspension with a 28 mm Gel-Weave graft. Cross clamp time was 94 minutes. Total bypass time was 127 minutes. Circulorespiratory time 19 minutes. He was transferred to the CSRU on milrinone, Neo and propofol in stable condition. He remained sedated overnight and on milrinone. He extubated himself on post-op day two. He also had a bronch which showed mild thin secretions bilaterally with no mucous plug. His pacemaker was evaluated and was shown to have a old battery which needed to be replaced. On [**10-30**] he underwent pacer generator change. He required aggressive pulmonary therapy and had his mediastinal chest tubes discontinued on post-op day five. The patient had his antihypertensive medications increased. He was transferred to the floor on post-op day five. On post-op day six he was unable to move his left lower extremity. Neuro saw the patient and felt that he could have some spinal component. He had a negative head CT. He then had a spine CT and a myelogram. The myelogram showed severe spinal stenosis at the L4-L5 region, but they also felt he had a spinal cord infarct, but this could not be visualized. It would have been helpful to have an MRI, but he was unable to have that due to his pacemaker. Eventually his leg function resolved on his own and he is now able to ambulate on his leg. Th[**Last Name (STitle) 1050**] continued to slowly improve. He also had a swallowing evaluation which revealed that he should have a nectar thick diet, but can eat other solid food as well. He had some intermittent confusion, but was easily reoriented. He was also seen by neurosurgery for his spinal cord stenosis and they felt there was no treatment at this time. He again had his pacemaker reprogrammed on [**11-14**]. So on post-op day 17 he was discharged to rehab in stable condition. He did have dehiscence of his sternum, but it was sterile and there was no drainage. He continues to have an unstable sternum and this will be followed by Dr. [**Last Name (Prefixes) **] in two weeks as an outpatient. We will leave his sternal staples in until that time as well. The patient also did undergo cardiac cath on [**11-9**] which revealed that the thoracic aorta repair was noted. There was an inferior plane distal to the repair without extravasation. This may represent access to the false lumen distal to the repair section. The repair is intact and the false lumen does not appear to fill from the thoracic arch aorta. His labs on discharge are hematocrit 33.8, white count 11, platelet count 441,000. Sodium 144, potassium 4.1, chloride 109, CO2 28, BUN 28, creatinine 1.2, blood sugar 90. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Aspirin 325 mg p.o. q.day. 3. Tylenol one to two p.o. q.four to six hours p.r.n. pain. 4. Quinine sulfate 325 mg p.o. q.h.s. 5. Dilaudid 1 to 2 mg p.o. q.four to six hours p.r.n. pain. 6. Levaquin 500 mg p.o. q.day times three days for E.coli UTI. 7. Albuterol nebs q.six hours p.r.n. 8. Nystatin swish and swallow 5 ml q.i.d. times seven days. 9. Lasix 40 mg p.o. q.day for seven days. 10. KCl 20 mEq p.o. q.day times seven days. FO[**Last Name (STitle) **]: The patient will be followed by Dr. [**Last Name (Prefixes) **] in two weeks and by Dr. [**Last Name (STitle) 1007**] upon discharge from rehab. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 28280**] MEDQUIST36 D: [**2140-11-14**] 13:01 T: [**2140-11-14**] 13:09 JOB#: [**Job Number 31994**] Name: [**Known lastname 2892**], [**Known firstname **] H Unit No: [**Numeric Identifier 5562**] Admission Date: [**2140-10-27**] Discharge Date: [**2140-11-14**] Date of Birth: [**2060-9-8**] Sex: M Service: ADDENDUM: Mr. [**Known lastname **] needs to adhere to strict sternal precautions due to his sternal dehiscence. This was communicated on Page One and Discharge Summary going to rehabilitation. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Name8 (MD) 5563**] MEDQUIST36 D: [**2140-11-14**] 16:50 T: [**2140-11-14**] 17:19 JOB#: [**Job Number 5564**]

[ "E878.2", "441.02", "427.31", "998.32", "336.1", "401.9", "724.02", "599.0", "998.11" ]

icd9cm

[ [ [] ] ]

[ "99.07", "35.39", "39.61", "37.87", "88.56", "34.03", "38.44", "88.42", "37.22", "33.22", "87.21" ]

icd9pcs

[ [ [] ] ]

1294, 1385

4918, 6529

1116, 1180

2118, 4895

1443, 2100

1405, 1420

855, 1089

1197, 1277

64,846

108,073

20444

Discharge summary

report

Admission Date: [**2193-3-16**] Discharge Date: [**2193-3-22**] Date of Birth: [**2141-4-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 13541**] Chief Complaint: UGIB Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: 51 y/o M transferred from [**First Name4 (NamePattern1) 8125**] [**Last Name (NamePattern1) **] with coffee ground emesis. Recently admitted to [**Hospital Unit Name 196**] service with an NSTEMI/viral myo-pericarditis. At that time cath demonstrated clean coronaries, but trop reached 3.0, and regional LV systolic dysfunction. No echo performed. Was treated with NSAIDS during hospital stay. Since going home has he intermittent chills, fevers. Black vomitus since Thursday. Went to OSH with coffee ground emesis. No BRB. Guaiac positive from below. No NG lavage done at OSH. In the ED, initial vs were: T 99.0 P114 BP105/70 R93-94% 2LNC O2 sat. Hct stable at OSH. OG tube was flushed and did not clear, but no BRB - was dark colored. No further emesis. CT torso obtained given recent instrumentation that showed airspace opacities in right, middle, and upper lobes, c/w aspiration and pneumonia. Was given vancomycin in ED, had received levaquin at OSH. GI consult felt this was likely not variceal bleed and said would see first thing in AM. PPI gtt continued, and octreotide d/c'd. At time of transfer, HR 105, 124/69, RR16, 93%2-3L NC, patient with 4 large guage peripheral IV's. Past Medical History: Hypertension Alcohol abuse (quit 2 weeks ago) PTSD H/o knife wound to chest, with damage to pulmonary artery status post repair Recent h/o testicular torsion status post surgical repair Hepatitis C GERD Pulmonary hypertension Social History: 10PY smoking history, quit 3 years ago. Remote h/o cocaine abuse. H/o EtOH abuse but clean x3 months. Family History: No FHx of early MI. Physical Exam: Gen: Comfortable in the hospital bed HEENT: No JVD, CN II-XII intact to confrontation CV: S1 & S2 regular without murmur Pulm: B diffuse crackles and rhonchi Abdominal: Soft, Tender Extremities: R hip tenderness Neurologic: Attentive, Follows simple commands Pertinent Results: [**2193-3-15**] 11:00PM PT-15.9* PTT-32.5 INR(PT)-1.4* [**2193-3-15**] 11:00PM NEUTS-71* BANDS-14* LYMPHS-9* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2193-3-15**] 11:00PM WBC-19.4*# RBC-3.19* HGB-10.3* HCT-30.4* MCV-95 MCH-32.3* MCHC-33.9 RDW-13.9 [**2193-3-15**] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2193-3-15**] 11:00PM CK-MB-15* cTropnT-1.12* [**2193-3-15**] 11:00PM ALT(SGPT)-63* AST(SGOT)-87* ALK PHOS-63 TOT BILI-0.7 [**2193-3-15**] 11:00PM LIPASE-11 [**2193-3-16**] 03:01AM LACTATE-1.6 [**2193-3-16**] 05:28AM WBC-14.2* RBC-2.72* HGB-9.0* HCT-26.0* MCV-96 MCH-33.0* MCHC-34.6 RDW-13.8 [**3-16**] Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). There is no ventricular septal defect. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. [**3-16**] CT Torso: 1. Inflammatory change of the right colon and mesenteric/portal venous gas is highly concerning for ischemia. 2. Extensive right diffuse airspace opacification in a pattern that suggests aspiration or bronchopneumonia. [**3-16**] Upper GI Endoscopy: Findings: Esophagus: Excavated Lesions [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear was seen in the gastroesophageal junction. Stomach: Mucosa: Erythema, congestion and friability of the mucosa with contact bleeding were noted in the antrum. These findings are compatible with gastritis. Duodenum: Normal duodenum. Impression: Erythema, congestion and friability in the antrum compatible with gastritis. [**Doctor First Name **]-[**Doctor Last Name **] tear. Otherwise normal EGD to second part of the duodenum Recommendations: No active bleeding seen, no varices. Continue PPI twice daily. Continue to monitor Hct and transfuse to Hct>26. CTA abdomen/pelvis ([**3-17**]): The lung bases demonstrate scattered patchy opacities which are more prominent on the right and may represent small foci of pneumonia. There are small bilateral effusions, right greater than left. Heart size is normal. There is no pericardial effusion. The liver, spleen, adrenals, pancreas and intra-abdominal loops of small bowel are unremarkable. Post-cholecystectomy changes are stable. The imaged venous and arterial vessels are patent. Wall thickening and stranding along the hepatic flexure to the mid ascending colon is slightly less conspicuous since [**2193-3-16**]. There are no definite areas of pneumatosis, with air in the non dependant portions of the cecum (3a:91-116) likely representing air. The kidneys enhance and secrete contrast symmetrically. The imaged small bowel is unremarkable. CT PELVIS: The rectum, prostate and sigmoid are unremarkable. The bladder demonstrates a Foley catheter and a small amount of air. Bone windows demonstrate no evidence of lesions that is suspicious for metastatic or infectious focus, with multilevel degenerative changes in the thoracolumbar spine which are similar to [**2193-3-16**]. A linear lucency along the superior right acetabulum (3B:372) likely represents nondisplaced fracture. IMPRESSION: 1. There is no evidence of ischemia with resolution of portal venous and mesenteric air since yesterday. Colitis involving the hepatic flexure to the mid ascending colon is less prominent since yesterday. 2. Likely Nondisplaced right acetabulum rim fracture. CXR ([**3-19**]): Bilateral airspace with greater involvement on the right is slightly improved. There are small bilateral pleural effusions. Heart size and mediastinal contours are unchanged. Old rib fracture noted on the right. IMPRESSION: Improving aspiration pneumonitis or pneumonia. Microbiology: urine cx ([**3-16**]) negative blood cx ([**3-16**]) no growth to date MRSA screen ([**3-16**]) negative Influenza a/b antigen negative ([**3-16**]) C diff toxin negative ([**3-18**]) Brief Hospital Course: This is a 51 y/o M w/ hep C who presented with UGIB after 3d of high dose ibuprofen for new dx of myopericarditis manifested by coffee ground emesis and aspiration pneumonia. # GI Bleed: Evidence of gastritis and [**Doctor First Name 329**] [**Doctor Last Name **] tear on endoscopy with hematocrits stable after 2 U prbcs given in the ICU. He also had a new finding of colitis on colonoscopy but this was not likely source for bleed. He has tolerated PO BID PPI and should continue this until follow up with his PCP. [**Name10 (NameIs) **] should avoid NSAIDs. - PPI [**Hospital1 **] - Monitor Hct daily # Aspiration pneumonia: The patient presented after vomiting with fever, elevated WBC count, and CXR/CT findings of infiltrate, making pneumonia likely [**2-25**] to aspiration of gastric contents. He was negative for influenza on admission. His infiltrate persisted over days. He will finish a 14-day course of levofloxacin/flagyl (for both pneumonia and colitis) on [**2193-3-31**]. Sputum culture was contaminated but did not show MRSA so vancomycin discontinued on transfer to medical floor. Supplemental oxygen was used as necessary to maintain oxygen saturation > 92%. # Tachycardia: Tachycardia on admission resolved with volume repletion, likely resultant from bleeding. He denied recent alcohol use on admission. He does take benzodiazepines as an outpatient so this was continued. Tamponade was considered but echocardiogram showed a trivial pericardial effusion. He tolerated beta blockade once blood pressure and hematocrit were found to be stable. # Myo-pericarditis: Enzymes were trending down on admission. Echo showed trivial effusion as above. Continued beta blockade. # Colitis: Unclear etiology but considered etiologies include ischemic vs. inflammatory. Surgery evaluated the patient after portal gas was seen on his first CT chest; on repeat CTA the next day, there was no evidence of portal gas. He was maintained NPO/sips for bowel rest and then regular diet was restarted without any adverse effects. He will receive a total 14 day treatment with levofloxacin 500 mg daily and flagyl 500 mg TID. This will end on [**2193-3-31**]. The patient was C diff toxin negative X 2. He will need an outpatient colonoscopy once this acute episode resolves. Pain was controlled with PO morphine. # Acetabular rim fracture: The patient was found to have a fracture on CT scan of the abdomen. Orthopedic consultation was obtained who recommended two months of touchdown weight bearing and two months of posterior hip dislocation precautions. He will follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/Dr. [**Last Name (STitle) **] at [**Hospital1 18**] in orthopedics. Once hematocrit stabilized he was started on lovenox 40 mg daily to continue until fully ambulatory. # Hepatitis: No evidence of varices on endoscopy. Should resume prior follow up plan. Medications on Admission: 1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. LeVETiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 9. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 11. Prazosin 1 mg Capsule Sig: One (1) Capsule PO at bedtime. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO once a day. 6. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily) for 1 months: Until fully ambulatory. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days: To end [**2193-3-31**]. 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days: To end [**2193-3-31**]. 9. Terazosin 2 mg Capsule Sig: One (1) Capsule PO at bedtime. 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for Anxiety: Please hold for sedation. Patient should not drive after taking this medication. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for dyspnea/wheeze. 12. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Hold for sedation. Patient should not drive after taking this medication. Please wean as tolerated. 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 14. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 1474**] Veteran's Hospital Discharge Diagnosis: Aspiration pneumonia Right-sided colitis, NOS Gastritis, probably NSAID-induced Upper GI bleed secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear Right acetabular rim fracture Recent viral myopericarditis Discharge Condition: Afebrile, normotensive, comfortable on room air/ 2L NC Discharge Instructions: You have been evaluated for your nausea/vomiting and were found to have an irritation of the stomach ("gastritis") as well as a small tear in the lining of the esophagus. Your blood counts have been stable since this finding. You will need to continue protonix to protect your stomach. You were also found to have a right hip fracture; you will need to continue touchdown weight-bearing only for two months. You should also continue posterior hip dislocation precautions for two months. You were treated for a pneumonia while in the hospital. This may have been related to your vomiting. You are being treated for an inflammation of the colon. This will continue for a total of two weeks of treatment. Please take your medications as prescribed and keep your follow up appointments. Please contact your primary care physician or return to the emergency room should you develop any of the following: fever > 101, chills, difficulty breathing, increased cough, increased abdominal pain, inability to take in liquids or medications due to nausea or vomiting, blood in the stools, or any other concerns. Followup Instructions: Please contact Dr. [**Last Name (STitle) **], your primary care physician, [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 54768**] within 1-2 weeks for a follow up appointment. You should follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] / Dr. [**Last Name (STitle) **] in Orthopedics on Thursday, [**4-4**], at 10:00 am on the [**Location (un) 1385**] of the [**Hospital Ward Name 23**] Clinical Center at [**Hospital1 18**]. Please call his office at ([**Telephone/Fax (1) 2007**] if there are any problems with this appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]

[ "530.7", "309.81", "423.9", "345.90", "808.0", "285.1", "530.81", "E888.9", "401.1", "E935.9", "416.8", "535.40", "410.72", "507.0", "070.54", "558.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

12239, 12305

6735, 9646

278, 296

12569, 12625

2230, 6712

13778, 14475

1914, 1935

10622, 12216

12326, 12548

9672, 10599

12649, 13755

1950, 2211

234, 240

324, 1529

1551, 1779

1795, 1898

984

104,271

7880

Discharge summary

report

Admission Date: [**2143-1-7**] Discharge Date: [**2143-1-22**] Date of Birth: [**2074-4-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: SOB Major Surgical or Invasive Procedure: V/Q scan CT scans TTE TEE PICC placement Bedside thoracentesis CT-guided thoracentesis Persantine cardiac stress test History of Present Illness: Pt. is a 68 yo active retired man with hemochromatosis, cirrhosis and DM, who had a mechanical fall 2 weeks prior to admission while at his winter home in [**State 108**]. After falling, he developed left sided rib pain (later found to be due to rib fracture), and sought care at the local ED, where he was told to take tylenol. After continuing to have pain for several more days he returned to the ED and was prescribed motrin for the rib pain. He reports taking 600mg every 4-5 hrs for 3-4 days. He also reports having very diminished appetite and eating and drinking very little during this time. Three days PTA, he developed SOB. At the urging of his children, he flew back from FL to be seen here in [**Location (un) 86**]. In addition to decreased PO intake, he reported insomnia and nausea/dry heaves. He denied abdominal pain, fevers, chills, sick contacts, or travel out of the country. . On admission, EKG showed right heart strain and possible lateral ischemic changes. Pulmonary embolism was considered; V/Q scan was read as low probability. Acute coronary syndrome was also considered, and cardiac enzymes were elevated with troponin 0.12 and MB index 14.8. Heparin gtt was started, along with ASA and beta blocker. Also on admission, he was found to have lactic acidosis in setting of ARF (creatinine 3.4 with baseline 1.1) with serum lactate 3.9 --> 6.7 and Anion Gap of 25. Serum potassium was 6.0 and bicarb 12. He was given bicarb gtt for acidosis and kayexelate, insulin and glucose for elevated K. . Initial temp was 94.4 and CXR showed vague opacity in RML. Blood cultures were drawn and levo/vanc started. In the ED, patient has 2 transient episodes of hypotension which resolved spontaneously. He was admitted to the MICU. Past Medical History: PMH: * Hemochromatosis with monthly phlebotomy; dx 15 yrs ago * Cardiac involvement from hemochromatosis * DM * hx of colon polyps * gallstones (asx) * Hypothyroidism * ARF in setting of NSAID use 13 years ago, requiring 5 months of HD. Social History: Widowed, occ alcohol, no cigarettes Family History: Parents died in their 50s, unknown cause Physical Exam: VS: T 95.2 BP 132/43 HR 74 RR 15 O2sat 100% NRB GEN: NAD, pleasant HEENT: PERRL, EOMI, no scleral icterus, MM dry NECK: JVP flat, no LAD CHEST: gynecomastia, decreased breath sounds at the bases, no wheezes, no crackles CV: Distant heart sounds, RRR, No m/r/g ABD: Normal bowel sounds, soft, nontender, no hepatomegaly EXT: bilateral 2+ pitting edema, flat maculopapular rash on left foot, 2+DP bilaterally NRO: CN 2-12 intact, 5/5 strength throughout Pertinent Results: LABS ON ADMISSION [**2143-1-7**]: . WBC-16.3*# RBC-4.63 HGB-13.8* HCT-39.5* PLT COUNT-131* MCV-85 MCH-29.7 MCHC-34.8 RDW-16.6* NEUTS-92.6* LYMPHS-4.4* MONOS-2.9 EOS-0 BASOS-0.1 . SODIUM-130* CHLORIDE-92* TOTAL CO2-13* GLUCOSE-291* UREA N-52* CREAT-3.2*# SODIUM-129* POTASSIUM-5.4* CHLORIDE-93* TOTAL CO2-14* ANION GAP-27* LACTATE-6.7* . ALT(SGPT)-21 AST(SGOT)-37 CK(CPK)-122 ALK PHOS-156* AMYLASE-265* TOT BILI-1.1 LIPASE-12 ALBUMIN-2.6* . CK-MB-18* MB INDX-14.8* cTropnT-0.12* . URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD URINE RBC-0-2 WBC-[**5-25**]* BACTERIA-NONE YEAST-NONE EPI-0 URINE HOURS-RANDOM UREA N-247 CREAT-178 SODIUM-49 POTASSIUM-38 URINE OSMOLAL-358 . TYPE-ART PO2-74* PCO2-29* PH-7.35 TOTAL CO2-17* BASE XS--7 . . STUDIES: . #. V/Q scan [**2143-1-7**] INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate very heterogenous ventilation with numerous subsegmental defects bilaterally. Perfusion images in the same 8 views show numerous small bilateral non-segmental defects. These defects are in the same areas as the ventilation defects, but are less prominent. The AP dimension is enlarged, and the diaphgrams are flattened. The chest x-ray is clear. The above findings are consistent with a low probability for pulmonary embolism, but are consistent with COPD. . #. TTE [**2143-1-8**] Conclusions: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 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. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global systolic function. Right ventricular cavity enlargement with free wall hypokinesis and moderate-severe pulmonary artery systolic hypertension c/w a primary pulmonary process. . #. ECG [**2143-1-9**] Sinus rhythm, right ventricular hypertrophy, Diffuse ST-T wave changes with borderline prolonged/upper limits of normal Q-Tc interval - could be due in part to right ventricular hypertrophy but clinical correlation is suggested Since previous tracing of [**2143-1-8**], further ST-T wave changes present and Q-Tc interval appears short. . #. CT chest with Contrast [**2143-1-9**] IMPRESSION: 1. Right loculated collection which has high CT attenuation value and may represent either empyema or hemorrhage within pleural effusion. 2. Right lower lobe opacity with bronchial wall thickening which may represent pneumonia/aspiration. 3. Right basilar atelectasis. 4. Small left pleural effusion. 5. Ground-glass opacity in the right apex. This should be followed up with a CT in three months. 6. Focal ground-glass opacity in the right middle lobe and right lower lobe may represent infectious/inflammatory etiology. This could also be followed up on the CT which will be obtained in three months. 7. Atherosclerotic coronary calcifications. 8. Gallstones without evidence of cholecystitis. 9. Liver granulomas. . #. Renal US [**2143-1-10**]: FINDINGS: The right kidney measures 9 cm in length, previously measuring 9.5 cm. The left kidney measures 10.2 cm in length, previously measuring 10.7 cm in length. In the interpolar region of the right kidney, there is an area with lobulated appearance consistent with cortical scarring, unchanged from the prior study. In the interpolar region of the left kidney, there is a tiny cortical crystal. There is no hydronephrosis, stones, or renal masses. There is no perirenal fluid. The bladder is unremarkable. IMPRESSION: 1. Slight interval decrease in size in both kidneys. 2. There is no hydronephrosis. 3. Stable area of cortical scarring in the right kidney. . #. TEE [**2143-1-15**] Conclusions: 1. The left atrium is dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is difficult to assess but is probably normal. 3. There are complex (>4mm) sessile atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6. There is a small pericardial effusion. 7. No evidence of endocarditis seen. . #. CTA Chest [**2143-1-16**]: 1. No evidence of pulmonary embolism. 2. Unchanged right loculated collection within the pleural space of hyperattenuation. Given the appearance with increased subpleural fat, this has the appearance of chronic right effusion. It is difficult to comment on possible thickening of the pleura. 3. Small left simple effusion, slightly increased from the prior study. 4. 3-mm nodule in the right middle lobe. In the absence of known malignancy, one-year CT followup could be considered. 5. Atherosclerotic coronary artery calcifications. 6. Cirrhosis of the liver, with low-attenuation oval lesion near the dome. It is incompletely characterized on the study. 7. Gallstones without evidence of cholecystitis. 8. Left lateral fifth and seventh rib fractures. 9. Cystic structure above the manubrial notch without enhancement, incompletely characterized on this study. . #. Core biopsy of R solid pleural effusion [**2143-1-17**] . #. Stress test [**2143-1-21**] Exercising stress test: No anginal symptoms or ECG changes from baseline. N Persantine MIBI: Left ventricular cavity size is normal. Resting and stress perfusion images reveal uniform tracer uptake throughout the myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 71%. No prior studies are available for comparison. IMPRESSION: Normal myocardial perfusion. EF 71%. Brief Hospital Course: #. Anion Gap Acidosis: Was likely due to lactic acidosis given his high lactate on admission. High lactate production likely occurred [**1-17**] sepsis and poor perfusion, and ARF prevented clearance of lactate. Was treated with bicarb in the ED and Gap resolved. . #. Hyperkalemia: resolved after receiving kayexelate, insulin and glucose in ED. . #. RV strain/Pulmonary Hypertension: On [**1-8**] TTE was obtained and showed a dilated RV with severe global free wall hypokinesis and abnormal septal movement. He was also noted to have moderate-severe pulmonary artery systolic hypertension consistent with a primary pulmonary process. LVEF was >55%. Elevated tropinins measured in the ED were thought to be due to RV strain combined with decreased renal clearance. By [**1-9**], troponin had trended down and heparin gtt was discontinued. For his pulmonary hypertension observed on echo, a pulmonary consult was obtained. Acute PE was thought to be an unlikely cause of his echo findings given the negative V/Q scan on admission, but chronic PE was thought to be a possibility. CTA was obtained on [**1-16**], which was negative. Other etiologies were considered, including porto-pulmonary hypertension from cirrhosis. HIV, [**Doctor First Name **] and RF were sent and found to be negative. Scleroderma antibody test is pending. He will undergo an outpatient work-up for pulmonary hypertension with PFTs, sleep study, and outpatient appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. . #. Hypoxia: The patient was dyspneic on admission, and was maintained on supplemental oxygen for oxygen saturations that dropped into the high 80's at rest on room air. This was thought to be related to a presumed RML pneumonia (seen as opacity on admission CXR) and underlying pulmonary hypertension seen on Echo. However, the opacity observed on CXR was not seen on CT from [**1-16**], so it is unlikely that the original opacity represented a pneumonia as originally thought. His dyspnea slowly improved, and he was weaned from supplemental oxygen by [**1-14**]. However, on [**1-15**] he again developed an oxygen requirement after IV fluids were initiated in preparation for receiving IV contrast, and on [**1-16**], resting oxygen saturation was measured at 89% on room air at rest, 85% while ambulating. CTA [**1-16**] showed an enlarged left-sided pleural effusion (fluid density) and a R-sided pleural effusion that was determined to be solid on thorocentesis (Path result is pending). These findings, in combination with his pulmonary hypertension and deconditioning were thought to account for the patient's continued hypoxia. Diuresis was initiated the following day, and satrurations improved, but he continued to have an oxygen requirement. He had also been noted to have worsened dyspnea while ambulating, and a stress test was performed to rule-out an anginal component. Stress test was normal, showing no ECG changes or anginal component and normal myocardial perfusion with Ejection Fraction of 71%. By discharge, oxygen saturations were 98% on 3L, and he was discharged home on 2L oxygen via nasal cannula. . #. Acute Renal Failure: On admission, the patient had a creatinine level of 3.4. This appeared to be related to a prerenal state, as supported by his history of very poor PO intake x 10 days and FENa<1%. The possibility of ATN from NSAIDs was also considered given his recent history of taking Motrin for pain, and renal followed the patient until Cr had improved. Renal ultrasound showed no hydronephrosis. Creatinine slowly improved with IVF and time, and had decreased to 1.2 by [**1-16**] (most recent baseline measurement was 1.1 in [**2140**]). When the patient's home diuretics were subsequently restarted for hyponatremia and fluid overload, Cr rose again to 1.6. By discharge, the patient's creatinine was 1.4. . #. Staph Bacteremia: Blood cultures on admission grew MSSA (4/4 bottles from [**1-7**]). Renally-dosed vancomycin was started on [**1-8**], then switched to oxacillin on [**1-10**] when sensitivities returned. 2/2 blood cultures from [**1-10**] also grew staph aureus. Surveillance cultures since then have been negative. TEE done [**1-15**] not show any valvular abnormalities. A PICC line was placed on [**1-12**] and the patient completed a 14-day course of IV antibiotics on [**2143-1-22**] and the PICC was removed prior to discharge. . #. Hyponatremia: While in the ICU, the patient had one set of serum chemistries with serum sodium of 122. Remainder of values were in 130s until fluids were started on [**1-14**] in preparation for CTA with dye load. Next measured Na was 127 on [**1-16**]. He was fluid restricted to 1500cc/day and encouraged to improve his food intake, which had been poor throughout his admission. Given that he also had evidence of total body fluid overload (peripheral and abdominal edema), he was restarted on his home diuretic regimen of Lasix 20mg and spironolactone 25mg. By [**1-22**], Na had risen to 131. . #. UTI: Urine labs from [**1-9**] showed UTI, for which the patient was treated with a 7 day course of Levofloxacin that finished on [**1-16**]. Urine Cx was negative, but was sent after the patient had started Levofloxacin and Vancomycin. Fever curve remained flat. . #. Anxiety: The patient consistently reported having a "nervous stomach" that felt like it had "knots in it." He has had these sensations for many years, and reported that it made eating difficult because it caused him to feel nauseus. This was thought to be a manifestation of anxiety, and the patient was tried on 0.5mg of Ativan. This was subsequently discontinued when he was found to be excessively somnolent. The patient agreed to start Remeron for help with anxiety and appetite stimulation. He tolerated it well and was discharged on 15mg Remeron QHS. . #. DM: The patient recived QID finger sticks and was treated with bedtime glargine and ISS. Blood glucose measurments fluxuated with his PO intake and adjustments were made as appropriate. . #. Hypertension/ CAD: The patient was treated with ASA 325mg and Metoprolol 12.5mg TID. As the patient had no apparent indication for digoxin, this was held during his hospitalization. He was discharged on atenolol 12.5mg daily and ASA 325mg daily. Stress test revealed no hypoperfusion at rest or with persantine stimulation. . #. Nutrition: Albumin was 2.6 on admission, 2.4 on [**1-16**]. The patient reported a 10 day history of anorexia on admission and continued to have poor PO intake throughout most of his hospitalization. He cited lack of appetite and nausea caused by his "nervous stomach" as reasons for his poor intake. The patient was maintained on a renal diet with liquid supplements (Boost) TID. He had poor compliance until 2 days prior to discharge, when he reported an increase in appetite and improved PO intake was recorded. . #. Hemochromatosis/cirrhosis: Remained stable during this hospitalization. . #. Hypothyroidism: Remained stable. He was treated with his home dose of Levothyroxine 100 mcg daily during this admission. . # Physical Therapy: The patient was evaluated and followed by PT, who felt he was safe to return to his daugter's home. . # Prophylaxis: The patient was treated with incentive spirometry, H2 blocker, and SC heparin (which was discontinued when he began ambulating) . #. Abnormal tests requiring outpatient follow-up: Seen on CTA [**2143-1-16**]: 1. 3mm pulmonary nodule in the right middle lobe. 2. hypodense oval lesion approx 8mm at the liver dome. Recommend follow-up CT in 1 year. Medications on Admission: Meds on admission: * Spironolactone 25mg daily * Lasix 20mg daily * Digoxin 0.125mg daily * Synthroid 0.1mg daily * Folic Acid 1mg daily * Diltiazem 30mg daily * insulin Discharge Medications: * Spironolactone 25mg daily * Furosemide 20mg daily * Synthroid 0.1mg daily * Folic Acid 1mg daily * Diltiazem 30mg daily * Mirtazapine 15mg at bedtime * Aspirin 81mg daily * Combivent 103-18 mcg/Actuation Aerosol 1 puff QID * Oxygen 2-3L via nasal cannula to keep O2 sat>94% * insulin Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1. Staph aureus bacteremia 2. Pulmonary hypertension 3. Acute renal failure 4. Lactic acidosis 5. Dibetes mellitus 6. hemochromatosis/cirrhosis Discharge Condition: Stable. Requiring supplemental oxygen at 2L via nasal cannula. Discharge Instructions: 1. Call your doctor or go to the ER for: - fever > 101 - chest pain, shortness of breath, weakness - other concerns 2. Please use wear your oxygen at all times. Avoid smoking or open flames as oxygen is flammable. 3. Please take all of your medications as prescribed 5. Take the Ensure supplement drinks three times a day; these can be purchased at most pharmacies. Followup Instructions: 1. DR. [**Last Name (STitle) **] [**2143-1-24**] at 9:15 AM [**Telephone/Fax (1) 1983**] (Please call before appointment to update your registration information) 2. SLEEP STUDY-Office will call you to schedule appointment. You can contact them at [**Telephone/Fax (1) 16716**] 3. PULMONARY FUNCTION TESTS: [**2143-2-14**] 11:30AM (Please go to the [**Hospital Ward Name 23**] building [**Location (un) **] & check-in at Rehab Services) 4. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PULMONARY) [**2143-2-14**] 1:10PM [**Telephone/Fax (1) 612**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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28116

Discharge summary

report

Admission Date: [**2174-1-21**] Discharge Date: [**2174-1-31**] Date of Birth: [**2108-5-6**] Sex: M Service: MEDICINE Allergies: Percocet / Lasix / Keflex / Wellbutrin / Sulfa (Sulfonamide Antibiotics) / Dilantin Attending:[**First Name3 (LF) 9598**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: History of Present Illness: Mr. [**Known lastname 13170**] is a 65 yo male w/ metastatic melanoma on CTLA-4 antibody protocol who presented to [**Hospital3 3583**] on [**1-15**] with complaint of weakness and diminishing PO intake x 3 days, per wife. According to his wife, he was ambulatory the day PTA and then was noted to be lethargic and confused on the morning of admission. She reports that he had not been eating or drinking for 3 days, and she had found food she had prepared for him in the trash. Of note, patient was seen in the Brain [**Hospital 341**] Clinic on [**1-10**] and reported upper respiratory tract symptoms, including a frontal headache, nasal congestion, and erythema around his eyes. He was treated with azithromycin for sinusitis. . On arrival to the [**Hospital3 3583**] ED on [**1-15**], he was felt to be dehydrated and was admitted for rehydration. A temperature of 101.1 was documented at time of admission. He received IVF following admission to the Medicine service. He subsequently developed urinary retention and was started on levofloxacin for UTI and ?sinusitis. A Neurology Consultation was obtained and CT and LP were performed which showed protein 75, glucose 58, WBC 13 (12N,78L,10M). GRAM STAIN: occ Polys, no organisms. Culture(-). AFB(-). It was concluded that his altered mental status was related to "metabolic encephalopathy" in the setting of UTI vs. sinusitis. He was treated with levofloxacin. PO intake remained poor and mental status continued to deteriorate. His wife states that he was ambulating until Monday, and has been lying in the fetal position for the past two days. Given his persistent and declining mental status, he was transferred to the OMED service for further evaluation and management. . Upon arrival to OMED, labs were notable for cortisol of <0.3 and sodium of 122. Team was concerned for leptomeningeal spread vs. CNS infection. He was started on acyclovir empirically for possible viral meningitis and plan was for repeat MRI and LP (to obtain opening pressure and cytology). Past Medical History: PAST MEDICAL HISTORY: 1. Metastatic melanoma with known mets to brain and lungs - He was diagnosed with melanoma in [**2171**] when a right anterior neck lesion was discovered. He then underwent excision and biopsy at this time and underwent 8 months of alpha-interferon treatment. He then developed right chest wall pain and a CT of the torso revealed metastatic disease to the lungs and the patient subsequently underwent 26 rounds of IL-2 therapy ending on [**2173-5-11**]. A head MRI in [**6-3**] did not reveal any intracranial masses. However, on [**2173-10-24**] he developed a headache with continuous occipital and neck pain that progressed to an intermittent bilateral frontal head pain with cough only and associated sensitivity to light. On [**2173-11-2**], he was taken to an OSH for evaluation and found to have an intracranial lesion on head CT. He was then transferred to [**Hospital1 18**] for a craniotomy on by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D., Ph.D., which was performed on [**2173-11-4**]. This was followed by whole brain cranial irradiation to 3600 cGy in 12 fractions. 2. BPH 3. Hypercholesterolemia 4. h/o viral meningitis in [**2172**] 5. h/o shingles in [**2172**] 6. h/o MRSA bacteremia . PAST SURGICAL HISTORY: 1. s/p appendectomy 2. s/p craniotomy for single met to right temporal lobe performed by Dr. [**Last Name (STitle) **] in [**2173-10-27**] Social History: Lives at home with his wife. [**Name (NI) **] 3 sons and 1 daughter. [**Name (NI) 1403**] part-time as a dispatcher for trucking company. Smokes 1ppd x 20yrs. Occasional ETOH use. Family History: Non-Contributory Physical Exam: GEN: NAD, opens eyes to voice, non-cooperative for exam HEENT: PERRL. CV: RRR, no mrg appreciated. PULM: CTAB though poor inspiratory effort anteriorly; does not sit forward ABD: +bs, soft, NTND EXT: no [**Location (un) **], 2+ DP pulses NEURO: pupils equal and reactive to light. Patient responds to voice but cannot follow commands. Replies yes to most questions. Cannot repeat words and can only move feet to voice. He is stiff and resistant to any attempts to change his position. Can withdraw to pain and startles easily. Reflexes symmetric. Withdraws to babinski. Pertinent Results: [**2174-1-21**] WBC 7.9 / Hct 32.3 / Plt 465 Na 122 / K 3.8 / Cl 90 / CO2 24 / BUN 3 / Cr .8 / BG 88 Alb 3.2 / Ca 8.7 / Mg 1.4 / Serum Osm 247 Cortisol < .3 TSH 2.3 / T4 9.2 ALT 15 / AST 23 / LDH 236 / Alk Phos 60 / TB .6 INR 1.2 Urine Na 182 / Urine Cr 111 Urine Osm 543 [**2174-1-22**] MR [**Name13 (STitle) 430**] No significant change since the previous MRI of [**2174-1-10**]. No leptomeningeal enhancement is identified. Post-surgical changes are seen as described previously. [**2174-1-29**] 12:00AM BLOOD WBC-10.0 RBC-3.46* Hgb-11.9* Hct-32.6* MCV-94 MCH-34.4* MCHC-36.6* RDW-14.1 Plt Ct-465* [**2174-1-29**] 12:00AM BLOOD Glucose-115* UreaN-17 Creat-0.9 Na-133 K-4.0 Cl-102 HCO3-22 AnGap-13 [**2174-1-22**] 03:33AM BLOOD CK(CPK)-193* [**2174-1-21**] 08:21PM BLOOD CK(CPK)-244* [**2174-1-22**] 03:33AM BLOOD CK-MB-2 cTropnT-<0.01 [**2174-1-21**] 08:21PM BLOOD CK-MB-2 cTropnT-<0.01 [**2174-1-29**] 12:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1 [**2174-1-21**] 04:03PM BLOOD calTIBC-200* VitB12-1633* Folate-14.7 Ferritn-467* TRF-154* [**2174-1-22**] 11:58AM BLOOD Osmolal-271* [**2174-1-21**] 04:03PM BLOOD TSH-2.3 [**2174-1-21**] 04:03PM BLOOD T4-9.2 [**2174-1-21**] 09:38PM BLOOD Cortsol-3.6 [**2174-1-21**] 08:21PM BLOOD Cortsol-<0.3* [**2174-1-21**] 8:21 pm CSF;SPINAL FLUID **FINAL REPORT [**2174-1-28**]** GRAM STAIN (Final [**2174-1-22**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2174-1-28**]): NO GROWTH. [**2174-1-21**] 08:21PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-31* Polys-0 Lymphs-72 Monos-24 Atyps-3 Macroph-1 [**2174-1-21**] 08:21PM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-69* Polys-1 Lymphs-72 Monos-24 Atyps-2 Macroph-1 [**2174-1-21**] 08:21PM CEREBROSPINAL FLUID (CSF) TotProt-65* Glucose-59 [**2174-1-22**] 04:55PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name Brief Hospital Course: Mr. [**Known lastname 13170**] is a 65 year old gentleman with metastatic melanoma on CTLA-4 protocol transferred from OSH for altered mental status. 1. Altered mental status: CSF analysis at OSH demonstrated protein of 75 with [**Hospital1 18**] LP with CSF of 65 concerning for HSV encephalitis. Patient was started on IV acylcovir empirically. Leptomeningeal spread of malignancy was also considered, with CSF cytology non-diagnostic and MRI without significant findings. HSV PCR on the CSF as well as all other culture data was negative (though other viral PCR/cultures were not done). He received 7 days of IV acyclovir. We decided not to re-LP to perform further studies as the risks outweighed the benefits, his mental status had cleared, and it would unlikely change the treatment plan. The patient was also found to be hyponatremic to 121 during his admission, which was may have contributed to his altered mental status and he had adrenal insufficiency which could have contributed as well. EEG was done which did not show evidence of seizure, but did show possible subcortical dysfunction within the right temporal lobe. 2. Hyponatremia: Patient came in with sodium of 121 and the differential diagnosis included SIADH and adrenal insufficiency. Random cortisol was low (0.3) and urine sodium was high. We treated him with fluid restriction of 1L day and his sodium cam up to 130, then we changed this to 2L day so he would not become dehydrated at home and his sodium returned to a normal range. He was also continued on dexamethasone. The etiology of his hyponatremia was likely multifactorial. 3. Adrenal insufficiency: He completed in mid-[**Month (only) 1096**] a dexamethasone taper. On admission, his serum cortisol was below assay. He was hyponatremic as well so we treated him with dexamethasone. We did not start a taper of his dexamethosone and suggested he start this as an outpatient. His previous taper was very slow, over one month, so his next one should be even slower. 4. Fever: Patient was febrile to 101 at OSH, but was afebrile during his hospital course. He had negative cultures at [**Hospital1 18**] and had 1/2 bottles of coag neg staph at OSH with follow-up cultures negative. Antimicrobial therapy was held during his admission. 5. Sinusitis: Patient was treated with a 7 day course of levofloxacin. 6. Conjunctivitis: Treated with 7 day course of erythromycin drops. 7. Metastatic melanoma: Per primary oncologist, Dr. [**Last Name (STitle) 1729**]. 8. BPH: Patient continued on tamsulosin. 9. Dyslipidemia: Statin held during admission. He was instructed to resume on discharge. Medications on Admission: OUTPATIENT MEDICATIONS: Dexamethasone taper since [**12-4**], stopped [**2174-1-10**] Atorvastatin Finasteride Levetiracetam 1g [**Hospital1 **] Lorazepam 1mg q6-8h prn Prochlorperazine 10mg 1 hour prior to radiotherapy Ranitidine 150mg [**Hospital1 **] Tamsulosin 0.8mg daily Azithromycin to have been completed [**1-15**] pet OMR . TRANSFER MEDICATIONS: 1. Keppra 1000 mg twice a day. 2. Ofloxacin one drop OU b.i.d. 3. Simvastatin 40 mg a day. 4. Tamsulosin 0.4 mg a day. 5. Promethazine p.r.n. 6. Tylenol p.r.n. 7. Calcium carbonate 1-2 tablets q.i.d. p.r.n. 8. Vicodin one to two tabs q.4h. p.r.n. 9. Ibuprofen p.r.n. 10. Heparin flush. Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO once as needed: please take 1 hour prior to radiotherapy. 4. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Dexamethasone 4 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily): Please continue until your appointment with Dr. [**Last Name (STitle) 724**]. Disp:*75 Tablet(s)* Refills:*2* 6. Acyclovir Sodium 500 mg Recon Soln Sig: Eight Hundred (800) mg Intravenous Q8H (every 8 hours) for 6 days: Last Day [**2172-2-4**]. Disp:*144 g* Refills:*0* 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: 1. Altered mental status likely [**2-28**] viral encephalitis 2. Metastatic melanoma. Discharge Condition: Stable, afebrile, alert and oriented x3 Discharge Instructions: 1. You were admitted for altered mental status. We determined that you were likely not having a seizure. You were continued on keppra, which you will need to continue taking as an outpatient. We believe you may have had a viral infection in your brain or your mental status may have been from adrenal insufficiency. We also found your sodium was low. We treated you with IV antiviral medications, decadron and your mental status improved back to baseline. . 2. Unless otherwise indicated, you should resume all of your home medications as taken prior to admission. It is very important that you take all of your medications as prescribed. We added the following medications: STOPPED Lorazepam ADDED Dexamethasone 10mg po daily. You should talk to Dr. [**Last Name (STitle) 724**] about slowly tapering this medication at your follow up appointment. . 3. It is very important that you keep all of your doctor's appointments as below. 4. If you develop chest pain, shortness of breath, or other concerning symptoms, please call your doctor or go to your local Emergency Department immediately. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2174-2-7**] 1:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2174-3-15**] 9:00 Provider: [**Name10 (NameIs) 22181**] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2174-3-22**] 2:00 . Please call your primary care doctor, [**Doctor Last Name **] Cueni, to schedule a follow up appointment in the next 1-2 weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]

[ "486", "049.9", "599.0", "253.6", "255.41", "285.22", "461.9", "348.31", "372.30", "V10.82", "600.00", "197.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "03.31", "99.04" ]

icd9pcs

[ [ [] ] ]

10902, 10973

6768, 6930

367, 367

11112, 11154

4691, 6745

12300, 12925

4067, 4085

10101, 10879

10994, 11091

9434, 9434

11178, 12277

3711, 3852

4100, 4672

9458, 9768

304, 327

9790, 10078

395, 2422

6945, 9408

2466, 3688

3869, 4051

11,285

163,263

5980

Discharge summary

report

Admission Date: [**2167-8-26**] Discharge Date: [**2167-9-3**] Service: MEDICINE Allergies: Bleomycins / Strawberry / Pineapple Attending:[**First Name3 (LF) 477**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 85M with PMH of both Hodgkins and non-Hodgkins lymphoma currently on chemo who presented to an OSH after a fall in his driveway, pt was noted to be febrile and tachycardic in ED so transferred to ICU for further evaluation and work-up. Patient reports that he accidentally tripped and fell while out on a walk. He reports that he bumped his head in the fall. He was found down by his neighbor and EMS was called. The patient states that he awoke in the ambulance. He was initially taken to [**Hospital3 **] where an EKG was performed that was concerning for ST-segment elevations. Patient received one dose of atorvastatin and cardiac enzymes were negative x1. His CBC was significant for a white count of 13.8 with an 18% bandemia. The patient was then transferred to [**Hospital1 18**] on a nitro gtt for admission to cardiology for STEMI. Upon arrival in the ED, vitals were 99.6 HR 80-140s 130/77 22 97% on 3L. The EKGs were reviewed by cardiology and were not read as ST-segment elevations. Nitro gtt was stopped. Cardiac enzymes were cycled and negative x1. EKG was notable for sinus tachycardia to the 140s. Patient was reportedly asymptomatic. A head CT was performed at the OSH that was reported as negative. A CT scan of C/A/P was done in the ED that was negative for pulmonary emboli and intra-abdominal pathology but he was noted to have a small-moderate pericardial effusion. In addition to the tachycardia, the patient was later febrile to 102. The patient was again noted to have an elevated white blood cell count with a bandemia of 8%. Patient was given 4L of NS, blood and urine cultures were sent. UA negative. Patient was started on vanc and levaquin and given one dose of Tylenol. The patient's primary oncologist is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He is scheduled to received Cycle 19 of Gemzar/Navelbine today. Patient has also been on neulasta, last received on [**8-13**]. On transfer to the Oncology floor pt was still noted to be intermittently in atrial tachycardia, asymptomatic with it. Cardiology consulted and pt was changed from a daily Atenolol dose to Metoprolol [**Hospital1 **] dosing. Past Medical History: HODGKIN LYMPHOMA: Relapsed disease: In [**2165-12-9**], he was markedly symptomatic with fatigue, feeling lousy, and weight loss.Bone marrow examination in [**Month (only) **] showed extensive involvement by Hodgkin lymphoma. Torso CT scan (full report on OMR) was mostly unremarkable; spleen was normal. Original disease: In [**2163-9-9**], Mr. [**Known lastname 23552**] became increasingly fatigued. He had poor appetite and worsening anemia. Bone marrow exam demonstrated CD30+ HODGKIN'S DISEASE. He then received dose-modified ABVD chemotherapy. Adriamycin and vinblastine have been dose reduced by 25%. He had an immediate reaction to the bleomycin and did not received further bleomycin. In [**2165-4-8**], repeat bone marrow showed no evidence of lymphoma or Hodgkin's disease either by flow cytometry or by histology. NON-HODGKIN'S LYMPHOMA: Mr. [**Known lastname 23552**] had been previous treated first for non-Hodgkin's lymphoma and later for Hodgkin's disease. Herb presented initially with a low grade lymphoma/massive splenomegaly. He received 6 cycles of CVP-Rituxan chemotherapy, and had a dramatic response to chemotherapy. His symptoms, fatigue and loss of appetite, resolved. In [**2163-5-10**] Herb began a course of Rituxan x 4 as part of a maintenance program. OTHER ISSUES: He had a right leg common femoral artery to posterior tibial bypass by the [**Year (4 digits) 1106**] surgery service, and then had a successful right lower vein graft angioplasty ([**December 2166**]). He had an episode of syncope ([**2163-11-9**]). No further syncopal issues. Cardiac echo shows left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). No change from [**2156**]. Social History: Married, former professor [**First Name (Titles) **] [**Last Name (Titles) **], graduate of [**University/College **] Business School. Former smoker, quit [**2108**]. Social Etoh. 4 kids, 5 grandchildren Family History: non-contributory Physical Exam: General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube, abrasions on lower lip and chin Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy Cardiovascular: (S1: Normal), (S2: Distant), No(t) S3, No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic), Distant heart sounds Peripheral [**Year (4 digits) **]: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Obese Extremities: Right: Absent, Left: Absent Musculoskeletal: No(t) Muscle wasting Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, Tone: Not assessed Pertinent Results: [**2167-9-3**] 12:00AM BLOOD WBC-11.9* RBC-3.18* Hgb-10.1* Hct-30.5* MCV-96 MCH-31.6 MCHC-32.9 RDW-20.0* Plt Ct-322 [**2167-9-2**] 12:00AM BLOOD WBC-10.1 RBC-2.77* Hgb-8.7* Hct-26.4* MCV-95 MCH-31.4 MCHC-33.0 RDW-20.0* Plt Ct-315 [**2167-9-1**] 12:00AM BLOOD WBC-11.1* RBC-2.61* Hgb-8.6* Hct-25.3* MCV-97 MCH-32.9* MCHC-34.1 RDW-20.3* Plt Ct-313 [**2167-8-31**] 12:00AM BLOOD WBC-10.7 RBC-2.78* Hgb-8.8* Hct-26.3* MCV-95 MCH-31.4 MCHC-33.3 RDW-20.1* Plt Ct-330 [**2167-9-3**] 12:00AM BLOOD WBC-11.9* RBC-3.18* Hgb-10.1* Hct-30.5* MCV-96 MCH-31.6 MCHC-32.9 RDW-20.0* Plt Ct-322 [**2167-9-2**] 12:00AM BLOOD WBC-10.1 RBC-2.77* Hgb-8.7* Hct-26.4* MCV-95 MCH-31.4 MCHC-33.0 RDW-20.0* Plt Ct-315 [**2167-9-1**] 12:00AM BLOOD WBC-11.1* RBC-2.61* Hgb-8.6* Hct-25.3* MCV-97 MCH-32.9* MCHC-34.1 RDW-20.3* Plt Ct-313 [**2167-8-26**] 10:57AM BLOOD WBC-12.8* RBC-2.72* Hgb-8.5* Hct-25.9* MCV-95 MCH-31.3 MCHC-32.9 RDW-20.0* Plt Ct-265 [**2167-8-25**] 11:00PM BLOOD WBC-18.5*# RBC-3.36* Hgb-10.9* Hct-33.4* MCV-100* MCH-32.4* MCHC-32.6 RDW-19.3* Plt Ct-271 [**2167-9-3**] 12:00AM BLOOD PT-23.1* PTT-30.9 INR(PT)-2.2* [**2167-9-2**] 12:00AM BLOOD PT-21.6* PTT-104.5* INR(PT)-2.1* [**2167-9-1**] 12:00AM BLOOD PT-21.2* PTT->150* INR(PT)-2.0* [**2167-9-3**] 12:00AM BLOOD Glucose-292* UreaN-25* Creat-1.3* Na-132* K-4.7 Cl-101 HCO3-19* AnGap-17 [**2167-9-2**] 12:00AM BLOOD Glucose-156* UreaN-17 Creat-1.1 Na-138 K-4.3 Cl-107 HCO3-24 AnGap-11 [**2167-9-1**] 12:00AM BLOOD Glucose-273* UreaN-20 Creat-1.3* Na-132* K-4.2 Cl-107 HCO3-22 AnGap-7* [**2167-8-31**] 12:00AM BLOOD Glucose-215* UreaN-20 Creat-1.2 Na-136 K-4.2 Cl-104 HCO3-22 AnGap-14 [**2167-9-3**] 12:00AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.0 [**2167-9-2**] 12:00AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9 [**2167-8-27**] 04:06AM BLOOD calTIBC-143* VitB12-GREATER TH Folate-GREATER TH Ferritn-GREATER TH TRF-110* [**2167-8-26**] 10:57AM BLOOD TSH-5.1* = = = = = = = = = ================================================================ ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior report (images unavailable for review) of [**2166-7-28**], the right ventricle is no longer dilated and globally hypocontractile. INDICATION: Fever, tachycardia and fall. TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained without oral or IV contrast as the patient could not tolerate fluids and had a recent IV contrast. COMPARISON: [**2167-8-26**]. CT Abdomen: There is a moderate-sized pericardial effusion. There is atherosclerotic calcification in the thoracic aorta. There is mild dependent atelectasis at the lung bases. Evaluation of the solid organs is somewhat limited by the lack of IV contrast: The liver, pancreas, and spleen are normal. The patient has had prior cholecystectomy. The right adrenal nodule measures 23 x 18 mm (2:20), similar to prior study. The left adrenal is normal. There is [**Year (4 digits) 1106**] calcification of the aorta, the splenic artery, the origin of the SMA and the renal arteries as well as the common, external and internal iliac arteries. There is no free fluid, free air, or adenopathy. The intra- abdominal small and large bowel is normal. CT PELVIS: The rectum, sigmoid, and bladder are normal. There is a Foley in the bladder. There is no free fluid, inguinal or pelvic adenopathy. BONE WINDOWS: There is degenerative change in the lumbar spine. The minimally displaced right 12th rib fracture is again noted. IMPRESSION: 1. No acute intra-abdominal process. 2. Minimally displaced right 10th rib fracture, which is chronic. 3. Diffuse [**Year (4 digits) 1106**] calcifications. Brief Hospital Course: 85 y.o. Male w/ Hodgkin's and non-Hodgkin's Lymphoma undergoing chemotherapy with Gemzar/[**Hospital 23553**] transferred to [**Hospital Unit Name 153**] from OSH for questionable ST elevation s/p fall, transferred to Oncology following negative fever, cardiac work up now with unsteady gait likely [**1-10**] hospitalization, asymptomatic atrial tachycardia. # Fever, hypotension, leukocytosis with bandemia: Upon admission to the ICU pt was noted to have a low BP, tachycardia, fevers and leukocytosis meeting SIRS. Pt was hydrated with IV fluids, work up included a CT chest/abdomen scan which showed a small pericardial effusion, no evidence of pulmonary embolism, no intraabdominal process. Following negative cultures, and fevers in spite of antibiotic therapy, pt's fevers were attributed to his Lymphoma and his leukocytosis with bandemia was atrributed to the pt's recent Neulasta treatment prior to admission. Prior to discharge pt was afebrile with leukocytosis only returning with onset of Neupogen. # Atrial Tachycardia: During hospitalization pt has intermittently going into Atrial Tachycardia usually with a heart rate in the 120s, he has been asymptomatic during these episodes and this may have been the inciting event for the pt's fall on admission. In the ICU pt was started on an Esmolol drip which showed no effect, pt spontaneously went back into sinus after it was discotninued. Pt then went into NSVT was trialed on Amiodarone, and then per Cardiology recommendations, was switched back to beta-blockade therapy. Since his transfer to the Oncology floor Cardiology has been following the patient, it is unclear as to the cause of the pt's Atrial tachycardia or how long he has had these episodes for. Recommend continuing beta-blocker therapy, specifically Metoprolol Tartrate three times a day (62.5mg at 0700, 62.5mg at 1300, 50mg at 2100). # Hodgkin's and Non-Hodgkin's Lymphoma: Pt's primarty oncologist is Dr. [**Last Name (STitle) **], prior to discharge pt was started on his 19th cycle of gemzar/navelbine. He will need to complete a 7 day course of Neupogen 300mcg S.C. daily, his last dose of this medication will be [**2167-9-9**]. Pt eas also received 1 unit of blood transfusion day prior to discharge. # Hyperglycemia: Pt is noted to be hyperglycemic on day of discharge, most likely due to the IV Dexamethasone pt was on yesterday for his chemotherapy. Will continue pt on ISS. # History of PE: Pt is currently on coumadin for his history of Pulmonary Embolism. Please check INR every two days and adjust Warfarin accordingly for a goal INR of [**1-11**]. # Hyperlipidemia: Pt was continued on his home regimen of Simvastatin. # Renal Insufficiency; Pt has a history of renal insufficiency with a baseline creatinine 1.2-1.3. # BPH: Pt has been continued on his home regimen of doxazosin. # Fall: Pt was admitted from an outside hospital following a fall, it is unclear as to why he feel but it may be related to his atrial tachycardia. Since admission to the hospital pt has decompensated and has not been able to ambulate as readily as he did before. Prior to hospitalization pt was able to ambulate long distances daily and now requires help when ambulating. Physical therapy recommended rehab placement. # Code Status: Full code Medications on Admission: ALLOPURINOL - 100MG Tablet - ONE P.O. EVERY DAY ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth Qday DOXAZOSIN - 2 mg Tablet - 1 Tablet(s) by mouth at bedtime GABAPENTIN [NEURONTIN] - 400 mg Capsule - 1 Capsule(s) by mouth three times a day MEGESTROL [MEGACE ES] - 625 mg/5 mL Suspension - 5 ml (one teaspoon) Suspension(s) by mouth once daily METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth once a day SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day in the evening WARFARIN - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth Q MON, WED, & [**Last Name (un) **] WARFARIN [COUMADIN] - 5 mg Tablet - one Tablet(s) by mouth Q [**Last Name (LF) **], [**First Name3 (LF) **], [**Doctor First Name **], & SAT Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Megestrol 400 mg/10 mL Suspension Sig: Two (2) PO DAILY (Daily). 5. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q 12H (Every 12 Hours). 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QTUTHSA + QSUN (). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H (every 24 hours) for 6 days: Please start [**2167-9-4**]. 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please give at 2100. 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO once a day: Please give at 1300. Please give with 12.5mg Metoprolol for a total dose of 62.5mg. 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)): Please give at 0700. Please give with 12.5mg Metoprolol for a total dose of 62.5mg. 17. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: Take per insulin sliding scale. 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a day: Please give at 0700. Please give with 50mg Metoprolol for a total dose of 62.5mg. 19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a day: Please give at 1300. Please give with 50mg Metoprolol for a total dose of 62.5mg. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnoses: Atrial Tachycardia, Hodgkin's Lymphoma Secondary Diagnoses: - Renal Insufficiency - Hypertension - Peripheral [**Location (un) **] Disease - H/O Pulmonary Embolism and Right DVT on warfarin Discharge Condition: Stable, afebrile. Discharge Instructions: You were transferred to this hospital after falling because there was a concern about your heart readings. Whilst in the ICU our tests showed you didn't have a heart attack but your heart rate was beating fast. We started you on a new heart medication that has kept your heart at a normal rate. During your hospital stay you had difficulty walking with full strength which is why we recommended you got to a rehabilitation facility. You also experienced some fevers which we believe is due to your cancer. You also received your 19th cycle of chemotherapy with a unit of blood before you were discharged to rehab. You have been started on several new medications: 1. Please take Metoprolol Tartrate 62.5mg every day at 0700. 2. Please take Metoprolol Tartrate 62.5mg every day at 1300. 3. Please take Metorpolol Tartrate 50mg every day at 2100. 4. Please take 7 days of Filgrastime 300mcg every day, your last dose of this medication will be on [**2167-9-9**]. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2167-9-23**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5629**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-10-21**] 9:30 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2167-11-11**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2167-11-11**] 2:45 [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

[ "600.00", "201.90", "995.93", "585.9", "276.2", "440.0", "403.90", "V12.51", "V15.88", "427.1", "V58.61", "V15.82", "E934.8", "423.9", "427.89", "443.9", "251.8", "288.60", "787.91", "355.8", "E932.0", "E888.9", "719.7" ]

icd9cm

[ [ [] ] ]

[ "99.25", "99.04" ]

icd9pcs

[ [ [] ] ]

16262, 16334

10105, 13391

250, 256

16587, 16607

5673, 10082

17619, 18280

4450, 4468

14221, 16239

16355, 16413

13417, 14198

16631, 17596

4483, 5654

16434, 16566

202, 212

284, 2465

2487, 4212

4228, 4434

58,731

181,249

38521

Discharge summary

report

Admission Date: [**2152-7-21**] Discharge Date: [**2152-8-23**] Date of Birth: [**2128-9-22**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: Near Drowning/diving injury Major Surgical or Invasive Procedure: [**2152-7-26**]: s/p IVC filter placement, Open tracheostomy, Percutaneous endoscopic gastrostomy. [**2152-7-27**]: s/p C5 Corpectomy multiple bronchoscopies History of Present Illness: 23 y.o. male with no PMH presents after near drowning event in warm, fresh water. Patient was reportedly up at a [**Doctor Last Name **] and dove from standing into the water. He was reportedly submerged for up to 8 minutes, and friends/bystanders believed that he was playing around. After they realized that the patient was not moving, he was taken from the water and found to be pulseless and apneic. CPR was initiated for 15 minutes with return of vitals and patient was intubated in the field and flown by helicopter to [**Hospital1 18**]. Here, the patient was found to have priapism and some decorticate posturing. No purposeful movements, and no movements of the lower extremities. He was hypothermic at approximately 33 degrees celcius upon arrival. In the ED, he underwent CT scans of his head, C-spine, and torso. Past Medical History: PTSD Unknown back surgery for bullet Social History: Diver for marines Family History: Noncontributory Physical Exam: T: 34 C on arrival, then 33.5 (prior to active cooling) BP: 130s/70s HR: 80s R: CMV 100% O2Sats Gen: Healthy appearing man s/p trauma. Comatose. Sand in ears. HEENT: Normocephalic without evident skull fracture Neck: In collar. Lungs: Clear with some reduced sounds inferolaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Cool poorly-perfused. Neuro: GCS 7 (flexor posture (of arms), no voice, opens eyes to voice). Pupils reactive 8 -> 4 (slightly sluggish), but no tracking, corneals present but diminished bilaterally. Jaw jerk present. Patient spontaneously moving head. Reflexes were absent but for pectoral, right > left. Toes mute. Rectal exam normal sphincter control. Priapism. Exam upon discharge: awake and alert, interactive, appropriate, biceps, deltoids, and trapezious [**5-17**] otherwise 0/5 in all motor groups. T7 sensory level. Pertinent Results: [**2152-7-21**] MRI head: 1. 4-mm lesion in the central mid brain may represent [**Doctor First Name **]. This can be followed on subsequent imaging. No evidence of an intracranial infarction or hemorrhage. 2. Widely patent intracranial carotid and vertebral arteries and their branches. Incidental note is made of a persistent left trigeminal artery. and cspine which demonstrated no ischemic injury. normal 2D TOF through the transverse sinuses. [**2152-7-21**] MRI C-Spine: 1. Burst fracture of C5 with associated spinal cord injury as described above. The C5 vertebral body injury is best depicted on the CT of [**2152-7-20**]. 2. Extensive opacification of the right upper lobe, most likely representing consolidation or aspiration. 3. Widely patent carotid and vertebral arteries.[**7-20**] - [**2152-7-21**] CT CAP - RUL, LLL aspiration PNA. No traumatic injury to chest/abdomen or pelvis. Retained metallic fragment b/t 11th and 12th ribs [**2152-7-21**] CT CSpine - C5 burst/teardrop fracture w/ retropulsion compressing canal. [**2152-7-21**] CT Head - Loss of grey/white junction in L temporal lobe concerning for infarct. Hyperdensity in L transverse sinus c/w thrombosis. Sinus opacification [**7-22**] - EEG - Diffuse delta slowing indicative of subcortical/deep midline dysfunction Brief Hospital Course: Patient admitted to trauma ICU intubated. On admission patient was originally not responsive. Imaging demonstarted C5 burst fracture, with fractured C5 penetrates cord, C2-C5 concering for ligamentious disruption. C2-C5 concern for ligamentous injury. Pt was initially cooled to 33C per policy for cardiac/anoxic injury. Upon rewarming, he became more awake, at the same time aggitated intermittently, follows commands now, tries to communicate. CVL placed as pt required pressors to keep MAP>80 to insure cord perfusion. He underwent bronchoscopy for mucus plugging which was required frequently throughout his hospital course. He was found to have evolving pneumonia started on vanc/zosyn.On [**7-23**] he was switched from CMV to PSV which he tolerated well, slowly weaning pressure support and PEEP. Arctic sun to maintain temperature 37 C as he was febrile. The ETT tube was exchanged, tube feedings were increased to goal of 70 cc/hr. LENIS demonstrated no DVT. On [**2152-7-26**] he underwent Trach/PEG and IVC filter without complication. On [**2152-7-27**] he went to the OR where under general anesthesia he underwent C5 corpectomy. He tolerated the procedure well but at the end of the case after bronchoscopy he spiked fever over 41. There was concern for malignant hyperythermia and he was treated for it but ultimately it was decided that this was not the case and the fever was likely due to bacteremia after bronchoscopy.By [**2152-7-31**] he had weaning trials off the vent though he did undergo almost daily bronchoscopies yielding large amounts of yellow thick secretions in right mainstem and below. He had improved oxygenation after bronchoscopies and CXRs also improving. Psychiatry was consulted and per their recommendations, the patient was started on fluoxetine and his other psychoactive medications were modified. Wounds were clean and dry. His pulmonary status slowly improved requiring no brochoscopy. On [**2152-8-15**] he had lo grade temperature to 100.6 with increased wbc. He got extensive fever workup including LENIs and CT torso which showed some abdominal fluid collections but was not of concern. LENIS were negative. On [**8-16**] his WBC bumped up from 18 to 22 and brochial washing specimen was sent which grew gram positive cocci. He was started on Vancomycin, Cipro, Cefepime with the plan to continue until [**8-26**]. On [**8-18**] he required a bronch. On [**8-19**] he had two episodes of panic attacks and received Haldol and Ativan. On [**8-21**] he received another bronchoscopy. He was also evalauted by [**Hospital3 **] who felt he would be appropriate for rehab at the [**Hospital1 **] in [**Hospital1 8**] where they could perform the broncoscopy's needed. On [**8-23**] he was given a bed at [**Hospital1 **] in [**Hospital1 **] and was discharged. Medications on Admission: PMH: none PSH: ?? back surgery for bullet/shrapnel Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 650 mg/20.3 mL Solution Sig: Two (2) PO Q6H (every 6 hours) as needed for fever/headache. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 9. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day) as needed for mouth care. 11. Metoclopramide 5 mg/5 mL Solution Sig: Ten (10) ml PO Q6H (every 6 hours) as needed for impaired gastric motility. 12. Ibuprofen 100 mg/5 mL Suspension Sig: Forty (40) ml PO Q8H (every 8 hours) as needed for fever. 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 14. Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-15**] Drops Ophthalmic PRN (as needed) as needed for dry eyes, burning. 16. Olanzapine 5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 17. Fluoxetine 20 mg/5 mL Solution Sig: 7.5 ml PO DAILY (Daily). 18. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 19. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety/aggitation. 20. Methadone 10 mg/5 mL Solution Sig: 2.5 ml PO BID (2 times a day). 21. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitiation/anxiety. 22. Ondansetron 4 mg IV Q8H:PRN nausea 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN flush Peripheral IV - Inspect site every shift 24. CefePIME 2 g IV Q12H Duration: 10 Days [**2152-8-16**] 25. Ciprofloxacin 400 mg IV Q12H Duration: 10 Days start [**2152-8-16**] 26. Vancomycin 1750 mg IV Q 8H Duration: 10 Days [**2152-8-16**] 27. 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. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital [**Hospital1 8**] Discharge Diagnosis: C5 Fracture Quadriplegia Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound clean ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. for 3 months as this decreases ability to fuse the bone. ?????? 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. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 548**] in 6 weeks with AP/Lateral Xrays of your Cspine. Please call [**Doctor First Name **] at [**Telephone/Fax (1) 2992**] to make this appointment. Completed by:[**2152-8-23**]

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icd9cm

[ [ [] ] ]

[ "81.62", "96.05", "80.99", "43.11", "81.02", "38.93", "33.24", "33.22", "96.6", "38.7", "31.1", "96.72" ]

icd9pcs

[ [ [] ] ]

9328, 9397

3717, 6536

347, 507

9476, 9476

2390, 3694

10069, 10299

1473, 1490

6637, 9305

9418, 9455

6562, 6614

9611, 10046

1505, 2209

280, 309

535, 1362

9491, 9587

1384, 1422

1438, 1457

2230, 2371

28,166

104,566

23359+57348

Discharge summary

report+addendum

Admission Date: [**2185-1-25**] Discharge Date: [**2185-2-18**] Date of Birth: [**2126-2-16**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Aspirin / Motrin Attending:[**First Name3 (LF) 165**] Chief Complaint: fever, back pain Major Surgical or Invasive Procedure: ERCP w/stent [**1-26**] Liver bx [**2-1**] History of Present Illness: 58 yo F with h/o TV annuloplasty in [**2159**] and TV replacement in [**2171**] who pressented to OSH [**1-21**] with 4 day history of fever to 103, back pain, nausea cough and diarrhea. Initial blood cultures were positive for MSSA and enterococcus and she was started on antibiotics. She developed hypotension and was transferred to the CCU. Abdominal CT [**1-22**] showed ? of pancreatitis/GB sludge, and RUQ ultrasound showed dilated CBD. She continued to have a rising WBC and TEE showed 2.3 x 1.3 irregular mobile mass on TV annulus with severe TR. She was transferred to [**Hospital1 **] for further management. Past Medical History: s/p TV repair '[**59**], s/p TVR/PFO closure '[**69**] c/b CVA/cardiac arrest,Breast CA s/p lumpectomy/Chemo/XRT '[**78**], sepsis related to Portacath, atrial arrhythmias, multiple spinal surgeries, h/o spinal stimulators-?removal, COPD, Left ing hernia repair. Social History: lives with fiance and granddaughter + tobacco - about [**11-17**] ppd, none for ~ 1 week prior to transfer denies current etoh/drug abuse Family History: Mother- Diabetes/HTN Physical Exam: Admission HR 80s BP 101/49 RR 30s 95% on 100% NRB Neuro [**Last Name (LF) **], [**First Name3 (LF) 2995**], grip/plantar flexion/extension [**2-18**] equal bilaterally; pupils 2-3 mm equal/reactive bilat. CV irreg 3/6 systolic murmur Resp course breath sounds anteriorly; clear at post. bases GI hypoactive bowel sounds, soft. RUQ tenderness GU foley draining [**Location (un) 2452**] urine Extrem 2+ pulses throughout, 2+ pitting edema in LE, RUE edema > LUE, right radial [**Doctor Last Name **] test with + ulnar flow Discharge VS T 98 HR 80 SR BP 149/63 RR 20 O2sat 97% RA Gen NAD Neuro A&Ox3, nonfocal exam Pulm CTA bilat CV RRR Abdm soft, NT/+BS Ext warm, well perfused. Trace pedal edema bilat Pertinent Results: [**2185-2-10**] 06:16AM BLOOD WBC-13.1* RBC-2.89* Hgb-8.9* Hct-27.2* MCV-94 MCH-30.7 MCHC-32.6 RDW-17.5* Plt Ct-248 [**2185-2-10**] 06:16AM BLOOD UreaN-8 Creat-1.1 K-2.9* [**2185-1-25**] 09:56PM GLUCOSE-78 UREA N-21* CREAT-0.8 SODIUM-138 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-18* ANION GAP-15 [**2185-1-25**] 09:56PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-431* CK(CPK)-12* ALK PHOS-162* AMYLASE-17 TOT BILI-12.6* DIR BILI-10.4* INDIR BIL-2.2 [**2185-1-25**] 09:56PM LIPASE-11 [**2185-1-25**] 09:56PM CK-MB-NotDone cTropnT-<0.01 [**2185-1-25**] 09:56PM ALBUMIN-2.5* CALCIUM-8.2* PHOSPHATE-3.3 MAGNESIUM-2.2 URIC ACID-3.5 [**2185-1-25**] 09:56PM TSH-1.3 [**2185-1-25**] 11:58PM LACTATE-1.2 [**2185-1-25**] 09:56PM WBC-20.8* RBC-3.40* HGB-10.7* HCT-31.9* MCV-94 MCH-31.5 MCHC-33.5 RDW-15.3 [**2185-1-25**] 09:56PM NEUTS-94* BANDS-2 LYMPHS-1* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2185-1-25**] 09:56PM PLT SMR-LOW PLT COUNT-76* [**2185-1-25**] 09:56PM PT-14.5* PTT-30.0 INR(PT)-1.3* [**2185-1-25**] 09:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.5 LEUK-TR [**2185-1-25**] 09:50PM URINE RBC-329* WBC-8* BACTERIA-FEW YEAST-NONE EPI-0 [**2185-2-7**] 06:18AM BLOOD WBC-7.8 RBC-2.49* Hgb-7.7* Hct-23.9* MCV-96 MCH-31.0 MCHC-32.4 RDW-17.2* Plt Ct-219 [**2185-2-7**] 06:18AM BLOOD Plt Ct-219 [**2185-2-7**] 06:18AM BLOOD PT-17.2* PTT-28.5 INR(PT)-1.6* [**2185-2-7**] 06:18AM BLOOD Glucose-95 UreaN-6 Creat-1.0 Na-140 K-2.6* Cl-114* HCO3-17* AnGap-12 [**2185-2-7**] 06:30AM BLOOD ALT-17 AST-23 AlkPhos-111 Amylase-62 TotBili-1.6* [**2185-2-7**] 06:30AM BLOOD Lipase-48 [**2185-2-7**] 06:30AM BLOOD Albumin-2.4* RADIOLOGY Final Report CHEST (PA & LAT) [**2185-2-5**] 12:37 PM CHEST (PA & LAT) Reason: pna [**Hospital 93**] MEDICAL CONDITION: 58 year old woman with RHONCHOUROUS bs THROUGHOUT / requiring increase in oxygen REASON FOR THIS EXAMINATION: pna CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [**2185-2-2**]. FINDINGS: As compared to the previous radiograph, the nasogastric tube and the endotracheal tube have been removed. Both lungs have increased in transparency, however the pre-existing bilateral extensive parenchymal opacities are still very prominent. No evidence of pleural effusion. The size of the cardiac silhouette is unchanged. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 59947**],[**Known firstname **] M [**2126-2-16**] 58 Female [**Numeric Identifier 59948**] [**Numeric Identifier 59949**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 59950**] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], [**Doctor Last Name 15785**],[**Doctor First Name **]/mtd SPECIMEN SUBMITTED: LIVER CORE BX...1 JAR. Procedure date Tissue received Report Date Diagnosed by [**2185-2-1**] [**2185-2-1**] [**2185-2-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/stu DIAGNOSIS: Liver, needle core biopsy: Portal tracts: Mild peri-ductular acute inflammation. Lobules: No hepatocellular necrosis or apoptosis. No steatosis. No cholestasis noted. Trichrome stain: No increase fibrosis seen. Iron stain: Mild iron deposition in Kupffer cells. Note: If findings are not specific, but may be seen in early biliary obstruction, ascending cholangitis, sepsis or drug reaction. Clinical correlation is suggested. Clinical: Elevated LFT, patient with endocarditis, ? cirrhosis. Gross: The specimen is received in one formalin container, labeled with the patient's name, "[**Known lastname **], [**Known firstname **] M" and the medical record number. It consists of tan-yellow tissue core measuring 0.5 x 0.1 cm in diameter, entirely submitted in cassette A. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 59951**] (Complete) Done [**2185-1-28**] at 3:31:07 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2126-2-16**] Age (years): 58 F Hgt (in): 67 BP (mm Hg): 104/69 Wgt (lb): 200 HR (bpm): 71 BSA (m2): 2.02 m2 Indication: Endocarditis. ICD-9 Codes: 424.90 Test Information Date/Time: [**2185-1-28**] at 15:31 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2008W000-0:00 Machine: Vivid i-3 Echocardiographic Measurements Results Measurements Normal Range Findings Pt maintained in ICU with paralytics and fentayl/versed drips during procedure. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Bioprosthetic tricuspid valve (TVR). Large vegetation on tricuspid valve. No TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was monitored by a nurse in [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). No TEE related complications. Conclusions Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 30 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. A bioprosthetic tricuspid valve is present. There is a large vegetation on the septal leaflet of the tricuspid valve measuring approximately 2cm by 1cm. IMPRESSION: Large vegetation on tricuspid valve as described above. No tricuspid regurgitation. No abscess identified. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2185-1-28**] 16:22 Brief Hospital Course: She was admitted to the cardiac surgery ICU. She was seen by general surgery and hepatobiliary services. She was intubated for respiratory failure and for an emergent ERCP/no obstruction was found but a biliary stent was empirically placed and she will require repeat ERCP for stent removal in 8 weeks. She was also seen by Cardiology & Infectious diseases. ID recommended tx with rifampin, vancomycin and gentamycin for 6 weeks. She initially required paralasis and sedation to be ventilated. She also required multiple pressors for hemodynamic support. Liver biopsy on [**2-1**] was negative for cirrhosis. A TEE revealed TV endocarditis with no TR. Gradually her sepsis resolved, the vent and pressors were weaned, she was extubated and her pressors were weaned to off on [**2-2**]. She was transferred to the floor on [**2-3**]. Over the next week she continued on triple antibiotics and gradually recovered her strength. On [**2-8**] overnight she developed a fever and was pancultured, these cultures are currently no growth to date. By hospital day 17 it was decided she could be transferred to rehabilitation to complete a 6 week antibiotic course prior to surgical replacement of her tricuspid valve. Medications on Admission: Percocet 10/375 QID/prn Albuterol Robaxin 750''' Discharge Medications: 1. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO twice a day. 2. Nystatin 100,000 unit/mL Suspension [**Month/Year (2) **]: Five (5) ML PO QID (4 times a day) as needed. 3. Nystatin 100,000 unit/g Cream [**Month/Year (2) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Rifampin 150 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO Q12H (every 12 hours): thru [**3-8**]. 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Year (2) **]: 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily MLs Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily . 9. Vancomycin 500 mg Recon Soln [**Month/Year (2) **]: Seven [**Age over 90 1230**]y (750) mg Intravenous Q 12H (Every 12 Hours). 10. Oxycodone 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO every six (6) hours as needed for pain. 11. Gentamicin in Saline (Iso-osm) 100 mg/50 mL Piggyback [**Age over 90 **]: One Hundred (100) mg Intravenous Q24H (every 24 hours): thru [**3-8**]; check peak and trough [**2-11**]. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care - [**Hospital1 **] Discharge Diagnosis: Tricuspid valve endocarditis PMH: s/p TV repair '[**59**], s/p TV replacement '[**69**], breast CA s/p lumpectomy/rads/XRT '[**78**], s/p PFO closure, s/p CVA '[**69**], cervical radiculopathy s/p cervical laminectomy &lumbar fusion, hx R&L spinal stimulator-?L side removed, COPD, Atrial tachycardia, sepsis from portacath'[**80**], s/p L ing hernia repair Discharge Condition: Stable. Discharge Instructions: Take all medications as prescribed. Keep all scheduled appointments, call for all other f/u appointments. Followup Instructions: repeat ERCP for stent removal (Biliary Service- Dr [**Last Name (STitle) **]8 weeks from [**1-26**] Dr [**First Name (STitle) **] in 3 weeks([**Telephone/Fax (1) 1504**]) Dr [**Last Name (STitle) 7443**] ([**Hospital **] clinic) on [**2-21**] @12noon [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2185-2-10**] Name: [**Known lastname 10984**],[**Known firstname **] M Unit No: [**Numeric Identifier 10985**] Admission Date: [**2185-1-25**] Discharge Date: [**2185-2-18**] Date of Birth: [**2126-2-16**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Aspirin / Motrin Attending:[**First Name3 (LF) 265**] Addendum: She remained in the hospital for surgery. Chief Complaint: Ticuspid Valve Endocarditis Major Surgical or Invasive Procedure: [**2185-1-26**] - ERCP w/stent placement [**2185-2-1**] - Liver biopsy [**2185-2-11**] - Cardiac Catheterization [**2185-2-14**] - Redo-redo TVR (tissue) via right thoracotomy & placement of 3 permenant epicardial pacemaker leads. History of Present Illness: 58 year old female with tricuspid valve replacement in [**2159**] at [**Hospital1 10986**] who was admitted to [**Hospital 328**] hospital [**1-21**] after she presented to the ER there complaining of severe back pain. Associated with her back pain was a sensation of nausea with associated vomitting, diminished appetite, fever to 103 as well as shaking chills. She was found to have elevated WBC and marked bandemia. She was treated with vancomycin, ciproflaxacin, and flagyl as initial therapy on [**1-21**] and subsequently had aztreonam briefly added. She had a CT scan of the abdomen and pelvis as well as evaluation of her lumbar spine to evaluate for epidural abscess. Her abdominal CT scan was suggestive of a possible inflammatory mass in the head of the pancreas, and she had a CT scan of the lumbar and lower thoracic spine which was suggestive of degenerative disease, with no clear collection, but a wire consistent with old spinal stimulator was noted from T11-T12. The lung areas picked up on her scans were suggestive of basilar consolidation with a question of cavitation in the left lower lobe. She was admitted to the ICU at [**Hospital 328**] hospital and she was noted to have a high grade gram positive bacteremia. Pending identification, her antibiotics were broadened to vancomycin, rifampin and gentamicin briefly with the addition of linezolid on [**1-23**]. A Surface echo on [**1-24**] revealed no vegetation but a TEE on [**1-25**] revealed a large tricuspid vegetation on her prosthetic valve. She was subsequently narrowed to vancomycin and linezolid. She developed right upper quadrant pain along with rising liver function tests and jaundice and she was started onto moxifloxacin on [**1-25**]. She was subsequently transferred to [**Hospital1 8**] for ongoing care on [**1-25**]. She was intubated for worsening hypoxemia and started onto paralytics as she was proving difficult to ventilate/oxygenate and underwent RUQ ultrasound. She had abdominal CT scan and underwent an ERCP this morning. She was found to have no clear cholangitis but had a stent placed. Past Medical History: s/p TV repair '[**59**], s/p TVR/PFO closure '[**69**] c/b CVA/cardiac arrest,Breast CA s/p lumpectomy/Chemo/XRT '[**78**], sepsis related to Portacath, atrial arrhythmias, multiple spinal surgeries, h/o spinal stimulators-?removal, COPD, Left ing hernia repair. Social History: lives with fiance and granddaughter + tobacco - about [**11-17**] ppd, none for ~ 1 week prior to transfer denies current etoh/drug abuse Family History: Mother- Diabetes/HTN Physical Exam: Tmax:99.4 T curr: 98.8 P: 74 BP:101/59 Vent: AC 450 x 32 fiO2 70 % RR: 32 Drips: levo and pitressin, cisatracurium General: Deeeply jaundiced, intubated, sedated and paralyzed HEENT: Eyes with scleral icterus, no conjunctival hemorrhages Neck: No LAD Cardiovascular: Regular S1 S2 with III/VI systolic murmur Respiratory: Coarse, crackles at bases Back: Unable to assess Gastrointestinal: soft, NT,ND, no hepatsplenomegaly Musculoskeletal: No joint swelling Skin: No rashes, no splinter hemorrhages Extremities: Right A line, right groin line. Pertinent Results: [**2185-2-14**] ECHO Pre bypass: The left atrium is moderately dilated. The right atrium is moderately dilated. A mass/thrombus associated with PICC line is seen at RA/SVC junction. The interatrial septum is thickened consistent with h/o ASD repair, no atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with normal free wall contractility. 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. A bioprosthetic tricuspid valve is present. A paravalvular tricuspid prosthesis leak is probably present; the jet is eccentric and seems to originate from the septal portion of the annulus. The leaflets of the tricuspid prosthesis are thickened. There is a moderate vegetation on the tricuspid valve. There is moderate tricuspid stenosis. The pulmonic valve leaflets are thickened. A probable vegetation or mass is seen in the RVOT adjacent to or possibly involving the pulmonic valve. [**Month/Day/Year **] aware of prebypass findings. Post bypass: Preserved biventricular function, LVEF >55%. There is a bioprosthetic tricuspid valve insitu with a trace central eccentric jet of regurgitation. Peak gradient 4, mean 2-3 mm Hg. Small perivalvular leaks resolved with protamine. A mass is still seen in the RVOT just below the pulmonic valve and appears essentially unchanged. MR remains trace. There is no AI. Aortic contours are intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2185-1-25**] 09:50PM URINE RBC-329* WBC-8* BACTERIA-FEW YEAST-NONE EPI-0 [**2185-1-25**] 09:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.5 LEUK-TR [**2185-1-25**] 09:56PM WBC-20.8* RBC-3.40* HGB-10.7* HCT-31.9* MCV-94 MCH-31.5 MCHC-33.5 RDW-15.3 [**2185-1-25**] 09:56PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-431* CK(CPK)-12* ALK PHOS-162* AMYLASE-17 TOT BILI-12.6* DIR BILI-10.4* INDIR BIL-2.2 [**2185-1-25**] CTA Chest/Abdomen 1. No evidence of pulmonary embolism. 2. Significant ground-glass opacities and consolidative airspace disease seen at the lung bases as detailed above. Nonspecific imaging findings with differential considerations including congestive failure and atelectasis as well as infectious etiologies. Clinical correlation is recommended. Small bilateral pleural effusions are identified. 3. No acute intra-abdominal abnormality is detected. 4. Mediastinal and right hilar lymphadenopathy [**2185-1-26**] Liver/Gallbladder U/S 1. Common bile duct dilation but no significant intrahepatic biliary ductal dilation. The distal common bile duct was not visualized. 2. Mildly distended gallbladder with sludge, but no evidence for acalculous cholecystitis. [**2185-2-17**] PICC Line Uncomplicated ultrasound and fluoroscopically guided 5-French double-lumen PICC line placement via the right brachial venous approach. Final internal length is 36 cm, with the tip positioned in SVC. The line is ready to use. [**2185-2-17**] ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. There is no mass/thrombus in the right ventricle. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. A bioprosthetic tricuspid valve is present. The gradients are slightly higher than expected for this type of prosthesis. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No RV mass seen. Tricuspid valve bioprosthesis with slightly higher-than-expected gradients. Preserved left ventricular systolic function. Dilated right ventricle with borderline-low systolic function. No vegetations seen. Compared with the prior study (images reviewed) of [**2185-2-8**], the previously-seen tricuspid prosthesis thrombus/vegetation is no longer appreciated. Right ventricular size/function appear similar, and the cavity size may have been slightly underestimated on the prior study. The other findings are similar. [**2185-2-17**] CXR Interval increase of opacity at the right base, due to some combination of pleural effusion and associated atelectasis; superimposed pneumonia cannot be ruled out. Possible small left pleural effusion. Brief Hospital Course: She was again seen by infectious diseases who felt that surgery was now warranted given that she had developed fevers, there was a question of new emboli and the size of her tricuspid vegetation had increased despite several weeks of therapy. She was taken for cardiac catheterization on [**2-11**] which showed no coronary artery disease. She was cleared for surgery by dental. Her fevers continued and she was taken to the operating room on [**2-14**] where she underwent a redo-redo tricuspid valve replacement via a right thoracotomy, placement of 3 permanent pacemaker leads and removal of her PICC line. She was transferred to the ICU in stable condition. She was transfused 2 units for postoperative anemia. She was extubated on POD #1. She was desensitized to PCN and started on unasyn and her vanco was stopped. She was transferred to the floor on POD #2. A repeat echo on [**2-17**] showed no RV mass, a tricuspid valve bioprosthesis with slightly higher-than-expected gradients, a preserved left ventricular systolic function and dilated right ventricle with borderline-low systolic function. No vegetations were seen. PICC line was reinserted on [**2185-2-17**]. She was gently diuresed towards her preoperative weight. The physical therapy service worked with her daily. Mrs. [**Known lastname **] continued to make steady progress and was discharged to [**Hospital **] Health Care rehabilitation center on [**2185-2-18**]. She will follow-up with Dr. [**Last Name (STitle) 1825**] in [**Month (only) 412**] for ERCP and removal of her stent. She will also follow-up with Dr. [**First Name (STitle) **], her primary care physician and the infectious disease service as an outpatient. Medications on Admission: Percocet 10/375 QID/prn Albuterol Robaxin 750 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Rifampin 600 mg Recon Soln Sig: 300 mg Recon Solns Intravenous three times a day. 7. Gentamicin Sulfate (PF) 100 mg/10 mL Solution Sig: One Hundred (100) mg Intravenous every twenty-four(24) hours for 2 weeks: Stop date is [**2185-2-28**]. 8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 9. Unasyn 3 gram Recon Soln Sig: 3 grams grams Intravenous every eight (8) hours. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care - [**Hospital1 **] Discharge Diagnosis: Tricuspid valve endocarditis s/p redo, redo TVR [**2185-2-14**] PMH: s/p TV repair '[**59**], s/p TV replacement '[**69**], breast CA s/p lumpectomy/rads/XRT '[**78**], s/p PFO closure, s/p CVA '[**69**], cervical radiculopathy s/p cervical laminectomy & lumbar fusion, hx R&L spinal stimulator-?L side removed, COPD, Atrial tachycardia, sepsis from portacath'[**80**], s/p L ing hernia repair Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 4294**] at ([**Telephone/Fax (1) 2092**]. 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 driving for 1 month. 6) Please draw gentamicin trough with renal function three times weekly. Please also check LFT's and a CBC once weekly. Please fax results to Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 10987**]. Gentamicin to continue for 2 weeks (Stop [**2185-2-28**]). Unasyn and rifampin timing will be decided per infectious disease service when patient seen [**2185-3-2**]. 7) Call with any questions or concerns. Followup Instructions: Repeat ERCP for stent removal (Biliary Service Dr [**Last Name (STitle) 1825**] in [**2185-3-17**] (8 weeks from [**2185-1-26**]). Dr. [**Last Name (STitle) 1825**] [**Telephone/Fax (1) 10988**] Dr. [**First Name (STitle) **] in 1 month ([**Telephone/Fax (1) 2092**]) Dr. [**Last Name (STitle) 10989**] 2 weeks [**Telephone/Fax (1) 5082**] Please call all providers for appointments. Scheduled Appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 494**], MD Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2185-3-2**] 10:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2185-2-18**]

[ "276.2", "572.8", "496", "996.61", "997.91", "V17.49", "486", "518.81", "995.92", "V09.0", "423.1", "038.11", "576.1", "V10.3", "415.12", "305.1", "421.0", "576.8", "785.52", "038.0", "996.62" ]

icd9cm

[ [ [] ] ]

[ "88.56", "35.27", "50.11", "37.22", "39.64", "38.93", "96.6", "99.04", "88.72", "89.68", "00.14", "96.72", "34.04", "99.07", "39.61", "99.21", "96.04" ]

icd9pcs

[ [ [] ] ]

24594, 24667

21824, 23522

13567, 13800

25105, 25114

16990, 21801

26181, 26861

16388, 16410

23618, 24571

4046, 4127

24688, 25084

23548, 23595

25138, 26158

16425, 16971

13500, 13529

4156, 9184

13828, 15930

15952, 16216

16232, 16372

16,197

120,381

20999

Discharge summary

report

Admission Date: [**2188-4-15**] Discharge Date: [**2188-5-9**] Date of Birth: [**2121-1-11**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: bilateral pulmonary nodules Major Surgical or Invasive Procedure: Flexible bronchoscopy and VATS right middle lobe wedge resection x3. History of Present Illness: Ms. [**Known lastname 7363**] is a 67-year-old woman with a history of breast cancer who had a recent episode of shortness of breath for which she underwent a chest x-ray showing a new nodule in the right chest. A followup chest CT revealed bilateral pulmonary nodules. Some of these were compared against a CT scan done in [**2187-11-6**], and the nodules appeared to be growing in size. Past Medical History: notable for breast ca s/p lumpectomy, CVA in [**2186**] w/L sided weakness and visual field defecit, HTN & DM. Social History: No drugs, no alcohol, and no history of cigarette use. Previously worked as a home health aide. No history of chemical exposure. Family History: Sister with ovarian cancer and another sister with hemophilia who died of HIV. Mother with heart disease and father with emphysema. Physical Exam: NAD RRR CTA chest wall incision clean dry intact soft nontender Pertinent Results: [**2188-4-15**] 06:33PM GLUCOSE-170* UREA N-16 CREAT-0.8 SODIUM-142 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15 [**2188-4-15**] 06:33PM CALCIUM-8.6 PHOSPHATE-3.8 MAGNESIUM-1.6 [**2188-4-15**] 06:33PM WBC-10.3 RBC-3.45* HGB-10.3* HCT-29.6* MCV-86 MCH-30.0 MCHC-34.9# RDW-13.8 [**2188-4-15**] 06:33PM PLT COUNT-167 [**2188-4-15**] 05:10PM TYPE-ART PH-7.45 INTUBATED-INTUBATED [**2188-4-28**] 9:57 pm SWAB Site: RECTAL Source: Rectal swab. **FINAL REPORT [**2188-5-2**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2188-5-2**]): ENTEROCOCCUS SP.. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN------------ =>64 R VANCOMYCIN------------ =>32 R [**2188-5-6**] 10:06 am SWAB Site: RECTAL Source: Rectal swab. R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Pending): [**2188-5-6**] 6:46 pm STOOL CONSISTENCY: SOFT Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2188-5-7**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 55792**] ON [**2188-5-7**] AT 10AM. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). [**2188-4-21**] 11:15 am SPUTUM **FINAL REPORT [**2188-4-23**]** GRAM STAIN (Final [**2188-4-21**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2188-4-23**]): OROPHARYNGEAL FLORA ABSENT. YEAST. RARE GROWTH. Brief Hospital Course: Patient received flexible bronchoscopy and VATS right middle lobe wedge resection x3 on [**2188-4-15**]. Patient tolerated procedure well recovered in PACU and transferred to [**Wardname **] for further care. On POD1 patient ws transfered to SICU for increased somnolence despite decrease in in narcotics (PCA was d/c'd). She developed ARDS and respiratory failure requiring intubation and lengthy ICU course involving ID consult and Pulmonary consults for assistance in care. She was extubated on POD 13 and transfered from the ICU POD 22. On POD 23 stool cx return postiive for C. Diff which ois currently being treated with PO flagyl. She tolerated PO diet after passing swallow evaluation [**2188-5-7**]. On POD24 patient was cleared for discharge to extended care facility for rehabilitation. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1) Injection TID (3 times a day). 2. Fluoxetine 20 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO DAILY (Daily). 3. Gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO DAILY (Daily). 4. Nortriptyline 25 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Dipyridamole 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3 times a day). 7. Aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable PO BID (2 times a day). 8. Nystatin 100,000 unit/mL Suspension [**Month/Day/Year **]: Five (5) ML PO QID (4 times a day) as needed. 9. Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical QID (4 times a day) as needed. 10. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) Inhalation Q4H (every 4 hours) as needed. 11. Acetaminophen-Codeine 120-12 mg/5 mL Elixir [**Month/Day/Year **]: 12.5-25 MLs PO Q4H (every 4 hours) as needed. 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-7**] Sprays Nasal Q4H (every 4 hours). 14. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3 times a day). 15. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day (2) **]: [**1-7**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 17. Furosemide 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily): baseline dose 20mg QOD. 18. Ferrous Sulfate 325 (65) mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 19. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day). 20. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Bilateral pulmonary nodules Discharge Condition: stable Discharge Instructions: Call Dr. [**Last Name (STitle) **] office [**Numeric Identifier 55793**] for the following: - fevers -shortness of breath -chest pain -foul smelling discharge for incision sites Please take all medications as prescribed. Do not operate heavy machinery/automobile while taking narcotics such as Percocets. you may shower in 2 days Followup Instructions: Please followup with Dr. [**Last Name (STitle) **] [**Name (STitle) **] 10-14 days call [**Telephone/Fax (1) 170**] for appointment. Provider: [**Name10 (NameIs) 5005**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2188-9-19**] 2:00 Completed by:[**2188-5-9**]

[ "008.45", "197.0", "250.00", "401.9", "518.0", "486", "428.0", "518.5", "599.0", "278.00", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "32.29", "93.90", "88.73", "38.93", "96.6", "33.22", "96.72", "38.91" ]

icd9pcs

[ [ [] ] ]

6392, 6464

3419, 4219

348, 419

6536, 6545

1369, 3396

6924, 7257

1135, 1269

4242, 6369

6485, 6515

6569, 6901

1284, 1350

281, 310

447, 838

860, 972

988, 1119

49,209

187,921

41856

Discharge summary

report

Admission Date: [**2161-9-22**] Discharge Date: [**2161-10-6**] Date of Birth: [**2094-12-28**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1943**] Chief Complaint: Fevers and pain Major Surgical or Invasive Procedure: Fluroscopic L4 biopsy ([**9-24**]) Endotracheal intubation ([**9-29**]) Transesophageal echocardiogram ([**9-29**]) History of Present Illness: 66 year-old woman with morbid obesity, CAD, NSTEMI, L4-L5 discitis, history of pancytopenia since [**2159**] was transferred from [**Hospital6 17183**] for further evaluation of fever. Patient was in her usual state of health until [**2161-4-19**]. On [**4-30**], [**2160**], she had an epidural injection for lumbar spinal stenosis. On [**5-2**], she developed chest pain and was diagnosed with NSTEMI and received a coronary artery stent. Blood cultures positive for Strep viridans and she was treated with Levofloxacin. Repeat blood cultures in [**Month (only) **] were positive for Strep viridans. She received 4 weeks of Ceftriaxone. TEE on [**5-27**] showed no vegetations. She was hospitalized again from [**7-2**] ?????? [**7-13**] with L4-L5 discitis and surrounding phlegmon. She was treated with another 4 weeks of Ceftriaxone. She was discharged to rehab where she stayed until [**8-30**] and had improved back to her usual state of health except for an area on her left thigh that looked like a cellulitis. Bactrim was prescribed by her PCP. She became febrile and very ill, so returned to the ED on [**9-1**]. She was admitted on [**9-3**] with fever, low back pain, and left thigh redness. Patient had pancytopenia (WBC 2.2, HCT 26, PLT 122), CXR showed right basilar atelectasis, temp 100.6 ?????? 103. Ceftriaxone stated. CT L-spine revealed stable changes at L4-L5. ID, Cards, and Hematology were consulted. Oncology thought pancytopenia was secondary to infection, and not a primary [**Last Name 15482**] problem. Pancytopenia workup in the past including iron studies, B12, folate, TSH, SPEP, lymphocyte testing, Rh, [**Doctor First Name **] were all per report inconclusive. Bone marrow aspirate was on [**2161-9-16**] in the L posterior iliac crest, that showed paucity of iron staining, for which the patient was started on iron supplementation. ID consult recommended Ceftriaxone initially while awaiting blood culture results. TEE [**9-7**] showed mild mitral regurgitation, mild tricuspid regurgitation, and trace pulmonic regurgitation, without any effusions, normal LV function, and without vegetations. Hepatitis panel and HIV serologies were negative. CT did not show any evidence of fluid collection or worsening of the discitis. ID also brought up the possibility of a PE, but ultimately had a negative CTA chest and BLE dopplers. At various points of the hospital course the patient received Vancomycin and Imipenem. Eventually ID recommended stopping all antibiotics; this was done [**9-21**]. On [**9-22**], the patient was transferred to the [**Hospital1 18**] for further workup of FUO. She was admitted to the [**Hospital Unit Name 153**] for BiPAP. Abdomen showed generalized anasarca. Review of systems: Unable to obtain. Past Medical History: Coronary artery disease NSTEMI Obesity Hypertension Dyslipidemia L4 and L5 discitis Social History: - Tobacco: Quit 27 years ago, stopped for smoking. 50 pack year history - Alcohol: No abuse - Illicits: No illicits. - Used to work as a hairdresser. Family History: Mother died in the 80s from Alzheimer's. Father died at 25 from MI. Physical Exam: Admission Physical Exam: VS: T 103.1 BP 152/59 HR 120 R 20 S 100% CPAP General: Alert, following commands, unable to speak [**1-21**] to Bipap HEENT: MMM, oropharynx clear Neck: unable to assess JVP Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, non-tender, non-distended, L abdomen is more firm than right Ext: warm, well perfused, 2+ pulses, gross anasarca, LLE with some mild erythema along the inner thigh as compared to the right Discharge Physical Exam VS: Afebrile x 24 hours GEN: Alert, obese CV: RRR ABD: Distended, nontender, normal bowel sounds NEURO: Eyes open, barely audible speech Pertinent Results: [**2161-9-22**] 10:44PM BLOOD WBC-3.8* RBC-4.06* Hgb-11.3* Hct-32.7* MCV-81* MCH-27.7 MCHC-34.4 RDW-15.8* Plt Ct-118* [**2161-9-22**] 10:44PM BLOOD Neuts-82* Bands-5 Lymphs-10* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2161-9-22**] 10:44PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2161-9-22**] 10:44PM BLOOD PT-15.0* PTT-32.2 INR(PT)-1.3* [**2161-9-23**] 05:38AM BLOOD ESR-64* Parst S-NEGATIVE [**2161-9-22**] 10:44PM BLOOD Glucose-158* UreaN-26* Creat-0.6 Na-137 K-4.0 Cl-101 HCO3-24 AnGap-16 [**2161-9-22**] 10:44PM BLOOD ALT-41* AST-83* LD(LDH)-2550* AlkPhos-51 TotBili-0.4 [**2161-9-22**] 10:44PM BLOOD Albumin-2.7* Calcium-8.8 Phos-3.0 Mg-2.0 Iron-15* [**2161-9-22**] 10:44PM BLOOD calTIBC-207* Ferritn-1468* TRF-159* [**2161-10-1**] 05:41AM BLOOD %HbA1c-5.8 eAG-120 [**2161-9-22**] 10:44PM BLOOD Triglyc-245* [**2161-9-28**] 04:19AM BLOOD TSH-1.5 [**2161-9-24**] 05:51AM BLOOD IgG-221* IgA-23* IgM-12* [**2161-9-22**] 11:24PM BLOOD Lactate-2.4* FREE KAPPA AND LAMBDA, WITH K/L RATIO - wnl ASPERGILLUS GALACTOMANNAN ANTIGEN - negative B-GLUCAN - negative ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) - negative CSF: Tube - 1 ---- 4 WBC - 5 ----- 11 RBC - 621 --- 470 Polys - 6 --- 2 Lymphs - 72 - 85 Monos - 22 -- 15 Protein 25 Glucose 72 HSV PCR - negative Micro: [**2161-10-3**] Urine culture - 10,000-100,000 Yeast [**2161-10-3**] Blood culture - PENDING [**2161-9-30**] Blood Culture, Routine-No growth [**2161-9-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {GRAM NEGATIVE ROD(S)} RARE GROWTH Commensal Respiratory Flora. [**2161-9-27**] Blood Culture, Routine-No growth [**2161-9-27**] URINE CULTURE-FINAL - Negative [**2161-9-26**] CATHETER TIP-IV WOUND CULTURE-FINAL - Negative [**2161-9-26**] MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY - No growth to date; BLOOD/AFB CULTURE-PRELIMINARY - No growth to date [**2161-9-26**] Blood Culture, Routine-No growth [**2161-9-26**] URINE CULTURE-FINAL - Negative [**2161-9-26**] Blood Culture, Routine-PENDING - Negative [**2161-9-25**] Blood Culture, Routine-FINAL - Negative [**2161-9-24**] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-FINAL; POTASSIUM HYDROXIDE PREPARATION-FINAL; FUNGAL CULTURE-PRELIMINARY - No growth to date; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY - No growth to date [**2161-9-24**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY - No growth to date; ACID FAST CULTURE-PRELIMINARY - No growth to date; VIRAL CULTURE-PRELIMINARY - No growth to date [**2161-9-24**] URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA} [**2161-9-24**] Blood Culture, Routine-FINAL - Negative [**2161-9-23**] Blood Culture, Routine-FINAL {PSEUDOMONAS AERUGINOSA}; Aerobic Bottle Gram Stain-FINAL [**2161-9-23**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL - Negative [**2161-9-22**] Blood Culture, Routine-FINAL - Negative [**2161-9-22**] URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA, ENTEROCOCCUS SP.} INPATIENT [**2161-9-22**] Blood Culture, Routine-FINAL - Negative IMAGING: [**2161-9-29**] CAROTID SERIES COMPLETE - IMPRESSION: Less than 40% left carotid stenosis. Right side could not be imaged due to placement of central line. [**2161-9-29**] TEE - IMPRESSION: No abscess or vegetations seen. Complex, nonmobile atheroma of the descending aorta and arch. [**2161-9-29**] EEG - IMPRESSION: This is an abnormal continuous ICU monitoring study because of moderate diffuse background slowing. These findings are indicative of a moderate diffuse encephalopathy which is etiologically non-specific. There are frequent bilateral broadly distributed epileptiform discharges indicative of epileptogenic potential. There are no electrographic seizures. [**2161-9-25**] MR HEAD W & W/O CONTRAST - IMPRESSION: Multiple foci of signal abnormalities on diffusion images with occipital lobe with questionable low ADC changes and could suggest acute infarcts. Some of these infarcts are likely subacute in nature seen in the left frontal and parietal region. None of this foci demonstrate enhancement. No MRI signs of an abscess formation or meningeal enhancement seen. No epidural or subdural fluid collection or enhancement seen. [**2161-9-23**] TTE - IMPRESSION: No echocardiographic evidence of endocarditis. Hyperdynamic LV systolic function. No significant valvular regurgitation seen. If clinically indicated, a transesophageal echocardiogram may better assess for valvular vegetations. Brief Hospital Course: 66 year-old woman with morbid obesity, CAD, NSTEMI, L4-L5 discitis, history of pancytopenia since [**2159**] was transferred from [**Hospital6 17183**] for further evaluation of fever. She developed hypotension requiring pressors and found to have [**Hospital6 89618**] UTI and bacteremia and possible embolic strokes per MRI. Now off pressors. Once the patient stabilized, she transferred to the floor. She became progressively more awake and was able to discuss management plans. Although we were recommending MRA HEAD/NECK and CT TORSO, she refused any further diagnostic tests. She also wanted her code status changed to DNR/DNI. The patient still has FUO, but she declines any further workup. Differential diagnoses include undiagnosed abdominal infections versus occult malignancy. Patient is not interested in further workup at this time, but does consent to continuing the remainder of the recommended antibiotic therapy and going to LTAC for further therapy. ACTIVE PROBLEM LIST: # [**Name2 (NI) **] bacteremia with history of other Gram positive bacteria in blood: Treated with Ceftazidime from [**9-27**] - [**10-4**], then changed to Zosyn [**10-4**] - [**10-25**]. # Encephalopathy, metabolic: Patient initially obtunded and a significant change to her prehospitalization status according to her sister. When her mental status did not improve with her fever curve and antibiotic therapy, an MRI was done with revealed acute/subacute infarctions. Neurology was consulted and felt that this findings were mostly likely septic embolic. An EEG was also done which did not reveal seizure activity and was consistent with diffuse metabolic encephalopathy. # CVA, subacute and acute infarcts: We did recommend MRA Head and Neck to better characterize lesions to see if they were septic emboli that caused CVA. Pt declined MRA. Her mental status did improve over the last one week of hospitalization. # Pancytopenia/Neutropenia: Unclear etiology; possibly [**1-21**] sepsis. Currently with ANC 920. Records revealed that she was pancytopenic in [**2159**], which was reportedly in the setting of an acute infection. She underwent a bone marrow biospy at the OSH which was reviewed by the heme/onc consult team and was felt to be neagtive. She was also found to be hypogammaglobulinemic for which she received IVIG. # Dysphagia, likely [**1-21**] CVA. Hopefully her function returns as her CVA improves. Would recommend repeat speech and swallow eval. # FUO: The patient was transferred to [**Hospital1 18**] with unexplained fevers, for which the OSH was unable to identify a source. While she was found to have the psuedomonal bacteremia as above, it was unlikely to be the source of her original fevers as she had negative blood cultures at the OSH. The biopsy of her L4/L5 was unrevealing and her CSF analysis was no consistent with infection. As she had a high LDH and splenomegaly on imaging studies, there was concern for an occult malignancy. Heme/onc was consulted and reviewed her bone marrow biopsy and felt it was within normal limits. She had concerning skin findings and tenderness over her left hip, which was reported the site of prior corticosteroid injections. Dermatology was consulted who felt that the changes were most likely resolving cellulitis that had been exacerbated by her anasarca. The etiology of her original fevers remains unclear. INACTIVE PROBLEM LIST: # [**Name2 (NI) **]/[**Name2 (NI) **] UTI: S/p Ceftazidime and Linezolid x 7 days. # Hypernatremia: Resolved with adding free water to tube feeds. # Respiratory distress: Thoughout her ICU course, patient was noted to be tachypneic with an oxygen requirement which was not present prior to her hospitalization. Her oxygen requirement varied throughout her course. She was electively intubated on [**9-29**] for a TEE and was sucessfully extubated on [**9-30**]. During her ICU course, she was also diruesed to help improved her breathing status. her oxygen requirement gradually decreased. She was transferred to the floor satting 97% on 3L nasal cannula. # Hypotension/sepsis: Upon arrival to the ICU, her blood pressures were stable at 150s systolic. Later in her ICU course, he BP dropped in the setting of apparent sepsis to the point where she required pressors for BP support for a few hours. After that her BP were stable and ranging from 130-160 systolic. # L4 and L5 discitis: As per imaging reports, appears to be stable. Patient underwent an IR guided biospy, which revealed only clots. The spine service was consulted who recommended TLCO brace if the patient was sitting up >30 degrees. Patient was also reported taking prednisone 10 mg po qday, which was held on admission to avoid masking an infectious source. # CAD: The patient had a drug-eluting stent per outside records placed in [**Month (only) 116**]. As there was initial concern for bleeding and hypotension, her home medications were held. When her BP was more stable her beta-blocker and lisinopril were restarted. Upon discussion with neurology regarding her MRI findings, her ASA and prasugrel were restarted. Her statin was originally held in the setting of an increase in her AST. It was later also restarted. Medications on Admission: Home Medications: Valium 10 mg QHS Fentanyl patch 75 mcg Q72 H Lasix 20 mg Daily Neurontin 600 mg TID Miralax 17 g daily Prednisone 10 mg Daily Senna 2 tabs QHS Bactrim DS 1 [**Hospital1 **] Flomax 0.4 mg QHS Medications on Transfer: ASA 325 Daily* Calcium Carbonate 500 mg [**Hospital1 **]* Lactosebacillus Acidophilus 2 caplets TID* Lisinopril 5 mg Daily* Metroplol Tartrate 12.5 mg [**Hospital1 **]* Multivitamin* TPN* Pantoprazole 40 mg Daily* Prasugrel Hydrochloride (Effient) 10 mg Daily?? Lovenox 30 mg SC Daily* Prednisone 10 mg Daily* Rosuvastatin 20 mg QAM* Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP<110 or HR<55. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP<110. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed for constipation. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 11. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 gram Intravenous Q6H (every 6 hours) for 19 days: Continue through [**10-25**] to complete 4-week antibiotic course. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: - Sepsis - [**Location (un) **] bacteremia - [**Location (un) **] and [**Location (un) 89618**] urinary tract infection - Fever, unknown origin - Cerebral infarcts, acute and subacute - Hypernatremia - Pancytopenia - Dysphagia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for further workup of ongoing fevers. You were found to have bloodstream and urinary tract infections. You were also initially confused. Evaluation of the head with MRI revealed multiple areas of stroke. You have been on antibiotics since admission. Your mental status has been slowly improving. You continued to have fevers despite having been on antibiotics for over a week. Followup Instructions: Department: INFECTIOUS DISEASE When: MONDAY [**2161-10-19**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2148-5-30**] Discharge Date: [**2148-6-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 86 yo female s/p CABG [**4-13**] recently admitted from [**Date range (1) 27052**] to [**Hospital1 2025**] for c diff colilits sent in from rehab with fever to 101 and lethargy. Her CABG hospitalization was complicated by Psedumonas UTI and she was admitted to [**Hospital1 2025**] with fever and diarrhea and found to be C Diff positive. Pt. was very drowsy and tired due to the time of day and also was a poor historian. Per report, the patient had been lethargic and febrile at the RN home with continued diarrhea prompting her admission. On meeting the patient, she denied any CP or SOb at this time, but was cold. Denied cough or dysuria. Noted her hemorrhoids are acting up. . In the ED: - Febrile to 101.3 with QBC count of 25.7 (it was 21.8 on [**5-29**]) - She received: Vanco/ceftriaxone/Flagyl - 1L NS as her BP was initially in the 80s -> but quickly rose to the 110s. Past Medical History: CAD: - s/p MI [**3-/2147**] - 3V CABG ([**4-13**]) - [**Hospital6 **] - EF of 68% 5/07 C Diff Colitis - on flagyl 500mg TID PVD PMR - on prednisone therapy AFib HTN Hyperlipidemia Hx of bradycardia with syncope - on amiodarone Diverticulosis with IBS MR AI Social History: Lives at [**Hospital **] Rehab. Family History: NC Physical Exam: T: 95.4 oral BP:152/54 P:80 RR:22 O2 sats:98% on 2L Gen: Chronically ill appearing; shivering; tired HEENT: OP dry. Neck supple CV: +s1+s2 RRR No murmurs. CABG scar is healed well without signs of infection. Resp: Slight wheeze. Good air movement without crackles Abd: distended. Non tender. No rebound. No guarding. Ext: trace ankle edema. Extremities cool, but perfused. Neuro: CN: [**2-19**] grossly intact Strength: 4+/5 dorsi and plantar flexion. Sensation intact in LEs. Pertinent Results: [**2148-5-29**] 10:40PM PLT SMR-NORMAL PLT COUNT-317# [**2148-5-29**] 10:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2148-5-29**] 10:40PM NEUTS-68 BANDS-2 LYMPHS-7* MONOS-23* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2148-5-29**] 10:40PM WBC-25.7*# RBC-3.30* HGB-11.6* HCT-33.5* MCV-102* MCH-35.1* MCHC-34.5 RDW-18.4* [**2148-5-29**] 10:40PM estGFR-Using this [**2148-5-29**] 10:40PM GLUCOSE-140* UREA N-11 CREAT-0.6 SODIUM-128* POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-26 ANION GAP-14 [**2148-5-29**] 10:50PM LACTATE-1.9 [**2148-5-29**] 11:08PM URINE RBC-0-2 WBC-0 BACTERIA-MANY YEAST-NONE EPI-0 [**2148-5-29**] 11:08PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2148-5-30**] 06:30AM PLT SMR-NORMAL PLT COUNT-274 [**2148-5-30**] 06:30AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2148-5-30**] 06:30AM NEUTS-63 BANDS-4 LYMPHS-9* MONOS-17* EOS-0 BASOS-0 ATYPS-7* METAS-0 MYELOS-0 [**2148-5-30**] 06:30AM WBC-30.3* RBC-3.22* HGB-11.4* HCT-33.8* MCV-105* MCH-35.3* MCHC-33.6 RDW-18.6* [**2148-5-30**] 06:30AM ALT(SGPT)-7 AST(SGOT)-14 LD(LDH)-244 ALK PHOS-90 TOT BILI-0.4 [**2148-5-30**] 11:59AM LACTATE-1.8 [**2148-5-30**] 11:59AM TYPE-[**Last Name (un) **] PO2-221* PCO2-41 PH-7.42 TOTAL CO2-28 BASE XS-2 COMMENTS-GREEN TOP [**2148-5-30**] 12:50PM WBC-19.4* RBC-2.83* HGB-10.0* HCT-29.5* MCV-104* MCH-35.5* MCHC-34.0 RDW-18.5* [**2148-5-30**] 12:50PM ALBUMIN-2.7* CALCIUM-7.8* PHOSPHATE-3.3 MAGNESIUM-1.5* [**2148-5-30**] 12:50PM CK-MB-NotDone cTropnT-0.02* [**2148-5-30**] 12:50PM LIPASE-13 [**2148-5-30**] 12:50PM ALT(SGPT)-6 AST(SGOT)-12 LD(LDH)-181 CK(CPK)-27 ALK PHOS-71 AMYLASE-29 TOT BILI-0.4 [**2148-5-30**] 12:50PM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-134 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-10 [**2148-5-30**] 01:11PM O2 SAT-75 [**2148-5-30**] 01:11PM LACTATE-2.2* [**2148-5-30**] 01:11PM PO2-41* PCO2-43 PH-7.42 TOTAL CO2-29 BASE XS-2 [**2148-5-30**] 07:14PM CK-MB-NotDone cTropnT-<0.01 [**2148-5-30**] 07:14PM CK(CPK)-38 [**2148-5-30**] 07:29PM GLUCOSE-101 LACTATE-1.1 K+-3.4* [**2148-5-30**] 07:29PM TYPE-[**Last Name (un) **] PH-7.36 . EKG: AFib with LAD normal int. V4-V6 TWI . CXR: [**2148-5-30**]: AP PORTABLE UPRIGHT VIEW OF THE CHEST: There are bilateral pleural effusions, left greater than right. There is a left lower lobe opacity. The pulmonary vasculature does not appear engorged. There is [**Hospital1 **]-apical scarring. The patient is status post CABG. There is calcification of the mitral annulus. IMPRESSION: Bilateral pleural effusions, left greater than right with left lower lobe associated opacity. The opacification of the left lower lung field may be secondary to the pleural effusion and/or an underlying lung process suggests pneumonia. . Imaging: 524/07; Portable Abdomen: UPRIGHT AND SUPINE VIEWS OF THE ABDOMEN: Patient is status post CABG. Chest is better evaluated on the dedicated chest film. Multiple loops of air and stool-filled colon are seen. Overlapping loops of small and large bowel containing air are present in the mid abdomen. Oral contrast is seen within the small bowel. There is a chronic left superior pubic ramus fracture. There are extensive vascular calcifications. There is a scoliotic curvature of the thoracolumbar spine convex right with extensive degenerative changes. IMPRESSION: Nonspecific bowel gas pattern. Please refer to the CT scan reported separately for further detail. . [**2148-5-30**]: CT Chest abd pelvis: CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral layering pleural effusions. There is associated compressive atelectasis. There are extensive coronary artery calcifications affecting all three vessels. There is mitral annular calcification. There is a small perihepatic fluid. There is a focal 10 mm area of hypo-enhancement in the right lobe of the liver (series 2, image 20), too small to characterize. There is periportal edema, a nonspecific finding. The gallbladder is nearly completely decompressed. Pancreas and spleen are unremarkable. There appears to be thickening of the left adrenal gland. Right adrenal gland is unremarkable. The left native kidney is atrophic. There is a 1.5 cm cyst at the interpolar region of the right kidney. There is no right-sided hydronephrosis. Loops of small and large bowel are of normal caliber. There is thickening of the cecum. The ascending and transverse colons appear normal. Descending colon is difficult to assess due to the presence of adjacent ascites in the left pericolic gutter. There is also thickening of the sigmoid colon and rectum, with adjacent fatty stranding. There is no intra-abdominal free air, pneumatosis, or portal venous gas. There are extensive calcifications of the aorta and iliac arteries. There are calcifications at the origins of the celiac and superior mesenteric arteries. CT OF THE PELVIS WITH IV CONTRAST: Foley catheter is within a decompressed bladder. Rectum and sigmoid colon demonstrate wall thickening with adjacent inflammatory changes. . BONE WINDOWS: There is a healed left inferior and left superior pubic ramus fractures. There are extensive degenerative changes of the spine. IMPRESSION: 1. Thickening of the cecum, rectum, and sigmoid colon consistent with colitis. 2. Bilateral pleural effusions. 3. Extensive atherosclerotic disease. 4. Small ascites and body wall edema consistent with anasarca . [**2148-5-30**]- TTE Conclusions: The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic root is moderately dilated athe sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Mild to moderate ([**1-9**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. . CHEST (PORTABLE AP) [**2148-6-2**] 1:35 AM A single AP view of the chest is obtained on [**2148-6-2**] at 01:43 hours and is compared with the prior morning's radiograph. There appears to have being an increase in the bilateral pleural effusions which is more marked on the left side. Cardiomegaly with congestive heart failure persists. Patient is status post median sternotomy. Marked thoracolumbar scoliosis is visualized. 1. Persistent congestive failure. 2. Increase in bilateral pleural effusions, left greater than right. . CHEST (PORTABLE AP) [**2148-6-4**] 7:29 AM Comparison with multiple previous examinations, the most recent of which is [**2148-6-2**]. Indistinct pulmonary vascular markings and fullness of the hila indicate pulmonary edema, slightly worse than the last examination. Bilateral pleural effusions are again identified, left greater than the right; the left is large and slightly larger than the last exam; the right pleural effusion is probably similar in size. Associated atelectasis is present; underlying pneumonic consolidation could also be present. Scarring in both lung apices is again noted. Changes of CABG and osseous structures are unchanged. IMPRESSION: 1. Increase in cardiac failure. 2. Bilateral pleural effusions, left greater than right, left slightly larger in the interim. Brief Hospital Course: 86 yo female w CAD s/p recent CABG, afib, PMR h/o and pseudomonas UTI, being treated for C Diff colitis admitted for fever and lethargy with transfer to the MICU for brief episode of hypotension. . # Dyspnea/respiratory failure- Hypoxia after volume resuscitation for C-diff, hypotension and question of sepsis. Concern for impending ARDS. Running diagnosis flash pulmonary edema in the setting of fluids. CHF on CXR persistent. Opacity was also seen on CXR which may indicate a pna. CTA negative for PE. Oxygen requirement at 4 L NC with 95-100% throughout stay. Pt was diuresed for a goal 1L neg daily. 40-80IV lasix given. Crackles on examination and bilateral pleural effusions L>R. Pt discharged with standing lasix. Potassium standing given hypokalemia in MICU on lasix. Pna treated initially with ceftriaxone and vanc, but changed to with linezolid and repleted as needed given diuretic. No utility in tapping effusions as likely result of VHF, patient clinically improving. Continuing abx course Zosyn, linezolid, 40 mg IV lasix to be adjusted as needed. . # Fever/WBC- 101.3 on admission. Pt with multiple possible sources of infection: C. diff colitis, UTI, PNA. f/u Blood, sputum cultures.Continued PO vanco for C.diff (stopped flagyl). Stopped vanc and ctx and started linezolid and zosyn [**6-1**] for pna linezolid for vre urine. No fever or leukocytosis at time of discharge. Linezolid 600 mg PO Q 12 for total of 14 days. Day 6. Zosyn 4.5 mg IV Q8 for a total of 14 days. Day 6 [**6-6**]. Oral vancomycin for C-diff to continue one week post stopping antibiotics to continue if continued symptoms. . #CHF-Appeared to be diastolic failure- Diuresis with 80 IV lasix during admission with goal negative 1 liter. Afterload reduction with ACE. Imdur also started. Atrial fibrillation worsening heart failure. ECHO with EF 70%, LVH with septal wall 1.5cm and small chamber diameter. 40 mg IV lasix daily to be decreased at rehab. . #Hypotension- Transient, likely result of hypovolemia and responded quickly to fluids. Considered cardiogenic shock, adrenal insufficiency PE. Sepsis. Lactate level at 2.2. Anterior TWI on EKG and tachycardia, atrial fibrillation, concerning for PE, but CTA negative for PE. Treated infection, limited fluids after initial bolus. Resolved within one day with subsequent hypertension. BB, and ACE held day 1. Then resumed metoprolol and captopril. . #Atrial fibrillation with RVR- HR to 140's. Likely in the setting of holding BB given hypotension. Increased metoprolol dose and considering Diltiazem for better rate control but patients HR to 40-50, bradycardia concerning. Cardiology consulted, recommended continued BB to increase to Metoprolol 100mg/100mg/75mg from previous 100 mg QAM, and 75 mg [**Hospital1 **]. Reported to hold on Diltiazem. Discussed anticoagulation. Pt is a fall risk in discussion and at this time will not start coumadin given risk for bleed. Discussed with husband risk for stroke when not anticoagulated. . # CAD s/p CABG- No current CP or cardiac symptoms at this time. However, EKG with new TWIs in V1-3. Neg for PE, Ruled out by enzymes. Continued ASA, Statin, increased BB, increased ACEI . # Anemia- No known bleeding currently. LDH, bili normal,coags relatively normal to rule against hemolysis/DIC. Possibly multifactorial (inflammation/dilution given IVF). Stable and cw iron def. Continued ferrous sulfate. . # PMR- Stable, continued prednisone during admission . # Code- FULL, discussed with family Medications on Admission: flagyl 500mg PO Q6 x 14 days (day #1 = [**5-29**]) Questram 4gm in 8oz fluids QD Lactinex 2tab PO TID x 14 days Ensure plus [**Hospital1 **] lisinopril 20mg daily lasix 10mg PO daily KCL 10meQ daily amlodipine 5mg daily (Stopped on [**5-25**]) ASA 325 daily metoprolol XL 150mg [**Hospital1 **] Prednisone 2mg/1mg QOD simvastatin 80mg QHS tylenol PRN albuterol PRN bisacodyl PRN ipratropium PRN ativan 0.5mg PO BID PRN MOM PRN Discharge Medications: 1. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Prednisone 1 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO once daily in the evening: hold for SBP<100. HR<55 . . 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID : hold for SBP<100. HR<55 . 16. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 17. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 20. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO ONCE (Once): 20 mg daily . 21. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 22. Piperacillin-Tazobactam Na 4.5 gm IV Q8H D#1 [**6-1**] 23. Furosemide 10 mg/mL Solution Sig: 40 mg Injection once a day: to be titrated as needed. . 24. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 15 days: to continue until one week post discontinuation of abx, continue if persistent symptoms. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Pulmonary edema A fibb with RVR Hypotension Pneumonia UTI . Secondary: Anemia PMR Discharge Condition: Stable Discharge Instructions: You were admitted with weakness, fatigue and developed shortness of breath and hypotension. You were treated with fluids and your hypotension improved. You were also treated with abx for the infection in your urine, gut and lungs. -Metoprolol changed to 100 mg twice a day and 75 mg at night. -Furosemide 40 mg IV daily, to be titrated as needed. -No anticoagulation at this time as fall risk. -Currently stable on 4 L NC -Please return to the hospital if patient is experiencing worsening shortness of breath, fever, severe diarrhea, chest pain, or other symptoms concerning to you. Followup Instructions: To [**Hospital6 459**] for the Aged MACU. Please contact PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27053**] [**Telephone/Fax (1) 27054**] for follow up

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

16362, 16428

10109, 13596

281, 287

16563, 16572

2063, 10086

17204, 17377

1546, 1550

14074, 16339

16449, 16542

13622, 14051

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1565, 2044

222, 243

315, 1199

1221, 1480

1496, 1530

22,753

139,561

2561

Discharge summary

report

Admission Date: [**2165-11-4**] Discharge Date: [**2165-11-8**] Date of Birth: [**2096-12-16**] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 68 year-old female with a past medical history significant for hyperlipidemia and hypertension who on a routine physical examination had received an electrocardiogram that showed questionable T wave inversions. She ultimately was scheduled for an exercise treadmill test that was positive, which led to a cardiac catheterization prior to this admission showing 100% occlusion of the right coronary artery and a tight proximal left anterior descending coronary artery lesion with a normal ejection fraction in the order of 50 to 70%. PAST MEDICAL HISTORY: Significant for a subtotal gastrectomy for gastric carcinoma in [**2158**] leaving her B-12 deficient and therefore requires B-12 injections. She has had a transient ischemic attack and stroke in the past. She has a seizure disorder. She has no real residual neurologic deficits in the way of motor, however. She has hypertension and hypercholesterolemia. SOCIAL HISTORY: She was a smoker in the past, but not in the present. FAMILY HISTORY: Noncontributory to her coronary disease. PREVIOUS SURGICAL HISTORY: Significant for the gastrectomy five years ago as well as a bunionectomy. ALLERGIES: Penicillin for which she gets a rash and hives. PREOPERATIVE MEDICATIONS: Tegretol 200 mg po b.i.d., Zestril 2.5 mg po q day, Lipitor 10 mg po q day, B-12 injections, 1000 micrograms po q day, Alphagan one drop OU b.i.d., Travatan one drop OU b.i.d. as well as a multi-vitamin and calcium supplement. PHYSICAL EXAMINATION: On examination when she presented to the Emergency Room, her blood pressure is 180/84 with a pulse of 66. She was in no acute distress. Preoperative weight was 63.6 kilograms. She is a well developed, well nourished white female. Pupils are equal, round, and reactive to light and accommodation. Mucous membranes are moist. Trachea was midline. There was no carotid bruit. Her chest was clear. There were no rales, rhonchi or wheeze. Cardiac examination was regular rate and rhythm with a prominent ST. There was no heaves or murmur. Abdomen was benign. There was a well healed laparotomy scar that is noted in the midline, otherwise bowel sounds are present. No masses. Extremities are warm, well profuse, palpable pulses dorsalis pedis and posterior tibial symmetric bilaterally. No varicosities are seen in the lower extremities and no edema. Neurologically was nonfocal. She therefore was evaluated and admitted on [**2165-11-4**] for an elective coronary artery bypass graft with the presumptive diagnosis of asymptomatic coronary artery disease with left main lesion. On [**2165-11-4**] she went to the Operating Room with Dr. [**Last Name (STitle) 1537**] where she underwent coronary artery bypass graft times three including grafts to the left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to the oblique marginal as well as saphenous vein graft to the right coronary artery. This was done under general endotracheal anesthesia. She left the Operating Room with the pericardium left open. She had an A line in the right radial arm. She had a right IJ Swan-Ganz catheter, two ventricular wires were present as well a two atrial wires, two mediastinal tubes as well as one left pleural chest tube were also present. Her mean arteriole pressure upon leaving the Operating Room was 82. CVP is 9. Her pulmonary systolic pressure was 15 with a mean of 20. She was on Propofol drip for sedation with 20 mics per kilo per minute and she was noted to be in sinus rhythm. Overnight she was rapidly extubated. She did well. She remained hemodynamically stable. On postoperative day number one she was off all of her drips. Her blood pressure which s90/50. She was not being given any pressure support except for volume. Her Lasix and Lopresor was subsequently held. She was started on aspirin and a cardiac diet was also started. Her chest tubes were removed and she was transferred to the floor by postop day one. She made a level four ambulation on her second attempt with physical therapy and she denied any significant pain. Her sternum remained stable. She had no exudate or drainage. There was no gross evidence of erythema. Her postop day number two laboratories were notable for a hematocrit of 27, BUN and creatinine of 13 and .8. The remainder of her examination was unremarkable. On postop day number two her Foley was removed. Her wires were removed on postop day three. She continued to work aggressively with physical therapy and was getting out of bed ad lib. On postop day number three her laboratory values were noted to be a hematocrit of 24, white blood cell count 6, platelet count 135. Additionally she had a BUN and creatinine of 11 and .7 with normal electrolyte panel. She was at a level four ambulation status. She was without chest tubes, Foley or pacing wires. Due to her rapid progress and her uncomplicated postoperative course it was deemed that she was appropriate and stable for discharge to home without any services. She will have follow up in the Wound Care Clinic in seven days. She does live at home with her daughter who happens to be [**Name8 (MD) **] RN who will help her additionally with her medications and be another surrogate for wound surveillance. DISCHARGE MEDICATIONS: Metoprolol 25 mg po b.i.d., Lasix 20 mg po q day times seven days, K-Dur 20 milliequivalents po q day times seven days, Colace 100 mg po b.i.d., Percocet 5/325 one to two tabs po q 4 to 6 prn, Zantac 150 mg po b.i.d., aspirin 325 mg po q day, Tegretol 200 mg po b.i.d., Lipitor 10 mg po q day, Travatan eye drops one drop OU b.i.d., Alphagan one drop OU b.i.d. as well as she will continue her B-12 injections and multi vitamins as she had done preoperatively. POSTOP FOLLOW UP: Seeing Dr. [**Last Name (STitle) 1537**] thirty days from the time of discharge, seeing her primary care physician in three weeks from the time of discharge. Wound check will be done in seven to ten days from the time of this discharge. She is instructed not to do any heavy lifting greater then ten pounds times thirty days, no driving times thirty days. She may shower. The wound may stay open and dry to air. DISCHARGE STATUS: To home, stable, afebrile, sinus rhythm. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times three, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to oblique marginal and right coronary artery for significant left main disease and three vessel coronary artery disease, normal ejection fraction. 2. Total gastrectomy for carcinoma in [**2158**] with B-12 deficiency. 3. Transient ischemic attack with a cerebrovascular accident and seizure disorder. 4. B-12 deficiency. 5. Hypertension. 6. Hyperlipidemia. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2165-11-7**] 09:52 T: [**2165-11-7**] 10:39 JOB#: [**Job Number 12953**]

[ "780.39", "266.2", "272.0", "401.9", "V10.04", "414.01", "411.1", "V10.79" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1217, 1423

6502, 7312

5522, 5991

6003, 6481

1450, 1678

1701, 5498

177, 744

767, 1128

1145, 1200

48,687

164,079

2853+55417

Discharge summary

report+addendum

Admission Date: [**2169-12-23**] Discharge Date: [**2170-1-3**] Date of Birth: [**2114-3-3**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2042**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 55F with metastatic breast cancer to bone on palliative gemcitabine now Cycle 3 Day 24 who presented the ED with acute chest pain and shortness of breath. Patient states that she was pale this morning and started feeling weak. She took a nap and awoke with pain with breathing. She describes a feeling of panic about her breathing, like she couldn't get air in. She has never experienced this exact sensation before. Her temperature was 101.7 one hour after she had taken Tylenol. She has a non-productive cough. . In the ED, vitals 100.8 135/59 103 38 90%RA. Responded well to 2L supplemental oxygen. She received 1L NS and 750mg Levaquin IV. For her pain, she received her long-acting, oxycontin. Chest x-ray was negative for acute process and the preliminary read of the CT scan did not show evidence of a pulmonary embolism. EKG unchanged from baseline. . On arrival to the floor, patient states that her symptoms are much better. She is now pain free and feels that she is breathing more comfortably with the help of the oxygen. Detailed ROS negative except for minor hemorrhoidal bleeding. Past Medical History: Past Oncologic History (per OMR): ONCOLOGIC HISTORY: # metastatic breast cancer: - diagnosed with L breast ca in [**2160**] - treated with neoadjuvant AC followed by left modified radical mastectomy with immediate reconstruction - rec'd paclitaxel x 4 cycles, XRT, followed by oral hormonal therapy for approx 2 years - began leuprolide injections in [**2163-1-27**] - dx'ed with bone mets (right humerus, iliac areas, multiple areas in T and L spine) [**10/2166**], started fulvestrant and zoledronate at that time - [**3-/2167**] progression of disease; initiated capecitabine which she took for 18 months. CT torso was obtained during a hospitalization for dehydration which revealed progression of a right pulmonary nodule and paratracheal nodes. Treated with liposomal doxorubicin for 12 cycles before progression of bone mets. - [**8-/2169**] began treatment with gemcitabine, continues on zoledronate every other month. . Other Past Medical History: 1. GERD 2. Depression 3. History of lymphedema in left arm 4. OSA - has not tolerated CPAP in the past 5. Valley Fever - treated with antifungals 6. Hyperlipidemia Social History: Lives in [**Location **] with her husband, [**Name (NI) **] who health care proxy, [**Telephone/Fax (1) 13873**]. Has two children, ages 18 and 24. Former remote smoker for about 15 year. No EtOH Family History: Mother had melanoma, father had prostate cancer. Two sisters who have Grave's disease but are otherwise alive and well. Physical Exam: Physical Exam: VS: T 96.2 122/60 82 18 98% on 2L GEN: AOx3, NAD HEENT: PERRL. NCAT. EOMI. MMM. Neck: No LAD. neck soft and supple Cards: RRR S1/S2 normal. II/VII systolic murmur Pulm: CTAB, no crackles or wheezes Abd: Soft, nondistended, ND, +BS. No rebound or guarding. No hepatosplenomegaly. No [**Doctor Last Name **] sign. Extremities: WWP, no cyanosis/ecchymosis/edema. Skin: No rashes or bruising Neuro/Psych: CNs II-XII intact. Strength and sensation grossly intact. Gait normal Pertinent Results: [**2169-12-22**] 08:45PM PT-13.0 PTT-29.7 INR(PT)-1.1 [**2169-12-22**] 08:45PM PLT SMR-LOW PLT COUNT-83* [**2169-12-22**] 08:45PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL [**2169-12-22**] 08:45PM NEUTS-76* BANDS-3 LYMPHS-9* MONOS-6 EOS-3 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-3* [**2169-12-22**] 08:45PM WBC-4.6# RBC-2.75* HGB-8.5* HCT-24.0* MCV-87 MCH-31.0 MCHC-35.5* RDW-18.8* [**2169-12-22**] 08:45PM CK-MB-2 cTropnT-<0.01 [**2169-12-22**] 08:45PM CK(CPK)-42 [**2169-12-22**] 08:45PM GLUCOSE-166* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 [**2169-12-22**] 08:53PM LACTATE-2.2* Brief Hospital Course: ICU COURSE ASSESSMENT AND PLAN: 55 year old woman with metastatic breast cancer s/p Gemcitabine who presents with fevers, headaches, shortness of breath and chest pain . A/P: 55yo F with Hx of metastatic breast CA currently on plliative gemcitabine transferred from the floor with worsening hypoxemia. . # Hypoxemia: She initially presented with shortness of breath. She was admitted to the oncology service. Initial CTA was negative for PE and cardiac enzymes were negative for ACS. SHe began to worsen clinically on the floor with development of ground glass opacities on CXR and drop in her sats to 70% on RA. She had coverage for PNA broadened to vanco, cefepime, and azithro, as well as Bactrim for PCP, [**Name10 (NameIs) 151**] [**Name11 (NameIs) 13874**] added for her history of coccidiomycosis. ID and pulmonary were both consulted. She had a bronchoscopy with BAL performed which was negative for organisms. Respiratory viral screen and culture negative as well. Her pCO2 continued to increase with sats still only 90% on [**Last Name (LF) 597**], [**First Name3 (LF) **] decision was made on HD 3 ICU day 1 to to electively intubate. She required high doses of sedation, SBP was high 80s-90s, so decided to put in CVL in anticipation of possible need for pressors. Her BP improved with fluid boluses. She was also started on Methylprednisolone 60 mg qday for empiriic treatment of gencitabine pneumonitis given the ground glass appearance on CT with lack of other systemic symptoms of infection. Continued on the ventilator, switching to Precedex for sedation on ICU day #3 as Fentanyl/Versed combination was not adequate. Pt. was gradually weaned and extubated from the ventilator by ICU day 4. Continued on methylprednisolone. Antibitoic regimen was adjusted, with cessation of vancomycin and Bactrim based on worsening renal function (see below)and continuation of Cefepime and Azithromicin. After transfer from the ICU, her hypoxemia continued to improve and she was able to weaned to 2L O2 by nasal cannula to keep her sats > 90% with exertion. Her antibiotics were changed to Cepodoxime with continuation of her azithromycin 2 days prior to discharge without worsening in her pulmonary status (4 days remaining in her antibiotic course at DC). She was switched to po prednisone and will continue steroids with a taper as an outpatient for the question of gemcitabine pulmonary toxicity. After transfer out of the ICU, her functional status rapidly improved and she was able to ambulate with minimal assistance or a walker by the time of discharge. . # Acute renal failure: Baseline Cr of about 0.6. By HD4/ICU 1, creatinine had increased to 1.6. UOP was tenous with 20-40 cc's an hour in the face of multiple fluid boluses. Several possible etiologies, including contrast induced nephropathy given prior imaging. Had urinalysis which showed granular casts s/o ATN. Medication induced ARF possible as well. Had renal US which was negative for structural disease. Continued to renally dose meds. Renal consult performed and aided in guiding treatment. Cr. peaked at 2.1, with levels at 1.8 at time of discharge from the ICU. Her Cre rapidly returned to [**Location 213**] and was 0.8 on the day of discharge. . # New urinary and fecal incontinence: On the day of discharge the patient reported new urinary and fecal incontinence. On physical exam she had a nonfocal neurological exam with normal rectal tone but point tenderness over her mid to low thoracic spine. Given her known spinal metastases, an MRI of T and L spine was obtained prior to her discharge. Preliminary report was without evidence of cord compression, but did note new pleural effusions left greater than right. . # New pleural effusions: Although the patient's pulmonary status continued to improve after her transfer from the ICU to the hospital floor, she was found to have assymptomatic new pleural effusions on an MRI obtained to rule out cord compression. After discussion of these new results, she declined further inpatient work up with the plan to discharged to home with early follow up in the next week with her primary oncologist (who was informed of these new findings). She will return earlier if needed for worsening pulmonary or other symptoms. . # Normocytic Anemia: Hct 24 on admission from baseline around 30. Had recieved approximately 1 unit/day since admission. Retic count 6.3%, normal haptoglobin. Stools were guiac negative. Iron panels suggestive of ACD. . # Anxiety/Insomnia/Depression: was anxious while ventilated. Had psych consult performed as concern for ICU psychosis vs. steroid induced psychosis vs. exacerbation of chronic psychiatric issues. Recommended continuing home medications, as well as Zyprexa 2.5 mg qhs prn. Additionally, suggested restarting her home Klonipin 0.5 mg [**Hospital1 **] for anxiety control. Also continued duloxeitine for depression and trazodone qhs for insomnia. . # Metastatic breast cancer: Received her last gemcitabine cycle #2 on Wednesday [**2169-12-20**] prior to admission. . # Hyperlipidemia: Continued lovastatin. . # History of orthostatic hypotension: Stable. Continued fludrocortinsone 0.15mg every morning, 0.10mg every afternoon. . Medications on Admission: Home Medications: * Clonazepam 1mg twice daily * Duloxetine 60mg twice daily * Fludrocortisone 0.15mg every morning, 0.1mg every afternoon * Lovastatin 20mg daily * Naproxen 500mg twice daily * Oxycontin 40mg twice daily * Percocet 7.5-325mg, two tablets daily as needed for pain * Compazine 10mg every 6 hours as needed for nausea * Vitamin D2 [**2159**] units daily * Multivitamin daily * Omeprazole 20mg twice daily * Senna 7 tablets daily * Lomotil 2 tablets qid prn diarrhea * Trazodone 200mg qhs . Allergies: NKDA Discharge Medications: 1. Home Oxygen 2L per minute for portability, pulse dose system 2. fludrocortisone 0.1 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). 3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO Q AFTERNOON (). 4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. oxycodone 40 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. naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. ergocalciferol (vitamin D2) Oral 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): may use more if needed to have 1 BM per day. 13. trazodone 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime) as needed for insomnia. 14. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 15. Percocet 7.5-325 mg Tablet Sig: Two (2) Tablet PO every [**7-4**] hours as needed for pain. 16. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*16 Tablet(s)* Refills:*0* 17. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 18. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 6 days: Take 3 tablets daily for 2 days, then take 2 tablets daily for 2 days, then take 1 tablet daily for 2 days. Disp:*12 Tablet(s)* Refills:*0* 19. prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for 4 doses: Take 2 tablets daily for 2 days then take 1 tablet daily for 2 days. Disp:*8 Tablet(s)* Refills:*0* 20. prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day for 8 doses: take 4 tablets daily for 2 days, then take 3 tablets daily for 2 days, then take 2 tablets daily for 2 days, then take 1 tablet daily for 2 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 6549**] Discharge Diagnosis: Atypical pneumonia Metastatic breast cancer GERD Depression History of lymphedema in left arm OSA - has not tolerated CPAP in the past h/o Valley Fever - treated with antifungals Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with an atypical pneumonia requiring IV antibiotics and steroid medication. You required ventilator support to breath and stayed in the intensive care unit for several days. Your breathing has improved, but we would like you to continue using oxygen until you have followed up with your primary oncologist Dr. [**First Name8 (NamePattern2) 189**] [**Last Name (NamePattern1) **]. Followup Instructions: Please call Dr.[**Name (NI) 13875**] office tomorrow morning for a follow up appointment in the next week ([**2169**] Department: [**Hospital1 **] When: FRIDAY [**2170-3-2**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], MD [**Telephone/Fax (1) 7477**] Building: [**State 7478**] ([**Location (un) 86**], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: None Name: [**Known lastname 2152**],[**Known firstname **] A Unit No: [**Numeric Identifier 2153**] Admission Date: [**2169-12-23**] Discharge Date: [**2170-1-3**] Date of Birth: [**2114-3-3**] Sex: F Service: MEDICINE Allergies: Gemcitabine Attending:[**First Name3 (LF) 2154**] Addendum: Gemcitabine has been added as an allergy given the possibility that the patient's atypical pneumonia is due to gemcitabine pulmonary toxicity. . The patient also noted new right forearm pain 2 days prior to discharge for which plain films were obtained and read as negative for metastatic disease. . The final read of her T and L spine MRI obtained on her day of discharge is also included below. Pertinent Results: [**2170-1-2**] Plain films of Right Forearm: RIGHT FOREARM, TWO VIEWS: Two views of the right forearm show no evidence of fracture. There is no suspicious lytic lesion or focal osseous destruction. Calcification adjacent to the medial epicondyle may represent calcific tendinitis. If there remains concern for metastasis, bone scan or MRI may be considered for further evaluation. . [**2170-1-3**] T and L spine MRI final results: THORACIC SPINE: Alignment remains anatomic. There is diffuse underlying low marrow signal within the thoracic spine, increased compared to [**2168-8-23**]. This may represent diffuse marrow infiltration with metastases or post-treatment changes. More focal regions of osseous metastatic disease in the thoracic vertebrae, most prominent in T2, T3, T6, T7, T8, T9 and T12 are slightly increased compared to prior. There is no evidence of interval fracture. Underlying degenerative changes include a Schmorl's nodes at the superior endplate of T7 and a disc herniation at T11-T12 which indents the anterior thecal sac. The spinal cord has normal contour and signal. There is no suspicious epidural enhancement and no suspicious intradural or intramedullary enhancement. . The partially visualized lungs are significant for moderate left and small right pleural effusions and heterogeneous signal within the lungs which is better evaluated on the [**2169-12-22**] CT. . LUMBAR SPINE: Alignment remains anatomic. Compared to [**2168-10-5**], there has been interval progression of the osseous metastases within the lumbar spine and sacrum with progression of abnormal enhancing low T1, high T2 signal lesions. There has been interval progression of the irregularity of the superior endplate of L3 likely due to metastatic involvement. Otherwise, the cortices appear intact. The conus medullaris terminates at the level of L1 with normal contour and signal. There is no abnormal enhancement within the thecal sac and no evidence of epidural or intramedullary metastases. Underlying degenerative changes include moderate bilateral facet arthropathy at L4-L5. The synovial cyst adjacent to the left L4-L5 facet is no longer evident. . IMPRESSION: 1. No spinal canal narrowing, no evidence of metastases within the thecal sac. 2. Slight interval progression of osseous metastatic disease with new irregularity of the superior endplate of L3. Discharge Disposition: Home With Service Facility: [**Location (un) 2155**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2156**] MD [**MD Number(2) 2157**] Completed by:[**2170-1-8**]

[ "285.9", "272.4", "V10.3", "E947.8", "197.0", "198.5", "327.23", "511.9", "780.52", "583.9", "518.81", "584.9", "300.4", "276.8", "530.81", "788.30", "486" ]

icd9cm

[ [ [] ] ]

[ "38.91", "33.24", "38.93", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

16761, 16972

4243, 9471

336, 342

12584, 12584

14368, 16738

13189, 14349

2856, 2977

10042, 12268

12367, 12563

9497, 9497

12767, 13166

3007, 3480

9515, 10019

264, 298

370, 1478

12599, 12743

2459, 2625

2641, 2840